Modified Medical Tattooing Techniques in Nipple-areola Complex Reconstruction.

Sir,

Nipple-areola complex reconstruction, which is the final step in breast reconstruction surgery, is extremely important for good aesthetic outcomes and improved patient satisfaction.[1] Among the many procedures reported,[2] nipple-areola complex reconstruction using a local flap or nipple graft in combination with medical tattooing is widely used today. However, only a few studies have reported its procedural details and modifications.[3] Here, the authors report our 4 innovative modifications of medical tattooing that enhance cosmetic outcomes of nipple-areola complex reconstruction.

This study was approved by the Ethics Committee of Tokyo Women’s Medical University. Subjects were 56 breasts of 56 patients who underwent nipple-areola complex reconstruction using medical tattooing at the Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University between April 2014 and October 2016. Our modified medical tattooing technique was performed using a Permark UltraEnhancer (PMT Corp., Minn.), a #18 needle (PMT Corp.) and several pigments (PMT Corp.). All medical tattoos were performed by a plastic and reconstructive surgeon. The time required for the procedure was about 30 minutes. The first of the 4 modifications was blurring the margin of the areola to create a natural appearance by depositing pigments in irregular alignment for a gradation effect. A needle angled perpendicular to the skin was used to ensure the finest micropigmentation, together with a scratch micropigmentation method. The degrees of gradation created were adjusted for individual patients (Fig. 1A). The second modification was creating the illusion of the uneven surface (bumps) of the areola due to the Montgomery glands. A polka dot pattern was created using either a darker or a lighter shade of pigment based on close examination of the contralateral healthy areola, to maintain similar appearances in individual cases (Fig. 1B). The third modification was adjustment of the areola position so that the breasts looked as symmetric and natural as possible. The conventional method that determines the areola position in relation to the apex of the reconstructed breast or the nipple would have emphasized asymmetry when breast reconstruction did not provide good symmetry. Instead of opting for conventional approaches such as determining the areola position in relation to the apex of the ipsilateral breast or the reconstructed nipple, the provisional position of the areola was marked for evaluation by using that of healthy side, and the final position, agreed with by the patient, was determined after fine adjustment in this study (Fig. 1C). The fourth modification was creating the illusion of the height of the transplanted or reconstructed nipple, by adding a shadow effect such as a trick art; the top and root of the nipple was covered by a lighter shade and a darker shade of pigment, respectively (Fig. 1D). The appropriate combinations of each of these 4 modifications was determined individually for each patient, resulting in successful nipple-areola complex reconstruction without complications (eg, cutaneous ulceration) in all patients (Fig. 2). Patient satisfaction, which was not examined in this study, needs to be studied in the future. Also, the optimal timing of tattooing, long-term follow-up results, pigment preparation methods, and the necessary number of tattooing sessions need to be elucidated in future studies.

Fig. 1.

Our 4 modifications of medical tattooing procedures in nipple-areola complex reconstruction. A, Blurring the areola margin. B, Creating the illusion of the Montgomery glands (areolar bumps). C, Adjusting the areola position to achieve symmetry. D, Creating the illusion of the height of the nipple by using shading.

Fig. 2.

Clinical photographs of the nipple-areola complexes reconstructed using the modified medical tattooing techniques.