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This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Cosmetic tattoos, which are better known as permanent make-up, have become popular in the last decades. This same procedure can be used to camouflage pathological skin conditions, to mask scars and to complete the aesthetic results of plastic and reconstructive surgeries. The risks and complications of tattooing procedures include infections and allergic reactions. Scarring can occur. Fanning and fading of the colorants and dissatisfaction with colour and shape are not unusual. Different lasers can offer solutions for the removal of unwanted cosmetic tattoos, but complications due to the laser treatment, such as paradoxical darkening and scarring, can arise.

Since the 19th century, several reports have illustrated the medical applications of tattooing for aesthetic purposes [1,2,3]. The introduction of eyelid tattooing in 1984 represented a new start of facial cosmetic tattooing [4]. The main purpose of cosmetic tattooing is to enhance natural beauty and to increase physical appeal. The majority of subjects choose cosmetic tattooing because it offers an easy alternative to conventional make-up.

Cosmetic tattooing, which is also called micropigmentation, is usually performed with an electrical tattoo device or a tattoo pen with a rotating or oscillating disposable needle (fig. 1). Small droplets of specific permanent make-up (PMU) tattoo ink are implanted into the superficial layer of the dermis in contrast with decorative tattooing, in which the deposition of pigment occurs deeper within the dermis. Some PMU devices are programmed for specific indications. A good knowledge of anatomy is important to ensure for good results. Single-use ink caps are advised, and registration of the colours used can be helpful for later corrections. Prepared inks are available on the market, but some professionals make their own mixtures to obtain optimal colours to match a client's favourite make-up. The elimination of pigment can occur during the first days of healing. After healing, the remaining pigment particles are stored in dermal macrophages and fibroblasts. The nature of the material used and the level of implantation influence the quality and stability of the results. Because the level of application of PMU is more superficial than that in decorative tattooing, the spontaneous elimination of the colorant and fading may occur within years.

Fig. 1

Tattoo (PMU) device.

Fig. 1

Tattoo (PMU) device.

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PMU is an excellent replacement for conventional make-up and a practical solution for people with an active lifestyle because it is time saving and always looks perfect and fresh [5] (table 1). Some choose this procedure because they have a physical impairment complicating the application of temporary make-up. Eyeliner or blepharo-pigmentation, lip liner and eyebrow colouring are very popular. When it is properly applied by an experienced technician, PMU can be more natural and realistic in appearance than conventional make-up. Medical indications include corneal reconstruction and nipple-areola complex reconstruction after breast reduction or breast cancer surgery [3] (fig. 2). Tattooing may help to camouflage scars, birth marks, vitiligo and alopecia and also offers a solution for patients with allergies to conventional cosmetics [6] (fig. 3).

Table 1

Indications for cosmetic tattoos/PMU

Indications for cosmetic tattoos/PMU
Indications for cosmetic tattoos/PMU
Fig. 2

Nipple-areola complex reconstruction before (a) and after (b) (courtesy of Rika Dubelloy).

Fig. 2

Nipple-areola complex reconstruction before (a) and after (b) (courtesy of Rika Dubelloy).

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Fig. 3

Vitiligo lip correction before (a) and after (b) (courtesy of Rika Dubelloy and Finishing Touches).

Fig. 3

Vitiligo lip correction before (a) and after (b) (courtesy of Rika Dubelloy and Finishing Touches).

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Tattooing in general is not without risks [7] (table 2). The major risk of complications and dissatisfaction is caused by the performing of the procedure by an inexperienced person under poor hygienic circumstances and with materials of dubious origin. Side effects can be related to the procedure and the aftercare and also to the instruments and compositions of the inks used [8]. Short-term side effects include mild swelling and crusting, which are usually dealt with by clients and tattooists and not reported. However, when more important problems, such as infections and allergic reactions, arise, medical advice is required [9]. The US Food and Drug Administration (FDA) registered only 5 reports of adverse reactions associated with PMU from 1988 to 2003. Beginning in 2003, the FDA received more than 150 reports of adverse events occurring in persons who had undergone PMU procedures, including some severe and long-term disfiguring complications. Symptom durations have ranged from 5.5 months to more than 3 years. More adverse reactions have been linked with a specific product line, suggesting an increased risk associated with the use of these inks. This product line was recalled from the market in September 2004 [10].

Table 2

Complications of tattooing

Complications of tattooing
Complications of tattooing

When performed under correct hygienic conditions and with sterile materials, the occurrence of bacterial infection is rare. Inks can be contaminated before or after bottles are opened [11]. In recent years, several cases of atypical mycobacterial infections in decorative and cosmetic tattoos have been reported [12,13,14]. Histological and microbiological confirmations are helpful to exclude other granulomatous conditions, such as sarcoidosis, foreign body reactions and allergic granulomatous manifestations and to identify the responsible pathogen [15,16,17]. Source identification is a very important issue [12]. The registration of inks in a client's file can help to identify contaminated batches. Recently, a voluntary recall of tattoo ink, tattoo needles and tattoo kits distributed by White & Blue Lion due to pathogenic bacterial contamination was announced by the FDA [18].

Viral and mycotic infections are extremely rare. Unsterile equipment and needles can transmit all types of blood-borne infections, such as hepatitis and human immunodeficiency virus. Preventive screening of body art practitioners and vaccination for hepatitis B are advised. The risk of herpes simplex reactivation on the lips induced by the procedure should be taken into account (fig. 4).

Fig. 4

Herpes simplex of the lip (courtesy of Jørgen Serup).

Fig. 4

Herpes simplex of the lip (courtesy of Jørgen Serup).

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The pigments and dyes used in tattoo and PMU inks are relatively inert and are usually well tolerated. Allergic reactions to colorants are rare, but when they occur, they may be particularly troublesome because the pigments can be difficult to remove. The majority of allergic reactions that have been reported have been related to red inks. Hypersensitivity reactions can have different clinical and histological presentations, including lichenoid, psoriasiform, eczematous, lymphomatoid and granulomatous reactions. Clinical aspects and histopathologies are often suggestive of a delayed-type allergy (fig. 5). Skin testing, however, has produced very disappointing results [19]. In vivo haptenisation of the colorant could be the explanation [20]. Contact dermatitis to other ingredients and additives or to the materials used during and after the procedure, such as topical antibiotics, can also occur. Photosensitivity of tattoos is probably the reason why more adverse reactions have been reported in tattoos in sun-exposed areas, such as the hands and face [7,21].

Fig. 5

Allergic reaction of PMU lip liner (courtesy of Jørgen Serup).

Fig. 5

Allergic reaction of PMU lip liner (courtesy of Jørgen Serup).

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In general, cosmetic tattooing causes little discomfort, and side effects are rare, although complications, such as eyelid necrosis, the loss of eyelashes, secondary cicatricial ectropion, hypertrophic scars and keloids, have been reported [1,13]. To reduce the risk of ocular injury, protective eye shields can be used during the procedure [22]. The possibility of the Koebner effect in patients with a pre-existing skin disorder, such as psoriasis, must be considered. There have been reports of people with tattoos and permanent make-up experiencing swelling or burning in the tattooed areas when undergoing magnetic resonance imaging. This has been reported only rarely and has not been associated with any lasting effects. Pigments may also interfere with the quality of the image, particularly in the eye area [23]. The extremely rare association of skin cancer with tattoos in general and with PMU in particular seems to be a coincidence rather than a causative relation [24,25].

Some people have unrealistic expectations and are unhappy with their cosmetic results. Customers should be informed that tissue augmentation, botulin toxin injection and plastic surgery of the face can change the appearance and lead to the distortion of PMU.

The most common complications and patient dissatisfaction, however, result from the misapplication of colorants, pigment migration and pigment fanning [5,26]. In these situations, the advantage of being permanent becomes the greatest disadvantage (fig. 6).

Fig. 6

Dissatisfaction. Unnatural aspect of eyeliner and fanning of the pigment.

Fig. 6

Dissatisfaction. Unnatural aspect of eyeliner and fanning of the pigment.

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Medical complications should be treated with specific case-related measures. Localised bacterial infections require antiseptic or antibiotic treatment to minimise the risk of scarring. For severe infections, systemic antibiotics are needed. Allergic manifestations can be treated with topical applications or infiltration with corticosteroids [19]. The combination of intralesional injections of steroids and 5-fluorouracil has been used to treat foreign body reactions and may be considered. The resolution of a lip-enhancing tattoo reaction by topical tacrolimus treatment has been documented by Wylie [27]. Granulomatous reactions are often problematic because the causative material is difficult to remove. Systemic therapy with corticosteroids and cyclosporine can be used but rarely provides satisfactory results. Chronic reactions sometimes require more invasive techniques, including surgical dermabrasion or pigment removal with ablative lasers [28,29,30]. Objectionable tattoos can be camouflaged with conventional make-up. Over time, most cosmetic tattoos fade spontaneously. Some people attempt to cover an unwanted tattoo with a new one with flesh tones, which seldom gives satisfactory cosmetic results because skin-toned pigments tend to look unnatural due to the fact that they lack the skin's natural translucence. Moreover, the dark underlying colours are difficult to hide. Medical advice is sought by people who want their tattoos removed. Successful treatments with tretinoin and with penta-monogalloylglucose have been reported but have not been confirmed by large studies [31,32]. Non-specific removal techniques, such as surgery and dermabrasion, are available but have risks of scarring and residual textural and pigmentary changes. The best cosmetic results can be obtained using pigment lasers, but even this technique has its risks, and the complete clearing of the tattoo cannot be guaranteed [33] (fig. 7, 8). Flesh tones and red tattoos containing ferric oxide may show immediate darkening when treated with short pulse lasers [33,34,35,36]. This is probably caused by the reduction of red-brown-coloured ferric oxide to black-coloured ferrous oxide (fig. 9). In our experience, the dark colour can often be subsequently removed using another appropriate wavelength [5]. Paradoxical darkening can also occur in tattoos containing titanium dioxide. The topical application of perfluorodecalin may be helpful for the reduction of laser-induced whitening, allowing for more laser passes per treatment session and improving the outcome [37]. In some recalcitrant cases, dermabrasion techniques with a carbon dioxide laser can offer a solution [28]. Pico-second lasers could be more effective but are still under investigation.

Fig. 7

Dissatisfaction with the colour and shape of eyebrow PMU.

Fig. 7

Dissatisfaction with the colour and shape of eyebrow PMU.

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Fig. 8

Results of partial clearing after treatment with a combination of a QS Nd-Yag 532 and QS Nd-Yag 1064 laser.

Fig. 8

Results of partial clearing after treatment with a combination of a QS Nd-Yag 532 and QS Nd-Yag 1064 laser.

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Fig. 9

Darkening of PMU after treatment with a QS Nd-Yag 532 laser.

Fig. 9

Darkening of PMU after treatment with a QS Nd-Yag 532 laser.

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Although cosmetic tattooing is a common and popular procedure and is usually well tolerated, complications can occur. One problem associated with this procedure lies in the lack of uniform legislation worldwide and the lack of control of the production of the substances used. The availability of correct information about the associated risks as well as the performance of the procedure by a well-trained professional can minimise complications and dissatisfaction.

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