3D Tattoos for Breast Cancer Patients Arrive in Pittsburgh

By Liz Petoniak | Photographs by Michael Fornataro


A google search for “mastectomy” results in thousands of images of women with large, painful-looking scars across their chests. For many who have just received a breast cancer diagnosis, these images serve as their frame of reference for what to expect. However, far more options exist today than what we have traditionally associated with breast cancer care in the past.

For more than 10 years, Dr. Jim O’Toole, double board certified plastic surgeon and owner of O’Toole Plastic Surgery, has strived to eliminate those shocking images for patients and provide them with a different, far more comforting, way to hide scars, utilizing cosmetic incision patterns for oncoplastic breast reconstruction surgery and specializing in the single stage direct-to-implant method. “Breast cancer is a social disease,” he says. “One in eight women will be affected by it and none of us will get away with our time on this planet without someone meaningful to us getting breast cancer. So, if we can improve the situation and improve breast cancer care with a more holistic, compassionate approach, that will be spread out to everyone they come across.”

With this strong motivation moving him forward over the years, he has consistently sought out ways to improve upon results for his patients. When we last spoke in 2013, he described the nipple and areola as a sort of “last frontier,” the final part of the reconstruction and healing process requiring significant improvement. Commonly used techniques like skin grafts and cosmetic ink tattoos applied by aestheticians simply were not producing up-to-par outcomes.

Finally, it’s safe to say that last frontier has been conquered. Teaming up with Cheri Croney, owner of True Image Tattoo, O’Toole and his new partner are excited to introduce FORMA Naturalis, a service that provides 3D nipple and areola tattoos for women (patients of Dr. O’Toole’s or not) who are fully recovered from surgery. This unique collaboration between a nationally recognized surgeon and a respected authority in the tattoo industry marks the first time these 3D tattoos will be available to women in the Greater Pittsburgh area, as well as the only service of its kind located within a plastic surgeon’s office in the U.S.

“These women have lost so much and it’s the final stage to help them feel whole again. We want to make them feel complete,” says Croney. “It’s an ending, but it’s a new beginning. It helps them start that next chapter with confidence. For me, it’s been a great healing process to provide these women with something they’ve lost but are getting back.”

Loss is something that Croney understands all too well. Less than a year ago, her husband Kevin, an award-wining tattoo artist and owner of True Image Tattoo, was tragically killed. Prior to his passing, Kevin and Dr. O’Toole were in the early stages of establishing FORMA Naturalis. For years, Dr. O’Toole referred patients to him for laser tattoo removal. O’Toole recalls, “Kevin knew he could create a more detailed and realistic nipple as opposed to an aesthetician. True tattooers possess the ability to blend and match shades because of their years of experience. He told me that the tattooing industry had been very good to him and that this would be a way for him to give back in a meaningful way that he hadn’t been able to yet.” At Kevin’s funeral, Croney asked that O’Toole continue on with what he and Kevin started, but little did she know, her husband and O’Toole had already drawn up the legal paperwork for the company. “It only made sense to have Cheri as a partner,” he says. “She’s a survivor, although a survivor in a different way, and she would really be able to relate to the patients in a way that the rest of the world simply can’t comprehend.” Croney also asked that she be allowed to select Kevin’s successor. During the time he was practicing the tattoos on the thighs of willing friends, he was mentoring Luke Romaniw, a man she felt possessed the heart and skill to step into her husband’s shoes in this role. As Kevin’s successor, Romaniw, has said that it’s “an honor and privilege to carry on his legacy.” “To have everyone involved in such a meaningful, emotional way creates a situation that you just can’t fabricate,” says O’Toole.

Thus far, the response from patients has been astoundingly positive and moving. “When they stand up and look in the mirror, they’re overwhelmed,” says Croney. “It’s euphoric to see the look on their faces.” Such was the case for Michelle*, a patient of Dr. O’Toole’s, who describes the tattooing as a “final step” in her six-year journey, which began about one year after giving birth to her first child. Her mother showed her a letter from a family member stating they had tested positive for the BRCA gene and within a matter of two weeks, not only did Michelle learn that she was also positive for the mutation that significantly increases a woman’s chance of breast cancer, but she discovered that she already had stage two breast cancer. “When I first met with Dr. O’Toole, I was in a very bad place because there was no warning. I felt like I had been hit by a bus,” she says. “But, I loved his approach. I loved his passion. And I wasn’t terrified.”

Michelle fought successfully through chemotherapy, but unfortunately after undergoing mastectomy and direct-to-implant reconstruction, she developed complications related to a blood clotting abnormality that she, her family, and physicians were unaware of. This killed her mastectomy flaps, and led to hyperbaric oxygen therapy, multiple procedures to achieve her reconstruction, referral to a hematologist (blood specialist), and the need for specialty medications for any invasive procedure for the rest of her life. “There was no time to mentally or even physically prepare for the pain of a bilateral mastectomy, let alone all of the complications I had with it. Dr. O’Toole went from a surgeon I was meeting who was hopefully going to give me my best results, to someone who now sits next to me and holds my hand in the operating room and laughs with me. He’s become a friend because of how much he cares about every aspect that you’re going through.”


With the support of her doctors, her husband, and the rest of her family, Michelle was able to make a full recovery and even went on to have another child. She says, “Frankly, Dr. O’Toole did such an amazing job that for a near 40-year-old with two children, in a bathing suit, my breasts look like a regular breast augmentation patient’s.” Still though, she was nervous about the idea of the tattoos because she didn’t want to risk infection and losing her implants a second time. For her, the final straw was a comment her three-year old son made as she was getting him into the shower and changing out of her bathing suit: “Mommy why don’t you have these like I do?” She says, “I thought I would try it and maybe it would distract my eye from the scars. I thought maybe if I’m working out with a friend, because I’m a very active person, I would be able to change in front of them in the locker room, and maybe I would look like I should in front of others.”

Following many phone calls filled with reassurance from Dr. O’Toole that she was ready to move forward, she went into his office for the tattooing with her mother by her side. “Although it was hard to sit in the chair because of the emotional aspect with everything I had been through, Luke was amazing,” she says. “The results are truly remarkable. I was so happy I had decided to trust Dr. O’Toole as I had done so many times through this process.” She continues, “Don’t be afraid of this part of the process. If you’ve made it this far, you can do this final step. You do have options, and you really can feel whole again, as much as anyone who’s gone through this can feel normal.”

Though the process varies depending on the patient’s reconstruction style and location of scars, Dr. O’Toole first and foremost ensures that the patients are satisfied with the shape and form of their breasts before tattooing. “I always ask, ‘Is there any type of clothing you won’t wear.’ If the answer is yes, like a camisole, a tank, or a bathing suit, then I’ll recommend they go back to see their surgeon, if it wasn’t me, and if they aren’t able to correct the issue, I’ll see what I can do to fix it myself. Every breast cancer survivor has an impact on their quality of life that you can’t understand unless you’re asking that question because they’re not going to volunteer that information,” he says. “I don’t see eye-to-eye with the comment that ‘you’re cancer-free, you should be happy.’ I’ve had too many patients come into my office who have been told that by somebody. If the woman says, ‘I wear whatever the heck I want,’ it’s time for her to meet Luke.” 

During the initial consultation, O’Toole takes detailed measurements of the nipple and areola, as well as photos, so that if the patient is pleased with what they have already, Romaniw can create something almost identical to what she had prior to surgery. If “before” photos aren’t available, O’Toole and Romaniw can tailor the areola and nipple size to what would be the average for the patient’s height, weight, and body type. The tattooing occurs in the privacy and comfort of Dr. O’Toole’s office as a team effort. O’Toole draws the outline of the tattoo on the patient and uses the same skin prep he uses for surgery that kills bacteria around the area for at least two to three days. Romaniw employs his expertise, mixing different shades of ink to provide depth and dimension, while Croney is available as a patient advocate to talk them through the healing process. The tattoos typically take less than an hour to complete. Afterward, it’s recommended that patients keep the tattoos covered for 24 hours and wear loose clothing. From then on, using unscented moisturizing cream works well for reducing scabbing and irritation. A few days later, they bring the patient back for FORMA Naturalis’ after-tattooing protocol. Dr. O’Toole says, “Theoretically, anytime you break the skin, you run the risk of infection, so the benefit of our approach is that if there are any signs of infection, which we fortunately have not run into yet, I can write the appropriate medications.” 

All of these elements combine to provide an unparalleled circumstance with remarkable results for patients. It’s true — the tattoos look incredibly real and three-dimensional. Without context, we wouldn’t be able to tell the difference between the tattoos and the real thing, a huge testament to Romaniw’s artistry. “The reality is that I could not walk out on the street today and become a tattoo artist — you don’t just wake up one day and decide to do it — much like a tattoo artist doesn’t have the ability to do certain things that someone in the field of medicine can,” says Dr. O’Toole. “That’s why we made this arrangement.”

Until now, those affected by breast cancer in our area have had to prolong the already lengthy recovery process by traveling to neighboring cities like Philadelphia and Baltimore for similar services. “We’re able to provide a visible appeal to someone who’s been through something terrible, right in their backyard. There are tens of thousands of women in Western Pa. who will face breast cancer. To at least give them the option of the tattoos is a very meaningful contribution,” says O’Toole. And above all, “The really gratifying thing is seeing the visible change in the patient.”

“For me, it was almost like gaining closure after something traumatic happens to you,” says Michelle. “It’s not that there are not daily reminders. There’s pain; there’s numbness; there
are all of those things that someone who goes through chemo and major surgery is going to have, but at least you have a package that resembles the person that you were before this trauma. When you finally breathe a sigh of relief, like for me after six years of going through this, that feeling is just absolutely awesome.”

FORMA Naturalis, 5830 Ellsworth Ave., Suite 300, Shadyside. 412.345.1615. formanaturalis.com. O’Toole Plastic Surgery, otooleplasticsurgery.com

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