Her wholly round 36Cs exposed, Paula Johnson watches Rose Marie Beauchemin mix pigment - first a little brown, then a little pink.

Through the magic of permanent makeup, Beauchemin is about to tattoo nipples on Johnson's reconstructed breasts.

"It's all about creating the illusion of protrusion," Beauchemin said one recent Monday afternoon at her Mount Laurel office as she gradually shaded in Johnson's areola and nipple area.

After just three sessions, Johnson's nipples look like the work of Mother Nature rather than Beauchemin's deft use of an electronic magic marker.

"This was the last step for me," said Johnson, 55, a trace of relief in her voice. The grandmother from Cherry Hill endured a double mastectomy two years ago after she was diagnosed with early-stage breast cancer. Johnson's mother died from the disease.

"Every day of my life, for so long, all I thought about was breast cancer. . . . I just wasn't ready until now" to get the tattoo. "Finally, I was like, 'Let's get this done,' " she said.

After reconstructive breast surgery, women have been known to go without nipples for years, explained Mandy Sauler, a West Chester-based tattoo artist who specializes in nipples.

That's because fighting breast cancer is a grueling process that often entails months or years of surgery, chemotherapy, and radiation. By the time entire breasts are removed, and nipples - which sometimes have malignant cells, too - go with them, getting a good facsimile is not always first on a woman's to-do list.

Doctors can build nipples onto new breasts as part of reconstructive surgery, but many patients are not satisfied with those add-ons because they lack natural gradual shading.

"Mine kind of fell off," said Jini Errichetti, 52, a school librarian and Cherry Hill mother of two, who was diagnosed with Stage 3 breast cancer in 2007 and had a single mastectomy. Nipples created through plastic surgery sometimes don't get sufficient blood supply, and the body rejects them. "I didn't even bother to go back in. I was left with this very light areola and you could hardly even notice it. ... "

Beauchemin completed her nipple tattoo last month.

Still, Errichetti is one of an increasing number of mastectomy patients demanding tattooed nipples, according to Sauler, who has started talks with the Abramson Cancer Center of the University of Pennsylvania Hospital to discuss fulfilling the demand.

After all, Beauchemin points out, it's the nipple that makes a breast a breast. This is why Beauchemin offers her tattooing services free to breast cancer survivors at her Beau Institute.

"I don't want women walking around without something that's so important to them that takes me less than an hour to do," said Beauchemin, who normally charges $300 to $800 per tattoo for women who have scarring from breast reductions or men who have had fat removed from their breasts.

Beauchemin, with perfectly cut black hair and unsmudged eyeliner and lipstick, worked as a makeup artist for most of her career. Then in the early '90s, a surgeon friend of hers suggested she learn the art of permanent makeup to help him with his trauma practice. He would reconstruct limbs lost in car and lawn-mower accidents, and she would use permanent makeup to cover up the scars.

Ten years ago, she opened her own office, first working with 20 breast cancer survivors a year. Now she's doing close to 50.

"Women are coming in younger and younger," she said.

Beauchemin wears pink scrubs in an office that looks more like a spa than a surgical center - and that serves her patients well, she said. Not only is everything pink, but flowers and fashion magazines populate the room.

Point them out and Beauchemin knowingly laughs, as the latest trends in fashion (flimsy-as-tissue T's and tanks) have actually brought her more clients - nipples that don't react to a chilly, air-conditioned room can be an asset.

Johnson's breasts were reconstructed using muscle tissue from her back. Although her doctor added nipples, they just didn't take. But like Errichetti, she didn't go back to her doctor to fix it. She turned instead to Beauchemin, whom she discovered on the Internet.

"I feel great," Johnson said. "If it wasn't for the fact that these breasts are a little uneven, you wouldn't even know I had surgery."

Contact fashion writer Elizabeth Wellington at 215-854-2704, ewellington@phillynews.com, or @ewellingtonphl on Twitter.