Tattooing of the nipple-areola complex: review of outcome in 40 patients

[Hairiness and Skin Colouration after Breast Reconstruction with a Deep Inferior Epigastric Perforator Flap and Reconstruction of the Nipple-Areolar Complex]

INTRODUCTION

Although DIEP (deep inferior epigastric perforator) is the gold standard for breast reconstruction, long-term results with a view to postoperative hairiness and flap skin colouration have rarely been described in the literature.

METHODS

Patients who underwent DIEP flap breast reconstruction followed by NAC reconstruction between 2010 and 2019 were invited to our clinic for a survey and a clinical examination. A total of 781 patients were invited. The survey included the BREAST-Q and a study-specific questionnaire. The clinical examination contained specific measurements regarding postoperative hairiness and skin colouration.

RESULTS

A total of 179 patients were examined, with 203 breasts having been reconstructed. Only breasts with a visible flap skin island were taken into further evaluation. A total of 109 DIEP flap and 77 NAC reconstructions were evaluated. In the patient-reported survey, 27.5% (30 of 109) reported additional flap hairiness and 62.4% (68 of 109) reported differences in flap skin colouration compared with the surrounding skin. The clinical examination revealed a significant difference between the skin colouration of the flap compared with the surrounding skin and the skin colouration of the reconstructed NAC compared with the existing original NAC. In both cases, the reconstructions appeared significantly "lighter" (p<0.05). No significant difference was found between patients with and without hair in terms of overall satisfaction evaluated by using the BREAST-Q. Neither did the colour difference have a significant influence on patients' satisfaction.

CONCLUSION

Additional breast hairiness and different skin colouration is relevant and should be communicated preoperatively.

Fading and Color Reproducibility of Nipple-Areola Tattoos in Asian Patients

Background  The purpose of this study was to clarify fading, red, green, and blue values (RGB) change, and color reproducibility for nipple-areola complex (NAC) tattoos. Methods  NAC tattooing was performed on 60 sites in 59 Japanese patients prospectively. The evaluation was assessed using digital photo, Casmatch standardization, and RGB and luminance values preoperatively, immediately after, 1 week, 1, 3, 6, and 12 months after tattooing. RGB and luminance values changes over time, time-adjusted fading rate, and the rate of luminance at 12 months were calculated. In color reproducibility study ( n  = 34), RGB values after 12 months were compared with the color sample about dark/reddish and light/less reddish pigments. Results  RGB varied widely from immediately after to 1 month after tattooing. For RGB and luminance, significant differences were seen between pre and immediate after, 1 and 3 months, 3 and 6 months, and 6 and 12 months. In G values, significant differences were seen between all neighboring points. The fading rate tended to decrease as time progresses, but was not significant, that is, fading continued even between 6 and 12 months. Luminance was 9% brighter than contralateral NAC at 12 months. Color reproducibility tended to be higher with dark/reddish pigments, despite no significant differences. Conclusion  The fading rate of tattooed NACs tended to decrease as time progresses, but fading still occurs between 6 and 12 months. Luminance was 9% brighter than contralateral NAC at 12 months after.

Technical Refinement in Three-Dimensional Nipple-Areola Complex Tattooing of the Reconstructed Breast

SUMMARY

Three-dimensional nipple-areola complex tattooing has previously been described as an alternative to surgical reconstruction using local flaps and grafts. This technique offers patients an option that can achieve aesthetically pleasing results without a donor site, changes in projection over time, or additional scarring. Plastic surgeons may be limited in their ability to create a realistic-appearing nipple-areola complex because of limited experience with basic tattooing techniques and unfamiliarity with the artistic principles of light and shadow required to create depth on a two-dimensional surface. Consistent results can be achieved with attention to the technical pearls discussed in this article.

Applications of Medical Tattooing: A Systematic Review of Patient Satisfaction Outcomes and Emerging Trends

BACKGROUND

Medical tattooing is often applied in the context of plastic, aesthetic, and reconstructive surgery to help achieve the best cosmetic outcome.

OBJECTIVES

This article reviews various conditions that medical tattooing has been empirically studied in terms of patient satisfaction outcomes, makes practice recommendations, and suggests future directions for research.

METHODS

This review was performed following the PRISMA guidelines. Studies were included if the tattooing application was associated with a medical condition and if outcome data were provided using at least a case series methodology. Where no cohort or clinical series exist, case examples are used from the literature and the author's practice to illustrate emerging medical tattooing applications that need further evaluation.

RESULTS

Eighteen studies met the inclusion criteria and addressed the following conditions: baldness, vitiligo, scars from incisions, lacerations or burns, and nipple-areola complex reconstruction.

CONCLUSIONS

The application of medical tattooing has shown high levels of patient satisfaction across conditions. The practice recommendation grade is "B" or recommend since the level of evidence for these interventions ranged from III to IV according to the American Society of Plastic Surgeons guidelines. This means clinicians can consider this treatment alternative, but they should be alert to new information and be sensitive to patient preferences. Recommendations are made for reporting future research including clearly describing procedural details, identifying the professional performing the procedure, increased use of standardized outcome measures, and that satisfaction ratings be assessed by someone independent of the health service provider. Further research using randomized controlled trial methodology with waitlist controls is needed.

LEVEL OF EVIDENCE 4

A Survey on the Safety of and Patient Satisfaction After Nipple-Areola Tattooing

BACKGROUND

Nipple-areolar tattooing is well accepted as part of breast reconstruction, but the clinical data on its safety and patient satisfaction after the procedure are insufficient. We aimed to evaluate the complications of and patient satisfaction after nipple-areola tattooing in Japanese post-mastectomy breast reconstruction patients.

METHODS

Patients who visited our center after undergoing nipple-areola tattooing from January 2017 to March 2020 were given an unmarked questionnaire with questions about complications related to their nipple-areola tattoo. Patients' registered their subjective evaluation responses regarding nipple-areola appearance using visual analog scale and that regarding overall satisfaction using 5-point Likert scale and free-text responses. Patients who were followed up within 6 months after tattooing or those with incomplete data were excluded.

RESULTS

Sixty-two patients (average age: 49.7 ± 9.8 years), with an average post-tattooing period of 21.2 ± 10.5 months, were included. No patient had infections or allergic reactions. The average VAS score for nipple-areola appearance was high (8.5), and 59 patients (95.3%) answered that they were satisfied. In the free-text patient responses, 25 patients answered that they now felt comfortable going to the hot spring or taking a bath with their children, and 19 patients reported improved mental health after the procedure.

CONCLUSION

Post-breast reconstruction nipple-areola tattooing with sterilized inorganic pigments could achieve high esthetics and patient satisfaction, without serious complications. It is recommended for Japanese individuals with a culture of visiting hot springs and public baths.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each submission to which evidence-based medicine rankings are applicable. This excludes review articles, book reviews, and manuscripts that concern basic science, animal studies, cadaver studies, and experimental studies. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

3D Nipple-Areolar Tattoo: It's Technique, Outcomes, and Utilization

BACKGROUND

Three-dimensional (3D) nipple-areolar tattoo is a novel approach to nipple-areolar complex reconstruction for which little data exist. Our aim was to evaluate 3D nipple-areolar tattoo outcomes and investigate if patient factors, payer status, surgeries, or therapies affect tattoo utilization.

METHODS

Patients pursuing skin-sparing (SSM) or attempted nipple-sparing mastectomy (NSM) with breast reconstruction from 2008 to 2019 were reviewed. Outcomes included frequency of 3D tattoo, post-procedure complications (infections, or other local adverse sequelae), and rates, indications, and timing of revisions. Patient factors, payer status, surgeries, and adjuvant therapies underwent univariate analysis comparing rates of 3D tattoo and revisions.

RESULTS

A total of 191 patients were identified; median follow-up was 4 years. The majority of patients were white (165, 86%), married (146, 76%), and post-menopausal (97, 51%), with private insurance (156, 81%). Surgeries included SSM (172, 90%) or attempted NSM (19, 10%) with implant (154, 81%) or autologous reconstruction (37, 19%). Sixty-two patients (32%) underwent 3D nipple-areolar tattooing. No post-procedure complications occurred. After tattooing, 20 patients (32%) pursued revisions, the majority due to color fading (12, 60%). Average time from tattoo to completion of revisions was 5.6 months. Patients undergoing autologous reconstruction had a higher rate of 3D tattooing (p < 0.001). Adjuvant radiation led to a higher rate of revisions (p = 0.02). Patient factors, payer status, index mastectomy, and chemotherapy did not significantly affect rates of 3D tattooing or revisions.

CONCLUSIONS

3D nipple-areolar tattoo utilization is likely unaffected by age, marriage, menopause, or payer status. Radiotherapy and color fading can lead to more revisions.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

'My face in someone else's hands': a qualitative study of medical tattooing in women with hair loss

The psychological and social impact of hair loss and its ongoing treatment can be considerable. Medical treatments are not always successful, and alternative treatments, such as medical tattooing, are growing in popularity. The aims of this study were to explore adults' motivations, experiences, and self-perceived outcomes in relation to medical tattooing. Individual telephone interviews were conducted with 22 women from the United Kingdom aged 26-67 years who had undergone medical tattooing in the past 5 years related to hair loss. Interviews were transcribed and inductive thematic analysis was performed. Appearance concerns, loss of self-confidence/identity, and the practicalities of daily upkeep were cited as reasons for seeking a semi-permanent solution. Trust in the practitioner and the ongoing costs of tattoo maintenance were important considerations in participants' decision-making process and their overall satisfaction with treatment outcomes. Participants felt the emotional impact of hair loss and the subsequent need for appearance-restoring treatment remains unrecognised. This study provides insight into participants' perceptions of an under-researched and unregulated but widely accessible treatment. Implications for the decision-making process are discussed, and suggestions for health professionals are offered.

A review of permanent marking for radiotherapy in the UK

INTRODUCTION

This paper presents the results of a survey of the routine use of permanent marks for radiotherapy in the UK. This was undertaken to provide an overview of current practice. Permanent marks are a somewhat invasive procedure, and should be subject to scrutiny and judicious application.

METHOD

The authors reviewed the literature on international radiotherapy permanent marking practice. Common themes that emerged were the psychology of permanent marking and ink-type considerations, current practice and training, and safety. These were used to develop a questionnaire in order to form an overview of the use of marks nationally, and to identify any recurrent issues. The questionnaire also sought information regarding locations and numbers of permanent marks used for common treatment sites. The survey was sent to 71 departments in the UK using email.

RESULTS

70% of departments responded. 62% of departments reported patients who had refused permanent marks. The reasons for refusal varied. India or drawing ink was used in 49 of the 51 departments (96%). The most common teaching method of tattooing involved combined observation and verbal coaching. Most departments had a written procedure for tattooing, but some did not. Although sharps injuries were rare, they were documented.

CONCLUSION

Most departments in the UK had encountered patient refusal of permanent marks, with breast patients representing the largest group which declined. There is variation in practice throughout the UK, and the equipment used is not specialised for tattooing purposes. Sharps injuries, although rare, do occur, and training methods are not consistent.

IMPLICATIONS FOR PRACTICE

The requirement for national guidelines is posited. Further investigation into the need for permanent marks in an era of state-of-the-art imaging technology is also required.

The Public's Perception on Breast and Nipple Reconstruction: A Crowdsourcing-Based Assessment

BACKGROUND

Breast reconstruction outcomes have traditionally been measured by evaluating the opinions of patients and surgeons.

OBJECTIVES

Our goal was to assess the views of the general public.

METHODS

A survey was designed and distributed through a crowdsourcing website called Amazon Mechanical Turk. Questions assessed participant demographics, personal experience with breast reconstruction, perceptions on breast reconstruction, and opinions regarding aesthetics results. Responses were analyzed using chi-square test.

RESULTS

A total of 992 responses were collected. Most participants were female (56.1%), white (32.1%), aged 30 to 39 years (40.4%), and had a bachelor's degree (42.0%). A total of 44.2% had personal experience with breast reconstruction and 25.8% with nipple reconstruction. Several aesthetic and reconstructive factors were significantly favored over others across sex, ethnicity, age group, education level, and personal experience with breast reconstruction. For instance, women were more likely to prefer reconstructed nipples (P < 0.0001), view a breast without a nipple as complete (P = 0.024) and place less importance on nipple shape (P = 0.002). Additionally, those who personally experienced nipple reconstruction were willing to undergo more procedures for a complete nipple-areola complex (P < 0.0001), to increase aesthetic results (P = 0.018), and to increase chances of nipple survival (P = 0.002).

CONCLUSIONS

Crowdsourcing can be useful in plastic surgery and has helped identify several key findings. The importance of the nipple in reconstruction has been validated; almost three-quarters of respondents did not view a breast without a nipple as complete. The aesthetic preferences seem to support bilateral nipple-sparing reconstruction when possible. Most importantly, the respondents helped elucidate key differences in perception of aesthetic outcomes.

Color Change After Paramedical Pigmentation of the Nipple-Areola Complex

BACKGROUND

Reconstruction of the nipple-areola complex is the final process in breast reconstruction. Local flaps and paramedical pigmentation is one of the major procedures for this. However, fading after paramedical pigmentation leads to a color difference between the selected pigment and its color in the skin. The aim of this study is to make a proposition in color choice of paramedical pigmentation for nipple-areola complex.

METHODS

Our research focused on investigating the color changes over time after unilateral nipple-areola complex reconstruction using paramedical pigmentation in 25 patients to propose suitable color selections. We measured the color by spectrometer and conducted comparisons using the hue, saturation, and value (HSV) color space and the color space defined by the Commission International de L'eclairage based on one channel for luminance (lightness) (L) and two color channels (a and b) (L*a*b*).

RESULTS

A comparison of the hue, value, and saturation of the reconstructed areola compared to the normal areolae was conducted using HSV color space; the value and saturation were satisfactory after 3 months and beyond, but the reconstructed areola tended to have stronger red hues. The color difference (ΔE₀₀) calculated in L*a*b* color space showed slow fading after the scab was peeled off.

CONCLUSIONS

This result indicates that a color with less redness and more yellowness, particularly 4-5 degrees of yellowness on the color wheel, than the normal side is the most appropriate color selection for this technique.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does nipple-areolar tattooing matter in breast reconstruction? A cohort study using the BREAST-Q

Background

Breast reconstruction is achieved through a series of surgical procedures often concluded with nipple-areolar reconstruction tattoo. The purpose of the tattoo is to increase the patients' satisfaction with the appearance of the breast, however, no published studies quantitatively compare patient satisfaction before vs. after tattoo. In recent times nurse practitioners are increasingly performing this specialised procedure previously undertaken by the plastic surgeon, but there is no evidence to compare patient satisfaction according to clinician.

Purpose

The objectives of this study are to examine patient satisfaction pre- and post-nipple-areolar tattooing utilising a validated patient-reported outcome measure the BREAST-Q, and to identify any differences in patient satisfaction between the nurse practitioner and plastic surgeon.

Methods

Data was collected from all breast reconstruction patients who underwent nipple-areolar reconstruction tattooing over a six-year period in a dedicated Breast Reconstruction Unit and had completed a pre- and post-tattoo BREAST- Q questionnaire. Analysis of data included paired t-test of pre- and post-tattoo scores and ANCOVA to compare clinicians and tattoo laterality.

Results

93 patients with completed pre- and post-tattoo questionnaires within the date criteria were included from the 204 patientswho had a nipple-areolar tattoo. There was a significant improvement in patient satisfaction with nipple reconstruction from pre-tattoo (m = 74.4) to post-tattoo (m = 81.0), p = 0.013 (2-tailed), with no significant difference between clinicians.

Conclusion

Patients reported through completion of the BREAST-Q, that nipple-areolar tattooing significantly improves satisfaction with their nipple reconstruction.

Nipple Reconstruction After Autologous or Expander Breast Reconstruction: A Multimodal and 3-Dimensional Analysis

BACKGROUND

Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume.

OBJECTIVES

The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses.

METHODS

Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10).

RESULTS

A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5).

CONCLUSIONS

Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4.

A Simple Alternative Treatment for Syndactyly of the Toe

Toe syndactyly is a common congenital malformation affecting approximately 1 in 2000 people and can cause significant emotional and psychological distress for the patient. We report a case of a 41-year-old female who was concerned about the aesthetic appearance of her bilateral second and third toe with incomplete, simple syndactyly and had requested surgical correction. A number of operative techniques have been described in the orthopedic and plastic surgery data, with no one technique proving superior. We used medical tattooing to create the appearance of a complete interdigital cleft. This low-risk, and low-cost procedure resulted in a satisfactory outcome for the patient. To the best of our knowledge, this is the first reported case using this technique, which we propose as a simple alternative to surgical correction of toe syndactyly.

Modeling fade patterns of nipple areola complex tattoos following breast reconstruction

BACKGROUND

Nipple-areolar complex (NAC) tattoos are an effective cosmetic solution for creating a finished look following breast reconstruction procedures. NAC tattoos are prone to significant fading, leading patients to seek revisions. This study was designed to quantify changes in NAC tattoo appearance over time.

METHODS

A total of 71 images of 39 patients were analyzed for NAC tattoo color and shape by 5 blinded medical student graders using a customized scoring system. Subsequently, each image was analyzed using ColorPic software (Iconico, New York, NY). Red/green/blue and hue/saturation/value color parameters were collected. Color quantities were normalized to the individual patient's skin tone to control for variability in lighting. Spearman correlations and nonlinear regressions were calculated utilizing GraphPad Prism 6.0 (GraphPad, La Jolla, CA).

RESULTS

The length of time after tattoo placement inversely correlated with color score (P < 0.0001) and shape score (P = 0.0007). The time following tattoo placement was also inversely correlated with all quantitative color parameters. Each color parameter fit a 1-phase exponential decay model.

CONCLUSIONS

The decline in qualitative color and shape score agrees with clinical experience of tattoo quality declining over time. The color qualities of the tattoo approach those of the patient's skin over time, ultimately reaching a plateau. This can be modeled using a 1-phase decay equation. In practice, tattoo colors may be selected that compensate for the predictable changes that will occur. The results of this study will help optimize tattoo color and may alleviate the need for NAC tattoo revisions.

Single-stage nipple-areolar complex reconstruction technique, outcomes, and patient satisfaction

INTRODUCTION

Nipple-areolar reconstruction (NAR) is the final phase of breast reconstruction and is associated with increased patient satisfaction. Nipple-areolar reconstruction is typically performed in 2 separate stages, which include nipple reconstruction and tattooing of the nipple-areolar complex (NAC). Previous studies have demonstrated that increased duration of the reconstruction is associated with decreased patient satisfaction. Because a 2-stage reconstruction prolongs the reconstructive process, we introduce a simple and novel method of single-stage NAR (SS NAR), which combines the use of local flaps for nipple reconstruction and medical tattooing of the NAC in 1 session and delivers predictable outcomes with high patient satisfaction.

METHODS

A retrospective chart review of patients who underwent SS NAR at our institution during the period from September 2010 to May 2012 was performed. Patient demographics, complications, outcomes, and overall patient satisfaction were assessed. A modified questionnaire (Likert scale) was used to assess patient satisfaction of nipple size, color, shape, and projection.

RESULTS

Twenty-nine SS NARs were performed in 18 patients: 7 unilateral and 11 bilateral. Mean age was 45 years (range, 34-60 years). No major complications were identified. Mean length of follow-up was 10 months (range, 2-22 months). A 17% complication rate was observed: 14% (4/29) had irregular dye uptake of the areola, and 3% (1/29) had dehiscence from silicone guard pressure on the incision. Two patients underwent revisions: one patient underwent additional tattooing, and the other required flap readvancement and implant downsizing secondary to the wound dehiscence. We obtained a 70% survey response rate with 100% of responders who reported that they were "very satisfied" with NAC in each dimension.

CONCLUSIONS

Our study demonstrates that SS NAR is a safe procedure with reproducible, excellent clinical results and very low complication rates or need for revisions. This method is cost-effective, convenient for the patient, and shortens patient recovery time with high patient satisfaction.

Bilateral areoleor depigmentation after augmentation mammoplasty: a case report and literature search

Breast augmentation is by far one of the most common aesthetic procedures performed by plastic surgeons, and silicone implants are the most common prostheses used. Complications arising from the procedure are broadly categorized as either surgery or prosthesis related. Most of the complications are well known and have been documented, but areolar depigmentation after silicone gel prosthesis has not been reported to date.

Medical applications of tattooing

Tattooing is an ancient procedure, practiced by humans from all parts of the world for a variety of reasons. However, relatively little is known by the medical audience of the numerous medical conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Tattooing for cosmetic and medicinal purposes, referred to as either micropigmentation, dermatography, or medical tattooing, may ensure permanent camouflage in a wide range of dermatological diseases. It can be a valuable finishing step in several surgical procedures in the fields of craniofacial surgery, plastic and reconstructive operations, cosmetic surgery procedures, and breast reconstruction. Other fields of application of medical tattooing include radiation therapy, endoscopic surgery, and ophthalmology.