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Principles of care

Asepsis

The procedure should be performed in an aseptic manner with meticulous hand washing to reduce any risk of infection. Any equipment that may cause a needlestick injury must be safely disposed of. Local anaesthetic procedure policies should be followed.

Techniques for implantation of pigment

The pointillist technique is a method for application of a series of dots of colour but can produce an unnatural effect. Circular movements around the nipple projection are the most effective, but backward and forward strokes can be employed. Feathering around the edge of the areola gives a natural finish.

Factors determining pigment acceptance

Several factors influence how well the skin accepts pigmentation:

One of the most important factors is the speed of the technician – the faster and more direct the pigment implantation, the better is the acceptance. With increasing experience, the right touch is developed.
Another factor determining pigment acceptance is the innate condition of the skin. Oily skin is associated with a thicker dermis, which results in pigment penetrating deeper than for a person with a relatively thin dermis. The dermis becomes thinner with increasing age, which allows the pigment to penetrate more readily.
Darker pigment colours take more rapidly and persist for longer periods than lighter colours; the former have a higher iron oxide content, which increases the density of the pigment.
Diabetes and certain other medical conditions can increase the chance of pigment rejection.
Impaired acceptance of the pigment may be observed in patients who have received radiotherapy to the breast (Aslam et al. [11]).
When performing the tattooing process, the technician should work with the pen positioned at an angle of 45% to minimize pigment migration.

Anticipated patient outcomes

Patients want to know what the tattooed nipple will look like and it is important that they have realistic expectations. A further area of concern is whether the procedure is painful; patients should be reassured that most reconstructed breasts are insensate. Another key question that is asked by many patients is ‘What will my partner think?’. Most women, post mastectomy, do not undress in front of their partner but may feel that nipple reconstruction and tattooing provides the opportunity to show their ‘new body’ to their partner. Some women will no longer have any form of sexual relationship with their partner and the simple procedure of tattooing can evoke profound emotional feelings (Allen [5]). The nurse‐led tattooing service can therefore be very special for these women.