Jennifer Jaye didn’t think about her mastectomy scar — much. Without a full-length mirror in her New York City home, she rarely noticed the site where her left breast was removed due to cancer nearly five years ago.

But the idea of a post-mastectomy tattoo to transform the scar had always appealed to Jaye. Last September she was in the right place at the right time, when Inked Magazine held a contest inviting local breast cancer survivors to enter for a chance to win a tattoo. One essay later, Jaye was selected and ready to meet with the tattoo artist. (Note: Jaye is a pseudonym, used by Jennifer in modeling work to preserve her privacy.)

Although plastic surgery and breast reconstruction have come a long way toward giving women who have undergone mastectomies a realistic breast with a natural-appearing nipple, for some women, scarring from surgery may alter their body image. That’s why some survivors take the bold step of hiring tattoo artists to apply personalized designs where breast cancer treatment has left its mark.

[See: What Only Your Partner Knows About Your Health.]

Turning Scars Into Art

On Tuesday, JAMA published an illustrated piece on the healing role of post-mastectomy tattoos, authored by David Allen, a Chicago-based tattoo artist. The piece was a change of pace from what medical journals traditionally produce.

Ten years working with breast cancer survivors has honed Allen’s technique, to which he brings a strong sensitivity. The period Allen spends with his client before applying the tattoo is as important as the procedure itself. “There’s a whole process behind this,” he says. “Part of it is empathy and composition and design. Part of it is just being able to be present and handle the amount of time with the person.”

First, Allen and the woman chat so he can learn about her tastes and personality. Once she feels comfortable, he says, “We start to design. It may be as simple as they don’t like roses. Or it may be as complex as, ‘I want this specific area covered.” Together, they sit in front of a computer as he moves and edits design features onto the photographed breast.

Allen uses a particularly gentle tattoo application process for these clients, selecting fewer and smaller needles and using a quiet rotary machine to create organic, botanical imagery. The tattoo takes anywhere between two and six hours, depending on whether it’s a single or double mastectomy, and the scar’s size and surface area. Another consideration is how women handle pain. While tattoos in the chest area can be “pretty painful,” he says, one silver lining of cancer treatment is that nerve endings may be dulled, reducing discomfort.

Allen charges between $1,200 and $2,200 for a post-mastectomy tattoo. While it’s not the most lucrative work he does, given the time commitment, he values the opportunity to help women regain control and see something beautiful evolve from the trauma of breast cancer treatment.

[See: What Not to Say to a Breast Cancer Patient.]

In her work, Dr. Michaela Tsai, an oncologist with Minnesota Oncology who also practices at Abbott Northwestern Hospital, in Minneapolis, has treated many women with breast cancer. About seven years ago, she herself became a patient, undergoing a double mastectomy.

“I had my surgery several years before I decided to get a tattoo,” Tsai says. “I was inspired by a patient of mine who had … a tattoo to cover her incision.” Once the idea took hold, Tsai did some research, talked to her plastic surgeon and discovered Allen’s work on the internet. They scheduled an appointment and off she went to Chicago.

“Women who do mastectomy and reconstruction often lose their nipple,” Tsai explains. In that case, she says, the norm is for the plastic surgeon to artificially create a nipple and do a nipple tattoo. This is a simple tattoo of the areola, matched toward the natural pigment, routinely done as part of reconstruction. But that’s far more basic than the work Allen does. His complex tattoo work is compatible with the process of breast reconstruction, he says, once a woman is far enough out from surgery to make sure the skin and underlying tissue have healed.

Tsai, who opted for a grayscale botanical image, says that before she had breast cancer, the thought of getting inked was not on her radar: “For me to travel to Chicago to go to a tattoo parlor was very much out of the norm for me and my family.”

Afterward, she says, “You always have that moment of, ‘Oh, my, gosh, what have I done?’ You can’t take it back.” Even so, she adds, “I really had no regrets and I grew to love it more and more every day. And I still feel that way.”

Key Considerations Before Getting Inked

With breast reconstruction, the goal is to create a sense of proportion and balance, and to remodel the nipple to achieve as believable a breast as possible, says Dr. Mark Migliori, a surgeon with MMK Plastic Surgery in Edina, Minnesota. Women who get post-mastectomy tattoos go a step beyond, he says, with an attitude not only of empowerment, but of pride and ownership.

Migliori, who has met and sometimes consulted with Allen, admires his design aesthetic. Even more importantly, he says, is the respect Allen has for the individual’s skin and his awareness that breast cancer patients have favorable or unfavorable scars, may have undergone radiation and could have surgical side effects like chronic swelling, or lymphedema.

Before women consider an artistic tattoo after breast cancer, Migliori and Tsai advise taking these steps:

— First, let time heal. Waiting at least one to two years after mastectomy allows the skin to heal and stabilize after surgery and radiation, Migliori says, and reduces the likelihood of problems including infections.

— Consider if a tattoo is physically right for you. “A patient who has had repeated infections or cellulitis is really not a good candidate,” Migliori says. “Because you are breaking the skin barrier when you do this.” That potentially raises the risk for future issues.

— Consult your doctor. Talk to your oncologist or plastic surgeon before taking the step of tattooing. They can evaluate if your recovery is far enough along to proceed to tatooing.

— Make sure you’re emotionally ready. Before getting a tattoo, it’s important for patients to experience the grieving process that comes after breast cancer and mastectomy, Migliori says. The tattoo shouldn’t be seen a cover-up, he says, but a triumph.

— Research many artists and get referrals. Talk with others who’ve had these tattoos and ask about their experience. Not every tattoo artist has the knowledge and skill needed for this delicate work. “You want to make sure they have experience working with scar tissue and radiated tissue,” Tsai says. “And do they actually have the empathy or the emotional sensitivity to work with people who’ve been through cancer and cancer surgery?” Your oncology team may be able to provide recommendations of capable artists. One unmet need Migloiri brings up is for artists like Allen with expertise in this area to construct some kind of educational process for other tattoo artists, to help them understand what can and can’t be done for safe application. This is one area over which the medical community has no control, Migliori notes.

— Check out the tattoo artist’s body of work. As one resource for comparing artists and exploring design ideas, Tsai suggests checking out P.ink for information on post-mastectomy tattoos.

[See: 10 Lessons From Empowered Patients.]

The Big Reveal

While some women might prefer to keep their body art a private boost to self-esteem, others are ready to show it off.

In September 2016, Jennifer Jaye spent a day at the Inked Magazine studio with Ryan Ashley Malarkey, a tattoo artist based in Kingston, Pennsylvania. Their tattoo session was videotaped and later posted online for Breast Cancer Awareness month. The resulting tattoo left Jaye awestruck. “It felt so good to have something this beautiful,” she says.

Jaye revealed her body art with a flourish — modeling her tattoo in a February show featuring breast cancer survivors, held as an independent event during New York Fashion Week. “It’s so awesome I want everyone to see it,” she says. “And I didn’t want anybody to see a scar.”

More from U.S. News

10 Ways to Prepare for Surgery

When Health Treatments Go From Hospital to DIY

Which Medical Screenings Should You Have in 2017?

How Tattoos Are Transforming Mastectomy Scars originally appeared on usnews.com