01Purpose and principlesWhat the treatment does and how it fits into care.
The nipple and areola provide a visual reference point on the breast, and some people feel that reconstructing them helps complete their recovery. Others are satisfied with the reconstructed mound, prefer a tattoo without another operation, use a removable nipple or choose no further intervention. These are decisions about the individual's desired appearance and experience of their body, not a compulsory sequence after mastectomy. Clarify what the person means by wanting a nipple: a coloured circle, an illusion of a nipple in the mirror, a structure that projects through clothing, or a removable option each leads to a different discussion. The existing skin, scars, mound position and previous procedures help determine what can reasonably be offered.
Surgical nipple reconstruction commonly rearranges a small area of local skin into a projecting shape. Areolar colour may then be added by medical tattooing once the wound is suitable. Tattooing alone can use shading to suggest a three-dimensional nipple while leaving the surface physically flat. Neither approach recreates the original breast anatomy, and a satisfactory visual result should not be presented as restoration of its former function or sensation. Consent includes uncertainty about matching, healing, persistence of projection or colour and the possible need for further treatment. The reconstructive team should also be clear about which follow-up and later touch-up services are locally available, allowing the patient to judge the full course rather than the initial procedure alone.
Key points
- Nipple completion is optional. A local skin flap creates physical projection; tattoo shading creates the appearance of projection and colour without a projecting nipple, and a removable prosthesis is another option.
- Agree position, size and the intended result with the patient after the breast mound has healed and settled. Account for planned symmetry surgery and other treatment before making the final position permanent.
- After nipple surgery, new colour change, severe pain, marked swelling or redness needs surgical advice. After tattooing, spreading redness, persistent heat/swelling or fever needs clinical assessment.
- Projection can flatten and tattoo pigment can fade or look uneven. Explain possible repeat procedures without promising an exact match or restoration of a natural nipple's function.
- Surgical local infiltration and topical tattoo anaesthesia are different routes. For the selected plain lidocaine 1% product, use the smallest effective infiltration dose; the generally recommended adult ceiling is 200 mg, with patient-specific reduction.
- Protect the healing reconstruction from friction and pressure, follow the procedure-specific dressing plan, and review a colour change or wound problem before considering a cosmetic touch-up.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Ask how the patient wants the breast to look in a mirror, in clothing and during everyday activities. A local flap can provide a physical nipple bud but involves another wound, and the prominence may decrease over time. Shading with tattoo pigment can create a three-dimensional visual impression without projection through clothing. A prosthesis can be removed and may be attractive to someone avoiding another procedure, although application and adhesion can be inconvenient. Offer these choices in neutral language; choosing a flat tattoo or no completion procedure is a valid outcome rather than a lesser reconstruction.
Examine wound healing, scars, the intended nipple location and the stability of the breast contour. An open, inflamed or changing area is unsuitable for elective completion until its cause has been assessed and the tissue is ready. Ask whether further mound revision, contralateral symmetrisation or adjuvant treatment is planned, because these may alter position or the appropriate sequence. NHS services describe waiting for healing and settling, with local examples around several months. The clinical state and the agreed overall plan matter more than reaching a particular calendar date.
A technically centred nipple may not be the position that best matches the opposite breast or the patient's preference. Discuss the intended areolar diameter, colour and nipple prominence and assess the appearance in an appropriate upright position. The Christie describes using a circular marker before local anaesthetic, with the patient checking the position in a mirror and adjusting it with the surgeon. This is a useful practical way to identify disagreement before surgery changes the skin. Record the final agreed plan and remember that bilateral reconstruction offers choices about both sides rather than requiring imitation of a remaining nipple.
After a local flap, a darkening or unusually pale nipple, worsening pain, marked swelling or spreading redness should trigger surgical advice. Do not label a colour change as expected pigment behaviour when no tattoo has yet been done. Tattooing can cause a modest early local reaction and later pigment softening, but persistent heat or swelling, progressive redness or fever requires assessment for infection or another complication. Redness may be less visible in darker skin, making warmth, pain, swelling and the patient's report particularly useful. Clarify which team to contact and the route outside clinic hours.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Clinical assessment of skin and reconstructionFirst step - Why
- Examine the proposed site for a healed stable surface, local scarring and any unresolved wound problem. Review the reconstruction and treatment history to judge whether a flap or tattoo can be performed safely at that site.
- Interpretation and limitations
- Routine imaging does not answer a simple preference or marking question. A new unexplained lump, ulcer or inflammatory change needs its own assessment before an elective cosmetic procedure proceeds; it should not be hidden by a tattoo or dismissed as a scar.
- 02
Medication and local-anaesthetic assessment - Why
- Before surgical infiltration, review allergy, body weight, renal and hepatic function where relevant, cardiac disease, anticoagulants and any other local anaesthetic already given. Identify the exact product, concentration and route.
- Interpretation and limitations
- Plain 1% lidocaine contains 10 mg/ml. A volume calculation is only one part of safe use: cumulative exposure, patient-specific dose reduction and inadvertent intravascular injection also matter. A topical product used for tattoo comfort requires its own instructions rather than the injectable product's dose.
- 03
Pigment and allergy history - Why
- Discuss previous tattoo or pigment reactions, skin sensitivity and the proposed pigments with the trained medical tattoo service. Where an allergy history raises concern, that service may arrange a product-specific patch test.
- Interpretation and limitations
- Guy's and St Thomas' describes selective patch testing before treatment rather than treating a patch result as proof that no later reaction is possible. A new reaction needs reassessment. Do not confuse symptoms of infection with a pigment allergy without examining the area.
- 04
Documented position and outcome review - Why
- Use agreed markings and, with permission, photographs to document the starting contour and intended result. At follow-up compare the healed nipple projection, position and colour with what the patient wanted.
- Interpretation and limitations
- This supports a concrete conversation about benefit, residual asymmetry and possible touch-up. Assess only once the relevant healing has occurred; immediate swelling or fresh pigment intensity is not the settled result, and a new wound complication takes priority over judging colour.
04Treatment approachPreparation, options, escalation and aftercare.
01Worked caseA healed mound and a chosen projecting nippleFirst stepA woman has a healed, stable unilateral flap reconstruction and wants physical nipple projection. She has no planned mound revision and understands that surgery will not recreate the original nipple.+
- 1The surgeon examines the skin, discusses flap surgery, tattoo alone, a prosthesis and no further intervention, and confirms her preference for a projecting local flap. She and the surgeon agree the position using an upright mirror check and a circular marker before the anaesthetic is given.
- 2After product, allergy and patient checks, the surgeon administers 5 ml (50 mg) of plain 1% lidocaine by local infiltration and confirms adequate anaesthesia before completing the planned skin flap. The total dose is recorded and remains below the weight-based calculation and the generally recommended 200 mg adult ceiling; the ceiling is not a target dose.
- 3At the early wound review the nipple has a healthy colour, the incision is closed and there is no spreading inflammation. She can see physical projection and is pleased with its position. The clinician documents this observed result and explains that some flattening may still develop.
- 4She receives a plan to protect the area and a named route for urgent advice if colour, pain or swelling changes. Once the tissue has healed sufficiently, the team will discuss areolar tattooing; pigment is not placed into an unhealed operative wound to accelerate completion.
02Clinical caseColour and shading without another flapAfter bilateral reconstruction, a patient wants a nipple-like appearance in the mirror but prefers to avoid another operation and does not want projection through clothing.+
- 1The clinician explains the distinction between a flap and a shaded medical tattoo, and also discusses removable prostheses and leaving the mound unchanged. The patient chooses tattooing alone after reviewing the expected flat surface, colour choices and the possibility of fading.
- 2The tattoo practitioner checks the healed skin, discusses pigment reactions and sensation, and agrees the outline and colour with the patient before treatment. The procedure is completed with appropriate comfort measures and a procedure-specific dressing and aftercare explanation.
- 3At the service's follow-up the skin has healed and the patient is satisfied with the three-dimensional visual impression despite having no physical nipple projection. A lighter area of pigment is identified and she elects a touch-up after discussion. The result meets her stated aim rather than a surgeon's assumption that a projecting nipple was necessary.
03Clinical caseA postoperative colour change interrupts completionSeveral days after nipple-flap surgery, a patient notices increasing pain and a darker area at the nipple tip. She had been waiting for advice about future tattooing.+
- 1She contacts the surgical service promptly and is assessed for tissue perfusion, pressure from the dressing, wound separation and infection. The team treats this as a possible flap-healing complication rather than arranging routine cosmetic follow-up or advising that the colour will simply fade.
- 2Examination identifies a small compromised tip and an overlying pressure point. The surgeon relieves the pressure, sets a wound-care plan and arranges close reassessment. The decision about whether any non-viable tissue needs removal follows the tissue findings; tattooing is deferred while the wound is unresolved.
- 3The remaining flap stays viable and the small tip wound subsequently heals with reduced projection. The patient is told what happened and offered a later choice between accepting that result, revision or tattoo-based completion after healing. The case records partial tissue compromise and its outcome rather than claiming that prompt contact guarantees complete salvage.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Aguettant lidocaine 1% (10 mg/ml), plain injection — surgical local infiltration
Use the smallest effective dose as local infiltration for the single procedure, in incremental amounts with checks against intravascular injection. The selected SmPC describes usual adult total dosing of 3–5 mg/kg with a generally recommended maximum of 200 mg (20 ml of 1% solution); apply the patient-specific lower limit and count all other local-anaesthetic exposure. Do not administer the calculated ceiling simply because it is available.Avoid amide local-anaesthetic hypersensitivity. Reduce for frailty and relevant cardiac/hepatic disease; the SmPC permits reduction up to half in cardiac/hepatic insufficiency and requires renal adjustment. Take particular care with conduction disease, reduced cardiovascular function, epilepsy and anticoagulation. Infected tissue can reduce effect and increase systemic absorption, so resolve infection before elective reconstruction. Inadvertent intravascular injection or excess dosing can cause acute neurological and cardiac toxicity: stop injection and activate the local-anaesthetic emergency response if suspected.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- After surgery, check the colour and viability of the nipple flap, pain, bleeding and the pressure exerted by the dressing. Give a specific contact route for deterioration. Do not wait for a tattoo appointment to assess a new surgical wound problem.
- At the wound visit, document closure and any area of tissue loss or separation. Discuss the likely effect on projection honestly and delay further elective surface treatment until the operative site is suitable.
- After tattooing, assess persistent or worsening inflammation, pigment reaction and healing. Explain that pigment often softens or fades during recovery, but spreading redness, fever or ongoing heat and swelling requires clinical review.
- Review the settled result against the patient's original aims: physical projection, visual appearance, colour or avoidance of further surgery. Discuss uneven pigment, flattening and possible repeat treatment without treating a touch-up as compulsory or promising permanence.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
A visible finish is optional
Some patients find nipple completion meaningful; others do not want any more procedures. Good counselling makes room for either choice and allows a person to reconsider without implying that recovery is unfinished.
Mark before changing the field
Anaesthetic infiltration and positioning for surgery can alter the appearance of the breast surface. Agreeing the site while the patient can judge it in a mirror prevents an avoidable mismatch of expectations.
Protect projection during healing
A newly constructed nipple can be vulnerable to pressure and friction. The dressing and clothing plan should protect the tissue while still allowing appropriate assessment of colour and wound condition.
Matching has several components
Position, diameter, pigment, projection and the changing shape of the mound each contribute to the perceived match. Improvement in one feature does not guarantee that the two sides will appear identical.
08Common pitfallsFrequent interpretation and management errors.
- 01
Calling a shaded tattoo a projecting nipple without checking whether the patient actually wants prominence through clothing.
- 02
Performing an elective completion procedure on an unhealed or unexplained abnormal area, or agreeing a permanent position before planned mound or symmetry changes are considered.
- 03
Using the local-infiltration dose of an injectable anaesthetic as if it were the instructions for a topical tattoo product, or mistaking an adult maximum for the dose to give routinely.
- 04
Attributing a painful darkening flap to ordinary tattoo pigment change, or offering a cosmetic touch-up before an unresolved wound problem has been assessed.