Elsevier

Clinics in Dermatology

Volume 25, Issue 4, July–August 2007, Pages 367-374
Clinics in Dermatology

Medical applications of tattooing

https://doi.org/10.1016/j.clindermatol.2007.05.014Get rights and content

Abstract

Tattooing is an ancient procedure, practiced by humans from all parts of the world for a variety of reasons. However, relatively little is known by the medical audience of the numerous medical conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Tattooing for cosmetic and medicinal purposes, referred to as either micropigmentation, dermatography, or medical tattooing, may ensure permanent camouflage in a wide range of dermatological diseases. It can be a valuable finishing step in several surgical procedures in the fields of craniofacial surgery, plastic and reconstructive operations, cosmetic surgery procedures, and breast reconstruction. Other fields of application of medical tattooing include radiation therapy, endoscopic surgery, and ophthalmology.

Introduction

Tattooing implies the process of implantation of exogenous colorfast pigments into the skin or mucous membranes leading to a discoloration referred to as a tattoo. In this process, only pigment particles introduced through the skin surface, below the dermal-epidermal junction, are retained by the dermal macrophages and fibroblasts where they reside permanently, producing an indelible change of the skin color under the form of a recognizable pattern or design.

The practice of tattooing has been in existence for thousands of years, with origins tracing back to the Stone Age.1 Throughout history, the core characteristic of tattoos, their indelibility, has been used by humans from all parts of the world for a variety of reasons, including decoration, to ensure uniqueness in the self-appearance, to mark a status, or to inflict punishment. Some tattoos are performed to enhance physical beauty, for example, to camouflage pathological skin changes.

The importance and meaning of tattooing have changed according to time periods. For many years, ornamental tattooing has been popular not only among seamen and the military but also among criminals.2 The prevailing view on tattooing from the 1950s could not be better represented than the statement by the author Hugh Garner who wrote:

Among all the forms of mass masochism practiced by that frailty known as man, none is quite as silly as the acquiring of tattoos. This egocentric perversion has had its devotees since the down of time, and in inverted sequence, it has been a tribal custom, penal stigma, class craze, snobbish adornment, and finally a vulgar affectation. Among the Maoris and various Hindu sects it is still a mark of caste and beauty, but among most Western peoples, it is at best a juvenile indiscretion, and at worst a thing of shame and loathing to those of us who are tattooed. It can, and does, slow a person's social life to a crawl.

During the past several decades, however, the public perception of tattooing has greatly evolved. In both the European continent and in the Americas, tattoos and other types of body art, such as piercing, have dramatically increased in popularity, especially among adolescents and young adults.3

With all of its prerequisites, tattooing has frequently attracted a great deal of scientific curiosity. From the medical perspective, it is an invasive procedure involving several components that might be potentially hazardous and may threaten the health of the tattooed individual. The unequivocal risk of transmission of several blood-borne and infectious diseases by tattooing has been shown and is a source of unabating public health concern.3 The demographic, psychological, and behavioral aspects of the tattooed have been the focus of extensive research in the mental health field.4, 5 As far as dermatologists are concerned, most patients are seeking help in relation to tattoos, either to have them removed or for treating the diverse cutaneous complications reported as a consequence of permanent and temporary tattooing.

Relatively little is known by the medical audience of the numerous special conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Examples of such medical applications are endoscopic tattooing, corneal tattooing, as well as the recently introduced treatment of viral warts by means of tattooed cytostatic drugs.

Section snippets

Historical aspects of medical tattooing

Perhaps the history of medical tattooing is as old as the history of ornamental tattooing. Speculation surrounds the tattoo marks seen on the naturally preserved human body from 3300 bce found in a snowfield in the Tyrolean Alps, near the natural pass called the Hauslabjoch.6 These tattoos, in the form of groups of small parallel lines, were located over the lumbar spine, the right knee, and both ankles of the corpse. Because radiographic studies revealed that the man from Hauslabjoch had

Cosmetic tattooing/Micropigmentation

Cosmetic tattooing is the art of improving the appearance of eyelids, augmentation or replacement of eyebrows, and improvement of lip contour after trauma or surgery. Other potential fields of micropigmentation surgery include permanent eye lining, eyelash enhancement for sparse lashes, and nipple replacement by tattooing.26 Various types of tattooing equipment are available for such treatment by aesthetic dermatologists: for example, Cooper Vision (Natural Eyes); Penmark, Dioptics (Accents);

Dermatography/Application of tattooing techniques in dermatology

In 1984, Van der Velden, a dermatologist from The Netherlands, began to adapt the classic Japanese tattooing techniques for application in a range of medical disciplines.25 The techniques that were developed have been termed “dermatography” in the 1990s. Traditional Japanese tattoos from the beginning of the 17th century are closely akin to the Japanese woodblock prints in design, coloring, and techniques.

The tattooing procedure in dermatography consists of implantation of different colors

Plastic and maxillofacial surgery

Tattooing may be a valuable finishing step in several surgical procedures in the fields of craniofacial surgery, plastic and reconstructive operations, cosmetic surgery procedures, and in breast reconstruction.25

Dermatography was successfully applied for correcting the color mismatch and reducing the scars in patients operated for unilateral and bilateral cleft lip and palate. For correcting the vermilion border, instead of simply drawing a red lip contour, color is inserted in the filtrum,

Radiation oncology

In radiation therapy, patient markings are used for target localization to ensure accurate and precise treatment setup. Precise beam alignment, with reproducible and accurate positioning and immobilization of the patient, is required during each day of a fractionated course of radiotherapy, which may last several weeks. Patient positioning is typically achieved by placing a set of dark pigmented tattoos on the patient's skin at selected points, generally along the treatment axis. Tattooing is

Endoscopic tattooing

Endoscopic tattooing is a technique where a specific site in the gastrointestinal tract is labeled by an intramural injection of a staining agent for future surgical or endoscopic surveillance. Initially introduced to mark lesions in the colon before surgical resection,69 endoscopic tattooing is now well recognized as an effective means to enable subsequent endoscopic and surgical localization of various subtle luminal digestive tract lesions, such as flat or small neoplasms, sites of

Corneal tattooing

Permanent tattooing of the cornea can be performed for both cosmetic and optical reasons. Although with the current progress of keratoplasty techniques and contact lens manufacturing corneal tattooing has lost its popularity, it may still be a reasonable alternative in high-risk cases of leukoma or leukocoria where corneal transplantation would lead to rejection and graft failure or in eyes without visual potential.78 In cases of eccentric semitranslucent scars and contact lens intolerance,

Significance of tattoos in forensic medicine

Tattooing is of considerable medicolegal import. Tattoos last for a lifetime and persist into the postmortem period and may help in the identification of living as well as of dead individuals, particularly when fingerprints or dental records are unavailable.84 For example, tattoo marks played a decisive role in the famous Tichborne case from the 19th century.85

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