Combining Cosmetic Tattooing with Other Surgical Procedures - by Whitney D. Tope, M.D.

Frequently asked questions by cosmetic tattoo artists concern the advisability of performing cosmetic tattooing in association with other common surgical procedures. Does one negatively affect the results of the other? Can multiple procedures be performed at the same time or at different times? Which should be performed first? How long should one wait before performing the second procedure? The answers to these questions lie in understanding the individual procedures, the changes they create in the skin, and the timing of wound healing.

First, we should understand the process of tattooing. This is well taught in cosmetic tattooing instructional courses and is witnessed first hand during the daily practice of tattooing. Briefly, tattoo needles create multiple puncture wounds extending into the dermis. The tattoo pigment on the needles is carried into the epidermis and dermis by repetitive motions, either manual or automatic. This process creates multiple puncture injuries and deposits foreign bodies; these events incite an initial clotting and inflammatory response to heal the wound and an influx of circulating macrophages to remove foreign particles. Fortunately for tattoo artists, the pigments used are quite inert and the majority go unrecognized by immune cells. Of those pigment particles which are consumed by macrophages, some are carried to the draining lymph nodes, but most remain stationary within the tissue. Generally, the tattooed skin requires a week or so of topical care. Within two to three weeks, the crisp appearance of a fresh tattoo subsides after the process of epidermal maturation sloughs the tattoo pigment which was deposited within the epidermis. Tattooing does carry a very low risk of infection and tattoo pigment reaction. The latter may occur from days to decades after tattooing. Importantly for this discussion, the tattoo’s shape depends upon the position of the skin within which the tattoo is placed. Also, the most common anatomic locations for cosmetic tattoos are the lips, eyebrows, eyelids, and areolae. Finally, once a tattoo has healed, any process which causes significant local inflammation can cause additional removal of tattoo pigment.

Given these anatomic sites and the prevalence of photoaging, one can predict the most commonly encountered procedures a client may wish to pursue to enhance their appearance. For treating wrinkles or excessive folds, one might pursue soft tissue augmentation to lift the skin back into place, botulinum toxin injections to eliminate dynamic wrinkles, ablative resurfacing to smooth wrinkles and improve skin texture, tissue tightening with radiofrequency or infrared light to create subtle lifting or tightening effects, or surgical lifting of the brow, upper, mid or lower face. Molded solid implants can alter facial shape. Laser for hair removal is commonly used on the face, as are Q-switched lasers to treat facial hyperpigmentation.

A now dizzying array of injectable filler substances are available for soft tissue augmentation (STA) of the lips, the melolabial folds, and atrophic scars. These range from collagen derivatives to hyaluronic acid to hydroxyapetite to silicone to autologous fat. In the absence of an allergic reaction, these substances are injected with mild degrees of inflammation, which settles quickly and should not cause enhanced removal of tattoo pigment. While occasionally STA leads to significant changes in skin position, soft tissue augmentation typically should not affect tattoo position and could be performed before or after tattooing. Another permanent “filler” employs use of Gore-Tex or molded silicone implants which are placed near the bone, commonly at the chin or malar eminences, to reconfigure facial shape. These also should have little effect on tattoo intensity or position.

Botulinum toxin injections paralyze selected muscles of facial movement to lessen the appearance of dynamic wrinkles. While virtually no inflammation accompanies botulinum toxin injections to affect pigment intensity, overuse or imprecise injection can lead to brow ptosis (droop) and lid ptosis (lid lag). These changes may alter brow and lid position, but appropriately placed tattoos will maintain their position with respect to the brow and lid lashes. These effects are also temporary, typically lasting no more than six months. Since few individuals will remain affected by botulinum toxin all of their lives, it makes sense to place cosmetic tattoos when no botulinum toxin is present and the face has its natural animation.

Lifting effects may also occur through “tissue tightening”, a method of creating deep dermal collagen contraction by heat application. Originally performed with radiofrequency energy by the Thermage device, other devices combining laser or intense pulsed light with radiofrequency energy (Syneron devices) or infrared light energy alone (Cutera device) may soon claim to achieve similar results. While the dermal collagen is injured, associated inflammation is typically minimal, and there is no current evidence that any of these devices, appropriately used, would interfere with a tattoo. The tightening effects are also subtle enough so as not to create dramatic changes in the position of the eyelids, brows, or lips. Since these are rather new devices, the treating physician should be informed of the presence and location of cosmetic tattoos, so that these may be avoided. The most aggressive lifting techniques, surgical lifts, are employed specifically to create more dramatic lifting effects than other techniques can deliver. A client strongly considering these therefore should probably undergo surgical lifting before tattooing. In addition to positional changes, more significant inflammation would be expected to accompany surgical incisions, tissue undermining, and their attendant post-operative wound healing.

Use of Q-switched laser (alexandrite, ruby, or Nd:YAG) are well known to cause permanent pigment darkening reactions in titanium and iron oxides commonly used in tattooing. Therefore it is exceedingly important that a physician who may use a Q-switched laser in an area of cosmetic tattooing must know of the tattoo’s existence; otherwise a beautifully performed cosmetic tattoo may quickly become an unsightly black tattoo. Ablative resurfacing (removal of the epidermis and portions of the dermis by dermabrasion, carbon dioxide or Er:YAG laser, or chemical peeling agents) should also be strictly avoided. This technique allows pigment to eliminate through the “open” surface and causes significant inflammation to remove tattoo pigment and decrease tattoo color intensity. While non-ablative laser resurfacing (creating a dermal injury while leaving the epidermis intact) has not been reported to cause problems with cosmetic tattoos, vigorous treatment can result in inflammation lasting hours or days and might theoretically lead to some pigment removal. Laser hair removal, which employs alexandrite, diode, and Nd:YAG lasers, deposits light over a longer pulse duration than their Q-switched counterparts and is not known to cause tattoo pigment darkening. Still, significant inflammation can occur and the multiple treatments required for successful laser hair removal might lighten cosmetic tattoos. Finally, topical photodynamic therapy using aminolevulinic acid (ALA) and intense pulsed light or pulsed dye laser is becoming very popular for improvement of photoaging. This technique alone can cause significant facial inflammation (2-3 days), and even more so if additional sunlight causes an unintended phototoxic reaction (2-3 weeks).