Dr. Allen Rosen

(WOMENSENEWS)–Alexandra Nolan has finally beaten breast cancer.

"This disease has haunted me since my mother died of it when I was 20," said Nolan, 52, of Montclair, N.J. "Despite getting early mammograms and taking the drug tamoxifen to ward off breast cancer, I developed it myself at age 50 and opted to have a prophylactic double mastectomy. But only since I’ve had my breasts and nipples reconstructed have I felt like I’ve finally put this disease in my rearview mirror."

One in eight American women develops breast cancer, which strikes 192,370 and kills 40,170 women each year, reports the Atlanta-based American Cancer Society. A total of 79,458 breast reconstruction surgeries are performed annually, according to the Arlington Heights, Ill.-based American Society of Plastic Surgeons.

Developed in the 1950s and popularized in the 1960s, breast reconstruction after mastectomy has seen dramatic changes and improvements over the decades.

Since the 1980s, fabricated nipples have been a routine part of reconstruction. New techniques developed within the last five to 10 years make them nearly as realistic-looking as a woman’s original nipples.

"For me, the end result looks like nothing ever happened," said Nolan. "My breasts and nipples look completely natural, which makes me feel like I’m healed and whole again."

Procedures With Positive Impact

Total breast reconstruction can lessen the trauma of surgery and the feeling some cancer survivors have of being "less of a woman" after mastectomy. The procedure has a "positive impact on well-being and body image," according to a 2007 study in the medical journal Breast.

One technique is the use of extra body tissue to craft a separate nipple mound–a procedure that the American Society of Plastic Surgeons covers in its learning seminars.

A second is tattooing "Montgomery’s tubercles," little bumps that ring the natural areola and that are recreated with stippled ink over a lighter, tattooed areola. This second technique is covered in seminars offered by both the American Society of Plastic Surgeons and the Society of Permanent Cosmetic Professionals, in Des Plaines, Ill.

Performed after a double or single mastectomy removes cancerous tissue, breast reconstruction typically consists of three phases. "First, the breast mound is rebuilt," said Susan Brown, director of health education for the Dallas-based Susan G. Komen for the Cure. "Second, the nipple-areola complex is formed. Then the final step is nipple tattooing."

During mound rebuilding, a surgeon reconstructs the breast using implants (made of silicone or saline) and/or flap surgery (which constructs a new breast with extra skin, fat and muscle taken from the abdomen, back or buttocks). However, the use of silicone implants for reconstruction and augmentation remains controversial. Though they have been used for reconstruction for four decades, the Silver Spring, Md.-based Food and Drug Administration banned silicone implants for breast augmentation in 1992, citing safety concerns. The ban was lifted in 2006, after manufacturers made implants more leakproof and studies showed silicone implants did not cause connective tissue disease, cancer or immune disorders.

During nipple reconstruction, the surgeon uses more extra tissue to craft a flap of skin that has a different texture from that of the rest of the breast. "You make a star pattern with the flap, then rotate it around," said Dr. Allen Rosen of Montclair, N.J. "This twisted area–a kind of nipple origami–is ideally the only place on the breast where there is visible scarring."

Tattoos Cover Scarring

During the tattooing phase, which can camouflage scarring and occurs three to six months after surgery, the areola (the darker area surrounding the nipple) is tattooed with "micro-pigmentation" that doesn’t penetrate as deeply as normal tattooing.

Using electric needles that pulsate 150 times per second, the tattooer (a surgeon, nurse, aesthetician or independent tattoo artist) carefully mixes dye to match the pink, brown or coral of the woman’s lips, remaining nipple or pre-operative nipples as seen in photographs.

Before the hour-long coloring phase begins, the tattooer will often map out the nipple on a woman’s breast so she can refine its shape, color and size.

"You have to be very careful to get nipple tattooing right," said Barbara Shimoda, a registered nurse and aesthetic specialist who offers the procedure at Timeless Image Aesthetics in New York City. "When there is a lot of scar tissue, the skin may reject the ink, so you often have to break down scar tissue with a laser or microdermabrasion."

To make nipple coloring as realistic as possible, many women opt to have multiple tattooing sessions. Shimoda recommends a total of four sessions, with touch-ups done as the color fades over time.

Costs of Reconstruction

Insurers that cover mastectomy as treatment for breast cancer typically cover the three phases of breast reconstruction, which run $5,000 to $9,000 for mound rebuilding, $1,500 to $1,800 for nipple reconstruction and $300 to $500 for nipple tattooing.

Though breast reconstruction usually follows these three phases, there are exceptions. In rare cases, the nipple from the original breast can be reattached if that tissue is definitely cancer-free (though, like fabricated nipples, these nipples will not be as sensitive as the ones before surgery).

However, just as many women feel perfectly comfortable without breasts after mastectomy, and many women are satisfied with the results of partial and not total reconstruction.

"Though I originally had planned to go without breasts after my double mastectomy, seeing myself in the mirror and shower felt devastating," said Linda Pelosi, 43, of Roseland, N.J. "I had the breast mounds done and the nipples reconstructed. But emotionally, I don’t feel that I need tattooing, too. I’ve had enough medical procedures during my battle with breast cancer. And having reconstructed breasts without tattoos–which only my husband and I ever see–is enough to make me feel like I’ve conquered this disease."

Molly M. Ginty is a freelance writer based in New York City.