Each year, more than 100,000 American women have a mastectomy — most often to treat breast cancer, but also for preventative reasons. (Think Angelina Jolie's prophylactic double mastectomy, which she opted for due to high genetic risk for developing breast cancer.) A mastectomy removes the entire breast, including the areola and nipple, and in some cases, the nipple and areola can be reconstructed, but usually, only smooth skin and a scar remain.
That's where the tattoo artists, armed with inks and a mission, come in.
While some people (as any gender is susceptible to developing breast cancer) choose to make a statement by adorning their post-mastectomy chests with designs such as flowers, a growing number are choosing 3D areola tattoos. These incredibly realistic tattoos look like actual areolas and nipples, offering survivors and "pre-vivors" a way to restore more of their breasts' original appearance — and their sense of self. "I wanted to look in the mirror and not be reminded every single day about my cancer," says Kelsey Carignan, a survivor of stage 3 breast cancer. "[The tattoos] helped me feel like me again. To me, the tattoos were the final chapter of my cancer journey."
Restorative tattoos are sometimes offered in surgeons' offices, but rarely with this level of detail, says Shaughnessy Otsuji, the specialist who gave Carignan her tattoos. "A lot of my clients were talking with their surgeons about getting their nipple tattooed on after surgery, but there was nothing very realistic," she says. "You get kind of a stenciled circle and they fill it in pink, and that's as realistic as it gets."
3D areola tattoos, on the other hand, are meticulously detailed. In other words, they're not impossibly identical or cartoonish. "There's imperfection in the areola," says Akili Worthy of Worthy Ink Studios in Phoenix, Arizona. "That's what makes them look real." Perfectly circular areolas and uniform shading don't look realistic, she says. A convincing restorative tattoo considers the way light falls on a natural areola, the Montgomery glands dotting the areola, and the texture of a nipple. "Adding in all those little details — those bumps and wrinkles, little highlights and shadows that a lot of people consider flaws — is what really makes it look as realistic as possible," Otsuji adds.
The tattoo process itself is straightforward, is suitable for adults of all ages, and can begin after healing from surgery, chemo, and radiation is complete. "The areola tattooing process should be done after all reconstruction and revisions have completely healed and implants or swelling have settled into place," Otsuji says, adding that if the tattoo is placed on any scarring, six months is the minimum to wait between surgery and the appointment. (And, of course, after a patient gets the green light from their oncologist and surgeon.)
Otsuji begins with a 20-minute consultation to discuss the client's surgery. "Was there radiation involved? That can usually lead to tougher, textured skin," she says. "In some cases, the reconstruction can't get the breasts perfectly symmetrical, so sometimes slightly shifting things can create a new focal point. My aim is to try to draw the eye to the nipples, rather than at any scars."
She also talks about desired shape, size, and color. Some clients bring photographs of their pre-mastectomy breasts; others use the opportunity to create something new. "Not everyone wants their new nipples to look like what they used to look like," Otsuji says. "Sometimes it's an opportunity to get exactly what you would want. When I first started, I was assuming that everyone would want these little cute perky pink nipples, but it depends." A mother who breastfed her three children, for instance, may prefer a look that's softer and darker than a child-free person in their twenties.
From there, the actual tattoo begins to take shape. To choose lifelike ink shades, Worthy considers not only her clients' skin color, but also their moles. "That's a good starting point of what an areola shade should be, and we can determine whether you want to go lighter or darker," she says. Worthy begins by outlining, then filling in with color and detail work.
What about pain? Minimal if present at all. Removing breast tissue during a mastectomy severs nerves that signal pain, so the reconstructed breast doesn't feel the same sensation as before surgery. "Most of my clients can't really feel much," Otsuji says. "They might feel a bit of vibration or a little bit of pressure here and there, but you don't really get that sharpness of a regular tattoo." The healing process, as with other tattoos, takes six to eight weeks and involves moisturizing with unscented lotion. And yes, like other tattoos, these are permanent. "When done properly, tattoo ink should not migrate too far from where it was originally placed unless the body experiences intense trauma or dramatic weight changes after getting tattooed," Otsuji says. Typically, the service costs between $400 and $1,000, depending on whether one or two tattoos are needed.
For anyone considering a restorative 3D areola tattoo — whether a breast cancer survivor or someone undergoing gender affirmation surgery — finding a restorative or paramedical tattoo specialist is crucial. (Some traditional tattoo artists also do 3D areola tattoos, but not everyone.) "Be sure to find an artist who is truly passionate about what they do," Carignan advises. "Do your research and be sure to review their portfolio of prior clients." Worthy says that the personality fit is also important. "I'm really about the gut instinct and feeling you have about working with people," she says. ""Work with somebody who allows you to be collaborative in the process. Get somebody who's going to take time to explain what the whole procedure and healing should look like, who's focused on getting all of your sessions complete."
People with brown or dark skin should also find out how much experience a tattoo artist has with their skin type. It's not always easy; online galleries of before-and-after tattoo pictures are vastly white. That's partly because fair skin is the default for training, Worthy says, noting that even highly accomplished paramedical tattoo artists often have extremely limited experience working on brown skin. Worthy, who is Black, hopes to counter the potential misconception that areola tattoos are only for white people. "I've talked with surgeons, and they all say the same thing: We don't know anyone Black who does what you do," she says. "But the need is vast for this type of tattoo work."
For survivors like Carignan, a restorative tattoo is not just a tattoo. "They are so much more than nipples," she says. "They were my finish line, my ability to feel feminine and not to be reminded every single day of what I went through. My self-confidence and my comfort with intimacy really took a hit, post-treatment. When I look in the mirror, I am reminded of the entire journey in a different way now."