of this procedure is that the color and texture of the nac is identical to that of the opposite breast. local tissue flaps: for patients who have undergone bilateral mastectomies (as well as patients receiving a unilateral mastectomy who do not want to pursue nipple grafting), a nipple can be created by raising a small, local flap in the target area and producing a raised mound of skin very similar in shape to a nipple. to create an areola, a circular incision may be made around the new nipple and sutured back again. while this option does produce the shape and outline of the nac, it does not affect the skin color. to make it appear more natural, the nipple and areolar region may then be tattooed to produce a darker skin color more similar to a natural nipple and areola. local tissue flaps with use of alloderm: as above, a nipple may be created by raising a small flap in the target area and producing a raised mound of skin. alloderm (cadaveric dermis) can then be inserted into the core of the new nipple acting like a "strut" which may help maintain the projection of the nipple for a longer period of time. the nipple and areolar region may then be tattooed later. there are, however, some important issues in relation to nac tattooing that should be considered prior to opting for tattooing, such as the choice of pigments and equipment used for the procedure. when looking at the entire process of breast reconstruction, patients typically report that nac reconstruction is the least satisfying step. compared to a normal nipple, the reconstructed nipple often has less projection (how far the nipple extends beyond the breast mound) and lacks sensation. in women who have undergone a single mastectomy with reconstruction, another challenge is aesthetically matching the reconstructed nac to the native breast. outcomes the typical outcome of breast reconstruction surgery is a breast mound with a pleasing aesthetic shape, with a texture similar to a natural breast, but which feels completely or mostly numb for the woman herself. this loss of sensation, called somatosensory loss or the inability to perceive touch, heat, cold, and pain, sometimes results in women burning themselves or injuring themselves without noticing, or not noticing that their clothing has shifted to expose their breasts. "i can't even feel it when my kids hug me," said one mother, who had nipple-sparing breast reconstruction after a bilateral mastectomy. the loss of sensation has long-term medical consequences, because it makes the affected women unable to feel itchy rashes, infected sores, cuts, bruises, or situations that risk sunburns or frostbite on the affected areas. more than half of women treated for breast cancer develop upper quarter dysfunction, including limits on how well they can move, pain in the breast, shoulder or arm, lymphedema, loss of sensation, and impaired strength. the risk of dysfunction is higher among women who have breast reconstruction surgery. one in three have complications, one in five need further surgery and the procedure fails in 5%. some methods have specific side effects. the transverse rectus abdominis myocutaneous (tram) flap method results in weakness and loss of flexibility in the abdominal wall. reconstruction with implants have a higher risk of long-term pain. outcomes-based research on quality of life improvements and psychosocial benefits associated with breast reconstruction served as the stimulus in the united states for the 1998 women's health and cancer rights act, which mandated that health care payer cover breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy. this was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. similar provisions for coverage exist in most countries worldwide through national health care programs.