Tattooing has been practiced across the globe since at least Neolithic times, as evidenced by mummified preserved skin, ancient art, and the archaeological record.¹ It was Captain James Cook, a British explorer (1796), who first coined the word ‘tattoo’ when describing a Polynesian practice of inlaying black pigments under the skin.² Traditionally associated with sailors and convicts, artistic tattoos are widespread in today’s society.

Queen Cleopatra in ancient Egypt and others in India and Africa have sought permanent eye enhancement with various substances over the years. They used plant and nut pigments or ground coals (carbon) as eyeliners or eye shadows and inserted these around their eyes with fine, sharp implements. This is where permanent make-up, as we know it today, originated.

Permanent make-up (micropigmentation) is the implantation of colored pigments under the surface of the skin, using a very fine needle or group of needles, via a hand-held manual device or an electrically driven handpiece. This is a self-elected cosmetic procedure to enhance facial features such as eyebrows, eyes, and lips on normal skin.

Medical tattooing is used to reconstruct features such as eyebrows (lost because of alopecia) and lips (owing to cleft lip or mouth cancer), and to replace the areola following mastectomy. It may also help to reduce the perception of hypopigmentation and hyperpigmentation in scars.

Medical tattooing can cosmetically improve the scars associated with interventions such as plastic and cosmetic surgery, radiation therapy, and endoscopic surgery. Although medical tattooing will use the same products and techniques as micropigmentation, the technician will require additional training because of the nature of working on scar tissue, rather than normal skin.

The age of the scar, type, color, condition, and underlying health of the patient will affect the pigment color and technique used because all influence the outcome, as does patient compliance with aftercare. The composition of scarred skin, different types of scars, and how the scars themselves react to medical tattooing are further considerations. For example, scar tissue due to burn injury will absorb more pigment and may require several medical tattoo sessions to achieve an acceptable outcome.

After the initial treatment, the pigment will fade over time. In fair skin (Fitzpatrick skin type I and II) after the pigment has faded, the residual color will tend to be even lighter because of the need for titanium dioxide (white) to mix the color. Consequently, frequent retouches will be necessary, possibly on an annual basis.

Variegation in the skin caused by freckles and capillaries, for example, should be added on the final visit; the skin must have fully healed between appointments. Healing will take approximately 1 month on young and healthy skin. On mature skin, approximately 2 months should be allowed between treatments. Healing affects the ultimate color as it requires a layer of skin to grow over the tattooed area; therefore, the pigment will appear lighter over time.

Patch testing using both glycerin-based and water-based colored pigments on several areas of a scar is paramount to determine how the skin is going to react. Scars are very unpredictable and different areas of the same scar can
respond differently to the pigment. At the initial consultation, pigment can be applied topically, covered with an adhesive dressing, and left in place for 24 hours. If the area becomes irritated, the pigment should be removed immediately. In this case tattooing should not proceed.

Pigment is applied using a circular, back and forth, or hair stroke motion, depending on the area worked. Shading is applied using a flat needle and working through a very thin layer of petroleum jelly. Stippling is the application of small dots with a fine round needle. Working in natural daylight is important. If this is not possible, then daylight bulbs may be used. Work should never be attempted under artificial light. Color application should be conservative initially, and can be adjusted on subsequent visits. This is because one cannot be sure how the pigment is going to heal into the skin, and it is easier to add more color at the second appointment.

It is essential that technicians are highly skilled and qualified in medical tattooing before they accept clients or patients. Because of lack of understanding of tattoo techniques, inexperienced and undertrained practitioners can cause damage to the scar, including permanent hypopigmentation. In addition, posttreatment hyperpigmentation can occur when tattooing patients with Fitzpatrick skin types IV, V, and VI. In most countries, the cosmetic tattooing industry is unregulated and without thorough training to a high standard (i.e., from a recognized training authority). Therefore expertise is potentially highly variable and insurance is difficult to obtain. A patient seeking treatment in any country can contact the Society of Permanent Cosmetic Professionals (SPCP) via their website spcp.org. They have a list of trained technicians worldwide who meet the very high standards in cosmetic and medical tattooing as required for membership.

Medical tattooing can be applied to all areas of the body, apart from the genitalia. This is because if a patient were to claim they had lost physical sensation, or if infection developed in that area, it would be nearly impossible to prove this was not caused by medical tattooing. Therefore it is unlikely to be covered on a technician’s insurance. Technicians generally work from hospitals and clinics, though they may work from other premises provided that they have been inspected and licensed by their local authority.

Good quality pigments must always be used and safety data sheets should be obtained from the distributors. For example, the author holds safety data sheets for the range of Mei-Cha Microcolors, Image, and Forever Lips pigments used for medical tattooing.

Pigments used to camouflage scars to a natural skin tone for Fitzpatrick skin types I to IV are mainly high-quality medical-grade products based on titanium dioxide. This is in contrast to pigments used in cosmetic micropigmentation, where the darker colors are more likely to have an iron oxide base. Color washes are a very important part of medical camouflage as well for blending the edges of scars or areolae.

A digital machine is preferable to alternatives because the power source is stable. Battery-operated machines are not recommended because battery power is affected by temperature and humidity. The machine must conform to the regulations of the relevant country. For example, in the United Kingdom all machines should conform to European Union regulations. The Conformite Europeene (CE) mark indicates the manufacturer’s declaration that the product meets the requirements of the European Community (EC) directives.