Following a breast cancer diagnosis or learning of a BRCA gene mutation, women are faced with a number of surgical treatment options depending on the type, stage and grade of the cancer or how aggressive they want to be in reducing their risk of a breast cancer diagnosis. Surgical options may include lumpectomies, single or bilateral mastectomies, all of which may be done with or without reconstruction. Deciding what option is best is complicated, and when the question of what to do about the nips is tossed in the mix, it can be overwhelming.
The good news is that today women have many options regarding nipples after breast surgery, and some of those options were created or perfected by survivors or previvors who saw a need and created a solution.
Let’s shine a light on this, shall we?
There’s been too much ado about nipples.
Following breast reconstruction surgery, where the nipples are not saved, some women opt not to do anything more and live with nipple-free reconstructed breasts. The reasons for this are varied. Some women experience damage to their skin from radiation or have complications from the surgery making it difficult to undergo additional nipple reconstruction surgery or nipple tattooing. Others have had enough with the medical procedures and call it a day. Then there are those women who simply don’t want or need to have them – no nipples, no problem.
In some cases, women may opt to have nipple-sparing breast reconstruction, including women who have prophylactic mastectomies. In nipple-sparing surgery, all breast tissue is removed except for the nipples. Nipple-sparing surgery has become more popular because it results in an improved cosmetic outcome, although the nipple’s function and sensation are lost once the nerves are severed, as is the case with all mastectomies. Advances in breast reconstruction techniques can help restore some sensation of the nipple after nipple-sparing mastectomy. When reconstruction is performed using tissue flaps like the DIEP flap, sensory nerve reconstruction can also be performed. Sensory nerves are transferred with the flap to the chest and reconnected to nerves cut during the mastectomy. This extra step provides patients with a better chance of regaining feeling to the breast and nipple. However, nipple-sparing surgery is not an option where the breast cancer is too close to the nipple, involves the nipple, is extensive, or is aggressive because the risk of recurrence is too great.
Nipples can be surgically reconstructed using skin from the breast itself. Fat grafting or cosmetic fillers also may be used to make the nipple more pert. The surgeon also may tattoo the areolas some time following the surgery or may refer the patient to a tattoo artist for the finishing touch. The main objection to reconstructed nipples is that they are always at attention. This makes some women feel self-conscious and may raise modesty concerns. It is important to know that even though a reconstructed nipple can look very similar to a natural nipple, it will not feel or respond like a natural nipple. However, patients who have sensory nerve reconstruction in conjunction with certain types of flap breast reconstruction procedures can have a better chance of regaining feeling in the reconstructed nipple over time.
Another option, which is becoming more common and eliminates the "headlights" problem, is 3D nipple tattooing. Of course the tattoos are flat, but skilled tattoo artists, like Tara Dunsmore of Pink Ink Tattoo, can recreate the look of a real nipple and areola in ink. Tara is a breast cancer survivor and a nurse. Following her own double mastectomy and reconstruction in 2012, Tara’s plastic surgeon told her that his nurse would tattoo her areolas, as there was no one in North Carolina who specialized in 3D areola tattooing at the time. “My color choices were bubble gum pink, brown and nude.” After her own experience, Tara decided that “women deserved better than this,” and she did intensive one-on-one training to learn the art of 3D tattooing. This has become her calling. Today, she tattoos full-time at eight different offices in North Carolina and one in Fort Worth, Texas. Tara also travels to tattoo. In addition to 3D tattooing, Tara enhances existing areola tattoos and does scar camouflaging.
“There is an indescribable moment for me when a woman looks in the mirror for the first time and smiles her ‘I’m back’ smile.” For her patients, the tattoos are “vital” in the emotional healing process following breast surgery, Tara noted.
When deciding whether to get 3D tattoos, patients should look at the work of the doctor, nurse or tattoo artist and confirm that the artist is licensed and has experience in nipple tattooing.
Temporary areola tattoos are another innovative solution to the nipple issue, if other options are not appropriate or wanted. Created by Elizabeth Vivenzio following her risk-reducing bilateral mastectomy, Rub-On Nipples® are temporary areola tattoos lasting up to two weeks and are removed with rubbing alcohol. After her surgery, like many women, Elizabeth had difficulty seeing a “blank canvass” in the bathroom mirror. She found that being able to see the areola boosts women’s self-esteem. “People are visual, and the areola tattoo can be a soothing sight.” she noted.
The tattoos come in nine different colors. They are an option for women who cannot get permanent tattoos for medical reasons, religious or cultural reasons, and for those who are not comfortable with the idea of tattooing. They also help fill the void for women going through breast reconstruction, which can take months or even years, before permanent nipple tattooing can be done. The temporary nipple tattoos also help women planning permanent tattoos to visualize placement and different colors.
Some women, like the 12 featured in the October 2017 issue of Inked magazine, get mastectomy tattoos and cover their scars with beautiful artwork. Karen Malkin-Lazarovitz, one of the 12, tested positive for the BRCA1 mutation and chose to have a prophylactic bilateral mastectomy and reconstruction. She did not save her nipples or reconstruct them. “I didn’t like or need my nipples,” Karen said. Following her surgery, Karen had magnolia flowers and cherry blossoms tattoos done. Karen enjoyed appearing in Inked to raise awareness of other options for women following breast surgery.
As with 3D tattoos, patients should always look at the work of the tattoo artist, confirm that the artist is licensed and has experience tattooing reconstructed breasts.
Michelle Kolanth-Arbel, a breast cancer survivor who underwent a single mastectomy, is the owner of Pink Perfect, a company that produces realistic silicone nipple prostheses that attach to the breasts with a waterproof medical adhesive. The nipples will adhere for up to seven days. Pink Perfect offers the option of making custom prosthetics or chose from ready-made nipples that come in 8 colors and three styles: modest, natural and bold. Learn more here.
If surgery, tattoos permanent or temporary, or prosthetics don’t work, why not create DIY nips? That’s what Adrienne Keith did after she underwent a prophylactic mastectomy ten years ago. At the time of her surgery, no one was doing nipple tattoos, and she was unable to reconstruct her nipples for medical reasons. Her appearance bothered her; she didn’t like having breasts without nipples. “It was like an egg without a yolk.” Since Adrienne is an artistic individual, she developed her own nipple tattoos using long wearing lipstick and a round stencil made using a simple circle cutter found at craft stores from a plastic sheet or card stock. Adrienne prefers the plastic because it’s more flexible and easier to use on breasts. It was a simple “visual trick” that helped Adrienne feel “normal again.”
Adrienne went through a period of testing out various long-lasting lip color until she found a brand and color at her local pharmacy. Adrienne shared her tips. First, look for a color that is close to one’s natural lip color because areolas and lips are in the same color family. Next, find a long-lasting brand that comes with a lip-gloss pad or use a lip-gloss pad to apply. Center the stencil on the breast and outline with the lip color. Once the outline is finished, fill in with the lip color and let it dry. Adrienne’s DIY tattoos last up to two weeks and can be removed with baby oil. Adrienne says that they are even kiss-proof, and she would know since she’s been making her own for 10 years!
And that’s the down low on the nips, with plenty of options, so that each of us can find one that works and be comfortable with our reconstructed selves.
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Guest Post: Katharine Doughty
When I found a lump in my chest in early 2010, I was ten years into a series of 26 self-portraits with four 4 images to complete. A theme of reclaiming runs throughout the project: reclaiming of self-representation, of our personal and collective stories and the power of visual image. Be it ten years or ten minutes, the essential gift is the same: focused discovery and reflection via the arts allows us to be a witness to ourselves. To hear and respond creatively to our bodies with our bodies is to reclaim a role in the healing of our bodies.