Emerging virus diseases are a major threat to humans and public health. Over the past two decades, there has been mounting interest in the increasing number of viruses causing unexpected illnesses and epidemics among humans. Emerging diseases also include as yet unrecognisable infections, or a previously recognised infection that has expanded into new ecological niche often accompanied by a significant change in pathogenicity. In the wake of these discoveries, the need for stronger infection prevention measures for personal services such as tattooing and cosmetic tattooing procedures needs to be revisited and re-established through more rigorous measures. This study provides an overview of some of the more common viruses and highlights their covert and sometimes non-symptomatic nature that tattooing practitioners need to be mindful of. It also presents precautionary measures that practitioners must take to protect against cross-contamination through infection prevention protocols. This study also looks at the importance of education and updates in education and the role of mandatory regulations.
Perception of skin color in the natural state, or with tattoo pigment installed in the dermis is highly complex and includes both optical requisites and eye and brain functions connected to advanced cognitive and psychological functions. Permanent makeup (PMU) is miniaturized tattooing on critical anatomical location aiming at fulfilment of a person's esthetic ideal. It is a special challenge since a satisfactory outcome depends on perfectionated technique and very critical selection of pigments. The eye can be compared to a digital camera, and the center of central vision in the brain to a computer and color integrator. Color perception is the end product of a complicated brain function. The background theory of color physics and perception is reviewed with emphasis on aspects related to changed skin color created by pigment installed in the dermis with the purpose to tattoo eyebrows, eyeliners, lips, and other locations. The delicate dosing of pigment relative to the natural skin tone is highlighted. The review is relevant for all aspects of PMU including medical tattooing, e.g., areola tattooing after breast cancer surgery. A detailed guidance to PMU artists and medical tattooists on selection and use of tattoo inks and pigments is provided. The guidance is also relevant to laser surgeons and technicians performing tattoo removal.
The European Union for Standardization called CEN (Comité Européen de Nomalization), as a result of the project named CEN/TC-435 in January 2020, released a new hygiene standard for tattooing as a non-binding recommendation on safe tattoo practice in Europe, ready for national implementation. It describes hygienic standards for facilities, instruments, tattoo ink handling, and tattoo procedures. Informed consent is included. It is generic and covers all sorts of tattooing. Medical tattooing is performed in hospitals, private clinics, and in tattoo parlors. Hospitals have their own settings and hygiene standards. The article describes practical challenges of medical tattooing performed in hospital settings, with medical tattooing performed in parlors as the reference, with respect to adherence to hygiene standards of different background and nature. It is a challenge possible to overcome in practice. The specialized field of medical tattooing is also visited, and indications and precautions described.
Cosmetic tattoos are in the same family as medical tattoos and conventional cosmetic care and fall within the overall concept of body modification. Each discipline has its own segment of users and its own techniques and professional providers. However, they all serve the higher aim of shaping the skin and the body and improving image and self-esteem.
Microblading is a rapidly expanding technique in cosmetic and medical tattooing, used for eyebrow correction and conditions of hair loss. Tattooing is performed by hand using a special blade; tiny cuts in the outer skin are filled with dark pigment to simulate a natural hair. Indications, the technique, and the microblading procedure step-by-step are considered in what follows. Details on client selection and a range of pitfalls are discussed. The leading application of microblading is cosmetic tattooing of the eyebrows adding pigmented "hairstrokes" to the natural brow area. Tattooed "hairstrokes" fade in color over months and a repeated "touch up" procedure may be required. Pretreatment with laser removal of tattoos of the past may be indicated when a client requests a "touch up" with another brow in another style, shape, or extension. Microblading carries the risk of scarring. The combination with conventional machine-driven needle tattooing for background shading the skin of the brow is also discussed. Microblading is also used as a corrective intervention in a range of dermatological and medical conditions. Having grown exponentially for cosmetic purpose in the first phase of microblading parallel to acquired refinement, the method is now mature and ready to make further progress on medical indication in the coming second phase. The medical community should welcome this opportunity for supplementary correction with restoration of the normal brow anatomy added to other achievements in dermatological and medical therapy.
Tattooing for medical purposes may have been around more than 5,300 years ago, but most of the interest and changes have occurred during the last 100 years as a consequence of scientific advances leading to quicker, cleaner, and less painful insertion of pigment into the skin as well as advances in medical knowledge allowing for more relevant individual information to be transmitted by the embedded pigment. These changes are ongoing. Cosmetic tattooing or tattooing for camouflage of body surface imperfections, likewise, has advanced during the last 50 years concurrently with the rise of social media, internet access, and the popularity of personal electronic visuals.
Vitiligo is an acquired skin depigmentation disorder that affects 0.5-2% of the world population. It is characterized by loss of the natural brown melanin pigment of the skin clinically manifested as few or many white patches on the skin and microscopically with the total absence of me-lanocytes in the epidermis. The change in appearance caused by vitiligo can affect persons' emotional and psychological well-being and may cause them to alter their lifestyle. The social complication of vitiligo depends on ethnicity and on geography and local opinion, which may deem vitiligo contagious. The aim of the medical tattooing procedure in vitiligo is to revert the white vitiligo patches to normal-looking skin of natural or near natural color through installation of brownish tattoo pigment. The coloring effect is not permanent and tends to fade over time, and repeated treatment may be needed after about a year. This chapter reviews vitiligo and indications, technique, and procedures associated with medical tattooing of the disease.
Tattooists and their customers are under special risk of airborne infection because of the short distance during the procedure and the unavoidable exchange of expired and inhaled air potentially containing droplets holding pathogenic germs. Moreover, the manual procedure involves a significant risk of contamination through physical contact. A range of personal protective equipment (PPE) is available, including three-layered disposable surgical masks, cotton masks, respirators without or with expiration valve, visors and shields, goggles, medical gloves and aprons. Disinfectant fluids and wipes are used for skin and physical objects. Alcohol is used but may evaporate too fast and lose biocidal efficiency; it carries risk of fire. Alternatives such as chlorine and a range of new disinfectants listed in the EU biocide directive should be considered as alternatives. PPEs and disinfectants are subject to formal testing and classification. EU and US requirements are visited. No PPE and no disinfectant have 100% efficiency. Efficiency of masks is influenced negatively by the reduced breathability from masks and respirators with leakage of air between mask perimeter and the skin. Gloves have micro-porosity dependent on wear time and already after 30 min become less efficient. The humid microclimate under masks and gloves easily causes skin problems. Thus, there are many pros and cons to consider. Thoughts on ideal aim, sound sense and realistic application of PPE and disinfectants in daily routine in tattoo parlours are provided, the risk and health of the tattooist included.
This chapter explains the international regulative framework on equipment and inks for cosmetic and medical tattooing. In the following text, the word "tattooing" refers to body tattooing, permanent makeup, and microblading. From a global perspective, regulation of equipment for cosmetic (decorative) tattooing, and especially inks, is inconsistent and mainly based on a diversity of national laws. In contrast, regulation of equipment for medical tattooing is subjected to the internationally harmonized medical devices regulation. Even though dermal invasiveness and biological mode of action are identical for cosmetic and medical tattooing, the regulatory requirements are separated in two divergent regulative frameworks.
Cosmetic and medical tattooing is miniaturized tattooing of high precision and thus requires many dedicated utensils including advanced devices for marking and anatomical delineation. Symmetry is a special demand, as is aesthetic outcome, building on perfectionated detail. The artist shall master design and strategy along with advanced technical performance helped by having and using the right tools. This article reviews and illustrates the many special utensils involved in good-practice cosmetic and medical tattooing, exemplified by selected tools used for cleansing, disinfection, pre-operative measurement and marking, and special tattoo machines, cartridges, microblades and needles. Personal protective equipment used to prevent infections among technicians and customers are also illustrated. Educational tools, such as face phantoms and eyebrow mats, are displayed. Mastering cosmetic and medical tattooing is a challenge and involves mastering the many auxiliaries along with needle configurations, machines, inks and the whole setting of the activity. This review is an illustrated practical record and a guideline to good professional practice.
The Q-switched neodymium-yttrium aluminium garnet (Nd:YAG) laser remains the gold standard method for tattoo removal including cosmetic tattoos. Modern picosecond lasers are referenced to the Nd:YAG laser and essentially do the same job. Persons with cosmetic tattoos in the face are especially eager to achieve perfect removal or correction and from start are critical to suboptimal results. Customers mostly request complete removal; sometimes the goal is fast treatment and bleaching to prepare for a cover up tattoo. Removal or correction of eyebrows is the largest group, followed by lip tattoos and eyeliners. The article gives a systematic and stepwise introduction to routine cosmetic tattoo removal by laser in an Austrian private medical practice. Rationales and selection of customers who can benefit from treatment, preparation, performance, and aftercare is reviewed. Emphasis is given to qualified power adjustment of the laser equipment and the treatment strategy, e.g. the delicate navigation between efficient removal and the risk of short-term and long-term adverse effects. Treatment relies on a partnership between provider and customer. Over the months of treatment, customers gain more insight into the possibilities of treatment, so that they get an understanding of the realistic results that can be achieved. Therefore, customers are also satisfied even with results that are not always optimal since best treatment was given a fair chance.
Cosmetic and medical tattooing are in rapid growth on all continents. The tattoos contribute to self-esteem and quality of life. Clients and patients have many different backgrounds and often highest aesthetic expectations, which the professionals shall meet. In this situation, correct, relevant, and personalized information on effectiveness, technique, procedures, and risks is highly important to reach a shared goal without misunderstanding and conflict. Information and agreement between provider and client are crystalized in the informed consent document. This article reviews the many aspects of pre-procedure client information explained in a book format providing information, which is of direct practical usefulness.
Medical tattooing aims to restore the normality of skin structures in patients who have skin diseases or suffer sequelae after surgical interventions or hazards. There are numerous applications, with tattooing of vitiligo and the nipple areola complex after breast cancer surgery as leading fields. The use of 3D or realistic tattoo techniques has increased the potential of medical tattooing and improved the aesthetic results. The tattooist must have good technical training combined with artistic and creative talents. In this chapter, two innovative applications of medical tattooing will be presented as examples, i.e. tattooing of the nailbed and the gingiva. Nailbed tattooing reconstructs the normal perception of the nailbed and the nail plate when the nails have previously been removed though a surgical procedure. Tattoo of the gingiva performed after a connective tissue implant of the gum is a new application. These treatments, approved by a physician and performed by a tattooist with proven experience in medical tattooing, also involve the use of specific color nuances that produce an extremely realistic outcome.
A characteristic feature of the anatomy of the human face is its arrangement in layers. The main layers include, from outside to inside: (i) the skin; (ii) the subcutaneous fat; (iii) the superficial musculoaponeurotic system; (iv) the deep fat, and (iv) the periosteum overlying the bony structures of the skull. Herein, the facial bones provide the basis for the ligaments and other facial structures that are attached to them. In contrast, the muscles control the mimics and movements, hence the dynamic anatomy of the face. The skin represents the outermost structure of the body and protects the organism from external physical, chemical, and biological stresses. The strive for facial attractiveness and beauty is a strong motivation for cosmetic and aesthetic procedures, including (permanent) makeup, minimal-invasive up to invasive surgical interventions, which have dramatically increased in numbers over the past decades. A youthful appearance is regarded as one of the essential characteristics of an attractive face. The characteristic features of the aging face are a downward migration of the facial soft tissues, a loss in volume of the fat compartments, the formation of mimic wrinkles, a decrease in dermal hydration, and others. Modern anti-aging treatments aim to reverse these alterations with the least possible side effects. However, effective and safe cosmetic, aesthetic, and medical treatments presume a profound knowledge of facial anatomy.
Tattooing of the eyeline is an utmost delicate procedure because of the subtle structure and the thin skin of the eyeline and the closeness to the eye. The esthetic outcome and customer satisfaction also have a narrow range. The artist therefore must be both talented and experienced. Indication, contraindication, customer information, and customer preparation and involvement throughout the procedure is reviewed along with the technical aspects of safe procedure and precautions taken. Examples of the many challenges of eyeliner tattooing both regarding the practical setting and the esthetic result are illustrated with many figures. Potential complications, some of them serious, are reviewed. Post-treatment care and need for retouching and cover-up are also discussed.
Cosmetic tattooing and medical tattooing of the face share basic principles and to some degree types and spectrum of technical and clinical complications known from decorative tattooing of other parts of the body. Cosmetic tattoos recently have grown exponentially in popularity in industrialized countries all over the world. The different complications and their clinical symptoms, pathophysiology, diagnosis, treatment, and prevention are analyzed versus culprit pigments and updated. Eyeliner tattooing is associated with special complications because of the subtle anatomy and the closeness to the eye, and the risk of meibomian gland damage. The spectrum of cosmetic tattoo complications includes early-onset complications (infections particularly with herpes simplex, healing issues, aesthetic and technical mistakes with regret), and late-onset complications (color fading and color shift, "blowout" pigment escape to surrounding skin, papules, nodules, granulomas associated with sarcoidosis, allergic reactions in lip tattoos with lichenoid dermatitis, eye irritation, and fibrosis and scaring especially after microblading); miscellaneous complications include severe burn sensation in tattoos during magnetic resonance imaging later in life. Corneal tattooing and subconjunctival/episcleral tattooing performed on medical indication by ophthalmologists, and for decoration by tattooists carry special risk of intraocular complications. It is recommended for the purpose of research harmonization that terms and diagnostic classification of tattoo adverse events follow the system introduced by the Tattoo Clinic of Copenhagen and already accepted in specialized tattoo clinics in other centers.
Cosmetic tattoos may cause burning sensation during magnetic resonance imaging (MRI) and interrupt the procedure, and thereby any diagnostic workup. Tattoos also may cause disturbing artefacts in MRI images. The sensation, which can be painful, is due to magnetic elements in the tattoo ink deposited in the tattooed skin. It is not a thermal burn but a subjective sensation of burning. Tattoo ink bottles can be tested for magnetic properties by the artist in the studio, before cosmetic tattooing is performed, using a simple magnet test. This test and the pitfalls of the test are described. Hospital departments and clinics should be aware of the problem, and patients assessed prior to MRI regarding their tattoos, particularly eyebrows and eyeliners made in brown and dark colors. Red tattoos exemplified by tattooed lips are not prone to MRI-induced burning sensation. The problem is related to inorganic pigments with ferromagnetic properties.
Alternatives or complements to laser tattoo removal are needed. Laser removal requires 8-12 sessions and can easily take longer than a year. Some colors cannot be removed, and scars may appear. Applied to allergic reactions in red tattoos, lasers can boost the allergy. A recently developed 20 MHz high-intensity focused ultrasound (HIFU) is introduced as a complementary method to lasers, but also as a stand-alone treatment for selected groups. 20 MHz HIFU allows for application of high-power ultrasound energy to very small focal targets in the dermis, and thereby precise confinement of thermal lesions in the outer layers of human skin, precisely where tattoo inks are deposited. HIFU treatment is "color blind" and can target any type of colored pigment in the dermis. It produces a controlled thermal lesion (up to 65°C) with superficial necrosis followed by an eschar with embedded tattoo pigment. This eschar, containing the tattoo pigment, is discharged over some weeks, and finally replaced by healed skin. HIFU can efficiently remove tattoos of any color in only 1-3 sessions. It can be applied to tattoos when lasers fail to produce efficient removal. The types of side effects are the same as with lasers. The operator shall be trained and knowledgeable. 20 MHz HIFU can furthermore be used in clinical and esthetic dermatology for various other applications, and a range of applications are open in clinical dermatology.
Needles, machines, and techniques used for professional cosmetic and medical tattooing have reached a high level of sophistication. Best utensils are combined with operator's insight - the key to best results. Nowadays, a broad range of different tattoo needles serving different purposes are available. The chapter reviews round, flat, triangular, magnum, nano, polished, textured needles, etc. and their coding and preferred use in practice. The chapter is intended to be the vade mecum for practitioners in the field, the newcomer as well as the experienced, in private setting as well as in hospital.
Medical tattoos are used for camouflage of a wide range of disfiguring skin pathologies and conditions. Recently, tattooing of the nipple and areola of the breast has been introduced as a corrective treatment of sequelae from breast cancer surgery and radiotherapy. The psychologic impact of a disfigured nipple and areola can invalidate self-esteem of the sufferer lifelong with major consequences for social life. Medical tattooing can often restore the visual appearance of the nipple-areolar complex back to normality and even improve the 3D impression of the entire breast. High skills of the operator are needed. The article reviews the theoretical background, patient selection and information, technical performance, and aftercare. Close cooperation between surgeon, dermatologist, and medical tattooist is essential. Medical centers treating breast cancer should routinely have access to corrective medical tattooing.
