A healthy self-image can be an important part of breast cancer recovery. Lori Stofman, licensed aesthetician with UPMC, discusses the process and art of 3D nipple tattooing to help patients feel their best.

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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– A healthy self-image can be an important part of breast cancer recovery, and 3D nipple tattooing is making a real difference in many patients’ lives. Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Lori Stofman. She’s a licensed esthetician with UPMC and the University of Pittsburgh’s Department of Plastic Surgery. Thank you so much for joining us.

– Thank you for having me.

– This is really an important topic for so many people. And, really, when you’re facing a breast cancer journey and you finally get to this point, what do you think this means for patients to be able to have the option for 3D nipple tattooing?

– Well, I mean, I think there’s several reasons, right? The majority of the women that I see have gone through minimum two surgeries, some eight surgeries – depending on infection, or rupturing, or irradiated breasts, or various complications. And, so, not only do they have the scar from the surgery, not only are they nervous about the cancer, and also, home life has been affected as well, but it’s a completion. It’s a completion of what they’ve gone through. The thing that I hear the most is getting out of the shower, they want normalcy. They want to see themselves like they used to be. And, so, I think it helps with that self-esteem. I had a woman today that I did, and when I just showed her immediately after, she broke out in tears because she had been three years without. And, so, I think that is what it is about. It’s the completion of their journey, their journey that hasn’t been pleasant for the most part. And, so, to put something in the past. They are survivors. And, it leads them to more of a positive future.

– And, so, let’s talk now about really what’s involved in the process. So, there’s micropigmentation, but that’s like tattoo makeup, right? Let’s tell folks what that is first.

– So, micro meaning superficial. So, it’s a superficial tattoo. It’s only in the epidermis or the top layer of the skin. So, eventually that will fade out, which is good if you want eyeliner, eyebrows, or your lips done. If you want it done at 40, probably at 50, it won’t be there anymore. So, you can change the color out, right? So, that’s a nice part of that. But, you don’t want to do that on the nipple areola because again, that will fade out. And, they’ve gone through enough. You don’t want to do it again. So, in that sense, then, that’s more of a standard tattoo. It’s deeper, and it’s lifelong. And that’s what you want.

– And this is really a skill and an art. There’s so much talent involved here. You’ve trained to do this for quite some time.

– Yeah, 27 years.

– Twenty-seven years?

– Yes. Started out with standard tattooing because the whole process of reconstruction was different. And, actually, I was brought into Mercy for burn and trauma. And, so, my first patient was a trauma, a domestic violence case. Her husband had poured a bucket of acid on her. And, so, when she came to me, she had lost one eye, she had lost her hearing, she had lost her hair. And, so, being my training, I taught her how to manipulate her tissue so it didn’t break down so rapidly. Camouflage makeup, glamour makeup, put a prosthetic eye, hair, a wig. And, she said, “Lori, I feel better, but I can’t do this myself.” Now, keep in mind, she was a model prior to this episode. And, I’m like, “Well, why can’t you?” And, she said, “I can’t see. I only have one eye to put my makeup on.” And, I’m like, “You’re right.” So, she goes, “You need to learn how to tattoo.” And I’m like, “No, that’s not going to happen.” And, so, she went to the head of the hospital. And the next thing I know, I have a ticket to go to New York for medical-grade tattooing and then another ticket for advanced medical-grade tattooing in Austin, Texas. And that’s how this started.

– Wow. And, so, over the years, as techniques have developed, when did 3D nipple tattooing really start to come about?

– I would say about six, seven years ago. Before, they used to graft the nipple areola from various sites on the body. And, a lot of times, sometimes the graft didn’t take. And it was another surgery that a lot of women didn’t want to go through a lot, right? Because they’ve already had so many surgeries. And, then, doctors started to tie off the nipple. And all we had to do was color it in, just as we had to just color in when they graft it. We’d just color the nipple when they tied it off and then just created the areola. But, that’s difficult in a lot of times. One, sometimes that nipple that is tied off retracts. And, so, it’s not there where it used to be. And it’s also hard sometimes to get it exactly where it needs to be. And, so, sometimes it’s off a little bit. So, when doctors just reconstruct the breast and they don’t do anything for the nipple areola, if the breasts are uneven, I can fudge it. It may not be exactly in the center of the breast, but no one’s going to see that because your eyes focus on the pigment. And, so, if I put them where the symmetry is, then they look symmetrical and no one notices.

– And, we say 3D because it really does look 3D.

– Yeah, there’s shading and highlighting to make it look that way.

– And, so, tell me about the process, beginning with when is a good time for someone to do this?

– I say three to four months after your final surgery. And, of course, always with the physicians agreeing to that.

– Most times the physicians will refer to me. That’s how the patients find me. So, the doctors will refer to me. And, at that time, I always ask, when was your last surgery? And if the suture lines look still irritated, I hold off. We’re like, “Let’s give it another month. Let’s make sure that everything is good.” So, it’s about three to four months.

– Is it painful? Talk about the process in terms of, are there numbing agents? Is it all done in one session? Or is it one of these things where someone comes back and comes back?

– I always do a test site. And, so, sometimes people don’t understand that if they’re covered with tattoos. They’re like, “I have tattoos anyway.” I’m like, “Yeah, but you don’t have mine.” And, so, I want to make sure that everything’s as safe as it possibly can be. So, they come in. And, I think it’s a good meet and greet as well. They’re nervous from everything else they’ve been through. So, it’s a way to meet me, to understand where I’m coming from, for me to meet them so I can see where they’re coming from, what their expectations are, what my expectations are, to make sure we’re both on the same wavelength. And, if their expectations are they want their old breasts back, it’s not going to happen. And I have to take the time to really explain it. But then we do a scratch test in the scalp. And I make them wait two weeks to see if there’s a reaction. I’ve never had one, but there’s been documented cases. So, we make them wait two weeks, schedule at the time of the appointment. And, then, I will see them. At the time of the appointment, we draw on them first. Alcohol the area off, of course, draw on them first. And I always tell them, “We’re a team from this point on. Your opinion counts very much to me. It’s your body. I’m here to work with you.” So, after we draw on, I have them stand up, look in the mirror, check for symmetry, the size, and the location to see, you know, because they’re all different breasts. And, they have, like, some of them will bring a picture in. “This is what my breasts looked like before.” So, it gives me an idea. And, I also tell them, you know, lookit, we’re tattooing. So, I can get in that range. But it’s not going to be, it’s not like coloring. I can’t get the exact color that you had before. But we’ll get in that range. Once we agree on the color, and the location, and the size, then what I do is I always test to see. If they say, “Oh, I don’t feel anything,” I always test. And, so, I kind of prick them with an 18-gauge needle just to see. I will tell you, for majority of the women that I see, even though they don’t feel anything, they want anesthetized, which is done with a local. And, again, I think – even if they’re covered with tattoos. And, I think it’s a psychological thing. They’ve had so much trauma with their breasts and so much discomfort that they don’t want anymore. They’re done with it. And, so, we always anesthetize, for the most part. Every once in a while, I’ll have someone who says, “No, I really don’t want one. And I don’t feel anything.” I’m like, “All right, that’s cool.” I like to anesthetize because the epinephrine that I use in there also hinders the bleeding. So that when I tattoo, I’m not fighting so much with the body as it’s trying to flush out what I’m putting in. So, it allows me to put a lot more pigment in a lot quicker. It’s about two and a half hours. So, I tell women, “Come comfy, eat, watch the fluid intake because I don’t want you to have to go to the bathroom in between because everything’s sterile.” But, we’ll do it in about two and a half hours. We’ll complete.

– I can tell you’re so passionate about it.

– I am. I think it’s meeting them in the first place and setting their fears at ease because some of them feel like, or at least appear like I could pry them off the ceiling because they’re so nervous. But, then, I get them laughing and tell them stories. Or, if they bring a significant other with them, we include that person. Or, we play different genres on my computer so they can listen to different music. I think music is a big part of relaxation. So, I tell them either you can listen to my music, or you can bring a headset, or you can bring an iPod, you know, listen to podcasts on your headset. You can zone out. Fifty percent of women sleep because they’re not feeling anything. And, then, I just wake them up and say, “You’re done.”

– And what do they say to you when they’re finished?

– I think that’s the most rewarding thing. Like the patient I did today. You know, they’re amazed, right? Because they don’t know what to expect. They don’t see what I’m doing, right? We talk through the whole thing, and we joke around while I’m working. And, so, I always tell them, “All right, I’m going to stand you up so you can see before I bandage you,” knowing it’s not the color that it’s going to be because we’ve already discussed that. And, I think they’re just amazed, and they’re shocked, and they cry, and we hug. And that’s what it’s about. That’s what I, you know, I always say, “I’m the cherry on the ice cream sundae. I’m done. When you’re done with me, you are done with the whole thing. You know, you have survived it, and you can put it in the past.” So, that’s the best part.

– What is the aftercare like?

– So, for 10 to 14 days, I always tell them, it’s my “don’t” list. You know, don’t swim, don’t get them wet. I do it much differently than tattoos are regularly done. Usually, with a standard tattoo, it’s three days of antibiotic ointment, and then you’re done. Mine’s 10 to 14 days. They stay covered. I do Aquaphor®, and then I bandage them with a nonadherent pad and paper tape. And that’s how they stay. I want them to check it out four times a day: breakfast, lunch, dinner, and bedtime. Change the pad at least once a day. When they shower, I, for a medical term, I tell them to gob the Aquaphor on because that’s their Band-Aid® in the shower. And, then they are to wash around, blot, put the nonadherent pad on again, and then the paper tape. And, I put the Aquaphor on with a sterile tongue depressor, but I have them wash their hands, and I want them to put it on with their fingers because microscopic scabs will form. So, I want them to feel that. And I always tell them, when it feels like normal skin, you’re done. And that’s around 10 to 14 days.

– Can this be covered by insurance?

– Yes. As long as it’s done in a medical facility, it is 100% covered, other than copay and coinsurance that they have to pay, their deductibles. But, yeah, they can come back to me as many times as needed. And, the other thing that sometimes, due to scar tissue, the tattoo doesn’t completely take because scar tissue either absorbs like a sponge or it gets finicky. And, so, I always warn our patients, “Don’t be disappointed.” Fifty percent of the people who come to me never need a touch-up. The other 50%, in six to eight weeks, which is a post-op – I always see them in six to eight weeks – if we need to touch it up, that’s the time that we’ll do it. And insurance will keep paying for that.

– How many patients might you see a year?

– I see, I only see two a day, because that’s five to six hours of me standing. But, I have every day, except for Fridays. So, Monday through Thursday.

– Talk about the team that you work with there, and just your role, and the overall journey.

– Well, I mean, I think all our doctors are fantastic. But I also get doctors that refer to me from Ohio, and New York, and West Virginia as well. And, I have to say, every doctor that I know that has referred to me is very caring and wants to do the best for these patients. And, if something’s not right, or the patient’s like, “Lor, I don’t know, I’m not really happy with this.” And, I’ll say, “Well, go back and talk to the doctor. They’re here to help you. And they will.” Then, they come back to me, they’re like, “You’re right, they did.” And they’re happy. And, then, I can go ahead, and tattoo, and complete them.

– Did you ever imagine all those years ago, getting on the plane for the first time, that this is what you would be doing?

– No, it just evolved. But I’m a believer that things happen for a reason. And, I’ve met, I’ve been fortunate enough to meet so many wonderful women in just not-so-great situations. So, I feel very blessed.

– Well, we thank you so much for coming in and talking with us today. Some really great information, and what you do is so inspirational. Thank you for joining us.

– Thank you.

– I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

Editor's Note: This podcast was originally published on , and was last reviewed on .

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