Timing of Nipple-Areola Complex Micropigmentation After Breast Reconstruction: A Narrative Review and Referral Protocol for Surgeons

Nipple-areola complex (NAC) micropigmentation, also known as medical or 3D areola tattooing, is the final stage of breast reconstruction, and its outcome depends largely on when patients are referred. This narrative review summarises the evidence on timing, eligibility criteria and process, and proposes a referral protocol for plastic, aesthetic and oncological surgeons. There is practical consensus on deferring NAC micropigmentation for at least 3–4 months after the last reconstructive procedure, with some centres extending this to 12 months. Prior radiotherapy is an independent predictor of post-tattoo infection (OR 4.1; overall infection rate 2.2%) and is associated with more revisions due to pigment fading. Treatment usually requires two sessions, 6–8 weeks apart. As no consensus exists on the interval after radiotherapy, the authors propose waiting at least 6 months and until acute radiation dermatitis has fully resolved. A referral algorithm, quality criteria for the receiving centre and a patient information sheet are provided.