A review of nipple-areola complex reconstruction and tattooing techniques

Fuentes, Patricia M.¹; Lascar, Emma¹; Sharma, Sahil¹; Chowdhury, Sheuli^1,2; Lee, Rachel³; Singh, Divleen⁴; Taub, Peter J.¹; Henderson, Peter W.¹

Abstract

Breast cancer is the most common malignancy among women, and as survival continues to improve, increasing attention has been placed on optimizing quality of life after treatment. Breast reconstruction is an important part of this process and remains among the top five reconstructive procedures performed in the United States. Reconstruction of the nipple-areola complex (NAC) is often the final—and in many ways the most rewarding—step in the reconstructive sequence. NAC reconstruction plays a critical role in psychological recovery by helping patients regain a sense of wholeness after mastectomy.

The objective of this study was to provide an overarching review on NAC reconstruction techniques, drawing from published literature and current institutional practices. A narrative review was conducted by querying PubMed using the terms (“NAC” OR “nipple-areolar complex”) AND (“reconstruction” OR “tattoo”) to synthesize contemporary literature on NAC reconstruction techniques including local flaps, grafts, implant devices, and tattooing.

Additionally, patients who underwent NAC reconstruction at a single academic institution were reviewed and outcomes included. Local flaps are the foundation of surgical NAC reconstruction, though projection loss can vary from 40–75% depending on flap type. Adjuncts such as acellular dermal matrix (ADM), bioabsorbable scaffolds, and implant devices can improve projection durability. Tattooing techniques have advanced substantially able to deliver three dimensional results with a high patient satisfaction and minimal down time; however, pigment fading is common. NAC reconstruction is an individualized process that can be achieved using a variety of tools including flaps, implant devices, and tattooing.

These techniques can be used in combination or on their own depending on patient preference and anatomy with the goal of delivering symmetry, durability, and high satisfaction.

Introduction

In the most recent decade, women younger than fifty years of age have experienced a steep 1.5% annual increase in invasive breast cancer incidence (¹). As breast cancer increasingly affects younger patients, attention to psychological well-being and quality of life has become ever more important (²). Many women diagnosed with breast cancer undergo non-nipple-sparing mastectomy, particularly those with high tumor burden or elevated risk profiles (³,⁴). For these patients, options for nipple-areola complex (NAC) reconstruction is an important component of the reconstructive journey.

NAC reconstruction is usually the final stage of breast reconstruction. Beyond restoring physical form, NAC reconstruction significantly influences patient self-image and psychosocial recovery (⁵,⁶). Improving quality of life and prioritizing cosmesis have therefore become integral elements of modern breast cancer care. Achieving symmetry in the nipple and areola in shape, size, and pigmentation is important to restoring a more natural aesthetic outcome. NAC reconstruction provides many patients with a sense of completeness and closure in their cancer treatment (²).

Several NAC reconstructive approaches are available for patients who are not candidates for nipple-sparing mastectomy. These include local flap procedures, nipple-sharing grafts, and tattooing. These techniques can be tailored, often combining tattooing with surgical reconstruction to optimize outcomes (⁵,⁷). The objective of the present study was to provide an overview of current practices in NAC reconstruction with an emphasis on graft and flap techniques and tattooing to restore aesthetic form in breast reconstruction.

Historical context

Breast cancer care has undergone dramatic evolution over the past several centuries. Complete resection of the breast began as the standard treatment for breast cancer with the introduction of the radical mastectomy by William Stewart Halsted in 1882. This technique involved en bloc resection of the breast, underlying pectoral muscles, and ipsilateral axillary fold (⁸). While Halsted’s method had low recurrence rates, it was associated with significant morbidity. Postulating that scar tissue served as a barrier to local cancer invasion, Halsted allowed wounds to heal by secondary intention, resulting in massive scarring along with large chest wall and axillary defects (⁹). Moreover, he was outspoken in his criticism of reconstruction, arguing that skin and lymphatic transfer could conceal recurrence and promote dissemination of disease (¹⁰). Given his influence, Halsted’s stance delayed reconstructive advancements for decades.

The Women’s Rights Movement of the 20^th century challenged the disfiguring and disabling approach that had become the standard of care. This discourse paved the way for breast-conserving techniques, beginning with the debut of the subcutaneous mastectomy in 1917 by William Bartlett Sr. which utilized fat grafting from the anterior abdominal wall, lateral thigh, and buttocks to reconstruct the breast (¹¹). Subsequent refinements included the pectoralis-preserving modified radical mastectomy described by Patey in 1948 and the skin-sparing mastectomy reported by Toth and Lappert in 1991 (¹²,¹³).

Advancements in mastectomy technique paralleled developments in breast reconstruction. Early efforts included the pedicled latissimus dorsi flap, first described by Tansisi in 1906 (¹⁴). However, the latissimus flap did not achieve widespread use until it was popularized in 1976 by Nevin Olivari. Subsequently, free flaps such as the transverse rectus abdominis myocutaneous (TRAM) flap and the deep inferior epigastric perforator (DIEP) flap were introduced (¹⁵,¹⁶).

These advancements in breast reconstruction underscored the growing emphasis on restoring breast form and function, which in turn spurred the evolution of NAC reconstruction. The first attempt at NAC reconstruction was reported by W. Milton Adams in 1949 using a full-thickness labial graft (¹⁷). Millard later proposed a nipple-sharing technique in 1972, followed by additional autologous grafts such as toe pulp, auricular cartilage, and mucous membranes (^18–20). These approaches fell out of favor in the 1980s with the introduction of smaller local flaps including the skate flap, star flap, CV flap, Bell flap, mushroom flap, and S-flap, that became part of the reconstructive canon (²¹). In 1986, Hilton Becker was the first to suggest tattooing for NAC reconstruction, a method later popularized by Scott Spear in the following years (²²,²³).

Intradermal tattooing has continued to gain popularity over the past several decades (²⁴). In 2014, Eric Halvorson described a three-dimensional approach inspired by tattoo artist Vinnie Myers, which created the illusion of nipple projection and thus further improved aesthetic results (²⁵). Today, NAC tattooing represents a safe, well-tolerated, and cosmetically pleasing choice for patients undergoing breast reconstruction. As the field of tattooing grows, techniques, pigments, and devices continue to evolve in pursuit of enhanced aesthetic outcomes and patient satisfaction (²⁶).

Patient indications and considerations

Patient selection for NAC reconstruction

NAC reconstruction is most commonly associated with patients with breast cancer following mastectomy or those with high oncologic risk who have undergone prophylactic mastectomy. However, NAC reconstruction also has applications in non-oncologic scenarios. Beyond these, NAC reconstruction and tattooing can also be applied in non-oncologic autologous breast reconstruction, including cases of congenital breast deformity, trauma, failed implant-based reconstruction, refinement of the NAC, or when autologous tissue is preferred (²⁷). In addition, surgical NAC reconstruction may be utilized for the management of severe gynecomastia and chest wall soft tissue laxity (²⁸). Recent studies on gender-affirming operations found that nipple grafting was routinely performed and offered by over 80% of surgeons, and three-dimensional (3D) tattooing techniques are also increasing in popularity to re-create the NAC and achieve improved symmetry (²⁹). Ferrin et al. surveyed 536 patients undergoing gender-affirming chest surgery and found that 13% of respondents elected not to undergo surgical nipple reconstruction, while 58% pursued NAC tattooing. These findings highlight the importance of preoperative counseling regarding expected morphological changes following nipple reconstruction, particularly postoperative deprojection, which may adversely affect patient satisfaction with nipple shape and size (³⁰,³¹). Figure 1 demonstrates a patient who underwent chest feminization with implant-based reconstruction. Postoperatively, the nipples demonstrated asymmetry and were disproportionate to the reconstructed breast; therefore, areola tattooing was performed to improve NAC symmetry and aesthetics as part of gender-affirming care.

Type of prior breast reconstruction is another important consideration when counseling patients on the risks and benefits of different techniques. Especially with radiation, implant-based reconstructions often leave thin, attenuated soft tissue. Thus, in these settings, 3D tattooing is recommended because local flaps risk perfusion problems or implant exposure (²⁴). Autologous reconstruction, particularly with larger skin paddles, affords a wider array of local flap or grafting options. 3D tattooing for nipple and areolar reconstruction has been utilized as an adjunct to both implant and autologous-based breast reconstruction to optimize aesthetic results (³²).

Contraindications

Local flap NAC reconstruction is contraindicated in patients with active infection in the breast mound or chronic, non-healing wounds or ulcerations overlying the intended flap site. Poor local tissue vascularity secondary to prior radiation therapy or extensive scarring that disrupts the subdermal vascular plexus is another contraindication. As previously mentioned, a thin skin envelope with dermal attenuation overlying breast implants may result in insufficient tissue to form a projecting nipple, increasing likelihood for an unsuccessful NAC surgical reconstruction (³³). Other key considerations prior to flap reconstruction include comorbidities that affect wound healing, such as poorly controlled diabetes and chronic steroid use, and history of keloid formation (²⁴).

Contraindications to tattooing include active infection at the tattoo site, known allergies to tattoo pigments, and uncontrolled systemic illnesses that would compromise wound healing. Additional caution is warranted in patients with radiation-induced skin changes. Patients who have undergone prior radiation therapy or prepectoral implant-based reconstruction may have a higher risk of post-tattoo infection (²⁴,³⁴).

Timing of NAC reconstruction

Surgical NAC reconstruction should be performed at least 2–3 months after primary breast reconstruction and revisions that may alter the breast mound, although the timing may vary depending on surgeon preference, need for adjuvant therapy such as chemotherapy or radiation, and patient specific characteristics (³³). Tattoo placement is typically performed at least three months after surgical NAC reconstruction to allow for scar maturation. Specific flap design has not been found to impact timing of tattooing (³⁵). When adjuvant therapy is involved in oncologic cases, one should defer tattooing for at least 3 months after chemotherapy and at least 6 months after radiation given pigment distortion in irradiated skin (²⁴).

NAC anatomy and positioning

The NAC is located on the breasts bilaterally and is a part of the mammary gland. Classic descriptions of the ideal anatomical position approximate the nipple to be 21 cm from the sternal notch, 7 cm above the inframammary fold, and equidistant from the midline along the meridian (^36–38). The nipple is a conical projection from the epidermal skin in the center of the breast surrounded by the areola. The mean diameter of the nipple is 1.3 cm and mean height is 0.9 cm. The mean diameter of the areola is 4 cm, however, these sizes can vary greatly across the population (²⁴,³⁹,⁴⁰). “Complex” refers to the convergence of the lactiferous ducts. These ducts drain the lobes of the mammary gland and are oriented radially toward the nipple. Montgomery glands are sebaceous glands found below the areola and appear as small projections surrounding the nipple. NAC pigmentation can range in color from pink and red to brown and black, with variations influenced by race and ethnicity (²⁴).

Optimal positioning of the NAC is generally along the breast meridian at the point of maximal projection. In unilateral reconstruction, it is recommended to achieve symmetry based on the contralateral breast. As “ideal” positioning is subjective, incorporating patient preferences into the surgical plan is essential (³³). No single reconstruction method is universally applicable, as such multiple techniques exist to adapt to variations in breast mound morphology, mastectomy scar patterns, and desired aesthetic outcomes.

Surgical NAC reconstruction

Local flaps

Local flaps remain the foundation of surgical nipple reconstruction. They allow for the creation of a projecting nipple using adjacent skin and subcutaneous tissue, with variations in design to suit individual anatomy. Flap choice may depend on patient characteristics such as skin thickness, breast mound composition, and scar location. Local flaps can be categorized as centrally based, subdermal, and double subdermal (²¹,³³,⁴¹).

Centrally based flaps are subjected to greater retraction forces acting on the flap base, whereas subdermal pedicle flaps are more protected from retraction because the majority of the flap is freed from underlying attachments. All local flaps are prone to varying degrees of scar contraction, leading to a gradual loss of projection over time. Long-term maintenance of projection remains one of the principal challenges in nipple reconstruction (²¹). Table 1 summarizes common flap designs and technical details for NAC reconstruction. These flaps may be combined with areola tattooing depending on patient characteristics and goals.

Table 1 - Common local flap techniques for NAC reconstruction (²¹,³³,⁴¹)

Flap type	Publication	Original description	Surgical technique	Notes	Modifications
Skate flap	Little JW 3rd (1984) (42)	Central elongated “body” with two partial-thickness lateral “wings” elevated and folded to form nipple	Line tangent to nipple marked at 12 o’clock; curvilinear arcs from 3 and 9 o’clock to 6 o’clock define the skate composite; wings elevated and abrupt transition from horizontal to vertical dissection; wings sutured over central dermal platform to create projection	The base should be directed away from the mastectomy scar in order to maximize blood flow	Zhong et al. (2009): avoids central fat wedge to preserve areolar contour, uses central subcutaneous stalk, tripoint stitch for support (43)
S flap	Cronin ED (1988) (44)	S-shaped skin incision from dermal column	Designed along scar; both flaps elevated with subcutaneous fat; flaps de-epithelialized and sutured; full thickness skin graft from upper inner thigh applied to nipple and areola for color match	Can be centered around mastectomy scar	Feng et al. (2017): uses a modified linear incision line at the base and evolved from dermal flaps to full-thickness skin flaps (45)
Double- opposing tab flap	Kroll SS (1989) (46)	Two dermal-fat opposing “submarine” shaped scars on either side of scar	Design two dermal-fat flaps with tab extensions; donor sites closed as Burrough’s triangles; flaps opposed to support each other’s projection; tabs cover exposed fat, eliminating need for skin graft	All scars within areola	Kroll et al. (1997): tabs are raised as full-thickness skin flaps and the back cut at the tab base is removed (47)
Star flap	Anton MA (1991) (48)	Three triangular flaps on subdermal pedicle	Lateral wings elevated as thin full-thickness flaps without fat; central fat pedicle is elevated; three donor sites are sutured; one lateral wing is used for nipple reconstruction	Carefully lift the central fat pedicle to protect vascular supply	Few et al. (1999) designed a modified star flap with a blunted central wing and two opposing lateral triangles (49)
H flap	Hallock GG (1993) (50)	H-shaped flap	Circle markings to outline the nipple; rectangular tabs on both sides of the circle within boundaries of areola; lift tabs with minimal subcutaneous fat; rectangular tabs are folded	Can be designed horizontally (H) or vertically (I) depending on location of scar
C-V flap	Jones G (1994) (51)	Two lateral V flaps rotated over a central C base	Two triangular V flaps laterally from nipple base; flaps elevated peripheral-central, keeping a central fat pad; C flap raised from inferior end to nipple; central fat released as needed for rotation; V flaps wrapped around core; C flap closed over nipple		Gougoutas et al. (2018): narrowed “cap” for conical shape and dermal platform (33) Chen et al. (2019): half-dome directs all tissue anteriorly, skin-grafted undersurface (52)
Cutaneous flap with rectangular plus circle shapes	Thomas SV (1996) (53)	Dermal-fat flap with circular and rectangular flaps	Flap design centered on proposed nipple; pedicle base placed half nipple diameter distance from center; lateral extensions and distal circle edge incised at superficial subcutaneous level; flap shaped into cylindrical nipple	Any orientation around nipple center
Arrow flap	Rubino C (2003) (54)	Arrow-shape and circular flap	Triangular area marked above areola circle; one side marked as arrow head, other side as arrow tail; tail-end is deepithelialized with dermis attached; flap elevated; cup, triangle, and wings shaped into nipple		Modification of the Thomas 1996 technique
Spiral flap	Di Benedetto G (2004) (55)	Spiral rotation flap from mastectomy scar	Circle marked at intended nipple location (often central to scar); incision medial to lateral with wide base; flap raised with fat; flap twisted ~3× on its axis to form spiral	Good option for compromised blood supply
Hammond flap	Hammond DC (2007) (56)	Skate flap combined with periareolar purse-string suture	Central flap cap drawn as smooth oval equal to vertical height of wings; base placed inferiorly for gravity-assisted projection; donor site incorporated into circular wound by de-epithelialization; full-thickness graft inset with central nipple opening; CV-3 Gore-Tex purse-string placed in periareolar dermis and cinched to desired diameter	Requires second donor site; relies on full graft take; tattooing grafted skin may have less color uptake; good option in case of autologous-based reconstruction (57)	Yoon et al. (2018): blunt-tip flap design deepithelialized crescent “balcony” at nipple base; dermofat harvested from dog ear correction and buried beneath nipple base (58)

NAC, nipple-areolar complex.

Expected nipple projection after local flap NAC reconstruction varies by flap type. Across flap types, nipple projection generally decreases by 40–75% within the first year, with the most perceivable changes within three to six months (⁴¹,⁵⁹). The star flap has been reported to maintain 41% of projection by two years with thicker flaps yielding greater projection (⁴⁷,⁵⁹,⁶⁰). Moreover, the C-V flap has been shown to maintain 54% of inti Due to the natural loss of projection, overcorrection of 25–50% is recommended (⁴¹). The modified C-H flap has been documented to have a projection loss of approximately 38% (⁵⁸). A high patient satisfaction with local flap reconstruction has been associated with achieving symmetry in shape and location (Sisti et al.).

Augmentation materials can be incorporated with local flaps to enhance nipple projection over time. Many options have been reported with varying outcomes. Autologous sources include fat grafting, rib cartilage, and auricular cartilage. Alloplastic and biologic adjuncts such as acellular dermal matrix (ADM), calcium hydroxylapatite, polymethylmethacrylate, and biologic collagen cylinders have also been used (⁴¹). Lee and Ock showed that a modified C-V flap with adjunct ADM for nipple reconstruction retained 64% of projection at 1 year (⁶¹).

In another study, Dong et al. showed in vivo that 3D printed poly-4-hydroxybutyrate (P4HB) and C-V flap for nipple reconstruction resembled a native human nipple after one year (⁶²). Konfino et al. recently published on a novel nipple implant device FixNip which was found to maintain stable nipple project during 12 months with medium to high patient satisfaction and one reported complication (⁶³). Similarly, Riccio et al. found patients to be generally satisfied with the FixNip implant device, and demonstrated no reports of skin infections (⁶⁴). Compared to autologous options, implant-based reconstruction avoids donor-site morbidity and offers a predictable shape.

Surgical reconstruction combined with tattooing

NAC reconstruction contributes significantly to patient satisfaction and sexual well-being (⁵). Surgical reconstitution of the NAC can be combined with NAC tattooing (²⁶,³²). Tattooing can play a critical role in achieving a natural-appearing nipple and areola. Medical-grade pigments applied in layered, multi-tone fashion can closely replicate native areolar coloration and NAC structures. One study using the C-V flap for nipple reconstruction followed by areola tattooing found that after one year there was an average decrease of 6.5% of color intensity compared to the native areola with a 70% satisfaction rate (⁶⁵). Color fading over time is a common concern, with studies reporting 25–80% fading, though this may be related to normal pigment uptake rather than the flap tissue (⁶⁶,⁶⁷).

It is also important to consider the sequence of nipple reconstruction and tattooing. A study by Lee et al. found no difference in nipple projection loss whether tattooing was done before or after local flap-based nipple reconstruction; however, the authors did find that tattooing before nipple reconstruction results in a higher rate of additional tattooing compared to when tattooing was performed after surgical reconstruction due to greater pigment fading (³⁵). Specific predictors of tattoo fading include prior radiation therapy, color selection, and Fitzpatrick skin type (³²,⁶⁸,⁶⁹). Figure 2 illustrates a patient who underwent right breast autologous reconstruction with a DIEP flap following mastectomy. Surgical nipple reconstruction was performed to restore projection, followed by right-sided areola tattooing to complete NAC reconstruction. Figure 3 demonstrates a patient who underwent mastectomy followed by implant-based reconstruction.

Local flap techniques were used to reconstruct the left nipple, with subsequent areola tattooing. In unilateral reconstructions, the contralateral NAC serves as an essential reference for achieving symmetry in nipple position, size, and pigmentation.

Unilateral (right) nipple reconstruction and NAC tattoo after mastectomy and DIEP flap reconstruction. (A) Prior to right mastectomy. (B) After right DIEP flap. (C) After right nipple reconstruction. (D) After right NAC tattoo. DIEP, deep inferior epigastric perforator; NAC, nipple-areolar complex.

Nipple sharing

Nipple sharing is a reconstructive technique in which a portion of the contralateral nipple is harvested and transferred as a full-thickness composite graft to the reconstructed breast. The approach can achieve size, shape, color, and texture match, as well as projection. It is typically performed in patients undergoing unilateral breast reconstruction who have sufficient contralateral donor nipple tissue to contribute approximately 50% of its volume while maintaining an adequate residual projection and contour (⁷⁰). In this technique, the donor nipple is marked for harvest in the erect state. For nipples that are not overly projecting, the caudal half of the nipple can be harvested. Conversely, in nipples with sufficient projection, a coronal segment can be excised, preserving the base while reducing overall height. Then, the harvested graft is inset onto a pre-marked, de-epithelialized recipient site designed to match the contralateral areola size and position (⁷⁰).

This procedure can be combined with other stages of breast reconstruction. For example, Cha et al. described combining nipple sharing with immediate tattooing in a single session (⁷¹). Egozi et al. successfully split a single nipple-areola complex to reconstruct bilateral NACs on immediate DIEP flap reconstructions (⁷²). Furthermore, Schwartz et al. demonstrated the feasibility of nipple sharing in a single stage for patients undergoing central lumpectomy (⁷³).

Surgical NAC reconstruction complications

Surgical nipple reconstruction is generally safe but carries a distinct set of complications. The most frequent issue is progressive loss of nipple projection, particularly in local flap reconstructions, often occurring within the first few months postoperatively (⁷⁴). Projection loss remains the leading indication for revision and may be addressed with flap readvancement or reinforcement using autologous or alloplastic support (³³).

Other reported complications include partial or total necrosis, wound dehiscence, infection, and asymmetry (⁴¹). Necrosis or tissue loss is typically managed with local debridement for small defects, whereas complete nipple loss may require delayed reconstruction once adequate healing has occurred (⁷⁵). Infections are usually treated with wound care and oral antibiotics, though severe cases, particularly in implant-based reconstructions, may necessitate surgical debridement or implant removal (⁵,⁴¹,⁷⁵).

NAC tattooing

Who can perform NAC tattooing

NAC tattooing can be performed by a range of professionals. Following breast reconstruction, plastic surgeons and dermatologists may perform NAC tattooing in an office setting (⁷⁶). Although NAC tattooing is not commonly taught in plastic surgery residency, one single-center study found high patient satisfaction when residents performed the procedure, suggesting that residency training should include this skill (⁷⁷).

Through paramedical tattooing qualifications, certified medical or cosmetic tattoo artists can create anatomic impressions and use tattoos to cover scars and discolorations (⁷⁸).

Paramedical tattooing requires a state or city tattoo license, two years of permanent makeup or tattoo experience, and a paramedical tattoo certification. NAC tattooing can be performed in certified private studious or medical spas. Due to its growing popularity, there has been increasing involvement of nurses in performing NAC tattooing (⁷⁶). In addition, both in-person and online training courses are available for aestheticians, nurses, and medical professionals interested in learning or refining this skill.

Consent and expectation management

Informed consent should include a thorough discussion of the procedure, who will be performing it, expected postprocedural care and healing, potential complications, and future expectations (³⁷). Patients undergoing unilateral NAC tattooing should be counseled that the tattoo may not perfectly match the dynamic coloration and size of the contralateral nipple. Pigment used in tattoos will not respond to environmental changes such as tanning. Additionally, patient skin tone and ethnicity may predispose to pigment mismatch, discoloration, or abnormal scarring (²⁴,⁷¹).

Color fading is the most common aesthetic complication, and multiple sessions may be required to achieve the desired result (⁶⁸).

Tattoo techniques

Tattoo-only reconstruction is safe and highly effective for patients who prefer a non-invasive option, have undergone radiation, or have thin skin that contraindicates a flap-based reconstruction (⁷¹). This approach offers immediate benefits, especially for patients who have been undergoing a prolonged surgical journey. If opting for a tattoo-only technique, it can be performed as early as 2–3 months of the final surgical procedure to allow for scar maturation (³⁷,⁷¹). Importantly, performing tattoo-only does not offer true nipple projection in the profile.

Tattoo equipment

Key equipment needed for NAC tattooing includes an automated tattoo machine, sterile pigments, tattoo needles, and antiseptic agents for skin preparation. Depending on how much skin sensation was spared in the patient’s reconstruction, oral analgesics, topical or injected local anesthetics may be administered to improve comfort during the procedure (²⁴).

Two commonly used needle types include the bugpin needle and the round liner needle. The bugpin needle is ideal for shading and creating gradient effects, while the round liner needle is better suited for fine detail work. Optimal pigment deposition occurs just below the dermal-epidermal junction, and automated microneedle injectors allow for rapid, precise delivery of pigment into the superficial dermis. Mixing different pigments allows for custom undertones and highlights based on the patient’s skin tone and preferences (Figure 4) (³⁷).

Tattoo equipment for NAC tattooing. (A) Tattoo device with foot pedal. (B) Medical-grade pigments. (C) Gauze pads. (D) Sterile needs. (E) Isopropyl alcohol. NAC, nipple-areolar complex.

Markings

The “Nipple by Numbers” device is a layered stencil with circular cutouts that can be used to recreate dark and light areas, as well as the appearance of the Montgomery glands and Morgagni tubercles (⁷⁹). Tegaderm can be used to keep the stencil in place, but markings can also be free-handed if the surgeon or tattoo-expert feels comfortable. It is important to identify landmarks including the nipple-to-sternal notch, inframammary fold, and midline prior to beginning.

Despite existing benchmark metrics, the nipple and areola should be recreated according to the patient’s preferred size and location. Once the central position of the nipple is chosen, measure the diameter of the areola in a circumferential motion. For transgender male patients, mark the nipple lateral to the pectoralis muscle and use a transverse oval areola shape (³⁷).

Pigment selection and needle depth

Pigment selection is a challenging step that requires managing both technical considerations and patient preferences. In unilateral tattooing, color matching is based on the native nipple. However, achieving a true match long-term can be difficult.

The tattooed NAC appears darker during the initial healing phase and then lightens gradually (²⁴). To counteract pigment fading, a deeper or darker pigment may be initially selected. One study analyzed pigment fading patterns in NAC tattoo images based on red, blue, and green values and found that the initial tattoo pigment should differ by 34% in blue and 28% in green hues compared to the desired color to counteract pigment decay over time (⁸⁰).

In bilateral NAC tattooing, pigment selection is determined collaboratively between the provider and patient since no native NAC is present for reference. Preoperative photos of the patient’s nipples or the Munsell color chart, which categorizes colors by hue, value, and chroma, can aid in pigment selection (²⁴,³⁷).

If patients are uncertain about their preferred shade, selecting a lighter pigment can allow for darkening at later touch-up sessions. Figure 5 demonstrates a patient who underwent bilateral NAC reconstruction following mastectomy and autologous breast reconstruction. Local flap techniques were used to reconstruct both nipples, achieving symmetric projection, followed by bilateral areolar tattooing to ensure symmetry in shape and pigmentation.

Bilateral nipple reconstruction and NAC tattoo after mastectomy and DIEP flap reconstruction. (A) After bilateral DIEP flap. (B) After bilateral nipple reconstruction. (C) After bilateral NAC tattoo. DIEP, deep inferior epigastric perforator; NAC, nipple-areolar complex.

Optimal pigment depth for tattooing is the dermal layer at reported depths of approximately 0.5–1 mm. This depth, however, can vary depending on the quality of the skin in patients, especially those who have undergone radiation (²⁴,⁸¹). It is important to maintain the pigment within the dermal layer to avoid pigment migration and reduce fading (³⁷,⁶⁸). Maintaining a stable depth maximizes color uptake while minimizing adverse outcomes.

Areolar pigment base

Begin the tattoo at the inner areola using a midtone, lighter base pigment or a pigment matching the contralateral nipple. Importantly, do not make any sharp lines, as this will create unnatural markings. Move in a circular fashion toward the outer edge of the areola. While doing this, a “flick shading” maneuver can be used by placing the needle centrally and flick outward radially to deposit deeper pigment centrally and light pigment peripherally (³⁷). The pigment can be diluted in sterile water to reduce contrast and create a natural transition with surrounding skin (⁸²). Allow the pigment to fade toward the outer border of the areola for a more natural contour and appearance (²⁴). In some cases, a crackling pattern is added to the center of the areola to simulate natural skin texture (³⁷).

Recreating nipple projection using tattoo

Two main strategies have been proposed to recreate nipple projection using tattoos. The first is the traditional central projection approach (³²,³⁷,⁸²,⁸³). In this technique, the nipple is defined using a centrally placed darker pigment that gradually blends outward. An equal mix of the base pigment which most resembles the patient’s skin tone and a brown pigment is used to fill the nipple. Finer details can be performed with round liner needles using a “bouncing” technique to avoid creating harsh or unnatural lines (³⁷).

The second strategy is the inverse 3D illusion technique, popularized by Vinnie Myers. Instead of emphasizing a darker central pigmentation, this method creates a light central circle representing the nipple, surrounded by a darker outer ring. The inferior portion of the ring is thickened to produce a shadow effect and simulate projection. This technique is especially useful for correcting asymmetries, as adjustment to the outer ring can restore balance without additional surgery (²⁵).

Highlighting and shadowing are essential steps in creating optical depth and a realistic three-dimensional appearance of the nipple. Highlights are typically applied at the superolateral part of the nipple using white, beige, or yellow pigments, to mirror areas exposed to light (⁸²,⁸³). To recreate shadows, Ruffolo et al. recommends a midtone mixed with dark brown placed beneath the nipple (³⁷), while Sowa et al. proposes blending orange and blue pigments to create a soft brown shadow. Heavy shadowing should be avoided in patients with darker Fitzpatrick skin types, as it can create an unnatural, exaggerated appearance.

Montgomery gland tattoo

Recreating the Montgomery glands adds important anatomical detail and texture. Several techniques have been described. Ruffolo et al. recommend tattooing 5–8 randomly placed inferior half circles using shadow pigment (³⁷), followed by highlighting the superior part of each half circle to recreate glandular depth. Sowa et al. employ a bright “spot sign” technique, achieved either through pigment removal or the addition of white or cream-colored ink to simulate elevation. Lastly, Hammond et al. apply highlight pigment directly onto the areola to resemble tubercles (³²). Regardless of the method, it is important to avoid mirrored symmetry, even in unilateral reconstruction, as it will create an unnatural appearance of the glands (⁷¹).

Temporary areolar demarcation (TAD)

The TAD technique involves a partial-thickness incision around the planned areolar border. This incision is closed with a running chromic suture to create localized dermal inflammation. This technique may help define the areola and improve pigment blending after tattooing (⁸⁴).

Post-tattoo care

At the conclusion of the procedure, an occlusive dressing with a moisturizing, unscented ointment such as petrolatum is applied. Occlusion should be maintained for approximately one week, and patients should be advised to change dressings as needed. Good wound hygiene practices are advised such as gently cleansing with soap and water, patting dry without rubbing, avoiding contact with unwashed hands, and refraining from picking at any scabs. It is advised to avoid submerging the tattoo in water such as pools or baths, excessive sweating, tight clothing, and direct sunlight for up to 2 to 4 weeks post-tattoo (²⁴,⁸⁵).

NAC tattooing complications

NAC tattooing is an outpatient procedure with a low risk profile. Most patient concerns are aesthetic, including pigment fading, patchiness, or asymmetry, with many requiring repeat sessions (⁴¹). Immediately following NAC tattooing, a portion of the injected pigment is shed through the epidermis, while pigment that penetrates the dermis may migrate to regional lymph nodes. Within the first 24 hours, an inflammatory response may develop, characterized by erythema and edema. Migration of pigment to lymph nodes may cause tender lymphadenopathy. Patients should be counseled on this phenomenon, as pigment deposition in the lymph nodes can present with future diagnostic challenges in oncologic monitoring. Approximately one month after tattooing, re-epithelialization is complete and dermal granulation tissue stabilizes the pigment in the dermal macrophages (⁸⁵).

Minor and transient complications include localized erythema, edema, discomfort, and superficial infection (⁸⁵). Prior radiation and implant reconstruction have been found to be independent risk factors for infection, and prophylactic antibiotics may be considered on a case-by-case basis (³⁴). Other considerations may include pigment overload which has been linked to scarring or granulomatous reactions at the tattoo site (⁸⁶). With sterile technique, medical-grade pigments, and appropriate aftercare, serious adverse events are exceedingly rare (²⁶).

Rare complications include hypersensitivity reactions, granulomatous or lichenoid inflammation, and extremely uncommon case reports of malignancies arising within tattoos, though no causal link to cancer has been proven (⁸⁷). Allergic reactions are typically managed with corticosteroids, whereas persistent reactions may require laser removal or surgical excision of the tattoo (⁸⁵).

Conclusions

NAC reconstruction represents an important and highly meaningful stage in the reconstructive journey of patients who undergo mastectomy. Often considered the final and most rewarding step, NAC reconstruction carries both physical and psychological significance. Choosing the appropriate technique should not be the surgeon’s decision alone. Patient input and preference are key to achieving an optimal outcome. Patients with thin irradiated skin may benefit most from tattoo-only reconstruction or 3D dermal pigmentation, as local flaps are at higher risk of ischemia or implant exposure. In contrast, nipple reconstruction with soft tissue can accommodate flap based techniques providing projection. Flap-based reconstruction can be supported with ADM, bioabsorbable scaffolds or implant devices for nipple projection. For unilateral cases where the contralateral nipple has sufficient volume, nipple-sharing offers a natural match in color texture and projection.

Finally, individuals seeking minimal downtime or those who prefer to avoid additional surgery may opt for tattooing alone which has been shown to result in high satisfaction despite the absence of true nipple projection. Ultimately, NAC reconstruction provides not only restored form, but it is a powerful contribution to psychological recovery and overall quality of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Sarah N. Bishop) for the series “Aesthetic Breast Reconstruction” published in Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-522/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-522/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was obtained from the patients for publication of this study and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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