Permanent Cosmetics Design Considerations

by Marjorie Grimm

Today and Tomorrow Considerations

It is difficult to imagine putting your facial features in fast forward in order to determine what, if anything will be different about your permanent cosmetics as your face continues to mature. This is rarely questioned at the consultation for permanent cosmetics because we have the tendency to think of having our permanent cosmetics look fresh, day and night, as we look today. It is however, a very important factor when deciding on design and color selections for permanent cosmetic procedures. Assuming you have selected a well- trained technician for your service, permanent cosmetics services today need not be a fear factor for the future.

When considering the natural progression of age and the longevity of the positive appearance of your permanent cosmetics, the most important issues are proper placement and design of your procedure. If not properly placed with the future effects of gravity taken into consideration, your procedures could very well not be as attractive as you had hoped. Conversely, proper placement and classic (rather than trendy) designs and colors, can ensure that you will enjoy the pleasure of a fresh face and youthful appearance for many years to come.

Eyebrow designs

The eyebrow design should be placed in the area where your natural eyebrows grow, or used to grow. If you are pursuing an eyebrow procedure to enhance your own eyebrow hair that is extremely light, following your own natural eyebrow placement is critical. Your new eyebrows, or enhancements to your existing eyebrows, will then age naturally along with the skin that in which it is placed. Some women, however, prefer to draw their eyebrow tails slightly above the bone. To consider this design proper for a permanent cosmetic eyebrow procedure may or may not be a good decision depending on whether you would consider cosmetic surgery such as an eyebrow lift in the future. Higher exaggerations of the tail of the eyebrows may work for those who never intend on having plastic surgery, but this is not recommended if there is a chance that you may want to pursue surgical modifications to your face.

There are many different techniques employed to create a natural eyebrow design. Some clients prefer a similar appearance to that which is produced by their eyebrow pencil. This is called a "powered eyebrow design". Some clients specifically request a "hairline stroke design". This is the simulation of multiple hairs in a specific design area that implies movement such as real eyebrow hair provides. This is an advanced technique and clients desiring hairline stroke eyebrows should consult with a qualified technician before proceeding. Many clients and technicians see merit in the combination of a soft powered eyebrow technique with strategically placed hairline strokes, normally in the bulb area to compliment the client's thin hair growth in that area. There are many artful techniques to choose from.

Top Eyeliner Designs

When considering a permanent cosmetic top eyeliner design, the best choice for the long term is pigment placed in and directly above the lash line. This design also gives the most options for using topical makeup for special occasions when a more dramatic appearance is desired. Often mature women feel wider eyeliner on the upper eyelids will compensate for the faltering affects of excess eyelid skin. This is usually not recommended, unless heavy eyeliner has always been worn. Most importantly, as eyelid surgery becomes increasingly popular, the potential for surgical removal of excess eyelid skin must be taken into consideration. If eyelid surgery in the future is a possibility, the removal of the excess skin will cause a wide eyeliner to appear even wider. If conservative eyeliner enhancements and top liners close to the top eyelashes are applied, your permanent cosmetic top eyeliner should not pose any challenges for a cosmetic surgeon.

One of the most ill-advised top eyeliner designs is the exaggerated extension of the eyeliner tails far past the last eyelash of the outer corner of each eye. What may give you the illusion of a "lift" or eye width extension in that area at the initial time of your procedure may in time appear misplaced, uneven, and/or partially or totally hidden in the excess skin that affects the corners of the eyes.

Lower Eyeliner Designs

The same principles apply to lower eyeliner, however there are several surgical technique options that could have an effect on lower eyeliners. Keep your design conservative and placement directly beneath the lower eyelashes. If in doubt, work with your client's surgeon to determine the best method of proceeding. As the skin in that area ages, your lower eyeliner will remain in its original placement. In the event surgical removal of excess skin beneath the eye is elected, depending on the technique utilized, at the most, you may need a touchup to restore the integrity of the original design.

Lip Design and Color Selections

The same thoughtful consideration must be given to lip liner placement. If placed properly, permanent cosmetic lip liner can actually detract from noticeable wrinkles on and directly above the lips. In order to slightly enhance the size of the lips and give the appearance of fuller lips or lip augmentation, the lip liner can tastefully be placed adjacent to the vermilion border, however the texture of the natural vermilion border is thicker and more noticeable than the thin tissue of the rest of the lip. As a result you will always see a lip within a lip if the lip liner is not placed on or directly above the natural vermilion border of the lip.

When choosing the color for your permanent lipstick, there are several factors to keep in mind. Over time the lips become less plump and small or large lines appear. As the lips decrease in size due to the aging process, the color may appear inconsistent. Where there is more wrinkling in the lip, the brighter colors will appear denser and thus, darker than other areas that are less wrinkled. Consider a soft, more natural lip color for your lip liner and full lip colors so that years later, when the overall configuration of your lips has changed, your color remains complimentary and the wrinkling less noticeable.

Summary

The primary consideration when determining permanent cosmetic design and color specifically for yourself, it is that you are involved with the process. Do not agree to allowing another person to maintain complete control over these factors. A professional, well trained technician will routinely solicit your preferences and do what is required to meet your standards. It is your face, and you, your family and friends will be the ones to eventually live with the results. Look forward in time, and work toward designs and color selections, and your permanent cosmetic makeup will serve you well for many years to come.

Original article here.

Micropigmentation (Permanent Makeup)

Another guide to refresh your knowledge or share with your potential client...

Applying some cosmetics can be bothersome, especially if you have a physical condition that makes it difficult (cataracts, severe arthritis, etc.) There's help in a procedure known as micropigmentation, or permanent makeup.

With this procedure, a trained doctor or specialist can inject iron oxide pigment into the middle layer of your skin (the dermis) for results that last longer than the eyeliner you have in your bathroom drawer. It has many monikers, including "dermagraphics" or "permanent makeup."

Who's a Candidate for Permanent Makeup?

We mentioned that anyone with physical limitations may seek out permanent makeup, but anyone (male or female) can have it done.

Do you want to improve the appearance of thin eyebrows or lips? Do you have an uneven hairline or allergies to make-up that create a problem? Micropigmentation may be a viable solution. It's not going to provide a perfect world, but it can help enhance certain features.

How Do I Find Someone to Apply Permanent Makeup?

Do your homework when looking for someone to apply permanent makeup. This is not school, but it is your appearance. You should make sure to find a doctor or specialist who has experience in this procedure.

Be warned. There are a lot of people out there performing these services who do not have your best interests in mind. When you visit the office, you should examine the area for cleanliness and professionalism.

A dedicated, involved specialist should be able to answer any and all of your questions. Make sure you feel comfortable communicating with your doctor or specialist and that you feel open to ask anything that's on your mind.

You should have a consultation with your chosen doctor or specialist before the procedure, during which time you discuss your expectations with him or her. At this time, he or she also will determine if you should receive anesthesia (usually local).

During the consultation, he or she may take a medical history. It's important that you are completely honest. Additionally, you should be honest for why you want permanent makeup so your doctor or specialist understands all of your concerns. He or she will evaluate your skin for tone, texture and complexion in order to best match your natural colors with the proper pigment. He or she also may take photos.

How Is Permanent Makeup Applied?

Typically, permanent makeup can be applied in an office setting. The procedure will be performed with a pen-like instrument or standard tattoo gun. Your doctor or specialist will wear medical gloves when performing the procedure. The procedure itself will take a short amount of time, perhaps 20 minutes to a half hour at most.

If you are receiving anesthesia, you will be required to arrive earlier in order to let the anesthesia take effect. After the procedure, your specialist or doctor will provide you with an antiseptic to cleanse the treated region.

What Should I Expect After Getting Permanent Makeup?

You will be sent home the same day you get permanent makeup. You should expect swelling in the treated region. Your doctor or specialist will instruct you on how often you should ice the area and what type of ointment you can apply to the area.

If you are having the procedure performed in your eye region, you should plan to have someone drive you to the office and home again. You may experience watery eyes, which is normal.

The pigmentation typically will appear darker in the weeks following the procedure, but will fade over time.

Follow your doctor's instructions on what to avoid such as peroxide and sunlight. Either of these can damage your new look.

After Getting Permanent Makeup, Contact Your Doctor Immediately If:

• You experience excessive swelling
• You develop a fever or rash
• The area feels excessively hot or burns

Follow-Up Care for Permanent Makeup

Your new look requires maintenance. Some people have to undergo two or more treatments with permanent makeup. Make sure you understand exactly how many session you will need. As the pigment fades over the years, you also may have to undergo additional treatments to maintain the look.

Does Insurance Cover Permanent Makeup?

No. This is an elective, cosmetic procedure that you will have to pay for on your own.

Original article, click here.

Shelf Life/Expiration Date

There are no regulations or requirements under current United States law that require cosmetic manufacturers to print expiration dates on the labels of cosmetic products. Manufacturers have the responsibility to determine shelf life for products, as part of their responsibility to substantiate product safety. FDA believes that failure to do so may cause a product to be adulterated or misbranded.

Voluntary shelf-life guidelines developed by the cosmetic industry vary, depending on the product and its intended use. For instance, a 1980 article by David Pope in Drug and Cosmetic Industry suggested a minimum shelf life of 18 to 24 months "to maximize cost efficiency in warehousing, distribution, and marketing."

The 1984 text Cosmetic and Drug Preservation: Principles and Practice, edited by Jon J. Kabara, recommends testing product stability by evaluating samples at regular intervals for 3 years or longer, depending upon the product.

The European Union's Cosmetic Directive, as amended in 1993, requires expiration dating only for products whose "minimum durability" is less than 30 months.

Conventional Cosmetics

The shelf life for eye-area cosmetics is more limited than for other products. Because of repeated microbial exposure during use by the consumer and the risk of eye infections, manufacturers usually recommend discarding mascara two to four months after purchase. If mascara becomes dry, discard it. Do not add water or, even worse, saliva to moisten it, because that will introduce bacteria into the product. If you have an eye infection, consult a physician immediately, stop using all eye-area cosmetics, and discard those you were using when the infection occurred.

Among other cosmetics that are likely to have an unusually short shelf life are certain "all natural" products that may contain plant-derived substances conducive to microbial growth. It also is important for consumers and manufacturers to consider the increased risk of contamination in products that contain non-traditional preservatives, or no preservatives at all.

Consumers should be aware that expiration dates are simply "rules of thumb," and that a product's safety may expire long before the expiration date if the product has not been properly stored. Cosmetics that have been improperly stored - for example, exposed to high temperatures or sunlight, or opened and examined by consumers prior to final sale - may deteriorate substantially before the expiration date. On the other hand, products stored under ideal conditions may be acceptable long after the expiration date has been reached.

Sharing makeup increases the risk of contamination. "Testers" commonly found at department store cosmetic counters are even more likely to become contaminated than the same products in an individual's home. If you feel you must test a cosmetic before purchasing it, apply it with a new, unused applicator, such as a fresh cotton swab.

Original article published in FDA.gov

Get the most "wow" from your permanent makeup

What are women asking about?

How can I get the most “wow” without ending up with a “botched-job”?

During personal consultations I get many questions just like that, it’s a safe place to ask. These are the questions that they may even be discussing with their friends and just don’t know where to begin.

What are men and women wanting to achieve? They want this to look like that or these lines to go away, they don’t want to erase everything… more often than not I hear “I look mad. Friends or family say I look tired. What can I do?”

My answer is usually permanent makeup for the lip and brow.
We have been educated in the signs of aging, lines, wrinkles, sun damage, thinning skin...

Many of us have dabbled in and/or maintain a schedule of injectibles like Radiesse, BOTOX@Cosmetic, and Juvederm. Personally, I really like the results.

As an artist using cosmetic tattooing I bring about a more youthful look because I can replace color that has naturally faded. Yes, as we age we loose color, we also get color that we don’t want, like brown spots and visible capillaries from the sun. Each of which distort our facial features.

Permanent makeup can restore definition in our eyebrows because loss of hair is loss of color. Using feather-like hair strokes of color I can create a natural looking brow that frames your eyes with a “brow-lift” effect. Eyebrows make a difference!

The other big “wow” --- the mouth, another area that shows the signs of aging. I don’t just add color to lips, I can redefine and correct the shape. The mouth goes as the upper lip goes. As we age it flattens out and curls under in some cases. Have you lost your lip? It happens. Restoring the contour of your lips begins with color and shape correction.

My recommendation is to add volume and fill lines after restoring color and shape. The doctor can be more specific treating the lines and loss of volume, giving you the best result because the color will define the area to be treated. The doctor’s treatment will be precise, combined to give you the best overall result.

Original article from Sarah Oliver, Licensed Esthetician

Magnetic Resonance Imaging and Permanent Cosmetics (Tattoos): Survey of Complications and Adverse Events

Whitney D. Tope, MD, MPhil,1 and Frank G. Shellock, PhD2*

Purpose: To use a survey to determine the incidence of complications and adverse events in individuals with permanent cosmetics (e.g., tattooed eyeliner, eyebrows, lips, cheeks, etc.) who underwent magnetic resonance (MR) imaging.

Materials and Methods: A questionnaire was distributed to clients of cosmetic tattoo technicians. This survey asked study subjects for demographic data, information about their tattoos, and for their experiences during MR imaging procedures.

Results: Data obtained from 1032 surveys were tabulated. One hundred thirty-five (13.1%) study subjects underwent MR imaging after having permanent cosmetics applied. Of these, only two individuals (1.5%) experienced problems associated with MR imaging. One subject reported a sensation of “slight tingling” and the other subject reported a sensation of “burning”; both sensations were transient in

nature.

Conclusion: Based on these findings and information in the peer-reviewed literature, it appears that MR imaging may be performed in patients with permanent cosmetics without any serious soft tissue reactions or adverse events. Therefore, the presence of permanent cosmetics should not prevent a patient from undergoing MR imaging.

Key words: magnetic resonance imaging, safety; magnetic resonance imaging, bioeffects; heating; artifacts; magnetic resonance imaging

J. Magn. Reson. Imaging 2002;15:180–184. © 2002 Wiley-Liss, Inc.

1 Department of Dermatology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota.

2 University of Southern California, Keck School of Medicine, Los Angeles, California.

Contract grant sponsor: Society of Permanent Cosmetic Professionals.

*Address reprint requests to: F.G.S., 7511 McConnell Ave., Los Angeles, CA 90045.

E-mail: frank.shellock@gte.net

Received July 18, 2001; Accepted October 11, 2001.

TRADITIONAL (I.E., DECORATIVE) and cosmetic tattooing have been performed for thousands of years. In the United States, cosmetic tattooing or “permanent cosmetics” are used to reshape, recolor, recreate, or modify eye shadow, eyeliner, eyebrows, lips, beauty marks, and cheek blush (1). Additionally, permanent cosmetics are often used aesthetically to enhance nipple-areola reconstruction (2).

Magnetic resonance (MR) imaging is a frequently used imaging modality, particularly for evaluating the brain, head, neck, and other anatomic regions where cosmetic tattoos are typically applied. Unfortunately, there is much confusion regarding MR safety aspects of permanent cosmetics (3– 6). For example, based on a few reports of symptoms localized to the tattooed area during MR imaging, many radiologists have refused to perform MR procedures on individuals with permanent cosmetics, particularly tattooed eyeliner (unpublished observations, F. G. Shellock, 2000). Obviously, this undue concern for possible adverse events prevents patients with cosmetic tattoos from access to an extremely important diagnostic imaging technique.

While it is well-known that cosmetic tattoos may cause MR imaging artifacts (3–11) and that both cosmetic and decorative tattoos may cause relatively minor, short-term cutaneous reactions (3,8,11–16), the frequency and severity of soft tissue reactions or other related problems associated with MR imaging and cosmetic tattoos is unknown. Therefore, the purpose of this investigation was to determine the frequency and severity of adverse events associated with MR imaging

in a population of subjects with permanent cosmetics.

MATERIALS AND METHODS

A questionnaire was developed to survey individuals with permanent cosmetics to determine the incidence and severity of complications

or adverse events associated with MR imaging. The questionnaire asked study subjects for basic demographic data, information about their cosmetic tattoos, information about their MR imaging examinations, and their experiences with these procedures relative to the permanent cosmetics. Table 1 shows the questionnaire used in this investigation.

The questionnaire was distributed in the United States to clients of permanent cosmetic technicians who were members of the Society of Permanent Cosmetic Professionals (SPCP, an international, non-profit

organization of cosmetic tattoo artists). This permitted individuals with cosmetic tattoos to be contacted confidentially through client lists of members of the SPCP. The study subjects were assured that the questionnaire would be analyzed with anonymity maintained. The questionnaires were returned to the primary author (W.D.T.) for tabulation, and the results were analyzed using simple descriptive data techniques.

RESULTS

Of a total of 3065 questionnaires that were distributed, 1037 (34%) were returned for analysis. Five surveys contained insufficient data for inclusion (i.e., the answers were incomplete), leaving a total of 1032 questionnaires available for tabulation. The majority (1027; 99.5%) of the study subjects with permanent cosmetics were women. The ages of these individuals ranged from 14 to 93 years old. Caucasians formed the largest racial population (961; 93%) for the respondents (14 [1%] Asian; 16 [2%] Latino; six [1%] African-American; two [0.2%] Native American; 30 [3%] data not provided).

Eight hundred ninety-seven (897/1032; 87%) study subjects with permanent cosmetics reported that they never had MR imaging examinations (Non-MRI Group), while 135 (135/1032; 13%) study subjects underwent MR imaging after application of permanent cosmetics (MRI Group). The mean age of the Non-MRI Group (50 +/- 5 years old) was significantly younger (P 0.05) than that of the MRI Group (56 +/- 5 years old). For the Non-MRI Group, five study subjects (6%) reported that the MR facility personnel or radiologists would not allow them to have MR imaging procedures due to potential complications with cosmetic tattoos.

For the MRI Group (N 135), tattoo site information was available in 131 subjects (97%). These subjects reported a total of 210 individual tattoos (i.e., 61 subjects, 45%, had more than one cosmetic tattoo). Of these, 210 permanent cosmetics were applied to the following body sites: 85 (41%) eyelid, 75 (36%) eyebrow, 34 (16%) lip, six (3%) cheek, four (2%) areola, and six (3%) trunk.

Information on tattoo pigment color was available for 112 of the 135 (83%) study subjects in the MRI Group. Notably, 91 of these study subjects (67%) reported that they had permanent cosmetics that were applied using pigment colors (e.g., brown, black, red, and flesh) that typically contain iron oxide.

For the MRI Group (N 135), information on the cosmetic tattoos and body sites for the MR imaging examinations was available for 133 (98%) of the subjects and is shown in Table 2. Forty of these subjects had MR imaging examinations involving more than one anatomic region (i.e., for a total of 173 MR imaging examinations). Fifty-six (42%) of the subjects in the MRI Group had MR imaging examinations that involved the immediate anatomic site where the permanent cosmetic was applied (Table 2).

One hundred thirty-three (133/135, 98.5%) of the MRI Group reported that there were no complications, adverse events, or other problems associated with MR imaging. Two (2/135, 1.5%) study subjects in the MRI Group reported complications or adverse events associated with MR imaging. One subject experienced “slight tingling” before MR imaging began and the other subject reported a “burning” sensation that started before entering the magnet (i.e., while in the MR system room, in the MR environment) that resolved by the end of the examination. Both of these subjects were women who had blue-black pigment colors used for periorbital (i.e., eyelid/eyeliner) tattoos and underwent MR imaging of the cervical spine. Each tattoo had been applied at least nine months prior to the MR imaging examination. In neither case did the severity of symptoms warrant cessation of the MR imaging. Neither subject reported any other problem with the tattooed areas (e.g., erythema, edema, irritation, etc.) subsequent to MR imaging.

DISCUSSION

The incidence of complications or adverse reactions and severity of these problems for patients with permanent cosmetics undergoing MR imaging examinations are unknown. Unfortunately, many MR healthcare professionals do not fully understand the relative risk of performing MR imaging in patients with permanent cosmetics and, as such, may not allow these patients to undergo examinations. (For example, findings from this survey revealed that 6% of the study subjects with permanent cosmetics were not allowed to undergo MR imaging because of MR safety concerns.) Therefore, the purpose of this investigation was to determine the frequency and severity of problems associated with MR imaging in a selected population of subjects with permanent cosmetics with the intent of providing guidance and recommendations based on the results of this study and those published in the peer-reviewed literature.

To date, only a small number of patients (estimated to be less than 10) that have undergone MR imaging have reported transient symptoms that included skin irritation, cutaneous swelling, or a heating sensation at the site of application of the permanent cosmetics (review of Medical Device Reports, 1985 to 1999). Because of these incidents, the latest MR safety recommendations and guidance from the Food and Drug Administration (Guidance for Industry Guidance for the Submission of Premarket Notifications for Magnetic Resonance Diagnostic Devices) states that the performance of an MR imaging examination requires particular caution for “patients with permanent (tattoo) eye-liner or with facial make-up” (17).

According to the findings of our study, there was an extremely low incidence (1.5%) of complications or adverse events, and the severity of these problems was relatively minor (i.e., there was no serious, permanent, or life-threatening injury). Of interest is that, for these study subjects, one individual reported a “burning sensation” that was unrelated to the actual scanning procedure (i.e., upon entering the MR environment), while the other subject’s symptom, a “tingling sensation”, has not been previously reported. Importantly, neither problem prevented completion of the MR imaging procedure.

Investigations of incidents related to patients experiencing cutaneous or other reactions in relation to the presence of both cosmetic and decorative tattoos revealed that there was a tendency for these problems to occur whenever pigments that contained iron oxide or other similar metallic substance(s) were used (3–16). The study subject that reported a “burning sensation” had her cosmetic tattoo applied by an ophthalmologist using black pigment that typically contains iron oxide. Unfortunately, the exact type of pigment that was used could not be verified and there tends to be little quality control over tattoo ink (15). Apparently, certain ferrous pigments used for the tattooing process can interact with the electromagnetic fields used for MR procedures, producing the reported problems (7–11,13,16).

Proposed mechanisms to explain tattoo-related problems encountered in the MR environment include magnetic field related interactions and/or radiofrequency (RF)-induced induction of heating. The fact that an individual in this study reported symptoms even before entering the MR system suggests that one possible causative factor is the static magnetic field. Presumably, traction or torque from interaction of the ferromagnetic tattoo particles with the static magnetic field may be partially responsible for the symptoms reported.

In a letter to the editor that described a second-degree burn that occurred on the skin of the deltoid from a decorative tattoo, the authors suggested that “the heating could have come either from oscillations of the gradients or, more likely from the RF-induced electrical currents” (15). However, the exact mechanism(s) responsible for complications or adverse events in the various cases that have occurred is unknown.

Interestingly, decorative tattoos tend to cause worse problems (including first- and second-degree burns) for patients undergoing MR imaging compared to those who have been reported for cosmetic tattoos (6–13,15,16). For example, a recent publication reported that a patient experienced a sudden burning pain at the site of a decorative tattoo while undergoing MR imaging of the lumbar spine using a 1.5-Tesla MR system (13). Swelling and erythema resolved within 12 hours, without evidence of permanent sequelae. The tattoo pigment used in this case was ferromagnetic, which possibly explains the symptoms experienced by the patient. Surprisingly, in order to permit completion of the MR examination, an excision of the tattooed skin with primary closure of the site was performed (13).

The authors of this report stated, “Theoretically, the application of a pressure dressing of the tattoo may prevent any tissue distortion due to ferromagnetic pull” (13). However, this simple, relatively benign procedure was not attempted for this patient. They also indicated that, “In some cases, removal of the tattoo may be the most practical means of allowing MRI” (13).

Kanal and Shellock (14) commented on this report in a letter to the editor, suggesting that the response to this situation was “rather aggressive”. Clearly the trauma, expense, and morbidity associated with excision of a tattoo far exceed those that may be associated with ferromagnetic tattoo interactions. A firmly applied pressure bandage may be used if there is any concern related to “movement” of the ferromagnetic particles in the tattoo pigment (14). Additionally, direct application of a cold compress to the site of a tattoo would also likely mitigate any heating sensation that may occur in association with MR imaging.

A comprehensive search of the peer-reviewed literature supports the results of this present investigation (8–10). That is, symptoms rarely occur, the symptoms are transient in nature, and the severity of the symptoms is relatively minor. Furthermore, when one considers the many millions of clinical MR procedures that have been conducted in patients over the past 15 years and that only a very small percentage of these individuals have had minor, short-term problems related to the presence of permanent cosmetics, it is apparent that this MR safety concern has an extremely low rate of occurrence and relatively insignificant consequences.

With regard to artifacts, none of the study subjects in this investigation were informed that the MR images were substandard due to the presence of tattoos and none of the examinations had to be repeated. Nevertheless, imaging artifacts associated with permanent cosmetics have been reported (7–10). These artifacts are predominantly associated with the presence of pigments that use iron oxide and occur in the immediate area of the tattoo. As such, tattoo-related MR imaging artifacts should not prevent a diagnostically adequate MR imaging procedure from being performed, especially in consideration that careful selection of imaging parameters may easily minimize artifacts related to metallic objects (3,4).

The only possible exception to this is if the anatomy of interest is in the exact same position of where the tattoo was applied using an iron oxide-based pigment. For example, Weiss et al (7) reported that heavy metal particles used in the pigment base of mascara and eyelining tattoos cause alterations of the local magnetic field in adjacent tissues. These changes in normal signal may result in distortion of the globes. In some cases, the distortion may mimic actual ocular disease, such as a ciliary body melanoma or cyst.

This investigation has possible limitations. For example, precise MR imaging details that may influence complications or adverse events in patients with cosmetic tattoos were unknown (i.e., static magnetic field strength of the MR system, imaging parameters, type of RF coil, RF power deposition, etc.). Given the limitations of MR imaging knowledge held by the respondents to this survey, this lack of information is understandable; however, we believe that it can be safely assumed that the subjects in this investigation underwent MR imaging procedures using standard, MR imaging techniques and procedures. Additionally, it would be advantageous to evaluate additional subjects with both cosmetic and decorative tattoos that undergo MR imaging. Thus, additional research that acquires specific MR imaging information in a larger group of tattooed subjects is warranted. This may help determine a mechanism responsible for the cutaneous reactions that sometime occur in the MR setting.

In consideration of the findings of this study and the available literature pertaining to MR imaging and patients with cosmetic tattoos, the following patient management guidelines are recommended:

1. The Pre-MR Procedure Screening Form should include a question pertaining to the presence of permanent cosmetics or decorative tattoos (3–5).
2. Before undergoing an MR imaging examination, the patient should be asked if he or she has a permanent coloring technique (i.e., tattooing) applied to any part of the body. This includes cosmetic applications such as eyeliner, lip-liner, lip coloring, and decorative designs.
3. The patient should be informed of the relatively minor risk associated with the site of the tattoo.
4. The patient should be advised to immediately inform the MR technologist regarding any unusual sensation felt at the site of the tattoo in association with the MR imaging procedure.
5. The patient should be closely monitored using visual and auditory means throughout the entire operation of the MR system to ensure safety.
6. As a precautionary measure, a cold compress (e.g., wet wash cloth) may be applied to the tattoo site during the MR imaging procedure.

In conclusion, because of the relatively remote possibility of having an incident occur in a patient with a permanent cosmetic and due to the relatively minor, short-term complication or adverse event that may develop (i.e., transient cutaneous redness and swelling), the patient should be permitted to undergo MR imaging. Any problem of performing an MR imaging procedure in a patient that has a cosmetic tattoo is unlikely to prevent the examination, since the important diagnostic information that is provided by this imaging modality is typically critical to the care and management of the patient.

REFERENCES

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5. Shellock FG. 2001. www.MRIsafety.com.
6. Tattoos. FDA medical bulletin 1994;24:8.
7. Weiss RA, Saint-Louis LA, Haik BG, McCord CD, Taveras JL. Mascara and eyelining tattoos: MRI artifacts. Ann Ophthalmol 1989; 21:129–131.
8. Carr JJ. Danger in performing MR imaging on women who have tattooed eyeliner or similar types of permanent cosmetic injections. AJR Am J Roentgenol 1995;165:1546–1547.
9. Lund A, Nelson ID, Wirtschafter ID, Williams PA. Tattooing of eyelids: magnetic resonance imaging artifacts. Ophthalmic Surg 1986; 17:550–553.
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11. Gomey M. Tattoo pigments, patient clothing, and magnetic resonance imaging (Risk Management Bulletin 12748-8/95). Napa, CA: The Doctors’ Company; 1995.
12. van Buren A. Dear Abby. The Oregonian July 23, 1994 and October 22, 1994.
13. Kreidstein ML, Giguere D, Freiberg A. MRI interaction with tattoo pigments: case report, pathophysiology, and management. Plast Reconstr Surg 1997;99:1717–1720.
14. Kanal E, Shellock FG. MRI interaction with tattoo pigments. [Letter] Plast Reconstr Surg 1998;101:1150–1151.
15. Wagle WA, Smith M. Tattoo-induced skin burn during MR imaging. [Letter] Am J Roentgenol AJR 2000:174:1795.
16. Vahlensieck M. Tattoo-related cutaneous inflammation (burn grade I) in a mid-field MR scanner. [Letter] Eur Radiol 2000;10:97.
17. Zaremba L. 2001. FDA guidance for MR system safety and patient exposures: current status and future considerations. In: magnetic resonance procedures: health effects and safety. CRC Press, Boca Raton, p. 183–196.