Why Don't Post-Mastectomy Tattoos Cause Lymphedema?
Although surgeons have been using tattoos to help create the look of nipples and areola on breast cancer survivors for years, more elaborate post-surgical tattooing is a growing trend. Using graceful line work and flowers or other decorative imagery to cover the scars of a lumpectomy, mastectomy or breast reconstruction surgery can help some women feel more whole in their changed bodies and divert attention from scars that would otherwise remind them of difficult times.
Although tattooing is generally regarded as a very safe practice with few if any serious complications -- when performed by a doctor or a licensed and experienced artist in a sterile environment -- tattoo needles do break the skin and can open the door to an infection. That said, triggering lymphedema -- a chronic and potentially disfiguring swelling of the limb where lymph nodes have been removed during surgery to treat the breast cancer -- is not generally a concern for patients getting tattoos after breast cancer surgery, even if "you've had a lot of lymph nodes taken out and you have lymphedema in the arm," says Dr. Richard Klein, section chief for plastic and reconstructive surgery at Orlando Health Aesthetic and Reconstructive Surgery Institute.
[See: 7 Innovations in Cancer Therapy.]
When lymph nodes are removed, that can disrupt the normal flow of lymph fluid through the body. This can create a blockage that leads to swelling. Patients who develop lymphedema are often prescribed management therapies including lymphatic drainage, physical therapy or compression garments. For patients with breast cancer-related lymphedema, a long, tight sleeve is the most common type of compression garment, and it helps prevent fluid from collecting in the affected limb. In addition to these management techniques, lymphedema patients are advised to avoid injury to the limb, as cuts, sunburns and even insect bites can sometimes lead to more swelling.
So if a mosquito bite can trigger lymphedema, why isn't tattooing usually a problem? Tattooing "doesn't necessarily affect the reconstructed breast because the chest has multiple [areas] for lymphatic drainage." For most people, there's enough redundancy in this region of the lymph system to deal with fluid as it moves through. "So, lymphedema of the chest wall -- although it can happen -- is relatively uncommon. It's safe enough to be able to tattoo the reconstructed breast to create a nipple," he says, and this is why larger tattoos to cover scars resulting from breast surgery are also unlikely to trigger lymphedema. However, Klein adds, "I would not allow somebody to get a tattoo on their arm, for example, if they have lymphedema. That would be a big no-no" because the arm drains to the axillary area under the armpit where lymph nodes may have been removed during an axillary lymph node dissection or sentinel node biopsy.
Holly Feneht, tattoo artist and owner of The Gilded Lily paramedical tattoo art studio in Santa Clarita, California, works with many breast cancer survivors to create nipples and areolae or larger designs that can help her clients regain confidence and complete their cancer journeys. She says even clients who are getting a regular tattoo and haven't had breast cancer or lymph-node-removing surgery may experience swelling when getting a tattoo in the axillary area. "Being anywhere near the armpits or underarms usually tends to swell more. " Therefore, she "errs on the side of caution" when inking breast cancer survivors and avoids the underarm area.
Feneht has worked with survivors who do have lymphedema and says that the tattoo doesn't generally create a problem, provided they follow all the aftercare advice, as any infection that develops could become problematic. Aftercare for paramedical tattoos is generally the same as for traditional tattoos. Most shops recommend gently washing with antibacterial soap, patting dry and applying a thin layer of fragrance-free lotion a couple times a day until the tattoo is completely healed.
As with all tattoos, bleeding is part of the process. Therefore, it's important to keep the area clean and "dressed like a normal wound," says Dr. Constance Chen, a board-certified plastic surgeon and member of the medical advisory committee of the National Lymphedema Network. "The normal full recovery period for a wound is six to eight weeks, although the area may look much better before then," Chen says. Most tattooists advise patients to avoid bathing or swimming for about two weeks after getting the tattoo and to protect the area from sunlight and physical stress indefinitely.
"Until you're all done peeling, no soaking in the hot tub or the pool," Feneht says. "I encourage my clients to continue going to the gym or working out as they normally would during the healing process, but I would say, 'don't sit in a gross sports bra for three hours while working out and then run errands.' Clean and dry is the way to go," she says.
[See: Breast Pain? Stop Worrying About Breast Cancer.]
Even though the risk of triggering lymphedema with a tattoo is very slim, Feneht still advises clients with lymphedema to "wear your sleeve a little more often and do more of the drainage massage. I've tattooed women with the sleeve on to make sure we don't have an adverse reaction." While working with these clients, Feneht will generally keep the tattooing sessions shorter and keep a close eye on how the skin is reacting and whether there's any unusual swelling near the tattoo.
"It's almost along the same lines as tattooing a diabetic," she says, as diabetes patients may also have issues with edema -- swelling that often occurs in the feet and lower legs. "I'll ink in shorter sessions, and it might take a full two weeks for the tattoo to heal." During this period, the client is "at risk of infection, so the aftercare is really important. If you see redness and swelling, see your doctor. If you have cellulitis [a bacterial skin infection], you need to be very attentive" to how the skin reacts to the tattoo. "Just knowing your body is really important," she says, noting that scarred or irradiated skin may also be a bit more challenging to work with and can take longer to heal.
Many of Feneht's clients are referred by breast surgeons in the area, and she says some of these doctors will prescribe their patients a preemptive antibiotic to prevent an infection before it even has a chance to take hold. Keeping your emotional stress levels down as much as possible and being well hydrated and rested on the day of the tattoo can also help reduce the chances of an adverse reaction.
Despite the loss of tissue and sensation in the area, some patients will experience pain during the tattoo. "Especially with [patients who've had] sensory restoration, it may hurt and it may be necessary to use local anesthesia," Chen says. In these instances, the doctor or tattooist may use a gel "placed on the tattoo site about an hour before the tattoo to numb the area."
Feneht says that in her experience, "about 90 to 95 percent of women have no sensation when we do the nipple and areola," but others find it very painful. "When the tissue has been cut during surgery, nerves have also been cut and put back together, and that can result in some hypersensitivity." If you're concerned about this, talk to your doctor about getting a lidocaine patch or gel to numb the area beforehand.
[See: What Not to Say to a Breast Cancer Patient.]
Finally, Chen says, "the most important thing to know before a mastectomy tattoo is that the color fades over time. Thus, it may be necessary to have the tattoo repeated after several years." Chen is referring to tattoos done with cosmetic tattooing ink, which is different from the ink typically used for conventional, decorative tattoos. Feneht says cosmetic ink fades faster because "the molecules in the ink that's typically used in cosmetic tattooing are smaller than the molecules in the ink used in traditional tattoos, so the body breaks them down faster." This may be viewed as a benefit in the cosmetic tattooing industry where clients may actually want to see their ink fade over time as styles change. But for a breast cancer survivor who just wants to have representation of nipples and areola, needing frequent touch-ups can be inconvenient. If this is a concern, speak with your doctor about the type of ink being used, or ask for a referral to a tattoo artist with experience in paramedical tattooing.
Elaine K. Howley is a freelance Health reporter at U.S. News. An award-winning writer specializing in health, fitness, sports and history, her work has appeared in numerous print and online publications, including AARP.org, espnW, SWIMMER magazine and Atlas Obscura. She's also a world-record holding marathon swimmer with a passion for animals and beer. Contact her via her website: elainekhowley.com.
