Nipple reconstruction and tattooing

Synopsis

Explain the distinct aims of nipple surgery and medical tattooing, select an appropriate optional procedure and recognise problems during healing.

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.

Key red flags

Healing problems have a clinical meaning

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.

Investigation priorities

Clinical assessment of skin and reconstructionFirst step

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.

Management branches

Worked caseA healed mound and a chosen projecting nipple

A 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.

The 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.
After 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.

Key medicines

Aguettant lidocaine 1% (10 mg/ml), plain injection — surgical local infiltrationUse 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.

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