The Healing Role of Postmastectomy Tattoos

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Moving the Needle on Recovery From Breast Cancer

am a tattoo artist who works with women after they’ve had mastectomies to transform their sense of disfigurement and loss of control into feelings of beauty and agency. On a good day, I can heal with my art.

Botanical imagery in a tattoo after mastectomy and surgical reconstruction.

Botanical imagery in a tattoo after mastectomy and surgical reconstruction.

David Allen

The women with breast cancer with whom I work share a feeling that they’ve been acted uponby cancer, the health industrial complex and its agents, the sequelae of their treatments. Their physical and psychological points of reference are destabilized, having changed so quickly. A successful tattooing experience establishes a new point of reference, a marker that’s intimately theirs that replaces their sense of rupture and damage with an act of creation and, in my work, images of natural life.

I screen the women who contact me with a lengthy phone call in which I ask hundreds of questions. I need to know that they’re ready. Some women don’t know what they want, which means I can’t be certain that what I do will help them, or they want to regain control by controlling me, which doesn’t work since it inhibits my freedom to help them. Some are managing disagreements with family members about the appropriateness of what I do. One woman wept when I touched herher husband had left her because of her illness and she hadn’t been touched by a man in many years. That wasn’t the time for me to begin my work. My contribution needs to be a healthy, organic part of their path through their illness. I’ll decline to do the work if I get the sense that this is not the case.

I interact with a small number of health professionals in the process. I review images and operative reports that women bring, and some put me in touch with their oncologist or plastic surgeons. Knowing what their skin has been through helps me plan. Some women are working with psychotherapists to come to terms with the changes caused by cancer. Generally, it’s important that I know that the woman’s physicians know she’s seeing me and haven’t voiced concerns about any contraindications to what I do. I am now hearing from some women in advance of their operations and imagine someday I might interact with their surgeons to influence the types of incisions they make with which I could work better after the procedure, knowing of course that their indicated surgical care takes priority.

Over the 10 years I’ve worked with cancer survivors, I’ve developed a tattooing process and imagery that’s a little different from other artists, plastic surgeons, and micropigmentationists. A standard approach to postmastectomy micropigmentation is to tattoo images of a nipple on a breast mound or reconstructed breast. To my eye, a clinical, trompe l’oeil image of a tattooed nipple lacks character. It has no relationship to the woman’s altered body and mind. The women I see want the opportunity to turn themselves into something that transcends an imitation of what they used to look like. Additionally, the nipple image fades with time. So over years of work I’ve evolved toward botanical imagerybranches, stems, leaves, flowersas the most effective way to transform the surgically altered breast (Figure 1). Artistically, the use of organic imagery lends itself to variance and deviation; the imagery is freed from a rigid adherence to scar patterns and can move the eye along designated paths and away from the areas of the chest that feel most abnormal or disfigured to the woman. It is forgiving of changes to skin and scars that come with healing and age. And the symbolism of quiet, inexorable change and growth evoked by flowering plants fits where the women are in their journey through and away from their illness.

The women with breast cancer with whom I work share a feeling that they’ve been acted uponby cancer, the health industrial complex and its agents, the sequelae of their treatments. Their physical and psychological points of reference are destabilized, having changed so quickly. A successful tattooing experience establishes a new point of reference, a marker that’s intimately theirs that replaces their sense of rupture and damage with an act of creation and, in my work, images of natural life.

I screen the women who contact me with a lengthy phone call in which I ask hundreds of questions. I need to know that they’re ready. Some women don’t know what they want, which means I can’t be certain that what I do will help them, or they want to regain control by controlling me, which doesn’t work since it inhibits my freedom to help them. Some are managing disagreements with family members about the appropriateness of what I do. One woman wept when I touched herher husband had left her because of her illness and she hadn’t been touched by a man in many years. That wasn’t the time for me to begin my work. My contribution needs to be a healthy, organic part of their path through their illness. I’ll decline to do the work if I get the sense that this is not the case.

Stages of tattoo application process after bilateral mastectomy and deep inferior epigastric artery perforator flap reconstruction.

I interact with a small number of health professionals in the process. I review images and operative reports that women bring, and some put me in touch with their oncologist or plastic surgeons. Knowing what their skin has been through helps me plan. Some women are working with psychotherapists to come to terms with the changes caused by cancer. Generally, it’s important that I know that the woman’s physicians know she’s seeing me and haven’t voiced concerns about any contraindications to what I do. I am now hearing from some women in advance of their operations and imagine someday I might interact with their surgeons to influence the types of incisions they make with which I could work better after the procedure, knowing of course that their indicated surgical care takes priority.

Over the 10 years I’ve worked with cancer survivors, I’ve developed a tattooing process and imagery that’s a little different from other artists, plastic surgeons, and micropigmentationists. A standard approach to postmastectomy micropigmentation is to tattoo images of a nipple on a breast mound or reconstructed breast. To my eye, a clinical, trompe l’oeil image of a tattooed nipple lacks character. It has no relationship to the woman’s altered body and mind. The women I see want the opportunity to turn themselves into something that transcends an imitation of what they used to look like. Additionally, the nipple image fades with time. So over years of work I’ve evolved toward botanical imagerybranches, stems, leaves, flowersas the most effective way to transform the surgically altered breast (Figure 1). Artistically, the use of organic imagery lends itself to variance and deviation; the imagery is freed from a rigid adherence to scar patterns and can move the eye along designated paths and away from the areas of the chest that feel most abnormal or disfigured to the woman. It is forgiving of changes to skin and scars that come with healing and age. And the symbolism of quiet, inexorable change and growth evoked by flowering plants fits where the women are in their journey through and away from their illness.

My application process differs too (Figure 2). Traditional tattooing is relatively heavy-handed, typically relying on 5 to 9 needles for drawing hard outlines, then 11 or more needles to fill in the lines with solid color. Given what the women’s skin has been through, I need to be more thoughtful and gentle. My technique is essentially pointillism, as opposed to the standard slathering of color, and is oriented toward efficiency and minimal trauma. I use a quiet, lightweight rotary machine and a small grouping of 3 needles directed toward one point. The needles and skin meet while I hold the machine and tube as perpendicular as possible, moving and adjusting dimensionally over the lay of the skin. My other hand stretches the skin taut during the application. It also works as a depth gauge based on variations in the vibratory response of the epidermis and papillary dermis, given its postsurgical density and elasticity.

That said, the procedural aspects of tattooing contribute less to a successful outcome than care, empathy, and a thoughtful reading of the patient. Anyone in my position can see these women are struggling, but their motivations for seeking a tattoo are important. I try to assess their attachments and detachments in relation to their altered body. Certain physical changes may be more or less important to them. Many of the alterations are unattractive to them or may feel “foreign,” but addressing each one through ink would result in a convoluted image. Once I understand their emotional reasoningwhat issues bothers them the most, and the leastI can prioritize the task. Are they seeking to conceal the rippling above their breast, or do I draw the eye down to create visual symmetry between both breasts when one is constricted lower? How do they feel about their chemotherapy port, and do I incorporate it into the imagery or design for a time it’s no longer there? What is their occupation, and how does that influence their feelings about the tattoo peeking out from their work clothes? A visual hierarchy starts to form based on this kind of information, and I can propose a design unique to that woman’s body and mind. After a lot of back and forth where I come to understand what they want for their bodies and they come to understand what I recommend (and can and cannot do), I use Photoshop to mock up an example of the design I have in mind, using the woman’s unique body image, so she can understand my vision, and we can revise and iterate the design until she is happy with it and comfortable with the plan.

Outcomes for my procedures are good, in the sense that I have never heard of physical or other complications. Once the work is over, I leave communication up to my client. Tattoos are constantly degrading, so I ask the women to send pictures after 6 to 8 weeks to make certain we’re both satisfied with the result, and in a small number of cases they or I suggest a return visit for a touch-up, typically darkening some lines and image elements. However, I do not set expectations or requirements for our interactions afterward. The majority of clients reach out to let me know their experience; some women are proud of their change and want to show the world their transformed chest; others feel resexualized by the imagery and carry themselves more confidently, while others feel the change deeply, but quietly, and keep it private.

What these responses have in common, of course, is a sense of transfiguration that they have fashioned for themselves, having wrested control of their bodies back from their anxious tenancy with cancer and health care.

  read more at JAMA

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