Thursday, July 29, 2010
Planned radiation following mastectomy for treatment
There remains the question of immediate reconstruction (at the same time of the mastectomy, and at the same surgery) versus delayed reconstruction (breast reconstruction performed after the mastectomy, which can be weeks to months following the initial mastecotmy)... This is an important discussion, as there are different viewpoints regarding the approaches... and a personal decision that is important to understand fully - initial tissue expander placement followed by subsequent staged "final" reconstruction versus no reconstruction and so on... be sure to ask what the differences may be, what the incisions may look like after reconstruction, and what their opinion is regarding implant reconstruction in the setting of radiation....
Nipple Sparing Mastectomy
Nipple Sparing Mastectomy
7/24/2010 (10:11:04am)Tags: mastectomy reconstruction nippleComments: (0)
It seems obvious that one of the more difficult parts of breast reconstruction is creating a new and natural-looking nipple and arerola. Women sometimes wonder about the possibility of a mastectomy that spares the nipple. Here is a brief interview, from MedScape, with Dr. Lisa Newman from the University of Michigan Medical Center about this surgery:
Nipple-Sparing Mastectomy With Breast Reconstruction
Lisa A. Newman, MD, MPH
Posted: 06/25/2010
Question
My patient is a 35-year-old woman with a clinical stage I left breast cancer. She has a strong family history of breast cancer and is considering bilateral prophylactic mastectomy with immediate reconstruction. She has asked about nipple-sparing mastectomy. Is this a safe approach, either for the therapeutic or the prophylactic mastectomy?
Response from Lisa A. Newman, MD, MPH
Professor of Surgery; Director, Breast Care Center, University of Michigan, Ann Arbor
Reports of nipple-sparing mastectomy are appearing more frequently in the published medical literature, with most groups suggesting that the procedure is not only technically feasible, but also oncologically safe. However, it must be strongly emphasized that the conventional mastectomy, which entails sacrifice of the nipple-areolar skin, is still widely considered to be the gold standard procedure for patients requiring mastectomy for either cancer treatment or risk reduction. Studies of nipple-sparing mastectomy have been retrospective in nature with variable selection criteria,
including mixed samples of patients undergoing the procedure for prophylaxis or treatment; the patient follow-up intervals have been relatively brief.
Nonetheless, the preliminary data in regard to outcomes following nipple-sparing mastectomy are promising, suggesting that it is a technique worthy of further study and should be rigorously evaluated in the context of a prospective clinical trial. Historically, the largest series of bilateral prophylactic mastectomy, such as the Mayo Clinic database,[1] featured cases performed by plastic surgeons as subcutaneous (nipple-sparing) mastectomy. In the now-landmark study of approximately 1000 selected high-risk women undergoing prophylactic mastectomy in this setting, Hartmann and colleagues[1] found that prophylactic mastectomy reduces breast cancer risk by 90%, and of the 7 prophylactic failures, only 2 were cases of breast cancer occurring in the retained nipple-areolar skin. These results have prompted others to explore nipple-sparing mastectomy for breast cancer as an extension of the skin-sparing mastectomy concept. The skin-sparing mastectomy includes a periareolar incision but sacrifices the nipple-areolar skin, and is now routinely
coupled with immediate breast reconstruction, with well-documented acceptably low local recurrence rates that are comparable to those reported after conventional mastectomy.[2,3] Pathologic analyses of the nipple-areolar skin from mastectomy specimens reveal occult cancer in this tissue in 6%-58% of cases,[4,5] with risk for occult nipple-areolar
involvement highest with central tumors. This has prompted some investigators to offer nipple-sparing mastectomy to patients with peripherally located disease. Simmons and coworkers[6] found that most cases of occult nipple-areolar
involvement were related to disease within the nipple, and this group has reported excellent local control with areolar- sparing mastectomy in 17 cases, but with follow-up limited to only 2 years.[7
Several single-institution groups have reported their outcomes with nipple-sparing mastectomy, with wide variation in local recurrence rates ranging from 0% to 28%, and with median follow-up intervals often shorter than 2 years.[8-10] In contrast, rare reports of larger sample sizes with longer follow-up have also demonstrated low local recurrence
rates.[11,12]
Of note, at least 1 group from Italy has reported on routine use of intraoperative radiation to the retained nipple-areolar skin.[13] The consistent observation that failures only rarely involve the preserved nipple-areolar complex has nonetheless prompted concerns that the limited exposure from a nipple-sparing mastectomy might actually compromise the adequacy of the mastectomy, leaving more at-risk breast tissue in the remote portions of the breast/chest wall.
Nipple-sparing mastectomy would be the preferred procedure for cases of small unicentric breast tumors located more than 2 cm peripheral to the areolar edge, as well as for cases in which the intraoperative frozen section analysis revealed no evidence of occult nipple-areolar involvement.
Patients considering this procedure should be informed that the nipple-areolar skin will need to be sacrificed if any disease proximal to the area is identified pathologically, and that if preserved, the nipple-areolar skin may be insensate or develop necrotic wound complications. Of importance, patients must also be informed about and understand the lack of high-quality prospective data in regard to the oncologic safety of this procedure.
Supported by an independent educational grant from Susan G. Komen for the Cure.
7/24/2010 (10:11:04am)Tags: mastectomy reconstruction nippleComments: (0)
It seems obvious that one of the more difficult parts of breast reconstruction is creating a new and natural-looking nipple and arerola. Women sometimes wonder about the possibility of a mastectomy that spares the nipple. Here is a brief interview, from MedScape, with Dr. Lisa Newman from the University of Michigan Medical Center about this surgery:
Nipple-Sparing Mastectomy With Breast Reconstruction
Lisa A. Newman, MD, MPH
Posted: 06/25/2010
Question
My patient is a 35-year-old woman with a clinical stage I left breast cancer. She has a strong family history of breast cancer and is considering bilateral prophylactic mastectomy with immediate reconstruction. She has asked about nipple-sparing mastectomy. Is this a safe approach, either for the therapeutic or the prophylactic mastectomy?
Response from Lisa A. Newman, MD, MPH
Professor of Surgery; Director, Breast Care Center, University of Michigan, Ann Arbor
Reports of nipple-sparing mastectomy are appearing more frequently in the published medical literature, with most groups suggesting that the procedure is not only technically feasible, but also oncologically safe. However, it must be strongly emphasized that the conventional mastectomy, which entails sacrifice of the nipple-areolar skin, is still widely considered to be the gold standard procedure for patients requiring mastectomy for either cancer treatment or risk reduction. Studies of nipple-sparing mastectomy have been retrospective in nature with variable selection criteria,
including mixed samples of patients undergoing the procedure for prophylaxis or treatment; the patient follow-up intervals have been relatively brief.
Nonetheless, the preliminary data in regard to outcomes following nipple-sparing mastectomy are promising, suggesting that it is a technique worthy of further study and should be rigorously evaluated in the context of a prospective clinical trial. Historically, the largest series of bilateral prophylactic mastectomy, such as the Mayo Clinic database,[1] featured cases performed by plastic surgeons as subcutaneous (nipple-sparing) mastectomy. In the now-landmark study of approximately 1000 selected high-risk women undergoing prophylactic mastectomy in this setting, Hartmann and colleagues[1] found that prophylactic mastectomy reduces breast cancer risk by 90%, and of the 7 prophylactic failures, only 2 were cases of breast cancer occurring in the retained nipple-areolar skin. These results have prompted others to explore nipple-sparing mastectomy for breast cancer as an extension of the skin-sparing mastectomy concept. The skin-sparing mastectomy includes a periareolar incision but sacrifices the nipple-areolar skin, and is now routinely
coupled with immediate breast reconstruction, with well-documented acceptably low local recurrence rates that are comparable to those reported after conventional mastectomy.[2,3] Pathologic analyses of the nipple-areolar skin from mastectomy specimens reveal occult cancer in this tissue in 6%-58% of cases,[4,5] with risk for occult nipple-areolar
involvement highest with central tumors. This has prompted some investigators to offer nipple-sparing mastectomy to patients with peripherally located disease. Simmons and coworkers[6] found that most cases of occult nipple-areolar
involvement were related to disease within the nipple, and this group has reported excellent local control with areolar- sparing mastectomy in 17 cases, but with follow-up limited to only 2 years.[7
Several single-institution groups have reported their outcomes with nipple-sparing mastectomy, with wide variation in local recurrence rates ranging from 0% to 28%, and with median follow-up intervals often shorter than 2 years.[8-10] In contrast, rare reports of larger sample sizes with longer follow-up have also demonstrated low local recurrence
rates.[11,12]
Of note, at least 1 group from Italy has reported on routine use of intraoperative radiation to the retained nipple-areolar skin.[13] The consistent observation that failures only rarely involve the preserved nipple-areolar complex has nonetheless prompted concerns that the limited exposure from a nipple-sparing mastectomy might actually compromise the adequacy of the mastectomy, leaving more at-risk breast tissue in the remote portions of the breast/chest wall.
Nipple-sparing mastectomy would be the preferred procedure for cases of small unicentric breast tumors located more than 2 cm peripheral to the areolar edge, as well as for cases in which the intraoperative frozen section analysis revealed no evidence of occult nipple-areolar involvement.
Patients considering this procedure should be informed that the nipple-areolar skin will need to be sacrificed if any disease proximal to the area is identified pathologically, and that if preserved, the nipple-areolar skin may be insensate or develop necrotic wound complications. Of importance, patients must also be informed about and understand the lack of high-quality prospective data in regard to the oncologic safety of this procedure.
Supported by an independent educational grant from Susan G. Komen for the Cure.
Tuesday, July 20, 2010
Free Teleconference re Breast Reconstruction
It can be very hard to identify the best web resources about breast cancer. One very fine organization and website is Living Beyond Breast Cancer: www.lbbc.org
They have the best printed materials of any organization that I know. Additionally, they sponsor many educational programs, both "live/in person" and teleconferences. Here is information about a July 28th teleconference about reconstruction options:
7/28/2010
Breast Reconstruction: Understanding Your Options
Our July teleconference will help you learn about your choices for breast reconstructive surgery
Speaker: Karen M. Horton, MD, MSc, FRCSC
Register now for this free teleconference about breast reconstruction.
Join Living Beyond Breast Cancer for our next free teleconference, Breast Reconstruction: Understanding Your Options, from 12:00 p.m. to 1:15 p.m. Eastern Daylight Time (EDT) on Wednesday, July 28.
Karen M. Horton, MD, MSc, FRCSC, a board certified plastic surgeon with Women’s Plastic Surgery, will help you learn about:
Different types of reconstructive surgeries
The latest research in rebuilding the breast
How to determine the option that is best for you
Microsurgery, nipple reconstruction and immediate versus delayed surgery
The stages of the reconstruction process
What to expect during your recovery
This teleconference will also discuss questions to help you explore whether you want to consider reconstructive surgery.
About Our Speaker
In addition to her board certification, Dr. Horton is a reconstructive microsurgeon. She practices in the Pacific Heights area of San Francisco.
Dr. Horton educates, empowers and informs women about options for breast reconstruction after cancer. Her goal is to use techniques that do not sacrifice major body muscles, enabling women to have reconstruction with the least number of stages. She specializes in microsurgical breast reconstruction, including DIEP flap, SIEA flap and TUG (inner thigh) flap.
Dr. Horton has published review book chapters on breast reconstruction. She presents clinical papers at national and international scientific meetings and has won research awards.
About the Program
Our speaker will give a brief presentation, followed by a question-and-answer period. To participate, you need only a telephone or computer with Adobe Flash Player or Windows Media Player. Social workers may be eligible to receive continuing education credits; see our registration form for more details.
They have the best printed materials of any organization that I know. Additionally, they sponsor many educational programs, both "live/in person" and teleconferences. Here is information about a July 28th teleconference about reconstruction options:
7/28/2010
Breast Reconstruction: Understanding Your Options
Our July teleconference will help you learn about your choices for breast reconstructive surgery
Speaker: Karen M. Horton, MD, MSc, FRCSC
Register now for this free teleconference about breast reconstruction.
Join Living Beyond Breast Cancer for our next free teleconference, Breast Reconstruction: Understanding Your Options, from 12:00 p.m. to 1:15 p.m. Eastern Daylight Time (EDT) on Wednesday, July 28.
Karen M. Horton, MD, MSc, FRCSC, a board certified plastic surgeon with Women’s Plastic Surgery, will help you learn about:
Different types of reconstructive surgeries
The latest research in rebuilding the breast
How to determine the option that is best for you
Microsurgery, nipple reconstruction and immediate versus delayed surgery
The stages of the reconstruction process
What to expect during your recovery
This teleconference will also discuss questions to help you explore whether you want to consider reconstructive surgery.
About Our Speaker
In addition to her board certification, Dr. Horton is a reconstructive microsurgeon. She practices in the Pacific Heights area of San Francisco.
Dr. Horton educates, empowers and informs women about options for breast reconstruction after cancer. Her goal is to use techniques that do not sacrifice major body muscles, enabling women to have reconstruction with the least number of stages. She specializes in microsurgical breast reconstruction, including DIEP flap, SIEA flap and TUG (inner thigh) flap.
Dr. Horton has published review book chapters on breast reconstruction. She presents clinical papers at national and international scientific meetings and has won research awards.
About the Program
Our speaker will give a brief presentation, followed by a question-and-answer period. To participate, you need only a telephone or computer with Adobe Flash Player or Windows Media Player. Social workers may be eligible to receive continuing education credits; see our registration form for more details.
Sunday, July 18, 2010
breast reconstruction and implants
I saw a patient of mine who had had 9 implant replacement procedures at another hospital who continued to have discomfort from the implant. I usually tell patients that Implant based reconstruction, while it certainly offers potentially a quicker upfront recovery potentially, may involve several implant exchanges or revision procedures in the future related to the implant (deflation, shift in position, visible surface asymmetries on the skin that are seen). On the other hand, breast implants for reconstruction can be the best option for other patients, depending on their history and physical examination.
Wednesday, July 7, 2010
Chemotherapy and timing of breast reconstructive surgery
As with a number of patients, chemotherapy can be a necessary part of the treatment process, as well as hormonal therapy. Usually, at the conclusion of chemotherapy, if one is in the process of breast reconstruction, we usually will wait at least one month for any staged procedure as part of breast reconstruction... The one month timing is for the body and immune system to recover... a patient's blood count may also be checked during that timeframe to make sure that things are getting back to normal
Thursday, July 1, 2010
The Final Stage: Nipples and Tattoos
I was very pleased to be invited by Dr. Lin to occasionally contribute to this blog. I have been an oncology social worker at BIDMC for more than thirty years and work primarily with women who have breast cancer. In addition to my professional interest, I have a strong personal one as I have been diagnosed and treated for two primary (unrelated) breast cancers, once in 1993 and once in 2005. I write a daily blog for BIDMC called Living with Breast Cancer; there is a link to it on the right side of this blog. To tempt you to read more of my musings, I am sharing here a recent entry about Nipples and Tattoos (that title ususally is an attention-grabber):
Breast reconstruction is always a hot topic, and women sometimes wonder about the value of the final phase: nipple reconstruction and tattooing.
A woman in one of my hospital-based groups recently asked others on our Listserv about their experiences. It occurs to me that others may find these comments helpful. I am, therefore, attaching some of the letters that she received in response to her questions.
If you have anything to add about your own reconstruction and decisions, I would love to hear from you. Just click on "comments" and share your thoughts.
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Erickson did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn't bother.
I had nipple reconstruction and a tattoo. The nipple was initially a little "pronounced" but it flattened. I requested a pale tattoo which faded to the point where it is almost not visible now. Dr.X trained with the doctor who did my reconstruction so I think you need not worry about the nipple if he does it even though he did not do any of my surgery. Dr. X did my tattoo. I would follow his advice about color. I did not and as I said, it has faded a lot.
My name is XXXX I had the nipple reconstruction. I was hoping for the most realistic version possible. So I wanted them to stick out like my previous ones did. My reconstructed nipples stick out but not very much nothing like the real ones. They look fine it's just for me when I look at them I think OK reconstructed. Also my tattoos faded very quickly. I had been told they would but I thought it would take a long time. Not so very much lightened to the point of needing to be redone even before the first year was up. I just had my 1 year follow up with the plastic surgeon and she thought they needed to be redone as well. I hope this helps,
I'm not really qualified to answer, as have only had lumpectomy. But I did some reading when I accompanied a friend to her nipple tattooing, though I'm hardly an expert.
If using a non-medical tattoo artist, please make sure that he/she follows the Mass. Dept. of Public Health model regulations for "body art" (attached), and uses sterile inks/needles. There is always a risk of infection/lymphedema in the affected breast. If the breast has been radiated, tattooing would be an increased risk due to the nature of radiated skin. My friend's tattoo was done by her surgeon's nurse. The only problem was that the choice of colors for the nipple tattoo was somewhat limited (sort of like choosing grout colors for tile) — there are only a few shades for each skin tone. Although the nurse did make "dots" with the tattoo needle, instead of a solid line, which would have been more unnatural, we couldn't get a close enough color match to her other nipple. We were told that tattoo inks do fade over time, though.
She did have her nipple reconstructed, and it does stick out a little bit, but it looks quite natural- perhaps your surgeon has photos of his work? One more thing -- I did have a "Nipple Party" for my friend, to commemorate the completion of her reconstruction. We thought it was a nice idea.
I can't be a LOT of help, but I did have nipple reconstruction. The nipples stuck out for a few months + or -, but soon became basically flat and almost completely unnoticeable. There is perhaps the slightest outline of a nipple in the very thinnest nighty. For the most part I wear stretch camisoles (with an inside elastic 'bra') now that I don't really need a bra - and the nipples can't be seen through these at all. I believe, however, there are several ways to reconstruct the nipple, so suggest you find out which version your surgeon suggests/does.
I have to say that getting nipples (which originally I wasn't going to do as I was out of energy & wanting the nighmare to be over) turned out to be a huge emotional boost to me. Having the 'details' gave my new 'breasts' personality. A glance in the bathroom mirror reflected an image that looked very natural. With a bilateral mastectomy, 'matching' a 'real' breast wasn't an issue.
My tattoos (almost 3 years now) have faded (the pink/brown colors don't have the lasting power of red/blue & my doc doesn't like to make them too dark), so I am considering having a touch up. Be really, really clear with your surgeon how big you want the aeroli to be...its not possible to make them smaller once tattooed.
I have had a nipple reconstruction and then a couple years later I had it tattooed by the PA that assists the surgeon that did my TRAM flap. My reconstructed nipple does stick out some but it is softer and is not nearly as noticeable in clothes as my natural one is. So, I have often gotten more padded bras to conceal my natural nipple whereas it is not an issue for my reconstructed one..
I also eventually did get my tattoo, just last September, a little more than two years after my surgery, and think that for me, because I had the nipple reconstructed, it looks more natural than it would than if I hadn't done it because the tattoo is more uniform in color than my natural one. For my natural one the nipple is darker than the areola. I've been tempted to go back for a little "touch up" to get a more natural effect. If the color scheme were closer to my natural nipple it might make having a reconstructed nipple less important as I think this is what makes it look more natural, out of clothes anyway. I guess I mean I think that having the coloring right might be more natural looking than having the reconstruction but don't know if going to a tattoo artist will increase the likelihood of a better tattoo outcome or not.
From what I understand there are several nipple reconstructions that may be offered; grafting from either behind the ear or the labia, the star origami -style which is done w/very little discomfort but needs the tattoo to define the color & shape, or just a tattoo, w/o depth or dimension. I had my reconstruction in '98 using a wedge of my back muscle & skin, i had the first of the origami type but didn't go back for the finish so the skin feels smooth rather than protruding and had the tattoo done last year by a tattoo artist not a plastic surgeon, she used several colors and her shading gives the illusion of depth. I like it – it is very subtle (I think). The result probably depends on the surgeon, yes?
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Dr X did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn't bother.
Breast reconstruction is always a hot topic, and women sometimes wonder about the value of the final phase: nipple reconstruction and tattooing.
A woman in one of my hospital-based groups recently asked others on our Listserv about their experiences. It occurs to me that others may find these comments helpful. I am, therefore, attaching some of the letters that she received in response to her questions.
If you have anything to add about your own reconstruction and decisions, I would love to hear from you. Just click on "comments" and share your thoughts.
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Erickson did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn't bother.
I had nipple reconstruction and a tattoo. The nipple was initially a little "pronounced" but it flattened. I requested a pale tattoo which faded to the point where it is almost not visible now. Dr.X trained with the doctor who did my reconstruction so I think you need not worry about the nipple if he does it even though he did not do any of my surgery. Dr. X did my tattoo. I would follow his advice about color. I did not and as I said, it has faded a lot.
My name is XXXX I had the nipple reconstruction. I was hoping for the most realistic version possible. So I wanted them to stick out like my previous ones did. My reconstructed nipples stick out but not very much nothing like the real ones. They look fine it's just for me when I look at them I think OK reconstructed. Also my tattoos faded very quickly. I had been told they would but I thought it would take a long time. Not so very much lightened to the point of needing to be redone even before the first year was up. I just had my 1 year follow up with the plastic surgeon and she thought they needed to be redone as well. I hope this helps,
I'm not really qualified to answer, as have only had lumpectomy. But I did some reading when I accompanied a friend to her nipple tattooing, though I'm hardly an expert.
If using a non-medical tattoo artist, please make sure that he/she follows the Mass. Dept. of Public Health model regulations for "body art" (attached), and uses sterile inks/needles. There is always a risk of infection/lymphedema in the affected breast. If the breast has been radiated, tattooing would be an increased risk due to the nature of radiated skin. My friend's tattoo was done by her surgeon's nurse. The only problem was that the choice of colors for the nipple tattoo was somewhat limited (sort of like choosing grout colors for tile) — there are only a few shades for each skin tone. Although the nurse did make "dots" with the tattoo needle, instead of a solid line, which would have been more unnatural, we couldn't get a close enough color match to her other nipple. We were told that tattoo inks do fade over time, though.
She did have her nipple reconstructed, and it does stick out a little bit, but it looks quite natural- perhaps your surgeon has photos of his work? One more thing -- I did have a "Nipple Party" for my friend, to commemorate the completion of her reconstruction. We thought it was a nice idea.
I can't be a LOT of help, but I did have nipple reconstruction. The nipples stuck out for a few months + or -, but soon became basically flat and almost completely unnoticeable. There is perhaps the slightest outline of a nipple in the very thinnest nighty. For the most part I wear stretch camisoles (with an inside elastic 'bra') now that I don't really need a bra - and the nipples can't be seen through these at all. I believe, however, there are several ways to reconstruct the nipple, so suggest you find out which version your surgeon suggests/does.
I have to say that getting nipples (which originally I wasn't going to do as I was out of energy & wanting the nighmare to be over) turned out to be a huge emotional boost to me. Having the 'details' gave my new 'breasts' personality. A glance in the bathroom mirror reflected an image that looked very natural. With a bilateral mastectomy, 'matching' a 'real' breast wasn't an issue.
My tattoos (almost 3 years now) have faded (the pink/brown colors don't have the lasting power of red/blue & my doc doesn't like to make them too dark), so I am considering having a touch up. Be really, really clear with your surgeon how big you want the aeroli to be...its not possible to make them smaller once tattooed.
I have had a nipple reconstruction and then a couple years later I had it tattooed by the PA that assists the surgeon that did my TRAM flap. My reconstructed nipple does stick out some but it is softer and is not nearly as noticeable in clothes as my natural one is. So, I have often gotten more padded bras to conceal my natural nipple whereas it is not an issue for my reconstructed one..
I also eventually did get my tattoo, just last September, a little more than two years after my surgery, and think that for me, because I had the nipple reconstructed, it looks more natural than it would than if I hadn't done it because the tattoo is more uniform in color than my natural one. For my natural one the nipple is darker than the areola. I've been tempted to go back for a little "touch up" to get a more natural effect. If the color scheme were closer to my natural nipple it might make having a reconstructed nipple less important as I think this is what makes it look more natural, out of clothes anyway. I guess I mean I think that having the coloring right might be more natural looking than having the reconstruction but don't know if going to a tattoo artist will increase the likelihood of a better tattoo outcome or not.
From what I understand there are several nipple reconstructions that may be offered; grafting from either behind the ear or the labia, the star origami -style which is done w/very little discomfort but needs the tattoo to define the color & shape, or just a tattoo, w/o depth or dimension. I had my reconstruction in '98 using a wedge of my back muscle & skin, i had the first of the origami type but didn't go back for the finish so the skin feels smooth rather than protruding and had the tattoo done last year by a tattoo artist not a plastic surgeon, she used several colors and her shading gives the illusion of depth. I like it – it is very subtle (I think). The result probably depends on the surgeon, yes?
My experience with tattoo/nipple recon was mixed. the nipple reconstruction does indeed protrude slightly, but this is not a problem since the saline pouch is a little smaller than the original and thus a small falsie covers the deficiency. As for the tattoo, Dr X did a fair job after I advised him on how to mix the colours. It is, by the way, not entirely painless even with novocaine. The ink fades slowly so the tattoo has to be darker than you might expect at first. In short, my view now is that had I had a double mastectomy and recons, the whole nipple and tattoo process would have been worthwhile; if I had it to do again, I wouldn't bother.
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