The surgeon has a direct role to play in advising on the timing of any NAC tattooing; usually the optimal time is 6–8 weeks after NAC reconstruction. It is essential that the newly formed NAC is fully healed before any attempt is made at tattooing it.

All non‐dissolvable skin sutures should have been removed at this stage. If any sutures remain they should be removed and tattooing rescheduled for one week's time. Caution should be exercised in those patients who are unhappy with the results of surgical nipple reconstruction, or indeed the breast reconstruction in general. These women should be referred back to the surgeon for further consultation. For younger patients with more advanced cancer, areolar tattooing can significantly enhance overall health‐related quality of life and help minimize sexual morbidity (Burke et al. [34]).

Photographic documentation is very important for the patient's records; all breast reconstruction patients will have signed consent for photography before surgery is undertaken (this is usually an integral section of the standard consent form). These photographic records will assist in choosing an appropriate colour of pigment for tattooing when patients have undergone bilateral mastectomy. Some patients benefit from seeing ‘before’ and ‘after’ photographs and this can be an essential component of patient education and information giving (Figures 27.43 and 27.44). Nonetheless, it should always be remembered that patients are individuals and each tattooed NAC is different.

Some have suggested that the manoeuvre of closing one eye and then judging the position of the nipples is useful for assessing balance. Matching the reconstructed NAC to the contralateral side can be challenging; the areola does not always have a completely circular outline and several adjustments may be necessary to achieve symmetry (Figure 27.45). Formal measurements are not always helpful when one breast is slightly higher or of smaller size than the other and indeed can be deceptive when there is any kind of ‘optical illusion’. Ultimately, the patient herself must be the final judge of the position, outline, contour and colour of the reconstructed nipple. The practitioner can advise patients, but they are accountable and more extreme requests should be dealt with by suitable compromise and always carefully documented. Tattooing will help to disguise surgical scars and detract the eye from focussing on these. The areola should never be coloured too dark or created too large as a reduction in circumference and tattoo lightening are both very difficult to achieve.

Patch testing is performed routinely in all patients with a history of allergy to ensure they will not have an allergic reaction to the pigment. This test should be carried out 3–4 weeks prior to the procedure and can conveniently be performed by a needle scratch to a mutually acceptable area (e.g. behind the ear). This area should be examined after a period of 24 hours.

A range of pigments are available from several companies. There are two base colours (light and dark) and it is best to keep things simple and not use too many different colours (Figure 27.46). Universal laws of colour state that blue is the darkest and the only ‘cool’ primary colour, red is medium and considered to be a ‘warm’ primary colour, and yellow is the lightest and represents a warm primary colour.

It is important to appreciate that black pigment can migrate or potentially turn blue; this can be avoided by mixing orange pigment with the black. Pigment colours generally change once they are implanted into the skin. Significant changes in shade can occur throughout the month‐long healing process.

The colour should be matched in a slightly lighter shade after discussion with the patient. It should be remembered that if a darker colour is selected, then subsequent lightening can be problematic and patients should be warned of this. Mixing flesh‐coloured pigments is difficult and can only be learnt through practice and experience. Often the colour of the areola is an excessively vivid shade of flesh and this should be avoided.

EMLA cream can be applied before tattooing to partially numb the skin, but topical cream should not be used when there is any history of lidocaine allergy.

Special consideration may be needed for those who are extremely anxious. Measures include ensuring that the patient has a family member or friend present and complementary therapies such as relaxation, massage and music.