Thursday, March 21, 2024

Creating Ultra-Realism in 3D Areola Restoration Tattoos

By Rose Marie Beauchemin-Verzella - 3D Areola Tattooing aka Areola Restoration procedures have evolved dramatically in terms of a more realistic areola and nipple area.  Additional training is often required to create these special realistic effects.

Creating this realism for areola restoration involves shading and the use of more than one color for the three-dimensional, Illusion of Protrusion, effect. This does not create actual physical dimension, but an ultra-realistic illusion of it. These advanced applications, using multiple shades and shading techniques, have the ability to mimic the texture and natural variations of an areola/nipple complex.

These Ultra-Realistic Effects are achieved by creating realistic-looking wrinkles throughout the surface of the areola, applying Montgomery Glands, texturizing the areola, and highlighting and lowlighting the nipple.

Step-by-step details of these areola restoration techniques are listed below.

Learn More About 3d Areola Restoration Tattoos

Before Embarking… Always research the regulations and requirements for areola tattooing, also refereed to as areola restoration, or paramedical tattooing in the county, city, and state where you plan to offer this service.                  

Areola Restoration Tattoo - Before & After
Before & After - Photo Courtesy of Maria Concepcion


Assuming medical clearance has been obtained for areola restoration, you will want to examine the residual scars to be sure there are no areas that are weeping or not completely healed. All work must be halted in this case and not rescheduled until this client is fully healed and/or with additional medical clearance. Proceeding with tattooing on unhealed areas can cause anecrosis (the death of the tissue) and cause this client/patient to suffer additional surgery/surgeries and extensive treatment.

Engaging Your Client/Patient

This client/patient for areola restoration is to be treated with a greater degree of compassion than your permanent makeup client. This person has faced their mortality and has likely been through the arduous journey of radiation and chemotherapy, the discomfort of expanders and may have experienced the trauma of their hair loss. It is important to take the time to ask about this journey, their type of cancer, their treatment/treatments, and where they are now regarding their treatments. This inquiry will also give you an idea of their emotional state.

Ask them about their expectations and preferences so you have a clear understanding of their vision for the final appearance of the areola restoration tattoo.

Be sure to enter all this information in their chart.

Mapping Reconstructed Breasts for Nipple Placement

Mapping for nipple placement may or may not be applicable. This depends on the symmetry or asymmetry of the reconstructed breast or breasts.

In the case of the Unilateral (one breast) reconstruction, the opposing breast will most likely dictate the position of the areola/nipple complex. Your eyes will need to engage as opposed to mapping.

The bilateral (both breasts) cases will often permit mapping and the most popular method is the Penn Triangle.

According to Dr. Jack Penn, well known plastic and reconstructive surgeon, the most aesthetic location at which nipples should be placed is at the 2 basal angles of an imaginary equilateral triangle that has its apex at the sternal notch and has 2 sides measuring 21cm.

We must consider that he based his method on a small number of women from 18 to 39 years of age.

Your breast reconstruction clients/patients may not have the symmetry of natural breasts,(although natural breasts often have some degree of asymmetry), but the Penn Triangle can be applied or at least helpful in most areola restoration cases.

According to Dr. Jack Penn, the most aesthetic location at which nipples should be placed is at the 2 basal angles of an imaginary equilateral triangle that has its apex at the sternal notch and has sides measuring 21cm.

Breast Restoration Mapping Triangle
Source: Dr. Stan Monstrey of Belgium

A slightly elongated triangle may be required for a more mature, slightly ptotic look in older and heavier women.

Another method of measuring for the nipple placement, contributed by Aesthetic Plastic Surgery, is to make note from the women’s profile, the apex of the breast mound, and mark it. This would be, X. From the frontal view, using a chalk marker, create a horizontal line across both breasts of the apex or X mark.

Mark vertically the medial lines between each breast, mark vertically the lateral lines, and horizontally, both top and bottom of the breasts. You will have a pattern that allows you to see where the 50:50vertical line Y is placed and that is exactly ½ between the top and bottom lines and ½ way between the medial and lateral lines.

Source: Aesthetic Plastic Surgery Journal

In a standing position, (never seated) and your choice of measuring, draw or chalk mark the NAC onto the client/patient.

Ensure that the size and placement of the NAC are proportionate to the individual’s anatomy. The natural position and orientation of the NAC is necessary for a realistic outcome.

It is of utmost importance that your client/patient participates in these decisions for the areola restoration process. Remember, the goal is wanting your client/patient to feel familiar, once again. So, size and placement require their approval.

Color Selection Using Color Analysis

Choose pigments or inks that closely harmonize with the person’s natural skin tone, which may be warm or cool. Peachy shades have warm undertones and look best on warm skin tones, while pinker shades have cool undertones and will look best on cool skin tones. This is best determined by placing the actual pigment or ink colors onto the breast, looking for the most harmonious color.

Color Selection for the Nipple

Choose a slightly darker or more saturated color for the nipple, compared to the areola color you’ve selected. This helps create contrast, dimension and realism.

Tattooing the Areola Base Color

Once the pigment color is decided by you and your client/patient for their areola restoration tattoo, begin by tattooing this base color onto your drawing. You will want to ensure even coverage in creating this natural base.

Avoid making a harsh line on the circumference of the areola. Instead, tattoo the outer perimeter softer than the interior of the areola.

Tattooing Areola Special Effects

Layering and blending different shades that are very close to the base color will add depth and dimension. However, you will want to blend these colors seamlessly to avoid a flat or unnatural appearance.

Wrinkles and Textures

Use fine needles to create subtle wrinkles and texture to the areola surface. Vary the depth and density of these tattooed lines to mimic the natural appearance of skin folds.

Subtle Raised Effects

Apply dots, with both a slightly darker color and a lighter color than the areola, with a gentle touch to create a subtle raised effect. Avoid making these bumps too pronounced, as they are generally small and subtle.  

Creating the Illusion of Montgomery Glands

Performing this effect on the areola involves fine detailing and color variation to simulate the appearance of these small, raided bumps. Observe and refer to the natural anatomy of these glands before attempting to tattoo them, as they differ among individuals and their complexions and ethnicity. Pay close attention to the subtleties and nuances of their appearance.

Montgomery Glands are typically random and a shade darker than the surrounding tattoo. Many areola restoration artists use a stippling effect or tiny dots with a fine needle to create a horseshoe pattern, leaving the center lighter. They should be irregular in size and spacing, resembling their natural distribution. Avoid making solid lines or circles when creating this simulation. Avoid creating a stark contrast between the simulated glands and the rest of the areola. Keep it subtle.

Tattooing the Nipple

Here are some steps to take in creating a most realistic nipple when doing a areola restoration tattoo:

  1. Study the anatomical details of a nipple to create authenticity.
  2. Incorporate texture into the nipple, using fine needles to create the appearance of folds.
  3. Mimic the texture of the nipple’s surface by including small bumps and creases.
  4. Apply shading to the center of the nipple to create the illusion of depth.
  5. Use varying shades to mimic the natural shadows and highlights that occur on a nipple.
  6. Create a gradual transition from the darker base of the nipple to the lighter surrounding areola. This transition should be subtle and natural, avoiding harsh edges.

Highlighting the Nipple

Introduce highlights to the highest point of the nipple. This can be achieved but using a lighter shade or leaving a small area without color. This technique helps create a more realistic and three-dimensional appearance and a sense of volume to the nipple.

Male Mastectomies

Yes, men do get breast cancer too. However, mapping men is not the same as mapping women.  There are a few articles published in medical journals but seem to differ. Dr. Penn’s equilateral Triangle does not apply to men when performing areola restoration tattoos.

In an article published in the Aesthetic Surgery Journal, in 2018, the largest study, Dr. Stan Monstrey of Belgium, found the average make areola to be 26.6mm with a nipple of 6.9mm.

The sternum notch to nipple (SNN) averaged 204.2mm on both sides but the nipple to nipple (NN) averaged 249.4mm. There doesn’t seem to be an exact formula to follow but we realize the NAC are much further apart than a woman’s. This awareness is certainly helpful when your client/patient is a male.

Post-Treatment Care For Areola Restoration Tattoos

Provide your client/patient with proper aftercare instructions for areola restoration tattoos as well as any materials required during their healing. This provides their safe healing and protects the longevity and vibrancy of the tattoo.


Aesthetic Plastic Surgery Journal

Dr. Stan Monstrey of Belgium

Dr’s Richard Lewin, Matteo Amoroso, Nikolina Plate, Clara Trogen, Gennaro Silvaggi of Sweden


To become trained in these advanced areola restoration techniques I recommend taking a course with certified instructors by the American Academy of Micropigmentation (AAM) or the Society of Permanent Cosmetic Professionals (SPCP).

Here are some general references that may provide valuable information:

"Micropigmentation: State of the Art" by Charles Zwerling:

This book covers various aspects of micropigmentation, including paramedical tattooing techniques. It may offer insights into areola restoration.

"Micropigmentation: Technology and Application" by Mark Walker:

This book explores micropigmentation technology and its applications, including in medical and paramedical contexts.

"Clinical Anatomy of the Face for Filler and Botulinum Toxin Injection" by Hee-Jin Kim and Kyle K. Seo:

While not specific to areola tattooing, this anatomy-focused book can provide valuable insights into facial anatomy, which is crucial for realistic paramedical tattooing.

Professional Organizations and Courses:

Check resources provided by professional organizations related to paramedical tattooing, such as the American Academy of Micropigmentation (AAM) and Society of Permanent Cosmetic Professionals (SPCP).Some organizations offer educational materials and guidelines.

Creating Ultra-Realism in 3D Areola Restoration Tattoos
March 21, 2024