Tara Dunsmore never imagined she would grow up to be a tattoo artist. The forty-three-year-old registered nurse never got into drawing as a kid. She pursued a medical path in school rather than an artistic one. But after being diagnosed with breast cancer in 2012 and undergoing a double mastectomy, Dunsmore heard about areola tattooing as a final step in reconstruction. She was shocked, however, to see a lack of options for breast cancer survivors who want realistic tattoos that look three-dimensional to get back a sense of normalcy. When Dunsmore finished her breast reconstruction, her doctor brought up areola tattooing but couldn’t refer her to anyone outside of the office nurse, who had been trained to do basic one-dimensional areola tattoos.

After searching in vain for a viable alternative, Dunsmore, who lives in Raleigh, relented and went with the in-office nurse.

“It was horrible, painful, and the only color options were bubblegum pink, chocolate brown, and nude,” Dunsmore says. “I didn’t have any control over the color or size, and when I walked out of there, I just couldn’t believe it. I couldn’t believe these were the options for breast cancer survivors. It was unacceptable.”

When she returned to her plastic surgeon, she voiced her concerns and told him she was going to go train with the best 3-D tattoo artist she could find. Then she was going to come back and do this for survivors. And she did.

Dunsmore trained in advanced 3-D areola tattooing with Rose Marie Beauchemin at the Beau Institute in New Jersey, and, in April 2014, she founded Pink Ink Tattoo and began performing realistic-looking areola tattoos on breast cancer survivors from across the country. Since 2014 she’s worked with more than two hundred clients and travels to plastic surgeons’ offices from Durham to Texas.

She charges $600 for bilateral tattoos (meaning both breasts) and $350 for unilateral (one breast), but because she’s a nurse and the tattoos are done in plastic surgeons’ offices, clients can seek reimbursement from their insurance companies. She says most insurance policies at least partially cover the procedure, thanks to the Women’s Health and Cancer Rights Act of 1998, which requires group health plans that cover mastectomies to also provide certain reconstructive surgery and other post-mastectomy benefits.

For many of these women it’s their first tattoo.

“I actually had a woman who was seventy-two years old, and she had waited seventeen years for her tattoos,” Dunsmore says. “She came in and waited until we were completely done, and she looked in the mirror and her eyes started tearing up and she said, ‘Tara, I’ve waited seventeen years for this.’ And I said, ‘What did you wait so long for?’ And she said, ‘I’ve been waiting for you.’ Even when I say it to this day, it jerks me up, because that’s what it’s about. This is the reassurance that I’m following the right path and doing the right thing.”

Even after tattooing more than two hundred clients, Dunsmore has yet to get her own tattoos redone, though she’s had plenty of opportunities to do so.

“Right now, I look at myself and it’s a reminder to me that this is why I do it,” she says. “They’re not horrible looking, but this is not acceptable. When I look at them, it reminds me of why I’m getting up tomorrow.”

While many women turn to a nurse or specialist for their areola tattoos, some women simply walk into a tattoo shop.

Caroline Moretto, a fifty-six-year-old who lives in Fuquay-Varina, opted to get her tattoos done by Candice Tekus of Mad Ethel’s Tattoos, whose work she came across through her daughter. Months before she was diagnosed with breast cancer in March 2015, Moretto had been scrolling through the Mad Ethel’s website and was enamored by a full chest and areola tattoo Tekus had done for a breast cancer survivor in Texas. So when she was diagnosed, Moretto figured the obvious choice was to visit Candice to add the finishing touch after her surgery and reconstruction.

“I figured a tattoo is a tattoo, and, to be honest, after a year of pulling your shirt off for everybody, to go in there and see Candice didn’t feel like a big deal anymore,” Moretto says. “Candice is so matter-of-fact about everything, so it wasn’t embarrassing or anything.”

Tekus has performed areola and nipple tattoos on a handful of clients during her eleven years working as a tattoo artist across the country, though Moretto was her first in Raleigh. When a survivor first approached her about getting areola tattoos years ago, she was nervous, but she was able to give the woman the illusion of realistic nipples and areolas using basic 3-D tattooing techniques.

In Moretto’s case, the plastic surgeon had already created a nipple by scoring the tissue in the center of the breast, so all Tekus had to do was create a little more shadow underneath the scar-tissue nipple bump, draw in the Montgomery glands, change the tone of the areolas, and blend out the scars.

“My husband’s really the only one who gets to see it, but I feel like showing everybody,” Moretto says, laughing. “You would not believe thisit’s amazing.”

Tekus charges about $80–$110 for a pair of areola tattoos, the same rate she charges for any tattoo of the same size. She says the shop has never filed a claim with an insurance company. Tattoo shops and doctors’ offices don’t often intermingle.

“Doctors don’t really refer clients to us because they tend to not have a lot of faith in tattoo artists, which is kind of sad, because we really could work together,” Tekus says.

Regardless of where survivors get their tattoos, Tekus and Dunsmore agree that this final step in the process of reconstruction can offer a sense of closure to the nightmare of breast cancer.

“When cancer comes along, these women are focused on fighting,” Tekus says. “When the fight is over, they’re left with this battle scar, which is an amazing thing, but at the same time, it’s a painful reminder every day. To be able to reconstruct it and bring it back to some form of normalcy is important.”

This article appeared in print with the headline “Invisible Ink”