Nipple tattoos, the finishing touch on breast reconstruction after cancer
On the last day of Breast Cancer Awareness Month, we wanted to share news of how tattoos are helping women look and feel most natural after breast reconstruction. Medical tattoo expert Mandy Sauler of Captivating Cosmetics is the pioneer of this 3D nipple tattoo procedure as featured in the Philadelphia Inquirer.
Some call it the "icing on the cake." Others deem it the "illusion of a protrusion." 
But for Patricia Missiras, 57, of Brookhaven, having 3-D areolas and nipples tattooed to her reconstructed breasts goes much deeper. It's part of her quest to put her bilateral mastectomy, chemo, and radiation firmly in the rear-view mirror. "I want to look as normal as I did before," she says. "I know it's not going to look exactly the same, but I want to get back to where I was before all of this happened." Missiras, a technical trainer at a Wilmington law firm, is at the end of an almost two-year journey in her treatment for breast cancer. She was first diagnosed in December 2011, when a large tumor was found in her left breast during a regular mammogram. After that, a small tumor turned up in her right breast. About 290,000 women will get breast cancer this year in the United States, according to the American Cancer Society. There are about 2.8 million breast cancer survivors in the U.S. "It was like getting hit by a Mack truck," Missiras says of her diagnosis. "But it emphasized the importance of mammograms; mine saved my life." (Experts say the test also produces a lot of false positives and unnecessary worry for many women.) On this night, at her doctor's suggestion, and accompanied by her sister Kristine Specht, 49, Missiras had come to Exton, to have her reconstructed breasts tattooed by Mandy Sauler of Captivating Cosmetics. Sauler, 31, of West Chester, who began tattooing in her mother's Downingtown tattoo shop at 14, has become one of the region's go-to tattoo artists for medical micropigmentation, which she calls using "art to heal." 
"Growing up in a tattoo parlor, my friends were often not allowed to visit. With medical tattooing, I've managed to turn that around and use tattoos to really help people." These days, those who call on Sauler's skills include plastic surgeons and dermatologists. She works for such groups as the Hospital of the University of Pennsylvania, Whitney Center for Permanent Cosmetics in New York, and Paoli Hospital. Her services include 3-D nipples, areola enhancement, and eyebrow replacements to fill in spots made sparse by chemotherapy treatments. The 3-D nipple procedure costs about $700, usually covered by insurance. "Mandy is that wonderful combination of a health care professional and artist, whose skill makes a profound difference in the lives of our breast cancer patients," says Joseph M. Serletti, chief of the Division of Plastic Surgery at the Penn medical school and head of HUP's breast reconstruction team. "For many patients, it is the nipple reconstruction and Mandy's skill that makes an important difference in how they view and accept their reconstruction." All the procedures can be remarkably lifelike. "For people with particularly translucent skin," she says, "I've even added veins." While Missiras undresses, Sauler points out a before picture of a botched job of nipple tattooing done in a doctor's office. Heavy black lines outline the areola, creating anything but a natural appearance. Sauler explains that by using shading and colors specifically designed for the individual, she managed to "fix" the job, creating a natural-looking nipple. "Another advantage of a properly done 3-D nipple is how it becomes a focal point on the breast that draws attention away from any scars," says Sauler. In the procedure room, Sauler starts by measuring a nipple size comfortable for Missiras. She notes that reconstructed breasts can often be a different size and shape from the originals, and nipple size needs to be proportionate to those changes. Once the size has been traced onto Missiras' breasts, it's time for color. With her finger she applies a beige/brown mix to the skin of Missiras' chest to check the shade. "A little pinker," Missiras decides. Sauler agrees and mixes the organic dyes until the two concur on the most natural color. 
"It's best to see the color on the skin to decide whether it complements it," says Sauler. It's good if a patient recalls the shade of her original nipple, but to realize that after surgery and reconstruction, "everything's different." Once the color is settled, Sauler tells Missiras that the initial tattoo will be darker and redder when a patient leaves the office, saying it takes about a week to see what the color will really look like. The tattoo should hold its color and not fade, unless subjected to sun. "I'm not planning to do any naked sunbathing," Missiras says. Sauler smiles. "I actually had a patient who was in a nudist community who thought it was going to be a problem for her. I told her not to forget to apply the sunscreen." By now, Missiras seems more relaxed. She settles into a cushioned bed while Sauler - in blue latex gloves and blinding white lab coat that makes her appear more lab tech than "tat artist" - arranges her prepackaged and presterilized needles. On her smartphone she bumps up country music, Missiras' pick, and switches on the power. Using a hand-held tattoo machine, she begins to work. A buzz reminiscent of a dentist's drill fills the air. Head down, Sauler works quickly and confidently, pausing only to swipe away blood that rises to the surface with the prick of the needle. Since reconstructive breasts don't have complete sensation, Missiras experiences only slight discomfort, but Sauler swabs on some local anesthesia cream to dull any sensation as she dips through the three layers of dermis. Slowly, the outlines of a nipple and areola emerge. "So this is going to scab over for about three to five days," she tells Missiras. "Then from Day 5 to 7 it will appear the lightest as skin heals over the wound. Then the pigment will emerge in a week and a half." Generally the procedure takes one visit, although a touchup, if needed, can happen in about four weeks. After about an hour into the procedure, Sauler steps back and sets down her needle. "Let's take a look," she says. Missiras sits up and takes a mirror from Sauler's hand. She draws in a deep breath, then takes a glance at her reflection. "Wow!" she says. Her eyes widen and fill with tears. "Oh my gosh." She looks at her sister and says, "Done."
But for Patricia Missiras, 57, of Brookhaven, having 3-D areolas and nipples tattooed to her reconstructed breasts goes much deeper. It's part of her quest to put her bilateral mastectomy, chemo, and radiation firmly in the rear-view mirror. "I want to look as normal as I did before," she says. "I know it's not going to look exactly the same, but I want to get back to where I was before all of this happened." Missiras, a technical trainer at a Wilmington law firm, is at the end of an almost two-year journey in her treatment for breast cancer. She was first diagnosed in December 2011, when a large tumor was found in her left breast during a regular mammogram. After that, a small tumor turned up in her right breast. About 290,000 women will get breast cancer this year in the United States, according to the American Cancer Society. There are about 2.8 million breast cancer survivors in the U.S. "It was like getting hit by a Mack truck," Missiras says of her diagnosis. "But it emphasized the importance of mammograms; mine saved my life." (Experts say the test also produces a lot of false positives and unnecessary worry for many women.) On this night, at her doctor's suggestion, and accompanied by her sister Kristine Specht, 49, Missiras had come to Exton, to have her reconstructed breasts tattooed by Mandy Sauler of Captivating Cosmetics. Sauler, 31, of West Chester, who began tattooing in her mother's Downingtown tattoo shop at 14, has become one of the region's go-to tattoo artists for medical micropigmentation, which she calls using "art to heal." "Growing up in a tattoo parlor, my friends were often not allowed to visit. With medical tattooing, I've managed to turn that around and use tattoos to really help people." These days, those who call on Sauler's skills include plastic surgeons and dermatologists. She works for such groups as the Hospital of the University of Pennsylvania, Whitney Center for Permanent Cosmetics in New York, and Paoli Hospital. Her services include 3-D nipples, areola enhancement, and eyebrow replacements to fill in spots made sparse by chemotherapy treatments. The 3-D nipple procedure costs about $700, usually covered by insurance. "Mandy is that wonderful combination of a health care professional and artist, whose skill makes a profound difference in the lives of our breast cancer patients," says Joseph M. Serletti, chief of the Division of Plastic Surgery at the Penn medical school and head of HUP's breast reconstruction team. "For many patients, it is the nipple reconstruction and Mandy's skill that makes an important difference in how they view and accept their reconstruction." All the procedures can be remarkably lifelike. "For people with particularly translucent skin," she says, "I've even added veins." While Missiras undresses, Sauler points out a before picture of a botched job of nipple tattooing done in a doctor's office. Heavy black lines outline the areola, creating anything but a natural appearance. Sauler explains that by using shading and colors specifically designed for the individual, she managed to "fix" the job, creating a natural-looking nipple. "Another advantage of a properly done 3-D nipple is how it becomes a focal point on the breast that draws attention away from any scars," says Sauler. In the procedure room, Sauler starts by measuring a nipple size comfortable for Missiras. She notes that reconstructed breasts can often be a different size and shape from the originals, and nipple size needs to be proportionate to those changes. Once the size has been traced onto Missiras' breasts, it's time for color. With her finger she applies a beige/brown mix to the skin of Missiras' chest to check the shade. "A little pinker," Missiras decides. Sauler agrees and mixes the organic dyes until the two concur on the most natural color. "It's best to see the color on the skin to decide whether it complements it," says Sauler. It's good if a patient recalls the shade of her original nipple, but to realize that after surgery and reconstruction, "everything's different." Once the color is settled, Sauler tells Missiras that the initial tattoo will be darker and redder when a patient leaves the office, saying it takes about a week to see what the color will really look like. The tattoo should hold its color and not fade, unless subjected to sun. "I'm not planning to do any naked sunbathing," Missiras says. Sauler smiles. "I actually had a patient who was in a nudist community who thought it was going to be a problem for her. I told her not to forget to apply the sunscreen." By now, Missiras seems more relaxed. She settles into a cushioned bed while Sauler - in blue latex gloves and blinding white lab coat that makes her appear more lab tech than "tat artist" - arranges her prepackaged and presterilized needles. On her smartphone she bumps up country music, Missiras' pick, and switches on the power. Using a hand-held tattoo machine, she begins to work. A buzz reminiscent of a dentist's drill fills the air. Head down, Sauler works quickly and confidently, pausing only to swipe away blood that rises to the surface with the prick of the needle. Since reconstructive breasts don't have complete sensation, Missiras experiences only slight discomfort, but Sauler swabs on some local anesthesia cream to dull any sensation as she dips through the three layers of dermis. Slowly, the outlines of a nipple and areola emerge. "So this is going to scab over for about three to five days," she tells Missiras. "Then from Day 5 to 7 it will appear the lightest as skin heals over the wound. Then the pigment will emerge in a week and a half." Generally the procedure takes one visit, although a touchup, if needed, can happen in about four weeks. After about an hour into the procedure, Sauler steps back and sets down her needle. "Let's take a look," she says. Missiras sits up and takes a mirror from Sauler's hand. She draws in a deep breath, then takes a glance at her reflection. "Wow!" she says. Her eyes widen and fill with tears. "Oh my gosh." She looks at her sister and says, "Done."
