Tattooing: Medical uses and problems
ABSTRACTDecorative tattooing is a custom thousands of years old and is growing in popularity today. Medical professionals may be less familiar with its medical applications—medical alert tattooing, reconstructive and cosmetic applications, endoscopic tattooing, corneal tattooing, tattooing in radiation oncology, and uses in forensic medicine. We review current medically related tattooing applications and discuss their potential risks and benefits.
KEY POINTS
- Tattoos that state an advance directive for health care are not recognized as meeting the legal requirements for advance directives. They should only be considered as a guide to treatment decisions.
- Tattooing for medical-alert purposes is part of current culture. People with diabetes should avoid tattooing of feet or lower legs in view of impaired healing.
- Endoscopic tattooing is commonly used to aid visualization of diseased bowel segments during laparoscopic surgical procedures. Complications are rare but include mild chronic inflammation, abscesses, inflammatory pseudotumors, focal peritonitis, and peritoneal staining.
- Improper sterilization of tattooing needles can cause a wide range of infectious diseases and skin reactions.
RECONSTRUCTIVE AND COSMETIC TATTOOING
Areolar reconstruction
Breast reconstruction after mastectomy is fundamental to the psychosocial health of the patient and helps her regain a positive body image.16,17 Tattooing of the nipple-areola complex16 is usually the final step of the breast reconstruction process.
Complications of areolar tattooing are rare but can include local erythema and infection. 18 And patients should be informed that the tattoos will likely fade over time and require re-tattooing.18
Tattooing as camouflage
Tattooing is used to repigment the skin in conditions that cause hypopigmentation or hyperpigmentation, 2 including burns.19 It is also used as an alternative to laser treatment in port-wine stain and in cosmetic surgery of the scalp.20
Tattooing is used for micropigmentation of the lips and fingertips in patients who have vitiligo. However, this should be reserved for those with stable vitiligo, since tattooing may trigger another patch of vitiligo at tattoo sites.21
Although medical management exists for vitiligo, it is often ineffective for lip vitiligo since the success of medical therapy depends on the pigment-cell reservoir at the site of depigmentation. The lips lack such a reservoir of melanocytes, so tattooing may be an option.22
Corneal scarring
Perforating injury, measles keratitis, and other conditions can result in cosmetically disfiguring discoloration of the cornea. When microsurgical reconstruction is ineffective or is not an option, corneal tattooing has been reported to provide satisfactory results at up to 4 years.23 Reopacification, increased opacity, fading of the tattoo pigment, and epithelial growth have been reported, and in one series, most patients required reoperation.24
Tattooing to hide surgical scars
Spyropoulou and Fatah25 reported three patients in a plastic surgery practice who underwent decorative tattooing to camouflage cosmetically undesirable scars. The authors suggested this as a valid option, especially in younger patients, among whom tattooing is common and acceptable.25
‘Permanent makeup’
Tattooing is also used to simulate makeup (“permanent makeup”) and may be beneficial to people allergic to conventional makeup or people with disabilities that make applying makeup difficult.26 Complications of this procedure include bleeding, crusting, swelling, infection, allergic reactions, hypertrophic scars, keloid, loss of eyelashes, eyelid necrosis, and ectropion, as well as complications related to magnetic resonance imaging (described further below).
Most pigments used for this purpose do not have an established history of safe use, and patients may experience severe allergic reactions. A recent report described severe allergic reactions resistant to topical or systemic therapy with steroids in combination with topical tacrolimus (Prograf), especially after exposure to red dye 181.27 Researchers have recommended the regulation and control of colorants in permanent makeup.27
RADIATION ONCOLOGY
Tattooing is used in radiation oncology to ensure accurate targeting of radiation therapy. Typically, several small, black marks 1 to 2 mm in size are applied by a medical professional using an 18- or 19-gauge hypodermic needle and india ink.2 The marks are permanent.
Although these markings are clearly helpful during radiation treatment, they can be psychologically upsetting to patients, as they are a constant reminder of the disease and the treatment, both during the treatment course and long after it is finished.
An alternative is to use temporary marks for the 6 to 7 weeks that patients typically need them. However, temporary tattooing is prone to fading, and this is a key limitation.
ENDOSCOPIC TATTOOING
In laparoscopic gastrointestinal surgery, lesions are often difficult to visualize and localize since the surgeon is unable to palpate the bowel directly to identify the diseased segment; this increases the risk of resecting the wrong segment of bowel.28 Endoscopic tattooing of the segment to be resected greatly improves the accuracy of laparoscopic procedures. Endoscopic tattooing is also used to facilitate identification of subtle mucosal lesions or endoscopic resection sites at the time of subsequent endoscopy.29,30
India ink or a similar presterilized commercial preparation is commonly used.31 Complications are rare but include mild chronic inflammation, hyperplastic changes, inflammatory bowel disease, abdominal abscess, inflammatory pseudotumor, focal peritonitis, peritoneal staining, and, very rarely, seeding of tumor via the tattooing needle.30
FORENSIC MEDICINE
Specialists in forensic medicine use primary markers such as fingerprints and dental records and secondary markers such as birthmarks, scarring, and tattoos to identify victims.32 Tattoos are useful for identification when finger-prints or dental records are unavailable,33 as in the tsunami of December 2004 in Southeast Asia34 and the London Paddington train crash of October 1999.35 However, as the body decomposes, tattoos can discolor and fade, making them hard to identify. Application of 3% hydrogen peroxide to the tattoo site has been reported to aid in identification, and infrared imaging has shown promise.32
