Right now Marta Bombardó Soria, a nurse from the Plastic and Reconstructive Surgery service of the Can Misses Hospital, is in Barcelona, in a course on micropigmentation of the nipple with one of the pioneers in this technique that just a few weeks ago that the hospital offered to women to those who after a mastectomy have had their chest reconstructed. It is a private course, but Bombardó is delighted. She was very excited to be asked to take charge of this service that tries to give back to women who have suffered breast cancer not so much the nipple and areola but their self-esteem and confidence. You will learn as much as you can because you are clear about your goal: “That when patients go and look in the mirror they say: Wow!”
What is nipple micropigmentation?
It is a technique with which we can introduce pigments approved for hospital use between the first two layers of the skin. It is important in the case of patients who have had a breast reconstruction in which the nipple or areola could not be preserved. It cannot always be preserved, sometimes you even have to take a piece of skin from the abdomen or back for reconstruction, to make what is called a flap. In those cases, a flat skin remains, a round breast, as if in a drawing we were erasing the nipple and the areola. Sometimes plastic surgeons make a reconstruction of the nipple, a small pinch or bulge, but it remains the color of the flesh from where that skin was taken. Micropigmentation helps to achieve a more realistic effect, but is sometimes completely flat. This technique is like a tattoo, but on a higher level of skin, and it is semi-permanent. It’s like if you were drawing a picture, you have to get a bit of shadow or effect to make it look like there is a nipple.
“These women are not aware of how important this treatment is until they do it”
Why is it important to these women?
It is super important. They are not aware of how important it is until they do it. Some hadn’t even thought about it. Those who are clear about it have already gone to a private center and have had it done, because there was a waiting list. There are women operated on in 2019 who are undergoing surgery now. There is one who had done it to her and when we called her she came because she had been depigmented. They come with a little I do not know if it is distrust or shyness. When they return after the first session they are more open and happy because they have seen the change. They looked in the mirror and had nothing.
The job will be different depending on the rebuild, right?
Yes, there are unilateral mastectomies in which you have to retouch the areola scar, which has been diminished. There are also bilateral mastectomies in very young women. Some have resigned themselves to not having a nipple or areola and others are looking for silicone nipple shields that are made to measure. When they are seen, even if only after the first session, with a minimal shape and with the color we have chosen, their face changes. They tell you that when they go to shower, for example, they look in the mirror and see an image that reminds them of who they were before. It is very important to them.
Is getting the color right as difficult as finding the exact shade of makeup?
Exactly! But with less color gamut. There are many pigments approved for hospital use, but we work with ranges of browns and pinks. The first thing is to mix them and put them on your skin. If they have an areola you try to compare the tone with it. If they do not have parts of what she remembers: the size of the areola, the color, if she had large or small nipples … You are also guided by the skin phototype, but the one who decides is the woman, how she wants them . Actually, they are teaching me a lot.
Do you have to be a bit of an artist?
I do not know if I draw well or badly, all my life I have liked to draw, but I had not done painting classes. This is training and practice, practice and much more practice. In artificial skin and then, as in all the techniques that nurses do, with patients. Each person is different and each skin reacts in a way to pigment. If the graft, for example, is of an abdominal or dorsal skin, it takes the pigment in different ways. Sometimes it seems that everything that would play is not marked and you have to do more sessions. There are also patients who have received radiotherapy and that skin is more complicated. The important thing is to try to make it look as beautiful as possible. It is a huge responsibility. With them liking it and feeling better, I’m already happy.
Is one session enough?
No. Minimum you have to do two. In one session you can do the main thing, the areola and the nipple, but then you have to continue with more details. After 15 days the pigment has already healed, the intensity decreases a little, and you can see the real tone that has remained, which is not final until the month. From there you can make some more shadow, the Montgomery mounds …
It hurt?
Mostly no. In the previous interview I asked them, among other things, if they have sensitivity in the area. If they tell you yes or they don’t know, I recommend putting on an anesthetic cream an hour before and so when they come to the consultation they already have the area asleep. Sometimes it can bother them a bit when you work on the scar, because there are, but so far it has not happened to me. If it were the case, we would stop and another day we would do another session.
How long are the sessions?
Now that I have started I do not plan to do more than four patients in the same day. Between the posture and that you’re squeezing with your hand… I’m quoting one per hour. During that time we do the interview, we draw, we look at the pigments … When it comes to bilateral reconstruction, we usually spend an hour and a half or even a little longer.
Is aftercare like a tattoo?
Similar. They go home with the nipple covered with a silicone dressing that helps heal. We recommend that they spend 24 or 48 hours without bathing or showering and a healing ointment like the one that can be used for a tattoo. The same in other clinics they advise some antibiotic ointment, I do not, and there has been no problem. They must be careful not to scratch the scab that is being created, during the first month it is better not to submerge, at first they should avoid the sun and then always put on protection. It is a very fast scar.
There are those who do tattoos to women who have undergone a mastectomy. Have you considered it?
No, I really liked starting this project, it surprised me. When they told me, I was very excited about my artistic side and because of the importance it has. I have to do well for them, so I am trying to train myself even more. This was very necessary and right now I am not considering anything.
Before these women had to go to Mallorca?
Yes, he sent them to Son Espases. In fact, I have recovered four that were left on a waiting list in Palma.
What do you learn in these courses? Technique? Art?
The training they gave me in Palma was more of a retraining. I went to see the consultation and she explained a basic theory to me: the material, how to use it, the frequencies … Then I was seeing how the nurse who does it there worked and I had the opportunity to be doing it with her too. In the courses that you do privately, all that is expanded. This weekend I do one and the syllabus includes theory of needles, pigments, colorimetry, techniques and a lot of practice that I will have to do remotely. It is what Ibiza has. And the pandemic, this year or so, has not helped either.
Do women speak in your office?
We talk a lot, about many things that have nothing to do with your process. The last few days I have tried to put on relaxing music. At the second session they already come with a higher level of confidence, much more cheerful, willing and confident. The first day I was so nervous and excited that I didn’t even think about creating a more comfortable climate. Now we are very comfortable. Talk later. I ask about their family. Some have daughters in the healthcare world. You hang out. They are relaxed and, actually, they distract me.
Do they arrive in fear?
Yes. At the first session, all of them. When I called them to make the appointment and ask them four things they were surprised. “Already?” They asked me. They had been put on a waiting list and were surprised that it was so fast. The day they have the first visit they arrive like when you go to the doctor and you don’t know him, you don’t love him. They did not know me at all and are putting themselves in my hands. Self-esteem is a bit touched. Some have been dragging the process for many years and are resigned that their breasts are going to stay that way.
They have assumed that it will not improve.
Yes, each one has lived it in one way and each one has its own story. They haven’t told me everything, there are people you notice who don’t want to talk about it. They don’t have that trust space. Each one will have had their own thing: the operation, chemotherapy, radiotherapy … I think they have all come a little scared and have gone well. They come happy and more than one has told me that they would hug me if we weren’t in this situation. I tell them to hug me, that I am vaccinated. They need it. They are exposing a very intimate part of their body, a part that some do not even consider theirs and we must find a climate of tranquility, intimacy and in which they feel good. After all, someone else is drawing on their boobs. [Ríe].
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