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CHAD S.

ZWERLING, MD
ANNETTE GWALKER, RN
NORMAN RGOLDSTEIN, MD

MICROPIGME
..........

STATE OF THE ART ~ "


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CHARLES S.ZWERLING, MD
ANNE11E C. \V.~LKER! RN
NORMAN EGOLDSTEIN, MD
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BOOK & . CQVl~R

DESIGN

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T A

B L E

C 0 N T E N T S
Dedication Vll
Foreword ix
Preface xi
Acknowledgelnents

Xlll

SECTION I:
An Introduction To Dermatechnology
I.

2.
3.
4.

Introduction 3
History of Tattooing 7
Instrume ntation - De. cription and Development 17
FDA and State Regulation s 31

SECTION II:
Preprocedural Considerations
5.
6.
7.
8.
9.
J O.
J 1.
12.

Psyc hological Considerations 51


Practical Clinical Anatorny 57
Morphology 69
Photography 83
Patient Selection R9
Clinical Evaluation 05
Preprocedural Consideration 105
Artistic Technique: CLIMB III

SECTION III:
l\'lethodology
13.
14.
15.
J

6.

17.
18.
19.

Anesthesia 123
Role of the Assistant 147
Blepharopigmentation Techniques 151
Brow Pi gmentation Technique 163
Li P Pigmentation Techniques L65
Breast Areolar Pigmentation J69
Advanced Dermalpigme ntL1tion Techniques

175

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SECTION IV:
Post-Procedural Considerations
20.
~ I.
')')
23.
24.

Management 181
Compl ications of Tattooing 185
Pigmen ls 199
State of the Alt 209
Quality Assurance 21l

APPENDICES
I.
II.

JJ L.
IV.
V.
VI.

Sample Forms 223


List of Micropigmenlation Organization.
and Experts 228
Talloos 011 Famolls People 232
References by Chapter 234
Glossary of Cosmetic Products 245
Marketing Considerations 248

INDEX

DEDICATION
AJiectionale/y dedicated to our spouses - Jean, Ramsay and
George; for !!rei r patience and support.
And to our children - T(fjlJl1Y. Alexis. and Patrick. .fohn Gnd
Cal, for the tillle that we should have spen.t H:ith you.

rii
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R E

w o

R D

The lise of permanent eye enhancement by illlradermal pigmentation was


first introduced in J984 as a new technology in the field of ophthalmology.
Over the past 9 years the field or dermalpigmeruation has expanded and
embraced other medical specialists and health care practitioners. At the time of
publication of the first book on this subject. MicropigmelllCition. there were
maTlY areas of speculaLion for the potential lise of this procedure beyond the
field of ophtha:Jrnology: nipple reconstrudion. burn treatment, vitiligo and scarcover-up are only a few examples of now well-established uses for dermalpigmentation.
Since the technology and information has changed at such a rapid pace
from the first book':> publication. it is imperative to review all the accumulated
data fur appropriated presentation to (he medical community. With this
properly processed information, rational judgements can be made on the worth
and place of the procedure, and so that consumers can educate themselves in
the h~lsic and advanced applications of this rnicropigrncntation. Many proce dures have foundered because or a lack of well-organized and documented
~ource m:l!crial.
Micro/1 igmentalioll. Slale-of-/he-A ,., has tackleu Ihis enormous task from
the scientific, aeiithetic. and practical approaches. Thi.~ book has gathered all
the available information accumulated lve)' the past decade and also potential
new techniques. uses. and indications for micropigmemation.

ix

p R E F A

Many medical practitioners may view this book and subject with
immediate disdain. Sinct.: lllicropigmcnwtion hm. developed directly from
tallooing, rhere are certain connotations that tend to taint this new field.
Thl' image of an uHc!c.\n lillloo parlor located in the p(lorer sections of a
large cily may cpme to one ' s mind. The presence of gross taUoo designs on
the human body is often associated with this scenario: huwever.
rnicropigrnentation represents the impl:llltation of inert pigment granules in
a clean, sterile atmosphere hy a truined praditioncr for the purpo.,e of a
natural-appearing cosmetic enhancement. Just as today's general su rgeons
had thci r origins from the old barber-~urgeons anJ untrained journeymen
or medieva l times, the lllicl"opigmcfllalion practitioner can trace his
heritage to the tattO(1 artist. We feel a debt of gratitud.:: to the taltoo artist
for helping us to reinvent the wheel. as sn often occurs in medicine. It i
for this renson of historica l perspect ive thal. we have a<.:knowledged the
taltoo specitllj~t in the writing or this book.
We feci that micropigmentution ha~ bet.:omc successful at this time
improved medical technology and pub.lic self-awarcm:ss. The
bec'lUse
medical companies can now rnnss-produtc high- tech state-of-the-art
machines and di~posabk a('cessorie~. and provide excellent health care
proyidcr and consumer support. The American public has Jevelopcd in the
1980~ u greater selfawarenc~s and sometimes self-indulgence of their
phy~icnl presence. Health foods and exercise programs are examples of
thi:" heightened interest in self-improvement. Therefore, the timing or a
new cosme!i\.: pro\.:cdure in th i!> de\.:ade has contributed to its immediate
acceptance.
Our purpose in writing this book wa:-. to present to the practitioner an
updated foundation of know ledge of this emergi ng fie ld. as wel l as u
referellce guiJc for future studies. We have attempted to venture beyond
the tcdll1ical accuracy or the first book which stressed safety and celtain
mechanical apPw:lchcl>. We have added to that reference source now the
idea;.. oj" artistic sub~tullce , namely coloI'. to create features anJ, thus.
emotional expression. \Virh the uni(lll of th e first. book's procedural
techniqlJc~ and this ncw book's artistic approach. wc have developed both
form and ... ub~l.al1ce. Thi~ lext is hy no mcuns complete. h will certainly
need i"ullIrc revisions. corrections, and additions by other ~recialists in
Nher ti(:'ld~. Rather than just write a glori1icd '-hLlW to" manuuL we fell that
the cnming tog.:ther or an ophthalllli.: ~llrge()n. dermato logist, and
registered lIur,e will provide a more ,cit'ntific basis for this book a::. well as
;t pnhpt.:ltive for quality <[!-"urancc and risk management. We have
attcmpted in ;l ,hon period of timc til accumulate a large amount or
~()l1letilllcs conflicting information and theory. and trieu to a:,.scmbk .md
,uri the ract~ into a mcaningrul form . With the henelit or a dCL'aJe of"
dinical experience. \\C feel we Clil (liTer it meaningful updated l-c"ourcc
and rl'lrospcctive of medical information ,illce the publicalion of the fir;,.t
hook. We again apnlogi/.c in advancl.: lO uny inuiviJual or cOlllpany for
inaccurate infornwtinn: we \\mdd appreciate any co nstruc tive comments

or

.Ii

PREFACE
from our colleague:-- so that we may impro e and refine our knowledge of
micropigme ntati~)n.

We hope that this book will serve as a springboard for future endeavors by
other colleagues in order to expand this new field of medicine. We have
endeavored to review medical principles and ethics thaI will assist the new and
experienced praclitioner. Wi! hope this information will diminish unnecessary
complications that may be due to a lack of knowledge.

Charll:'s S. ZwerlinR
Anl1ette C. Walker
Norman F. Coldsleill

xii

ACKNOWLEDGEMENTS
SPECIAL CONTKlBUTORS
George P. Walker Ill. M.D., QualilY Assurance
Bernard Schulman. M.D .. Psyc hol ogical Considerations
L. Will iam Luria. M.D.. Breast Pigmentat ion
Frank H. Christensen, M.D., friend and previous co-a uthor of
M1CROPIGM I:'NTA nON
In the preparation of thi s medica l textbook.. a true cooperative effort
was necessary. We wish to thank all the com pani es for t.heir time and
information. We are especially grald 'ul 10 Frank Christensen. M.D .. for hi s
friendship. original guidance and co-authorship in t.he preparation of the
first book Micropigmenfllfioll . Much of his in:ight and thoughts persist
into this new textbo(,k. Furthermore we appreciate the special written
con tributions of L. William Luria. M.D. , GeNge P. Walker Ill, M.D .. and
Bernard Schulman, M.D.
Dr. Goldstein would like to !.hank in particular th e Stat.e Health
Department Director)., State Att()rncy~, the Illany classic tattoo artists and
cos metic tattoo artists who have ass isted with the national survey of 1993.
In panicular a special thank you 1.0 Pnli Pavlik for her contribution in
the secti on on hi story of tattooing. to Su~an Preston of the A. Mason
Blodgett and As:-.ot:i atcs of San Fra ncisco. Rose Marie Beauchemin of
Mount Laurel. New Jersey, and Tanya Noland of Little Rock, Arkansas.
Mahalo (thank you) to the Honol ulu Medical Library. Lyle and Judy
Tuttle. the Tattoo Art Museum. and the World of Tattoos CoHection in
Hawai i for their generou:-. contrioutions.
And finally, his staff for t.heir invaluabl e assistnl1ce with our phone
ca ll s, faxes and mai l surveys. A special "mahalo" lO Lois Chinen. Miyo
Deal. Anna English. Arlene Floyd. Ali ce: Greer. Lana Llzaro, Chris
Mackler. Cristi na Simon. Merle Stelscr and his exec ut ive assistant. Russ
Sowers.
An nette Walker wishes to acknowkdp: the late Helen Sheldon who
cOlllributed much to the fi el d and Ihe advancement of Ihis book. Her deep
appreciation to Arretla Dubose ancl Irma Dial. ['or the loving care of her
children during the writing of the hook. A specia l thank you to Samantha
Caruthers. Marci a Cohen, Norma Stadmil ler. Cathy BuKaty. Pati Pavlik.
Kathleen Sligar, Con nie Bernabucci. Dr. Pa ul Manson. Ph ylli s Azman .
CANP. RN. Dr. Benjamin Johnson, Slephen Kahn ESQ .. allll Christy and
Michael Van Wagcncn for all their support and advancemen t of rhe field
or rn icropiglTJcntalion.
A ~ pec i:.ll thank you to Darlene Templetol} for her ne ver-ending belief
:tnd belp in the preparation of this book.. her loya lty. ;md dedication to the
field .
Finall y. to her h u~b and. Dr. Genrgc P. Walker III fo r hi s enduring
love and support. Thank. YOLI for hi~ belief in ,md c lI1~lant encouragement
of this project.

xiii

ACKNOWLEDGEMENTS
Dr. Zwerling would like to e~pecially thank his wife Jean S. Zwcrling,
R.N. ror her preparation of the chapter on the Rol' of the Ao.;sislanl. her
original stimulation 10 write this :;econd book. and for all her love and
support. To hi~ Siaff for all their valuable help in typing and preparation of
the manuscript. running errands, and help with the compuler: Anne Howell.
Sadie Futrell, Tracy Rosner. Cyndi Wilford , and Sue Strunk.
In nduilioll a special thank you 10 Tifrany A. Zwerling for her two
orig inal line art pictures as well as our previ IU~ illuslratOr David L.
Newman.

His special th:mks to Kristanne Matzek at the American Institute of


Permanent Color Technology for her guidance and resources; and. lO Susan
Guziek. BSN , for sharing h..::r excellent photographs and providing helpful
references.
We wish to thank the contribution of Dnrryl Stephens or Ihe Mm'inc
In!>ul'ance Company for his assistance in our chaplcr on risk management.
We owe a great deal of <II preeimioll 10 Vann Dennis for editing of the
manuscript and line art contributions.
We give vay special thank YOLIS 10 all our patients and models Wh~l
have allowed U:- 10 lI~e lh-:ir rhtllographs and case histories for this book.

Section One
An Introduction

to Dermatechnology

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H A p T E R

Introduction

Dermalpigmentation. commonly known a~ t;{lIooing, has been present


for centur ies in our cultures for the purpose of body adornment. The
implanting of pigments. colors. and/or dyes illtraderma.lly results in
permanent alteration of Ii 'sue to gain a cosmetic .:flecr. The pigmentation
effect is obtained by a procedure in \vhich minute, metabolically inert
pigment granules are mechanically placed beneath the epidermis. When
the procedure uti lizes microscopes or magnifying lOll pes, the appropriate
term is micropigmcntation.
The intent of this book is to serve as t.he updated clinical reference
guide to instruct. orient and !,erve as an historical reminder for the
physician. nurse. and practitioner who wishes to hccome familiar with the
prm:edure of permanent cosmetic application. This new technique has
mushroomed in popularity over the pa:t ten years with the advent of the
nurse practitione r and trained cosmetologi.st as new providers for this
procedure. The introduction of new instrumentation and pigments by select
nurses ucveloping interest in
manufacturers and the growing popularity
this exciting new procedure was the stimulus to updut.e this textbook. The
book will serve as a historical perspective and an orientation to the
in~trument<; offered by various manufacturers and to the techniques
developed by pioneers in this field. For the novi('e practitioner. the text is u
general guide to orient and cducate the provider to the various facets of
l1licropigmelllarioll. For the experienced practitioner. this book will expand
their knowledge of the field with the new techniques and dala thm we have
accumulated o\'er the pasl decode.
New techniques require an assimilation lime . The micropigmentation
can be mastered b, any practitioner u~ed to working with the ocular
adnexa and/or skin. lnitially. the art of applying. pigmentation to the lid!> or
other body parts will be awkward ami pt;rhaps even lime-consuming. After
a rev,.' patients. the initial hurdles will be overcome and contldence gained.

or

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C HAP T E R

The
micropigmelltati(J1l
procedure of the
eyelids will
ellhancethe
o~'erall appearance
of the patiellt, by
giving definitioll
and c%r to the lid
contours in the
same way aframe
delineates all oil
painting.

Within a . hon span of li me, the proceumc will become rOlltine and
can be added [() the other procedures within the co!)metic practice.
As with any new procedure. familiari ty co mes with practice and
repetition. A complete and thorough knowledge of the anatomy is
im perat iv.:: before beginning any cosmetic procedure. In addition to
the acqui~il i oll of the technical ski ll s, a practical knowlet.lge of
patient p:-ychology and cos metology wi ll further aid the practitioner in obtaining bettcr results. Facial morphology. lid st.ructure.
patient psychology, and co. metic enhancement techniques are
equally important to obtain the desired results for the patient.
Although the technique is easily maste red and becomes repetitive.
it must be applied to the inuividual as a cUSll>mized application.
The practilioner should initially approach this tec hnique slowly and
devote time to the understanding of how all fact.ors interrelate and
affect the overall result. This can be obtai ned only by approaching
each patient individually. ,Although the mastery of the techniques fo r
impl anting the pigments is easy, the artistic understanding of facial
morphology and cosmetology is complex and can be gai ned only
with experie nce. This texl wi ll focus on those factors thut are
con~idered nitica l ill obtaining the aesthetic result that both patieaL
and practit ioner desi re. The anatomy and physiology of the eyelids
a nd ot her areas app li cable for de rm aJ pi g menttll io n must be
1I11(Jer~(()ou before attempting the procedure. This is a simp le
outgrowth for the experienced physician and nurse, but wi ll req uire
more diligence for cosme tologists and tattooists. After reading this
textbook. all health care providers should be well cH:quainted with
the information neces5ary to allow them to become comfortable with
micropigrnentation.
Certain prerequisites are necessary to sllccessfully undertake
micropig.mentatioll procedures. First. th e procedure requi res a steady
hand wi th little or no tremor motion. BecHu),c the placement of the
pigment is pe rmanent. inappropriate placement of the pigmem wi ll
lead to an undesirable eflet: t. The bcst way to avoid thi , unnecc. sa ry
problem is to place the pigment correctly in the begin ning. This require.
concentration and a stcady hand . Second , because the procedure often
requ ires assi:-ted vii>ua l magnifica tion. experience of familiarity with
magnifying hillocu lar loures is helpful. There are many l(lupes currently
available on the markct, and a recommended loupe power from two to a
maximum of six is recomlllt:nded. Thiru, th.:: practitioner should have good
binocular visio n with full (h:PLh perception . Even though a monocular
practitioner cou ld probably perform this procedure safely, the practitioner
with binocu lar vision has the advantage of s imult aneou ~ perception of both
eyes of the patient duri ng th~ procedure , and thus can ascertain the
~ymmetry and color intensi ty of tile pigment.
Good patiC lll selection i,' vital for a satisfactory result. It ha~ been our
experience that there is a ~eglTlcnt of the population that will b~ wil li ng and
~\ccepting of th is procedure. It is COrnmllf1 sense to choose thc~e motivated
pa tients ror Illicropigmentation rather than rho~e who are not truly motivated
a nd need ('()axin g. Never tr y to create all atmosphere or need for the

lNTRODUCT

unmotivated or unsure patienl. The ideal patient i:- one who has confidence
and self-assurance. Such patients are highly motivated toward the benefits
and positive results that the prm;edure will add to their lifestyle.
After the patient has been selected and feels confiden1 about
undergoing the proccuurc, it is imponant that the patient and practitioner
have a disclIssion regarding the realistic expectations. The patient needs to
remember that micropigmcnlation doc). not correct other abnormalities
!>uch as skill wrinkling. Time spent with the patient discussing other areas
of skin. adnexal. and/or lid characteristics will lead to better patient
satisfaction. The micropigmentation procedure of dle eyel ids will enhance
the overall appearance of the patient, by giving definition and color to the
lid contours in the same way a frame delineates an oil painting. Like the oil
painting. the eyelids arc not anatomically changed. but rather demarcated
and enhanced. If the patient desires further plastic corrective procctlures or
facial reconstruction changes. these should be discussed prior to
undertaking micropigmentation. and in most casel> the dermalpigmenlation
l>hould be the tinal procedure.
The practitioner is both technician and anist. One needs to read about
cosmetology and speak to professionals in the beauty field in order to get a
better appreciation of what women and men do to improve their
appearance. It is important for (he practitioner to learn about different
beauty aids such as mascara, eyeliner. skin foundation. and eye shadow
and to understand the needs of the patients and (he complexities of
co') metology. Through thorough mastery of the tc(hnique and comprehen sion of beauty aids. the practitioner will become truly successful in
performing micropigmentalion procedures of the human body. Finally,
with this procedure the practitioner gaills a scn:-.c of accomplishment that
transcends t.he traditional technical aspects of cosmetic procedures. In
rnanyinstances, for the first time, the health care provider will feel the
sense of accomplishment as an anist.

H A p T E R

History of Tattooing

Pictorial se lf-adornment has a long


hisrory. The earliest evidence of tattooin g
dates to the Ice Age, or more than 8000 BC
These early bodily adornments were probably
used to imitate the color of animals. have some
mystical Of religiou s purpose , or possibly
camoull age. though there i . no clear evidence fOf
thes e su pp os itions . Modern tattooing is an
extension of the primiti ve custom of painting the
body . Examples of body paint include
lhe red ochre found in prehi storic
burial sit es; blue woad, llsed by
the ancient Britons: koh l. used in
Asia to enhance the beauty of the
eyes; henna. use d on fin gernails
in rh e Middle East: and, o f
co ur se , the war painls of the
American Indian tribes. The giant
co metic industry today mi ght
wel l be considered a modification
of primitive "war paint" customs.
Early cfucie tattoo need les made of
bone, and bow ls that held pigment
(usuallv soot) have bee n found in caves and
rock stJata in France, Portuga l. Romania. and Scandinavia.
Egyptian Illummi es, some as old as -lOOO years. di~play tattoos on
womcn bUl not men . These ta\laos were placed on da ncing girls.
conc ubinc~. and womcn si ngers. and ul-ually depicted the symbol of Res.
the goddcs who protected these women.

CHAPTER

However, men were tattooed in


Libya. Male mummies with symbols
of sun worship on their skins were
found in the tomb of Seti l (I DO
BC).
In very early Greece, men were
tattooed as a sign of nobility or proof
of bravery. Later. when that custom
declined, taBOOS in Greece were
limited 10 slaves and criminals.
There is no evidence or rallooing
among Hebrews even before the
Mosaic Law, which forbade it. There
is a scarcity of tattoos Oil Jews. even
nonreligious Jew, . today.
From the ancient Middle East,
t.he practice of taltooing spread to
Southern Asia. By 2000 BC, it was
practiced by the Shans (Eastern
Burma), then the Burmese and
Indians, and probably extended to the
Is.lands of Lbe South Pacific. There is
some controversy concerning the
origin of tattooing in the South
Pacific . One explanation is that
tattooing came from China via
Formosa. the Phillippines, and the
East Indies. In China, there is
evidence thal tatLOoing was. done as
early as 1000 Be. The custom
continued until the Chou Dynasty
(300 -100 BC), primarily in the
barbaric tribes of the North. and
usually only for branding criminals.
A second theory of the origin of
South Pacific tattoos is that the
practice came later. about 450 BC.
from the Scmites of Arabia. A third
explanation is that the practice of
tattooing carne from South America
wilh sailors along the Kon-Tiki route
to Polynesia and New Zealand. The
fourth. less scie ntific but definitely
more romantic explanation i that it
was brought to the islands of the
South P:l(:iric by the Goddess of
Tattooing. who sang the virtues of the
arl as :.he ~wam from Fiji. The theme
of her song was that it was proper that

HISTORY

o F

TATTOOING

women be rattooed. but not men. Somehow the message became confused,
and it carne about that men were tallooed instead or women.
It has been well documented that the Jnca~, Mayas, and Aztecs were
tattooing themselves long before the Christian era. Daniels, Post, and
Amlelagoi> described mummified skin and published photographs of two
taHooed hands, one from Ancon. Peru (AD 900-1450), and the other (date
unknown) from elsewhere on the coust. They a!. 0 reviewed the histology
of mummy skin and could clearl y identify black tattoo pigment , presumed
to be carbon, melanin, carotene, and ac id rnucopoly saccharides.
The Ainus were u nomadic people who traveled
across Asia t.o Siberia lind Japan. Ainu tattoos were
originully of a religious nature. The Ainu settled
on the Island of Hokaido in Northern Japan.
Some contemporary Ainu women have their
chins and upper lips tattooed with all imitation
of hair or lip accentuation for sexual
attractiveness (black or blue-black lipstick).
By the time of the Roman Era, the Britons,
Iberians, Gauls, Goths, Teutons, PiClS , and
Scots were practicing the art of tattooing.
"When the Roman Legions finally
conquered the Britons and pushed northward
into Scotland, they met with the unyielding opposition of the original
lhcrianinhahilants, now pushed
buck by their carlier Celtic
co nqueror s into the Highlands of Central, Northern
and Northeastern Scotland.
The name -Pict' used by
these people is actually a
Roman o ne meaning
'painted men ' lind referred
to their practice of
tattooi ng themsel ves with
woad, a blue dye derived
from a nat.ive plant. They
also co lored their entire
bodies hlue before battle
with dye as they. like the
Celts , o[tcn went into
battle naked. And while
wc think of them a~ being
' hlue Pic IS: the Romans
abo r<:fer to them as being
green.
( From the
J o urnal 0 1' the Clan
Campbell Society. USA.
1984).

,
(

CHAPTER

Early Romans considered


tatoo barbaric. Later, a few
Roman ' had an intere!>l in the
art of tallooing, but only for a
limited time. When Julius
Caesar raided Britain in 55
and 54 BC , he found lhe
Britons with animal tattoos. It
is believed that the name
" Briton" is derived from a
Breton word meaning "painted in various colors." Early
Christians u. ed small tattoo.
slIch as the sign of the eros ,
a lamb, a fish, or the letter
"X" or ''IN'' to identify themse lves, just as members of
present-day Mexican American gangs and clubs often
s port the "Pachuco Mark "
between the thumb and index
finger.
When Emperor CorlSlantine established Christianity
as the Empirc's religion in
AD 325, he forbade facial
tattooing because it di 'figured
the human body. made in
Gou" image. In AD 787,
Pope Hadrian I banned all
forms of tallooing. "Ye shall
not makc any cUllings in your
flesh for the dead, nor print
any marks upon you."
(Leviticus XIX:28)
At about the same lime
us Constantine was banning
facial tattoos, Eskimo women
were tattooing themselves. A
mummy of Olle ~uc h E.-kimo woman was found on St. Lawrence island.
Alaska, in the Bering Strait 40 miles from Russia and 130 miles frolll the
Alaskan mainland in 1972. The 1600-year -old tattoos on one arm were
clearly evident, but infrared photography was required to delineate the
Laltoo. on the other. A. unique tattooing technique, limited tor many years to
Alaska. was (kscribed in 1928: "Some of the 51. Lawrence Island Eskimo
women and girls have beautifully executed tatroo marh, These are made
freehand although sometimes an out li ne is traced before the tattooing takes
place. The pigment is made from the soot of sea l oi l lamps. which is taken

/0

S TOR Y

TATTOOING

from the bottom of tea kettles or similar containers used to boil meat and
other fm)d over the open name. The soot is mixed with urine, often that of
an older woman. and is applied with steel needles. Two methods of
tallooing arc practiced. One method is to draw a string of sinew or other
thread through the eye of the needle. The thread is then soaked thoroughly
in the liquid p.igment anu drawn through the skin as the needle is in serted
and pushed just under the skin for a distance of about a thirty-second of an
inch when the point is again pierced through the skin. A small space is left
without tattooing before the process is ug'din repeat.ed. The other method is
LO prick the skin with the needle which is dipped in the pigment each
time." (Geist, 1928)
Cabeza de Vaca, 1530, and Captain John Smith, 1593, recorded
tauoos on natives ill the Gulf of Mexico and in Virginia and Florida.
Captain Cook wrote .in his diary, called "First Voyage, 1976," " Both sexes
paint their bodies, Tattow. as it is called in their language. This is done by
inlaying the Color of black under the skins in such a manner as to be indelible ." Cook's sailors were in tri gued by the Polynesian tattoos and
startcd the almost universal fascination with tattoos by sailors, soldiers and
other military personnel of all countries ever since. The word "talloo"
actually came into the English language because of Captain Cook. It is
interesting rhat the only other Polynesian word that became cOrt'ent in
lan guages other than those of the South Sea Islands wa" "taboo:' from the
Tongan .. tabu." a word often used in connection with orders to ban
tattooing. The word "tattoo" is a variation of " tattow," "tatau." and
'tattaw." all forms of " Ia. " thc Polynesian word ror striking or knocking. In
the act of tattooing, Polynesians u 'c a piece of wood to strike a piece of
bone or shell with many points on it. carrying the pigment to be driven into
the ~kin.
Tattooing flourished in Japan in the 17th Century. it had been reinstated in the 13th Century, after having been abolished for 200 years. Its
use was largely confined to the branding of criminals, a punishment that
replaced former harsh sentences like t.he loss of a nosc. or an ear. The
greater thc number of cOllvictions. the lIlorc tattoos showed on the riminal'~ skin.
The late J 8th Century marked the beginning of tallooing as a true art
all over Japan. with awards given for the bcst dcsigns of' tattoos.
Individual s frequently bequeat hed their tattooed skins. Some of these h<lve
been mounted in th e Anatomy Museum of the Un iversity of Tokyo
Medical School.
In 1868. Emperor Mciji Illade tattooing illegal. He considered it a
barbaric custom tbat humiliated Japan in the eyes of Europe. Although
Japanese people in general obeyed Meiji ' s law and !.topped getting tattoos,
the Japanese tattoo arti st ~ continued to practice on foreign visitors. They
became ~o famous that many Europeans and Amcricans made trips to
Japan juS! to have bcauti ful desi gns skillfully put 011 their skins.
It is important not to forget or diminish the role thut tattoo artists have
played in thi~ field. Intradermal implantation of pigments for cosmetic or
reconstructive reasons has its origins with the ancient art of lattooing. It

/l

C HAP T E R

11

HISTORY

TATTOOING

has been from lhe experiences and experiments of Lanoo masters over the
last century lllat we have developed the current micropigmenLation.
Modern tattooing can be dated LO 1880, when Samuel 0 ' Rei lIy
designed Ihe first electric tartoo machine in New Yor.k. It was later patented
in Great Britain in 1891 by his cousin, Tom Reilly, Tattoo machines used
today by tattoo arti sts arc very similar to the original O' Reilly uoit, with
some ingenious modifications and artistic embellishments. Many of these
modern tattoo machines may be seen in lhe Talloo Art Museum in Sun
Francisco or at the World of Tattoos exhibit in Honolulu.
All of the rnicropigmentation instruments now available on the market
are in one way. shape or form derivalives of the original O'Reilly
instrument. A standard tattoo instrument has the abi lity to change ils
frequency from less than 30 cycles per second to over 120 cycles per
second. Reciprocating and rolary tattooing machines represent the basic
lype~ . Of these two types, the double coil reciprocating machine is the
conventional type most used by tattoo artii>L .
According to Pati Pavlik, the Standard American Style of tattoo
presently consis'ts of a sol id black outline with a body of color. The
proression underwent an important transilion
in approximately 1968 when tattoo artists
began adopting basic art techniques in
lhe application of tattooing . Consequently, tattoo art transcended its
previoll s single dimension style 10 a
multidimensional arl form.
A true pioneer in taUoo recipro<.:aling machine development.
needles. and pigments has been Huck
Spaulding, a master tattoo artis t wilh
45 years experience and president of
Spaulding and Rogers Mfg, Inc ., the
largest and oldest supplier 0(' taLLoo
equipment.
Tultoo ma ' ters Lyle Tutlle
of Califomia. Joe Kaplan of New
York, and Jack Rudy of Califomiu
began lheir professional tattoo
careers dccaCles ago. True innovaters, neither artisl limited his
business solcly to tradilional t(11100
art.
I
Lyle Tuttle opened a San Francisco
tattoo ~ llIdio in 1960 and i~ best known
traditional tattoo art on celcbritie~. He has al~o
been a guidi ng force in the evolulion of intradermal c:osmeti 's for three decades. He i~ the
director of the TaHoo An Museum localed
in San Francisco and is the editor of the
national pub lica tion , The Talloo His-

13

CHAPTER

torian.Mr. TUllie also aCIS as a consultant on reconstructive pigmentation


doctors specializing in breast reconstruction at Stanford University.
Joe Kaplan has been a major inf1uence in intlddermal cosmetics for the
last twenty years. His work with physicians helped legitimize cosmelic and
reconstructive taltooing within the medical community. His impact on the
industry comi.llucs through his tattoo tudio and supply businesse, in Mt.
Vernon and his collaborations with plastic surgeons such as Dr.
Schoen bach. Chief of Plastic Surgery at OUf Lady of Mercy Hospital in the
Bronx.
Jack Rudy was the first tattooist to introduce the single needle finc line
technique. This use of single needle was crucial (0 adapting to the array of
situations and circumstances.
By the late 1970s, a greater number of women established them, elves
within (he mainstream of tattoo art. Mary Jane Haake. Winonna Martin,
Shelia May and Pari Pavlik are all tradilionally trained tUlloO artisls who
began offering intradermal makeup and reconstructive pigmentation.
Although they were unaware of each mher's venture into intradennal
cosmetics and reconstruction , they all shared a basic parallelism in
development: an c1':pertise in classical tattooing and an appreciation of
cosmclOlogy with a view toward facial morphology and the disciplines of
makeup artistry.
From the standpoint of relatively modern medical applications, the use
of tattooing can first be traced to Dr. Pauley who. in 1853, used a form of
tattooing to treal "congenital purple plaques" and other various lesions of
the skin. In 1848, Cordier had used tattooing as a means of treatment for
nevi, and Schuh, in 1858, had the idea of first using skin tattooing in
transplanted tissue in the practice of cheiloplasty. Twenty-one years Jarer, in
1879, Dc Wicker began using India ink in tattooing corneas for the cosmetic
improvement of unsighlly glaucoma') or comeaI scar. . In 1911. Kolle was
the first 10 use tattooing of a reddish pigment to change the contours of
scarred lips with the vermilion border. He al 0 performed work in the area
of scar revisions as well. In the late 1920's and mid '30s, Knapp. Duggan,
and Nanavati began using various metals such as gold and platinum chloride
to improve corneal scarring and give the illusion of normal-appearing iris.
In the 19405. Moestin. Mauclaire, Duformentel. and PUSSQt are
generally given credit as the fiJ" t group of doctors to introduce the u e of
tattooing in general surgery. Also in Ihe I 940s, due to the landmark work of
Conway. Hante, Brown. Cannon and McDowell, tattooing was performed in
permanent pigment injections in skin grafts and tlaps, as was inlraderrnal
injection of tattooing for treatment of capillary hemangiomas.
In the 1960s. Dr. Crowell Beard described in the literature the use of
eyelash tattooing with a hypodermic needle anti syringe using a brown
pigment as an alternative to eyelash grafting. In 1984. Dr. Gio)'a Angres
published his now famous landmark article on the U$e of eyelash tattooing
to create an eyeliner and/or eyelash enhancement effect for cosmelic
purposes. Dr. Angres was the first medical doctor to tlevelop his own
machine and pigments for the specilic purpose of this c:yelincr procedure.
During the slimmer of 1986. the first textbook. MICROPIGMENTA TlON. wa . written by Drs. Zwcrling, Chri , tcn:en , and
(0

/ f

HISTORY

TATTOOING

Goldstein. This book provided a foundation of knowledge of the field,


served as a reference guide, and created the basis of acceptable technical
accuracy for this emerging field .
In 1987 the Permaderm Corporation developed and expanded
dcnnalpigmentation to cosmetologists and other non-medical people. Due
to numerous legal prohlems with the FTC in 1989-90 and training
deficiencies, the company was short-lived. However , a number of
cosmetoJogi 'ls and estheticians continued to pursue rnicropigmentation
procedure.
In 1989 Dr. George and Annette Walker formed a new company
named Derrnouilugc. The unique concept of Demlouflage was to creare an
allied approach to dccmalpigmentatkll1 with the emergence of the nurse as
an alternative practjtioner to the field. Moreover, with the creative and
investigational ability of Annette Walker and other nurse pioneers, new
uses of delmalpigmentation were discovered and utilized for patients. Now
reconstructive applications for bum victims, vitiligo, scars, and portwine
stains were available based on the new techniques and research by Mrs.
Walker and others. DennouOage Clinic~. Incorporated. have graduated and
trained over 1250 nurses and over 400 technicians in 4 I states, Canada.
PUCliO Rico and Mexico.
[n 1992 The American Institute of Permanent Color Technology was
formed. This new company offers jts members various training programs
around the United States as well a ' educational seminar~ in which leading
authorities in the field of pemlanent makeup participate. The company's main
purpose i .. to serve as an educational fOTum for the procedure as well as a
means of interdisciplinary communication with Lhe field among the physicians,
nurses. cosmetologists. and tattooists.

15

H A p T E R

Instrumentation:
Description and
Development
AI publicalion time or the tirst book on rnic:ropigmemation, there
wcre a towl of seven legitimate companies that produced micro~
pigmcntation products, offered educational courses, and/or provided
practitioner assistance. Since that time, a number of companies have
undergone significant reorganization. Several of the previous companies
are no longer in business and, therefore, there arc no $lIppor\ service~
for their equipment. It is imperative (hat the pructitioner is a"'lure of
these changes so that fUflIrc purchases of obsolete products are made
with good di cretion.
There were a number of companies thal had manufactured micropigmentation machine.;: CoopcrVision (Natural Eyes), Perm<lrk.
Dioptics (Accents), Vi~i()11 Concepts (Glamour Eyes). Cosmedyne.
Alltek, and Eyclitc . At this present time. we understand that only
Pennark, Derrnouflage Clinics fnc .. Natural Eyes (Akon). Lasting
[lllpressions I, ant.! Accents still manufacture, sell, and markel their own
machines LInd/or pigments. [n addition a new company. the American
Institute of Pemlanent C< lor Technology ha;. been recently formed to
promote education , training and research in the field of
micrnpigrnentation. We are also aware of talton arli~ts who perform this
procedure using a variety or tattoo equipment and pigments from the
Spaulding and Rogers firm. In this chapter we will JiscLfss {he
companies with their products and services. In ~lIbst:qucnt chaplers, we
will di~eu~s the marketing and pigment formu lary of orne of thc
companies.

Dermoujlage Clinics, Inc.


Derrnounage Clinics, Inc. was eSlahli:-,hed in 19R9 by George P.
Walker III. l\tI.D .. Jntl Annellc C. Walker. R.N. for the purpose of

17

CHAPTER

provid ing educ atiol1. tral n I ng. and research in the tip pi icati on and
development of the field of micropigrnentation.
From a historical perspeclive, the Walkers identified a neet! to bridge
the gap between the non-medical (cosmetologist') and tattooist) and the
rnet!ically-trained pbysicians and surgeons. They believed that tbe nurse
represented a viable alternative to this dilemma. Ultimately. nurses have
become the largest grOllp of praclitioners in the micropigmentuliol1 markel.
Nurses have provided the means of instilling quality issues of appropliate
health care in the industry. Because of the acceptance of the nurse by both
thc medical field and the cosmetic fiel.d, there has been an increased desi.re
for unification within tbe field of rnicropigrnentation .
Derrnouilagc has assumed this enonl1()Us task of educating nurse ' and
answering to Lhe numerOUl> nursing boards across the coulIlry regarding
nurse practice issues. Annette Walker has travelled the ollntryextensively
addressing these nursing boards and convincing them of the legitimacy of
this procedure. Many states. due to her sole efforts. have now establishet!
nurse practice acts that have approved of micropigmenturion a: an
acceptable procedure.
The success or Annette Walker and Dermouflagc Clinics. Inc . in
gaining recogni.tion and acceptance of micH1pigmentalion by nursing
boards has been the primary stimulus ['or the re-cmergence of micropigmentation in the 19~Os.
Derrnouflage continues to provide quality education in basic and
advanced micropigmel1lrtlion tcchniqucs. Specialty courses and research
llpportllnitics are available through the company ' s eXlensive referral
network. The graduates of the Dcrmouflage courses qualify for the only Aratcd liability insurance available (as rated by Standard and Poor's) through
Marine Insurance.
Derrnouflage Clinics. Inc. provides a large variety of iroll oxide
pigments, meeting color recommendations for cosmetics by the FDA. The
glycerol-based pigmcl1ls are packaged in sterile containers and meet the
requirements of 6 micron or greater pigment granule size to inhibit
po~tprocedural migration. The company distributes autoclaves and
manufactures a slate-o['-Ule-an, inexpensive. ergol11atically contoured dermtable equipped with a stainless steel mayo stand and non-heat producing
magnifying lamp. The company produces and distributes a cost-effective
implanter with sterile disposable batTels and probes available.
The company provide~ training. certification. cOlllinuing education.
and materials in the application of permanellt micropigrnentarion of the skin
Cor cosmetic and ci1mouJlaging of disfigured areas such as in the corrccLive
coloration of scars due to burns. wounds. etc .. vitiligo. alopecia. nirthrnarks.
plastic surgical reconstruction. etc. Includes such cosmetic application ' as
permanent eyeliner. eyebrows. and lip coloration. and corrective coloration
Ille'burcs ror a:.ymmetrical racial rcatllrc~ . Currem resc:arch and ernerging
applications include correction of hypertrophied scars and scar
c()ntracturc~. especially racial . by the Dermnuflage techniques. Courses
available for graduate~ include ba;;ic. advanced. and cuntinuing educatil.lI1.
For a complete listing.
all available products. services. and
educational courscs. the reader can c al! 205-543-27M~ ror further
i nrormation.

or

/8

NSTRUMENTATION

Permark
Tile Enhancer system was introduced in 1985 by Dr. Michael Palipa,
an ophthalmic plastic surgeon, practicing in West Palm Beach. Florida.
This comp;my still provides very active invo lvenlcnt in the micro pi gmentation field today .
The Enhancer's pigmenting pen is straight, like a conventional writing
pen. In addition to its ergomatic shape. the straight pen provides maximum
visibility of the reciprocating needle cnd~ . This safety design is extremely
important in ensuring the proper location for pigment introduction. For
additional visibilit.y , the cone is beveled, permitting practitioners to see the
needle location before it leaves the cone and enters the skin.
The pen-shaped handpiece provides the surgeon with a choice of
performing the eyelid enhancement either facing the patient or from
overhead. The pen utilizes five different need le sizes and operates at a
~pccd range up to 9000 reciprocations per minute with a low noise facl()r.
To ensure that the needle exi ts the cone in the same exact depth for each
penetration. the needle is directly connected to the reciprocating shaft. This
prevents any movement or notation of the needle in the cone. The patented
pcn has a calibrated dep th gauge which permits needle penetration
selection from [Amm to 2.0111m.
Instruments
Maximum
66 Cycle

S<I> 60
<I>
0..

CJ)

<I>

'0 50
<I>
<I>

..!!..
N

:r: 40
~
0
zw
::>

aw

cr:

30

lJ...

20

cr:

OJ

:>

10
2

SPEED SETTING (on knob)


Graph demonstrates the relationship of handpiece
vibration to speed settings. Values shown are
approximate. (Courtesy of Vision Concepts .)

19

- - -- --

- - --

- - -- --

- -

- -

--

CHAPTER

Presently there are two basic model. of the Enhancer system: the
Enhancer II and the MicroENHANCER.
The Enhancer 11 is an Underwriter Laboratory (lJ/L) approved unit
thm can function as a micropigmemation device as well as a dermabrader
handpiece. A unique printed circuit board provides maximum . peed control,
and all speeds are controlled by the practitioner with a linearly accelerating
root pedal. Low speeds are ideal for individual dOL pb cement with
maximulll safety and control. High speeds arc smoothly and easily attained,
ami are used for completing the eyelid pigmentation and in other tissue
pigmenting procedures. In case of foolswirch failure. a unique backup
system in the power pack permits manual control of the needle speeds by
l\1eans of a rheostat.
A prccision high-torquc motor permits arraumatic penetration of the
skin by thc rcciprocating needles . At the same time. the li ghtweight.
powerful motor permits penetration of scarred and grafted tissues for
pigmenting. This is especially important in skin grafts. breast
reconstruction s, and trauma cases requiring pigment enhancement. The
motor requires no maintenance or lubrication, and is guaranteed for the life
of the cqu ipment.
The MkroENHANCER was introduced in the fall of 1992 as a
micropigmcntation device only. Utilizing the same patented handpiece as
the Enhan<.:cr II this device also has dual hand and foot pedal controls. Its
Illaximum i>peed of 6000 rpm allows for all micropigmentation type
procedures. Micropigmenration Devices lnc ., the manufacturer and
distributor of the Pcm1Urk Enhancer System supports its equipment with a
full line of gamma radiated, heat sealed pigments and necdles as well as a
customer service department.
Micropigmentation Devices Jnc. under the Permark brand eurrel1lly
supplies 37 colors of gamma radiated pigments in reusable container. The
colors range from flesh tones. nipple areolar shades, eyebrow and eyeliner
colors. lip tones, and skin toner" ' mixers of whi te, yellow. brown, and red .
The base pigment is an iron oxide compound. suspended in a mixture
of glycerol and alcohol. The company maintain stricL quality control of tbe
product and has full product liability insurance. The only disclaimer is if a
practitioner mixes or lIses the Permark pigment in conjunction with noninsured products by other suppliers. Each pigment package has an
expiration date. The company has a policy of Tcstcrilizution wirhout charge
for any pigment that is returned unopened within one year from the
e.\ piration dalc. All colors are stockc:d and can be shipped within 24 hours.
Currently Pc:rmark runs training seminars in the use of their equipment
only. This six hour in -serv ice training program is taught at various locations
around the counrr)'. A cerriticate i~ awarded at the completion of the course.
For additional information, color charls, seminar schedules, and
product lilerature contact Micropigmcntation Devices Inc., 450 Raritan
CenLel Drive, Edison, ~cw Jersey 08X37 or call 8002825228 or in New

Jersey 9082253700.

20

NSTRUMENTATTON

Alcon (NatllralEyes)
Originally, the CooperVision Company, in association with Dr. Giora
Angres, developed a prototype Natural Eyes unit thal function plin1<u'ily
with a footswitch. compressed air supply. and handpiece. In the 1980's,
COQPcrvision sold all its interest in Nalliral Eyes to the Alcon Company.
To our knowledge the same information conccl1ling the technical aspects
of the machine has nol changed from the ori ginal Angres design.
A regulated air pressure of 30 to 35 p!'>i was used to drive the
reciprocal motion of the handpiece needle assembly al 100 to 200 Hz. The
frequency could be varied linearly by pressure on the footswitch pedal. The
handpiece consisted of an air driven motor. drive unit. and s{erilizable
head. The needle assembly and the coned pressure lit into the head of lhe
handpiece and were removed at the conclusion of the case. Now, however.
the Natural. Eyes machine is an electric unit and does not rely on a
compressed air supply. The hasi<: componenrs of the BPS inslrwnent are
the handpiece assembly. console and footswitch.
Hand piece. The handpiece contains a disposable tip as 'embly that is
use d to place the pigment into the dermi s and is connecte d to a
reciprocating head that can be removed for cle'Hling and sterilization
purpo ~ cs. Connected to this is a drive unit powl!red by a Swiss selfcontained motor unit. The unit emploYl! a rotary cam drive which tran~lates
into very little vibration. This is unlike tattoo machines. which are solenoid
pile-driver types and result in a lot of vibration, according to the company.
The BPS Natural Eyes handpiece is 5.75 inches long with a weight of 2.3
ounces and a diameter of 1 inch. The power requirements are) 151230 vac,
50-60 he, 30 va. The motor is a precision 24 VDC mOlOr with a nominal

Instruments Cost Analysis

Gra pn represents actual cost per case


comparisons among Ina various companies. The
graph demonstrates the importance of the cost of
the d.sposable packs.
INVESTMENT DOLLARS :
cost of the
machine + disposables + course inslruc1ion.

\\
250

200

Init.al

~----_

_ __ _ _ _

ACCENTS

15D
......... , ..., ................ ._ ........................................... . . (,'OSMEDYNE'

tOO
- - :'-'-

: -._ .-

_ _ _ _ _ _ COOPE"VIS!ON

..' - ' - '-

~: - ' -

'-

: -'-

.- PI~~~~FI.AGE
VISION CONCEPTS

-----------------------A-,~-TE:K-

50

25

50

75

100

125

150

175

NU MBER OF CASES

21

CHAPTER

operating range of 6,000 to 16,000 pulses per minute (100-270 Hz). The
maximum speed of the machine is 16,000 pulses per millllle with a
nominal needle excursion of 1.25 mm. The tip assembly is a disposable
three-pronged 27 gauge needle, bonded together in the shape of a pyramid.
Viewed from above. the needle points are like an equidistant triangle. The
needles protrude out or the nose cone for a distance that can vary from 1.5
111m to 2 mm. Optimal pigment placement is approximately 1 mm to 1.2
I11JTl into the skin. Actual needle tip penetration is then controlled by the
surgeon.
Console. The console includes all the wiring and powering
connections to which the handpiece is attached. The console con.'isls of a
pulse rate display unit. which is a solid state analogue panel meter. This
depicts the pulse ratc percent thaI represents the natural DC voltage applied
to the motor drive handpiece. The maximum pulse rate slide adjust control
sets the maximum voltage for a pul.se rate that can be delivered to lhe
handpiece via the f'ootswitch. The main power switch is a simple onloff
butto!) Ihal applies voltage 10 the machine from an external wall unil. The
handpiece connector is a chrome-finished connector used to connect Ule
handpiece cord to the front of rhe macbine. In the rear of the machine the
chrome-finished connector is used ro connect the foo ts witch cord to the
console ullit..
Foot..<;witcb. The varinble-speed footswitch linearly controls lhe pulse
rate of the handpiece tip and is connected to the rear of the console. As the
footswitch is deprcsst:'d, the power will advance to the maximum .IillJit
present on the front of the control panel with the slide cursor. By traveling.
through the range of power. pigmentation can be made darker or "lighter,
thicker or thinner. as desired.
Stcri.li7-3tion. Sterilization of the BPS 1.000 unit is recommended only
for the head portion of the BPS handpiece. The tip assembly is at the end
of each case, and the drive unit requires only cleaning with alcohol. The
motor and cord portions of the BPS handpiece do not require any
sterilization. The head portion may be auloclaved or dry heat sterilized.
The company recommends nol exceeding 310 F on dry heat stcrilizatjon,
and the head should then be lubricated. When rhe procedure is not being
performed, the handpiece should be stored along with the fOOlswilch.
Checkout Procedures. Natural Eyes recommends the following
procedure for setup and checkout of its instrument: (1) wnnect power cord
to the hospital grade AC outlet; (2) connect fOOlswitch Lo rear console: (3)
connect handpiece assembly without tip assembly to the front of the
console; (4) turn on main power: (5) depress [ootswitch fully and hold: (6)
adjust maximum pulse rate control to the desired setting; and (7) release
the rootswitch, gradually depress the fooc-;witch again, and observe a
slllooth increase in the actual pulse rate on the display monitor. Listen [or
the corresponding increase in the molor frequency of the handpiece unit
and if this increase is not heard. recheck all connections and see if the BPS
handpiece unit has been correctly secured and connected.
Once the instrument setup is complete, lhe company recommends
installing the tip assembly and testing it as fol lows: (1) (urn off the main
powcr swiLch to the console unit: (2) remove tip assembly from sterile

22

NSTRUMENTATION

pouch; (3) thread the assembly tightly into the handpiece head withoul the
use
tools; (4) press the needle tip or cover firmly againsl a hard. sterile
surt'ace in order to "scat the needle". (Listen for an audihle click. which
ensures engagement. Also the praclitioner shou ld note the removal of a
small piece of metal from the posterior portion or the head unit. which
usually guarantees a proper connection.): (5) remove the protective metal
cover from the tip: (6) hold the drive unit, rolate the motor base, and
observe a 1.2 mm nominal needle ex.cursion (recently. U1C company has
stated it is not unu~ual to have a 1.5 mll1 to even 2 m111 needle excursion).
The recommended procedure at this timc is not to press the cone to the skin
surface while performing the proceJure. To reseat the needle, (1) reinstall
protcctive cover, press against a hard. sterile surface. and listen again for
an audible click, which ensures engagement.
problem s pers is \' the
practitioner is usually advised to see the troubleshooting section in the
operator's manu<lJ.
The company recommends that. at the conclLl~ion of the cases for each
day, the machine be completely disassembled with the removal of lhe
handpiece unit. The drive unit is then disinserled from the motor electric
cord base and, by means or a cleaning and lubricating silicone spray, the
cntire drive unit and handpiece are luhricated. Once lubrication has been
completcd, the handpiece is removed for sterilization and the drive unit is
reconnected to the motor base and stored .
Warning. Natural Eyes makes a very clear disclaimer that the
company will assume responsibility for its Natural Eyes system only if the
practitioner uses the Natural Eyes products and docs not leI anyone tamper
with the machine .
Readers who arc interested in further information regarding thc
Natural Eyes machine should contact the Alcon Company at California
922713. The phone number in California is 800-321-8994 and outside

or

rr

California,800-XS4-01SS.

Dioptics (Accents)
The Accents defining system ha;, been developed to place permanent
pigment s.lfCly and dTcctively underneath the skin. Dioptics, ill association
with Dr. Robert Fenzl, had developed the first variable thrust and singJe
needle machine. More recently. Dioptics has added three-needle cluster 26,
three-needJe duster 28, and a seven needle cluster 28 for the handpieces.
The ~ystem consists of a power unit side A and B. handpiece and foot
CQ lltrol.
Power U nit. The Accents power ullit is designed to function in
conjunction with the Accents handpi ece as a "microsurgical system" for
pigment implantation. The power ~oun:e drives the needle within the
handpiece at a fixed r:lle of 3D HI. (or 30 reciprocations) per second on si de
A and (i0 Hz for ~ide B. The power control 011 lhe fronl panel varies the
Coree or penetnllioll to the control depth of penetration into different skin
typc~.

23
- - -- - - - - - - - - - - - - - - - - - -- - -

- -- -

-- -

CHAPTER

The dimensions of the machine arc 3 3/4 inches by 8 1/3 inches by 9


inches. Tht! power requirements are 115 volts pills or minus 10% at 0.25
amps. The leakage facrm is less than 100 microamps.
Starting from the number one power selling on the power control unit,
the Accents single needle handpiece cxtends only slightly from the needle
guide. thereby creating the illusion thai the needle is nOI in mOlion.
Gradually adjusting tht! power conlrol to the higher settings of 3,4. or 5 will
cause the needle to extend to its proper extension, as wcll as providing 1'01'
appropriate penetration of the skin (depending on the skin lype). Settings of
6.7. and 8 arc thc mo:-t widely used. as they prove to be the most suitable
for average skin tissues. It is important to nOle that the AcceJ1ls handpiece
was designed so that the needle will not eXLend pasL the predetermined
length of (l060 +/- O'()IO inches (or 1.5 +/- 0.25 mm). regardless of what
sClting is used. Placing the power unit setting at 9 or 10 will not increase
pcrfonnancc. but will only increase t.he vibmtion of the unit. Dioptics does
nOt re(;Ommend using settings of 9 or 10 unless penetration i, not obtainable
at a lower power setting.
Dioptics took into <.:ansiueralioll that even the most sophisticated
equipment will fail to operatc during the course of its lifespan. so a backup
power source bas been created for the practitioner's convenience. Since the
publication of the first book. Accents has modified the back-up or side B of
the power unit. This part of the power unit has been augmented to 60 RPS
('or use with multi-needle handpicces to provide stronger power for
feathering and shading. Also located on the power source is a red extend
bulton. When the unit is cOllnected properly. this button may be pressed to
cause the needle to become fully extcnded. This will enable one to properly
inspect the physical condilion
the needle. Alway do thi~ prior to all
procedures to ensure that the needle has nol. become damaged in transit.
Although Diopties Medical Products maintains a rigid quality control
program on all ils procillcl~ . the company recommends that the pracLitioner
is responsible as the ''final inspector" .
Ilandpiccc. Upon determining the needle to be "undamag.ed," the
provider should then check the actual operation of the handpiece. Thi .. can
be accomplished by depressing the foot pedal and observing the visual
effects of the unit. The COIllPiHlY suggests the following as basic guidelines
Itl keep in mind while performing the inspection: (1) Check the ncedle for
any dcfc<.:lS. burrs. and foro::ign material. as well as the sharpness of the
ncedle tip. (2) Make surc that Ihc needle is extending from the center of the
needle guide. (3) Check the speed of the needle extension to make su re that
it is not sluggish. (4) Makt: s ure that the needle extends without rotating. (5)
If the needle d()e~ not appear to be extending from the needle guide
properly. try increasing tht' power control while applying steady pressure to
the root pedal.
The Accents needle guide is bcvc.led at a 3U degree angle, which allows
the surgeon greater visibility of the 26 gauge needle. The distance from
\' ariou~ point~ on the bevel In the tip of rhe needle ranges from U.060 +/n.olo inchel> (/.5+/-0.25 111m) 10 0.075+/-0.01 inches ( 1.9+/-0 .25 mm) .
Since (he dL'rmal layer of the skin measures only 1.5 to 1.75 mm in depth,

or

2-1

NSTRUMENTATION

needle extraction of 1. 9 mm rnayirnplanl pigment in the orbicularis muscle


uncVor tar. liS plate. Because this ha:, been shown to increase the potential
for hematoma and pigment migration, it is quile important to operate the
handpiece wilh the bevel open. In the past few year~ Accents has offered
additional needle configurations: seven needle dimension ( 28 gauge! .015"
with maximum neetlle extension of 0 to 2.Smm+f- .25I11m): three needle
dimension (2)) guage! .0 IS" with needle extension of 0 to 1.5mm+/.25 mill ): and, a three needlt: dimension (26 gauge/ .018" with maximum
needle extension of 0 to 2.5lT\1l\+!-.25I1lm).
The handpiece is tapered down from the final third of the unit to rhe
tip, thus increasing the visibility of the needle tip. The grainlike texture of
the handpiece is easier to grip. The needle guide, made of a plastic,
maintains more pigment per series of dots than its metal predecessor.
The company recommends thal if any tlefccts are discovered while
testing the handpiece, thc unit should be repackagetl in ils entirety and
returned to Dioptics. A replacement pack will be sent immediately.
Warning. The company cautions that the Accents handpiece is a
disposable. single-usc instrument and (;unnot be reused. There are two
specific reasons why reuse is cOlltraindi(;ated. First , the handpiece and
especially the needle and guide , contain moving parts. This makes cleaning
and subsequent sterilizing extremely difficult since pigments from a prior
case can remain insitle the needle guide. This warning is consistent with
hospital accreditalion policy regarding reu~e of disposables. Secondly, as
the handpiece utilized a needle to penetrate the skin 10 a very specific
depth. a dull (reused) needle may not penetrate 1.0 the propcr depth,
resulting in a less effective procedurt:' , and implantation of pigment in thc
epidermis. Reu. e of disposables (both pigment and handpieccs) may also
affect liability insurance exposure in the event of any legal proceedings by
patients.
Table 3 I: PigmcllI Mixtures and Mlic hinc Design Features
~mell!

Needle Type
Single,
MultIlJ'e

D;sposab:e
H~ndp!eCIJ &

Autcmabc
Pigment

Pigment

Se:nipermlnent

RfSe~;OIr

Pigment

MixtlJre

Titanium

Mixture

Containing

Dioxide

Con!ammQ7~

Ethyl

Pigment

A\'2I~bIe

Iron Oxide
Pigfl'.en(
Avai'abIf

Avai~bie

Isopropyl
Akllnol

A!Gchol
&G!'iWlIl

Handpiece
Compatability
Yidh Other

Vanab~

Variable

(Pri)ojuct Name) Spetd

Thrust

Backup
Power
Supply

Yes

No

No

YES

No

Yes

Yes

Ves

Nu

Yes

tfu

Uo

~o

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

~,o

Yes

Yes

Yes

)'~s

v.,

..

Yes

Yes

Yes

Yes

YdS

Yes

No

Yes

Yes

~o

Yes

riO

YeS

NQ

~{}

YES

Yes

Yes

IJo

YeS

Ves

Derrmutloge

Yes

No

rIo

Y15

Yes

No

Yes

Yes

Yes

No

Yes

T"II

Cosmetyr.e

flo

Yas

lID

Yes

Yes

~1C

No

No

No

No

No

No

Yes

No

'110

Yes

YES

No

Yes

Its

Yes

flo

Yas

NQ

N(j

No

~~o

Yes

Yes

Yes

Yes

Yes

Yes

~.o

Yes

No

Man~1actw2r

Alcon

Colors

~ines

INa1Ura!:I~i

:1!cpt!CS
[Actenls)

VlSlCn Cw:rPIS

iGlamour EifSI
A
Jiler.
I Penna! lie)

iDSL5())))
Permark
\Ennarn:er)
Concep; inc.
ilasnj"e!}

25
- - - - - - -- - - - - - - - -- - - -

- -- - -- - - - -

C H A P TE R

For further information, the r~ader may write to Dioptics M edica l


Produ cts, Accents Di vision. 15550 Roc.kficld Boulev ard , Suite C,
Irvine. California 92718. The phone numbe r is 805-541-0811.

Lasting Impressions
Lasting Imprcssio ns I is a rnedical-csthctician manufacturer and
distributor of micropigmcl1tation products and services. Its founder,
Darlene and Richard Story have committed their company to a five-point
approach:
1. Improve pigment quality, selection and sizes: All the company' ,
pigments are manufactured from FDA approved products under sterile
condit ions with pigment granu lar size at 6 microns. The company u es 44
different Microcolors and the shades come in 4 sizes l5cc, 2cc, and 0.5cc
vials and a 0.5cc tester vial.
2. Create a color mixing system: The compa ny created a patentpending mixing sy tem for its 44 base color set. This system all ows the
practitioner the flexibility for cus tom color preparation.
3. Establish a consultant" support group: The company provides the
practitioner with appropriate physician, nurse, and technologL ts referrals
within the micropigmcnLation field.
4. Estahlish a Lrainiog program: The company is establishing its own
training program to assist the novice practitioner in proper training and
certifjl:tltion within the field.
5. Integrate estheticians with the medical field: Wilh the increasing use
of physicians and nurses relying on eSLheticians to assist and even perfonn
various pennanent makeup procedures. La. ting Impressions I is committed
in helping the estheticians integrate into the medical field.
For further inrormation contact Darlene or Richard Story a t
237 Liberty Road, Englewood, New Jersey 0763 1. Phone toll free 800377-40li8. In New J ersey call 201-87l-7388 and FAX 201-871-4942.

VlSion Concepts (Glnmour Eyes)


Vision Concepts, Inc. developed a new system for micropigmenwtion
known as Glamour Eyes in 1984 and had the following features: reusahle
handpiece, separate disposable needles, reasonable price, separate
pigments, and complete backup circuitry for the machine. The Vision
Concepts system consist.ed of a handpiece. power unit. and footswitch. The
company had designated the LOtal system as the GLE 100 System .
Ha nd piece. The handpiece wa~ it se mipermanent, linear solenoid
clevice:! thaI wa!> guaranteed ror 90 days. The handpiece conriguration was
straight, allowing for a better surgical field of view while reducing hand
ratigue. and was compatible with the Dioptics conso le. The handpiece was
unique with its relillahlc reservoir that automatically fed the pigment to the

26

INSTRUMENTATION

needle, thus eliminating the need for const<1nt dipping of the needle into the
pigment container. The total electric current to the handpiece was only 24
volts; thus. it was safe for patient use. Attached to the handpiece was a
sing.le-tipped, modular stainless steel needle tbat coulJ be removed and
disposed of at the end of lhe case. The needle excurs ion was 1.0 mill to
1.25 mm; if the power is lowered suffic iently, the excursion will drop, but
in the working range , increasing the power will affect needle excur 'jon
negligibly .
Power Unit. The power unit consisted of two complete power ~yslems
and handpiece plug ' so that. in the event of a machine fai .l ure. a complete
backup ~ystern existed. The power con:ole offered the unique features of
variable speed and thrust controls. as well as a test need I.e button . With the
separate con trol s for speed and power (thmst), the surgeon had complete
tlexibility in performing each surgical proccdure. The power contro l varies
the voltage delivered to the. handpiece, and controls the force (not the
amplitude) of the needle excursion. The speed control varies the frequcncy
of the needle excursions between 15 and 40 cycles pe.r second. This , olid
state device with a 24-volt power sllpplyis UL approved. according to the
comp<lny. and could therefore be used legally in a hospi tal setting.
Footswitcb. The foolswitch is attached to the power console and
allows the surgeon to control the power flow to the handp iece . By
depressing the footswitch. the operator tums the power now either on or
off. The fOOL control switch, needle modules. pigrnent~, handp.i ece and
power unit comes with a compact carrying case.

Table 3-2
Design Features

....

'0

Q)

0.
a..

::J

U)

"0

en

a..

..c:

Q)

Q)

:0

:0

'~

'~

Q)
Q)

:u3:

Alcon
"Natural Eyes"

$6.000

$60.

'15

Diopllcs
"Accents"

$2 .500

$150

t~

Permark

53,500

Company

""
:>
'"

OJ

""

:>

:0

<..>

"0
0>

co

2:

'"

"0

,9'

<.:>

7'
..::.:

c:

a>

c:
en
:J:

CL

Cost of
Disposables
per Case

t-

~
::J

'E

Original
Cost of
Machine

U)

'"
a:

Q)

o..

Number 01 Cases
Performed to
Recoup Investment
(Allow $500/Case)

'0.

Vl

>.

Q)

Q)

'"aen

CL

en

5
N

Q)

Q)

0>

0::
.~

E
0

:;

<t

Compatibility
with Other
Machines

No

Yes

No

Yes

Yes

No

Yes

3
$65

3
S71.

Vision Concepts
"Glamour Eyes"

51 .850

Alltek
"Permline"

51 .250

$36.

Dermoufiage

$ 450

$40 .

Cosmedyne

51 ,500

$115.

1
3

27

CHAPTER

To our knowledge the company is no longer in business. Buyer should


beware of any old equipment purchases since there appears to be no one
servicing this equipment today.

Alltek (PerrtUIline)
Pennaline eyeliner system is another microsurgical devicc for applying
permanent lashliner. This system was produced by the AlltekCompany and
included a solid state power unit, semidisposable handpiece, sterile tips and
pigments. Unfortunately. this company is no longer in bu iness. The
fonowing information is of historical significance only and could be helpful
in the even! that a practitioner may wish to buy a used unit.
Power Unit. The console or power unit for the Permaline system is US
made, microprocessor controlled circuitry with a digital display readout.
The unit is 9 inches long , 6 inches wide, [Uld 2 inches high. With the digital
readout sYSlel11. the company stated, the results are exacting and repeatable.
Handpiece. The Alitek system handpiece is reusable and consi'ls of
one pre,cision moving part. The system is designed to function with similar
singleneedle systems such as the Dioptics-Accents machine system.
According to the company. the handpiece can be used for over 50
procedures before a replacement is necessary.
Needle Assem bly. The company offers a disposable needle assembly
to be used in conjunction with the multiuse handpiece. The stainle's 'leet
needle is fine-gauged and manufactured to exacLing toleran<.:es.
Footswitch. The semipermanent handpiece connected to the Permaline
power unit is activated by a footswitch. Thi footswitch is replaceable and
connects directly to the power unit.

Cosmedyne
Cosmedyne produced an instrument that con, iSIed of a power unit.
handpiece and footswitch. As with the above examples, this company is
also defunct
The CosJ11edyne power unit known as the CPU 100, consisted of a
variable thrust mechanism with a built in bat:kup unil. The s ize and
function of the CPU 100 are similar to the Accents equipment. The DSLSOOO handpiece is fully a 'sembled LInd presterilized. requiring no needle
Insertion or autoclaving. The DSL-5000 handpiece is uls\) compatible with
the Accents equipment Of' power unit. The footswitch is connected to the
CPU 100 power unit and provides an on/off capability 10 the handpiece. Al
this lime the company is planning to market four colors based on the iron
oxide and gJycerol suspension. These pigmcnts will be manufactured and
shipped in ~terile vials.

28

INSTRUMENTATION

Eye-lite Inc. (EL2000)


The EL :WOO by Eye-Lite, Inc. was a new instrument in the marketplace. Again this company represents another casualty in the instrumentation companies of the late 1980s. The company i~ out of husiness. In
tlc~igning the EL 2000, Eye-Lite had taken special care to ensure that the
surgeon h ad the facility , during the procedure, to alter the depth of
penetration of the needle. the speed of the needle, and the pulsatility of the
needle. It i ' fclt with these three features. greater control is afforded the
surgeon and thus a safer and more even application of the pigment can be
achieved.
Speed. The range of cannula speed in the EL 2000 can be varied by the
surgeon from approx imately 1000 cpm (0 2000 Cplll. This range allows fast
penetration and even pigment application while keeping the needle speed at
a safe controlled rate.
Penetration Depth. Due to variances in eyelid thickness from patient
to patient and the angle at which different surgeons hold t.he handpiece, EL
2000 corporales the facility of manually adjusting the protrusion or the
needle beyond the needle guard. By simply turning the nose cone of the
handpiece ill a clockwise direction , the penetration depth of the needle can
be increa~cd from 0.6 111m up to 1.5 mm . Thi s adjustment can be done
during the procedure. even with the machine running.
Pulse Rate. Another feature unique 10 the EL 2000 is a "burst" or
"pulse" mode. With this feature, the surgeon can set the needle speed
anywhere within the manufactured range while also ~etting the pulse rate,
which ba s an approxi mate range from 0.5 seconds to 1.5 seconds. For
example, if the pulse rate has been set at it maximum and the speed ha
been set at 2000 cpm. the surgeon depresses the foots witch to position j
and the needle wi II activate at 2000 eplll per period of 1.5 seconds, then
top for 1.5 seconds, and then activate for 1.5 second . etc. If at any time
during the procedure the surgeon wishes to operate in a continuous mode,
he simply depresses the footswitch to position 2, and the needle will run
continuously at the preset ~peed.
System Accessories.The EL 2000 sy~tel11 includes the control console,
the footswitch , the instruction manual. and the handpiece.

American Institute Of
Permanent Color Technology
The American Institute of Permanent Color Technology specia lizes in
educational programs for demographic application, including micropigmentation and l11ultitrepannic procedures. The In stitute administrates a
natural micropigl11entation research program. consisting of seven approved
research facilities (nationwide). an "esthetic:> research r"cility in Ohio, and

29

CHAPTER

an education center in Kentucky. Each facility is responsible fo r oil-going


co ntributions to the industry. as well as loca l affiliate participation. the
Schei bncr Center in Sydncy, Australia. Other affiliate projects include
Ca nada, Mexico and New Zealand (projected 1993).
The AIPCT was created in it joint effort con isting of an '"all -star team"
of accompli.shed Derl11a-Techs and medical professionals nationwide. and
heraldcd the comi n g together o f th e "Macro-Theory" approach to
permanent color application. Macro-Theory is a specific combination of
ALL variati ons of pemlanent color application. both "age-old" anc.l "new
wave" . Irs purpose is t.o provide the tech ni cian witb the most effective
appli cati on for each individual situat ion as it occurs, providing an mTay of
alternati ve procedures and the proper method of dctcl111ining which is best.
The American In sti tute offers a multitude of specialized programs
divided into th ree main categories: (J) Permanent Color Application. (2)
Paramedical/Corrective Pcrmanenl Col()f Procedures, an d (3) Multitrep<lIlnic latro!ogy.
"Certifica t ion tr ai ning" teaches th e new Derma-Technic ian
fu ndamentals of micropigmentation. PCn11anenl makcup applications suc h
as eyeliner, eyebrows, and liplioer/fu ll lip color are the significant focu .
The AIPCT certi fication course is approved and recog ni zed by member
states of the American Nurses' Associatjon . The scho01 is at 0 approved
and registered by the California Board of Education.
Advanced internships arc conducted annllally for specialized training
in "corrections " (fo r previolls permanent makeup applications ):
" paramedical" (medically related) camouflage: post mastectomy arcola
pigmentation; scar ti ssue treatment; and cleft lip reconstruction. In addi tio n,
specialized internships have been developed fo r advanced training in the
prot:ess of Multitrepannic Collagen Actuation procedures.
The American Institute provides referrals daily, to phy_icians requiling
various dermagraphic services , an d tho se seeking qua lifi ed Der maTech ni cians for s pec ific permanent color procedures . For curre nt
information pertainin g to availab le Derma-Tcchnicians or material on
education and training as a Derma-Technician. the reader is advised to
contat:t Kristanne E. Matzek, MA, Director of Education at 150 El
Camino Refil, Suite 120, Tustin, California, 92680. Phone 714-573-4448
and FAX 714-544-6171, or caU toll free 1-800-77-A-I-P-C-T.

SUMMARY
lJllyer "eware would be the hes/ advice tt) IILe nell: praclitioner who
wishes 10 pursue a cLl r eer ill thi.l"jield. 011(' can easily appreciate Ihe rapid
lind serious chclTI8es tltat have occ/ured since the plfblication oj tlte .first
book. We would c(ll/lion Ihe lIell' practilioners If) align lizelTlseh'es with
IflOse companies thal ojJer the best probahilitv Jor .filtHre existence and
growth.

30

H A p T E R

FDA and State


Regulations
HISTORY
The historical evolution of todny's modern drug and cosmetic
regulations can be traced to the Federal Food and Drugs Act of 1906
which was created largely by the work of Dr. Harvey W. Wiley in 1906.
The essence of the 1906 legislation dealt with the prevention of ales or
transportation of adu lterated, misbranded , poisonous or deleterious foods,
drugs. medicines and liquors, and the regulation of their traffic through
inlerstate commerce. Unfortunately. the act never discussed premarket
testing for efficacy and safety. The acl also discussed tl,e tenn "drug" as
recognized in the United States Pharmacopoea or national formu lary for
internal and external use.
Federal Food , D r ug a nd Cosmetic Act. or 1938. ft was not until
1938 after numcrous complaints by the public sector that the Federal Food.
Drug and Cosmetic Act of 11)38 was passed. Unfortunately. it took a
disaster involving diethylene glycocol, a toxic substance mixed i.n the
elixir of :"ulfanilamide. in which 100 peop le lost their lives in 1938, lO
prompt the passing of ihe acl. The! t)38 provision defined more clearly the
concepts of cosmetics. drugs and foods. The 1<.1\-1/ further discussed the
issue Ilf adu lteration and misbranding in which a poisonous or deleterious
substance could calise injury (0 the user unuer condi tjons of the pn:!sclibed
customary or normal lise. Also, if the item consi~ted in part or whole of a
filthy. putrid or decomposed substance that had been packaged or prepared
under unsanitary conditions, the cosmetic, food or drug would be
considered adulterated. For 'the first time, a drug Ileeded to be tested for its
l>afcty and was required to use labels stating whether any specific dangers
or habit-forming factors were present. Also for the first time, the federal
government discusst:d the nature of devices and dclinitions of cosmetics.
Throughout the 1940s. variOliS amendments to the public law were added
by Congres. concerning the certification of batches of drugs composed
wholly or partly of insulin. as well as u varit!ty of antibiorics.

31
-------- ---

CHAPTER

Durham-Humphrey Amendments of 1951. The next major addition


the federal guidelines were the Durham-Humphrey amendments of 1951,
!>ometimcs known as the prescription drug amendment. These amendments
considered that distribution of drugs was to be done by pharmacies and
clarified the nature of prescriptions.
Color Additive A mendment of 1960. Tn order to simplify the product
development of color additives, as well as provide scientific data, in 1960
the FDA developed the Color Additive Amendment, which exempts certain
chemicals, dyes, and pigments from batch testing. Throughout the decade of
the 1960s, various cosmetic and pharmaceutical companies began in-depth
scientific analysis of these pigments and provided the FDA with the
appropriate data and analysis necessary for their exemption.
Drug Amendme nts of 1962. As with the sulfanilamide disaster of
1l)38, in 1962 history repeated itself with a thalidomide disaster. Because of
this tragic cpi. ode, the Kefauver-Harris drug amendments were added to the
previous acts concerning safety, effectiveness, and reliability. as well as
standardization of drug names. In add ition. the articles considered factory
inspection and effect of state laws. registration of drug establishments, and
patielll information (informed consent).
Fair Pac kagin g Act of 1966. In 1966, the Fair Packaging Act was
passed in order for consumers to be informed of label statements of the
products identified and the quantity of contents a. specilied by law. The
purpose of this act was to prevent deception and to offer consumers a means
of evaluating and comparing different products.
Medical Device Am endments of 1976. On May 28, 1976. the Federal
Food. Drug, and Cosmetic Act was amended again as the "medical device
amendmenls of 1976." The act consisted of classification of device
intended for human use, performance standards, premarket approval. band
devices, and judicial revic,,,' . Tn addition, the Jaw discussed general
provisions respecting control of devices intended for human use as well as a
classification of the devices themselves.
In the 1970s, numerous publication of cosmetic investig~ltion were
published in the Federal Register, and various subcommittees such as the
Cosmetic, Toiletry, and Fmgrance Association Subcommittees on Quality
Assurance were created. These various studies and agencies have
considered the issues of product preservation and antimicrobial and
antifungal safety of cosmetics produced in the industry.
In 1976. the Federal Food and Drug Administratioll (FDA) received
variolls petitions for the listing of iron oxides as permanent color additives
to be used in externally applied cosmetics, including lipstiCKS and those
used around the eye. The commissioner evaluateo the clata ancl concluded
thaI iron oxides were safe as long as the following criteria were met; (a) that
the color additives of the iron oxides consisted or combinations of
:"ynthetically prepared iron oxides and was free from admixture with other
substances: (b) that the iron oxides would contain no more than three parts
per million of arsenic. no more than ten parts per million of lead, and not
more than rhre.:: pans per million of mercury: and, (c) that the iron oxides
were safe when applied to the areas surrounding the eye as long us their
production was con:.iSlcnt with good manufacturing praclices. However. in
LO

32

--- - - - - -- - - - - - - - - - - - - - - - - -

FDA

AND

S TAT E

REGULAT I ONS

a later amendment known as Titk 21. part 70 concerning color additives,


sc<:tion 7.5 under New General Restrictions on Use of Color Additives. pan
B. states that color add iti ves for use in injections arc not HuthOJized even
though tlle use of the color additives was authorized for other areas.

DEFINITIONS
The development of micropigmentation has been fraught with various
discussion ' and disagreements among the various aspects of the federal
age.ncies and the manufacturers as to the exact nature of the micropigmentation procedure. Before discussing the more subtle aspects of these
various disagreements, it would be quite useful to define the key temlS as
discussed in the Federal Food, Drug, and Co melic Act.
Food. I) Articles used for food or drink for man or other animals; 2)
chew ing gum; and 3) articles used for components of any such article.
Drug. 1) Articles recognized in the official Unitetl States Phamlacopoea. Official Homeopathic Pharmacopoea of the United States. or
ofticial national formulary, or any supplement to any of them; 2) articles
inte nded for use in the diagnosis, cure. mitigation. treatment, or prevention
of disease in man or other animals; 3) articles (other than food or cJothes)
intended 10 aHeet the structure or any function of the body of man or other
animals; 4) articles intended for use as a component of any article specified
in clause 1.2, or 3, but not including devices )1' their components, parts or
accessories.
Device. In truments, apparatus, and contrivances. including their
componen ts. parts and accessories, intended: I) for use in the diagnosis,
cure. mitigation, treatment, or prevention of disease in Illan or other
animals: or 2) to affect the structure or any function of the body of man Or
other animals.
Cosmet ic. I) Articles intended to be rubbed, poured, sprinkled. or
sprayed on, introduced into, or otherwise applied to the hUlllan body or any
part thereof for cleansing, beautifying. promoting allractiveness. or
altering Lhe appearance; and 2) articles intended for use as a component of
any such article; except lhat slich term shall not include soap.
Label. Display of wrillen. printed , or graphic material upon the
immediate container of any article: and a requirement made by or under
authority of this act that any word. statement, or any information appear on
tllc label shall not be considered to be complied wi th unless such word,
wltement, or other information also appears on the outside container or
wrapper. if .my there be, of the retail package of such article. or is easily
legible through the outside container or wTappeL
Co lor Additive. A material that: a) is a dye, pigment. or other
substance Illade by a process of synthesis or similar artifice or extracted.
isolated, or otherwise derived, with or withoLit intermediate or fina'! change
of identity from a vegetable. animal. mineral. or other source: and b) when
added or <lppl ied to a food. drug, or cosmetic. or to the human body or any
part thereof, is capable (alone or through reaction wi th other substance) of

33

CHAPTER

imparting color thereto. Color includes black, white, and imermediate grays.
Tn the earlier part of 1985, ajoint meeting of the various departments of
the FDA was convened in order to discuss the subject of tattoo colors and
tattooing apparatLis. The purpose of this meeting was to determine the
enforcement policy regarding human body tallooing. especial.ly in the area
of the eye (eyelid tattoo). A general resolution was created that stated the
following decisions:
'That the agency policy continue to be that the dyes and pigments used
in tattooing are color additives as defined under section 201(T) of the FDC
Act and that they are cosmetics.
'That tattooing in the area of the eye is considered to be more of more
serious concern than other body areas. The agency policy concerning
human body tattooing. generally will remain unchanged from the past
policy.
"That the devict! status of the apparatlls used to create a tatloo i:
unclear; however, it was concluded that the device authorities would not be
applied at this time. After CDRH has responded to any 51 O(K) submission
for the use uf such an apparatus. the.y should refer the information to the
CFSAN for any appropriate action.
''That the CFSAN will dral't the policy statement of the regulatory
status of tattoos with special reference to the eyes. (e.g., colors, dyes,
pigments and apparalu , used to create tattoos) for the concurrence by
ORA."
The essence of this resolution is that the device status of the
micropigment<llion equipment is still unclear. Presently. the device
regulations of the Food, Drug, and Cosmetic ACI will not be applied to this
Illicropigmentation equipment as long as it is promoted and labeled for use
as part or a ta.ttoo procedure. The FDA states further that if future hazards
may be associated with the use of this equipment, the agency would
reevaluate the device status at thc time mentioned by the reference 51O(K)
stipulation.
Sincc the unfortunate experiences in the 1930s in which certain dyes
and color additives, such as cual lar hair dyes and various metal-additives
including nickel, silver, lead, and mercury, were implicated in harmful
effects to the human bcxJy, the FDA has maintained a strong hold over the
usc and proliferation of color additives in cosmetics, drugs, and food '.
However. contrary to popular belief. there are no ~talUl.Ory requirements that
cosmetic products be tested to be proven safe or thaI the accuracy in
labeling of tJ1e cosmetic products be substantiat.ed before the cosmetics are
introduced to the American buying public. Alw , various co metic
manufacture.r:- and di1>tributor s are nut rt'LJuired by law to register
Illanufaclllring establishments, product formulations. or consumer reports of
udver!;c reactions to the FDA or make available other information on their
products. Even if it company voluntaril y offers this information to the FDA
prior to distribution and receives an assignment of a registration number by
the agency , the FDA docs not consider this registration number to be
approv~tl or the firm or its material or its products. The FDA further stales
that even with a registration number ancl labeling. a conspicuolls disclaimer
phrase must be noted. It is interesting to note that drug manufacturers

34

FDA

AND

S TAT E

REGULATIONS

undergo far more stringent and careful regulation by the FDA than does
the cosmetic industry. In essence. a drug company is considered to be
guilty and must prove its innocence before a new drug: can be released to
the American public, whereas in the cosmetic industry the burden of proof
falls on Ihe FDA. The FDA mllst prove that the cosmetic finn's new
product can cause potential harm 0 the human being. IIi. rather obviou.
that there j,' a vast dillcrcnce in the approach of these regulations between
a drug <IIld a cosmetic, Therefore, it is quite easy for a cosmetic to be
distlibuted and cause serious injury before the FDA has any legal authority
to halt und hinder further distribution or the hannful cosmetic through
interstate commerce. With the exception of certain prohibited ingredients
in color additives, any cosmetic manufacturer may use essentially any raw
material as a cosmetic ingredient and marker that product: without FDA
approval. Some of the restricted and prohibiled chemicals in cosmetic, are
bithianol. mercury compounds, vinyl chloride. hallogenated salicylanides,
zirconium complexes in aerosol cosmetics. chloroform, chloroJloral
carbon propellants, and hcachlorophene.
Presently. the agency is currently evaluating eye area tattooing to
determine if a lattoo of the eyelid can rail within the agency's safety
st andards . In the meantime the agency has concluded that policy
concerning human body tattooing will generally remain unchanged from
past decisions. namely, that the dyes and pigments used in tattooing are
still to be considered color additives and. as such. will be subject to the
olor additive regulations.
The FDA still considers tattooing. to be cosmetic since it is for the
purpose of beautifying. promoling attractiveness, or altering the appearance, In numerous personal and wrillen communications with the FDA. we
have been told thal the FDA still would prefer to defer various legislation
regarding tattooing to the various state, city. and lucal ordinances (see
Table). We would recommend that any practitioner interested in beginning
the micropigmcntation process take it upon himself to check wilh the local
ci ty or !'ltale health regulatory affairs department to be SlIre tlwt tattooing
procedures arc within the local law , {l would also be prudent for the
practitioner to check with hi:; malpraclice carrier, since ulere have neen a
few instances in the various states in which the malpractice carrier has
refu!'led to cover Lhe micropigmentUlion procedure. A sample letter to a
malpractice carrier can be located in the appendix section of thi book. In
the meantime. any practitioner who is interc~tcd in further information
regarding regulatory requirements for the marketing of cosmetics should
direct his questions to the Food and Drug Administration, Division of
Cosmetics Technology (HFF-440). 200 C Street, Washington, DC
20204. Question!> pert aining to the requircmcnts for marketing products
that are also dl1lgs should be adure!'lsed to the Division of Drug Labeling,
OTC Compl.iancc Branch (HFD-312), 5600 Fisher's Lane. l{ockville,
Maryland 20857.

35

CHAPT E R

Current State Laws Pertajning to Tattooing


Norman Goldstein, M.D., F.A.C.P.,
Clinica l Professor, Medicine
John A. Bums School of Medi cine, Un iver 'ity of Hawaii
State
Alabama

No

Ahl~ka

Nil
No

Aritona
Arkansas

36

State
Statutes

Local
Ordinances

1993 Reply
Pending
X

y~>

California
Color<IJIJ

y~,

Connecticut
Delaware
f'lorida

Yc,
No
Yes

Georgia

Yes

Ha __ aii

YI:'\

Idaho
lllinllis
Indiana

y.:,1
yc,

Iowa

YI!S

Kansas

:-1n

Kenlll,ky

No

Louisiun:1
xfainc

Yes

Maryland

Yc,

.\iassachuse![<.

Yes

Ye,

No

No

Remark.~

Yes

X
X

Yes

Leg~lation being consid~red .


Writren conscnt of parent or guardian
of minor ( I g yrs.). A 6-month appr(oticeship under a Iicenscd physician
or certi fied ~nnanen t ani,1 licensed
for 3 vrs.
No r;gu latillns 2
MU~I be licensed co>metologist or
cnsnJctician or medical doctor. or
a l ic~lIsed nur;e under direct
u~r\'ision of a medical doclor.

Limited to a person liceR:;">! to


practice medicine or dentistry, or
by a person under his direclitln.~
Dr. must train technician 2xfyr."
Eyeliner prohibited except in conjunction wilh Doc(()r's office.
Other tattoos are penniued.
Regulations first e":lbli 'hed 1949.
rc\iscd 198 I. Annual inspection
and pennit reqllired. During
WW II, 400 people tllttooed daily!
Today, 21 licensed tattoo parlors
on Oahu_ I 011 Maui. 6 on "Big
Island" of Hawaii.
May have local ordinances.
No Regulation~~
ts inducted in license to pmctice
medicine Of osteopathic medicine.
No cosmetic tattoo regulations ~r
,c at thi, tim~.
Legi~lalion being considered IApr..
1993) to be done by docUJr only.1
Legislation cnnsidc:red: all rattoo,
must have Registered Nurse prc~ent at all rillles during tallooing.

Tart{)ning of minors ( 18) prohibited. Fine:, $50 1{1 $500 or prison


up to 6 months. Prior to 1975 it
was ill~eal ro tattoo the Ixxh of a
female person.
Cosmetology Board prohibit COirnetologilots trom doing cosmetic
lattooing in ('oslIIctology salons or
by liccnseJ co,mclOlogists .
Pennitl~d by qualilied physil'ian:
only. fil1~ of ~300 or il11prislJl1ll1enl
tip 10 one year. or Ix1th.

FDA

AND

Slate

Statutes

Slate

LOC'.tI
Ordinances

S TAT E

1993 Reply
I'ending

REGULATIONS

Remarks

A liCell\cd ~(}smetoJogisl may do


cosmetic wltoQing in a licensed
cosmetology t:~tnblblunl!nL Other
licensees may: ifl'rmittcd in their
scope of practlc~ .51. Paul and Minneapolis

Michigan

Yes

Minncwta

No

Yes

Mis~i 8S ippi

No
No

Yes

Local ordinance ' in Springfield and


Waynesville.

Yes

Cosmetology Boord prohibits tatlooing. No S[al~ liccns.ing for tJuooi ng.


but Reno aqd Las Vegas have sirict
guidelines:'

Miswuri
Montana
Ndmlska
Nevada

No
No
Yes

New Hampshire
New Jersey
New Mexico
l\ew York

No
Nol
Nol

North Carolina

Yes

North Dakota
Ohio
Oklahoma

No
Yes

Oregoo

No

Pennsylvania

Yes

Rhode Lland

y~s

South Carolina

Yes

South

Yes

D:JKOla

Yes
X
Yes

No

Tennessee
Texas

Nol
Yes

Utah
Vermont

Yes

Virginia

No

Washington
Wesl Virginiu
Wisnmsin
Wyoming

No

No

No
;\01

Banned in New York City boroughs


(Jicpalitis cases Coney L~land 19(1)
Buffalo (Eri~ County) & N.Y. Stale
considering lleW regulations.
Prohibited under 18 yrs. J;ine up to
'SOO, impnwnment up to 6 mOluhs.
or both.
No ,ramtes or I'ule~ to date.

X
Onl)' perillits a .licensed practitioner
of the healing arts, performed in the
COlu:e of his practice.
Slat~ laws under Eleelrology Boan:!
~nJing , Ponland has regulations.
Tm[ooing minor,; prohibited without
parent's consent OK yn:..). Fine not to
ex,ced $2.500.
Comprehensive regu lations about
tauOl) [lI1ists and lattOO parlor
inspections.
Prohibits all titltO()~ (1966). In 1986.
physicians may perfonn for cosmetic
or re.constructive surgery.
SWtc ,lnd local regulations being
considered.

Yes

Yes

Yes

Yt>

Unlawful to litnO\) any person under


age of 21 yrs. Some cilies and counties
ha\e local ordinances.
Salll.;(ke County has regulations.
pf(lhibir~d except by a p.:rsOIl IkenseJ
til practice medicine or osteopathy.
Rrg!Jiakd at local lc\'e!s. PCl1nit~
Illedicul JOCftJr>, vdclinuriulls, regisIcrl."(lliuThC~ 0r 3nv other liecos.:d
medical <;ervire pCl'Scmnel.

X
X

:-:0

37

CHAPTER

STATE lAWS AND REGUlATIONS


Tattooing was forbidden by Moses because il was the worship of idol '.
The Mosak Law does seem to have been obeyed by most of his followers
throughollt the centuries. However, despite biblical injuctions. despite
Muhammed's 1 prohihitions (nine references in (he Hadilh pertaining to
tattooing), despite decrees by the Roman Emperor Constantine in ca, AD,
300. Pope Hadrian in A.D. 787, Emperor Mcjci in Japan in 1868. Natjonal
Laws such as that of the French in 1889. and despite more laws against. or
limiting tattoos for reasons of public health. tattooing persists today.
Indeed. the number
tattoo artists,. professional and amateur, as weJl as
the number of physicians and veterinarians who arc doing tattooing for
cosmetic purposes. is increasing at a phenomenal rate . Membership in
regional. national and imclllational tattoo clubs i .. also increasing yearly.

or

CURRENT STATE lAWS PERTAINING TO NURSES


Allnette Walkel; R.N.

State
Alabama
California
Colorado
Connecticut
District of Columbia
Florida
Georgia
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
New Jersey
New York
North Carolina
Ohio
Oklahoma
Pennsylvania
South Carolina
Texas
Vcrnwnt
Virginia

38

State
Statutes
No
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No

Nursing Board
Rulings

Remarks

2,3
1.2,3

Under dodor's supcrvision

Under doctor's supervision

1
1
2,3
I

2,3
4

Doctors only

2,3

No

I
I

Ycs

2,3

No
No

I
I

No
No

No

Yes
No
Yes
No
....cs

2,3

1 = Independent Conlractor

2. = Advanced Nurse Practice

2,3

No

2,3
I

LEGEND
3 = Standardized Nurse Pracrice
4- = Not Within Legal Scope of
Nursing Practicc

FDA

AND

S TAT E

REGULAT

N S

With the participation of nurses. cosrnelolObrjsts, .lIld cstheticians. the field


has more than doubled in the past 3 yeurs.
In 1979. a review of laws and regulations pertaining 10 tattooing was
published in the Journal of Dermatological Surgery and Oncology. A
fol lowup . urvcy was conducted in May 1985 and published in
Micropigmen/(J/io/l ill 1986. These surveys were based on information obtained from directo[s of State Health Departments and! or their legal
advisors in selected major cities in the United Slales. A 1992 national
survey has been completed and is inc luded in this text
Replies were received from 46 states, as well as several cities. Based
on this urvey and the 1979 and 1985 reports. 26 states do not. have
regulations, or statutes pertaining to tattoos. Several health department
directors or attorneys have related that. even though theiT stille. do not
have regulations. some cities and ("ounties within the stales do regulate
taltooing. Several states, such as fduho.lowa. Missouri, Minnesota. South
Dakota, Texas. and Virginia. advise persons engaged in such activities to
contact local authoritics about locaJ ordinances.
States with cities tJlat have local ordinances include: Minl1e~ow (S l.
Paul. Minneapolis), Nevada (Reno, Las Vega, ). Oregon (MultnoJTlah.
Portland County). Ula h (Salt Lake County), California (Long Beach,
Oceanside, San Diego. San Francisco), Maryland (Baltimore). New Jcrsey
(Camden), New Mexico (A lbuquerque. Las Cruces, Sante Fe). New York
(New York City). Ohio (CincinI1Uli), Virginia (Chesapeake. Hampton.
Newporl News. Norfolk , Portsmouth. Virginia Beach). and Washington
(Seallie. Tacoma).

CHANGES IN STATE LAWS


SINCE THE 1979 AND 1985
SURVEYS
The Arkansa.s Board of Health adopted Rules and Regulations for
Talloo Establishments in April 1992. and these were signed into law by
Governor Frank White on June 30, 19lr2. Tattoo ~lI1i s L Hre required to be
examined and certified. Adequate knowledge of bacteriology and aseptic
technique must be proven by examinat ion . A chest x-ray and bloodtest for
syphilis must be performed: and . an annual Certificate of I.nspeclion for
wttoo shop::. is required . The physical environl1len t and operation standards
for taltoo ~hops are s pecified in the Rules and Regulations. Written
consent of a parent O[ guardian is required for tattooing
minors (under
age 18).
Since the last survey in 1985, Colorado, Georgia, iowa. Maryland.
Michigan. Nevada. Rhode Island. South Carolin a and South D:.tk.nta have
instituted regulations com:erning tattoos.
New Hampshire. Pennsylvania. and Texas also have State Regulations

or

31.,1

CHAPTER

perll.11ll1ng to tattooing. At this time, twenty-four states now have statute '
pertaining. to classic andlor cosmetic tatLOoing. M.my of the state health
department directors or their legal departmentS have indicated considerable
interest in establishing rules and regulations in the ncar future. These
include Arizona, Kansas, Kentucky. New York and South Dakota.
Current official information is still pending from AJaska, California,
Florida, Georgia. Idaho, Hlinnis, Louisiana, Minnesota, New Mexico, Nonh
Carolina, Ohio, Tennessee, Utah, Virginia. West Virginia and Wi consin.

24 STATES HAVE STATUTES


PERTAINING TO TAITOOING
Arkansas, California. Colorado , Florida, Georgia , Hawaii , lIlinois,
fndiana. Iowa. Maine, Maryland, Massachusetts, Michigan, Nevada, New
Hampshire. North C~u'olina, Oklahoma" Pennsylvania. Rhode Island, South
Carolina. South Dakota, Texas, Vermont.

TATI'OOING BY PHYSICIANS AND


PARA-MEDICAL PERSONNEL
Six states (Georgia. Indiana, Massachusetts, Oklahoma. South Carolina
and Vermont) permit tattooing by medical personnel only. Kansas has
legislation pending to permit tClLLooing by doctors only. Florida permits
tattooing by a person licensed to practice medicine or dentistry. or by a
pcr~on under his direction , and the doctor must train the technician two
limes a year. Connecticut permits a licensed physician, or technician under
the supervision of a physician, to elo tauooing. Tattooing is included in the
license. Tattooing is included in the license to practice medicine or
osteopathic medicine in Indiana. Interestingly , in 1985, a Monroe County,
Indiana Circuit Judge ruled that tattoo artist Kevin Brady was not practicing
medicine. but was given permission to tattoo as "un art form". Virginia
does not have State regulations but does permit any county, city or town to
regulate its tattoo parlors (excluding medical eloctors, veterinarians,
registered nurses. and any other licensed medical doctors in performance of
their professional duties). Kentucky is considering regulations requiring a
registered nurse to be presenr at all times during tattooing. In 1966. South
Carolina outlawed tattoos. but in 1986, physicians were permitted for
reasons of cosmctic or reconstructive su rgery .

FDA

AND

S TAT E

REGULATIONS

PROHIBITION OF THE
TATTOOING OF MINORS
Of rhe states that have rules and regulations prohibiting tattoos, to
have specific laws that controllattooing of minors.
Arkansas. Written permission of parent or guardian is required for
minors under the age
18. The wnsent HUlst be kept on file for two years.
Hawaii. Similar pemlission is required for tattooing under the age of
18. Hawaii also prohibits tattooing of any person under the influence of
intoxicating substances: ''These substances shall include, but shall not be
limited to alcohol, drugs. paints and glues." Hawaii has l.icensed tattoo
artists (classic artists and cosmetic artists): 221 are on the island of Oahu.
Maine. Prohibits tattooing of persons under the age of 18, as verified
by a drive r' s license, liquor 1.0. card . military LD. card. or other adequate
record. Maine further prohibits tattooing for the purpose of removing.
camouflaging or altering any blemish. birthmark or scar" by tattoo anists.
Prior to 1975. it was legal to tattoo the body of a female person.
New l-hl m ps h ire. Tattooing of person!> under the age of 18 is
prohibited. In March 1985. legislation was passed and signed by the
Governor, allowing towns to regulate tattooing facilities.
No rth Car olina. Prohibits any person or persons from tattooing the
arm, limb. or any part of the body of any other person under 18 years of
age. This i:- a misdemeanor, punishable by a fine not to exceed $500,
imprisonment for not more than six months. or bot.h.
Pen nsylvania. Prohibits Mooing of minors without parental consent.
The age of minority is 18, and fines arc not to c.x ceed $2,500.
Mjnncso t ~l. Does not have state laws pel1aining to tattooing, but in St.
Paul. [aIlOOS are prohibited Oil persons under the age of 18 . In
Minneapolis. persons under the age of 18 , except in the presence of and
with the written pcrmission of the parcnt or legal guardian. are prohibited
from being taHoned. Springfield and Waynesville (Fort Leonard Wood)
have local ordinances prohibiting tattoos under the age of J8.
Nevad a. Washoe County (Reno) has regulations concerning tattoo
parlors. but docs not have a specific age restriction . Clark County (Las
Vegas, North Las Vega s, Henderson , and Boulder) prohibit tattooing of
persons under the age of 18,
Texas. It is unlawful to tatloo any persons under the age of '21 , but
some cities and counties do have local ordinances.
Sout h Dakota. Prohibits tattooing under the age of I H. unle~s the
minor' s parents have signed a consent form. Any person who lattoos a
minor without paremal consent is guilty of tI Class II misdemeanor. This
act and the laws permitting an, municipality in the State of South Dakota
to re g ulate the practice of tallooing was passed by the 1985 State
Legi slature. and became effecti ve Jul y I, 1985.

or

./1

CHAPTER

STANDARDS OFTAITOO PARI1JR


INSPECTION
Several states, including Arkansas, Colorado, Hawaii, Nevada, Majne
Rhode Island. South Dakota and Utah have specific standards for tattoo
parlor inspection. Michigan has OSHA (Occupation Safety and Health
Administration) rules if an employee-employer relationship exists in the
tattoo parlor. The citics of Reno and Las Vegas, Nevada, and Springfield
~U1u Waynesville (Fort Leonard Wood) in Missouri also have inspection
regulations. Included in the main regulations isa prohibition relating to
tallooing of animals in a taUoo cstablishment used for tattooing human
beings.

STATE BOARDS OF NURSING


RULES, REGUlATIONS, AND
OPINIONS
With the advent or nur~es, allied health practitioners, and
cosmetologists performing dennalpigmentation, a number of the various
stales' boards of medical examiners, nursing boards, and/or cosmetology
boards have hau to address this issue of paralllcdical practices. The various
boards and agencies have struggled to ueal with this rapidly growing field.
Unfortunately there have been a number of conflicts nnd confusions
resulting from the different board interpretatiolls. The opinion. rendered in
variolls stales usually have not con ' iuered the ovcran aspects of
micropigmentution (the treatment of various di:easc~ and disorders as well
as its use for cosmetics and/or body adornment) but rather short tcrm
problems. For example. in Michigan in 1989. in response to whether
cosmetologists could perform the procedure, the ALlorney General's opinion
\Va that beautifying the skin was in the scope of practice of a
cosmetologist. In 1992. when nurses were beginning to becomc involved in
rnicropigmemation , the Michigan cosmeto.logists attempted to use that legal
opinion to prevcnt nurses from performing this procedure. Since other
practitioners slich as plastic surgeons and dermatologists also "beautify the
skin" . it was argued that this scope of treatment was not in the sole purview
or cosmetology. Thl.! Attorney General's Office finally escaped the whole
argulllent by stating that their statement was an opinion and nor a law.
In January 1993 , the Alfomey General of Colorado made a ruling and
law that minopigmentalion is to bt! regulated by the Board of Cosmetology.
By our understanding. a practitioner cloe.~ not have to be a cosmetologists
but will be regulated by the Board of Cosmctology. No specific rules ,
policil!s, and/or guidelines have been made available . Htw.:t!ver. all

FDA

AND

S TAT E

REGULATIONS

education of mkropigment.ntion is to be provided by cosmetology schools


with no outside experts or educators in .. llied fields to be allowed.
Physicians and their technicians have been exempted from this ruling.
The Boards of Cosmetology differ from state to state as to whether
minopigmemution is deemed within the Board's scope or purview. The
reader is urged 10 check with each state's board for precise clarification.
We know of instances in which a board has stated that the procedure
could not be performed within a licensed salon, but. if within that salon
there exists a separate designated arC<1 functioning as a separate business,
then a co metologi t may peli'orm the procedure as a separale entity with
lhe permission of local ordinances.
Within the field of nursing. there have been many recent rules,
opinions, and regulutions set, forth by the various states boards of nursing.
There i:. general acceptance among the states thaL the procedure of
micropigmentation can be safel.y performed by nurses. However, there is
significant disagreement a~ to whether this procedure should be
considered appropriate nurse practice.
In those states thal have defined micropigmentation an appropriate
nurse practice, the procedure is regulated under the auspices of a board of
nursing. Within lhe legal scope of nurse practice, the board of nursing
exercises juri diction over nurses only. The practicing nurses , who
n:prcscnt themselves as R.N., are held to all the same standards, rules.
policies, and regulations of nursing when performing Ihis procedure.
These nurse may perrorm micropigmentation as independent providers
answerable only to that state's board of nursing. Kentucky was the jirst
state to deem micropigmemation as nurse practice.
In those stales in which the board of nursing has staled that
micropigmentatioJ1 is not within the scope of nurse practice, a nurse must
perform the procedure as a separate entity from their nursing and are not
allowed to represent themselves as a Registered Nurse when performing
or markcting the procedure . Therefore . the nursing hoard has no
juri diction. However, there is an unresolved legal question . In the event
of a malpractice suit will that nurse be held to the same standard of
practice of nursing?
Some stat.es have developed Advanced Practice Acts for those nurses
who wish to perform micropigmenlarion. These acts encompass nontraditional [(lIes with specialized guidelines beyond the scope of lIsual and
customary nurse practice.
Finally there are boards of nur~ing who have ruled that nurse
practitioners performing micropigme.ntation must be under lhe general
direl'tion and/or supervision or a duly licensed physician. These boards
have interpretcd thut llIicropigmclltat.ioll as a Standardized Procedure is no
diffcr~'nt thun a physician giving u standing. written, or verbal order to a
nurse to perform some similar invasive or therapeutic procedure. for
example , the initiating or an I.V. , injection. or removal of sutures.
The fullowing summaries represent the most recent rulings from
these hoards . It is important to remcmber that these rulings are ~lIbjecr to
1l10difi<:ation~ by these present and future boards and tbe reader is urged to

43

CHAPTER

check with their local boards before beginning any dermalpigmentation type
of practice.
Presently the only state to consider micropigmenlation with the scope
of legal nurse practice is Kentucky. North Carolina has established an
advanced nurse practice act, but has also stated that the procedure i not
within the legal scope of practice for a registered nurse. Alabama. Illinois,
Ohio. Louisiana, Maryland. Michigan. New Jersey, New York,
Pcnnsylvania. Texas. Virginia, Di. trict of Columbia, and Florida have ruled
that micropigmentation is "not witJ1in the legal scope of practice of a
registered nurse."
California is the only state that has ruled that micropigmentation is a
standardized procedure in which a registered nurse performs the procedure
under the general superv.i sion or direction of a licensed physician. At the
September 1991 California Board of Nur. ing. the board concluded that
micropigmenLation procedufCs applied as tTeatment of disease, injuric . or
defom1ities would be regarded as a medical function beyond lhe usual cope
of registered nur. ing practice. The procedures may be performed by a
registered nurse in accordance with a standardized plan in an organized
healm care system. The California Board and Legislature, in the amendment
of Section 2725 of the Nursing Practice Act, recognized thal llursing is a
dynamic field, continually evo lving to include more sophisticated palient
care activities. Furthermore, there exists an overlapping area of functions
and procedures between physicians and registered nurses in which either
party hu. a clear legal authority to provide functions and procedures for
patients. The means designated to authorize such performance by a
registered nursc is u St~U1dardized Procedure which is not subject to prior
approval by the respective boards of nursing and medicine; however,
standardized procedures must be developed according to cel1ain regulatory
requirements.
[n Florida, a rec.:ent ruling has stated that tcchnicians mu. t now perform
micropigmentation under the direct supervision of a Iicensed physician..
Heretofore, technicians were permitted to work independently under general
supervision of a physician who was not required to be present on the
premises.

A SUMMARY OF THE FEDERAL


FOOD, DRUG AND COSMETIC
ACT WITH AMENDMENTS
Public Law No. 384, 59th Congress, approved June 30. 1906. For
preventing the manufacture , sale. or transportation of adullerated or
misbranded or poisol1ous or deleterious foods. drugs. medicines, and
liquors, for regUlating traffic.: therein.
Public Law No. 538, 71st Congress, approved July 8. 1930. An act to
amelld sct:lion 8 of the act approved June 30, 1906.

44

F D A

AN D

S TAT E

R E G U LA TI ONS

Public Law. No. 541 , 73rd C ongr ess, approved June 22, 1934. An act
to amend the act of June 30, 1906 relating to seafood.
P ublic Law No. 356, 74th C ongr ess, approved August 27, 1935. To
amend section I OA of the Federal Food aod Drugs Act of June 30, 1906,
relating to seafood.
Publi c LA w No. 717, 75th C ong r ess, approved June 25. 1938.
Federal Food. Drug and Cosmetic Act.
Public Law No. 151 , 76th C ongress, approved Ju ne 23. 1939. To
provide for tem porary postponeme nt of the operations of certain prov isions
of the Federal Food, Drug and Cosmetic Act.
}-'ublic Law No. 366, 77th C ongr ess, as amended, by providing for
the certi tication of batches of drugs composed wholly or partly of insu lin.
Public Law. No. 139, 79th C ongress, approved July 6 . 1945. To
amend the act of .J une 25. 1938, as amende d , by providi ng for the
certification of batches of drugs composed wholly or partly of any kind of
penicillin or derivative thereof.
Public .Law No. 16, 80th Congress, approved March 10, 1947. To
amend Lh e ac t of J une 25, 1938, as amended. by pro-vid ing for the
certification of batches of drugs composed wholly or partly of any kind of
streptomycin, or any derivative thereof.
Public Law No. 749, 80th C on gr ess, approved June 24, 1948 . To
amend sectio ns 30 I (K) and 304(A) of the Federal Food. Drug and
Cosme tic Act, as amended.
Public Law No. 164, Si s t C ongress, approved Ju ly 13, 1949. To
amend the act of June 25 , 193X, as amended. by providing (or the
ccnilication of batches or drugs composed wholly or partly of any kind of
aureomycin, chloramphenicol or bacilracin.
Public La w No. 360, 81 st C ongr ess, approved October 18, 1949. To
amend secLion SO 1 of the Federal Food. Drug, and Cosmetic Act. as
amended.
Public Law No. 215, 82nd Con gr ess, approved October 25. 1951 . To
amend sections 303(C) and 503(B) of the Federal Food. Drug , and
Cosmetic Act. as amended.
Publ ic La w No. 201 , 83rd Con gress, approved August 5. 1953. To
amend sections 502(L) and 507 of the act of Ju ne 25. 1938, ill order to
identify the d r ug known as aureomycin by its chemical name.
chlortetracycline.
Public Law No. 217, 83rd C ongr ess, approved August 7. 1953 . To
amend the Federal Food. Drug, and Cosmetic Act. to protecl the public
health and welfare by providing certain au thority for factory inspection.
Puhlic Law No. 335, 83rd C ongr ess, approved April 15. 1954. To
amend sections 40 I and 70 I of the Federal Food. Drug. and Cosmetic Act
lO simplify the procedures governing the estab lishment of food standards.
Public Law No. 5 18, tUrd C o ng ress, a pproved Ju ly 22. 1954. To
amt:nd Ihe Federal Food, Drug.. and Cosmetic Act with respect to residue '
of pe~ticidc chemicals in or on raw agricultural commodities.
Publi c La w No. 672, 84 th Con gress, approved July 9 , 1956. To
amend ~cction 402(C) or the Federal Food. Drug. and Cosmetic Act. with
respect to the coloring of orange.

45

CHAPTER

Public Law No. 905, 84th Congress, approved A u gu~t I, 1956. To


amend sections 40 I and 70 I(E) of the Federal Food, Drug. and Cosmetic
Act to s implify the procedures governing t.he prescribing of regulation
undcr certai n provisions of such act.
Public Law No. 250. 85th Congress, approved August 31, 1957. To
amend section 304(0) of the Federal Food , Drug, and Cosmetic Act, with
respect to the disposition of certain im ported articles which have been
seized or condemned.
Public Law No. 929, 85th Congress, approved September 6, 1958.
Food Additives Amendment of 1958.
Public Law No.2, 86th Congress, approved March 17. 1959. To
amend the Federal Food. Drug, and Cosmetic Act to permit the temporary
listing and certification of citrus No.2 for coloring mature oranges under
tolerances found safe by the Secretary of Health, Education and Welfare, to
permi t continuance of established coloring practice in the orange industry.
Public Law No. 537, 86th Congrcss, approved June 29, 1960. To
amend the Federal Food, Drug, and Cosmetic Act, with respect to label
declaration of th e use of pesticide chemical. o n raw agricu ltura l
commodities which arc the produce of the soil.
Public Law No. 618, 86th Congress, approved Jul y 12, 1960. Color
Additive Amendments of 1960.
Public Law No. 19, 87th Congress, approved April 7. 1961. Food
Additives Transitional Provisions Amendment of 196 I.
Public Law No. 781, 87th Congress, approved October 10, 1962.
Drug Arnentimellls of 1961.
Public Law No. 625. 88th Congres,,<;, approved October 3. 1964. Food
Additives Transitional Provisions Amendment of 1964.
Public Law No. 74, 89th Congress, approved July 15 1965. Drug
Abuse Control Amendments or 1965.
Public Law No. 477, 89th Congress, approved June 29, 1966. To
,tllJend section 402(D) of the Federal Food, Drug. and Cosmetic Act.
Public Law No. 399, 90th Congress, approved Jul y 13. 1968. Animal
Drug Amendments of 1968.
Public Law No. 639, 90th Congress, approved October 24. 1968. To
amend the Federal Food, Drug, and Cosmetic Act to increase the penalties
for unlawful acts involving lysergic ac id dielhylamide (LSD) and other
depressant and stimulant drugs.
Public Law No. 387, 92dn Congrcss, approved AugUSt 16, 1972. To
amend the Federa l. Food, Drug, and Cosmelic Act (0 provide for a current
listing of each drug manufactured. prepared. compounded, or processed by
a registrant under that act.
Public Law No. 295 , 94th Congress. approved May 28, ) 976.
Medical Device Amendments of 1976.
Public Law No. 203, 95th Congress, approved lovember 26, 1977.
Tn require studies concernin g carci nogenic and other toxic substances in
food. S~lccharin Study and Labeling Act.
l'ublk Law No. 633, 95th Congress, approved November 20. 1978.
To alTlend the Comprehensive Dru g Abuse Prevention and Control Act of
1970. Psychotropic Substances Act of 1978.

46

FDA

AND

S TAT E

REGULATIONS

Public Law No. 273, 96th Congress, approved June 17. 1980. To
amend the Sacchari n Study and Labeling Acl.
Publk Law No. 356, 96th Congress, approved September 26, 1980.
To amend the Federal Food, Drug. and Cosmetic Act to ensure the safety
and nutrition or in fant formulas.

47

Section Two
Preprocedural
Considerations
_.,.. .. --- -.

>-

-~

,I
!
I

,,r
!

t
i

,
i

t!

!
It
J

\i

t,

\
\
!

I." ....:.'4-".-

H A p T E R

Psychological
Considerations

Since micropigmentation is safe and effective. it is easy for lhe


practitioner to believe that his prospective patients will automntically be
happy with the final results a<; long as the procedure is accompli hed
wi thout gross complication. The prac(iti(JIlcr COIl be lu ll ed illlO a fal 'e
sense of security because of the simple office-based approach, the lack
of any structural facial modifications. and the relative case of patient
comprehension of the actual procedure (for example, a liquid-based
eyeliner can be applied to create the final "errect"'). For the most part.
the practitioncr should encounter very liule diftieulty in communicating
and explaining the fulJ pertinent infolll1ution to his patients. However, it
is importam for the practitioner to rccognize ccrtain psychiatric issues
when planning any permanent makeup procedure in order to avoid
patieots with underlying personality disturnances,

PATIENT EXPECTATIONS
In the case of blcpharopigmentation we are only adding pigment to
the eyela<;h b~lses [0 create the effect of an anificial eyeliner: the final

appeantncc of the patient will be essentially unchanged. h is important


that the patient's cxpectations of the final end result not be
inappropriatc. For example. an introverted personality with lov,,' sclfesteem or feelings of inferiority will not become outgoing and sc![assured. Patients with unrealistic and inappropriate ex.pectations ,lfC less
likely to bc satisfied with the outcome. For example. a patient who feels
that the mi(.' ropigmentation will changc her life and give her a "lifC witl
not likely receive Ihi!- bencfit.
Since potential complications of pigment malpositioning of the
eyeliner anJ/or other permanent make-up can lead to an unpleasing
appearance . it is vit:.tl that the practitioncr inform patients or thi .

51

CHAPTER

potential complication as well as other potential pitfalls. Unfortunate results


can lead to unhappiness in patiellls and possible litigioLls retaliations.
Patient's expectations are directly related to motivation. The patient
who undergoes permanent eyeliner or other micropigmcmution procedures
has certain expectations about the outcome. The patient who wishes to look
younger and like a movie star has obvious misdirected expectations about
outcome. It is necessary that the practitioner discuss the possibilities of
complicalions with the patient. It is al so important to stress to the patient
that the procedure should be considered permanent and essentially
irreversible. The patient's reaction to this information should be investigated
and documented.

PATIENT MOTIVATION
When the patient. comes for pemlanent eyeliner and/or other rOlm~ of
micrupigmcntation. certain motives and reaso ns are obviously more
legitimate than others. For example, convenience. allergies to known
makeup. motor dysfunctions of the hand, poor vision. and blepharitis are
among the more COllllllon and reasonable reques ts for . eeking
micropigmcntation. The most common reason seems LO be the convenience
factor. For the professional woman wilh little time to spare for the initial
makeup application in the morning or touchups during the day, permanent
eyeliner is a pracl.ical time-saver.
It i~ important to determine lhat the stated motive is the true motive.
PoJysurgery addicts maybe hiding their true motives when they reque t
surgery or micropigment3tion. Besides the peculiar preoccupations of
polysurgery addicts or the inappropriate motives found in psychologically
d i stu rbed patients, i Ilegi ti mate moti ves are usua l Iy associated with
inappropriate expectations. An example of a well -motivated parient is one
who has had previou, cosmetic facial surgery and has been happy with the
results, and now would like to have the blepharopigrnentation done for
similar rl!a. ons of enhancement. On the other hand, patiems who are more
impulsive and lend to be Illore invo lved in faddish trend. will often regret
tlleir decision after the procedure.
Often so me patients may want the mieropigmentation to save a troubled
m<1lTiage. Sometimes it may even be the hu. band who urge the wife to have
the procedure with the hopes of improving her looks. Therefore, it maybe
help ful during the initial work-up to discuss the permanent pigmentation
with the !'.pollse, if t.he practitioner senses this type of motivation .
During the history portion of the exam. the practitioner has an excellent
opportunity to assess the motivation of the patien\. Obvious questions
pertaining to medications, previolls cosmetic and nOt1cosmclic urgeries, and
so forth. arc helpful in gaining a good clinical picture of the patient;
however, at this timc the practitioner can also query the patient about her
lifestyle. marriagl!. job . and other soc ial information, thcreb. eliciting
II nderl y i ng 1I1oti yes for t he proced ure . As a general rule. illl pulsi ve

52

PSYCHOLOGICAL

CONSIDERATIONS

prospective candidates will have Jess atisfactory


emotional results than candidates who have made more
considered decisions.

PSYCHOLOGICAL
CONSIDERATIONS
OF THE PATIENT

Patient-practitioner
trust based Oil
honest interaction
and open, frien dly
exchange wiU lead
to greater
satisfaction, even in
cases with a lessthan-satisfactory
result.

In addition to the well-defined contraindications of


micropigmentation. a for example pregnancy, Accutanc therapy. keloid
formation , certain dermatological disorders, and so forth. there are certain
psychiatric disorders lhat are contraindications. These disorders are states
or severe anxiety, the psychotic states, hypochondriasis, and depression.
The paranoid can oftcn suspect and misinterpret tile practitioner's behavior
and approach. The acute schizophrenic can be too irrational to cooperate
with the practitioner. The over-optimistic manic patient can often make
unreasonable and impulsive demands and usually will fail to comply with
the pre- and postprocedural instructions. The hypochondriac will be
dissatisfied and often overembellish the lIsual sequelae of the healing
process. The depressed patient rnay seem to be uplifted in the initial
post procedural period and then ex.perience a rebound return of depression
only heightened further by the permanency of the pelmanent makeup. It i
well documcnted that :OITIC patients can develop aClIte p ychosis through
eleuive surgical procedures when they are in already shaky contact wilh
realily . Drug addicts and alcoholics creare special dilemmas, since chronic
abuse and intoxication withdrawal symptoms can complicate the
postoperativc care medical! y. as well as create unusual demands for
medicalion, e.g. , narcotics.
n addition , there are other psychological states that can also influence
expectations and motivations ill the behavior of the l11icropigmentation
patient. These states arc not mental disorders but rather personality traits
that can be particularly annoying and disturbing to the practitioner and his
starr. Patients with major psychopathology can he easily recognized by the
practitioner; however. patients with minor personality disturbances can be
di rflcult to recogniz.e except by certain behavioral characteristics. These
personality traits should alert the practitioner not to proceed with any other
cosmetic pemlanent pigmentation.

HYPERACTNITY
Patients who dominate the conversation and change from one topic to
a nother while exhibiting overactivity and exuberance are often
demonstrating possible . igns of a manic or hypomanic state. The prac-

53

CHAPTE R

litioner will find it very difficult to express any orhis opinions. Even though
these patients can be friendly and endearing, the practitioner should he
cautiou, before proceeding.

EVASNENESS
Patients who relate accurate and specific information about their
medical and socia l past. but conceal certain aspects and may ever appear
suspicious during the history portion of the exam, are often exhibiting signs
of paranoia. A lypical example of concealment is when the practi tioner asks
the pat ient about pre\'illlis cosmetic surgery and the patient continually
attempts to change the subject. Sometimes previous surgical scars are
clearly evident and the paLienl refuses to admit having previous surgery.

EMOTIONAL EXPRESSION
The practitioner should develop a sense of warning that a patient maybe
in'Ulional because tIl' too much or too little emotional expression. Slate,
acessive emotional exp rcssion may refle~t an irra tional and illogical
patient. Major psychopathology found in !luch Slates or disorders as
schi.wphrcnirorm condilions or anxiety disorders often dcmon:trate

or

inappropriate emotiona l intensities as well as mood changes and


Iluctllutions.
The prescm;e or increased emotional di!lplay is not an inttication that
the patient is mentally ill It ~h()lI[d. however. compel the practilioner to
inquire further as to possible underlying causes for the emotional display.

OBSCURITY
During. the preoperalive assessillent and history portion or the
practiLioner's exam, a patient who deillonstrates {)b~curity by a vague
medical history or rca~on~ for pre ious surgical events should alert the
practitioner to a possible schizophrenic behavioral pattern. The hysteric can
often prc!-'cnt a !-'pe(;i fie and d~lail~d medical history or the pa~t. but become
vague and evasive about the prc~cnt medical conditions. Typicall . , the
greatl':r the amount of information t.hat the hysteric relates to the
pw(;titioncr. the more perplexing the medical history bcnJTtlcs.

ANXIOUS BEHAVIOR
Jt is (;crtainly a 110l'1nal and ht'althy patient who quesLions the
practitioner abollt ri~ks and potcntials for L'omplic<ltions. Howt:\'t:r. there are

54

PSYCHOLOGICAL

CONSIDERATIONS

people with intense anxieties who may become obsessive and demand
more and more speciiic information about their procedure. It is not usual
for the practitjoner to answer the same questions over and over. Obsessivecompulsive paticl1Is will query the pr<tctilioner (tbollt the most miniscule
aspects of micropigmentation that are often extremely technical and
unimportant to the normal and healthy patient; whereas hypochondriac
palient& will often describe their expectations in minute detail and
overfocus on the potential pathologic consequences of the more minor
elements of micropigment3tion. Sometimes depressed patients may exhibit
analogous. anxious behavior and seek reassurance and guarantees of
sllccessful outcomes.

PERFECT SELF IMAGE


Some patients may be excessively concerned with seeing themselves
as perfect. These patients can sometimes be described as exhibiting
excessive vanity and will often come to the doctor's office witbout a hair
out of place. Often this patient exhibits this type of extreme fastidious
appearance while, in reality , hiding decp. internal insecurity.
In addition to these behavioral c lues of minor psychopathology, a
history of hospitalization for psychiatric illnesses would cerrainly suggest
prior mental or emotional stability and prompt the practitioner to request a
psychiatric consultation before procccdin~ with micropigmcntation. A
hi tory of rcpeated surgery need not be a direct contraindication for
micropigmentation or other cosmetic interventions, but should at least alen
the practitioner to pause and reneet on the potclllial mental fitness or this
patient. Personal vanity in attempting to outperform those practitioners
who have failed in the pasl with lhese types of patients is usually doomed
to failure.
Ralional palients with reasonable motives and appropriate expectations
are ideal candidates for this procedure. However, even will, careful patient
selection. informed consent, and explanations of potential complications.
rhe pmctitioner will 110 doubt have some patients who arc dissatisfied after
micropigmenlatilln . Avoiding postprocedllral dissatisfaction can be
accomplished by a sound doctor-patient rappon in which the practitioner
di~play!> concern and communicates openly in a friendly manner with his
patients. Patient-practitioner trust based on honest interaction and open ,
friendly exchange will lead to greater ~atbfaction, even in cases with a
les~-than -salL ' factory result.

55

H A p T E R

Practical
Clinical Anatomy
EYEliD ANATOMY
A thorough working knowledge of the anatomy of the ocular adnexa,
lids , and orbit is essential in performing both routine and complex
cosmetic and reconstructive procedures. Ophthalmic and anatomical
textbooks should be consulted for fine details of lid and adnexal anatomy.
The following summary is an overview and is not intended as a
comprehensive presentation of eyelid anatomy. The outline should serve as
a guide to the practitioner who .is not well acquainted with these areas and
a reminder of the more important anatomical landmarks.
The upper and lower eyelids are analogous structures. The levalor
muscle and aponeurosis. the main upper lid retractor, is analogous to the
capsulopalpebral fascia, the main lower lid retractor. The levator evolved
from the :-uperior rectus rnu~cle as lhe ~keleial retractor in the upper lid,
while the lower eyelid retractor icapsuJopulpebral fa 'cia) i$ a fascial
extension of the inferior rectus.
The eyelid is considered to have six layers: skin, orbicularis, levator
aponeurosis. Mulier'S muscle. tarsal plate, and palpebral conjunctiva.
C linical note: It is useful to consider the tarsal position of the lids as
being composed of an anterior and posterior lamella. Eyelid reconstruction
following tumor excision or trauma should reconstitute both the anterior
and posterior lamellae.
Su r face Anatomy: The Skin . The skin of the eyelid~ is among the
thinnest in the body. The skin or the brow and temple is lhicker, but over
the eyelid proper. lhe skin is thin with a loos.: connective tissue devoid of
fat. permitting the movement or the lid (i.e. , blinking) . The skin is
composed of two principle zones: the epidermis and the dermis. The
epidermis can be divided into 5 histologic layers- stratum corneum.
stratum lucidum . stratum granulnslIllI. stratum spil1osum. and stratum
ba:-ale. The stratum spinosum and basale are also considered the stratum

57

CHAPTER

germanativul11 since thi . is the area of new epithelial cell production. As the
cells age they migrate more superficially along the previously mentioned
layers. Once reaching the outermost layer. . tratum corneUlTl the cells become
keratinized. The second principle zone is the dermis . Wilhin lhi zone are
located the blood ve. se ls nerves. fal. arrector pili (smooth) muscle of the
hair follicle. , hair follicles, sweat and/or sebaceous glands, and connective
tissue.
The eyela'ihes in the upper lid are coarser, longer and more numerous
than in lhe lower. These coarse hairs grow between 7 111m and 9 mm in
length and arc located in three to five indistinct rows, usually more densely
populated temporally and thinning more medially.
The upper eye lid is divided into an orbital (prescptal) and a tarsal
ponion. The orbital rim and the superior border of the tar. us define the
orbital portion. The tarsal portion of the eyelid contains the tarsal plate. A
transverse crease which i: approximately 7 mm to 12 mm above the eyelid
margin . is formed by the
superficial attachment of fibers
Ocular Adnexal Anatomy
from t.he levator aponeuros is to
the skin. This crease is absent in
many oriental .
Laterally, there are lines that
radiate from the lateral canrhus,
frt'quentJy known as "crows feet'
or "Iaugh lines." For camouflage
purposes. the folds and creases in
the . kin of the eyelids make
convenient locations for s kin
A
incisions in surgery.
B ---'IIIThe skin of the preseptal or
orbital portion has no attachments to the aponeurosis or the
sullcutane(lUs tissue. With aging
and loss of clastic support,
stretching occurs. The skin can
override the eyelid crease, producing the eyelid fold. Redundant
eyelid s kin i s known as dermatochalasi s and may obscure the
.. Epidermi c
s uperior visual fie ld when it
B. Derrni ,
overhangs 111C lash margin . Other
C. ()rbicul~lIi, Musde
folds involve the nasojug al. the
D. Crypts of Henle
malar, the inrerior orbital. and the
E. Tar~u~ and tvleibomian Gland
F. Tarsal Conjunctiva
superior orbital. and are produced
G. Eydash Fnllide~
by the junction of the skin bound
H. Gland of Zei!>
by
loose connective tissue in t.he
r. Orifice of Meibomian Gland
eyelid
and the denser connective
J. Gland of Krall se
tissue in the check.
K. Main Lacrimal Gland
L. Gland of Wolfling
The sebaceous glands of the
hair follicles are small. They are

58

PRACTICAL

CLINI.CAL

ANATOMY

callt'd the g.lands of Zcis. TIll! sweat glands lend to he fairly :(might and, in
their terminal portions, only slightly coiled. Elsewhere in the skin. the
~weal glands tend 10 form a complex glomerulus type of structure. These
eyelid sweat gland:- are those of Moll.
Clinical Notcs: Epicanthus is a fold of sk in in the medial canthal
region. These folds usually diminish with the development of the nas.lI
bridge in adolescellce.
Epiblepharon is the presence of a fold of ski n thaI overhangs the eyelid
marg.in. causing the lashes to roll against lhe globe (frequent in orienlal
patients). and is not to be confused with congenital entropion.
Because in younger patients the ski n of the upper and lower eyelids is
morc tightly bound to the underlying subcutaneous tissue. it is better to lise
as small a needle as possible and to inject a~
~ lowl y as possibk when performing the
anesthetic lock. In elderly patients, where more
Ocular Adnexal Anatomy
loose allachments occur. the injeclion process is
usually easier and les!' painful.
A.
Lid Margin. The transition lone bdween the
B.
skin of the eyelid and the palpebral conjunctiva
c.
defines the eyelid margin and is about 2 mm ill
wid th. The puncta also lies approximately 6 mm
O.
to 7 Inm from the eyel id margin lUld is about 2
Eo
f.
mm in widt.h. The puncta also lies approximately
0. ~~~::::;;;;;:
G.
6 em to 7 mm from the medial canthus and
P.
---11.
divides the horizontal dimensions into the
mt:clial 116 and the laleral 5/6. The puncta is
directed slightly inward [0 approximate the
globe. and also represents the na::ial end of the
R ,.r--- O,
Larsu ' .
The grey line li es sli ghrly anterior to the
middle of the lid margin and represents the
anterior border of the 1ar~us. Between the grey
line and the posterior lid ma rgin lie the
I1lciohomian orifices which number approxi,
mately 30 in the upper lid lllld slightly lcs)' in lhe
lower lid. Medial to Ihe puncla. there arc no grey
line and no meibomian orifices, only a ITlUCOcutancou!-> junction. The pilar appJratlls marks
A. Front~Ji , MllSdc
H. MlllldsMlIsde
the transition of the surface epithelium from
B. Fn>nwl , inus
I.
Tarsus
J. Eydash F()lIide~
C. Eyebrow
keratini7.ing to l1ol1keratinizing stratified
DI Orbicularis Muscle
K. Globe
sqll<lmou ...
The lateral can thu s is about 2 ITllll h ighcr
than the medial canthus, although there is con-;idcrablc variatiOIl.
Clinical Notcs: The lateral <:anthus and the
Illt.!dial superior inferior puncta serve as valuable
landm<lrks in hlepharopigmentation . The
placemenl of a pigment line al the lateral canthus
area should not connect the upper and lower lids

(Orbital)

O.

Cap::;ulo Palpebral
Fa~ cia
Inferior Tar,al Muscle
Inferior Oblique Muscle
Levator Mu,clc

p,

Superior Rectus Musde

L.

D, Orbicular Mu,c1c
D3
E.
F.
G.

( Pre,eptall
Orbic ular Mu,c[e
(Prct<lNII)
, eplUlI1 Orbilak
Orhiral Fal
Levator Ap()nellro~i

~1.

N.

Q. jnfcrinr RCCIU' Musdc

CHAPTER

temporally. Also, the pigment line should never be deposited more medially
than the upper or lower puncta. As a general rule the pigment should begin
to fade from I 111111 to a maximum of 4 mm before arriving at the puncta
proper. This I ml11 to 4 mHl variation allows the practitioner to create an
"artificial" shift of the eye separation. Shifting the end points of the pigment
line more medially or laterally can achieve an optical illusion of closer or
more separated eyes. Placing the pigment at different vertical level.s can
make the eyes appear smaller or larger. With rare exceptions, the general
rule of pigment placement should always be symmcrrical; otherwise. an
asymmetrial optical iUus.i on of eye balance will occur and be very
noticeable.
It is al 'o usefuJ [0 divide the upper and lower eyelids into one-third
.ectiofls when performing the procedure as a useful reminder to begin
various transition zones, as will be discussed later under procedural
techniques.
Under no circumstance hould pigment be placed posterior to the grey
line. Since the grey line represents the anterior border of the tarsus, there 'is
a greater chance of pigmentary dispersion. shift and/or migration onto the
mucocutaneous junction.
Subcutaneous Tissue. Beneath the skin lies the loose areolar connective
tissue, which contains li!lk. if any, fat. This tissue allows the . kin to move
easily over the underlying orbicularis.
Within the substance of the subcutaneou tissue, the hair follicle
originates with the hair shaft extending through the subcutaneous tjssue and
exiling through the epidermal layers protruding onto the outside skin
surface. The base of the hair follicle is approximately 2.5 mOl below the
epidermis. The pilociliary complex of the eyelid area differs from other hair
complexes of tJle body in that there are no erector muscles in the eyeJid
associated with the hair foHide.
Clinical Notes: In dermalpigmentalion procedure. , the pigment
granule are usually located from a minimulll of 0.5 mm to a maximum of
2.0 mrn below the superficial epidermal layer.
The deposition of pigment granule s in micropigrnentation usually
accumulates around lhe various hlnod vessels in the subcutaneou ' tis 'ue
area. This accumulation is due to the lIlacrophages' attempt to engulf and
remove the " foreign body" from lhe dermis by means of the circulatory
and/or lymphatic system. Becallse the pigmenl granules are approx.irnalcly 6
microns in size. the macro phages are unable to completely engulf the
pigment and. even with engulfment, the pigment-laden macrophage i
unable to enter the pore system or endothelial lining of the blood vc~sel or
lymphatic vessel system. Thus the pigment accumulates predominantly in
this area.
The pigment granules that accumulate near hair follidc shafts are
usually removed with the sebaceous sccretjons of the accessory glands
associated with the hair shaft. With the removal of this pigment along the
hair shaft, a postoperative "halo effect" occurs.
Orbicularis Muscle. The protractor of the eyelid is a concentrically
arrungcd muscle sheet sunounding. the palpebral opening and is divided into

o(}

PRACTICAL

CLINICAL

ANATOMY

the oribiwl and palpebral (prcscptal and prctarsal) ponions. Innervation is


by the fClcialnerve (cranial nerve 7).
The orbi tal portion is the strongest and thickest part of the orbicularis
muscle and overlies the orbital rims. The muscle extends into the region of
the eyebrow .wd joins with the frontalis , pro<..:crus, and corrugator supercilia
muscles. The lateral portion lie. over the anterior aspect of the tcmporalis
muscle and extends into the cheek. The bony attachments for the orbital
fibers are the medial orbital margin, frontal process of the maxilla and
frontal bones. The preceptal orbicularis overlies the orbital septum. The
upper and lower lid portion. join at the lateral raphe overlying the lateral
canthal tendon and the lateral orbital rim. It fuses with and attaches to the
preseptal tar al fibers. A portion of the preseptaJ orbicularis extends into the
fascia overlying th e lanimal sac and assists in the lacrimal pump
mechClllism.
The pret.arsal pan of the orbicularis lie s anterior to the tarslis and
becomes tendinous at its medial ano lateral extent of rhe lid. Medially. the
condensation of orbitularis forms two heads. The anterior limb lies anterior
to the canalicu li. while the posterior limb. known as Horner' s muscle,
pa~ses posterior to the canali culi and inserts into the lacrimal fascia and
posterior lacrimal ampUllae. Blinking movements will cause the ampullae
to dilate. thereby aiding lacrimal now by sucking f1uid from the lacrimal
lake.
The medial canthal tendon has two heads: one deep and one superficial. The thinner deep portion runs behind the lacrirnal fossa. attaching to
the posterior lacrimal crest. The superficial portion is thicker and lies
anterior to the lacrimal fossa. Directly beneath the anterior the anterior
portion of the medial canthal tendon are the lacrimal canaliculi. Extensive
trauma to the medial canlhaJ region results in lateral. anterior, and inferior

Ane~the:;ia

Anesthesia or 1he L.m;rymal


Z ygomat ieo-faci al
Supraorbital nervI!'

of the
S upratroch lear and

ini"rat.f"ocilicar nerves

6/

CHAPTER

displacemellt of rhe canthus. reflecting the loss of the tendon' s attachments.


Clinical Notes: When the injecting the anestheti it is important that
the needle not penetrate the orbicularis muscle. Because of the rich
vascularization of this muscle, a hematoma formation is quite likely. The
injection process should be as superficial as pos ible and the needle
directed into the subcutaneous loose areolar connective tissue (Sec Chapter
on Ancsthcsi:l).
When applying a chalazion clamp or "h lepharostat" clamp, it is
important that the clamp no! be tightened excessively because this will
result in vellous pooling with subsequent intraoperative and postoperative
ecchymosis and intcr.titial Huid edema. Tht: intraoperative ecchymosis can
be ~igniri~ant, making it dillicult to a~~ess whether or not adequate pigment
deposi tion has been achieved. Jf the clamp is applied (00 loosely, the
valuabk effect of the clamp as a lid stabilizer is lost. The clamp therefore
should be placed on the eyelid with sufficient force to hold the lid relatively mo\ionles~ and to provide a safety platform upon which the surgeon
or practitioner call perform the pigmentation
process. The clamp also
serve:- as a useful protective mechanislll for the
cornea.
Nerves. Motor nerves
include the third. fourth,
and sixth cranial nerves,
which enter from the orbital apex and supply the
extrinsic ocular muscles.
Eye Enlargement
Sensory: The ophShowing
Pigment Placemenl
thalmic di vision and branches of the maxi llary
division of the trigeminal
nerve transm it sensal"ion
to the orbital and pcriorbitaltissucs.
Clinical Note: Anesthesia of the eyelids for
blepharopigmentalion can
he achieved by local or
regional blm.:ks. For most
cases a lot:al block is
~urficient: however. in
those cases in which blepi1aropigmclltation is to be
c()1l1bi ned wi th blepharoplasty. ey~brow lifts,
ptosis repairs. etc .. a
regional block will allow
Hair Growth Under Skin
for less tissue distortion

62

PRACTICAL

CLINICAL

ANATOMY

and provide more prolonged anesthesia.


Aut.onomic: The intrinsic ocular muscles and Muller's muscle of the
eyelid arc supplied by autollomic fibers. The ciliary gangl ion, which is a
small quadIilat.eral struc ture located lateral t.o the optic nerve, transmits the
sympathetic and se n~ory fibers. In addi tion, this i:. the sile for the symlp:.e
of the parasympathetic nerves. The short ciliary nerves exit from the
cilim)' g:lOglion to perforate the sclera around the oplic nerve.
Arteries. The ophthalmic artery (providing the major blood supply to
the eye and adnexal arises intracranially from the med.ial side of lhe
internal carotid artery just afte r the carotid has passed through the
cave rnous sinus and pierced the dura. In the optic canal. the ophthalmjc
infero laleral to the optic nerve . The artel), then e nters the orbit in the
muscle cone. runs inferolateral to the optic lIerve. crosses over the nervc
bctween the nerve and the superior rectus muscle, and continues anteriorly
to reach the medial orbital wall of the nose. There are numerous branches
of the ophthalmic .:U1ery within the orbit, the most importam of which is
the central retinal artery. Other branches include the c iliary, ethmoidal,
lacrimal. !TIuscular. and supratrochlear arteries. There are several sites of
anastomosis between the infernal and external caroid arterial systems.
Veins. The venous drainage system occurs mosLly by a superior
ophthalmic vein and. to a lesser extellt, by :111 inferior ophthalmic vein.
Extensive, valveless communication hetween the facial, orbital, paranasal
si nus, and intracranial venous system pennlts the propagation of in feet ion
from onc area [0 another. The vessels are tortuous with many plexifoml
anastomoses. The superior orbital vein ultimately runs deep to the superior
rectus fllu sc le and leaves the orbit near the annulus of Zinn via the
supcriN orbital fissure, draining into the cavernous sinus . The inferior
ophthalmic vein drains into thc pterygoid pkxus by the inferior orbital
fissure.
The eyebrows are bilateral supercilia or crescenlic arches of hairs that
arc located above the eyelids at Ihe superior edge of the orbit. Beneath
these hairs is a spcci::tliLcd area of integration of the orhicularis muscle
with the frontalis muscle. Medially and inferiorly arisc the specialized
fTluscle~ of the corrugator slIperci li aris and procerus f1lu~cles. Con traclion
of the frontalis muscle is associated with the lifting of the eyebrow. while
('ontractioJ1 of' the orbicularis. corrugator, and pweerus cau~es depression
of the eyebrow.
The skin of the eycbro\V~ i~ similar 10 the eyelids except il is Ih icker
wi th a den:er ,If!d more adherent subcutaneous fib road iposc layer. The
hair follicles are larger than the eyelashes and are as:.ociated with similar
Sl: baceou~ and ~udor iporius glands. The unique di~tribution of eyeh row
hair hus it!'. origins from embryological development. The newborn t:h ild
or late stage fetus develops a distinctive growth pattern of whorl-like hair
di~trihlftion on the forehead . Hair g rowth extends ill a curvilinear
dowllward flow from the supe rior area, or Ihe for.::h ea d to meet the
upward hair growth now eminating from the inferior brow line. At thc line
of union of the<;e two hai r growth flows. the evclllual adult eyebrow hair
pattern distribllliofl is t:fl.!tIled. It j" helpful to think of th e eyebrows as
composed of two hair growth planes or an upper and lower eyebrow: the

63

CHAPTER

!>uperior plane or upper eyebrow reprc1>eots an arched pallern with a 30


degree growlh pattern below t.he horizontal plane (sec diagram). The inferior
plane or lower eyebrow represents a transitional angulation-medially the
hair growth is at 90 degrees above the horizontal, centrally at . 0 degrees,
and laterally parallel with the superior plane. This two plane concept is
important in both dermal pigmentation reconstruction procedures and
surgical operations involving eyebrow hair.
The anatomic relationship of the eyebrow to the eyelid is important
whcn evaulaling patients for drooping eyelids or ptosi . Many times the
illusion of' a ptotic lid is really the result of brow ptosis. Since the lateral
brow is less firmJy attached to the underlying sopraorbital ridge, we usually
sce brow ptosis first in this area in the aging adulr. Cardinal rulc--do not try
to correct brow ptosis by using derrnalpigmentalion to create the illu ion of
lift 10 the brow. These patients need to be referred 10 a plastic surgeon for
correction. Brow pigmentation can be utilized post-op for scar camouflage.
Clinical Note: Male brows tend to be more horizontal and closer to the
upper eyelid than the female brow which naturally has a more dislinctive
arch. This generali'l.ation is imponant when dealing with palien!. male or
female so that a morc appropriate design is created for the patient.

UP ANATOMY
The lips urc two highly mobile tleshy folds that form the rima oris or
orfice of the mouth and extend laterally and form the angle of the mouth.
EXlernally, the surface of t.he lips represents one of the most significant
transitional areas of epilhelium of the body. Externally lhere are modified
zones of keratinized skin epithelium which become a mucous membrane as
the lining proceeds internally. The area of the superior lip centrally at its
junction with the frenular of the nose is known a~ cupid's bow . The general
framework of the lip is formed by the orbicularis oris muscle. Beneath the
surface of the integument or epidermis externally i.. the dermis composed of
typical skin type epithelial derivates such as sebaceous glands, hair follicles
with arrector pili muscles and sweat glands. Beneath the ' urface of the
mucosal lining internally is the lamina propia composed of labial glands
interdispersed among the Ilumerous vascular supply. The red color or
vermillion of the lips is due to the thin covering of the epithelium and it!
abundant underlying vasculature.
Clinical Note: The epithelium of the lip mucosa is thicker than the
epidermis of the skin.
The blood supply to the lips is rrom the labial superior and inferior
arteries and vcin!>. There i~ also an ahundanl Iymphati.c drainage. Nervc
su pply to the lips arc from the sensory and !notor cranial nerves: Trigeminal
and Facial nerves.
Clinical Note: Lip cancer is the mosl common cancer (25-30%) of Ihe
hcad and neck with <)5% occurring in the lower lip and 5C;0 in the upper lip.
Males outnumber females significantly possibly clue to the L1SC of lipstick by

PRACTICAL

CLINICAL

ANATOMY

women which may ofTer some protective factor.

BREAST ANATOMY
The female breast is a speciali zed anatomic structure. It is made up of
glandular tissue which is of skin origin, (hat is emo(ionally charged due to
its association with a woman's femininity and sense of wholeness. The
breast stTlicture has both function and form.
Functionally, the breast is made up of approximately 20 lobes, each
with its own ductal sy. tcm which culminates with thc nipple areolar
complexes. When (he breast is actively lactating , the glandular tissue is
surrounded by :.tromal tissue consisting of fibrous connective tissue and
fat Breast tissue in Some individuals can be found not only in the axilla
but also on rare occa-sions. in isolated collec-tiol1s in (he underlying
muscles of the chest wall.
The nipple areolar complex is the si te where the large ducts collect
and the surrounding area of the areola has specialized glands which
lubricate both s(ructures during lactation. The cmire breast is held in a skin
e n velope, und both the
envelope and the breast
are suspended from the
chest wall by Cooper 's
ligaments. These suspensory ligaments are imporPectoralis minor m.
lant in maintaining the
youthful configuration of
the breas(s when Illey lose
(heir tone. The weight of
Intercostal mm
the brcas( may then be
trall smitted LO the skin
envelope and can result ill
Pectoralis major m
ptosis of (he breast.
The blood supply or
the brcast ori g inates
from : (sec diagram) (I)
Pectoralis fascia
the internul mammary
artery which sends perforators in to the mcliial
portion of the breast. (2)
the external mammary
artery, a branch of the
axi lIary artery which
provides the circulation to
the upper ponion or the
breast, (3) the intercostal
perforators which are

65

- -- - - - - - - - - -- - -- - -- -- - - - - - -

CHAPTER

f~>u nd along the flank area and provide the circul ation to the inferior and
lateral portions of the breast. The above three arterial sources form a ple.xis
of vessels that: interconnect and nourish the enlire breaSL

The nerve supply LO the breast ineludes: (see tliagram) (I) the medial
intercostal nerves. (2) the supraclavicular nerves. (3) the lateral intercostal
nerve". The cutaneous se nsation of the nipple areolar complex is provided
by a branch of the fourth latenll cutaneous nerve; this nerve enters the
areola at its ollter lower quadrant after transversing the underlyi ng breast
tisslle,
The ly mphati c drainage of the breast (see diagram) includes over SO
lymph nodes, Approximately 35 of these lymph nodes are found in the
axi llary grou p. an additional 5 to 7 lymph nodes make up the internal
mummary chain , while the rem ai ning lymph nodes are found in the
Pee! \)I'a Ii ~
major mu~cle

La!i,~ ill1u,;
d()r~i 1l1lN:

Loculi in Ihe
conm:ct ivc lbsue

Ampullae
Lac:!i rerou,
Illbuk

Lohllk.;

Fal

S.:rrd lll'
anterio r lnu"le

PRACTlCAL

CL1NICAL

ANATOMY

subclavian group which drain. to the supraclavicular node '. Several lymph
node ' are found between the pectoralis major and minor muscles. The
a.,dllary lymph nodes are the group of nodes used to stage malignancies of
the breast. An adequate lymph node di ssection for the purpose of staging
canca of the breast should include at least 15 lymph nodes.
When we discuss surgical ablation and restoration of an anatomical
structure. we must consider both its function and form . While aesthetic
recons truciions of the breast are now possible , reconstruction of a
functional breast (one which lactates) is at the present time not possible.
Therefore. the goal of the reconstructive . urgeon is not only to restore the
three dimensional mount but also to recreate a nipple areolar comple.x
which will mirror as closel y as possible the opposite normal breast and
brings an aesthetic harmony to the patient's chest.

67

H A p T E R

Oculofacial
Morphology

According to Sir Wi lliam Osler. "There are no straight [;lees, no


sy mmetrical faces, many wry noses, and even legs, We are a crooked and
perverse generation," The ideal . normal , perfectly balanced face. for all
intents and purposes, does not exist. All human being. are essentially
a, ymmetrical creatures. However, from the standpoint of blepharopigmentation and general facial plastic surgery. it is hc.lpful to define
"noJ11ml face." With the mental image of the "perfect" or normal face, the
practitioner has a useful poim of reference in comparisons and can make
wise decisions in the structural alteration or hi . patient's facial
morphology. The patient's face is in a continuous state of change. From
that of a baby and young child to an adolescent. an adult, and eventually an
elderly person. These changes arc due to variations in growth, fat distribution, hair distribution, and change in muscle tone and elastic tissue
properlies. When perfonning blcpharopigmclltalion, it is helpful to recall
thi s metamorphos is. A practitioner would not be wise to apply pigment
with inten e, heavy distribution in an elderly patient where a more subtle
effect would fit naturally with the skin tones and the quality of the hair and
face. It is the combination of tl1e facial contours, color, texture and desired
effect that all must be considered prior to the prol.:edmc so that the ultimate
aesthetic result can be obtained.

FACIAL MORPHOLOGY
Fundamental Reference Lines
The ability to assess facial configuration is facilitated with an
understanding of facial morphology . The assessment or the face can be
broken down to various components and :>wdied in a systematic fashion.
After practice and use of the concepts for facial assessment. the process

69

CHAPTER

will become part of the skills thal the practitioner is already using. before
attempting facial plastic, oculoplastic, or other procedure such as micropigmentation.
Analysis of the face can be made simplified by dividing the face into
two geographic zone. It is helpful to define the zones by fundamental
reference lines. The first fundamental reference line is the midsagittal facial
line or Fl. which is a vertical midline that divides the face equaJly into a
right and left portion. This line does nOl necessarily coincide with the
middle of (he nose, but rather should be determined from the apex of the
cranium to the inferior middle portion of the chin. In the ideal face, this line
would perfectly bisect the nose into equal right and left hnlves; however.
most faccs have the nose deviated to one ~ide.
The second fundamcntal reference line is the midhorizontal iris line or
F2, which is drawn perpendicular to the midsagittal facial line or Fl,
extending through the center of a t least one iris (choose the eye that
represents or nearly equals the position thai would divide the face equally
into an upper and lower half). In the ideal face, this line would bisect both
halves. These reference lines or Fl and F2 create the basis for further
reference lines or ~ubordinate reference lines, which are useful in the
determination of facial symmetry.

Oculofacial Morphology
Fundamental and Subordinate .Reference Lines

,\\~(I ~
I Fl

-:::;.-

Ii
Nl
12

I"

FI = Midsagittal Fat:ialLinc
F2 = Mid -Ho ri zontal Iris Line
N I ::= Vertical Narcs Line

N2::= Oblique Nares-Canthal Line


N3 = Hori70lllal Narcs Line
II = Inlier Iris Line
I2 = Outer Iri ~ Linc
L I ::= iVI idlllllZZlc Horizontal Lip Linc
1..2 =Supelinr Horizont::!! Lip Line

70

~rLN3
,

_ L __
' L1

OCULOFACI.AL

M 0 R P H 0 LOG Y

Subordinate Reference lines


The);c refcrence lines are drawn with respect to the two previously
described lines, FI and F2. They serve as further landmarks in lhe total
assessment of the face .
Vertical Para llels. A vcrtical line drawn parallel to FI cxtending
through the lateral aspect of the nares and extending superior through the
caruncle should delineate the more medial aspect of the brow line and is
designated as the N I linc. A vertical parallel line drawn through the inner
border of lhe iris extending inferiorly should reach the lateral aspect of the
"c<1mhus" of the lip and is designated as I I. A paral lcl line dmwn on the
temporal portion of the iris extending superiorly should reach the poinl or
maximum apex of the eyebrow arch and is designated as 12. A vertical
parallel to FI passing through the apex of cupid ' s bow of the lip on each
side is designated as L3 and should divide the narcs of the nose into equal
halvcs.
Horizontal Parallels. A horizontal line drawn parallel to the F2 line at
the inferior border of the lower lip should divide the muzzle (the portion of
the face between the tip of the nose and the chin) into equal halves. This
line is designated as L 1. A line L2 represents the superior horizontal lip
line. Lines B I and B2 are analogues horizontal parallel lines defining the
brow srruclur.'e. Line B I should connect the most nasal brow hair with the
most ternpor II hair locmion in the ideal face . The ability to assess vertical
asymmetry
the face is easicr if on.c remcmbers these horizontal parallel
lines.
Obliqu Lines. An oblique line drawn from the latera.l aspect of the
nares exten ing superiorly and intersecting the lateral canthal tendon
should delineate thc most temporal aspect of the brow and is designat.ed as
N2. With contjnuation of N2 inferiorly the line should rail at the midpoint
of cupid's bow of the lip.
In the following sectiom of this chapler, these lines will be used in the
discll~sion of facial features. It is important to ernpha~ize that the
subscquent sections of the chapter are meant only to serve as a reference
guide for a general understanding of facial features. For more detailed
analysis on this subject mattcr, the intcrcl>tcd physician should refcr to allY
of ule excellcnt texts that have been written on ulis subject and can provide
more in-depth knowledgc (sec bibliography).

If

FUNDAMENTAL FACIAL

FEATURES
It is well known among arti sts who perform portrait studics that
cert ain facial feature s are more fundamental and critical than o ther~ in
faei:ll morphology. Proceeding from the most prominent of thesc fUI1-

71

CHAPTER

damental features in describing order are the eyes, mouth, nose. eyebrows
and overall facial shape. These five features are basic in portrait work a
well as reconstructive facial plastic surgery. Less noticed featuJe:; delining a
face are designated as subordinate facial features and include hair color and
style, eye color. skin color and tones. facial hair, and ear placement.
Because micropigrnemauon involves three of the five most fundamental
facial features (eyes. eyebrows and lips), it is not only helpful but critical
that the practilioner approach each patient with a certain analytical
approach. Using the previously discussed fundamental and subordinate
reference lines, a classification system has been devised that we feel is
relatively all -encompassing and provides an easy assessment of facial
morphology.

EYES

;~
/remporal
,
Zone
N2

N1=Vertical Nares Line


N2=Oblique Nares-Canthal
Line
11 =Inner Iris Line
12=Outer Iris Line
(Represents maxim um point of
brow arch)
(a) & (b) vertical parallels.
Distance between (a) and (b)
should be approximately 1/2" in
the proportioned brow.

72

N1

N2

Dr. Zwerling and Dr. Chri tensen have created a 5-S system
for the classification of the eye
and eyelid morphology. The 5 S's
are defined as siZt!, shape, separation, symmetry, and set of the
eyes.
Size. The impression of size
in an adu lt person's eye is usuaJly
considered large, normal, or small.
The perceived impress ion of size
of the eye is determined by a
number of independent variables
slIch as the palpebral Ii. sure, size
of the globe. and volume of the
orbit. I n the vast majority of cases,
it is the palpebral fisslIre thut
usually defines or creates the
illusion of size of the eye. The
palpebral fissure in the vertical
axis measures approximately 7
mm to 10 mm. and in the horizontal axis 25 mm to 30 mm in lhe
normal patient. The general size of
the auult globe is 23 mm +2 mOl
in axial len g th and 24 111m in
width . Variations in the size of the
globe usually do not creale a '
IIlllch of an effect in the impre :;ion or size as does the palpebral
fiss ure. Certainly. patient!. with
high axial myopia in a shallow

OCULOFACIAL

MORPHOLOGY

orbit will have the appearance of large eyes. and conversely those patients
with high hyperopia in all orbit of larger volume will have the appearance
of small eyes.
Shape. The typical eye has the shape of all almond. Variations of this
con lour occur with Oriental eye or eyes that have either small narrow
palpebral fissure. that give the appearance of a slit or eyes with a round
appearance because of large palpcbral fissures . If you cons ider that the
vertica l measurement- approximately 10 mm-is about one-thi.rd of the
horizontal measurement of 30 mm. then the almond configuration is
present. This basic almond shape changes depending on the curve of the
upper and lower lid. The upper lid lends to have an arched appearance.
while the lower lid is the hape of a bow. An angular-shaped eye occurs
when there is less of a curve to the upper eyelid arch. A round -appearing
eye is noted because of both a large palpebral fissure and a dramatic arch
to the upper eyelid. The lower lid is more dramatic temporally than nasally
and may be accentuated in . orne patients with more sclera show, giving a
wider appearance to the eye. The third variable that define eye shape is
the relative placement or the medial and lateral canthal tendon attachments.
Normally, lhe lateral camhal angle is 3 mm to 5 mm higher than the medial
canthus and gives the impression or temporal lift to the adnexal area. When
t.he latera l canth us is lower than the medial canthus, a " hound dog"
appearance is presen!.
Separation. T he idea.! imerpalpebraJ distance is not considered an
absolute measurement, but rather is related to a concept of proponion. The
width of a patient's natural eye should approximate the distance between
the eyes. Thi s can be best imagined if an imaginary third eye is drawn
between the two natural eyes. The widely spaced eye would have a
distance exceeding the space of this third eye, and similarly, in do, ely
pJaced eyes. the space is less than the imaginary third eye disUlnce. This
concept needs to be taken into consideration with the blepharo pigmentation procedure as it relates 10 the amount and location of the
placed pigment.
Symmetry. A signifIcant aspect of ocular morphology is facia l and
adnexal symmell)'. Nowhere else in the body does 'ymmetry play such a
crucial role from the aeslhetic standpoint. Lt is commonly accepted that one
hand or foot tends to be larger thall ih counterpart: however. this is not
readily apparent to the observer due to the widely spaced di!>tance between
)ur arms and legs. The face, however, i composed of variolls features {hat
are seen at the same time . Therefore. small differences between the eyes
are readi ly apparent. For example . a ptosi s of one eyelid when viewed
together with the contralateral li d becomes nuticeable. tn tcrms of
understanding oculofacial morphology, a consideration of symmetry as ;l
factor affecting appearance should be understood. When performing a
blepharopla. ty. the oculoplastic surgeon sllives to place the upper eyelid
creases at an equal distance from the lid margin in both eyes. [n th is way
he prevents an asymmetrical postoperative re su lt. Patients will complain
more about the asymmetry of the result between the eyes than the aesthetic
resuLt if each eyelid is viewed sep~lrately. Therefore. surgery done to a face
should be done in a 'yrnmerrieal fashion or with ~ymmetry "racfOred in."

73

CHAPTER

Likewise, on considering facial of oculoplastjc procedures. gros.


asymmetries must be taken into consideration preoperatively to avoid
further accentuating the asymmctry. Tn some situations asymmetric~t"I
surgery may be indicated to compensate for inherent a ymmetry.
Blepharopigmentation generally is performed in a symmetrical fashion,
since most patients have naturally symmetrical. eyes and lids. Thi '
symmetry cannot be assumed on all patients; therefore. the examiner mu t
detcnnine whether or not the eyes and lids are symmetrical. lL is helpful to
refer back to the ocular morphology reference lines PI and P2.
The lines Fl and F2 divide the face into vertical and horizontal
components. The impression of vertical alignment of the two eyes is noted
by drawing the F2 line that bisects the irises of the patient. One globe i
noted to be either above or bclow its contralateral glohe and is considered
to be upwardly or downwardly displaced by thc reference line . The
impre 'sion of horizontal symmetry is gained by using the distance from lhe
FI midsagital line and noting the distance from lhis PI or midnasal line to
each eye. The horizonlal symmetry can be measured either to the medial
canthal area or to the centra l pupillary area (as long as there is not a
horizontal strabismus present). Other facial symmetric such as brow
placemenl and canthal relationships should be noted at this time, in order to
fully appreciate and evaluate thc critical importance of maintaining or
creating symmetry.
Set. The sct of the eye is analogous to the set of a diamond in a ring.
Similarly, the set of an eye can be considered either prominent or deep.
This sen, e of set is caused by the anterior location of the cornea in relation
to the lateral. supra- ami infraorbital rim, the sizc of the nose. the presence
of supertarsal sulci and the proll1iencc of the brow and cheekbones. Thc
apex of the cornea. in mOSl situations, is located approximately 2 mill to 3
mm anlerior to t.he pl ane created by connecting the supra- and infraorbital
ridges. Prominent <!ycs arc more anterior to this plane and give the
impression of protruding. Conversely. clcep set eyes are posterior to thi
orbital ridg e coronal plane. In general. patients with prominent noses.
brows, and cheekbones tend to have the appearance of deeply set e, es.
Patients with shallow orbits or high axial myopia, or suffcring from Grave '
or thyroid eye di sease. tcnd to bave the appearance of prominent large eyes.
The palpo::bral Jissurc width also relates to the imprcssion gained of cither
deep or prominent set eyes. Some patients may have a deep ' upratarsal
suicli . (from orbital fat a troph.y or other lrauma) . which gives the
impression of a deeply set eye. All factors mu st be considered together in
determining tlJe set of the cyc.

MOUTH
After the cyc~, thc mOllth ( composed of the upper and lower lips) is
considcred the next mosl noticed feature in the face. Not only do our
mouths come ill various sizes. shapes and configurations. but {hey also play
a critical role in facial expressions . This factor is especially noted by

74

C U L 0 F A C

A L

M 0 R P H 0 LOG Y

photographers. painters, and cosmetic surgeons as they perform


(heir various trades. The lower lipline. designated by Ll, is
Skuz pigmentation
usually located halfway belween the tip of the nose and lower
is a major factor in
border of the chin in the muzzle area. As a generul rule. the
determining proper
distance from the lower lip muco-cutaneous junction to the
micropigmentatiotl
upper lip mucocutaneous junction (the palpcbral fissure of the
in other areas of
closed lip distance) is equal to t11C distance hetween the upper
the body_
lip mucocutaneous junction and the base of the nasal
columella. The lips can be located high or low within the
muzzle area and vary in size, shape and symmetry. A useful
orientation [or symmetry is the use of L3 or the vertical lip line. Thi line
passes through thc apex of cupid's bow on each side. The two L3 lines
divides the lips or ovcrall mouth into three equal zones: a central and two
lateral zreas. By utilizing the three L lines the practitioner cao define a
"normal" appearing mouth and lip structure.

NOSES
Noses come in a vast variety of shapes and s ize. : long, short . wide or
nan-ow. The nostrils may be asymmetrical or symmetrical, with the septum
in the midline or deviated to one side. The superior ridge of the nose may
be concave, straight or convex. As a general rule, the width of the nose at
the nares should approximately equal the intercanthal distance. The tip of
the nose should be about halfway between the F2 line and the roo ' ! inrefior
aspect of the chin. The lateral aspect of the nares is important in defining
the N I and N_ lines. By under5tanding the relationship of the nose to the
facial l11orphology it is easier to understand how the placement of the nose
can bave an important effect in defining the eyebrow's length.

EYEBROW
Eyebrows represe nt the fourth major dominant feature in the hierarchy
of facial features. Scanning the facial features usually begins with the eyes,
then the moufh, followed by rhe nose and then returning back to the eye
area; nallle Iy, the eyebrows. B rows are described according (0 their
architecture, thickness. color. and sy mmetric:.l1 or asyrnmctrit:al
positioning. They may be widely separated or placed close together with
hairs growing above the bridge of the nose. In these s ituations, the brows
appear to be connecled. A general concept is that the male brow tend to be
closer to the upper eyelid so thaI the dis tance from the lid to tJle brow is
sho rter i.n men than in wom.::n; and, that men "s brows tend to have a
horizontal con fi gu ration while women .. brow ' tend to be higher from the
lid margin. more arched and cCllIcred. Eycbrow~ arc altered cosmetically
by plucking or clcctrohyfrecution to remove excess hair follicles . CosIl1cti ally, eyebrows arc made more dominant by the usc of an accentuating

75

CHAPTER

color change . .\lith brow penci Is, and in some situalions where there i '
extrl!me blondness or thinning of the brow. patients actually draw artificial
brows. More important than the individual characteristics of a particular
brow isilS relation ' hip to the en tire ocular lid and upper facial morphology
and how they interrelate. and blend to help complement the other facial
features. The line B I, a horizontal parallel 10 F2, connects the most inferior
and medial brow hairs with the most lateral or temporal brow hairs. Line
B2 or superior horizontal brow line connects the highest aspect of the
brow's arch. The zeni th of the brow arch is detined by 12.

SHAPE OF HEAD
The shape of a person's head is the last of the major five fundamental
facial features. Facia l shapes come in five general categories: the classical
oval, square. round. triangular or heart-shaped, and elliptical or narrow
presentations. Tl is sometimes useful to consider the overall face to be
divided into thirds. with the upper third consisting of the supraorbital ridge
and forehead area equal in ~ize to the middle t11ird facial portion consisting
of the eyebrows, eyes, nose and upper portion of the muzzle and the entire
mouth and chin area. In the ideal face all these "thirds" are equally
balanced. A face can be considered long or short by virtue of the relative
portions of space in any onc of the three areas. In genera1. faces tend to be
long in the brow or in the chin and muzzle area and not in the middle third
area except in dysostosis facial syndromes (cranial facial dysostosis .
Having discussed the five major facial features (eyes, mouth, nose,
eyebrows and head shape), it should be pointed out that the ocuLar adnexal
area encompasses two of these live. It is no wonder that attention is drawn
toward the eyes preferen tially when viewing an individual. This help
explain why slTlall variations. asymmetries. pathology, etc., become more
noticeable to the observer when viewing a patient's ocular area in relation
to any of the other areas . Small changes to the adnexal area, through
cosmetic applications or surgery, can have dramatic effects on the overall
appearance. Likewise. adverse co metic applications or surgical
misadventures may have disastrous consequences as they relate to
perceived appearance. The overall geographic area of the ocular adnexal
area occupies a relatively small ponion of the total face: however. its
aesthetic importance is disproportionately large. This di proportion
between the amount of adnexal real estate to total facial geography give:
the ocular area it magnified importance when consjdeJing altering any of its
component parts. Therefore. a blepharopigmentation procedure can have an
overwhelming and dramatic effect on patient perception.

SUBORDINATE FACIAL FEATURES


The fiVe major facial fcalllres eX<!rl the most duminant effect in the
patient's facial appearance. Besides the~e dominant facial features there are

76

0 C U L 0 FACIAL

M 0 R P H 0 LOG Y

CONTROLS 0 F SKIN PIGMENTATION


1. CONSTfTUTfVE or inborn genetic codes
2. FACUlTATl VE
ll. U.v. light exposure
b. Hormonal changes

M ELANOCYTE
Melanosome
rosmase
ty
ly roSlIlC
m elanoprotein & phaeomclanin
MELANIN

non-p igmentation of skin


oc curs at this stage

transfer

+'
KE RATINOCYTE
accumu lation of melanosomes
a. no naggregated: negroids
b.ng gregated: caucasoids , mongoloids, etc.
0 EGRADATION
pigme nlalion of skin occurs

FINALSKIN COLOR
1. melan oproteins: brown-black
2. phaeo melanin: yellow-red
3. indole: yellow
4. dopac hrome: red
S. vascul ar supply: red-blue
6. skin b y-products carotene/xanthophyll: yellow

77
- --

-- -

CHAPTER

subordinate facial features and characteristics including hair color. style.


iris color, the color of the skjn and its texture, amount and distribution of
facial hair, and the placement and prominence of the ear. We have
classified skin as a subordinate facial feature, because of its tlat lining
effect and lack of tructural elevation . Skin pigmentation i. a major factor
in determining proper micropigmenlution in other areas of the body.
Hairstyles generally consist of one of the two classical form: the socalled widow's peak and the founded hairline form. The e form . are
genetically predetermined and vary according to the patient's age. Hair
color i. a fluctuating feature in most women depending upon fashion
trends and individual tastes. In general, most women tend 1.0 fall into
categories of blonde, brunette. black. grey or red. One should consider the
pigment selection for the blepharopigmentation on the color of t1le natural
hair.
Iris colors lClld (0 be green, blue. hazel. brown. and black-brown: also.
there can be color variation within the same iris. Iris color is predominantly
determined by the amount of melanin content in the posterior pigment
epithelium of the iris. This melanin content can change with the natural
aging process as well as in disease states. trauma, and surgery; and,
therefore, alter the ovet1llJ color of the iris.
The color of a person's skin is determined by lhree different factors:
melanin pigmentary ystem, the number of supcrticial blood vessels, and
facultative inrluences such as UV light and hormonal influences. The
primary factor for overall skin color is U,e melanin comen! of the skin.
The melanin pigmentary system represents the interaction and
regulation of melunin production and transfer between the two specialized
pigmentary cells of the skin. mclanocytes and keratinocyte ' (see chart).
Melanin is a brown-black insoluble natural skin pigment composed of
insoluble polymers or tyrosine derivatives. The production of melanin
occurs within specialized cells, melanocytes . In addition oU,er specialized
cells, kcratinocytes participate with the melanocytes in the dispersion of
the melanin particles throughout the dermoepidennal interface.
Melanin is manufactured within the subcellular organelle or
melanosome of the melanocyte. The mclanosorne is the site of tyrosinase
enzyme biosynthesi::; for the biochemical production of the melanin and the
vehicle for the transfer of the melanin to the surrounding. keratocytes. The
production of melanin occurs over a four stage process. According to
Today , it is the number. size. stage, degree of transfer. and type of
aggregation of the melanosomes within the keratocytes that is the
determining factor for overall skin color. PrevioLisly, we thought that the
density of mclanosomes \vithin the kerawcytes was the critical factor. The
size of the mclanosome is genetically detemlined with Negroid skin containing 1.0 to 1.3u in greatest diameter. wherea..'l Caucasiods and Mongoloid '
extend from 0 .6 to 0.7u. In the fair complexion individuals we see
diminished pigmentation of melanin within the keratinocytes and mostly
stage. I. II. and III melanization , whereas in Negroids there is a
predominance of stage IV melanization in non-aggregated rOlm.
The overall pigml!nt.ation of lhe individual"s : kin i. due to the tran fer

78

OCULOFACIAL

M 0

R P H 0

LOG Y

of the melanin pigment from th e melanocYlc to the surrounding


keratinocytc. If transfer is inhibited then hypopigmentation occurs. A
variety of influences will increase or decrease thi s transfer process. This
transfer can be modified by facultative factors such as the amount of
sunlight and hormonal influences of the melanin slilnulating or adrenal coriical stimulating (ACTI-f) hormones. Skin color can be modified by
various disease states, diet. body temperature. blood volume and now near
the skin surface, and trauma (sec. chart).
Because of the different skin colors, the practitioner needs to consider
how the micropigmentation will blend with the natural ski n tone s.
Generally speaking, all individuals have either blue or yellow skin
undertone . . Thi. concepl will be more fully discussed in the chapter on
Artistic Technique.
Facial hair distribution in the form of mustaches, beards, s idebums,
etc., can affect the contours of the facial bones. and often are used to cover
defect and minimize malformations. Men often wear short beards or
goatees to mask a weak, underdeveloped chin. Ears can come in a plethora
of sizes and shapes. As a genera l rule, the upper aspecl of the auricle
shou ld be in line with the la teral canthal angle. whereas, the inferior aspect
of the auricle should be approximately in line with the inferior border of
the nas al columella. As a whole , ears playa very small role in the
heirarchy of facial features unless gross malformations or asymmetry are
prescnt.
1.

CHANGE IN MELANOCYTE AND/ORMELANOSOME


NUMBER
A. Increased number of melanocytes
l. Exposure to UV light
2. Psoraleos

U.

3. Lentigo
Decrea'ied number of melanocytes
L

Freckle

2. Loss of hair color with aging


3. Tuberous sclerosis
4. Malignant melanoma
C. Absence of melanocytes
J. Vitiligo
2. Halo nevus
3. White forelock in some genotypes of piebaldism
D. Increased size of melanosome
1. Cafe-au-1ail of neurotibromatosis
2.
3.

Nevus spilus
Congenital nevi

II. ALTERATIONS IN MELANIN BIOCHEMICAL SYNTHESIS


A. Decreased tyrosimL'iC activity and melanization
l. Hair color ch~lOgc with aging
2. Dilul.ioll of hair color in phenylketonuria
J. Hypomel~lnotic macules
ll.
tuherous sclerosis
h. nevus dcpigmentoslIs

79

CHAPTER

Oculocul~lOeous albinism
a. tyrosinase positive
b. tyrosinase negative
5. Tyrosinase inhibition
a. chemical inhibitors (i.e. I)henol)
h. phenylketonuria
c. pityriasis rosen
B. [ncreased tyrosinase activity and melanization
1. Stimulation of increased cyclic AMP
a. Increased~ISfl
b. Increased ACTH (Le. Addison disease)
c. UV light exposure
d. Prostaglandins
2. Increase in circulating metabolites of melanin
melanosis of' metastatic melanoma

4.

1lI. DISTURBANCES IN MELANOSOME TRANSFER


(clinically decreased pigmentation)
A. Alteration in melanocyt.e structure
1. Inadequate dendrite formation
a. Chronic exposure to UV light
b. Nevus depigmentosus
2. Long, thick dendlit.es
a. Red skinned New Guinean
b. Hypopigmented areas of malignant melanoma
c. Active horder of vitiligo
B. Increased rate of keratinocyte proliferation without transfer
1. Psori.asis
2. Verruca vulgaris
3. Condyloma acuminatum
C. Interkeratincytic pathology
1. Eczematous dermatitis
2. Edema ancVor necrosis from trauma

[v.

PIGMENT INCONTINENCE AT DERMO-EPIDERMAL


JUNCTION WITH ASSOCIATED PHAGOCYTOSIS OF
J\'lELANIN 8Y DERMAL MACRO PHAGES
A. Incontinentia pigmenti
B. Fixed drug eruption
C. Post-inflammatory hyperpigmentation
D. Lupus erythematosus
E. Lichen planus
* !nodl/ied j i'mn Fit:p alrick er aI. , 1971

80

OCULOFACIAL

M 0

R P H 0

LOG Y

SUMMARY OF OCULOFACIAL
MORPHOLOGY
AND DERMALPIGMENTATION
In lhis chapler 011 (}cullljuciul /Ilorphology, H,Ie cO/leluded that the eye
area plays a dominant role in opera/! facial j'e{l/ures. Because of this

significance, the blepharopigmen1ation procedure achiere. a dramatic


effect whe1l appropriately pe/formed. Likelvise, procedures pedormed with
nriscalculCilions or trw/positioning of pigment can be devastating. The 5-S
Classification was deve/oped LO assist the practitioner in emil/olion and
orielltation of any patient for ocu/opiastic. facial recol1..,t1'llctive, cosmetic
(lrdermalpigmentation. For the ophthalmologist or practitioner who is no'
familiar lVitl! th e process of cosmetic evaluation. it aCiS as a guide and
reillforcl:'s hasic con cepts. Beautiful results call be achieved whell Ihe
pracliliona incorporales the principles of the 5-S class(jicatirlfl Wilh the
palient's desires.
It is interesfillg 10 nOTe that since lhe )irst edition of this book. we now
lIfili;.e micropigmelllioll for (!yeliner, eyehrows. lips, alld .~kil1 color in the
facial areas. The only jimdamellw/ feature not efFected by this proCt'dlire
H'ould be the shape o.f tlie head!

Sf
- - -- - - - - - - - -

H A p T E R

~~ '::~.~"""{;"
,

"'~

"',

'0,_,

!
;

\,

'e;

Photography

Photography i an important adjunct to cosmetic procedures. The


photograph provides the practitioner wilh accurate documentation of the
pat ient's condit ion. The practitioner can study the p reprocedural
photographs from various ang les and care fu IIy plan the m icropigmentation, Wi th the he lp of the photograph he can demonstrate to the
patient the proposed procedure, alld this time the patient can add he r
comment as well. This gives the patient a feeling of greater
participation in micropigmentation, and. thereby. helps to diminish
anxiety, The photograph also serves as legal documenlatjon following
cosmetic pigmenta tion, and is further helpful in demonstrating progress
to the patient. Always obtain a model consent release form if you intend
to use the photos for teaching and/or promotional situations (a copy of a
model release form is in the appendix), Unfortunately, photography has
become somew hat complex. and to lhe inexperienced praclitioner. the
choosing of proper photographic equipment can be confusing. This
chapter provides a basic review of the more critical aspects of
photography and, hopefully. will serve as a practical guide for those
novice. For a more comprehensive treatmcnt of this Sll~jCCI. consul t the
numerous textbooks available on the subject (see bibliography).

CAMERA SELECTION
Choosing the proper camera ('or facial photography can be a rather
costly venture, Convenience, cost. and quality of the rinal photographic
reproduction are i1ll important. considerations, Expensive camera
equipment docs produce excellent resulL. but there i~ a point at which
additional costs outweigh the quality of the result. For all practical
purposes there are fi w basic types 01' cameras 011 the market today : 35
mill single lens retlcx, rangefinder 35 lTun 110nreflex, twin lens rellcx

8J

CHAPTER

(large format reflexes), 110 disc, and in tant picture cameras. The
di fferences among these five categories afC related to the negative side and
the vUlious viewing methods.
From the standpoint of cost and qua lity of photograph ic reproduction .
the 3S mm single lens reflex is certainly the best overall camera for
ophthalmic-facial photography. With the, ide variety of accessorie ,
interchangeable lenses, and formats, this basic camera unit can be u.-cd from
the fine microscopic detail in retinal angiography to the macroscopic facial
photography areaS. T he inconvenience oJ changing the lenses is outweighed
by the reasonable cost of the film and development, and the wide range of
available format~.
The rangefinder 35 mm nonrerI.ex cameras is essentially a 35 mm
camera without the great flexibility and interchangeability afforded by the
choice of lenses and various other accessories. The e camera, contain
certain fixed focal relationships and arc hybrid between 35 mm and 110 disc
or old "instarnatic cameras." The!'c cameras arc generally inexpen 'ive and
easier to use for the novice photographer.
The twin lenses rctlex or large format retlex cameras are rather bu lky
and have a more lim ited range of accessory items; however. they offer the
definite advantage of a larger negative, which renders a higher reso lution of
facial details and great ly expanded ability in photographic enlargement;
however, the inconvenience is not reflected in a vast superiority of
reproduction when compared to a 35 mm camera.
The 1LO or disc camera offers the ultimate in convenience. These
cameras have exceptional ease of photography , especially for the untrained
liseI'; however, the cost of the film is rather excessive, the reproductive value
of the tilm produced is very limited. and interchangeabi li ty of lenses and
necessary items is virtually nonexistent.
The instant picturc cameras offer the advantage of immedia te
gratification. Although the reproducibility and detail of these photographs
are very limited, they also assure the physician tha t a viable medical record
ha s been obtained. We all know too well lhe situations in which
photographs have been taken with non-instant camera. and the film has
either been deslroyeJ, lost, or poorly deve loped. We would recommend the
lise of one of these inexpens'ive instant picture cameras in association with a
35 111111 single lens reflex camera ill the photographic workup of the cosmetic
patient.

FILM SELECTION
Thae are three g.eneral categories of films available in photography:
color print. black and white print. and color ~Iides. All three types have
distant advanrages and can certainly be used in racial photography. These
films are e~scntially light-sensitive silver halides t.hat produce a black-andwhite reproduct ion. With the addi1ioll of complex organic chemicals,
additional colors then become available in the developed tilm. The minute
silver halide crystals, the greater the area exposed in a certain time, and thus

P HOT 0 G RAP H Y
the faster tbe speed of the film . Films with a high speed lend to have a high
The 35 mm
grain and poor detail. Grain can be defined as the g ranular pattern of
single Lens reflex is
minute density varialions in an area of photographic emulsion. This
certainly the best
gran ular pattern can be actually measu red by a microdensi tometer and
overall camera for
express in RMS (route mean square) granularity. The lower the number,
ophthalmic-facial
the more microscopic the grain and the greater the detail and ability for
photography. With
enlargement. The various speeds of photographic film are meas ured by
the wide variety of
three 'tandards: ASA (American Standards Association) , DIN (Deu tsche
accessories,
Inclu slrie Norm). ancl more recently, a combination of the two, ISO
interchangable
(International Standards Organization). The higher the number quoted on
lenses and formats,
the standard, the greater the se n ilivity of the emul ion to light. Becau e the
this basic camera
fast color or black-ancl-white films procluce an excessive graininess in the
end resull, ASAs between 25 und 64 or DIN s between 15 and 19 are ideally u"it can be used from
suited for ophthalmic-facial photography.
the fine microscopic
The color film hould always be stored in a cool, dry place away from
detail ill retinal
any type of heat, and, once the film has been lIsed it should be developed
angiography to the
rather rapidly si nce color dyes tend to rade over a period of time. It is also
macroscopic facial
very practical and helpful to carefully label the film that is sent for
photography areas.
devel.opment with the practitioner's name and, if possible, some type of

Polaroid automatic

Range Finder 35mm

Kodak 110 pocket camera

Polaroid pop-up
Collapsible Polaroid

85

CHAPTER

coding system with the patient's chart number. We have found the u e of
black-and-white Punatomic-X to give excellent reproducibiliry, and ASA.
of 25 to 64 in the color slides can also be made from the prints if necessary,
with lillie if any detail losl. The advantage of print film is the ability to
write critical patient infomlalion on Ihe reverse side of the photograph, and
it offers a more convenient method of patient viewing. Creating copies of a
color print from a negative is also les expensive and easier than making
copies from color slides.

FlASH ATTACHMENTS
Once the film has been selected for the camera, often a nash unit will
be needed because of the slow ASA numbers. There are numerous flash
aITangemellts available on the market, ranging from the simple flash cube to
the much more complex light sensors charged to an AC current with
rel1ecting umbrellas. We have found the rechargeable battery attachments to
be the most dependable and readily affordable systems. U ing multiple
flashes on a single camera base minimizes the casting of shadows due to
room lighting variati.ons. A light sensor meter can be useu to further
measure the amount of available light in the room. Selenium cell and
cadmium sulfide exposure meters are rather inexpensive and readily
available on the market.

LENSES
The type of lenses to be used with the 35 mJ1l single lenses reflex
camera base is of critical importance. The patient and practitioner hould
remember that the photographic image used in oculoplastic facial
procedures should be actual and 110t artistic. 1n portrait photography ,
telephoto lenses in the 100 mm to 200 111m range arc used to create artistic
photographic images by limiting depth of the field by an increased focal
length, the less its angle of view: thus, a telephoto lens of 200 mm creates a
more restricted angle of view with a curtailment of the depth of 1ielc1. The
depth of field is the area in focus in front of and behind the image of regard.
These telephoto lenses produce beautiful portrait photography; however,
because of the very limited depth of field. we feel. that these are not the
id~al lenses of choice. The macrolens oIlers the besr reproductive quality in
racial photography for the practitioner. These macro\enses come in 50 mm,
or 55 111m, and 100 mill or 105 mm focal lengths with different ratios of the
sile of the llriginal object to rhe s ize of the reproduced photographic image,
i.c. I: I or I :2. By aujusting the aperture or f-stop, the depth of field can be
further enhanced. These m<lcruknses offer the ability for sharp close-ups as
well as excellent full facial views. Lifesize or even magniticd areas of the
eyelid ~tructure can easily be obtained with these lenses without having the
practitioner literally right un top of the patient'" face while taking the

86

P HOT 0 G RAP H Y
photograph. Because of excellent dept.h of field obtained with these len. es,
tile magnification features, and the decreased perspective distortion, we feel
thai these are the ideal lenses for eyeliu and overall facial photography.

SUMMARY
There are numerous miscellalleous accessories thal the practitioner
can use ill his photography. Di.!ferenl backgrollnd drops. filters. tripods.
and jpecial rej7eclOrs can all be used ill l'arioul' degrees to create higher
quality professional results. However, to most practitioners with a busy
practice, convenience and speed are ofren the mosT critical factors. In
summary. we find Ihat the use of a macro lens attached 10 a 35 mm single
lens reflex wilh electronic flash using ASA 64 or 25 color slidl! film 10 he
the overall "(1St approach in this type of photography. One dist inCT
advantage {~l sing II! lells rejlex camera is thaI many of them offer a
"preview" button. The use (~r The preview bl/lfo" will enable the
practitioner to judge the (:{rective depth (~f the field al dij/erelll apperture
settings. By pressing (he but/on. [he reflex viewing system screen u:i/l show
exactly how m/./ch of tM piCTUre \\'ill be ill fOCl/s, al/d by 1I1lering ,lie lstop.
the depth offield ('all easily I)(~ changed. It is important to remember,
however. that when the j~slop is changed. the Light imensi(), is altered.
Compensation for this change ill light intensity is accomplished by alwring
the shulter speed. We have sl/ch a call1era on hal/d in our offices ((I
photngraph pre- and postsurgical pa(ients without ha ving to set up each
lime. Such a system can be obwilled/or $300 to $400.
When rakillg photographs of the {Jalienr, it is important to gel full
facial "iews and oblique views wilh magnijlcation of the critical eyelid
area. We reco/lunend that lull photographs be done of the paJielll with 110
makeup. with full eye makeup, alld with full eye makeup without mascara.
It is difficult (0 assess the ejJl!CI of color inlensit} with mascura and
eyeliner worn lUgerher. By removing olle of these variatiolls. i.e. the
eyelil/er. (he practitioner can bl!uer assess the effect l?f the mascara. Most
mascaras are a black or dark brown color. and thereJiJrC' have a proj{JlLI1d
(~rfect on lhe overall eyelash (Ind lid color. By knowing rhe quality of
mascara that the plIliellf l1onno/ly IIses, the practitioner will be less likely
tv apply 100 much pigmel1( during the procedure. In addition 10 the series
of prepf'Oceduml photographs. we generally like t(l takt~ f1holOgraphs
immediately offer the procedure. and then again at (IVO weeks alld a month
ojil!Y the micropigmenwlioll.

87

H A p T E R

Patient
Selection

Arter the practitioner has purchased hi~ dermalpigmentatioLl


equipment and panicipmcdin an instruction course. he or she is ready to
begin performing micropigmentation procedures. In most situations. the
company that sold the im,tful11cnt to the practitioner will provide ancillary
product information (see appendix, Marketing Considerations), such as
advertising brochures. video cassettes, informed consent packages. or
pigment color charts. The next phase is to begin palient seicction with the
choosing of the first candidate. As a genera] rule the first patient should be
an eyel iner candidate. We do not recommend select ing a lip liner or some
other sophisticated type of procedure in the carly sla~es of one's
rnicropigmemation career. Most insura nce companies will not cover the
novice pratitioner for the more complex procedures. From an ethical
swndpoint. we supporl the concept of experience and additional training
before pursuing riskier inLCrvelllions. There are certain indications and
contraindictions ror the eyeliner procedure.

INDICATIONS
Contact Lens Wea re r. Peuple who wear contact lenses frequently
complain tha t the convelltiona l eye makeup i~ difficult to apply and often
~ heds into the ocular surface causing corne;, I irritation . For these patients,
micropigmcntation eliminates the problems with makeup application. since
the pigment line is permanently implantecl.
Allergies. For persons who desire eydincr or eyelash enhanct!l1lcnt but
do nOI tnlcrate st.andard cosmetics, the micropigmcnlation procedure offers
a viable alternative. Many commercial eye makeup products are known to
produce allergic reactions and. more onen. chemical irritation to lhe "kin

89

CHAPTER

and eye (due Lo chemical additives lhal provide prolonged producL


prel'ervalion such as mercury) . These inflammatory skin reactions pose
problems 10 tbe patient. ranging from the mild to the severe, and some
necessitating medical altenrioll. The procedure of micropigmcmation
contains no known skin irritants. Natural Eyes (TM) had a small portion of
talc as a possible irritant within the dye mixture; but. this talc additive was
removed years ago. Prcselllly none of the micropigment3tion eompanies use
talc in their pigment mixtures. In Ihe past 10 years of testing and
development. there have been no documented eases of allergic reactions.
There have been a number of patients with documented eyelash loss from
this procedure. For more detailed information refer to our chapter on
Complications. For patient.s who have an allergy to standard cosmetics or a
his-tory of allergic problems associated with the use of paint, crayons, elye.
etc., it is advisable to perform a simple scratch test to detect any allergic
reactions to the pigment or possibly one or the component'> of the vehicles
such as glycerol; moreover. willt these particular patients. wait at least one
month berore proceeding in order to rule out delayed hypersensitivity
reactions. The micropigment:'ltion procedure is contraindicated if any
allergic reaction occurs. With over 100,000 estimated procedures performed
throughout the United St3tes, there has not been one documented allergic
reaction to iron oxide pigment used for micropigmentation procedures.
Visual Problems. Patients with poor visi.on due to either impaired
eyesight or problems rdated to presbyopia find it difficult to apply makeup.
In many case. depth perception is altered and the drawing of a fine line
under the lashes is un arduous task. These per ons are usually hesitant to
apply conventional makeup simply because they do not see well enough to
apply it easily. In addition. they may accidentally cause corneal abrasions
\vhilc trying to apply the eyeliner pencil.
Motor Dysfunctions. Other patients who suffer problems with
application arc those plagued by medica.! conditions such as arthritis.
:>trokes. tremors. Parkimon's Disease. or any other condition that may
prevent them from either holding onto the applicatOr or maintaining the
coordination necessary to apply their makeup. These women seem to
benefit greatly by the micropigmentation procedure in re toring renewed
confidence in their overall appearance.
Convenience. An increasing number of women are working outside the
home. These acrive women lind it difficult to take the extra time to apply
their eye makeup . A~ the application is time consuming and requires
adjustment during the day. some women often resent the process of having
[0 apply makeup Of apply it in a hasty rashion. The micropigmentation
procedure reduces the time required to apply makeup and does not require
[otl(.:h up.
Trauma. Patients who have had previous trauma to the lid, loss of lid:
from tumors or traumas , or oculoplastic rccoJ1l-truction after burns also
henefit frum the procedure or micropiglllentatioll with redefinition of their
lid margins.
A("tivc Sportswomcn. Micropigmcntation surgery is bcneficial for
patients who have prohlems \vith their clIIrent makeup smudging or wearing
olT during heavy exerci se. Perspiration or oily skin causes standard makeup

9(1

PATIENT

to sm udge and smear. The micropigmentation procedure


eliminate!> these problems so that these women can maintain
a made-up appearance while participating in these activities.
Alopecia of Eyelashes, In patients who have lost their
eye lashes from either disease or trauma . b lepharopigmentation can create an effect of eye lash enhancement as
wd l as the eyeliner effect.

CONTRAINDICATIONS

S E LEe T ION

Patiellt
con venience,
flexibility, and
return to a normal
lifestyle as soon as
possible are
important variables
for overall patient.
satisfaction,

K e loi d F ormati o n : M icropigmenta t ion is not


recommended in patients who have a history of kc\oid formation. Keloid
formation is usually secondary to deeper incisions. Becau e the pigment is
applied at a depth of only 0.5 mm to I mOl , keloid format ion shou ld nOl
occur. We know of no instances where a keloid has formed econdary to
the mieropigmentation process. However, in the interet of safety. a smaU
scratch test and/or pigmen t line behind the pa t ient's ear shou ld be
pcrformed and watchcd for a mo nths to ascertain jf a keloid reaction will
occur. For the time being, we do nOl advocate that the rnicropigmentation
procedure be performed in thi~ patient group.
De rmatographcsis : Women with a history of derma tographesis are
not recommended for Ihis procedure. Pl'Iticnts who have marked reaction to
minor skin trauma are usually well aware of this condition and would
probably not seek the procedure anyway .
Accuta nefRetine-A: A number of patients cUlTcntly taking Accutune
and/or Reline -A medication ror acne problems have encountered
pigmentary skin changes as well as reports of eyelash and hair loss. We do
not recommend performing the micropigmclllation procedure on patients
cUITL"nlly taking this dru g; however. if the use of the drug is discontinued , il
would be safe to proceed with the procedure. As a general precaution, it
would be pruucm not to consider the proel!dure on women taking any drug
with known pi gmenlar_ side effects until furlher rescarch in thi s area has
been accompl ished.
Ac t ive De rm atolog ical Uisorders: For patients who are currently
~ llffering from certain ac tive dennatologieal disorders such as psoriasi ',
lichen plal1u~ , warts, molluscum eontagiosum. activc herpes simplex or
zoster. ancl Darier's Disease. the micropigmentation procedure shou ld be
deferred until the active di s~1se has been controlled. Atopic dermatiti s and
chronic pyoderma are possible contraindications.
Pregna ncy : Because or the well-documented pigmentary changes t.hat
can occlIr while a woman is pregmmt, we advise against performing t.his
procedure during preg nanc y; however, aftcr the birth. the woman is
ce rt.ainly eligible for the procedu re.
Age: We do not recommend the micro pigmentation procedu re on
wO lllen be low the auult age of 18 because these patients arc too
inexperienced and immature to make permanent cosmetic decisions that
will affect them the reM
their lives. In addition, patients of any age who

or

!II

CHAPTER

are inexpericnced with makeup application are not candidate::;. There are
certainly exceptions to this rule, such as a bum or trauma victim; however
the practitioner who operates on these yo unger patients will probably
e[lcounter greater problems with the group later on.
Blood Dyscrasia: For patients with a history of blood dyscrasia. ueh
as sickle cell anemia, platelet disorders. or hemophilia, and patients taking
anticoagulant drugs , the dermal pigmentation should be deferred until soch a
time as the dyscrasia is under adequate medical control.
Psychological Disorders: It would be prodenr not to pelform this
procedure Oil any ind.i vidual undergoing therapy for a psychological
disorder or on those individuals that the practitioner feel s may present
underlying psychological problems. This discussion of psychological
disorders is treated fully in our chapler on Psychological Considerations.
The ideal first parients should be highly motivated and psychologically
balanced. They should be knowledgeable about the use of tandard eye
makeup. and have confidence and experience in applying their own
makeup. They should view this established procedure as a freedom from the
time consuming process or applying eyeliner.
An ideal first patient has dark-toned sk in and thick eyelashes. and tends
to dramatize her eyes with heavy eyeliner and mascara. In patients with
darker complexions, minor imperfections will be less noticeable than those
performed on blonde, fairskinned people. This is not to say. however, that
lhe practitioner should take less care with this type of patient, only that
these patienrs offer a greater degree of latitude to the practitioner
pedorming. the procedure for the first time. Patients who apply thcir makeup
heavily will not object to a thicke r Of darker line of pigment. The practitioner should ex.plain carefully that the alTlount of pigment may be less
Lhan what the patient is accustomed to wearing, but that more pigment may
be applied at a later date.
The practitioner's first candidate must not be their spouse or
relative. All too often. we have see n practitioners who have used their
wives as "guinea pigs" in their first patient selection. Not only does lhis add
strain to a marriage, but it al. () creates a poor first candidate to show other
potential patiellts. Patients may feel that the wife lTlay have been coerced
into having the procedure and that the practitioner was unable to be
objective with his own wife. The axiom of not taking care of your own
holds especially true with micropigmentation.
The practitioner's first candidate often will have heard abollt the
rnicropigmentulion procedure from television news stories. magazine
articles, or the palient information literature in the practitioner's reception
'lIea. Other candidates include nurses and hospital personnel. The private
office stafr is an excellent source for refclTing palients.
Even after the practitioner feels that be ha~ a good lir ' l candidate, he
may find thaI even lhe 1l10st lllotiv alcd patient is apprehensi vc about being
the "g uinea pig" for the inexperienced practitioner. The patient's anxiety
will be lessened by the practitioner's conveying to the paIient that he has
complete confidence and knowledge of all contribu ting aspects of the
procedure. and any complicalion~ that may occur. By choosing a well-

91

PATIENT

S E LEe T

motivated and infomlecl patielll who is Familiar with the practitioner and
has demonstrated contidcnce in his abilities. the practitioner will find that
this own anxiety will be diminished as well.
After performing the procedure on two or three patients. we feel lhat
the practitioner should probably stop the procedure for a few weeks to gain
lime to assess the initial patient , resuIL<; . This extra time for reOcction will
allow the practitioner to rcconsiuer his approach anu techniques for this
procedure. As with any new technique, there exists a learning curve or
assimilation lime. The new micropigmentation practitioner should not
expect the first few cases to proceed with tbe . <lme ease as would his future
cases.
Patient convenience, flexibility. and return to a normal lifestyle a soon
as possible are important valiables for overall patient saUsfactioll. This
increases the patient' s acceptance of the procedure and ultimately improves
patient referrals. After a few patients have had the procedure performed, the
amoul)[ of time spent in the assessment of the patient and the time spent
procedurally will lessen.

93

H A p T E R

Clinical Evaluation

The assessment of the micropigmenl<Jlion candidate for eyeliner,


eyebrow, andlor lip pigmentation should include an eye examination with
ocular adnexal evaluation and/or an overall racial analysis. Adnexal
problems and their importance will be discussed in this chapter. In the
cases for other micropigmentation applications such as vitiligo or areloar
pigmentation. the practitioner needs to exercise good judgement in
requesting medical consultations. Remember failure to consult could lead
to malpractice litigation.

EYE EXAMINATION
The eye examination for micropigmentation should be no different
than the examination given for any other ocular procedure and include the
visual acuity measurement. motility examination. slit lamp examination.
etc. The examination gives the practitioner or ophthalmologist an
opportunity to assess not only the ocular needs of the palient, but also her
psychological needs. Information gai.ned althis examination will be useful
in performing blepiJal'opigmelllation. Through the understanding of the
patient's needs and evaluation of her ocularfacial morphology, an
appropriate procedure can be planned.

HISTORY
The patient is instructed by the recepti on ist 10 appea r for her first
examination with her makeup 011 as ,' he would like to. have it reproduced

95

C HAP T E R

by the hlepharopigmentation procedure. This provides an opportunity for the


praclitioner to evaluate the patient's cun'em makeup and to assess what the
patient considers attractive . Makeup is app li ed by different technique to
achieve certain results by each patient A thorough questioning of the
patient's history of makeup and her desired results also helps the
practitioner to decide how best to proceed. In addition to becoming familiar
with the patient's history of makeup use, the practitioner can e.valuate
patient concerns with olher associat.ed facial problems aLthis time.
With any patient contemplating micropigmentatjon, a thorough history
noting systemic medical il1nesses, allergies to drugs, dyes, paints,
medicines, and history of medication use is recorded. Systemic diseases.
such as thyroid disease, edema from hem1 failure of kidney disease, clotting
abnormalities. use of aspirin, etc., should be known prior to attempting
blepharopigmentati.on or any other procedure. For a more derailed
discussion of contraindications for micropigmcntation, please ee the
chapter on Patient Selection. Associated medical conditions such as thyroid
disease should be evaluated by an internisl before the pigmentation
procedure is undcl1aken. In addition. questions concerning prev iolls corneal
infections, trauma, and wetting problems, as well as other anterior and
posterior segment pathology, are asked and noted in the chart.
The history of previous ocul.ar or adnexal surgery i extremely
important. For example, a patient who ha. undergone a previous lid
resection for a skin cancer may no longer have lushes present, and thi may
be the motivating factor for the blepharopigmentation procedure. Although
the procedure defines the lid contours and creates an eyelash enhancement,
it docs not replace lashes.

EXAMINATION
A complete ocular and facial examination follows the history portion.
After the evaluation. the ophthalmologist or consulting practitioner will
appreciate the relative importance of other adnexal abnormalities in the total
eva luation of his cosmetic consult. Brow and lid ptosis, dermatochala 'i: ,
herniation of fat, facial creases, and other features that arc not affected by
the blepharopigment3tion procedure needs to be explained to the patient and
documented. By properly assessing these problems before the procedure
with the appropiate special ist and mak.ing suggeslions to the patient for
correction of these specific problems. the practitioner can avoid dissatisfied
patients. "Vith proper evaluation and correct as:essment, palient and
practitioner can attain a realistic expectation of the final result.
Too often. an ophthalmologist' s examination i. oriented only towards
the globe. ocular surfaces. and intraocular structures. While examining the
blepharopigmentation patient, the ophthalmologist or practitioner should
gain an ovcrall perspective by stepping back and examining her facial
sy mmetry. );kin texture, and color of hair. lashes. brows. iris. etc. By
examining the patiem at arm's length, he or she will notice subtleties of
features about the facial structure that otherwise may have been missed.

96

CLIN.lCAL

EVALUATION

This is a standard approach with plastic surgeons and experienced,


~orreclive cosmeLOlogists: ophthalmologists, however. are !lot oriented
towards the whole face and tend to look for the lree rather than assessing
the forest. Female nurses have been so sliccessful with rnicropigmentation
in the past few years. since they have a greater experience and
understanding of makeup than their male physician or male nurse
colleagues.
A pra~litioner might also consider the use of a co~mdic ~on$lIltant to
make recommendations regarding the aesthetically correct color and
placement of the pigment. However, the final rendering of the pigment
placement and color must be the decision of the patient and the
practitioner. Often a compromise is achieved in the final decision. In those
cases in which there is a large margin or difference of opin ion, it would be
advisable to question whether to apply the pennanem makeup. When in
doubt DO NOTHING!
After eva luating the total facial configuration - the ocular, oral,
facial. and nasal morphology, symmetries, colors and texture - a closer
examination of individual components can be performed. The practitioner
~hould e pecially examine the eyebrows and the lids for ptosis, entropions,
ectropion!). canthal detachments, tearing abnormalities, abnorma.l scars,
and lid lesions. This part of the examination will determine other areas that
may need correction for overall cosmetic enhancement and that will
complement the blcpharop igmentation procedure.
One helpful way of evaluating a cosmetic patient is to have the patient
examine herself in a l11irror and point to variolls areas of her face and
ocular area that are of concern, for example. blemishes defects or growths.
By having the patient actually point with her finger to thi .. area of her
racial anatomy, incorrect assumptions can be avoided by the practitioner.

EYEBROW EVALUATION
Eyebrows are examined for symmetrical or aSYlTlmctri~al ptosis al1d to
determine whether various aspects of the brow (nasal or temporal )
predominate. During the aging process. the laxity of fhe forehead causes
the brows to droop. which in turn causes excess skin to herniate onto the
upp..:r eyelid. Patient:. may note the subsequent loss or the lid platform
where e. cliner. shadows , etc. arc placed ane! may be under the
rniscon~eptioll that blepharopigment.llion will COITect these problem~. The
ophthalmologist or practitioner needs to explain to the patient that a brow
elevation or excision or redundant upper eyelid skin is necessary.
Measurement of brow ptosis is made forl11 the central upper lid margin to
the central brow llsing a ruler with the patient' S head in primary position .
While the patil'llt look.s into (I mirror, the examiner' s finger~ elevate the
brown or forehead. thlL giving the patient an indication of the extent of the
ptosis. A surgical pro~edurc for brow ptosis is Llsually indicated fore
measurement, less than I() 111111. Various approaches to brow elevation arc
currently in vogue. The brows can be elevated by a suprahrow excision of

97

1 ________________ _

C HAP T E R

Through the
understanding of
the patient's needs
and evaluation of
her ocularfaclal
morphoLogy, all
appropriate
procedure call be
planned. The more
information reLated
to the patient, the
smoother the el1tire
process will be.

skin placed obliquely to avoid cilia 10, s and with direct


closure fo r elevation of the brow directly. Brow lift
can be secondar ily elevated by a coronal fore head
approach. Determining whether the patient has a
receding hairline, thinning of the hair, or forehead
wrin kles will help to decide the best surgical approac h.
Standard textbooks or oculopla, tic and general plastic
surgery should be consulted before attempting tJ1ese
procedures or rcfelTing these patients. The important
aspect is the preprocedural determination of a
condition to avoid patient di satisfaction.

UPPER UD EVALUATION

Afte r an assessment of the brows, an upper eyel id exam ination is made.


A genera) assessmem as to the heavi ness or fullness of the upper eyelids can
be gained at ann's length . Measuring the palpebral tissure between lower
and upper lid is useful to nOte whether ptosiS is present and/o r whether the
patient has prominent eyes. Normally this value sho ul d be anywhere
between 7 mm to 10 111m. Wllen measuring the patient for ptosis, the lower
to upper eyelid [issure measuremcnt should be noted, as well as the central
cornea to upper eyelid measuremenl. This measurement is u uaJly
perforllled with the aid of a small penl ighr directed at the cornea in the
primary posi.tion , and a measurement of the light reflex made from the
central cornea or visual axis to the upper eyelid. Normally, this
measurement should be approximately::; mm to 4 mm . Measuremenls les '
than thi s are indicative of either congenitally narrow fissllres of a fami lial
nature or ptosis. Ptosis is measured as a bilatera l phenomenon when both
the central cornea-to-upper-eyclid measurement is Iloted to be less than 3
mm to 4 nlln or an asymme tri cal ptosis is noted when the central cornea
upper eyelid measurement is dissimilar. For example, if a patient ha: a
unilatcml ptosis, the fissure height measurement may reOect 5 nun or 6 nun
Oil OIlC side with the contralateral eye normally measuring, say , 8 mm to 9
nun . Thus there is 2 mm or 3 111111 of ptosis. A minor ptosis may not be
noti ced by the patient: however. after the blcpharopigmcntation procedure
w ith enhancement to the eyelids. the patient may complain that this wa '
induced secondary to this injection of anesthetic and/or the pigment
deposition procedure itself. Ptosis or the UpPl.!f eyelid may be primary or
congenital, or an acquin::d defecl. Acqui red ptosis is thought 10 he
secondary to detachment or the levator aponeuro ' is from the tarsal plate
wi th posterior retraction into the orbit. The assessment of ptosis with a
thorough ocu lopl::uic evaluation will delineate which type of ptosis is
pre~enl. Correction of the ptl)sis can be suggested to the patient. The amount
(ll' exce~s !' kin is noted and recorded. Herniation
orbital fal is examined
by gemle palpation of the lid , forcing the fat to herniate forward into the fat
pockets . The upper eyelid has two fat poc ket , one centrally and one
nasally. The temporal prominence sometimes noted may represent a

or

98

C L

N I CAL

EVALUATION

herniation of t.he orbi tal lacrimal gland. If there is a fullness in the temporal
upper eyelid region, the examiner should nol.e the possibility or hemiation
of the lacrimal gland. Fat is not present in the temporal aspect of the lid
and, in severe cases. gentle palpation in thi s area notes a finnnes ' that is
not consis tent with orbital fat. If that e. iSIS, the procedure to correct it i.
re positioning or the lacrimal gland rather than rernoval of the suucture.
A patient desiring blepharopigmentation may be an excellent
candidat.e for an upper eyelid blepharoplasty with a:.sociated excision of
hcmiated orbital fat. In dramatic cases of dermatochalasis, the skin may
actually herniate down to the lashes, causing mechanical inferior
displacement. Blepharopigmentation of the upper lid will not be noticed as
it is covered by the fold of the upper eyelid skin. The amount of upper
eyel id skin may be exacerbated by brow ptosis as Iloted earlier. and a
possible combination of brow elevation with excision of excess skin and
fat may be the procedure of choice prior to the blcpharopigmentatioll
procedure for a qualifil:!d surgeon. The upper eyelid crease is examined by
asking the patient (0 look down. then up, and noting where the upper eyelid
skin folds . The upper eyelid crease is p resent in most patients aild
represents the extension of the levator aponeurosis through orbiculari:. with
attachment to the skin. This formation of the upper eyelid creuse is pre ent
bet ween 7 nun to 1.0 mm in most patients. If the upper eyelid crea e is less,
the patient should be considered for a reconstruction or the LIpper eyelid
crease at the time of blepharoplasty procedure. If the upper eyelid crease is
greater than normal, an examination for a ptosis secondary to levator
di)'in -enion is indicated. The eyelid crease frequently elevates as the
levator recesses posteriorly.

LOWER liD EXAMINATION


The lower lids are examined in a fashion !>imilar to the upper lids, with
specific concem regarding whether the lower eyelid appears ectropic or
cmropic. The lid is examined for eyelash 10 s, sca rs and/or defects. The
eye may appear proptotic or prominent. cith~r in " fami liar fashion or
~l:!condary to orbital pathology, e.g. Graves' disease. In thi~ situation, the
lower eyelid does not bisect the lower limbal area of the cornea. but rather
is placeJ I mill o r more below the limbal area with sclera exposure. In
those patients with sclera showing between the 6 o'clock limbal area and
the eyes is perceived. Examination of the lower
lower lid. a prominence
lids includes a ge ntle pinching of the celllral a~pecl of the lower lid and
pulli ng the lid away from the cornea to note any lid laxity medial/lateral
camhal lendon abnoll11alities. A hrisk snap should be present if the lid is
placed I em from the g lobe. In patients with horizontal lid laxity due to
either of the lid or medial or lateral canthal tendon atten uation . this brisk
snap is nOI noted _ This indicates the pOl('mial for lower lid ectropion or
tearing problem.) due to poor lid-tn- globe appositi,}Il. Surgay 10 correct
horiz.onlal lid laxity is directed at plicating the cant hal tendon or
horizo lltally ~ hortcning the liel by a pentagonal resection and

or

99

C HAP T E R

microanastomotic lit! margin closure. The patienr with prominent fat pads
can be examined by asking the paticnt to direct her gaze superiorly and
gent ly palpating the globe through the upper lid to help herniate the fat
forward. By gen tlc palpation in this manner, the herniated orbital far is
engaged and the fat pockets are noted . Excess lower lid skin is rarely as
prominent as that in the upper eyelid. In considering a lower lid
bJcpharoplasty proccdure. a con 'ervative approach to the eyelid skin should
be considered whether or not fat excision is contemplated. The injection of
the ancsli1elic into the lower lid [or the blepharopigmentatiol1 procedure
and/of postsurgical edema may exacerbate horizontal laxity and induce a
lid malrotation. If the lower eyelid renactor dis inserts from the farsu and
retracts. a condit.ion of entropion i. present. This lower lid retractor (the
capsular palpebral fascia) is incriminated in involutional acquired
entropion. Whether the lid assumes an internal or external rolation depends
on a combination of factors : the capsule palpebral fascia, the laxity of the
lower lid, and the intcglity of the medial and lateral canthal tendon. To test
for attenuation of the lateral or medial canthal tendons, the lid is gently
grasped and displaced in a horizontal direction. If the punctum moves more
than 4 mm to 5 I11Ill then a medial canthal laxity is present. Pulling the
lateral ~:anthlls nasally a few millimeters of movemenL is considered
normal; with greater movement , a lateral camhal tendon attenuation i '
present and a canthal tendon plication procedure should be considered.
While examining thc lower and upper eyelids. the lash and lid area
should be evaluated. Segmental loss of I.ashes may indicate either previous
surgical int.crvention or a possible pathological process. Benign and
malignant lesions should be noted and corrected in an appropriate fashion.
A deficiency of eyelasbes may be present in patients who have undergone
prcviolls oculoplaslic repair for lesions of the lid with secondary repairs.
PeJi'orming the blepharopigmentation procedure while missing an obvious
lid margin lesion is inexcusablc. Assessment at the slit lamp of the lid,
lashes and margins will aven this occlIrrence.

EVALUATION OF TEAR FUNCTION


Patients who have problems w.ilh epiphora or discharge should have a
lacrimal evaluation and tear welling test performed. The Schrimer werling
strip test is simple to perform and provides u~eful information. This is done
by placing the Schrimer strip into the temporal lower lid cui-dc-sac and
measuring the amount of wetting to the paper. After five minutes the strip
is removed and a mcasuremenl made fo rm the notch to the end of the
welting of the paper. This measurement should be between 10 mm and 15
111m of wctting in five minutes and, if it is less, the patient should be
evaluated for hyposecretion or dry eye problems. This test i useful in
consideration not only of the blepharopigmcmation candidate but also if
uther ol:u l(lplaSlic repair or cosmetic blepharoplasty is to be performed.
These patients may have hyposecretion or intermittent dry eye and
symptoms of ocular irritation. These sym ptoms will be exacerbated after a

100

CLINICAL

EVALUATION

blepharoplasty procedure. The patient who tolerates hyposecretion preblepharoplasty may be intolcrant after a surgical intervention. The
blepharopigmentation procedure may calise a temporary exacerbation of
the underlying hyposecretion , and this potcntial should be expJaincd to the
patient. The test of the Schrimer weUing will also help detennine patients
who may benefit from a conservative blcpharopla, ty so as not to
exacerbate their presurgical symptoms. Artificia.1 tear s s hould be
prescribed for those having diminished tear secretion or corneal wetting
problems.

SUT lAMP EXAMINATION


After examination of the ocular adnexa, brow, lids, canthal tendons,
etc., the slit lamp examination records abnom1alities of the punctum, lids,
lashes, ocular areas, foreign bodies, etc. A thorough slit lamp examination
is performed. noting corneal epithelial integrity and previous corneal
trauma. Evaluation of the comea includes corneal sensation with the sue of
a colton-tipped applicator or tissue paper, and the testing for staining of the
cornea by LIse of fluorescein dye placed into the cul-de-sac; in so me
patients, the placement of Rose Bengal dye is helpful in the diagnosis of
devitalized epithelial cells. The dye testing for epithelial keratopathy is
important in preparing the patient fo r any oculoplastic procedure.
A s lit lamp examination of the punctum is reco rded to avoid
discrepancies that may be noted after the blepharopigmemation has been
performed. The blepharopigmentation clamp, if used by the practitioner, is
frequent.ly clamped across the upper and lower canalicular tructures, and
documentatioll of whether these structures are normal and functioning
should be done. Examination of the anterior surface of the globe will also
determine if previous trauma has induced sy mblepharon formation. The
clamp used in blepharopi grnentalion not only clamps the lids in all areas,
but also mechanically contacts the comeal surface and can lead to some
minor corneal abrasive phenomena. After the blepharopigmentation
procedure. a fluorescein stai n test to the cornea should be pel1'ormed,
noting any induced corneal abrasion. For those practitioners that do not use
a clamp. a fluorescein stain test would not be necessary.

VISUAL FIEIDS
Evaluation of visual fields is performed on patients who are
cand idates for other adnexal procedures iluch as brow elevation. ptosis
correction , or excisiun of redundant upper eye lid skin. Evaluation of the
visua l field s will help a su rgeo n aS~cs~ medical and functional
improvement from the patient desiring su rge ry for cosmetic purposes. A
visual field is not needed fo r a routine eyeliner aJld/or eyebrow procedure:
however, a visual field is important for reimbursement if additional

101

C HAP T E R

cosmetic surgeries are performed in conjunction with micropigmcnralion of


the eye. lnsurance companies usually request this information prior to their
compensation for a procedure that may be considered cosmetic. The proof
Ill' thi~ in the form of confrontation fields in addi tion to pre- and
postsurgical photographs and written SlatemeOL~ noting the functional need
for the procedure , wiJJ often benefit the patient by having her insurance
company make compensalion for rhe su rgery. Rather than performing
tangent sc reen or Goldman visual field, a confrontation visual field is
us ually sufficient. This is perfol111ed by having lhe patient cover one eye
wilh a parch or other occludeI' while the examiner closes his contralateral
eye. A finger in moved midway between the examiner and the patient from
the peri pheral arcas of v isuil I gaze - nasal, inferior, temporal, and
s uperior- until the patient first notes the object. The point at which the
examiner sees the finger is compared to the patient respon . e, and any
differences bctween patient and examiner noted. The patient and ex.aminer
should he facing each other without abnolmal head positioning, and the
patient's forehead should be lixed to eliminate excess ive frontalis action.
Following this complete ocu lopl a tic evaluation. the remainder of a
standard eye exarni nati on is performed, noting intraocular pressures and
posterior segmellt SlrllClllres. All abnormalities should be documented on
the paliclll' s chart. For those practitioners 110t trained in ophthalmology,
thi s remainder of the examination is not critical for blepharopigmentalion.
[t is important for nonphysicians to recognize the importance of obtaining
second opinions before proceeding with any micropigmcntation procedure.
if there is a doubt to the health of the patient.

PATIENT ASSESSMENT
The res ults of the external and internal ocular exams are related to the
patient in simple terms. The more informa tion the practitioner can provide
to the patient in simple term~, the smoother the emire procedure will be.
Drawings, photographs, or even the use of a hand mirror to point out
variou: structural asymmetries. abnormalities, and potential problems wi ll
be hdpful in recommending additional surgical com:ctions suc h as brow
devations, blcpharoplasLies. ptosis repairs, etc. Following the ocu lopJ astic
portion of the examination . questions are asked regarding the patient'
imp ression
her ~kill, hair color. use of dyes and facial creams. base
makeup. mascara. lid liner. Clc. The pati.ent is questioned about her natural
hair color and/or if she is anticipating any dramatic Change i n her hair color
in the future . This informatioll is usduJ in planning the blcpharo pigmentation a~ it relates 10 the intensity of the dye pigmentation and
choice of pigment co lor$. A change in hair co lor may bias the amount of
pigmentation . A photographic n.:cord of the patient will be needed with the
patienl wearing and not wearing makeup. This visual record is helpful in all
micropigrncntation procedures 1'01' medical-legal protection anu also serves
as a lIseful reference.
If the patient elects to proce ed with the blepharopigmentation

or

102

C L

EVALUATION

CAL

procedure, a discussion then follows concerning the technique, anesthesia,


prc- and postprocedural consideration . surgical fees , etc . Following this
ui scussion , the patient is given information malerial and a consent form to
,' ign . This i.. un important time for the doctor and the patient to discuss
inrormeu consent concerns: possible eye infections , the potential for lid
10 os, possible lid scarrirJg. lid bruising, hemorrhage, infection, elC . The
more information related to the patient, the smoother the entire process will
be. Any sign ificant change in patient motivation or aspect
the procedure
(for example, a different pigment color choice) OJ1 the day of the procedure
should alert the practit.ioner to postpone unlil the patient is me of her
decision.

or

10J

H A p T E R

Pre-Procedural
Considerations

PREPARING THE PATIENT


The previous chapters have discussed lhe ideal patient for the
procedure and patients with extenuating circumstances or other conditions
that contrai ndicate rnicropignlentation. Til is chapter will consider the
factors involved in preparing the patient [or the procedure.

A LLERGY TEST
In the chapter on patient selection. mention was made of the skin
allergy lest. Skin testing for possible allergies should be performed on
every patient prior to any micropigmcntation procedure. A small amount of
pig.ment is firsl applied to the lip or a LUberculin type needle. The pigment
is placed in a postauricular or other less noticeable area that has been
cleaned with alcohol. The patient remain~ in the office for half an hour
after t.he placemellt of the dye. and then, any reaclion to lhe dye is noted. If
a patient shows no reaction to the dye, we may proceed with scheduling the
procedure. An immediate allergic response would be evidenced by
erythema and/or wheal formation. In the event of an immediate allergic
reaction. the physician should have. on hand the appropriate medication
(i.e. , epinephrine and bcnadr, I) fllr treatment of this complication. We are
not aware of any patient having an immediale aClIte allergiC' reaction to the
~kin lest or a dclayed skin relic lion following micropigmenlalion.
Approximately two weeks hiler. the patient should be checked for any
delayed hypersensitivity reaction. This appointment can be made in
conjunction with the actual procedure. Thus with a negative skin test, the
practitioner can then proceed with micropigmentalion.

105
L--_ __

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_ __

_ __

_ __ __

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CHAPTER

GENERAL CONSIDERATIONS
The patient should be made aware of certain preprocedural
considerations. She should not apply any makeup for 24 hours prior to the
procedure. No facial makeup of' any kind or contact lenses should be worn
the day of the procedure; and, arrangements should be made for a friend to
drive the patient home as there will be some lid swelling and blurred vision
secondary to the usc of eye ointment especiall.y in the case of eyeliner
application. To rdieve anxiety and produce relaxation. the licensed
practitioner may prescribe 5 mg to 10 mg or Valium approximately one
hour before the procedure is scheduled to begin. The patient is instructed
that, in addition to the Valium. a local anc ' thetic may bc used to prevent
pain during the procedure (the procedure for micropigmenwtion can also be
done without injections, as developed by Annette Walker). The injection of
the anesthetic, when used by a properly licensed practitioner, will cause
some mild discomfort and this should be explained to the candidate. The
injection will also caLise some loss of sensation without loss of motor
ability. The patient should be told lhat the procedure will last approximately
30 to 60 minutes. Ocular or topical luhricant will be used during the
procedure. and vision will be temporarily blurred immediately after the
eyeliner procedure (with other type or micropigmeotatioll applications thi.
problem would not exist). The candidate is also inl>tructed that follow up
examinations are necessary. The candidatc is instructed to refrain from
eating for four to six hours prior to the procedure to cmpty 1he stomach. No
alcohol should be consumed for 24 hours prior. Aspirin therapy should be
discontinued for one week prior to any micropigmentatioo procedure to
minimize ecchymosis and potcntial hematoma formarion. Aspirin prevents
platelet aggregation and has potential complication for postprocedural
bemorrhage. Hemorrhage can be avoided jf the patient relate ' any history of
blood dyscrasias. Prothrombin. panial thromboplastin times, and a simple
bleeding time can be ordered to evaluate patient" s clotting history. if there is
any doubt. In patients who have diabetes, kidney transplants. pacemakers.
or other prosthetic devices, prophylactic antibiotics hould be begun prior to
the procedure. We have found that some physicians lise additional
anesthesia for the tense or extremely nervous patient. Nitrous oxide Inay be
delivered by intranasal canula in a ratio of 2: I nitrous oxide to oxygen.
Time spent questioning the patient regarding her ability LO tolerate pajn
procedures will help guide the practitioner as to how much sedation will be
necessary.

PIGMENT COLOR SELECTION


Patients are instructed to corne to thl:!ir first examination fully lIlade up
with their eyeliner. l11a~cara. eye shadow, elc. This affords the practitioner
the opportunity to :-;ee how the patient appears with her usual makeup. As

106

PRE-PROCEDURAL

CONSIDERATIONS

each candidate has a unique oc u.l ar and facial morphology. and,


preferences to her makeup, the procedure needs to be tailored to the
individual. The practitioner should evaluuLe and discuss with lhe patient
her particular preference of makeup usc. A careful eva luati on of the
interaction of eye shadow, mascara. and eyeliner need!. to be understood.
Tn some patients , th e products are applied with the intention of
enhancement. 1n other patients. the usc of the same makeup docs not
achieve Ihe desired enhancing result. The dirference between the desired
and undesired resul! is how the patient uses these various products.
Similarly , the application of the pemJanenl pigmented lines to a paLient can
either enhance or detract frOIll a patient' s appearance. An artistic result .is
achieved through the understanding of the patient's individual mOflJhology
applied to the l11icropigmeo tation procedure.
Most women have an intuitive idea of how they like to wear their
makeup. and have had expclicnce in its application. In most situations, the
practitioner will simpl y try to reproduce the color and placement of
micropigmentation to match the patient's current usc or her standard
makeup (for example eyeliner, eyebrow, and/or lip liner). However. to
help achieve the most attractive appearance possible. the practitioner
should occasionally interject his knowledge and c()nSi.ntctive criticisms to
the patient tn t:reate a better resull.
The selection or t.he pigment color will depend on a number of facial
features as dist'usscd previously in Ihe chapter on Morphology: hair color,
sk.in tone and color, iri .. color, and eyebrow and eye lash color.
A:- a general rule. in about S5% of the cases. a brown-black or dark
brown pigment is used for eyeliner and/or eyebrow procedures . Mo 't
women ' s mascaras and eyeliners are in these colors, and the average
woman patienl will be happy jf we can ~il11ply reproduce this standard
color. The brown-black or dark brown co lors LU-e suited for the brunette,
medium complexion with brown irises. This color will work well with
other iris colors as long as the eyelash and eyebrow colors tend LO be
predominant or dark. In more dark-skin-toned patients such as Hi spanics
and Latins, the LIse of a black -brown or black color is preferable. With the
dark black patient. the use of a true hlack lin er becomes necessary;
however. there exists even with these patients. the potential for a
postprocedural blue liner effect. Therefore, it may be necessary to
neutralize the true black liner with ~omc yellow-brown pigment during a
seco nd application. The:e pati.ents need to be properly counselled for this
po~sibi Iity.
In patiellts with fair complexions. natural redheads. or blondes, a light
or med ium brown shade should be considered, The darker colors \V'ould be
lOO harsh. However. there arc exceptions -"ueh as redheads with brown
eyes and dark eyebrows. Also a charcoal grey can be rather attractive with
the redlleaded patient.
For the eldt:rly patient \vith silver, grey or white hair. a charcoal grey
or a li g htl y applied medium brown pig ment can be very pleasing . The
application of any pigment color in older patients should be less than in
young.er patient.;.
Because hair color can he a highly changeable feature. the practitioner

107

C HAP T E R
must elect pigments that complement Skin tones, eyelash, eyebrow, and iris
colors rather than hair co lor.
Any change in the selection of the pigment color or its placement on the
day of the procedure should aleJ1 the practitioner to defer to a later time.
Micropigl1lent<ltion i" an elective and cosmetic procedure: therefore. there
should be no last minute change in the cosmetic technique or plan.

COSMETIC TECHNIQUE
Each patielll's ocular morphology and facial morphology has individual
and personal characteristics. fn addition to the factors involved in the actual
technique of applying the pigment, there is an equally importanr aspect to
the procedure, which we refer to as cosmetic tec hnique. The cosmetic
technique of the micropigmcntation concerns itself with the understanding
of the ocular and facial morphology, and the ability to plan the appropriate
procedure. A paticnl's panicular facial and ocular conslruction and contour
can be enhanced through the proper application of the cosmetic technique.
Mastering the handling of the machine, the placing of tlle pigmem within
the epidermis, and the various topical and injectable anesthetics are the
mechanical and technical factors involved with the procedure. Allhough
familiarity with the technical aspect can achieve an acceptable result with
most patients, the Olicropigmel1tation should not be performed without an
understanding of its cosmetic nature.
The concept of "cosmetic technique' is well known to thc plastic
surgeon. When the plastic surgeon cvaluate facial anatomy for face lift.
brow lift, rhinoplasty, elC., decisions arc made in the presurgical portion of
the examination with patient input as to how to achieve the bcst de ired
result. The decisions arrived at during this phase are then lIsed at the time of
surgery, dictating where inci. ion lines are placed, how much skin to remove.
ClC. The surgeon generally doe. not vary from hi , prcsurgical decision .
Injections of ancsthetics. edema, etc. , can change the appearance of the
patient on the operating table. If the surgeon changes his mind
intrasurgically, the possibility of undesirable results exists. The concept of
sticking to a game plan or "cosmetic technique" is no different with a
micropigmentauon procedure. Cosmetic tcchnique utilizes these concepts.

INFORMED CONSENT
At the time of the initial cvalualion, an instruction guide is al so given to
the plltienl. explaining the postprocedural care with follow up appointment '
and other pcrtinent information regarding the actual procedure. Questions
regarding the micropigmenration technique are elicited from the patient and
encouraged. with the belief that the better-informed patient will have fewer
problcm~ during and following U1C procedure. One instrument manufacturer,
the Accents devcloped an informed videotape consent. The patit::nt is asked

108

PRE-PROCEDURAL

CONSIDERATIONS

to view this tapc and then take a small quiz documenting that 'he has
understood the nature and purpose of the procedurc, its ramifications,
complications, etc. (Please refer to the appcndix for u sample informed
conscnt form .)

SUMMARY
After the practitioner alld patient have had the oPPol1!lIIity ro discuss
the natllre and purpost' of the procedure. fhe decision is made whetlter 10
havt' th e micropigmemafion. If the paliel1f elects to proceed. a date is
chosen and illformed COl/sent is given. The signing of the informed consent
sheet should be (/ol1e at this time. ratlter thall althe time of the procedure.

109

- - - - - - - - -- - - - -- - - - -- - - -

--

H A p T E R

~i>"~'

;; ( ;
".

Artistic Technique

In the first book on micropigll1entation, we presented a useful


approach to the placement of pigment for the creation of blepharopigmentation or permancnt eyeliner. In the past decade, major new
applications for permanent makeup and rcconstructive surgery have
become a reality, such as treatment s for vitiligo, lip liner, and burn victim
sk.in recolorization. Since colors in a small area are viewed as a whole, the
ability 10 project a sense of unity and harmony i~ an art. It is necessary to
consider color and structure as equally important factors in the scientific
lise of permanent makeup or micropigmentation.
We have coined the word CLIM B to instill the importance of the
various artistic techniques that must be employed for the practitioner to
achieve a sut:cessful resLiIt with the micropigmemution procedure. CLIMB
stands for C-Color. L-Line, J-Insertion , M-Movement. and B-Borders.

COLOR
The crea tion of natural human color from inorganic pigmcnts is (he
ultilnate challenge, The practilioner must develop true artistic techniques in
order to (.;rcalC the illusion of proper color. By following our guidelines,
any practitioncr can develop a disciplined approach to color application and
recreate the proper color of any area on the human body with micropigmentation,
Human skin color is the result of the various combinations of three
pigment colors: brown-black (melanin). ye llow (phaeomelanin, indole,
carotene. xanthophylls) , and red (hemoglobins and dopachrome) . The
pra(.;titioner need~ to eval uat.e thl:: namral skin pigments in each patient
nefore arbitra rily and (.;apriciollsly introducing foreign pigmenl colors. In

III

C HAP T E R

chapter 7. we discussed the melanin


pigmentary system. This system explains
C-Color
that human skin color i the result of the
L-Line
production of melanin and its derivatives.
We now know that the synthesis of
I-Insertion
melanin and its deposition with the
M-Movement
epidennal-dennal layers is more complex
than originally thought.
B-Borders
The universally accepted foundation
for all color theories is the cool/warm
concept. Skin will show either a blue
(blue-pink) undertone or a yellow (golden-beige) undertone. The
practitioner must first determine the :;kin undeI10ne before proceeding with
the integration or additional colors. The advantage of pointillism is its
principle of optical mixture on a rnicrolevel of depositing isolated color
until a natural blend is achieved. The practitioner is not camou n aging the
natural skin undertone. but rather utilizing the skin undertone as a canvas to
integrate complementary hues (colors).
For example, in a patient with vitili go with a blue undertone who
exhibits some pink dominance in the area of pigment loss. the practitioner
would decrease the amount of pink to be added to the color mixture. In a
pat.ient with a strong blue undertone, the use of a black eyeliner might create
a hlue-black cyeline. By neutralizing the underlying blue with a neutral
yellow-brown. this side-effect can be eliminated.
For the purpose of clarity we have defined t.he following terms:
HUE: a color
VALUE: the brightncs~ or lightness of a color
TINT: the li ghtening of a color by adding white
SHADE: the darkening of a color by adding black
TONE: the amount of gray added to any color
UNDElrI'ONE: the cool/wann concept of skin color
SIMULTANEOUS CONTRAST: a color appears darker when the
surrounding colors are lighter and conversely, a color is lighter in
appearance when the sUITounding colors arc darker.
If we accept the coo l/wanll theory of skin color with its blue or yellow
undertone and that this natural skin undertone is the resultant of brown,
ye ll ow, and red pigment mixtures. we can now develop a simple algorithm
for skin color.
The first step is the determination of the individual's undertone color.
Th is dccbion can be Illade by direct observation and experience, or by skin

HUE: a c%r
VALUE: The brightness or LighTness of"a color
TINT: the lightenillg (~f" a color by adding witile
SHADE: the darkening afa color by adding black
TONE: the amoun! qf gra}' added To any culor
UNDERTONE: the cool/warm concept (~fskin color

112

ARTISTIC

T E C H N 1 QUE

color testing. For example. a vitiligo patient can be given a small amount of
eo.lor applied with a Q-tip to the skin area: a mixture of dark brown.
yellow. and white (the color mixture for yellow undertone) and in another
area. a small test area of dark brown. pink. and white (the color mix.ture for
blue undertone). The patient'~ true skin undertone is determined by which
of the two test areas the mixture appears to disappear or blend best with the
sLJlTounding ti ssue color.
After detennining !be undertone color for that patient. the practitioner
can now implant sma ll amounts of the mixture in a dispersed area. The
major advantage of pointillism versus camouflagi ng i: that the color can be
easily modified with the pointillistic approach. The practitioner can
detem1ine if a lighter tint (adding white) or a darker shade (adding dark
brown) is needed for the basic mixture. If there is tonal color variance then
small amounts of yellow or pink can be added.
The next step would be the utilization of simultaneous contrast in
which the lines of demarcation are nullified by either adding more color to
the depigmented areas or lightening the color of the darker surrou nding
ti . sue. With a vitiligo patient. the eyes are drawn to the Jines of
demarcation between the pigmented and dep igmented ski n coloI'. By
altering: one or both we can nullify this line of demarcation and diminish
the flaw. The use of tinting (pink-whi te or yellow-white) and shading (dark
hrown) allows the practitioner this option. Generally. tinting produces
luminosity and creates a sense of movement, whereas shading prove more
valuable in contouring and creating the illusion of altered shapes.

U NE
The term line refers to the various lines. dots. aneVoJ' combinations of
implanted pigment that is used in the micropigmentation procedure. The
practitioner has a wide resource of various sizes and shapes of pigment
deposits to utilize in this procedure: however. in order to avoid confusion,
we can simplify certain aspects of the procedure. We fee l lhat the 5-5

HUMAN SKIN
~ UNDERTONES~

WARM .......I - - - - - - - - - - - - l...~ COOL

YELLOW (Golden Brown)

BROWN
(Shading)

YELLOW
(Tonality)

WHITE
(Tint)

BLUE (Blue-Pink)

BROWN
(Shading)

PINK

(Tonality)

WHITE
(Tint)

1/3

------------------------------------------------------

C HAP T E R

classification as discussed in chapter seven


represents an analytical approach to the use of lines
anywhere on the human I ody. Whether the
practitioner is perrorming areolar reconstruction,
eyeliner, lip pigmentation e tc ., the use of a 5-S
classification affords the practitioner the means to
plan a . ucees . ful procedure. In the b.l epharopigmentation procedure. we feci mat the two most
imporlant areas to consider are the separation and
the size of the patient'S eyes. The other three factors
- shape , set and symmetry - have an important
function and need to be considered prior to the
procedure. yet arc not as dramatically important in
the procedure itself. To elaborate an understanding of symmetry of the
ocular area is importan t. and minor variat ions shou l.d be kept in mind.
Symmetry in and of it.-elf, however, docs not define how much and where
the pigment is placed or the choice of color. The set of the eye. prominent
or recessed . and the sha pe of the eye are closely related to the overall
impression of the patient's eye size. Instinctive feeling will be gained by the
praclitioner after examining many patients. 'The cOlllbinatil.l!l of . ize and
separation or the eyes determines how the blepharopigmentation procedure
should be performed to accommodate and enhance lhe patient's ocular
morphology .
The pnx:ess of placing the pigment on the
eyelid is done in segments with interrupting
of Pigmcnt Placemcnt
dot matrice s. The end effect i ' Ihal uf an
eyeliner andlor eyela h enhancement. For the
sake of discussion and practical appl icalion.
we have divided the eyelid into three zones:
nasal, central and temporal. The nasal zone i.
that area extending from th e caruncle and
punctal area to th e inner iris border. The
central zone is that area between the medial
iris border and the temporal iris border:
finally. the temporal zone is thar area
extending from the temporal iris border to the
lateral canthal area. In the majority of
situations, the practitioner will place the
pigment along the lower lid lashes at their
bases eXlending from an arca of I mm to 2
nun temporal to the punctum all the way to
the mU Sl temporal lash near the lateral
canthus. A snwll area or lateral canthal lid i)'
left unpigmented so a~ to nOl gain the
impression of closi ng the lids by having the
upper amI the lower pigment lines meet. The
ani~lic flav(Jr or (h e procedure i~ gained by
placing more or less pigment in these rhree

Tn the
procedure . ..
the two most
important areas
to consider are
the separation
alld the size of the
patient's eyes.

Variations

JI..J

ART

S T

TEe H N

QUE

regional zones. The pigment should never be placed nasaJ to the punctum
or temporal to the lateral canthal area. The pigment is placed at the base of
the lashes. If the eyeliner is placed too inferior. a pscudoectropion effect is
created: aVllidance of the lid margin is important so as not to damage the
glandular open in gs of the meibomian glands. II should be noted that some
patients actually usc eyeliner on their lid margins and these palicms shou ld
be instructed that their permanent eyeline r wi ll not resemb le their
tcchniquc of placement of eyeliner. It is critical to avoid the nat portion of
the lid margin a nd thereby preve nt pigment dispersion at th e
mucocutaneous juncti on. By following the lid contour of the lower lid near
the puncta. a nasal roll can be created so that the line is not ended abruptly,
but rather thai the l inc has started as a natural con. equence of the lid
anatomy from the nasal puncta.
In general, the upper eyelid pigment line is thicker and longer than the
lower lid line due to the greater amou nt of lashes and the larger size of the
upper eyelid. By l eaving the mo st inferior row of (he upper eyelid
eyelashes unpigmented. the practitioner wil l ncate a l1lore open appearance
to the eye and will be less likely to invade the li d margin. In most palients,
the nasal third of the upper and lower lid should have thin lines placed with
little variation in the thickness of the li ne. The onl y variation in the nasal
third is the location or initiation of the line.

~-~

~~
DeepscllAl1gular l:.~yes

ROlllldlPmminefll Eyes

,~

~\ ~

Orifntllf Eyes

;I/mont! Ere.1

11 5

C HAP T E R

In the temporal zone a great deal of variation with the amount and
placement of the pigment is possible. fn this area, a tlaring and lift can be
accomplished by placing more pigment. The increase in the pigment in the
temporal zone tends to enlarge eyes and to bring the eyes forward. The
variabi l ity of the tempo ral zone allows the practitioner to modify the
thickness of the line as well as the line ' s endpoint. The more flaring
created by the disposition of pigment, the wider and more prominent the
eye will appear. The endpoint of the line can affect the optical illusion of
separal.i<m within a certain zone. This temporal 3 mrn to 4 mm zone nex t to
the lateral canthus and a corresponding upper and lower lid zone of 3 mm
to 4 mm in the nasal upper and lower eyelid are considered the shift zone
areas. The perceived appearance of wide or close separatjon of the eyes is
affected by pigmentation in this area. The middle or central zone functions
as a blending zone between the nasal and temporal are1.l. fn this zone, many
subt le aspect. of artistic optical illusions can be performed by altering the
shape, affecting size, and enhancing set by the placement of the pigment.
With this concep t of the three zones, we can now integrate the 5-$
C lassific,uion into practica l applications for the blepharopigmentation
procedure. The 5-S classification can also be use in the similar analytical
approach for other procedures such a. lip liner and areolar reconstruction.

SIZE
The impression of whether a palient's eye is :mall or large depends
primarily on lhe opening of the palpebral fissure and. LO a le:ser extent, on
the shape and set. By adding more pigment in the temporal zones of (he
upper and lower lids. an impression of widening the palpebral fissure and
bringing forward the globe is created; the upper and lower lines should not
meet in the temporal zone or latera l canthal angle , because thi "
convergence will make the eye appear smaller. By placing the pigment at
the inferior portion of the lower lid eyelashes and at the uperior aspect of
the upper lid eye las he, . we can also give the impression of a larger eye.

SHAPE
The :-.hape or an eye i determined by the (U'ch of the upper and lower
lid contours. the palpebral fissure. anu the relationship of the medial and
lateral canthal attachments. The basic eye shapes are angUlar, round.
almond. and oriental. By comparing the horizontal fissure distance lO lhe
vl.'.rLical palpebral fissure in a ratio form, we can mathematically describe
these basic eye shapes. For example. the round eye wi II have a ratio of 2: I,
whereas the angular eye is lIsually 4 : I horizontal to vertical dimension.
The standard almond-shaped eye is approximately 3: I. The oriental eye i '
the result 1)1' the cpicamha l fold medially combined with the absence of a
lid crease or the presence of a lid crease near the lid margin: however. even

/16

ARTISTIC

TECHNIQUE

the orienlal eye can display a more round quality based on this ratio
concept.

Angular Eyes
In eyes that have an angular appearance, the lid contour can be
softened by adding additional pigment in the superior temporal zone of the
upper eyelid with an extra row of dots. This extra row wil l give a more
rounded appearance to the eyes.

Round Eyes
By adding extra pigment in the temporal zone of the upper and lower
lid, the round eyes are made more prominent and accentuated. By using
thinner l.ines a round eye is attenuated and given more of an almond shape
when the pigment line is extended nasally using the roll technique.

Almond Eyes
In eyes chat have the ideal almond appearance, it is best to just follow
the actual lid contour ' and avoid excessive pigmentation. A small amount
extra pigment temporally can give more prominence to the eye.

Oriental Eyes
1t is important that the practitioner ask the patient witll oriental eye
whether or not additional cosmetic surgery of the epicanthul fold or lid
crease i~ contemplated in the future. If this type of cosmetic surgery i
planned, we wou ld recommeod deferring the blepharopigmentation until

..

Width One Eye

('1'(1

Classic Proportioned Eye Placement

11 7

C HAP T E R

further surgcry has been comp leted. If this surgery is not anticipated. then
a lifting effect can be achieved by adtting more pigment to the temporal
zone of the upper lid. The epicanthaJ fold can be decmphasiz.ed with the
placement of a thi n deli cate Iinc in the nasal z.onc of the upper lid.

SET
The set of the eye gives the impression of the eyes as deep o r
prominent. The overall appearance is related 10 the actual ize of the
eyeball. prominence of the nose alld brow, and volume of the orbit. The
deepsct eye should have a liglll application of pigmen t along the upper
nasal and medial zones in order to minimize the deep set of the eye 111 this
area where the supratarsnl sulcus is more pronounced. Adtlitional lift or
narc can be applied in thc temporal zone to bring the eyes forward. With
the prominent eye, the appli cat ion of the pigment should be light across
the entire upper and lower lid with the avoidance or flaring in the temporal
zone in order not to furtllcr accent uate the eye'~ prominence. With marked
prominence one can consider virtually joining the upper and lower
temporal wnes at the lateral cantha l area. With u!>e of lighter pigments.
less attention i:. drawn to lhe eye.

SEPARATION
The separation of the eyes is related to the intcreanthal distances. In
the most nasal and tempora l mnes an area of 2 mm to 3 mm is defined as a
shin 7.onc. To make closely separated eyes appear wider apart, the pigment
should be placed temporally in the nasal and temporal shift wne. To make
widely separated eyes appear closer together. a !lhift nasally is performed
by starting the line doser to the puncta in the nasal zone and ending. the
line sooner or more medial in the temporal zone. Thus by using a nasal or
temporal shift. eyes can be made to look closer or farther apart.

SYMMETRY
A~ mo:,t patients' ocular morphology is symmetrical , it is useful to
apply the pigment in un equal fashion to hoth upper lid:- and likewise 10
both !twvcr lid~. If one Inwcr lid line i:" thicker. then the practitioner needs
to balance the other eye's lower lid with the same amount of pigment.
Starting and ending points of nasal O[ temporal ilhifts and flaring in the
tcmpo[al zonCi- must be equal anti symmetrical. Asymmetrical application
will detract fmm the patient ' ~ appearance and draw attention to an
"ahnonnality" when none existed prcprocedurally.
There have been numerous concepts as to the best method to implant

11 8

ART

S TIC

TEe H N

QUE

pigment below the skin. A number of practitioners have recolllmended the


u~e of a single needle whereas others feci that a multi-needle is the best
approach. Furthermore there exists debates as to the techniques of
inseJ1ion of the pigment- poillliliisllI versus airbrushing. We will pre em
the various techniquc~ in this section. Re~'()gnize that the method of
insertion is an important COIH;cpt in ollr discussion of CLIMB for
achieving artis ti c technique.
Pointillism is an artistic term that was coined to describe the artisti<:
technique of some famous impressionism arti);IS of the latc 19th century.
These artists would place small points of co lor that would create the
images of objccts when viewed at a distance from the painting. Up dose
the viewer would only appreciate dot matrixes without the sense of any
pal1icular form . Thus with the usc of a dot matrix. the practitioner can
create the texture and grain of three dimcnsional depth and ~ubstance from
a flat sUliacc.
Airbrush method is a term that has been lIsed to describe the
placemcnt of pigment by tattooists in which the pigment is placed in
homogenous layers like spray paint to create areas of shading and col.or.
Despite claims of new implantation techniques. all micropigmentation
pig.ment insertions can be described with either of the above basic
tcchniques. We have found that in certain treatments. various needlc
configurations can a~sist the practitioner in completing the case in a more
timely manner. For example. a three and/or {'ive l1l:-edle complex is an
advantage in performing brow pigmentation veL us the single ncedle.

MOVEMENT
This lerm in thc CLIMB acronym i:-. difficult to explain. We are
the :-ense of a kinetic appearance to a patient's skin after
successful micropigmentation. For example, a patient would not want a
fixed smile after lip !>urgery. hut '.llher a mobi le appearance to lbe moulh
and lip area that reflects various moods and emotions , With
micropigmentulion we do not want to simply paint lines and/of color in
dcfe ...'ts. We attcmp t 10 creatc depth. shading. and movement or living
color to the areas of treatment.. If an observer senses a spray paillled look
then the term of covertlp permanent makeup would be appropriate. With
micropigrnentation we are integrating additional (;olors 10 the desired
areas by utilizing the patient' s own natural color <1:; part or the palette
process.

de~cribing

BORDERS
As with any procedure. lh.erc arc important guideline:- and cardinal
rules. The human body has natural borders and boundaries for its vW'iolls
strllclUre~ and appendages. In any reconstructive procedure our goal

J/9

CHAPTER

12

should always be to recreate the natural appearance of the human fonn and
color. We should not be swayed by various marketing and cosmetic
fashions of the day. For exampJe, eyeliner should not be permanently
applied past the pul1t:llIm or used to connect the upper and lower lids.
Conversely, in patients with vitiligo, try to eliminate lines of demarcation
by either adding color to the depigmented skin undertone area or by
lightening the darker sun"ounding tissue color-{he ruk of simulanteneous
contra~t. Furthermore, practitioners should not u. e colored eyeliners such
as "fashionable blues and greens" for the procedure but rather slay with the
more acceptable and natural-appearing earth tone. " Do not try to change the
human form but rather enhance it.

flO

Section Three
Methodology

.",,,,

~~"i1S;'LiC

r
;

J
,

,,
t

,/

.'

H A p T E R

13

Anesthesia

Effective anesthesia is critical in any procedure and especially


micropigmcntation. The well-anesthetized palient is more comfortable,
less apprehensive. and more cooperative wilh a surgeon Of practitioner.
Any patient movement during the micropigmenlution process could
cause significant complications: possible malposilioning of the pigment
or injury to the treated tissue. Tn this chapter. the different types of
aneMhetic agents are discussed. There are four genera.l categories or
anesthesia: topical applicat ion, local infiltration, regional blocks,
and general anesthesia.

TOPICALAPPUCATION
ANESTHESIA
For those pract it ioners who aft:: not licensed for IOl:al or regional
b locks and general anesthesia, Illicropigmcntation can qill he
performed with a cooperative patient by using topical anesthesia. For
the nurse rractitioner in most states, the practitioner can use topical
anestheslics with physician "pproval and achieve adequate comfort.. The
lI~e of ice prcproccduraUy will also assist in the comfort. or the patient.
With a physician's approval, preproccdurall:H.Jminislration or Valium or

its equivalent will also help. Annelle Walker has noted Lhat Hcnadryl is
an excellent rre-operative medicine because of il!', mild anesthetic and

123

C HAP T E R

sedative qualities. The practitioner will not be able to u e a lid clamp for
micropigmentation of the eyelids with the topical anesthesia approach.

LOCAL INFILTRATION
ANESTHESIA
A local infiltrative anesthesia in combination with an oral tranquilizer
is used for most micropigrnentation procedures by properly licensed
practitioners. We have found this approach to be a simple, safe, and most
effective method of anesthesia. On occasion. a surgeon may plan to perform
cel1ain oculoplastic or facial procedures with regional or general anesthesia.
and at that time cou ld schedule micropigmentation as an as ociated
procedure. Infi ltrative anesthesia causes ballooning of the ti ue and
widening of the distance between the external skin and the deeper lid
structures. Because of lh is ballooning effect, pOlenlial damage to deeper
structures by needle penetration is avoided, and the surgeon i given an
increased margin of safety.

LOCALINFILTRATNE
TECHNIQUES
For blepharopigmen lation, the modified Van Lint block delivers the
ane thetic in the lateral canthal area and is continued super.iorly and
inferiorly along the lid contours, blocking the facial nerve for motor and the
trigeminal nerve for sensory functions. In the traditional delivery of this
anesthetic. the needle is advanced across the lid substance. cau ing
orbicularis muscle trauma and secondary bruising with pos:ible hematoma
formation. Usually only I cc to 2 cc of anesthetic per eyelid is necessary to
achieve adequate eyelid anesthesia. A modificalion of this would be 10 place
the needle in an area approximately 2 mm to 3 mm from the lid margin
acro-;$ the upper and lower lids. delivering less anesthetic mixture; however.
the potential for lid hemorrhaging and bruising is still present.
Another recommended method is (0 use a mall gauge 27 or 30 needle
with the placement of the needle tip below the kin, in the midportion of
each lid injecting approximately 0.5 cc of the anesthetic 2 mm to 3 mm
from the lash line. After allowing the anesthetic to "settle in' for five to ten
minutes with some spreading action. further reinjection can take place into
the nasal and temporal q uadrants of the eyelid. This reinjection both
laterally and medially completes the injection process. After the anesthetic
has been fully injected, we recommend waiting approximately 10 to 15
minutes for the hemostatic action of the epinephrine and reduction of the
tissue swelling. A small bruising or slight hematoma should not interfere

124

ANESTHESl A

with the blepharopigrnentation procedure. The discomfort felt by the


patient from the anesthetic comes from the stretching of the lid tissues and
the acidic nature of rhe combination of lidocai.ne with epinephrine.
A third method has been developed by Dr. Richard Tenzel with
modification for eyeliner procedures by Dr. Michael Patipa. This met.hod
of subconjunctival injection has proven very effective for other types of
eyelid surgery.
A drop of topical ancsthetil: is applied to both eyes. The lower eyelid
is pulled slightly away from the globe. A colton-tipped applicator soaked
in 4% Xylocaine (for topical use) or 5% cocaine is placed in the central
one-third of the fornix against the underlying infraorbital rim. This is
allowed 10 remain in the same position for several second ' , thereby
anesthetizing the adjacent conjunctiva. A 1-5/8 inch 27 gauge needle is
bent to 30 degrees at its hub with the bevel up. A .10 cc syringe is filled
with xylocaine with I: IOO.DOO epinephrine. The . urgeon. positioned at the
patient's head. pulls the lower eyelid away from the globe as the patient is
requested to look up. The needle enters the .infranasal conjunctiva in the
topicaJJy anesthetized region of the cui-dc-sac. The needle is advanced
: ubculaneously in a downward direction. Occasionally. the needle tip hits
the periosteum and should then be angled anteriorly toward the anterior
maxillary wall. Advance the needle about J-l/2 inches and aspirate to be
sure the needle has not pierced the infraorbital vessels. Now slowly inject
as the needle is withdrawn. Approximately 0.5 cc of ane ' thesia is injected
and a wheal of tissue is e.levated. When the needle is removed from the
conjunctiva. reinsert it through the same spot, now directing the needle
infralaterally. Advance the needle and again inject 0.5 cc as the needle is
slowly withdrawn. Next, reinsert the need.le directed toward the nasolabial
fold and repeat the injection. Approximately I IS cc is injected into each
lower eyelid in three aliquots. Massage the lower eyelid to promote

Summary ofthe Zwerling-Christensen


Infiltration Metlwd No-Bruise Technique
I) Cool the eyelids and anesthetic prior to the injection (augmenting vasoconstriction effect).

2) Stretch the ski!l prior to insertion of the needle lip to avoid superficial blood vessel. .
3) Avoid injecting into the orbicularis muscle, as this will cause bruising and hematomas.
4) Never advance the needle; only insert the rip of the neeule just below the epidemlis.
5) fnjec( sl )wly. LeI the anesthetic fluid separate the tissue plane. and alJow
approximately 30 seconds per I cc or injection.
6) Avoid needle movement.
7) Apply gentle digital pressure to tbe lid during the injection to facilitate spreading
of the solution temporally and nasally.

125

C HAP T E R

difrusion of the aesthetic and repeal on the left lower eyelid. The right upper
eyelid is now inverted on a Desmarres retraclor. A 5% cocaine or 4 % topical
xylocaine soaked cotton-tipped applicator is applied to lhe conjunctiva jusr
above the central superior tarsal margin. The same needle is inserted jusl
beneath the conjunctiva, and the conjunctiva is ballooned up. The
supratarsal conjullctiva should be ballooned up by the injected anesthetic.
Inject in the sallle manner in the lateral and Illcditll upper eyelid. Repeat lhe
proces: on the left eyelid.
A fOll!1h method bas been developed by Dr. . Zwcrling and Christensen
for maximum patient comf0l1 with it minimal amount of postoperative
bruising. Firsl, the pa li.ent's eyelids are numbed wilh ice packs live to ten
minutel> before the injection. The anesthetic is usually 2% xylocaine with
I: 100.000 epinephrine cooled in the refrigerator just prior to injection. Then
a 5 cc syringe is filled wi th the cold anesthetic fluid with a large bore needle
to facilitate drawing the aneslhetic into the syringe, and attached to a 30
gauge one- half ineh needle. The needle is inscl1cd just slightly lateml to lhe
midline point of the upper lid and lower lids 4 mm from the eyelash line in
order to avoid the marginal artery which is 2 mm from the lid margin . Only
the bevelled portion or the needle is actually inserted jusl below the
epidermis. The anesthelic tluid is then injectc:'d very slowly into each lid .
One cc of ane 't.hetic tluid is injected ovcr a :lOsecond time frame, causing
the tissue to swell and separate inlo "tissue planes." In order to avoid hitting
even a superficial blood vessel , the skin should be stretched to expo,'c any
larger sliperiicial blood vessels just prior to injection of the needle tip; thus,
by slow injectioll \vithollt needle advancement. tissue , [retching and
separation with patient discomfort are Ie ' sened and bleeding with
pO~lsurgical hruising is virtually el .i minated.
After the anesthetic has been injected. it is wise to wait approximately
10 minutes with any of the above methods to allow for the hemostatic effect
01" the epinephrine and for reduction in swelling and re-establishmel1l of
reactively normal anillOmy. Testing of the skin prior to beginning the
surgery ~hould be done with a needle tip or tooth forcep and reinjection of
unanesthetized areas can be performed as needed.

KEGIONALBLOCKS
Regional block anesthesia may be useful in certain circulTlslances.
Nerve block anesthe~ia creates minimal local tissue distortion frolTl the
inliltral.ion and enables less of the ane~thetic agent to achieve the same level
of ane~lhesia in extensive lid procedures in poor lisk patients. In dealing
with inl1amed tissues. regional aneSLhesia can be used when local infiltration
is contraindicated, .R egional blocks may be used when other ancillary
procedures are contemplated: for example, supraorbital nerve block for
brmv elevation. The trigeminal nerve supplies the sensory innervation of the
perioc ular area. The trigeminal nerve undergoes separation into its lhree
components as it leaves the skull: a) lhe superior orbital lissurc division. b)
the maxillary division through the foramen rOlundum. and c) the mandibular

!Hi

ANESTHESIA

hranch throu gh the foramen ovale. The tri geminal nerve branches that
innervate the orbit.al area and arc involved in regional block ancsthesia of
the ~yelid area are locateu in six areas around the orbital rim. In the
superior medial area. the supratrochlea r and infratrochlear nerves are
prese nt; in the infraorhita l medial area the large infraorbital nerve is
present. Temporally in the lateral cantha l area, the lacrimal bmllch and
inferiorly the zygomatic facial branch are present. Superiorly, the large
' upraorb ita l nerve brnnch is noted. Blocking of the six branche~ requires a
good working knowledge of the anatomy of [hi, area and is usually not
needed in most I id procedures; however, the nerve block or the I wo inferior
branches of the trigemenial nerve can achieve cxcellent anesthesia of the
oral area for lip pigmentation. This type of regional block impres iV1!ly
reou 'cs the amount or distortion und discomfort postoperatively 10 this
area. for further information, the reader should co nsult the st~lI1dard
textbooks on thi s subject.

GENERAL ANESTHESIA
The potcnljal for cardiovascular und respiratory embarrassment make
general anesthesia an unnecessary and inappropriate risk [or micropigmentation ai> the sole procedure. Ir multiple and complex oculoplaslic
procedures are to be perrormed with micropigll1cntation, then general
anesthesia would be reasonable,

SUMMARY
/.IIC(I/

(l11I!srhe.sia It'orb by preventing tiepolari:.orilJn (~r Ihe cell

II1ltll1hrane. 11 SlupS rhe pmpa!?ario/l I~r [he .\'el/~()I~\' stimulus wulthe motor

impulse by impairillf.! conducrion. " is useful to reacquaillf yoursc({ l1'irh


proper cOI/Nmlrations, dosages, contraindicarions. and complications of

Ihe various locol alld topicul anesthetics !/YflU are not familiar with them
1Ilreadr. The methods (!f adlllinistration of af/esrhetics are regional nerve
h/ock. lo ca l illfillrlllioll. Of topical adminisrrrlliol/. The chemical
COli/positions o{these (lflesthelics are wllines or esters.
,'.10.11 medical t/oC(ors and lIurses lire familiar Ifitlt the w/Jical and
IO{lI.! ane.\theric.\ Itsed ill slIr!{cry. For rhe CO.lrllcto[ogisf.l. [allolJists, lind
orl/{' r floll-medica! peoplt I'I'ho h1ve not received training ill tllis area,
familiorin' Ivirh IOpiml IlI1('slltelics is IIseful. TIre 1105(' (~f Illesc ageilis is ro
anesrhcri:.e the corneo prior to rltc p/(IceJllelll IIf Ih e lid elamp and/or soft
COlllllC! /ens, The' agentJ comlllon/\' tlSt~d are propII/'{/cailll' and terrw:aille.
PWfJo/'IJClline is ((I'tlilabl(' os 1I solll1iOIl
O.5(k anc/Tetracaine ill solutions
(!( O,jCi( /() 29;'.
ane,lrhelic e./leet (~r both drul'S IlCCurS ilt le,ls Ihan 30
seconds lind fasts J() to 30 l1IiI/Ule:>. Both dntg~ hlll'e additil'e,I' /or slerility.
ch lorhllrill(l[ (lnd bcn~al/.:onil//Il chloride. Pro{Jucaine prodLices less
discomfort and /.:~/,{lIlIl)alh\ tlrun lt~ frllC{/if/e ( 11/ initial instillarion.

n,c

or

127

- - - - -- - - - - - -- - - -- - - - - - - - - -

-- - -

C HAP T E R

Occasional allergies to henzalkonium chloride preservative have been


doel/menled, \1:ith the allergic manifestations ranging frnm injecred
conjunctiva to ilching. burning and mild edema. Of the infiltrative
anesthetics. lidocaine is probably most commonly used and has an
excellent track record. Other drugs with a longer duration of anesthesia
inc /rllie mepiv(lcaine and bl/pivicai/le. Since most micropigmentatioll
procedures take less than 0111' hour. we recommend the lise of lidocaine.
Lidocaine is available in sl)/utions of 0.5% to 2'70. We recommend the use
{~l the 2% with the addition of epinephrine for added hemostatic lind
pmlonged anesthetic effect. With the use of rhe epinephrine combination, a
maximum dose of 500 I11g call he sqfely injected
For patients undergOing other {)culoplastic procedures. a prolo/lged
duratio/l qf anesthetic effect is obtained \1:illl the use of hupivacaine, which
is available in 0.25%, 0.5% and 0.75 % solutions. In those oeu/aplastic
procedllres where prolonged duration eJfeu is indicated.. one can use a
mixture (~r 2% Xyiocaine with /:.100,000 units of epinephrine mixed as a
50150 soLution with 0.5% hupil'l1caine (Marcaine) and .I:200,OOa IInits (~f
epinephrine. The /mpil'{Icaille 110. a prolonged Ollset (~r aClion, alld by
combining this witl! xylocaine, a rapid anesthetic effect with prolonged
duration is obtained.
Knowledge of the complicatiolls and toxic reactions is important.
Toxic reactions iI/elude convulsions, cardiovascular compromise. and
respirmory arrest. Because of these complications, rhe surgeon or lIurse
should ht/l'e available epinephrine, bellodr.vl. kllowledge of cardiopulmo/lary resuscitation (lnd oxygen. A/though these mea.wres may never
be necessary, the surgeon or nurse should stay conversant with their lise.
~ff()r allY reOSOH halo/hane anesthesia is used for all ancillary
oeuloplastic procedure. the surgeon should remember that epinepiIrine
hydrochloride sllollld be withheld because of the potential danger for
I'entriclliar arrhythmias (hat hal'l? heen associated with halotliane.
Norma"y. this oneslhelic quantity (~f lidocaine with epinephrine is not
needed. wilh only I cc {(I 2 cc per eyelid heing adequate for the total
anesthesia tffect. Tlte maximum recommended interval betweell injections
\Vould be 90 minutes. Any secondary injection of the aI/esthetic Lidocaille
sO/lllion should not exceed 7 IIlm per kilogram or 3.2 mm per pound of
body weigiIt.
Any w/'Verse reaction to rhe il~il!ctiol1 {~l an anesthetic should be
/tan dIed hy cOl1l'emiUlw/ methods. COllvlIlsiollS ean be treated by the use of
judicious a/l101llifs Of(fllticonl'ulsoflt medica/ions such as henzodiazlpille or
(/ sllOrt-actill8 harbituote, s/lch as thiopenthol or pentobarhital. Re.\piratory
emharrassment call Ix handled bv venti/aliun eqllipment with establishment
(II WI ainvay alld sllpplemelltal oxygen. Cartiiol ,(tsclilar depression alld
col/apse (frc treated with I'(/sopressors such as ephedrine. The know/edge
('{ these drugs is extremely importallt. and we refer the s urg eon 10
texthoo/.:..\' fhot deal with litis slIhject speCifically. Nurses who perform this
procedure in u physicia/l's {~ffice lInder medical supervision with the use of
illjectable anesthelics m/lsl he equal/y edu cated ill (I(h'anced cardiac
sUf'IJOn.

11H

ANESTHESIA

With careful pJanning and good surgical techniques (~t administration.


lhe use of topical Gild/or local infiltration anesthesia lffers the
micropigmentarion candidate the convenience alld safety of a com/ortable
experience.

129

- - - - - - - - - - - - - - - - - - -- - - - - -- -- - - - - - -

CHAPTER 2

HISTORY OF TA1TOOING
Figure 2A:
Ancient Chinese
bamboo tattoo
instrument.

Figure 2B:
Polynesian thorny
bush configured
for use in
tat/ooing.
Figure 2e:
Modern day tattoo
machine modified from
the original patented
S.F. O'Reillv machine
of 1891. .

Figure 2D:
Early 20th century
3 pound tattoo
machine. Cords were
used 10 suspend the
unit from the ceiling.

Figure 2E:
Homemade
Japan ese tattoo
machine.

Figure 2F:
Early adjustable
tattoo machine.

131

CHAPTER 15
Figure 1Se-J:
An example of
Zwerling-Christensen
no-bruise injection technique
in blepharopigmentation
patient. Note the lack of
advancernent of the needle
with lhe baLLooning effect of
the subepidermal tissue.

Figure 15c-2:
A lid clamp secures the lid
from any movement and
allows the practitioner a
safer allgle of approach to
the Lid margin.

Figure 15c-3:
Th e use of calipers to
demarcate the nasal extreme
of the eyeliner ensures
bilateral symmetry. Note the
temporaL markfrom the use
of the lid clamp; however,
there is 110 evidence of lid
bleeding.

/32

BLEPHAROPIGMENTATION TECHNIQUES
Figure lSc-4:
The machine should be held
ill a pencil-like fashion. Th e
probe is sterilized by a
fingerfrom contraLateral
hand.

Figure lSc-S:
With the use of an assistant
to help maintain lid clamp

and patient stability, the


practitioner can concelltrate
01/ the procedure. Note the
use oj cotton tip applicator
TO mOl'e The LIpper lid
eyelashes away from the
field.

Figure lSc-6:
AT The conclusion of the
case, the protective contact
lens can be removed. Note
the upper and lower eyelid
pigmentaTion wiTh The lack
of all) bleeding. Today with
The increase of AIDS we
recommend The use of gloves
for the procedure.
Photo sequences courTesy of

C. Zwerling, M.D. and F


ChriSTensen, M.D.

133

CHAPTER 16

BROW PIGMENTATION
Figure 16a-l:
Before photo of
patient with alopecia
of eyelashes and
brows.

Figure 16a-2:
After photo
demonstrating
eyeliner and brow
enhancemen (s.
Photos courtesy of
Cathy Bukaty.

Figure 16-B:
Annette Walker
performing brow
pigmentation with
the Dermouflage
handpiece.

134

CHAPTER 17

Figure 17b-l:
Before photo of white femaLe lip liner
patient.

LIP PIGMENTATION

Figure 17b-2:
After photo of lip liner patient with full
coLor.
Photos courtesy of Annette WaLker, R.N.

Figure 17c-l:
Before photo of femaLe patient with
disfigured Lip resuLting from a childhood
fall.

Figure 17c-2:
After photo of patient with scar correction
and full Lip enhancement.
Photos courtesy of Annette WaLker, R.N.
and Christy Van Wagenen.

135

CHAPTER 18

BREAST AREOLAR PIGMENTATION


Figure 18-1:

Pre-operative view of
mastectomy patient
demonstratin.g scarring.

Figure 18-2:
Same patient status post
mound reconstruction with
silicone breast implant.

Figure 18-3:
One week status post
mastopexy of right breast and
trap door flap with
micropigmentatiol1 for nipple
recollstruction of left breast.
Photos courtesy of W Luria,
M.D.

1J6

CHAPTER 19

ADVANCED DERMALPIGMENTATION

Figure 19c-l :
Before photo offemale patient injured by a
naTural gas explosio1l.
PhOTOS courtesy of S. Guzick. B.S.N.

Figure 19c-4:
White male burn viCTim. Pre-procedure.

Figure 19c-2:
Mid-treatment photo of patient after initial
scar relaxation and lip contouring.
Treatment pla1l to include additio1lal scar
relaxation and skin color balance. and
pigmentation of damaged brows and
blepharopigmeluation.

Figure 19c-4:
Post-procedure. Additional treatmel1l ill
process. Generally acknowleged that the
relaxarion of scar phenomenoll was first
noted a1ld taught by Annette Walker.
Photos courtesy of Annette Walke,; R.N.

137

CHAPT~
E~
R ~1~
9 ~__~========__~~~________
Figure 19a-l:
Irregular left brow with
transl'erse, depressed scar
in female patiellf.

Figure 19a-2:
Photo taken olle hour after
procedure. Single needLe
was used to correct the
depressed scar as well as
apply brow pigmentation.
Note the irregularity of the
left brow is virtually
eliminated.

Photos courtesy of
C. Zwerling, M.D.

Figure 19a-3:
Evebrow loss due to
t(aumafrom
11l0torc)lcle accident.
Note skin grafi in area
of brow loss.

Figure 19a-4:
8rol11 pigmentation
completed.
Photos courtesy of
Annette Walkel; R.N.

/38

ADVANCED DERMALPIGMENTATION
Figure 19b-l:
Before photo offemale
vitiligo patient.

Figure 19b-2:
After photo of vitiligo
patiellt. Note the lack of
demarcatioll lines. The
patient has a natural color
balance.
Photos courtesy of
s. Gu:ick. B.S.N.

Figure 19b-3:
FemaLe patient
demostrating a severe
scar in left deltoid region
secondarr
acromioplasty.

Figure 19b-4:
AJ;er photo following 2
treatments.
Photos courtesy of
s. Guz.ick. B.S.N.

139

CHAPTER 19
Figure 199-1:

White male burn victim with


marked areas of scarrillg, hair
loss. and skin discolorization.

Figure J9g-2:
Patient has undergone initial
scar relaxatioll in evelid. em;
and oral areas.

Figure 199-S:

Patient has received


additional pigmentatioll with excellellt
reconstrtlclive faciaL
skin appearance.
Photo sequence
courtesy of
S. Gu:ick, B.S.N.

Figure 199-3:

Patient 7 1I10ntl1s into


rehabilitation. Skin
pigmentation and scar
relaxation have been initiated.

Figllr!! 199-4:

At one yew; pallent scar


relaxation continues. Note
the careful procedural
planning.

}m

ADVANCED DERMALPIGMENTATION

F igure 199-6:

Figure 199-7:

Be/ore Periocular Vitiligo o//emale patient.

After corrective camoflage using


simultaneous contrast technique developed by
Annette Walker, R.N.

Photos courtesy 0/ Annette Walker. R.N.

Figure 199 -10:

Annelfe Walker, R.N.


pelformillg lip
pigmentation. Mrs.
Walker has begun
research into rhe use of
high frequency equipment
10 reduce edema {Ind
lI/inill1i~e trauma.

Figure 199-8:

Figure 199-9:

Before: Left brow port wine stain


(hemangioma)

After corrective brow pigmentation.

141

CHAPTER 20

MANAGEMENT
Figure 20g-1:
A classic almond shaped eye.

Figure 20g-2:

2 days post-op ecchymosis/hematoma


complication offemale eyeliller
patient due to improper injection
techniques.

Figure 20g-3:
Misplaced lip liner 011 skill rather than
mucosal sUlface.
Photo courtesy of Annette Walker,
R.N. Please note that this patient was
/lot done by Annette Walker.

142

CHAPTER 21

COMPLICATIONS OF TATTOOING

Figure 21-d:
Phoroallergic reaction to the red cadmium
selenide pigment. This sun-induced reactiol/
also occurs with cadmiulIl sulfide (yellow
pigment ).

Figure 21-e:
Same patient with improvemefll of
inflammatiollfrom the use of a sun screel/.

Figure 21-['
Erythema lIlult(forme secondary to tattooing.

Figure 21-g:
Atopic dermatitis flare-up ill a taftoo.

143

COMPLICATIONS OF TATTOOING

CHAPTER 21
Figure 21-a:
An example of impetigo
with the need for topical
therapy.

Figure 21 -b:
Keratocallthoma il1 a
tattoo (rarely seen).

Figure 2l-c:
Koelmer phenomenon
the green portion (~f a
tattoo.

1-1-1

;/1

CHAPTER 22

PIGMENTS

Figure 22b-l:

Figure 22b-2:

H & E histology slide of caucasiall female patiellt.


demollstrating acclImulation of micropigmelltatioll
granllles ill dermal layer.

At higher po .....er the macrophages alld fixed tissue


histioc)'tes are ellgulfillg the pigmellt at 2 weeks
post-operatively.

Figure 22b-3:

Figure 22b-4:

Halo effect noted with the micropigmentation


pigmelll concentrating around the shaft of an
eyelash follicle.

At higher power the some of the iroll oxide


pigmellt is elimillated illto the follicle shaft by the
macrap/wges.

Figure 22b-5:

Figure 22b-6:

H & E slide slide takell from patiellt 6 months


f()II()1rill~ eveliller micropigmeIllClti()//. Note Ihe
illcreased depositioll of co//agell ill the dermal
regio/l (Il1d Ihe h(llo e.ffeel.

At higher magnification macrophage activi~\' is


preullt wilh pigmelll elil1lill(l/ion progressing to
Photo sequences courtesy of
Ihe skill .I'll/face.
C. ZwerliTlg, M.D. aTld M. Palipa.
145

CHAPTER 22

PIGMENTS

Figure 22/-1:
Small malpositioned dotes)
call be removed by simple
curetting H ith granulation of
the site.

Figure 22/-2:
For larger areas a strip
removal with surgical
excision alld recollst ructive
repair may be necessary.

Figure 22f-3:
CO2 laser vaporizing a
decorative tattoo. Note the
use of suc/ioll to remove toxic
vapors from sw:gical sile.
Photos courtesy of
N. Goldstein. M.D.

H A p T E R

Role of the Assistant

The a.'i~is!al1t can be of marked imponance in the ll1icropigmentatiol1


pnK'edurcs for both the practi tioner and patient. The practitioner relief> on
the a:,.si~tant to prepare the room and instrumcnt s, l1lajl1l~lin a clean
atfllospht:re, and assist with the instrumen tation during Ihe procedure,
Also, the assistanl can aid the practitioner with a "second opinion" of the
phll'c ment of the pigment from a macroscopic perspective. From the
patient's standpoint. the assistant is a vital link in minimizing patient
an iety. t:specially if tile assistant herself has had the procedure performed.
III addition. lhe assiqulH ensures that all proper documentation has been
~igned, the patient's name corresponds with the proper chart. and thaI all
photography has been performed. The a!->~istanl makes a careful check Ihat
the pa l ienl has no known allergic:- to any of lhe medications to be used and
that the patienl'~ vital ~igns arc ' table . Since the publication of the first
book on micropig.mentalion, nurses have hecome productive, independent
practitioners in the field of microp.igmentation; howe va, !DaIlY nUf!,CS and
cO'; l11etologi!->ts often a:,.sisl phy~icians in this procedure. Thererore. the
practitioner. physician or nurse can have their assistants l1S(' Ihis chapter as
a guide l'(lr the procedure.

INSTRUMENT PREPARATION
Once the a!>~i~tanl is :-alislit:u thilt the palient is prepared and ready,
the i n~trlllllcnt tray ii> then prepared. Il include~ alcohol sponges. a Sec or
I(ke ~j'fingc, it 22 gauge l1eedk. twn 30 gauge needles (one for each , ide),
a vial or sterile 2% lidocaine ~ollition with epinephrine, four sterile 4, 4
ga u/c~, IWO sterile extcnded wear contact lenses or similar corneal
protcl,ti\t: ~hielcb, an ice pack. and topical ane.'lhelic drop". On a separate
til

/47

C HAP T E R

rray. the a~sjstant prepares the remainder of the equipment needed for the
micropigmenralion procedure: a generou ' supply of sterile Q- Tips ('I'M):
antibiotic ointment: and a contael case with two wells, in which the pigment
shou ld be placed with 70% isoprophyl alcohol for the CooperVisiol1 system
or the premixed pigment with glycerol for lhe Dermouflage, Accent and
Perrnark systems. In the other .'ide of the well, llse plain 70% isopropy l
should excessive clogging or accumulation of dry pigment occur. Also, the
lip can be cleaned of any pigment in case of malpositioning of rhe pigment
and be used as J dehrider-type instrument. The tray should also include a
package of Wecksel sponge,,; the blepharostat (for eyeliner procedures): a
pair of nonlOOlh forceps (to be used for removal of the contact lens a: well
as pO')iti(lning or eyelashes on the blepharostat); a pair of calipers; balanced
salt solution wi th an irrigating syringe: a Icc tuberculUIll syringe tilled with
700/(' isopropyl alcohol to be used for addition to the pigment, since during
the procedure evaporation of some of the 70% isopropyl alcohol will
thicken (he pigmentary alcohol sLispension (again, on ly necessary for
CooperVisioll system, nor for the olher systems); a stir stit:k: patient cap;
and patient drape.

PATIENT PREPARATION
The patient is placed into the c, amining: chair or on an operating room
table. depending on the practi tioner's office. The patient" head cap and
drape are put inw position , As an option , earphones and music cas ette
recorder are then positioncd so the patient can listen to a pre-chosen music
casselle, rn the case of eye liner micropigmemation procedures. the
foll owing sequence can be followed: tetracaine ophthalmic solution is then
placed into each corner to provide topical anesthesia. The lids are carefully
cleaned with disposable alcohol wipes to remove any exces ' skin oils.
rna~caril, and/or eye liner. Because the bkpharopigmcntation procedure is a
clean one and the lids are well v<L'icularized. strong sterile preps uch a '
betadine solution arc nol needed. However. we do prefer a Betadine ~oap
prep for three minutes. Ice packs are then placed onto the patient'l' eyelids
for approximately rive minutel'. and then the praclitioner is ready to begin in
the case of a topical anesthesia approach or, in the case of a physician or
surgcoll, the local anesthetic i~ ready for injection as disclIssed next.

LOCAL ANESTHESIA
Six cc of 2% xylocaine solution with epinephrine an: drawn up in a
syringc and attached tn a 30 gauge needle. The solution has been cooled in
the refri.gcrator ano thus calise!> less palient irrilation upon injcction . After
the initial injection. icc packs ,Ife again applied to the patient' ~ eyclid~ 1'01'
anoth<.:r five millutes and the :\0 ~augc needle is replaced with a new ]0
gauge needle. The surgeon then returns and rcblocks the remainder of lh~

us

R 0

L E

o F

THE

lids, if necessary. After the second block, ice packs are applicd
\() the eyelids fo r 10 to 15 minutes longer in order to reduce
the edema and minimize the inflammatory response. Once the
lids have returned to relatively !lonnal anatomy. the surgeon
may hegin the blepharopigmentation procedure. [t is important
that the assistant not appear to disagree with the practitioner
and thus Clugment patient anxiety. Rather, the practitioner and
the assistan t shou ld develop a special means of
comJllunication to point out areas that need additional
correclioll. For example. we use a pointer to discuss those
areas that may need additional pigment. If the assistant and the
practilioner have a good working relationship. it is unlikely
that any problems will occur. We have found it to be most
helpful and reassuring to the patient to havc the assistant make
po"itive comments during the procedure. 11 is im portant that
while {he practitioner is performing the actual impregnation of
the pigmcnt, absolutely no movement of the lid speculum, if
this technique is used. shou ld OCCLIr. Once the procedure has
heen completed, the assistant aids the practitioner in the
removal of thc contact lenses and the sccondary pigment in the
conjunctival fornices. At this point, the practitioner will
usually leave the room and the assi tant then reapplief> the icc
pack and begins to lake to minute vital signs as needed.
Because mo~t blepharopigmentatiol1 patients are in good
health. it is vcry unusual to find any abnormal vital signs.
rlowcver, in our elderly pat.iell! s and diabetics, we have found
it particularly helpful to monitor them closely since the elderly
tend to metabolize their drugs more slowly and the potential
for respiratory and/or cardi ovascular embarrassment is more
likely. In a nearby area. a crash cart should always be
avail able with supplemental oxygen.

CARE OF INSTRUMENTS

ASS[STANT

ASSISTANT
CHECKUST
V

I. Patient and chart


number correctly
identified.

V 2. Preoperative vital
signs are
performed.

3. Any known

4. All preoperative

allergies noted.
photos ha ve been
taken.

V 5. Consent forms
V

V
V

signed.
6. Pigment selection
for procedure
verified.
7. Administration of
preoperative
sedative (e.g.
Valium).
8. Tray setup
completed.
9. Machine checked
for proper

/\1 the completion of the procedure. all parlS of the


equipment and instruments that are suitable for chemiclaving
are then assembled and checked. Instruments arc washed in
soap and water and then placed in tbe Chemiclavo:: for
s!.erilization. For the Per-mark and tilC CooperVision Natura l
Eyes system. the handpiece Ill" the machine is then removed (if
tbis is the last case of the day). and the lubricating silicon spray is placed
through the end port.ion of tbe hand piece. The foot peoal and remaining
parts of tbc machine are disa s sembled and carefully stored in the
appropriate area~. For the other systems. like DcmlOuflage. Accents. and
Vi:-.il)1I Concepts wilh the disposahle items. qerilization of equipment and
care of handpiece~ are not necessary. From the nursi ng standpoint.
di'p()~:.tble ih.:m~ arc certainly easier to use and eliminate. Becau~e the eye

functioning.
10. Room prepared
for procedure
(lighting, mu ie,
icepacks, etc.)

149

C HAP T E R

instrUlllents ;Jrc th:licatc anumost e,\ pensive. it i$ important that the clean up
is not ",ft tll untrained perS0llncl. The 1'00111 is then cleaned of any debri:
while the patient remains in the reclined p01>iti()J1 wi th ice pa<.:h:s.

IMMEDIATE POSTPROCEDURAL
CARE
It is important that. even with patient urging , the assi~lalll does not
allow the paticnt to look at her eye: until the practi ti oner gives the finul
au t hority, Patients tend to be most anxious and have a lJ'ightcned
di~art)tlintm":l1t if they sec their ey..:lids with an excessive amount of lid
..:dema and brui sing. It isimponant, thereforc. that the ice pack be lert on fo r
a \uitable alllount or time and that the practitioner examine Ihe eyclids or
any other area lhal htl:-- received l.l1ieropigl11cntatioll before the palient sees
thenl. After the practitioner h a~ in spected the cyc~ nnd feels that no
additional pigmentation or removal is n,xc~sary . then the assistant and/or the
practitioner can explain (0 the patient the poslprocedural in~truc ti ons. If a
seeun d ca~e is th en planned. the assi:.tan! will kt the palient sit with
additiona l ice pads while she proceeds to ~et up the next case. It is
important never to clean up the room and rt'move the handpiece and/ r
needles unti l the praclitioner g ives lhe approval that the C<lSt' ha~ been
comp leted: otherwise. <lnoih.::r rad; and ~.::t-up may be necessary at un
unllcces,ary :md additiolla l cost It is important that lhe palient not leave the
ofricc until all vital signs arc stable and that the palient fully understands all
instruction\. It i~ abo important that Ihe assi~tanl understands all a~peet. of
postprocedural care because 1ll0 ' t quest ion" are usually relayed to the
as:--istant by the patient over the phone in the Iir~;t 24 to 48 h()ur~. If the
assistant SllSp~CIS a serious or potentially ~cri()us problem. ~he shou ld
iml11ediat~ly conwct tile practitioner. Und..:r flO <.:ircumstance should an
unlicensed indiv idual olfer medical opinion"
The llur,ing functions related 10 hlc pharopigme ntaliuJl arc rather
S1raightj~}f\vanl. Because or the close contact of the nurse with the pati..:nt
durillf! tilt' pre - and postpr )('cd ural period. contact with t.he pmicnt can
h(X'llllIC mllrC pcr~(lllal and lll()J'C gratifying.

{50

H A p T E R

Blepharopigmentation
Techniques

This chapler will be subdivided into the following areas: patient


preparafion, selup of the instruments. and various techniques as it relates to
micropigmcnt3tion of [he eyelids or blepharopigmcntatioll. This chapler
can also serve as a guide for general micropigmcntalioll patient
preparation.

PATIENT PREPARATION
The patient will either have been given instructiolls for the use of
preoperative medication or be medicated upon arrival at the physician's
ollice. For the licensed phY)'lcian . we su~gest 5 mg to 10 mg of oral
diazepan tValium), wh ich is effective in reliev ing the anxiety felt by most
palient:. In '\ome cases. we have found additional sedation necessary. This
may be obtained with nitrous oxide in a ralio of two 10 one nitrous oxiele to
oxygell.

Approximately half an hour after the Valium has had an opponunity


10 take cffe<.:1. Ihc patient i~ brought illlo the room where the procedure is
til be performed. This will usually be the doctor's examining office or
minor operating room. The lighting in the worn should be adequate but not
excessive for palient exam ination. There ~h()lIld be no distractions to ei ther
lhe patient or the practitioner. The as~istant act!> as a v~ l uable aid in
de livering comforling comments and reassurance to thc pmiem, and should
remain with Ihe palient at all times. The pa l ient is in!>lrucled th<ll the
procedure wi ll be performed in a ::>upinc position , which can be obraineu
with a standard examining chair tilted. ba.:kward, a chai r \>,'jth rec lining
capabilities. or a !>lrclcher.
To help distract Ihe patienl and eliminate extraneous n()i .~c~. we
recol1lmend that the patien\. hring along her f:.woritc casselle tape 10 listen

/51

C HAP T E R

to while the procedure is being performed. The advantage of music is well


known in the medical field for comforting and relaxing the patient and
minimizing fear. The music has the additional benefit of reducing the
machine noise, whit'h we found [0 be quite distracting for somc of our
patients. The preparation of the procedure suite is best left to the assistant or
office nursc. The 1I. e of a reg istered or licened practical nurse as an
assiqant is not critical t"or this procedure: however. an LPN or Rl can
usua lly aid the physit:i::m in the other areas of patient preparation beller than
the untrained office staff member. For the regi s tered nurses who are
qualified to perform this procedure. the use
an assistan t i ' just as helpful.

or

SET-UP
The materials necessary for the eyelincr and most micropigmentation
procedures consist of the following : (l) alcohol wipes. cOl\on balls. sterile
saline. ~terile drapes and cap. lid damp . cotton-tipped applicators, topical
anesthetic drops, soft extended-wear contact lenses. calipcrs, and forceps;
(2) micropigll1cnt<'ltion machine, handpiece. needle assembly. and foot pedal;
(3) pigment: from the manufacmrer with a reservoir for the pi gment. alcohol ,
and sterile antibi(ltic ointment; and (4) mugnifying surgical loupe ' or
micr~l scope and a fiber optic or well-focused light ;,ource.
ft is optiona l for the practitioner to maintain absolute sterility for the
procedure or per fo rm il as a relatively clean operation. We do not
particu.l arl y stre~s that sterility be maintaincd. We routinely prep the
patient's face with ~tcrik: soaps or solutions; howeve r. we did nOl use or
originally recommend surgicaJ gloves. With the prevalence of AIDS. we
urge all practitioners and assistants to be gloved for all micropigmcntation
procedures. The preparation and set-up arc similar to those of a routine inotlice procedure. We havellot noted complications. infectilln~. or other
untoward event~ caused by performing tile procedure under clean. rather
than sterile, condition~. The lids are highly vascular and the risk of infection
from this procedure is extremely low. 'INc recommend thaI the pnlctitioner
thoroughly dean his lJand~ prior to the procedure with Betadin c or
pHisoHex cit.:aning solution.
After the patient ha~ been prepped and dr.lped in clean or sterile fa~hion.
the an~~sthctic can be injected into the eyelids or applied topically . The
practitioner ~ho uld he .~i lling with the patient in the supine position with an
egg crate O[ donut ror added head support and comfort. The patient is
instru'ted to n.:frain from mov ing during the injection. The eye is topically
ancsthcli7..cd with tetracaine or pfIlparacainc. and protective contact kn~es
arc placed ooto lhe corneas ([his technique is optional). The patient's eyelids
are then injected . using it local infil!rativ e technique by the lic e nsed
physician Llr the lids can be anesthetized with topical solutions and icc for
the practicing nur~e practitioner.

157

BLEPHAROPIGMENTATION

TECHNIQUES

TO ClAMP OR NOT TO ClAMP


-)11cre arc two general st:hools of thought on the use oj the lid clamp.
Natu ral Eyes has recommended the use of the lid clamp to provide lid
stahility. belter eye lash presell tation , and increased visibility and safety to
the underlying cornea. Lid notching after prolonged clamping and bruising
rrom overzealous tightening of the lid clamp against the lid margin are
recognized complications. Natural Eyes stres 'cs that the lid clamp must be
considered an integral pa11 of the procedure.
Accen ts and DerIllouflage maintain that the lid clamp is not idcaJ
because of the distortion of the lid margin from the notching effect of the
clamp and venous pool.ing resulting from impeded blood flow . Lid
not.<.:hing could create an in-egular line deposition from the temporary loss
of normal lid t:ontours . Dr. Fenzl has stated that the amount of
postoperative bruising is increased because of the venous pooling, whieh
hinders the norm al removal of blood from the lid margin area. Our
cxperien'e has been that the occasional intraop 'rative discoloring
associated with venous pooling can camouflnge the alTlount of actual
pigment disposition. In addition , venous pooling causes an increase in
tissue transudates and bleeding form the sites of the needle penetration:
Illoreover, the needle lip assembly can be clogged with this tran~udate , and
hemorrhage will cause less pigment to be deposited below the skin. With
the usc of the conventional blepharostat clamp. it is important not to
lighten the clamp excessively in order to minimize lid notching and vcnou.
pooling.
One of the authors, Dr. Char.les Zwerling., has been testing a new open
ended lid clamp. Because of its larger diameter <mel open end. the clamp
eliminates the notching effect from venous pooling. The clamp allows
increased vi:-,ibility of the lash base; moreover. the angled base of the lid
clamp allows the practitioner's hand to rest in a comfortable position OJl
the patient's face without the handpiece em;ountering the clamp in this
confi ned area. The clamp is dc~igneu to take care of an upper eyelid on one
si de and lower lid on the contralateral side. and COmes in light- and Iefthanded s l yle~ to act:oml11o late all four lids. More research with the clamp
is necessary before" final clamp design can be manu factured.
For lbe nurse practitioner, the inability to perform lid injection of
anesthesia solutions would render the clamping argument us at:ademic. For
these practitioners. there would obviously be no way to usc the lid damp.
Annette Walker ha . developed a lid clamp with the use of topical
ane;o;t.hetics.

OINTMENT
.An an tibiotic ointment, preferably with a ~teroid . is ;Ipplied to the
upper and lower eydashe;. and lids hefore the placement of the clump or

153

C HAP T E R

the ointm~nt can be used on the skin. The ointment ha~ a number of
advJllwges. First. the ointment provides antibiotic coverage to minill1il.e
postoperarivc infection. The antibiolic also allows "asia sliding of lhe
clamp along the lid margin and minimizes the possihility for corn~al
abrasion because of its lubricating action. The oinllnent fills tbe pores or the
skin and facilities removal of excess pigment from the skin surface. In
addition. the ointmcnt allows better visibility ()j' the eyelash bases by
keeping the eyelashes' movement to one siue or the other during the
procedure.

Q-tips arc used to help mow lashes out of the field and to wipe away
execs!> pigmenl as il is deposited on the skin surface with each illlphll1lation.
This may hc donc by either the assistant or the practitioner. Firm Q-Tips are
preferahle to colton tips that unravel easily. and can be llsed for lruction of
the skin to rotate lushes for better visibility.

CAllPERS
The procedure is made simpler with the usc or calipers. Distances from
the punctum anu lateral canlh<ll area shou ld he measured to ensure
.;;ymmetry be twcen the cyelids. eyebrows. Iir~ and/or arcolar areas.
Occasionally it is difficult to sec the punctum in the lower or upper lid. and
il is easy 10 forgel where to cnd a I.ine. The u~e of caliper reference dots is to
help the practitioner to locate the nasal and temporal endpoint:;. as well as to
guide lO prevent displaced pigment lilles. The calipers are also used 10
measure the maximum needle excursion of the handpiece unit.

NEEDLES
The practitioner needs lo in,pecl lhe needle assembly before
proceeding with the micropigmcntation. The needle :-.hould be checked for
any deformities. The lengrh or the needle excursion should be mea'>ured
with the calipers (the length ~ hould bl.! between I 111m and 2 l1un). Needles
with lengths less than J mm will Jeposii th~' pigmt'nt ~uperllcially and will
L:au~(' ~ignificanl postopaativc pigment loss. Needles with lengths greater
than :2 rnm arc more likely III deposit the pigment within the orbicularis
rllUSt'le. with rostprocedural pigment migration and increased prohability
for hematoma forrnat ion. The neculc should ()sci II ate ,IT}oolh Iy wit.hin the
COllI.! or nose tip portion or the asscmbly.
It is easier to create a narrower line with the single-needlc in<;trumem
lhan with the threc-ncl.!dle tip handpiece. 111 the three-needlt' lip a:-.sembly.

15-1

BLEPHAROPIGMENTATION

TECHNIQUES

th~

skin is impregnated by the three needles with the formation of an


equidistant triangk. This inherently protluces a wider line than the singleneedle apparatus. and thus the overall time for 1he total procedure i~
shortened . With the three-needle tip configuration. improved capillary
amactiDlI along the center of the three-bonded needle allows the assembly
to retain more pigment. A potential area for concern i. the placement of
too dark a pigment line in the lower eyelid. With the three-needle
assembly, the practitioner needs 1.0 check for equal excursion and spacing
of the needles. The Ileedles should form an equilateral triangle when
viewed from below. Ir the formation re~embles an isosceles triangle. there
wi II be improper pigrnenr depo _ition.
With the use of a single needle tcchnique, the handpiece is directed
toward~ the skin and the Ilt:edlc inserted with individual placement or the
dots. with wiping of the area and inspection between dOl placement.
Subsequent dots arc then added in a linear fashion , with the spacing of the
dNS not exceeding the one-dot dialllctl~r. This procedure has the potential
for mulpositioning of the tlots in an irregular line, as it is difficult to
c(lntinuc to come back each time to the same precise location as the
previous dot placemenl. However, thi:. reorienting procedure can be
perfected with experience until an even line is maintained. If the hand is
completely removcd from the face each time an impregnated dot is placed.
there is a stronger likelihood for an irregularity. A . ingle-needle assembly
is usefut for 1he lower lid. while a multi-needlc lip is preferable for flaring
purpo~es and a thicker line. At this lime. we feel there are indications for
both and cannot recommend the single-needle over the multi-needle
device. However. in order to obtain a true pointillistic method ror the
treatment of correction~. lip liner and vitiligo. a single needle is mandatory .

EYEUNER
We have incorporated the CO!lcept of caliper and surgical reference
dots to orient the ~urgcon to the eyelid. Caliper dots are placed by dipping
the cal iper tips into the pigment well unci then applying dots at designated
I()C;lli()n~ on the lid. The implanted dots follow the placement of the caliper
refcrcm:e dots. These dOlS arc applied by II micropigmentation instrument.
Although additional time is spent in placing these rderence dots.
proccdural mistakes arc significantly reduced.
The caliper is st:! at 4 mm in placing the initial reference dot 4 mm
from thl." lateral canthal angk in the temporal lower and upper lids. Thi~ 4111m placement reprcscnb the temporal shift Lone. The caliper reference
dots ~hOllld he placed within the lash follicle area. Additional caliper clots
arc then added along the lid margin nasally. The~e reference doti> arc
alway~ placed the same di8tance from the eyelid margin ' i> mucocutaneous
,iullctitll1 :lnd :11 4 mm to 5 'mm intervals. The dots should nevcr be placed
,)J1 the flat portion or ftll:' lid margin proper. By carefully paying auention

155

C HAP T E R

It is advantageous
to perform the
procedure by
a/ways stroking or
drawing towards
olleself rather than
tryillg to draw
away. This simple
reminder facilitates
the drawing of a
straight line and
appears to be
easier for most
people.

to lhese reference posi tions. the surgeon avoids the tendency to migrate
away fro m the lid margi n as the arch of thc lid changes.
The permanent reference dots are placed adjacenr to the caliper
reference dots in the tempo ral as pect of the lid. A decision is made
preprocedura\ly as to where the eyeli ner will end Lem porally. An
implanted reference dot i~ placed at lhat point. Rarely wi ll the most
tcmporal extreme end or the line come to more than I mrn to 2 mm
from the canthal angle, and so this dot becomes variable by on 2 mm to
3 111m.
In the nasal area. the calipers are sct 0 11 4 mm and a caliper dot is
positioned 4 mill from the puncta in the nasal shi ft zone. The permanent
line i:-. usua ll y on I mm t() 2 mm from the punctum. giving t.he
practitioner on ly approximately 2 mm, at most 3 mm, of variation for it'
placement. Jt is not necessary to place permanent. reference dots other
than at the nasal and temporal ex tremes.

MAGNIFICATION
The practitioner should lise wide-fie ld magnifying Inupes. These
IOllpes provide satisfactory magnification of the eyela, hes and also enable
the surgeon to view the entire eyelid. Magnification higher than five or s.i
time s is unn ecessary and te nds Lo
Variations of Pigment Placement
produce the effect
0 1' -ecing the tree
rather than the
forest. The use o f an
ope ratin g micro scope crca tes an
ullu!>uaL and d istorted view of the
eyel id area.

156

BLEPHAROPIGMENTATION

TECHNIQUES

CONTACT LENSES
We have found that postoperative keratitis and corneal microabrasions
can be virtually eliminated with the use of soft extended-wcar contact
lenses during the blepharopigmem<ltion procedure. We have not found thai
the use of ointments againsl the contact lenses or repetitive cleaning and
sterilizing or the lens presents any problems to the patienl.

PIGMENT DIPPING
As a limited amount of
pigment can be placed into the
lid with each application, the
needle tip needs to be dipped
repctitively into the pigment
well. To avo id needle lip
trauma, the needle should be
stationary <Jnd not reciprocating
in the tip assem bl y. Ex.cess
pigment should be wiped from
the end of the needle assembly.
Since the pigment is held to the
needle by capillary attraction.
lhe multi-needle configuration
l ends to hold on to more pi gment and require Ic ~~ dippin g.
Natural Eyes and Enhancer
make usc of the multi-needle
as~elllbly. while the single needle as:,cmblies ine1udc
Accents. Eye-Lite. Co, medyne.
and Vi~ion Coneept~. The
Vision Concepts machine
incorporates a re~erv()ir system
that provides a continuous-feed
pigment sy~ tem to avoid
repetitive dipping.

~~

N1

~--",.

~
,hmporal
,
Zone
N2

I
I
I 12

N 1=Vertical Nares Line


N2=ObJique Nares-Canthal
Line
J1: Inner Iris Line
12=Outer Iris Line
(Represents maximum point of
brow arch)
(a) & (b) vertical parallels.
Distance between (a) and (b)
should be approximately 1/2" in
the proportioned brow.

N2

157

C HAP T E R

THE ZWERUNG-CHRISTENSEN
TECHNIQUE
The prHctitioner or surgeon should sit at the patient's side in order
to gain a direct yiew of the patient's face. Sitting at the head of the
patient and viewing the patient upside down crcates a distorted
orientatiun and may confuse the surgeon during the procedure. The
entire procedure should be performed from one position, rather than
shirting form side to side or shifting from right to left hand. A righthanded persoll should perform the procedure from the patient's right
side and begin with the right lower lid, proceeding to the left lower lid,
right upper lid, and tinallJ left upper lid.
The pigmclH lilJe of the lower lid is usually placed by an ill-and-out
motion when using either a ~inglc- or multi-tipped instrument. placing dots
adjacent to other dots in a .- lightly overlapping fashion similar to a brll~h
stroke: i.c .. "p;linting the dots." This provides a fine series or dots placed in
a confluent ra~hion f(lrming a line.
The fbring in the temporal portion of th.: lower lid and the thicker line
throughout most of the upper eyelid is formed by the juxtaposition of Iwe) or
threc row~ of interlpeking pigment lines. This ;$ facilitated by imagining thc
drawing of a spiral. This spiral is created by a circular or side-Io-side hand
motion while the instrument travels in a linear direction . The combination of"
the linear and circular motions cr('ate~ the spiral effect. The spiral effect
increa~es the deposition of pigment and, therefore. facilitates making a
Ihicker or \\ idcr-appearing line. This thicker linc or placement in the lower
lid shou ld be lIsed on ly in the most temporal ex treme of the lower lid.
However. it can he llsed in the temporal t:Im.:e-foUl1hs of the upper lid. The
in-and-OLlt lechnique creates a thin finc line and should be performed in
three-fourth~ of Ihe lower lid and in the nasal agpeCl or the upper eyelid.
The central ponions of the upper and lower lid become a transition zone
between the in-and -o ut stroking or painting-the-dot technique and the
circular ~piral or side-to-side technique. It i~ advanrageous tu perform the
procedure by always ~troking or drawing towards oneself rather than Irying
to draw away. Thi~ simple reminder facilitates the drawing nf a straight line
amI appcan; to bt' ca~ier for most people. The procedure begins with the
palient's right lower lid for a right-handed practitioner facing the p~ltienl
directly. t\ caliper is placed into the pigmenl wdl and a smull clot is placed
wit.hin the. lashes -+ tnm J"rom the lateral canthal angle. The caliper i~ lhen
lIsed to place ;111 additional n:rerenee dot in the centra l ponion of the eyelid.
i\ third dot biseCh Ihe se two dOls ~o that two lones in the tCIll POI4l I lower lid
have been Jdim:ated. The instrument is then dipped into the well and un
implanled dot placed I mm to 2 mrn temporal 10 the caliper rckren(:e dol.
The placement or the dots is then perrormed by staning in the centr:!1
portion of the Iid and pai Ilting the dot towarJ.~ the lateral canthal area. not
going heyond the permanent irnrlant~d rckrencl.! dot. The d()l~ arc placed in
;til in-and -ou t stroking patern aero;",> the clHire j(l\-vcr lid. Addi tional flaring

158

BLEPHAROPIGMENTATION

TECHN[QUES

is obtained by performing the sp iralling technique if indicated in the


temporal extreme. blending it in the central aspect or the lid. After tile
temporal right lower lid has been pigmented . the damp is replaced in the
nasaJ portion of the lid . The cotlon-tipped applicator facilitates the
evers ion of the lid so that the flat portion of the lid margin and
Illllcocutaneous junction are all vis ualized . Starting in the most nasal
extreme, a caliper reference dOl. is placed 4 mm from the punctum and the
lid i~ again bisected into two zolles with another reference dot placed with
the caliper ncar the lid margin. The surgical nasal extreme pemlanent dot
is placed I 111m to 3 1llJ11 from the caliper reference dOl, depending on the
presurgical decision for creating the line. With placement or the needle
more superficially nasally a smaller, thinner line i. obtained. The eyelid
clamp generally covers between one-half and two-thirds of the lid, and so
there should be overlap in the central area from the temporal portion of the
procedure. The pigmcnt dots are then applied sequentially so that they
barely overlap. The procedure is continued by filling in between these
reference dots. remembering ttl make fewer penetrations of the needle
mcdially for a finer line.
The central portion of the eyelid is a transition zone where the single
row of dot can be blended into a ~ccond row for patients needing a light
amount of flair. The right lower lid completed, the clamp is removed and
the ('mire L~ycli 1 in~pected . Skipped or missed areas can be retouched at
thi s time.
The clamp is then placed in the temporal ponion or the left lower lid
.md lhe process of the caliper reference ancl permanent dots is repeated in
an analogous fashion. It ~hould be remembered Ihat. in the 'ceond lower
lid, the line is tlrawn from a temporal to a nasal direction. One should
avoid the placemenL of Ion thick a line on the lower lid in attempting to
make the lids sy mmetrical. It is preferable to leave minor imperfections
alone a\ related to the thickness of the lower lid linc.
Attention i~ then turned to the right upper eyelid. hy clamping in the
tempnral portion first. placing. a ca liper reference dOl 4 mm from the lateral
c<lnrhus as well as cen trally. and then implanring a permanent reference
dol. Because of the arched configuration. the LIpper eyelid is sl ightly larger
in linear dimension than Lhe lower lid. From t.he central reference dot, 11
spiraJ pigment line is deposited toward the temporal permanent reference
dol. A ~ingle row of pigJl1cnt dots i~ placed wit hin tbe inferior row of the
eyela~hes away from the mucocutaneous border. A heavy line m;}), require
i W(1 or even three row~ of pigrnenlalilll1 aJjacellt to th e first row :H1d
ovcr\appi ng the tlots con flue ntly .
A transition zone is present in the l"c:ntral ,Lrea of the eyelid. where the
~pirallil1g tc:chnique is tape red to ;\ ~ingle line as the nasal lid is
approached.
The clamp i!-' removed from the temporal upper lid and placed into the
na~al upper lid area. The caliper and permanent reference dOh are placed J
Illlll 10 :; nnn i'rurn the puncta. The procedure continues as a fine stroke inand-oul line lhat keeps the li ne de licate and narrow in the na~al aspect of
the lid, until the central zone is encoLilltcred with a blending of the two
pigmenr lines. The central z.one acb a~ the tmll.ition area between lhc fine

/5<.1

C HAP T E R

stfoking Of painting method and the spiral or circular method for pigment
placement.
The clamp is removed and pigmentation of lhe tinal contralateral upper
lid is performed by initialing the pigment line in the temporal portion of the
lid and working nasally. The reference dots are placed as in the orher
eyelids and symmetrical application is perfofmed. At the end of the
procedure. any areas that were missed can be filled in. The upper eyelid is
more forgiving in the amount of pigment placed. The rotary or spiralling
motion or the practitioner' s hand increases the amount of pigment
Jepo~ited and tends to speed th procedure.
The handpiece should be oriented at a 45 degree angle to the lid
margin with the needle pointed superiorly in the upper eyelid away from
the lid margin. In the lower cyelid, the lash follicle is avoided by directing
the handpiece 45 degrees to the lid margin. This reduces the lisk of eyela~h
loss or inadvertenl trauma to the follicle root area. The procedure is
facilitated by the lise of an antibiotic ointment ;Jnd Q-Tips (TM).

The procedure completed. the eyelids are then cleaned of all ex.ce s
pigment by using 11 sterile-balance salt rin se applied to a gaule pad and
gently wiping the lids free of pigment and oilllmenl. If th practitioner has
chosen the usc or Ihe soft contact lenSeS, they can be removed at this lime
and the fOlnice.' cleaned of residual pigment debris with a Weeksel sponge
or Q-tip (TM). For patient who do not have contact lenses, a mild amounr
of irritation from mechanical abrasion of the clamp against the cornea is
inevitable and artificial tears hdps to decrease the symptoms. The patient is
given an ice-cold compre$s to place over the lids for approximately 1()
minutes aftcr the proccdure. A wriUcn set (If in:-truetions on care of the
eyelids is then explained and given to the patient by the practitioner.

ANNEITE WALKER EYEliNER


TECHNIQUE
Since the preparation of tht; patient

i~ c:>~entially

the same as with the

Zwerling-Christcnsen Techniques, we will summarize Annette Wall,er' s

actual methods for the eydiner procedure.

UPPER EYEliNER
Al'!er an appropriate skin preparation. dots are placed at the nasal and
temporal lilllit:-. with a LIne surgical pen as a marker. An ice pack is applied

for .5 minutes for vasoconstrict ion and anesthesia, Pigment is then placed
frOI11 the temporal extreme to rhe na,al side by placing the dots within the
cyc la:-.hes, The dots an.' then superimposed in a staggered fashion over the
initial line to neate the desired depth or cnlor. Since there is 110 lid clamp.

16()

BLEPHAROPTGMENTATION

TECHNIQUES

the well-vascularized upper eye lid tissue quickly develops edema.


Thererore, it is important to proceed in a deliberate m<tnncr to implant the
rigment before [issue swelling distorts the lid and makes further
implantation difficult.
For artistic elleCl, the practitioner can create a flaring tcchnique in the
temporal areas of the upper eyelids by placing additional row s of dots
beginning in thc central portion and extending temporally or by staggering
the dots farther apart in the temporal zone. By inserting the pigment at an
angle. the practitioner can create an ellip itical dot which will assist in
blending (he dots together in order to create a more harmonious line.

UJWER EYEUNER TECHNIQUE


After the sa me ty pe of .l id preparation , the praclltlOner again
establishes the proper limits nasally and temporally along the lower lid line.
Dots are then placed between these two limits side by side O.5cm <lpan. The
practitioner now simply fills in the ~paces along this rel'erem;c line between
the nasal and temporal limits. Again a staggering and superimposing
pointillistic methodology is performed to achieve the proper color depth
and width. By sweeping the hand-ht:ld instrument a feathering and
connuent effec t can al so bl end the line. Flaring in the corners can be
adjusted according to the patient 's desires. For an intcre~tin g "sm udge
effect", the pmctitioner can use diluted color at the edges of the temporal
limit.
There are cardi n al rules thaI should be remembered in the
performancc of this procedure. (1) Never connect the upper and lower lids
tem porarily. (2) Never extend the pigment line medial to the punctum . (3)
Avoid placing pigment on the lid margin proper. (4) Never place the
pigmcnt line outside of the la~h fo llicle area in the lower lids. (5) Do not
perf01111 the circular or spiral technique in the na_al ponion of either upper
or lower eyelid. (6) Always be con:ervativc when in doubt as to the amount
of pigment neeued.

161

H A p T E R

'/
1&
.'.

..J-:'
.... '4-,;.>'

,,

.'

Brow Pigmentation
Techniques

After the consultation with the patient and appropriate work-up, the
brow pigmentation should be performed with the palient as an active
participant. Using the CLlMB approaL:h and the 5-5 dassifiemion as vita l
guidelines to determine the proper borders, shapes. and colors of the
implanted brow lines. the practitioner can be more confident in the
recommendati ons for the patient. Once the practitioner and patient are
confident a~ to thl! planned procedure. then the actual technique can be
discussed .

PROCEDURE
First the brow area is deancd with the antiseptic of choice. Then the
patient is gloved in a sterile fashion and given a sterile toothpick. Using the
predetcnnincd brow pigment color, the patient applies this color with the
toothpick to the brow arca and recreates the desired brow makeup. The
practitioner and assistants can offer advice 10 the patient: however, the
patiefllll1l1SI. make the final decision for color selection and placement. The
"finished" result is photographed and the patient is reclined for the
procedure. After Jllowing the pigment to dry, ice packs and/or injections or
anesthesia i:-; performed. The single or three-pronged needle is used to
define Ihe borders of the eyebrow (lccording to the patient's design. A light
lubrit.:<tlll or antibiotic ointmcnt is applied to the eyebrow area to allow
easier needle movemen t 3nd implantation. The pigment is implanted
simulating the natural growth patlem or the brow hair by placement of the
pigment at various degree:.. or insertion: med.ially the pigment is oriented at
90 (kgn::e\; centrally the pigment is implanted at 45 degrees: and. linull y.
temporally Ihe pigment is placed at a 30 degree angle with rC5pect to the

163

C HAP T E R

verticaL This directional pattern of pigment pia 'ement is critical in order to


obtain a more nalllral appeaJance and "movement" of the artificial eyebrow.
A root and hair effect can also he obtained by aJlowing a greater density of
pigmelll 10 be applied with the needle probe followed by a gentle feather
and stroking act.ion of the handpiece with the practitioner's wrist.
The process is repeated with overlapping of the previously pigmented
areas. Careful attention is necessary to achieve proper halance and
symmetry of the brows. RESPECT YOUR INITIAL BORDERS! Finally an
overull lust general sweep of the brows arc performed to blend allY scattered
dots ano remove any uppearance of fragmentation.
The patient should be
allowed to view the final
product in order to offer any
additional suggestions. The
practitioner should listen to
the palicm's observation
Central Zone
~
and
try (0 integrate these
Zone
"II
'
suggestions at this time. Jr

N2
rhe patient has been sedated, their participation in the
procedure at this point will
be limited.

N1~.~1~"~
. ~4~~

.l/;'.,'
I
' ,1
~~ ...

;}, 1r. f:

Nasal
Zone

Tempora~

11

I
112

N 1=Vertical Nares Line


N2=Oblique Nares-Canthal Line
11 =Inner Iris Line
12=Outer Iris Line
(Represents maximum point of
brow arch)
(a) & (b) vertical parallels.
Distance between (a) and (b)
should be approximately 1/2" in
the proportioned brow.

164

H A p T E R

17

Lip Pigmentation
Techniques

Sincc the lip is the most variable feature in the face, it is critical for the
practitioner to evaluate the lip posilion in bOUl repose and action before
allcmpting any reconstructive work. In many situations certain
cOl1lpromi~cs need to be performed to allow the best overall impression.
Since the general expression of the face is predominantly detemlined
by the corners of the mouth, one needs to be careful to approach lhis area
with caution. As a general rule, with aging the position of tbe lower lip is
subject to a cel1ain amount of atrophy of the elastic subepidermal (issue.
With this dcgenermive change, the lower lip's vermi.llion angular border
becomes poorly defined and the central lower lip zone maintains good
definition. Overall. there is less of this type of change in the upper lip
zones . It is important to consider any angular ptosis before attempting
minopigmemation reconstruction. We would recommend correction of
this problem either by collagen injection and/or surgical correction
initially: and. then proceed to the subtle improvements by micropigmentation. The lower lip is composed of two rounded halves wiLh a
rounded ledge formation located celllraUy. This ledge which flattens with
age creates a hollow spot thnt allows a shadow to form. This indclllation or
ledge is very important when atlempting to either reshnpe or reconstruct
the I(lwer lip.
Since the mouth ha~ a smooth tmlll-ilion into the surrounding facial
features. it is important to blend the color outward rather than create
artificially fixed plane~ or borders. In the natural stale the lip color blends
subtly and eventually disappears into the surrounding skin,
There arc three planes above the lip that transition into the lip matrix..
The fi it rum is the groove in the central zone or the upper lip. The lateral
portion of the filtrulTl forms the peab or t!levations. This relationship of
the filtrum centrally with it. lateral elevation is known as cupid's bow in
co~metology and is vital to maintain in lip reconstruction.

165

C HAP T E R

During fetal develupment the lip is actually three unattached lobes that
slowly creale a union in the second trimester of development. The center
lobe becomes the creased section while the outer two lobes develop into
angled planes lalerally, Sinl.:c this embryologic division persists inlO adult
life. we must strivc to maintain thi. relation.-hip of the filtrum or cupid's
bow in (he proper blending of color.
In the consultation with the patient pre- procedurally ("or lip
enhancement andlor correction. it is imponant to explain to the patient that
in order to obtain a larger upper lip appearance, one must strive for
di~tiO(;tion of the zones rather than an arbitrary size increase of the lip
borders, So by using the principles or light and dark for shading and
following the anatomical guide lines rather than simply enlarging the lip
surface area, we can create a more youthful and ae '(hetic appearing lip
structure.
We aclvi~e the practitioner to eSUlblish a rcpigmemation of the existing
vermillion border as the initial step ill micropigmcntUliol1 before attempting
to reshape. enlarge, co lor. andlor reconstruct the lip structure. By using this
cautious step by tep approach. more precision and predictability in the final

Oculofacial Morphology
FUlldamental and Subordinate Reference Lines

,\\\.(l r~
j Fl

Nl

~ F1

1M

-=-

FI =:'.1itbagittal Facial Line


F2 = 1\'lid - Horizontaltri~ Lin~
N 1 = Vertical Nare!> Lille
N2 =Oblique Nares-Canthal Line
1\3 =i-IoJizonlut Nare, Line
II = I nncr Iris Line
12 =Outer Iris Li nl!
L 1 =Midrnuzzll! Hnnl.Ontal Lip Line
L2 =SLtperior Horizontal Lip Line

LIP

PIGMENTATION

TECHNIQUES

outcome can be assured as well as enhancing paLielll's confidence. This


!lame technique is utilized in the eyeliner and eyebrow micropigmentation.
Remember estahli sh the boundaries! Don 't sacrifice outcome for speed!

UPUNER
After establishing the proper lip color for implantation , implant the
pigment along the vermillion border. IT the vennillion boundary is poorly
defined, it is advisable to stay within the lip tisslie working outwa.rds rather
than risking misplacement of the pigment outside the natural boundaries of
the lip structure.
Initially the lip is prepped with tlJl antiseptic of choice followed by a
li ght lubricant for example, mineral oil instead of a heavier petroleum
jelly. lee is applieo for approximately five minutes for vasoconstriction
and anesthesia. Topical aneslhesia can be used when the practitioner has
the appropriate licensure: however, the use of injectable local anesthe 'ia is
ri~ky because of the distortion effed to the lip ~ tructures as well as the
increased risk of pmt-procedural hematoma. If injectable anesthesia is
required, we would recommend the use of a regional block: anesthesia of
the 2nd and 3rd branches of the trigeminal nerve at its ex.it fJ'0nl the
rna . illary and mandibu lar foramina. Small cotton dental roll s can be
saturated with the topical anesthetic and placed between the lip tissue and
the teeth . It is illlpoJ1am to note that the oral cavity has a high absorption
capacity for topical l11edita l ion~ with systemic effects in certain sensitive
inUividuaJs . Careful observation and good preliminary workupI' are
important to avoid complications such as cardiac alThyrmias.
After establishing the pigmentation of the lip houndaries, a staggered
placement of the suhsequent dots is utilized 10 achieve the de<;ired width of
liner from the lip boundary inward towards Ihe remaining lip tissue. Since
the lip is highly vascularized. it is important to minimize the number or
qu,mlity of lip penetrations with the single needle probe. The greater the
number of penetrations, the more likely hematoma form ation could occur.
Therefore. it is advisable to use oarker or brighter color mixtures to
achieve color depths rather than to try to obtain thl.! same end result using
more needle pcnetmtions of a more diluent color base. It is nOleworthy that
ill many cases when the patients request "more" or "darker" color, they arc
<Ictually tie:-iring more contrast Therefore, it is important to create contrast
than color inlensity.
If edema (swelling) OCClil'S during the procedure , it is necessary LO
place the pigment deeper in the tissue. With cxce~sive swelling, it is
advisable to stop the procedure al that point allli treat with ice packs
immediately, since any further trauma could result in seriolls bleeding ano
complication . . After the procedur..:: has been completed. the patient is then
treated with ice packs to the upper lip. The practitioner can now begin the
micropi gmelllatiol1 to the ll)wcr lip in the same manner as with the upper
lip. First begin by establishing the lip bo('(.Icrs and t11en proceed from the
c:('nter working to\vards the corners. More density or color is achieved in

IfJ 7

C HAP T E R

thc ccntcr by compact placement of the pigmcnt dots: then. proceed to the
corners with a feathering movement and less dense placement of lhe
pigment to achieve a gentle color transition and ultimately the natural
blended colorappearallce.
Refining color touches arc lhen compJeledin the cupid's bow area. The
dcnsity of the color may be modified for a Illore precisc detinition of shape.
A lighter color can be ~callered in a grid fashion throughout the body of the
lip to crcate the illusion or more fullness or thc "pouty look".
Due 1.0 the complex nalllre of the lip structure and color, it is advisable
to present lip micropigmentatioo to the patient as a multi-staged process.
By using photography at each stage of lip pigmentation. the practitioner can
demonstrate to the patient the improvements in color and contrast. Also, the
paticnl may forger that now nonexistent naws once existed.

I fiX

H A p T E R

Breast Areolar
Pigmentation

As this book is being published. woml!n's choices have been limited


by Dr. David Kessler and the FDA. Among the choices already lost are the

polyurethram:.' coated breast implants. the silicone gel-tilled devices made


by both Surgitek and Dow Coming and the gel-filled Silastic U soft nipple
areolar implants also made by Dow Corning. The modalities for nipple
areolar reconstruction still left to the mastectomy patient include: the use of
vari()u~ Ilaps and grafts or combination of these for the nippl0 areolar
reconstruction. and the usc of grafts and or micropigmentution for the
areolar reconstructions.
Once the decision has been made by the palient to undergo nipple
areolar reconstruction. the first major consideratioll involves the timing of
thb reconstruction following the creation of the breas[ mound. An adequate
interval of lime wi ll need to be allowed so that the reconstructed breasl
mOllnd has sen led or dropped into it. final position. In addition to the
above, the reconstructive surgeon must develop a plan which includes the
contra lateral breast. To creMe symmetry between the reconstructed and
ounrecollslfucted breast. the surgeon will have to advise the patient on
whether a mastopexy (the reducrion of the skin envelope) or a erduction or
sometimes an augmentation should be considered to improve the
appearance of the breast.
Ovcr the years the author, L. William Luria. M.D .. has used a number
of tcchniques for nipple reconstruction which have included composite
g:ran~ taken from the car. a,~ well as nipplc ~harillg from the opposite bre~t
when <I<.kqll::ttc ti~sue has be~~n available. Other options which have been
used include trapdoor dermal !laps. mUltiple Y- Y advancement !laps and
lhe 1110-;t rcccnt innovations or v:H;aljons ()f [he double opposing tan flaps.
Wilen a local nap is u. cd to f'om1tilc nipple's projeclion, iL is covered with
a "plil-thicknes~ skin graft and this prl1Cedllre can be combined with a graft
reconl>truclion for the areola at the same rime: or at a later date. There ::Ire

169

C H APTE R

Masternocleidomastoideus

Clavicula

Extremitas acromialis claviculae


Acromion

Reglo Infraclavicularis. Trigonum __L'::':'::':":::':.2'::2~:'::':


deltoideopeClorale
Regio delloidea

_-_-

Regio axillaris

Regio
brachillat.

Regio
brachii ant.
Tubercula areolaria
(Montgomery)
Reglo thoracica lat.
Reglo mframammalis

Regio mesogaslnca

Pars lal. regionis abdom .


mediae
Pars umbllicalis reglonis
abdom. mediae

Reglo femons lal


Reglo femons ant

Fossa subingUinaiis

171)

B REA S T

AREOLAR

PIGMENTATION

three stages ill which dermalpigmenlatioll can be used during the


reconstruction ()f the areolar compl.ex:
Stage 1: Pigmentation can be applied at the time of surgery to the
lllHlcrsurface of t.he graft in order to improve its color match with the
opposite breast. This approach has a distinct advantage in that the surgeon
can appreciate immediately the color match.
Stage ll: Oemlalpigmentation can be placed during the second stage
by either elevating the outer layer of the skin at the site of the aerolar
recon struction or the previously placed skin graft lIsing a tunneling
technique and then placing the dye in the undermined pocket. This stage 2
technique has been used with individuals in which previously performed
dennalpigmentalion pigments have faded prematurel.y. The colors which
are most frequently utilized in the operating room to create the desired
areola include a combination of rose , white. and tan for the lighter colored
areolas and a combination of rose, white and mahogany for darker ones.
Patients need to be advised that the tattoo pigmenl-; may fade over a period
of years requiring a . econdary touch up. In this author' , experience, 2530% of patients have required a toudmp procedure dUling the first 3 to 6
months postop.
Stage III: In mo st cases. the practitioner or plastic surgeon will
usuaUy see patient., slatlls post mastectomy/reconstruction repair.. In these
ca:-cs, where there has been ':H1 actual reconstruction of the nipple and
areolar complex. the borders arc detennined by the scar. skin tone, and the
contralateral breast. The color to be used is determined great ly by (he
existing. color of the contralateral hrea:-t's nipple and areolar complex. The
range of color to be used \vould typically be from light brown to red
brown. The illlegrution of multiple colors creates gr~aLer dimensions and
thus a rnore natural appear'l!lcc. By applying color principle~ of light and
dark. we can give the illusion or larger Of smaller areolas. Tinting and
shading may also be utilized to give a fu ller appearanc~ to the nipple ,
Color i~ scattered throughout the areolar cornplex starting from the nipple
and progre:.sinJ toward the incision line. Feathering the placement: of
pigment across the incision line assists in camoullaging the scar. By
sca ltering and graduating the pigment from lighter to darker from the
incision to the nipple. a more three-dimensional appearance is created.
Abo. thi s transition from light to dark moves the viewer's eye away from
the indsion line toward the nipple and thus. a more pleasing focal point.
The scars resulting from breast reconstruction are pigmented initially
to induce relaxation of the tissue adhe:-ions below the skin . urfacc.
The use of the dennalpigmcn talion technique in reconstruction or lhe
nipple areolar com plex has been of great benefit to the reconstructive
surgeon. It has given the surgeon a grcall:r range in color options. therefore
making it casier 10 match the recon,tructccl breast with the patient's
remaining brea~L Whil e the problems with this technique are minimal ,
sometimes so:condary procedures may be required. and the patient should
bc made aware or the possibility thal later LOllChllPS may be needed either
initially or at a laLer date. The dcrmalpigmentalion ponion of the rccoll~truclion LI~ually requires only a ~mall amount of local anesthesia and can

171

C HAP T E R

be safely performed as an office procedure.


Before onc can undertake the con'ection of a surgical problcm, one
needs to define the nature of the problem . In reconstructive surgery thi')
means to define what is the acceptable normal range for a structure's form.
A~ thi~ book is bring printed. surgical tcchnique. have improved. so have
the definitions and the means of measuring deformities. Using similar
concepts of facial morphology and reference lines, we can use certain
landmarks and I11ca<;urcments in the majority of women with pre-pregnant
breasts : lIsing the stemal notch and the distance between the notch and the
nipple, we find that the majority of WOllll!n will have a distance b tween 18
ern and 21 cm. The distance from the notch to the inframammary fold is
usually in the range of 7 to R cm. The size of the nipp.le m'eolar complex, to
look its most aesthetic . is in the range of 4 to 5 em in diameler. The most
important concept in reconstruction is symmetry and balallce. It is important
to use the contralateral breasl and areolar complex as a guide for color,
shape. and size when performing reconstruction and breast derlTlulpigmentulion. The reconstructive and the cosmetic surgeon can establi. h
objeoives and develop an operative plan for lOlal reconslruction or
con'ection of a limited defonnilY. The lypes
deformities that the surgeon
corrects include congenital. traumatic. or acquired origins. Congenital
deformities include unilaleral absence of the breast as in Poland's syndrome,
asymmetries in the development of the bre:lsl , hypoplasia. poor
devt!lopment, hyperplasia or hypermastia. (I , well <1 . acces 'ory breast.
Traumatic or acquired deformities of the brea st include burns with
associated sc arring which prcvent developmcnt of the breast. tra umatic
amputation and other accidental injurie:; resulting in the los~ of breast ti ssue.
Acquired deformities can be lhe results of mastectomies for cancers as well
as partial mastectomy for fihroadenoma or simple mastectomy for
tuberculosis
the breasl, as well as postradiation deformilies. the deformity
which can be seen after multiple breast biopsies and the involution noted
after pregnal1cil'~ .
Reconstruction of the breast can be accomplished in a va riety
fashions. from a simple one stage placement of a permanent implant to
mu s cle flap:, including latis~imll~ dorsi muscle I.Q the usc of rCClU
a bdOl)1inis muscle or tram flap , and finally free flaps involving
microvascular surgery. Not every patient is a candidate for these procedures
and so me patients are lIot candidates for any of the procedures. The
mastecl.omy patient Illllst be made awan~ or the limitations imposed by the
present !>latc of art. Eac h of the ahove operations may also require more than
one stage. and will have its own set or associated ri sks. The reconstruc tive
~u rge() n must as:>c~s the patient and present her with all of the options.
Once the decision has been made lO reconstruct the nipple areolar
complex, ~ l' vc ral problem~ must be addressed r0lated to the form and the
quality of the color match . Over the years all of LJ~ have see n good efforts
eml lip \vith ~oll1e level ()f dissatisfactioll due 10 the poor color match that
can re~1I11 i'rom a number of older techniques. The available skin for grafting
to reC(ln ~ tru c l ;m arcola has limited range ot' pigmentation. Some of th.; early
attempts to OVL~n':OI1lC this problem rl!sulrl!d in the deve lo pment of nippk

or

or

or

/7]

B REA S T

AREOLAR

PIGMENTATION

sha ring procedures. These procedures have several drawbacks such as


Illany women do not have large enough areolas to provide adequate donor
and the aJditional associated scarri ng.
Today a variety of techniques are available for nipple reconstructio n:
small local !laps. cartila ge grafts from the ear. silicone nipple areolar
implants and nipple sharing procedures. The above techniques can then be
combined with areolar reconstrlll.:tion using either dermalpigmentation or
pigmented . k..in grafts from a variety of sites. All of the above-mentioned
su rgical techn iques have drawbacks which need to be di cussed with the
patienl. Reconstructive surgery of the breast is an evolving surgical art with
mallY prescnt day techniques which have only been available for the pa. t
ten years.

L-__________________________________________________ ___ ---

173

H A p T E R

Advanced
Dennalpigmentation

Over the past decade many advancements have been made in the field
The success of this procedure within the medical
field has been especially noteworthy . .In the past few years Annetle
Walker, R.N., has introduced numerous new techniques. We are fortunate
that a number of other pioncers in the field of micropigmentation have also
been stimulated to research and venture into new uses for micropigmentation. The following section on scar contractures and vitiligo
represents the work of Annette Walker. R.N. Her work has encouraged
other practitioners to implement ncw directions for micropigmcnlation.

or micropigmentation.

SCAR CONTRACTURES
One of the most exciting new usc ' for micropigmelltation has been its
application in the treatment of scars. From clinical experience with tfauma
patients and bum victims, Annette Walker was the first to note that by
utilizing a single needle or probe, relaxation in the scar tissue can be
achieved: tllu . , the patien1 call assume a more normal appearance anu
achieve incrc:! 'cd comfort. It is not unusual for the patient to feel
immediate relief from an initial scar relaxation treatment!
The hypothesis for the success of a single needle is that the applied
energy to the ."car tissue b:lnd i ' highly focused like a surgical laser. Thus.
the ~urrouncling tissue i~ minimally affected by the physical disruption and.
therefore. minimal ),ccondary scarring results. With this precision the
practitioner can safely select the areas for scar disruption,
In those ~ituations in which there have been no color changes but only
~C;lr contractures. the practitioner can treat Ihese areas with a "dry probe"
after applying an antiseptic followed by a light lubricant.

C HAP T E R

A random in-and-out motion of a


reciprocating only needle is prefclTed. rn
those cases in which a spiral and/or
vertical movement was used more
secondary scar tissue resulted
postprocedurally. It is prudent to work in
a unnoticeable. slllall. test area of the
patient in order to predict the potential
results of this treatment.
It is highly recommended that scar
relaxation is performed initially on the
patient before pursuing other cosmetic
enham;emcnt techniques , uch as brows or lips. With relaxalion of the scar
tissue. the position of the eyebrow or lip will shift, thus leaving the patient
in a potential asymmetrical state. For example, in working on a burn
survivor. olle might complete a brow initially and then rclease the scar
contracture. The corrected brow could result wilh a brow ptosis or droop
and be asymmetrical with the contralateral brow. Even the release of a slight
scar contracture on a repaired cleft lip would most likely affect the
placement or the pigment in establishing the appearancc of a symmetrical
lip.
It is important in any ~car management regimen to include the use of
appropriate scar massages andlor exerci~es. By stretching the scar in various
planes, the contracture ability of the regenerative fibroblasts is markedly
retluced. It is important that the practitioner who desires 10 treat. scar patients
become more educated in this area. A number of benericial unicles have
been published on this new technology by Susan Sobel Guzick, B.S .N.
R.N .. in the rei'crence section of this book. and should be consulted.

It is !lot unusual
for the patient to
feel immediate
relieffrom an
initial scar
relaxation
treatmellt!

VITIUGO
Vitiligo is a skin disorder of unknown etiology that affects lout of
every 200 men. women. and children. The disease is characterized by a nonspecific loss of pig.mentation that can be localized or widespread . The
pigment loss is attributed to a deficiency ill the melanocytes of the ~kin to
produce adequate amounts of melanin . Before the introduction of
micropigmenlation, the only two trcatrm:nts ,wail able to a patient has been
either camoullage make-up or the use of PUV A (J'soralcn Ultraviolet A
Light) which is effective in some 60% of all cases. PUV A is Jess effective
in the more e po~ed areas of the hands , lip s. race a nd feet.
Micropigmcnlatioll has proven succesi>ful ill the management. of those cases
lhat arc poorl y re~p()nsi\' e to PUVA treatment. [n the treatmcnt of the
vitiligo palient. it is imponant to cOl1llllunicate to the patielll tltat the lise of
micropiglllctHation as Ll LreatmCn! modality will require multiple sessions.
Tlli,; (UIK'Cpt must be acknowledged on the paticnt's informed co nsent form.
G~nerally, it j~ helpful III treat a small lest area first 10 instill patient
confidence in the procedure before attempting larger areas. Working. with a

176

ADVANCED

DERMALPIGMENTAT]ON

mall unnoticeable test area, the practitioner can be more assured of a


proper color match.
The goal in micropigmenlution of vitiligo is to diminish skin contrasts.
Oftcn the borders of the vitiligo are darker than thc center. By scattering a
lighter color through those edges and proceeding into the unaffected areas,
the contrast difference will diminish immediately.
After achieving an appropriate color match, a single needle probe is
used to scatter the pigment throughoul the desired area. The advantage of
the single needle probe compared to the larger cluster lypes is that with a
single needle a true pointillistic approuch is created. Only with pointillism
can the artist creale the subtle lone or increased warmth (addition of
yellow) or a pink tone for improved blending with <t strong blue undertone.
To darken an area simply introduce darker color values.
The final acceptuble result is achieved when the color tran, ilion blends
with the surrounding skin tones. Blending eliminates the line of
demarcation which, in itself, brings attention to the affected area.
Experience in micropigmen!u!ion has demonstrated that iron () ide
pigments lighten with time. It advisable to begin with lighter color ' for the
vitiligo patient opting for improvemellt after each application rather than to
overtreat and allow for normal pigment lightening. Using this more
conservative approach of multiple scssions, the patiem's anxicty and sclfconsciousness will be reduced.
Recently the usc of a laser or microentomology needles lO stimuJate
collagen and melanin repigl1lcfltalion has been under curren! research with
the American Institute or Permanent Color Technology with Adrianna
Scheibner. MD and Margot Schweiller. RN. This process is designated as
MlIlti!repannic Actuation ( MeA) , derived from the Greek word.
trypanon- to bore. The researchers claim a consistent succe. s ratio with
MeA for the treatment of vitiligo. Further publications on this process are
pending.

COLOR NEUTRA.UZATION
Historically. the traditional approach to skin camouflage was to cover
the affected area with one or lwO colors. AnnclleWalker has taught that
lhi~ stalic approach is unsuccessful and leaves the palient with an obvious
artificial appcaram.:c. With the use of a pojntilli~(ic approach and multiple
colors with tonal variallce. the practitioner can achieve a more natuml,
blended, and three dimensional appearance to the ~kin.
Highlights and slInlle variations to the !>kin call be amended w.ith the
lise of color and a :-.ingle needle probe. Annette Walker continues to
inve~tigate and research techniques to expand th.e applications. She is
clIrrclllly ex.perimenting with high frequency currents in assisting pigment
ac~: ertance hy the tissue with impressive r('~ults. The ability to minimize
edema or eliminate a traumatic respollse speeds up the proces~ for those
l'onditiom requiring Illult.iple applications. such a~ vitiligo.

177

C HAP T E R

HAIR LOSSffRANSPIANTS
A number of praclitioners have suggested tlle u -e of micropigmentutiQn

for hair loss on the scalp. Although thil' procedure can be easily performed,
it i:; preferable to consider hair grafts because of the degeneralive. continued
process of further hair loss. Thus. secondary and tertiary color matching
would not be necessary. With the success of grafts and hair weaves, dle 'e
approaches would appear to be preferable.

SUMMARY
In Ihe jit/Llre. H'e expect newer idclis and techlliques to be added ro Ollr
arlJ1elllariul/l for the treatment of these ahove mellliolled disorders as well
as uther c1isc(l.,es alld disorders. Micropigm('nl(1fion has provell to be an
ill/wI'alive alld va/liable procedure in l/ie fields of reconstructive and
cusmet it.' procedures.

17X

Section Four
Post-Procedural
Considerations

--- --- -.... -.7"~'."':-'


.

f:/"'r<~",

.;";'~': ...,...-:~ '>!,:,/

/';y~-'

,'"

-.'
L-_____________________________________________ __

..

-~

---------------_
c H A p T E R
2(};

.....

Management

At the conclusion of blepharopigmentation. the eyelids arc cleaned of


any residual pigment. and the COlli act lense ' arc removed. lee packs are
applied to the eyes. After 10 minutes, the icc packs arc removed and the
patient observed for immediate results. Possible bruising and some
swelling may he prcscll t. Most patients arc relieved that the swelling and
bruising are not a~ bad as they had anticipated. The eyes are examined at
the sl ir lamp (if available) for corneal staining. which is usually present to a
minor (it!gree. The lid. are examined for any possible skip areas or maJpositioning of the pigment. The assistant should refrain from disassembling
the micropigmentation unit until the practitioner is satisfied that the
procedure ha~ been satisfactorily achieved. The ideal time to make minor
adjustments with the pigmentatioll j:. immediate.ly following the procedure.
Small residual amounts or pigment within the fornices should be irrigated
from the eye to avoid chemical conjunctivitis and 10 prevent pos ' ible
lttailling frol11 prolonged contact with the mllcous .membrane . A careful
irrigation with a balanced salt solution and removal of residual pigment can
be performed with a Wecksel sponge or a couon-lipped applicator. The
practit ioner or one of his assistant:'. can then infonn the patient of the care
or [he eyelids. A typical instruction ltheetthat we use for our patient's care
is shown in the appendix . This instruction sheet is givl.!n to the patient
following: the procedure and the key points arc reviewed with her at that
Ii me.
tV1ascara call not be lIsed for two weeks after blepharopigmencation. as
this can cause bacterial contamination LO the healing area. Eye shadow and
foumbtion-type facial makeup can be u. ed. however. a. long <I), it docs not
come il1l0 contact with tht: treat~d area. A foundation concealer may be
u!'.t;d aftc.r a few lbys to cover small bruises.
Pain medication is rarely Ileccssary---perhaps only for the day or night
aftcr the procedure Jnd many patiellts require only a mild analgt;!siu such a~

L-______________________________________________________ __ -- 18 1

". ...

~.

-'"

CHAPTER

2 0

acel<lminophen. If stronger analgesic is necessary, then Percodan. Darvol1


or Tylenol with Codeine i~ acceptable, when prescribed by a physician. Eye
di~c()mfort is caused by the kermiti!> that can follow the procedure. Severe
eye lid pain is a rare complaint.
The trauma to we superficial ~kill layers from the needle penetration
will caus a se rous exudate with pigment adherence. The patient i '
instructed not to pick or disturb the treated sites ill any fashion, and only the
app] ication of ointment is permitted for the first few days. ft is possible that
the deposited pigment will be pulled our if the crusts are pulled off. The
crus t will falloff naturally within a few day~. lcaving the pigment behind. If
the pigment and crust nre removed inadvertently. a skin area on lhe
pigmented lid linc is crented that will require a touch up procedure (touchups can be peJ1'onncd three [0 four weeks later, if indicated).
A potential complication in the early post-procedural period is eyelid
infection. The incide nc ~ of infection , however, is extremely low. and
prophylactic systemic antibiotjc~ are indicated. A steroid antibio tic
ointment will suffice during the immediate post-treatment period. This
ointment. provides Sali. facwry antibacterial .)clion with the addi tion al
henel'it of the anti-inflammatory steroid . A few patients may have an
allergic reaction to tlllo'ir medication if it i. of a neomycin stero id
combination (i.e. Nc )sporinl. If an infection is present. it would likely be
due to ambient bacteria sLlch as Staphylococcus uureus. Staphyloc()ccu,
epiciermidis, or slreptococcu:. In such sitLinliofls , a broad spectrum
antibiotic widl high gram positive coci aggressiveness. such as ampicillin.
tetrac ycli ne , erythromycin or cephalosporin would be prescribed by a
phys ician.
A sHlali amount of ccchyrno~is and lid edema is usually present and
can be reduced by lI~ing ice packs poslsurgi 'ally for the first few hours.

Complications of BJepharopigmentationu

C,'mpli(Ulioll,'
Major
E:dJ~h

Il'"

AC'::COl,

C(Xlper
ri,ioo

P~nnar~

Vi,iPli
CIlI1<xpl;

Health Tck

( U ~I )

12.159)

( IIXI

1131/)

il l)

(i

0
()

(I

/)

0
0

/)

()

()

Ii
0

()

(I

()

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If)

P~mlr.llll'n

of IJr, :!1 pla l~


ClJm~a lInplJnldlion
\ ieclianiral ""~riti,
L"l \l'arnn~
Minor
lkmatllllJ3

52

Bkph:ll1ti,

K(, nldt1~

Skip area,

~7

Spaulding.

34
3

15

(l

()

()

~6

and

R()ger~

(20)

Micfll

~li:;tel

Cootep"

lan~l'u;

TOLlls

tlb)

III i!

t 7.9j[)

()

12

()

\l

0
I

Rc\u!r\ or I/:t: qU(HioIHWire filinl'il:/tll'y litt' Aw('rium S. ,fin." ~Jf ly/icr!llliglllt,ltw!ifllf SUff!Cr,\ In.' . 1986 {Or b\'r~rling (llui Dr. ('ltri.'i(('I\(,II;'
t

J'Oidi (~majf~r1l1lm{1r c(lwpli('(uiul!\": ]h,i. Tfltol complic(1!inu rule: 3'L


VliJlihu o/prtJretfuffJ pe,. mUIJI/fill fIlfer i~'i ,\/Ul it'll

182

ill p!lrtmhp\'c(

Hajor: !i.75 ": lII':'IN: 2.75"i.

20
II I

MAN AGE MEN T


Mild mechanical conjunctivitis/keratit.is from the clamp often occurs. By
nOI using the lid clamp when properly trained, the practitioner can avoid
many of thcs~ problems. Ointment along with artificial tears will usually
provide comfort for these symptoms. O<.'ca~ionully, some los:> of eyelashes
may be noted a~ a direct result from needle insult to the exposed lash.
Usually this is of a mild degree. Permanent eyelash loss has not heen a
problem. even in the upper eyelid, where penetration is over the follicle
area.
A patient may occasionally develop a mild ptosis from the use of an
injectable anesthetic, in addition to some mild lagophthalmus. An ocular
lubric~lIlt such as Lacrilube ointmel1l, or a non-prescliption preparation can
bl! lIsed along with artificial tears to keep the comea from drying out, until
the plotic effect of the anesthetic wears off. Older patients should be
observed to be sure that there io; no delayed cardiovascular or respiratory
embarrassment. Trained personnel wilh appropriate resuscitative
equipment should always be available Juring in office procedurc.~ . In most
patients. however. 30 minutes in the office is satisfactory to be sure that no
delayed reactions to any of the medications used will occur. As Valium
and xylocaine anesthesia are buth considered safe medications with few
untoward reactions , patients Cim be discharged relatively soon after the
proceJure if these medications are used by appropriately licensed
practitioners. A friend should always be (lvailable to lmnsport the parient
horne, since eye irrilation, mild keraLilb. and blurred vision impairs driving
capabililie~ .

We recommend checking the patient one day after the procedure to be


sure that no signs of infection are prescnt and that the ~orneal surface is
intac\. Possible lid problem:; such as an ectropion or entropion should be
as!>essed at every visil. Any significant complicatioll requires immediate,
mandalOry medical referral. The vi~it also provide an opportunity for
photographs for future reference. At the second visit, one or two weeks
after the procedure. the practitioner can careful[y inspect the liJ margins
for any ,kip areas, malpo:-.itioning of the pigment, and any signs of lash
loss, innammation. or latent infection. PholOgraphs may be taken if
desired.
The p,nient );hould be reminded that the final assc!>sment of her
bkpharopigmenlatioo will be Jcferred until one month laler. Al that time,
patieot~ may !lOte a less intense pigment appearance. The reason for thi.. is
that in the immcJiate period there is retention of pigment clumps at the
ba~e of the lashes associated with the crusting. This usually faJls off by
two weeks, diminishing lhe ov~rall efrect. The remaining pigment i~
located below the surf:.iCI': and some of this pigment is later removed by
expres~ion through the 1'011 ick orifices, over a two - to three-lTlonth period.
creating the " halo" effect. At the slit lamp cx.amination , the area
immediately surrounding the follicle is free or pigment: thus the term
"halo." This extrusion or pigrnc,nt from the follicle shaft also diminishes
the overall concentration :.lnd the inten~ity of the pigment line. More
pigment or LOuchup may be pcrfonned after one month. h should also be
uuderstood by the practitioner as well tb the patient , that the usc of eye
shadow alld a skin-toned facial base will diminish the COlllrast between the

INJ

CHAPTER

20

permanent eye liner and the face without makeup.


Until sllldics arc performed evaluating the long-term results of this
procedure, it is wise to follow patients for as lung u:; possible. Based on our
ten year experience with micropigmcntation, we have observed no longlerm complications. Examinalions should evaluate any evidence of pigment
migration. scarring. keloid formation. lash loss, or any other potential
abnormality (e.g. delayed allergic reacrions).

18';

H A p T E R

21

Complications
Related to
Micropigmentation

Allhough somewhat rare today, in the past, numerous medical complications resulted frolll tattooing. Since micropigmentulion has developed
from La!looing, we believe it is helpful to review the histOl;cal problems
that have been associated with traditional tattooing in order not to repeat
similar problems within the field of micropigmentation. The c talloo
complications have ranged from trivial to some serious enough to cause
necrosis, amputations, and fatalities.
In 1869, Berchon. a French Naval surgeon reporting on forty-seven
cases of complications from talloos, found twenty-nine severe infections
resulting from tattoos. Eight of the patients required amputations, while
another eiglll died. In 1972, as reported in the Journal or the American
MedicaJ Association, a 21-year-old man in London died of staphylococcal
septicemia secondary to massi ve hepatic nccrosis clue to serum hepatitis
contracted a few months after being tattooed. De 'pite lhe above findings
and the. largc numbers of tattoos being performed throughout the wodd,
very fcw microbial infections have been implicated in tattooing, with the
possible exception of viral hepatiti .
Dermatologists have always had an interest in tattoos and their COIllplications. Some of the most eminent American and British dermatologists
have contributed to the wealth of knowledge that we have today on
tattooing. Inc.1uued among these arc Marion Sulzberger and Rudolph Bacr:
Hennan Veennan. who kindly donateu hi:- entire collection of talLoO ' lides
to the World of Talloos Library; Arthur Conan Doyle: Henry Roenigk,
Roslenbcrg. Brown and Caro; J.S. Madden. Rook and Thoma~; and R.
SClitl.

or

The classification
complications from tattooing (see tabid is a
modification of the works of Veennan and Davis. and incorporales the vast
experience of ollr coaUlhor. Dr. Norman Goldstein. while he was in
military and civilian practice in Hawaii.

L-_______________________________________________________ ---- ----

185

CHAPTER

ASEPTIC INFlAMMATION
AND PYOGENIC INFECTIONS
All tattoo sites become irritated and inflametl merely from the
punctures and deposition of foreign body in the skin. Some erythema.
edema and crusting are inevitable and temporary: some [altoo pigmcnt may
come out with the crust, depending on the depth of the insertion of the
tattoo. As previously mcntionetl, the depth or micfopigmcntaliol1 a
PCrrOrlllCtl hy modern medical doctors should be at least 0.5 mm below lhe
epidermi~ to minimize loss or pigmem from crusting. Because of the cle:lO,
aseptic conditions and marked vascularity of Ihe litls, micropigrncntation
procedures rarely become infected; howcver, homcmade tattooS are
frequently seen. with mild secondary pyogenic infections. Ecthyma and
cellulitis arc occasionally found. Seplicemia and tieath from tauooing ha
.t1so been reponeLl in the Journal of the Amcrican Medintl Association in
1972. In the past, pyogenic infec,lions from tattooing must have been rife;
modern practice with better ambepsis is rarely accompanied by . erious
infection. Nevertheless, minor sl1perficial inrcctions like impetigo and
ecthyma may occasionally occur even now. Such complications occur, too,
in minor surgical operations in ordinary medical practice. Deep infection
like furunculosis, erysipelas, and cellulitis from staphyl( cocci and
SLrCptococci arc still Jess common than superficial pyogenic infections. but
ncvertheless do occur. Complications like local gangrene ancl septicemia
from deep infections arc lhe most seriolls. but rarest. of all infectious
consequences of tattooing,

NONPYOGENIC INFECTION
Syphilis
Veerman and Lane compiled Crom the literatLlre sevcmy-two cases of
primary lesion ..; of syphilis. i.e. cankers, in (allOO~; eighteen cases of
seconJary sypbi lis circumstantially related to tattooing; and one casc of
tcrti.u'y syphilis limill!d 10 a taltoo. Syphilis as a complication or t3t1ooing
wa~ first reported by Hutin in Paris in 1853, A French tattoo anist had
IllUCOUS patches of :o.yphi .lis in the moulh and l1Iust have contaminated his
tallooing instruments on a leasl one occa~ion . .Iosia ' . in I X77, described an
example

or mass

innoculatioll of syphilis in which nine men developed

multiple c<LIl kers a~ a result of tattooing. According to Rukstillat. in 1886.


Arthur studied enlisted iTlen in the Americall Army and Navy and found
r(\rly-one cases of extragenital syphilis. Twenty-six of these were the resull
llf laltol)ing hy a man who fIloistencLl his tattoo needle with saliva. no doubt
C<lntaining spirochck'S. In 1906. Lipshutz reported lesiQf1s or secondary
syphilis in blue or blad portions llC latloos and sparing of the red portions.

/86

COMPLICATIONS

Thi!'. phenomenon is related LO the spirochetocidal effect


of mercury in t.he red coloring of the tattoo.

Leprosy
When one considers the va .( number of people with
leprosy in certain pans of the world and the popu lari ty
of tallooing there, it is surprising thaI leprosy is so rare a
complication. BUI then the transmission of leprosy in
general is slill a mystery. Veerman and Lane ciled
Milsuua. who. in 1928. reported a case of leprosy in a
tattoo. j\1accla. also citing Mitsuda's observations,
reported Iwo more cases of leprosy in tatloocd subjects.
[n one of his cases, nodular lesions of leprosy developed
in the red parIs of Ihe talloos. Histo[ogic examination
~h()wed " ~wollcn" cells cont<lining red granulc~ and
enclosing many Icprabacilli. The most often recalled
report or leprosy stemming from placemcll1 of talloos is
that or Porritt and Olsen in 1947 . Two men in the
American Marine Corps were ta tt ooed by the same
"arli~t" in Melbourne, Australia. in 11)43. Both
developed tuberculoid leprosy two mId a hal f years later.
More recently in 1971, Sehgal of India reported a ease
or leprosy that developed seven years after tattooing of a
25-year-old woman . Two hypopigmen!ccl infiltrated
plaque~ measuring 7 em in diameter were situated on
bOlh forearms at the sites of 13tlOO$. Temperature, touch.
and pain sensations were markedly impai red in these
~ite:,. A lepromin reaction was strongly po~itive and the
nerve supply in the areas involved was thickened and
tender. The bi .lj)sy showed tubercu loid Icpro~y.

Classification of
Complications from
Tattooing
l.

Aseptic Inflammation and


Pyogenic Infl'Ction
A. Temporary, aseptic inflammation from trauma of
punctures
B. Pyogenic Infec tions
I. Superficial infection~
a. Impetigo
b. Ecthyma
2. Deep infections
a. Furunculosis
b. Erysipelas
c. CeJlulili

II.

Non pyogenic Infection'


A. Syphilis
B. Leprosy
C. Viral hepatitis
D. Tuberculosis cutis

E.

RubeJla

F.

Ch~U1CfOid

G.

Telanu~

H.

Molluscum conlagiosum

flI. Cutaneolls Diseases that


Loca[ize in Tattoos
A. Vaccinia
n. VCIl.ICca vulgari_'
C. Herpes :implcx and ZOofer
D. Psoriasis
E. Lichen planus
F.
G.

Daricr ' ~ di~ca~

Chronic di coid lupus


erythemato~us

H.

Vtral Hepatitis

Keratoacanthomas

IV. AC(IUired Sensitivity to TaUoo


In 1950, ELF. Smith reported seventeen Cll),e:-, of
hepatitis th:.!t developed lIncr tattoos had been placed in
a Panamanian tattou parlor. Tattooing in New York
Slate for rea~ons other than medical became illegal in
1'161. bCG.lUse of the large numbers of cases of hepat itis
traced lo tattooing.
The following items appeared in "Interna lional
Comments" in the Jllurnal of the American Medical
A ~s() c iati()11 in 1972 under the ti lIe or .. Death after
Tallooing." .
A young man. age 21. died in London arter ncing

Pigment'l
A. Chromium (green)
B. Cobalt (blue)
C. C::tdmium (yellow)
D. Mercury (red)
E. Carbon (blac1.)
F. Talc
V.

Miscellaneous
A. Keloicls
B. San:oidal granulollla~
C. Erythema mutlifonnc
D. Localilcd ~clerod.::rma
E. Lymphadenopathy

187

CHAPTER

treat.ed for a serum hepatitis. first at Salisbury General Hosp ital. The
coroner's investigation and necropsy findings revealed that the cause of
death was staphy lococcal septicemia, secondary to massive hepatic necrosis
due to serum hepatiti&. A few months prior to his dInes. , that patient had
been tattooed. The customer who had immediately preceded him at the
tattooing parlor had been found to be a carrier of hepatitis.
In another report from England. an incident of two patient ' who
developed hepatitis three months after being tattooed at the same shop is
dc~cribed as follows:
A visit to the shop disclosed that the tattooing was carried out in a dmb
single room without run ning water. The proprietor was unaware that the
:;ame needle ' were rarely used on more than one or twO clients. Before
using. the needles were immersed in boiling water to which an antiseptic
had been added. A different antiseptic was addt:d to the colors, and the arm
wus shaved and wiped with the same antiseptic. The tattoo was sealed with
a styptic ferric chloride. The proprietor was then given advice on the
importance of sterilization of needles and equipment belween clients and on
hand hygiene and U1C need for installation of hot and cold running water..
Scottish investigators. Mowat ct al., reported twenty-eight patients widl
hepatiti s that in all probability, resulted from tattooing by an "artist" in
Aberdecn. and recommended that tattooed individuals not be accepted as
donors of blood. Because hepatitis virus is so ea.,<;ily transmitted by tattoo
ncedles, strict laws concerning tattoos are now enforced in many American
states.

ACQUIRED IMMUNE DEFICIENCY


SYNDROME (A.I.D.S.)
At the time of publication of the first book on micropigmenlation, there
had been no cases of A.tO.S. being reported associated with tattooing. We
had predicted the possibility of this transmi ssion and, since then, there
indeed have been a number of reported cases related to tattooing. Thus, the
dermatologi st and other physicians who have the opportunity to examine
tattoos and their possible compilations have a unique chance to detect
A.1.O.S. from tattooing. The calise of AIDS tran 'mission .bas been Lraced to
the use of improperly sterilized needles.

CUTANEOUS DISEASES
THAT LOCAliZE IN TA1TOOS
Viral infections may localize in tatloos, or may affect tallot)cd area> as
nontatlooed areas.
Wildc, in 1929, described a vac.;cination reaction in a tattOo '0 severe

1St?

COMPLICATIONS

that the tattoo was removed by the inflammatory reaction. Lesions of


rubella were preseni on tattoos as on the rest of the skin.
Warts were first reported in "tattooed lines" by Fox in J884. This was
Defore the identificati.on of the viral nature of vermca vulgaris. Sporadic
r~ports of warts in tattoos have appeared since that time. Watkins reported
one sllch case of a sai lor who developed warts in his "rose Tattoo". It i.
strange that Qf the 7,000 slides in the World of Tattoos Library, only two
depict tattoos with warts.
Hcrpc~ simplex and herpes zoster are also surprisingly rare in tattooed
sites. When [hey occur in tattoos, the phenomena eem to be fOrlui tous
rather than related to the tall 00. There are also relatively few reports of
lesions of psoriasis in tattoos. Teliehevsky, in 1940. reported a 20-year-old
man with acute generalized psoriasis who developed lesions in tattoo sites
with each exacerbation of his psoriasis. In Pilsbury's text. a luttoo of a nude
female figure is shown with the playful title of "Venus revealed" because it
became evident when the lesions of psoriasis that obscured it were cleared
by treatment with tar ointment and ultraviolet light. Lesions of psoriasis
may localize more readily in some colors than in others, and psoriasis may
flare up in tattoo sites as readily as in other areas after antimalarial therapy
with chloroquine.
Lichen planus was reponed to have developed in tattoo sites as a
Koebner phenomenon by Sehgal. Lesions of Darier's disease may also be
localized ill tattoos. These reactions are quite rare.
SarcoidaJ granulomas, keratoacanthomas, and chronic discoid lupus
erythematosus usually occur in the red -colored portions of tattoo si tes.
Discoid lupus ery thematosus was first reported in tattoos by Hall in 1943.
He recounted the case of a 35-year-old man, tattooed nineteen years
previously, who developed discoid lupus erythemato us in the red portion
of hi s tauoo. Maddcn in [939 repOlted the case of a man who had repealed
flare-ups of discoid lupus erythematosus in red sit.es after exposure to
sun1>hine even though lhe tattoo was protected by a shirt and heavy leather
jacket Rook and Thomas reported a third case of lupus erYlhemato 'us in
red tattoos in 1951. In their case a 24-year-old man de veloped discoid
I upus erythematosus seven years after gelling tattooed. Again. lesions
developed only in the red sites. Lu veck and Epstein in 1952 reported
exacerbations
lupus erythematosus in tattoos after ult.raviolet light
therapy in a 30-year-old man.
A group of mil itary dermatOlogists reported still another case of "tme
discoid lupus erythematosus" in a 30-year-old sailor who developed these
lesions on his face and ears in addition to the red portions of the tattoo
s itc~ . Fields ct al. studied a 35-year-old man who developed lesions of
discoid IUPlis erythematoslis in red sites of a talloo exclusively aft.er t\"'O
months of cxpo~ure to sun in Florida. They were able to reproduce the
lesions of lupus erythematosus in their palient wilh Kromeyer hot quartz
lamp.
Reports of kcraLOacamhomas in tattoos arc relalively few . Cipollaro in
1973 reported a 24-year-old man with keratoacanthoma in the recl portion
of his tattoo. Drs. Ackennan and Mcnn also reported additional example.
keratoacanthomas in the recl portions of tattoos.

or

or

189

CHAPTER

ACQUIRED HYPERSENSITIVITY
TO TATTOO PIGMENTS
Th.:rc are numerous reports in the liternture of localized and generalized sensitiv it ies to taHoo pigmcnts. Some of these reactions arc simply
allergies to the pigment.

Green
Rostcnberg and associatcs reportcd a case of green tattoo allergy eight
years after the tattoo was applied.
The color green wa~ rdated ro the
Tattoo Pigment Chart
usc or chrllmiulll oxide. These
au thors also reviewed var ious
White
pigmcnts and dyes and their
Titanium Dioxide
sources and chemical chara Zinc Oxide
cteristics. Loewenthal rcviewed
Barium Sulfate
seven cases of green tattoo
allergies and added one of his own
Black
from Johannesbu rg. South Africa.
Carbon
Hc included in h is paper a
- IrQI1 Oxide Fe304
discu!>sion (If the differen t balance
states of chromium dyes lIsed in
Brown
tal!O(l~. In addition to chromic
- Iron Oxide FC203 (Ochre)
oxide. chromium sesquioxide ha.
also heen implicatcd in ensitivity
Blue
reactions.
- Cobaitous Aluminate

Blue

Yellow
C~ldmium Sulfide
-Iron Oxide

Rorsman of Sweden reported


thrce patients with granulomas in
ligh t bluc tallooS. 'I'hese patients
dcveloped an allergic granulomatous uvei tis. He concluded
that these reactions \verc a ''special
sarcoidal reaction induced by the
hypcrsensitivity to cobalt. Two of
[he three patien ts dcmu nstrated
marked il11pruvclTlellt. of their
lIv('iti~ whell the <;,Ircllid like taltoo
reacti()n~

IYU

were

cXLi~ed.

V iokl
' Mangancse Oxide

Red
IVlc rcuric Sulfide (Cinnabar)
- Cadmium Selenidc
- Alizarin
Green
Chromic Oxide

- Chwllliulll Sesquioxide

COMPLICAT

N S

Yellow
Tindall and Smith reviewed lbe literature on tattoo rcactions and
reported the first two cases of yellow reactions in Laltoos. Urticarial
reactions in both patients developed after sun exposure. This phOlOloxic
reaction is well known to tattoo artist- and was described in the Classic
Book of TallOOS by Ebensten in 1953.
Djornbcrg studied twenty-four Swedish patients with yellow tattoos.
eighteen of whom devcloped swelling and pruriLis when exposed to Slln.
Four of these patients also had reaction in red tattoo sites. These reactions
oceun-ed while the subjects were in the tropics . Djornbcrg discusses the
role of cadmium sulfide as a photoelectric cell constituent, hence, the
photosensitivity reaction in tattoos while in the tropics.

Red
While investigating the photoallergic reactio ns in red tattoos in
Honolulu , one or ou r coauthors. Dr. Norman Goldstein, discovered that the
phOloallergic reaction noteo in the red portion of the tattoos of ont: of his
patients was, in fact, due to trace amounts of cadmium sulfide present in
trace amounts with the cinnabare (mercuric sulfide). Brose, ill 1927. was
the first to describe a reaction to red in tattoos . Veerman and Lane included
a total of 18 such reactions in their review of tattoos in 1954. Since tben
Bonnell and Russell, Rabbills, Whiteman, Andrade and Franks, Lane e( aI.,
and Biro and Klein each reported single case,. Lamb. et 31. and Davis rep< rted two case, each. They had all describe.d three patients in Glascow in
1977. There arc now at least fifty-six reports or reactions to the red in
talloo~ .

There are various cxplanations propm.ed for the dclny in symptoms


after tatlooing. Exposure 10 mercurial solutions. ointments, diuretics, and
trace amounts of mercury found in influen za vaccines along with latent
Sllrcoidosis mu st be considered 3, pos::.ible etiologic cau~es. Although the
histology of l'llllle red talloo reaction is that of a ),arcoid-like granuloma,
mOSl sarcojd- like tatlo)s are not manifeSl1Itioos of S3n.:oidos i:,. \Vhiteman
and coworkers reported an interesting case of ~ystemic sarcoidos i: in
which Ilattening. or the ~kill lesion:; and reducli o n~ of pulmonary findings
after a lalloo biopsy wa~ performed, Erickson and Pelko reviewed ~arcoid
rcanions in lallOO;, and concluded. "patients with sarcoidal reactiOlls in
ta ttoos a~::,ociated with systemic findings or ;,arcoidosis should be
followed." Their disease does not seem so progressive and indeed has been
noted to re v 'r~c !'>pomancously. Mercury-cadmium . cnsilivity in red tattoo
silc~ has been noted by a number of authors since the reaction was first
de,cribcc\ by Dr. Norman Goldstein .

/9/

CHAPTER

21

Black
The black particle~ of carbon used in lndia ink talloos have nOI been
implicated in allergic reactions. Thesc small 3-micron particlc:s are well
known to cause spreading and migration of the pigment in subsequent years
following the tattooing. This 'pread of the pigment is related to the ability
of fixed tissue histiocytes and migrating macrophages [0 engulf the pigment
granules and move them along tissue planes.

White
Titanium dioxide. which creates a white opacifying appearance. has
never been implicated in any a'llergic reaction. However, Dischoff and
Bryson , in their study of tissue reaction to and fate of parenterally
adrnini~tered titanium dioxide, noted that lhe relative catalytic activity of
the tiranium dioxide molecule is related to variation of its substructure.
Their analysi ' was that titanium dioxide was bound to four oxygens and the
oxygcns to two titaniums with the exception of the periphery. They nOled in
their experiment that intlammatory responses occurred in a Peyer's patchlike area due to the formation of a titanium dio.xide colloid of smaller
particles from the deposit in the adjacent serosal areas.
Talc has been used f(lr years in tanooing for its unti-caking ability. as
well a~ its usc as an opacilicr and whitener. Talc granulomatosis has many
similarities to sarcoidosis and, because of t.he potential for granulomous
formation, surgical gloves today are no longer coaled with talc. It is the
specific concern of a potentia l for talc granulomatosiS that one of the
companies (Cooper-Vision) has elected to remove talc from its iron oxide
pigments.

DElAYED SENSITIVITY
REACTIONS

Keloids
Kcloids Jo occur sct:ondary to lal1ooing. but far morc keloids are the
rewlt of the removal of tattoOS. These are most often seen on the deltoid.
This is probably more anatomic than duc to the talloo or the method of
rell1(1Vul. since rhese are seen with dermabrasion. sulabrasion. excision. or
laser therapy allhese sites. Fortunalely. keloids are rare on the eyclitls.
Intt:t1tional keloid, or st:u rirication. is practiced by many tribes in
Africa us a form of body an. Since taUoo pigment injected in dark skin is

1<J2

COMPLICATIONS

nol ve ry visible, some Arrican tribes cut the skin and abrade the incision
with cither salt or sand to further irritate thc wound, resulting in raised.
hypertropic scars or keloids. The. ub equent bas relief of these keloids is a
true Ul1 form in many cultures.

Papillomas and Varrucoid Nodules


Papi l10mas and verrucoid nodules do Otcur. but arc rarely seen and
usuall y temporary. True walts have been previollsly discussed.
Some other interesting, though rare. react.ions include erythema
l1lullifonl1e secondary to tattooing, loca lized scleroderma, possibJy related
to a cht!st tattoo, and an arteriovenus aneurysm. Some dyes and tattoo
pigments rnay be radiopaque. hence showing up as x-ray opacities.

Lymplwdenopathy and Lymplwdenitis


TallOo pigment may travel to regional lymph nodes and cause a
nonspeciftc lymphadenopathy. The heavy pigment secp in the lymph nodc
might be confused by an inexperienced pathologi. t with melanoma.
A 30-year-old male was presented to our co-author, Dr. Norman
Goldstt:in. M .D. because of axillary lymphadenopathy and a pathology
repon of a lymph node biopsy pcrfomled on the United States mainland.
The surgeon had excised several lymph nodes, fearing a melanoma from
the tattoo. Histology was beni gn lymphadenopathy with taHoo pigment
clearly seen in the macrophages . The man, who wanted to become a tattoo
artist and advertise his art. wanted more tattoos in the future. Since there
were no medical contraindication, the patient was cleared to receive
additional tattooing. To lILlle there have been no complications.

Melanomas
Malignant mcliU10mas have indeed been reported in tattoos. Kirsh, in
1969, desclibcd a malignant melanoma with axillary metaslases occun'ing
twcnty-~cvell years after receiving a tallOO. The tattoo was removed , and
regional lymph node s dissection actually revealed metastatic melanoma
confined to the axilla.
Soderstrom hall a 36-year-old man with u tattoo of Christ on hi. back.
The man developed a melanoma in t.he tattoo . subsequently developed
metastatic disease of the brain, and died three months I:lter. Wolfort and
associates. in the British Joumul. of Plastic Surgery in 1974, described a 55yea r- o ld man tattooed twent y-nine years ear lier who developed a
~upcrficial ~prea din g malignant melanoma with no lymph node involvement.

193

CHAPTER

More recl.!olly, Yeu-Tsu and Craig. in 1984. reponed a 44-year-old


male who had multiple tattoos on his arm. and upper chest for ov r 20
years, who developed a 3 x 2 x 2 em polypoid malignant melanoma on hb
left areola. Biopsy showed it to be invasive to Clark's Level 4 and 2.5 mm
deep. Eleven axillary lymph nodes were examined. While they did cOl1lnio
tallOO pigment. they contained no evidence of metastatic melanoma. Two
years latc:r, the patient tlied wilh metastatic melanoma to the brain.
Radiation therapists arc also usi ng talloos to delineate sites to be
trea ted. A very intere~ting report of two cases of melanoma in radilltiofltrealed areas of tllttoos used for site localization was reported by Bartal,
Cohen. and Robinson. One ('ase was a primary melanoma, Level W. on the
t:he~l. In the second t:tlsc. two metastatic malignant melanoma nodules at
Latloo sites Wl!re rounJ on till! low back of;) 34-year-old man treated with
cobalt rays for Hodgkin 's disease six year~ prior to the JcvelopmcnL of Lhe
melanomas. 1l1ljia ink was used in both cases.

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20

10

R('slI/ls (~l fh(' l{lIesliol/l/(/jrl' ('Oil/piled hy Tile Americal/ Soc;et\, {~f'.ivlicr()pipnel1latio/1 Surgery. /ne..
(Dr. brer/ing (IIul Dr. Chrislt'IISt'IIJ 19M.
Total of' lII(JjoJllllinflr cOll1plicliliollS: 263
TII/ul coltlpfi(,lIliorl rate: 39f

/9-/

III

COM P L J C A T I O N S

Sarcoidnsis and Sarcoid-like


Granulo11U1S
It i~ the consensus of most investigators that most granulomas in
lalloo::. rcpre::.ent ~an.:oidaJ response, that arc nor manifestations of u'ue
:.arcoidosis. Sun:oidlll histopathology is also known to occur in

tuberculosis. leprosy , and deep fungiosis infections, and with inorganic


sall s of magnesiul11l1nd silicon (laic ).

HISTORICAL AND CURRENT

METHODS OF PIGMENT
REMOVAL
It is always important to remember thaI the pigments used in modem
tattooing are so biologically inert that there cxi~ts no natural metabolic

mechan ism or artificial means of removing them readily without some


damage m;curring to the site of the original placement. There is no way

or

restoring the skin to its normal state. The most reasonable and practical
method of removal certa inly would indude the previously-mentioned idea~
o f mec hanical r~m(l va l at (he time of rhe procedure or careful surgical

exci::.ion using a natural skin fold crease in the postproceuural period.


However, damage to the hair root follicles of the cye.Jashcs and the
potential for unsightly scaning are likely to occur. Historically, [here have
been many other meth ods of tattoo removal; however. most of lhe. e
mcth()d~ ,Ire not applicable to the deli 'ate eyelid area. [11 193., Parry listed
eighteen methods a~ "scientifically tc~ted, and approved by chemisb.
physicians. and surgeons": (l) the French method of variot with th' use of
tannic acid and silver nitrate; (2) salicylic aciu~ (3) monochloroacetic acid
or trichloroacelic acid; (4 ) carbolic acid; (5) sulfuric acid; (6) nitric acid:
(7) 'line tlu()ride: (X) mercuric f"luoridc ; (9) cantharides pla~ler: (10
glycerol of papoid (or glycerol of caroid): a powerfu l organic digestal1l thm
digc~ls the ti sslie in queslion: (11) zonite: a sol ution of sodium
hypochloridc approximatcly twice as strong a:-. Dakin's solution : (12)
c1eLlroly~is: ~i milar t(1 hair removal by electricity, feasible only on small
1alloo dc~ign.,: (13) slII"gcry: mechanical removal by raising the !lap of :-kin
and scr:lping otT the pigment from the dermal areas: ( 14) surgery using a
gra ttage (a lillie steel scrub bing brush ) alld then applying hydrogen
peroxide:: (15) cmancou'. trephining: (16) freezing with ury icc and then
~uh~cquent mechanical debridement: (17) simple excision: and (IS)
acbion with grat'l for the purpose of a more modern day c1as~ilicalion.
We have recommended the followi ng general categories fo r tattoo
rCll1oval.

}1)5

CHAPTER

Surgery. Simple excision with primary closure appropriate for small


Ii removal in segments or excision and
subsequent grafting:
Punch Removal - with or without su tures for some small clark tattoos.
Dermatome removal- with or witbout grafting.
Dermabrasion - use of a wire brush or diamond fraise with or without
grafting.
Salabrasion - use of salts with mechanical application.
Chemical Methods. Many of Parry's methods are still being used
today, including phenol. nitric acid. tannic acid, sulfuric acid. silver nitrate,
and silycilic acid in the combination of dermabrasion with tannic acid or
si I vel' ni trale.
Countcl'tattooing and Retattooing. By the use of white or off-white
pigment. an attempt: can be made to lighten the underlying tattoo. Blending
of the tattoo line with the natural su rrounding skin will mitigate any
unpleasant cosmetic effects.
Physical Methods. Physical methods include cryosurgery, with the lise
of freon sprays, tarbon dioxide and liquid nilmgen; heat. with ule use of
electrocautery with or without curettage and ultraviolet light: and laser
therapy, with the usc of carbon dioxide or argon Insers.
Complications related to all the previously-mcntiont~d technique.
include : hyperpigmentatioll. hypopigmentation , atrophy. keloids
hypertropic scars. local hypere~;thesia, and failure to remove the pigment
itscl r.
The best results [or correction of malpositioning of pigment in
micropigmcntation around the eyelids would he obtained with immediate
removal at the time of the procedure. Two of our authors (Drs. Zwerling
and Goldstein) have been conducting ongoing research with the new iron
oxide pigments to see whether or not these can be removed safely and
effectively with the argon la~er. Their results have been consistent with
other researchers in the field: hypopigmclllation and postlaser scarring.
Laser removal of decorative and traumatic tattooing has been performed for
many years by many different investigators. A number of differen t la'\"ers
have been utilized for this purpose including argon. Nd- Vag. tuneable dye,
Q-switcheu ruby. and C02 lasers. Since all tattoo pigments . electively
ahsorb laser light regardless of color or composition, all these la~ers have
had varied success. The pigment is vaporized by the laser light into a plume
that exits the skin \'-'ith minimal uamage to the surround in g skin and .its
<lppcndages. The postll1ser inflammatory period is dominated by the
introd uction of tissue Illacrophages that continue to remove additional
pigmentary residues. Finally, the upper I 111m of the dermis is replaced by
dilfuse collagen.
E<Jrly attempls at tattoo removal with the ruby. Q,switehed ruby,
carbon dioxide and argon lasers have met with mixed results . Subtotal
pigrnel1l blanching and hypertropic sears were common side effects. or a.1l
the lasers 1l0led in the stlldies by Apfelberg and associates. the argon laser
has rroven to be the most effective for cutaneous vascular lesions and
trCl1lrnent of tattoos. Dr. Apfelberg noted in his experiments that excellent
Of good rc;"ult~ were achieved in greater than 50% of the Lalloos lreated.
taHooS; for .Iarger tattoos, staging

/t.l6

COMPLICATIONS

One hunured percenl of all patients. he noted. e:'\pericnced a permanent


chang.e in skin texture. consisting of a fine lauice-like tiligree of shiny skin.
as well as associated hypopigmentation in approximately 26% of Ihe cases.
In the histopathologic studies foUowing the argon laser treatment, it was
noted that the norlllal epidermis had full reconstitution with disappearance
of pigment. cells in the upper dermal areas.
Lisrn::Il1, Smith, Rodriquez-Saing. and Jclk;; noted in their experimental
protocol at Manhattan Eye. Ear. Nose and Throat Hospital that tile use of
the laser could be by direct laser depigmentation. derll1ahra~ion followed by
a laser. or cxcision followed by a laser in white patients only. They nOled.
as in the Apfelberg studies, that hypertropic scars had occurred ill some
cases.
The llpparcnt mechanism by which the tattoo removal is accomplished
is localiLcd vaporization of the dye particles. which are expelled from the
tissue in a gaseou. form as of a laser reaction "plume". Tissue damage is
generally confined to the areas in which the laser energy is absorbed by the
pigment granules. Healing of the epitheliulll over the laser-lreated areas is
usually complete, with underlying increased fibrobla~tic and collagen
activity.
Dr. Adrianna Scheibner has conducted some interesting case studies in
which the Q-sw itchcd ruby laser was llsed to treat hypopigmented and
atrophic skin. The p(l~tlaser fragmentation period was completed with the
llslIal collagen response as noted above ; however, there was a definite
repigmentation of the atrophic. hypopigmcnted skin. These studies seern to
indicatc that melanocytes allcl keratinocytcs are reactivated when particular
collagen restructing occurs. In an erfort to reproduce this collagen-melanin
reacLion with a more asscssable procedure, Margot Schweiner. RN. COT
has utilized micro-entomology needles WiUl a modified tattoo machine to
perform concentrated sysLematic trcpannatioll (CST). The initial results
have uemonstratcd a consistent success ratio of repigment<ltion similar to
the results of Dr. Scl!cibncr' s la<;er approach . The pr(Kes. of repigillentation
hy u~e of the laser or needk stimulation of the collagen bas been termed
MultiLrepannic Col1agcn Actuation.
From our WNk with local cO~ll1etologists , we have round a relatively
,impl e and safe method for "artificially reversing" the blepharopigmcntation proce~~ . The usc of a translucent white facial powder applied
10 the eyelashcs has the effect of "erasing" the results of the blepharopigmcntation. Thi temporary reversal for cosmetic purposes is particularly
important in wumen who pursue an acting career and wish to have the
blepilaropigmentaLioll performed . Under slit lamp microscopy one call see
the fine translucent white powd~r interposed among the bases of the eyelash
, hafts . Even tilough this is not a pcnnanctll rcmoval process. it is most
comforting to tell Ollr patients about it prior to the blepharopigllh: nlation. as
it gives them the feeling of ~ome tlcxihilii y.
We wi::-h to reemphasize that. presently there is no treatment that has
proven 10 be a hundred percent effeclive method for the removal of taltoo or
micropi g.IllCntatioll -type pi gmcnl.

197

H A p T E R

Pigments

Currently, there are a number of major companies providing pigments


for blepharopigmentation. Significant differences exist in the chemic:al
composition of these pigments, as well as in lhe color selection available
to the practitioner. This chapter will discuss unly those pigments currently
availuble on the market and w ill mention any future plans only in
summary. Most companies are using some form of synthetic iron oxides to
aeate the basic ea rlh tone co lors for micropigmentation. For a detailed
discu~sion of current FDA evaluations of thc pigments as color addilives.
the reader is directed 1O Chapter 4 .
The ideal pig.ment used in micropigmentation shou ld have the
following characteristics: nontoxic, non-irritating to tissues. stable to light.
inert to tisslie metabolism . a nd extremely insoluble. In addition, the
pigmenl granules should he large enough (at leas t 6 microns in . izc) thai
tis s uc macrophages or bistiocytcs have limited anility 10 migrate the
pigment granu les over a period of ti me.
The synthetic iron oxide used in pigment is made from iron su lfate
mixcd in a basic sol ution to create ferric hydroxide; then by heati ng the
Solulion and remo vin g the water. iron oxide in a ferric sy nthetic state is
created . Different tones of color arc crea ted by the adding of FC20},
esse nti ally a brow n nesh-tone ~' o l or, mixed with Fe304. a rather black
tone quality uftcn used in l1la~cam. Titanium dioxide can be added to the
iron oxide co lors as an opac itic r or whitener to e ither lighten the brown
color or creatc an appealing charcoal grey color. Both metallic oxides arc
metabolically incrt and nonreactive within human tissuc . Some of the
companies havc deve loped a vast variety of skin tones and iron oxide red
formulUlions for lip liners . In order to ddiver the pigment under the ~kin ,
the pig.ment l11u~t be slispended in a sol ution. the dry pigme nt powder can
be mixed wit h 70 9(' isopropyl akoho l or the practitioner can buy the
pigme nt premixed wit h glycerine. water. and akoho l in sterile containers.
The Natural Eyes Company , when owned by CooperV isioll lIsed to
provide a pigment based on iron oxide wi th the addition of 700 pans per

199

CHAPTER

22

million of talc to provide anti-caking propertie . The pigment is


manufactured under sterile conditions and packaged in small glass vials
similar to those in which con tact lenses are packaged. The pigment was
mixed with 70 % isopropyl alcohol at the lime of the procedure . The
intensity of the color was mouiticd by adding more Qr IeI'. or the alcohol.
The company, since its sa le to Alcon, has removed all talc from its
preparations. [n audition the company now provides the pigment~ in premixed sterile containers. Because of the theoretical comp lication of Lalcinduced granu lomas. it is important that practitioncr~ check the chemical
composition and steri lity uf any pigment used in micropigmemation. The
lahoratory chemical analysis of lhe amount of talc in e.ach sample of the
original Natural Eyes pigment was determined by analyzing samp les of
magnesium by atomic absorption. The amount of talc - u mineral
contain ing magnesium, specifically hydrous magnesium silicate - ~ as
computed hy multiplying the amount of magnesium hy the stoichiometric
proportion or m..lgnesium in the talc. The analysis assumes thaI talc is the
only source of rnagnl:sium in the sample. The result of the tcst showed that
the amount of magnesiulll in micrograms/gm was 667, or 0.35 % 10 0.4%
laic by we ight percenl. In other words, the amount of talc wa
approx ima te ly Jess than 700 pans per million when mixed with the
synlhetic iron oxidl:. This data was furnished by the CooperYision
Company. The CooperYision Company had conducted extensive safety
resting of its pigment for blepharopigmentation in the early 1980_. A
cytotoxicity-agar overlay MG26, Arne, mutagenicity tcst. and 14-30-90 day
intracutaneous rnicroinjeclioll biocompatibility study were performed, and
all tests revealed that the iron oxide pigment and talc mixed with 70%
i:;opropyl alcohol was nonirritating and nontoxic.
The Ac<.:cllls Company produces a number of pigmcnts based on the
mixture of iron oxide and titaniulTl dioxide. The iron oxides produced earth
ton'~ from nesh browns to a black color. By adding an opacifier or whitener
such as litanium diuxide, the company has produced the following

Chemical Pathway for Production of Synthetic Iron Oxide


Basic
Iron Sulfate - - - - - - - - - - - - - -........ Ferric Hydroxide
Solution

Iron Oxides

2()(}

P1GMENTS

pigments: black, dark brown , medium brown , and charcoal grey. The
pigmcm comes packaged in sterile cmllact lens-type glass containers and
premixed with glycerin. water. and alcohol. The consi stency of the
pigment is similar to 1110lasses as it is poured from the container. No
stilTing of the pigment is necessary once surgery has begun. The company
has e timated Ulat its particle size is about 6 microns ill vil'o and thu!), this
pigment offers less chance for migration. Many additional colors arc now
available.
The Accents Company also performed analytical atomic ab orption
analysi . of its pigment and found that it coniains no talc or magnesiulll
residues, and the company has also offered statistical data in which ocu lar
ilTiulti.on studies. Ames mutagenicity tests. preautoc!ave and po tautoclave
cytoloxicity tests. and modified LD-50 subcutaneous and intntcutaneous
microinjcctions test in rabbits were performed , all producing negative
reactivities. The lack of reported complications from intradermal use of
iron oxides or titanium dioxides is consistent with the reports from
dermatologists in the medical field. The Accents Company feels that its
product, consisting of synthetic tested iron oxide and titanium dioxide. has
been shown to have no complications when compared to materials used in
commercial therapeutic or cosmetic tattooing. in a newsletter written by
Dr. Fenzl and Thomas D. Keeley, the company also points out that certain
materials were found unsuitable for use in tattooing. such <L'> mercuric,
sulfide , cadmium . ulfidc. cohallOus aluminate, and cadmium sclenide.
These specific materials have been implicated in swelling and erythemas
following tattooing, as well as granulomatous reactions. The company also
points out, based on references to articles written by Pat and Kahn, the
potemial for granuloma formations whcn using materials containing talc.
Vision Concepts marketed three pigments containing a proprietary

Pigments
Multiple
Pigment
Colors
Company Available

Contains
[ron
Oxidc

Contains
Titanium
Dioxide

Contains
70% I ropropyl
Alcohol

Contains
Ethyl Alcohol
& Glycerine

Contains
Talc

Natural Eyes Yes

Yes

No

Yes

No

No

Accents

Ye:-

Yes

Yes

No

Yes

No

Lasting
Jmpressions

Yes

Yes

Yes

No

Yes

No

Permark

Yes

Yes

Yes

No

Yes

No

Dcrmou Flage Yc'>

Yes

Yes

No

Yes

No

201

CHAPTER

2 ')

mixture of iron oxides and litanium along with USP glycerine. waler, and
ethyl alcohol. The company esrimated the pigment pa11icie size to be 20 to
35 microns; the particle ~ize prcvented pigmentary migration. The pigmenl
came premixed aJ1d in sterile container~ similar to those of the above two
companies. The color. of the pigmenls that were available are black.
brown-black, and brown .
The Alltak Company produced n variety of pigment colors based on
lhe usc or iron oxides lind titanium dioxide mixed with glycerine. water,
and alcohoL The color~ available were solid grey. black, medium brown,
black-brown, and blue-black. The pig.ment came prernixed ill sterile glass
containers.
The Eydite Company offered three earth tone pigment colors: black.
black-brown. and hrown. The chemical c()mpo~ition of lhe pigment was
based upon the mixture of iron oxides with glycerine, water. and alcohol.
The pigment was m,-Illufactured Gnd packaged in sterile glass containers.
The Pcrmark Company producc~ a vast variety of earth-tone colors
based on iron oxides mixed with glycerine. These pigments have beell
prepared under sterile conditions <lOll packaged in vials very similar [() the
Accents prepurution. Permark contil1l1c~ to research and develop nc\y
pigments including a complete spectrum of skin tones and uppropriute Up
liner colors. These pigments have been used over the pasL 6 years with no
rcponed complications.
Since 1989. the Derllloullage Clinics, Inc . has produced iron oxide
pigments for the usc in all micropigmentat.iol1 procedurcs. These sterile
pigmcnts are also prepared with iron ox.ide and titanium composition: with
a glycerine hase. The company offers a wide variety of colors including
useful color charts and guide, for the practitioner);
La~ting Impressions [ has recently cntered the micropigmenlation
market with a large variety of iron oxide has'd pigmems. The company
oilers also hdprul wlor charts and mixing guiddines to aid the practitioner
in producing appropri,lte colors. The company guarantees strict quality
control and sterility of its product - which is ollered in four conwnienr
co~t-cffecti e size~. The iron oxide particle sile is also :iix microns or
greater.

HISTOLOGIC REACTIONS IN
MICROPIGMENTATION
The initial histologic reaction to the micropigmentuliol1 i~ due to the
mechanical disruption of the skin by the reciprocating needle injecting the
iron oxide pigment below the epidermis. During the first one lO two week"
there i:-. an acu((; inflammatory reaction due to thi~ tis!>ue damage alld local
area~ or necrosi~. Following the usual g.ranulati.on response to li .. ue
damage , the cpidcrmi:. anJ !>upcrficial deflni~ heal without .,ignii"icaIlL
histopathologic reactions. In the areas of the papillary and reticular dermis

20::

GMENTS

where the iron oxide pigment has bcen dero~iled. there are usually
minimal aggregates of lymphocytes, rixed tissue hystiocytcs. and
rnacrophages surrounding the pigment. Over the next few weeks. the
mucrophages begin tl} engulf the iron oxide pigment. and there is a local
migration of the pigmem-Iuden macrophage towards nearby blood vessels.
Throughout the papillary dermis, there is a mild fibrosis with areas of the
refactiie pigment. granules imerdispersed among the col lagen bundles. The
blood vessels in the superlicial demlis are usually dilated.
From a histological , talldpoint, the body's response to tattoo pigments
can be classified in three general catcgOlies: (l) minimal tissue response
with Illild fibro:i:; of the papillary dermis and accumulation of pigment
aggregates surrounding superi"icial blood vessels and pigmenl granules
intcrdisper~ed between the collagen bundles: (2) marked fibroplasia with
aggregatcs of giant epilheloid cells. creating a fibrohistiocytic pattern
similar to dermatofibroma; and (3) marked hisLOcyLOsis cau , ing a
granulom<ltcous intlammation with (a) foreign body-typc reaction with a
prcponderancc of giant cells containing pigmcnt"; or (b) the san.:oid type"
consisling of aggregatcs of epitheloid histocytcs also containing small
quantities of pigment.
With the use of inert iron oxide pigment in micropigmentation, only
(he mild fibrotic type of reaction has been documented. Thcoretically,
thosc pigments containing talc as part of the formula have the potential for
forming a hi:'>tocylic gfHllulomatousintlammatory responsc typica l of the
foreign body-typc of reaction.

MALPOSITIONS OJ?PIGMENTS
One of the mmt frequent questions asked by patients ii) that if they do
not like blephampigmentatioll procedure in the futlire. can they have the
pigment removed') Another common question is how would the
practitioner best manage malposition.ing of the pigment spot or even a
whole pigment line? The beSl I11ctJlOd to avoid rnalposi tioning of pigment,
of course, is correct positioning in the first place. Malposition of the
pigment can be minimil.cd by precise technique with a cooperative and
immohile patient and having a good first assistant. However. if
rnalposirionillg of the pigment does occur. it is ideal to remove the pigment
immediately. First, lhc practitioner should take the tip of his
micropigll1cntation ncedle asscmbly and rin~e it profusely in 70 %
isopropyl alcohol or ethyl alcohol, removing any residue of pigment. Once
the needle tips are cleaned and debrided or .tll pigment, the area of
pigmentation is then dehrided signi tieantl)' with the needle to remove all
t.raees of the pigmcnt. It is best to proceed ~Ijghtly deeper than the usual
pigmentation level to crea le an uplifting effect, therefore removing the
pigment granules. There should be a certain amount of heme and exudate,
which hdp in the pigmentation removal. Since the patient has n certain
amount of swelling and brui,"ing from the procedure anyway_ the eXira
.1Il10Ulll of welling and brlli~ing from this debridemcllt procedure will not

203

CHAPTER

2'"

be as greatly noticed as it would if the patient h~td to return at a later time.


The practitioner should be absolulely sure that the positioning of the
pigment is in fact correct. because after the reduction of the swelling a
slight mal positioning of the pigment is unnoticeable.
In a modified version of salabrajiion . Dr. Zwerling has lIsed another
rechnique for the removal of extraneous or malpostioned pigment. He
cremes a mix.ture of glycerin, sodium chloride, and alcohol, and then runs
the needle ()vt::r the area to be extracted in ~t manner analogous to the
method llsedin implantation of the pigments. Apparently, the solvent
alcohol and salt 'Iowly extract the pigment after multiple applications;
however, due to the probability for 'econdary scarring, this method is
applicable only in the removal of small single dots or in a few isoltued
patch areas.
If. however, the debridement process of deallSing the needles is not as
!iuccessful as the practitioner would like. the practitioner call use a riny
curet and/or bent cystotome needle to dig out the pigment granules. Careful
allemion should always be appliecl LO the eyelash root follicles in order to
prevent subsequent damage. As noted in the previous chapter on tattoo
removal, we have worked on a research project investigating the use of the
argon laser to treat the rnicropigl11enl granules by direct photocoagulation
energy. The final net effect of argon laser lherapy and more reeenlly, the Q~wilched ruby red laser, and C02 laser has shown a definite
depigmentation or cOl1ventional tattoo and rnicropigrnentation pigments in
the skin. There is a tendency for post-laser hypopigmentary skin changes
and scarring with increased laser energy. With the use of a local ane thetic
injected into lhe sudepidennal space, we have found that the effect of laser
depigmentation has been more successful.
Scarring aml secondary pigmclllary changes have diminished, as well
as a marked decrease of hair loss. We believe the reason for this
improvement is rdated to better cooling of the surrounding tissue from thc
" buffer effect" of the anesthetic. as well as an increase in the phy icaJ
the pigment t'romthe hair shaft and the damaging effects of the
distances
thermal energy of the laser. This situarioll is similar to treating pigment
epithelial dctachments or !-oubretinal neov({scuJari'l.ation in the macular area
of th(~ rctina, ill whieh the thcrmal damage is located at the level of the
pigment epithelium
the retina. and the sensory nerve fibcr level of the
retina is spared. Howcver. further documentation and research are
llecess:.uy to be sLlre that the process is complete and without serious
complication.
At the suggestion of Dr. Albert Klegl11an of Phi.ladelphia, one of the
pioneers in the u<;c of Tretinoin (Retin - A), Dr. Goldstein has started
treating a serie~ of patients with classic tattoos with Rctin-A am] laser. By
pretreating the tallo() site with Helin-A for three to six Illonths. Ics.
aggressive C02 laser energy is required for tattoo removal. The
prclim.inary findings indicate Ull improved post-laser cosmetic result. The
use of Retin-A in th~ ocular area is toxic to the conjunctiva. Themf'orc. this
combined druglla~er treatment modality must Tlot be used [or the removal
of eyeliner tattoos.
Another intere&ting and promising method for improving Laser

or

or

20.;

PIGMENTS

PIGMENT HISTOLOGY

c - - - ___

Fi rst Phase of Uealing wilh Crusting of Injection. Initial


inflammatory r~sl)ollSC (If the ti"~Ut to the physical injury of
Ihe p<'nctrating needles and t.hc inscl'tion of Ihe iron o" idc
pigment granules. Th.is ph.1,)C (Onsist.;. of increase in vascular
permeabil. it~ and I i.SUl scrous exudall'S_ There, is a migration
or tClIcocylcs and macrophages to Ihe ureu of trauma by
chrnlotllxi '.

The sccond phase demonstrates resolution of tbe tissue


exodattos and r~pair of the epidemJis and dennis (crusting
noled Oil the skin Surface). In this stage. the leu('ocytcs
hal'\' been replaced by lymphocytl'S. wsinophils, ftlrd~lI
hody giant ccll~, and tlcclisionatly plasma cells. At this
stage the lIIacrophuges show signs of engulfmenl of the
pigment aggreg:ltl'S.

c
D

The third phase, ahout ten dll) s IJUs t operatively, reprcscnh rcpair Hf tile cjlidermis.
remodeling of dermal collagen. nnd red is
irihution of the pij.(lllcllt ir"n (lxiflc I!ranulcs.
The epidermis h l'omplete l)' he a led with
db:1PJlearanl't~ of the slIpcl'lil'inl crusting. The
papillar~ and retkular dermis demonstrate
signs of remodeling of tissue coll:tgcn. The
pigm~nt is present in rli.tinct arras \Iith
aCl~ullllllati"n within macf(lpha!!e~ around t.he
dermal blolld ve:ssek and hetween the collagen
hUI1(II~s of the dam is. There is u distinct
pcrifollicle clear zone wlltainill~ IHI pigment

LEGEND
A.
B.

C.
D,

E.
F.
G.
H.

Epidermis
Papillary Dermis
Reticular Dermis
Hair Follicle
Blood Vessels
Pigment Granules
Point of needle
penetration with tissue
serous exudates heme
Area of collagen
remodeling

tlemcl1t~.

L-___________________________________________ --

The fourth and final phas~ demonstrates the absence of UIl)' inflammatory respons~. There i an accumulation of the pi!!Olcnt around the
blood n-s.o;cls wit.h an occasional macroIlbage. The dermis reveal igns of
fibrosis from the contrnClion and relltudeHnj! of the coll:lJ,:cn bundte. . Sum'
pigment can be found bet ween the
collaJ,:cn l.lIUldkos. With excessive depths
,)f needle pendration, pigment can he
found within the orhil-ularis muscle
I"yer.

205

CHAPTER

22

aporization of tattoos is employment of colloidal dressings. silicone gel


sheets and other non-adherent wound dressings. Preliminary comparison
studie:-. are underway and will be reported at a later date.
An interesting variant III pigment malposition is deficient pigmentary
t.lepllsition. In this situation. the amount of pigment deposited decrease >
wbi Ie the amount of tissue damage is increasing. There are a number of
causes for lhis problem: pigment t.lillltion. needle port occlusion, and the
railroad track phenomenon.
Wilh pigmentation dilution. lhe suspension of pigment. is mixed Wilh
tissue exudates and heme on the sUltile\! of the skin :0 that the amoulll of
pigment being placed or inserted below the epidermis is diminished due to
the dilution effect of lhe tissue exudates and/or heme. Thi~ problem can be
solved with lid clamping adjus tlllclHs or by removing the lid clamp and
allowing for natural hemostasis before proceeding in that area. Also. the
needle tip assembly will need cleaning Wilh an alcohol-type mixture La
remove any residual debris before proceeding.
Needle port occlusion occurs when the pigment suspension is allowed
10 dry on the needle whi le the practitLoncr i, preoccupied wilb some other
aspect of the procedure. This problem i~ eal)ily solved by cleaning the
needle with 70'k isopropyJ alcohol or ethyl alcohol solution and tJ1en
reuipping the needle into the pigment suspension.
The railroad track phenomenon has occurred only with the three needle
tip assemblies. This multi-needle assembly is essentially an equilateral
triangle of the three needk~. If one of the needles is sligh tl y longer and
displaced, the disposition of the pigment occurs in two lines instead of one
single line. The two lines are separated by it small area of unpigmented
tissue. Ir this problem 0 Cllrs after beginning the case, the praCtilioner
shoulu immediat.ely stop and open another pack and replace the needle tip
assernbly. If the practitioner tries to simply fill in this unpigmented area, he
will invatiably ovcrpigment lhe line.

A DDITIONAL PIGMENTATION
Thl.! practitioner . hould be ahsolutely slIre thal the patient really does
necd the extra pigment, and that u careful plan of allack has been
cOllsidered. The addition of eXlra pigment is actually easier than the initial
proces~ and takes only a few minutes. From a marketing standpoint, we
recommend that the prnctiti~)J1er only charge for the cost or a di:;pos,lble
pack. Modification of the color can also be done al thi~ time i r it i really
necessary. The application of the new pigment is performed in exuuly the
same manner as the original pigmelllation process.
After approximately one month of healing from the initial procedure,
the practitioner will notice under m<lbrnification. areas of depigmentation
along the eyelash ll1argin~ . These areas have been called "halos" by Dr.
Giora Angres and repre:-:ent zone:. or pigment removal hy the secretion of
the :-iebaceous glalld connected to the hair follicle shafts. Thesl;! halos crcat >
a l110re natural appearance in the bkpharopigmental iol1 and other

206

PIGMENTS

micropigmentarion procedures. In the ca~e of permanent eyeliner. by


breaking up the monotOny of the line, these halo. create a lovel y and appealing appearance in the la. h margin.
These natural halo" around the base of the eyelashes need to be
differentiated from " skip areas" that are noted along the eyelash margins
and cause disruption of the lid contours. Skip areas can be due to two
causes: the practitioner could have missed placing Ihe pigment granules
along the eyelash borders or the palient may havc picked at the crust
po~tprocedllralty and removed the pigment frolll the suhepidennal space. In
either case, additional placement of pigment should be defeJTcd for at. least
one month in order to better as. ess the skip area condition.
The application of the new pigment is performed in a manner relatively
similar to the original procedure. The major difference in the process.
however. is the need to c.:rcate a harmonious balance with the opposite lid.
When the prac.:tilioner returns to add additional pigment [0 one side, he is
faced with the dilemma lhat the carpenter has when he tlies to balance a
four-legged table. The tendency is [0 overpigmem the lid in the secondary
application process and cause another situation of unbalance between the
two eyes. To minimize the po 'sibility of' overpigmenting. we recommend
the lise of single needle to apply the pigment. Also, we recommend that the
pigment densi lY be approximately half the strength of the initial pigment
:trength used. During the reapplication process , the practitioner should
always compare the eyelids carefully. If there is a choice between adding
additional pi g ment to a preexisting pigment site verses an area of
hypopigrnemation. it is aJway~ more prudent to add the additional pigment
to t.he hypopigl1lented area.
An unusual and potential source for additional pigmentation can occur
with the novice practitioner applying the pigment line too far from the
mucocutaneous border of the upper and/or lower eydash borders. This
creates a "white zone" between the pigmented border and the mUCQcuteous
bordl!f. The appearance can simulate in the lower lids a pseudoectropion
effect and in the upper lids a rnalpositioning of the pigment. In these special
cases, we, recommend the lise of additional pigmentation approximately one
month laler. Before the practitioner bccome s too aggressive with
rcpigmenting these pmticular patients, the patient should be asked whether
she is truly unhappy with her "new look:' Often what the practitioner feel s
is Ie. s than ideal is a quite satisfactory effect in the patie nt' s opinion.
Therefore . the practitioner should be most carerul not to create an
atmosphere of discontent when there is none to begin with.

PIGMENT MIGRATION
There is essentiall y three mechanisms by which pigment call migrate
ark r injection bcneath the skin in either tattooing or micropiglllcntation.
The rir.~t meei1anisl1l il> the movement of the pigment granules along the
Juct:, of !'ccrcting gland. In this instance. the pigment gmnuJcs are inserted
~ol11cw her(' along or in clo~c proximity to a scbaecolls gland. The gran ules

207

CHAPTER

22

are collected and remnved through the duct system of the sebaceous gland.
It i!-, thi~ mechanism that create. thc w-called halo effect noted around the
base of the eyelashes . The movement and removal of this pigment i .
relativdy slow and takes from one to two weeks to complete. If the pigment
is inserted too deep into the eyelid area and penetrates the tarus. then
superficial spreading can occur primarily by this mechanism into the ductal
system of the l11eibomian glands.
A second mechanism for pigmentary migration is the injection of dye
Of pigrnenl into loose connective tisslie or the orbicularis muscle. Because
the tis.~lIc does not have a compact density. the pigmcnt granules can slowly
migratc over a long period of time along tissue planes due to the
surrounding muscle action.
Tile mechanism ror migration. and probably the 11l0:o;t significunt, is
engulfment of pigment granules by fixed tissue histiocyte. or l1ligrating
mauophages. 'DIe pigmcnr-Iadell macrophage mo\'es toward the nearest
bl 10(\ vessel or lymphatic channel by , ome chemotatic factor for final body
removal. Howevcr, if the size of the pigment grJ.llule is 6 microns or larger,
then phacocYlosis by the maaophagc is more difficult and penetration of
the blood vessel is markedly limited by the size of the pigment-laden
macrophage. If the pigment granule is approximately 3 microns in size,
such as the pigment granu]e~ associated with India ink or ~)rbon panicles,
then maerophages arc able to engulf these pigmenls granules and "lit"
through the endothelial pore system or the blood vessels. Iron oxide
granules are approximately 6 microns in size, and thi .. would account ror
their low tendency for spreading or migration. The macrophage or fixed
ti!-'sue hisliocytcs generally move the pigment towards blood vessels by
somt; chemotaxic racton; for final removal by the circulatory system and
possibly lymphatic sy~tem in deeper lis~ues . IL is for thi: reaSon that we can
sce the accumulation of Lhe pigment primarily in the papillary and reticular
dermis around the bl<)od vessels.
In the cydid area, all three of the ahove mentioned mechanism: can
and do occur. The halu cffect is created by the accessory sebaceous gland
removal or the immediate pigmcnt following the procedure primaril.y in the
first o ne to two weeks. The fixed l1onmobilily of the pigment i .
accomplished by relativcly high tissue density at r .2 mm to 1.5 mm in
deplh helow the skin ~lIrrace. as well as the " boulder size" of the 6 micron
o ide pigmelll grallllle~: however. if tilC practitioner is too aggressive and
penetrates the tarsal plate, ~pre<lding can occur Jue to the glandular ductal
sys tem as well as the looser subcutaneous tissue area just prior to rcaching
the tar~al plat!:".

H A p T E R

State of the Art

Over the pasl decade the fie ld of micropigm.::ntation has undergone


numerous changes. From the initia l humble beginn ings as an adjunct to the
surgica l armcntari ulll of only oph thalmologists, micropigmentation ha~
now ~pread 10 otha med ical . pecia lists as well us nurses. [II the nonmedical fields, cO'melOlogists and tattooists have begun to employ
micropigmentation concepts in Iheir aesthetic: work. There have also been
substanti al changes within fhe compan ies that service the practitioners as
well as revolutionary new state laws that. affect physicians, nurse . ,
cosmetologists, and tattoo ists fo r providi ng micropigrnen tation services.
With all this change there has developed a critical need for organization,
siandardization, and cel1itication. If micropigrnentation is to survive and
be(orne lru ly re putable in lhe eyes of the public and medical specialties,
Wi: need to addre~s Ihe imponal1l issue:, of educatio n, credenliab, and
ethics. Instead of numerous self-serving private for-profi t ~ocietie$ and
org;l!lizations. we need a unified not-for-profit Academy to oversee the
proper dcwJoprncl1l of micropigrnem:llion . With this concept in mintl. the
~llIthors have suggested the formation of an A mcrican Acad emy of
Micropigmcntation.
This Academy wou ld be under lhe strict guidance of an American
Board of Micropigmcntation co mprised of the key kadel'S in the field
loday. The BO:1rd wou ld oversee the criticnl aspect of Board Certification
in Micropigmentation. Depending on their educational level. applicants
for certi llcation wou ld have to demonstrate dinical compe tence as well as
proper mora l c mduct and ethical iotanclarcb ill their practice. Membership
in the Acaderny wou ld nol depend Oil n:rtification ; however. all elected
officials would need 10 be Board Cenilied. B.:cause of the varioll S
.::ducational lev.:ls for the Illcmbcr:hip in the Acadtc'lll)' of
Micropigmentation. the authors he lieve that the Academy could have
different levels of educational attainment: for example, with the medical

209

CHAPTER

') 3

doctor ,mel/or IlUI"\C. there would exist the potential for Fe110wship based on
~ucccs~fu l compkt ion of the requirements for board eligibility as well as
passing an oral :1I1d practical exa mination with cu, e presentations. To
hecome Board Eligible un applicant would need (0 be a memher in good
standi ng in the American Academy of Micropigll1entatiol1, provide letler: )f
recomme ndation bil ~ed on the observation of the applictlm's perrorrnance.
sliccessful completion of a Board recognized course in micropigmentat.ion,
successful completion of a written examination. and tinally a rea'lonable
time limit of cmnpletion of all the above requirements. Only with serious
guideline: and a ~trict crcdcntialing process will hoard cenification ha e
any Ine<lning with publ ic and medical acceptance.
For the non-health l:llrc provider. cosI11eto iogists and tattooists, the
Academy can pro"ide affi liatc membership status with certi fication us a
Dcrmatccluwlogist. This statu s would enSUJc that rhe applicant has met
millimal Slandard~ and demonstrated competency as a technician in the
field . fl is the opin i(ln of tbe authors as well as [he m:1jor companies thaI all
non-health care providers must be under direct medical supervision and/or
local Health Department standards to ensure public ::-afety. Policy and
quality as~ural1ce ill regard to this subject will be discussed ill the next
chapter 011 quality assurance.
The membership of lhe Academy could e lect a President and two
cxecutl\'c Vice-Presidents with Regents rerre~ent e d by health care
providers from each State of tho: Uniled Stales of America as well as each
Province of C;U1ada. The Regents then would fnrOl a Hoard of' Regents to
govern the members of the organization and see to t.he various educational
and sciemilic meetin gs throughout the year. The A.:ademy could develop
dillerent publications. newsletters. and/or journals for the membership.
Eventually we might even see the formation of a scientific center for
research wi th a library.
The Amcrican At'adem), of Micropigmentalion should establish certain
objeclivci>: maintain ilIl a~s()cialin n of ethical and compe tent health care
providers in a nOIl-prolit environment for tile benefit of the public hy the
furthe r dcveli)pl11~,nt or the an and sl.jel1cc of l\.1icropigmentatiol1.
The auth,}!'s welcome comment about this concept. We request t.hat you
write to the ;IlHhor~ with your advice and criticisms. Only with your help
\vill idca~ weh a:- an Amt?rie~1I1 Academy of Micropigmcmation hc(;olllc
reality.

2111

.- .....

H A p T E R

24('

....
"',

"""

\.

\"

Quality Assurance

In our previous chapters, we have reviewed the current legal


unci medical applications of micropigmcmarion. We have
discussed the need for education. certification, and ethics. Consistent with
these necd~ are also the importance of establishing peer review. quality
assurance, and r.isk management. These issue~ are part of the everyday
performance of physicians uml nurses within the present day United Slates
health care system. Whether these issues are administered in a hospital,
nursing home. retirement village, or private medical offices, there are
review processei'> for quality of care of patients, The review process occurs
on many levels: peer review. boards of medicine and nursing. state. and
federal agencies. As physicians and nurses. we tIre accustomed to this
review process and believe that the field of' micfopigmentation must
devdop appropriate standards for a quality <ISSllrance and peer review
system. No doubt this concept will alien:Jte many practitioners especially
in the nnn-medical fields of cosmcto.logy and wtlooing; however, if these
people want credibility and acceptance within the health care system and
by the American public, then we lfIust relinquish a certain amount of
pre~enl individual "freedoms" , With mutual respect and compromise. we
can arrive at a common ground of ag.reement as to how different
practitioners should participate wi.lhin the field of micropigmcntation. The
ntlr~es, through the efforts of Annette Walker, R.N. , have established
excellent ground work in thi!> urea in their negotiations with the different
stale nursing boards. Certain policies have emerged during this process thaI
h;1\ e practical applications to the fidd as a whole.
Micropigmentation io; ;In invasive procedure that permanently alters
the human !>kin and i~ performed for the trea tment of medical disease or
disfigurement. cosmetic improvements, and/or body adornment. The
procedure i~ perforrm:u hy physician , . nurses, cosmetic technicjan~. and
talLOoi~t-; , Clearly there i~ significant overlap among rhe different
pre~.::denls

211
L-_______________________________________ _ _ - -

CHAPTER

') 4

praclitioll~rs who perform the procedure.


The authors believe that the true issue is not
w ho , hould be a ll owed to pe rform
micropi g men lul ion. but rather how the
procedure should be done within our health
care systcm. Certai nly no rca~onable per. on
would disagree that a patient wi th medical
disease, disorder.. , and/or disligurement mUSl
bc under the Illanage ment and supervi sion of
u licensed ptlysicia n. However, with physic ian approval and cleara nce, this patient
could receive micropigmcntation from any approp ri ate ly certified practitioner within the field. A patient: with no prior medica l problems should
certainl y be .tll owed to receive (;os metic enhancement from any qualified
pru(;titioner of micropigmenration. Therefore. we seek a system of inclusion
or all the practi tione rs of the art and science of l11icropigmentation rather
than any attempt to exc lude any panicular individua.l or grou p. An allinclusive system will onl y work if we reli nqui sh some of our indivi du al
freedom ~ and agree to establish standardized procedures for the application
of mi cropigmentalion as we ll as systems for peer review, quality assurance,
;lnd risk management.

We seek a system
of inclusion [forI
micropigmentatiofl
... rather than any
attempt to exclude
allY particular
individual or
group.

STANDARDIZED PROCEDURE
Any patient who desires micropigmentation for th e treatment of a
medica l disease. disorder. and/or disfigurement should preferably be under
lhe general supervision and clearance of a licensed physician. The physician
need not be present for the treatment, but should provide the praclitioner
performing the procedure specific instruc tions an d guide li nes. The
treatment protocul should consist of subjective and objective data that relate
to the diagnosis and specific tn;atmcnt plan . All patien ts should receive
appropriate informed co nsenl and be patch re~lcd at least 7 days prior to the
procedure. AllY complication must be referred immediately to the physician
and pos t treatment c\(lm in ation by the practitioner and physician is
required . .'\ ppropriate record keeping with signed and dated physician
orders, patient history. informed release. body maps. and pre/post procedure
photographs are required for all patient.s. The records ca n be used as the
hasi! for pet.'r review. quality ass urance. and risk manag.ement by
appropriate age nc ies. soc ieties. and/oJ' boards.
For tho se patient:" who dc:"ire cosmetic enha ncement wi th
micropigmcnlution and have 110 pre-existing or present Ill'dical disease.
disonkr or disfigurement related to the p1:J1l tr.:atmclll area. then no medical
supervision is required. A physician's deara m;e wou ld be recommended to
prokcl the practitioner. but would not be req uired. For e,,.arnple a healthy
Jl~jliellr requesting eye line r enhancement could bring. her eye doctor's
ckarance with her. This statement wo uld protect the rnicropigmelltat ion
practitioner from pnstprocedurallitigalioll if the patient or doctor had failed

21'2

QUAL[TY

ASS U RAN C E

to warn the practitioner of some pre-exisling medical condition. All records


and history and liwndalQfY referral patterns would remain Ihe same.
Similar reviews should also be perfonncd.

QUAliTY ASSURANCE PIAN


A duly-formed American Academy of Micropigmentatioll as
discussed in the previous chapter would create a Qualit)! Assurance Plan.
The Academy would endeavor to provide patient care of optimal quality
consistent with the cSlablishcLl instilUtional goals. A quality assurance plan
will promote effedive evaluation and improvement of the ongoing
activities designed to evalu,lIe objectively and systemically the quality
patient care provided by practitioners of micropigmenlation. to pursue
oppoJ1unities to improve patient care and services. and to resolve identitied
problem~. Problems are those set of circumstances or situations that, if
allowed to continue. could rc:-.ult in potential harm to a patient. The
importlliH aspects of this monitoring process would be performance and
procedural review, drug usage, medical records, infection control. risk
management, and any other data source deemed important by the
Academy. After the appropriatc data. quality and volume indicawr~ have
been hmnulaled, quality assurance boards or the Academy working in
conjunction with local micropigmcl1t:ltion societies, state and/or federal
health agencies can tben begin the monitoring process. It is important that
t.he non-medil.:ul rcader of thi .. book understand that these reviews and
agencies are already in existence and can be readily Ulilized 10 perform
these tasks. [f we do !lot fOllnuJate our own objective Academy with its
speci t~c quality assurance programs and credential process then we will
have our procedure dicta ted to us by uninformed bureaucrats or by
spccialty board~ with potclltial conflicts of interest.

or

RISK MANAGEMENT
A. Mason BlODgett & Associmcs, Inc. arc insurance brokers who haY('
kindly provided their guidelines for proper risk management for those
technicians who arc currently performing micropigmentation procedures.
The rea(kr j~ advised to update these guidC'lines direct.ly with this company
or their particular insurance carrier.

TECHNICIAN GUIDELINES
l.

BUS.I NESS SETUP


I. Business owner shall have a business license at hislher
headquarters address.

L-__________________________________________________________ _ _

213

--

CHAPTER

n.

24

PROFESSIONAL GUIDELINES
1. TtX',h nician will maintain medical history form on every client.
2. Before and after photos will be hlken 011 all coverup work and
all cosmetic work.
3. A follow-up ~Ippointmenl wiII be scheduled after every
procedure.

1I1. EQUIPMENT AND PROCEDURAL GUIDELINES


I. AU pigments wiII be purchased from U.S. manufacturers (FDA
administered).
2. Needles will never be reused.
3. Some method of heat sterilization or ethylene oxide gas
sterilizat:ion is recommended.
4. All cquipment must be in proper running order.
S. Glovcs will be worn with each procedure.
6. There will he hot and cold running water on site.
7. Pigments will be dislloscd of after each client.
8. The ofl1ce will be maintained in ~l sanitary manner per Center
for Disease Control Guidelines.
9. Disposable materials that come into contact with blood or
t1uids are to be disposed of in a sealable plastic bag. Disposable
sharp ob.iects that come into contact with blood or fluids
must be disposed of in a sealable rigid (i.e. puncture proot)
container.
10. Technicians operating a Pennanent Makeup or Cosmetic
Tattoo Business must observe and foUow all health division
and other state regulations pertaining to public bealth and
safley, and comply with state fire. plumbing, and electrical
regulations.

[v. SKJLL LEVELSIJ>ROCEI)(JRES


1.

2.

Beginners (those in husiness less than one year)


a. Eyebrows
b. Eyeliners
c. Beaut~' Marks
d. Lipliners
Advanced/Camouflage training
1. No camounagc student will be accepted unless they have
done 50 total procedures.
2. Camout1~lge students should have alleast two hands-on
procedures in cach category being taught.
3. Advanced students desiring advanced or camouflage
training in each area of expertise should have donc at least
tcn procedures On their own before being accepted for
such advanced training.
4. Camoutlage and advanced training teachers will maintain
12 to 16 hours of continuing education every ye~lr.
5. Stretch marks will not he a rccommended procedure.

QUA L

T Y

ASS U RAN C E

According to A. Mason Blodgett & As~ociates. U1C most significanr


malpractice claims have originated from inexperienced technicians
attempting to perform repigmentlltion/carnoutlage on large areas of skin.
Other significant exclusion would include the treatment of slretch marks.
chemical peels, and/or mil:ropigmentalion involving dermabrasion . The
reader i~ urged to communicate with the carrier directly for the mostup-LOdate information on insurance coverage.

MAlPRACTICE/LOSS
PREVENTION
Malpractice is bodily und/or propcl1y injury arising out of negligence
by personal or professional services rendered .

Bodily injury means physical injury , sickness. or discil-'ic sustained by


a person. including death which might result from any of the 'e at any time,
for exa mple. the inappropriate reuse of an unsterilized needle transmitting

the AIDS virus.


Propel1y damage is physical injury to tangible property. for example.
patient's clothing becoming stained from a spilled liquid. There are other
types of injury. such as, monetary injury. A patient may be unable to work
because of the ir injury. If the patient was a profess ion al model , the
monetary los ~ cou ld be ~ i gniticant.
The following step~ outline a basic common sense approach that will
not onl y reinforce your professionalism. but should also help you avoid
claims:
I.

Follow established professional .wd ethical s tandards. Keep lip


with current trands through education <LIld professiona'i
assoc iations.

2.

Keep accurate and detailed records! Use questionnaires. check


Illedical history. consult wit h other professionals if necessary.
Document treatment dates. times. special si tuations.

3.

Obtain client sigmlturcs, especially if there are pre-existing


Photographs may be helpful.

condition~ .

4.

Be consistent! Develop a ;' tandard method for handling all


clients: but remember that each client is unique and requires
individual care.

5.

Educate your clients! Be honest with your clients and present a


prokssional attitudc.

6.

Make sure that you maintain stute and local requirements for
training. continuing euucation, and licensing if necessary .

215

CHAPTER

2 4

ClAIM SETTLEMENT PIAN


I.
2.

3.
4.

5.

00 not admiL Ihlhility! Even with a legitimate claim. you do not


want to prejudge your case.
Gather all the facts. records. letters, summons. etc. These may be
your best defense.
Contact your insurance carrier as soon as you are aware of a
possible problem. Make a report. even if for record purposes only.
no not antagonize the claimant. Do not be overly defensive. Do
wh:lI you can to soothe the claimant's anger. Be polite and
profes:ional. Many minor nuisance claims often are eventually
orl)pped once the claimant'S initial emotional anger subside . .
Do not discuss the case with people not involved with the claim.
RUlllors may only harm ynur professiOlwl reputation.

The lechnician has the right to practice his profession if duly licensed
and appropriately trained. Undue criticism of the results or a procedure by
another tc..:hnician withollt knowledge of t.he circllm~tances surrounding
that procedure call result in oamage to the reputation of that individual and
constiwtcs lib~1. It may also result ill unwarranted legal action again. t that
technician as well as tarnish the reputation of the field . Professional "liabilily
insurunce data have demonstrated lhat the majority of filed law suits have
resulted from the inexperience of newly trained technicians who h,lve
improperly selected and/or applied micropigmenration colors, re~lIl1ing in
"permanent" damagc. Inexperienced technicians shou ld develop their skills
with ea~icr procedures, such as eyeliner and eyebrows. before doing the
more complex procedures. such as full lips and camoutlagc. Furthermore
the newlytrained practitioller should seek additional hands-on training
bef'on: aLlelllpring advanced procedures. Legal action against a medical
pra.:ti(ioner uwally re~lIlb in a civil suit fer injury. MOI1I:!Y damages Illay bl:!
awarded for pain and suffering. loss of wages and possible consortium, and
paymcnt of medical costs and corrections. Punitivc damages may be
awarded if reckless.or gros~ l y negligent condw.:t can be proved. Negligence
is the mo~t common complaint in medical malprat:!ice actions. In
malpractice cases. the patient must estab li sh that the practitioner was
responsible for the injury through some direct a.ct or omission or illliirectly
by practicing bdow the generally recognized standard or care. Liability for
negligence may require proof that the injury was nnt the resu lt or the
ratient"s contributory negligence by hi~ nwn action or conduct. Once
treatment is initiated . a professional relationship ha~ been established . The
practitioner then ha~ a duty to complete the treatment or refer the patient to
someone qualified to properly conclude treatme nt. If the patienl faiL to
follow instructions. the practitioner may withdraw from the case
prclllawrely by giving reasonabk notice and the reason for the withdrawal.
Furthermore. he mU;'1 refer thc paticllt to other practitioners who are
qualified to cOl1lplete the treatmellt. This should be documented hy mail to
the patient and in writing in the medical record.

2 10

QUA L

T Y

ASS U RAN C E

STANDARDS OF CARE
A standard of care is a minimum level of
care below which negligence occurs and is, by
uefinilion. malpractice. Normal training and
practice should exceed fhi minimum level.
Standards are established by coul1 precedents Of
expert witnesses who may refer to statistical
studies, the average level of skills of
practitioners, or those guidelines recommended
by educational groups, insurance regulations,
local or Slate law~. professional trade organizations. etc.

A practitioll er
should never give
verbal or written
promises of
guaranteed results.

CONSENT
Treatment without consent is battery. The relationship between the
practition'r and client is an oral contract, which if breached, may result in
a lawsuit. A practitioner should never give verbal or written promises of
guaranlecd results. The probability of expected results may be mentioned.
but no guarantees should be documented in the medical record . Pictoral
examples of previous results on other clients can be used as guidelines, but
nOI as a guarantee. Informed consent consists of the client's acceptance of
the recommended procedure by the named practitioner after verbally
reviewing the nature of the procedure, its risk.s. alternatives, and generally
accepted results. Long term complicalions such as fading, pigment
migration, and change of color should be discussed and documented .
Permission should be included to modify the procedure if unforseen
circumstances arise. All technicians involved in the procedure should be
named anel sign the consc-nt. A statement in Ihe consent form waiving
Iiabi Iity for ncgligen<.:c by the practitioner, signed in udv:lnce by t.he
patient. is not enforceable. All procedures planned should appear on the
consenl form behre the act and never changed wi thout the written
permission or the client. Plior to the procedure , photographs, illustrative
drawings, body map. , und color proposals arc documented and signed by
the cliem. Photographic documentation is crucial in pre-corrective work,
e~pecially when attempting to improve someone else ' s work. All
photographs should be attached to the written consent and kept as part of
the permanent record.

THE MEDICAL RECORD


Maintaining complete and ac<.:urate records

i~

necessary for good

21 7

CHAPTER

2 4

patient care as well as documenting compliance with standards of care


should a negligence suit arise. Business or medical rewrds are exceptions to
the hearsay rule. which slates that unsworn out-of-court statements are
inadmissable evidence. The record must be kept ill the ordinary cour e of
business by or under the supervision of lip praclilioner, signed and dated by
him/her and maintained uIlder the control of the business. This professional
document must not be self-serving or written for a litigatory purpose despite
il:-. pivotal role as the basis fur the legal settlement of claims or disputes. It
can subpoenaed by the court and must be truthful and accurate. Legal
pr<!scriptions must only be written by licensed practitioners and
documented. The meJical record contains the client's pertinent medi 'al
hi'\lO[Y. consent forms. photographs, and description of the procedures,
including rnedications.instnllnems. and pigments. NEVER alter lhe record
since this appears as an attempt to deliberately mislead a jury. Corrc:.ct
errors in the chart. by drawing a thin line through the original entry. sign.
date. and document that it W;IS an error. Any breach of the usual process of
;,,(andard of care should be documented and explained in the record . Records
should not be released to anyone withoUl signed authorization from the
patient. who can limil the specific lise the information. The dated and
signed release should document the recipient and be maintained within the
permanent record.

PROFESSIONAL LIABIUTY
INSURANCE
Malpractice insurance mu:t be maintained by each practitioner of
micropigll1entation. The provider shoulJ ascertain the reputation of lhe
insurance carrier and underwriter. understand the coverage and exclusions.
and maintain a copy or the policy.

2 11-i

Appendices

..._, -

~~'i=f-- .-.--""'.c:-....~

I .::.-.\....,. . ~'~~. . .' ' "' -".-,......,.,~'~

I,

;
I

\
f

\
!

'/

/1

, . . ,.,~ ,

y .

Appendix!
SAMPLE FORMS
Postp.-oceduraJ Patient [nstru('tions
I. \Ve recommend thaI ice packs be applied for 10 t() 15 minutes each
hour for the first 24 hours following lhe procedure, ex.cept at bedtime. It is
importaIH to place clean (issue paper between the ice bag and the kin to
prevent frostbite. The ice is used to minimize swelling and provide
comfort. After the first 24 hours the u~e of ice is no longer beneficial. Do
nO! take aspirin, as this promotes bleeding at the micropigmentation sites.
Tylenol (TM) is recommended for temporary pain relief.
2. We recommend for blepharopigmentation thm artificial tcurs be
used everyone to two hours in both eyes as a lubricant for the firs t 48
hours. In addi tion to lhese eye drops. a stero id eye drop may be prescribed
as well. At bedtime. the ophl hahnic ointment given (0 you after procedure
sh ould be applied to . wrile Cotton swabs and gently dahbed along the
eyclashes of the upper and lower lids. The ointment is used to help prevent
infection and minimize crusting.
3. You should expect a certain amount of mattering around the
eyelashes in the morning, swelling of the eyelids, and/or bruising around
the eyelid margins. Some pigment and blood-tinged tears may be expected
from the lid margin during the first post procedural day and may be
carefully dabbed with a clean tissue.
4. Under no circumstances should you pick. scralch or rub the eyelid
margins Of make any attempt to remove Ihe crusty material along the
eyelashes. Removal of the crusts may result in the removal of the actual
pigment.
s. Normal activity can be resumed immediatcly . We would
recommend that heavy exercise such as aerobic dancing. weight lifting.
ctc .. be delayed for approximately two or three days following the
procedure.
6. It is permissible to clean around the eye lids following blepharopigmentation with clean cotton balls soaked in wam1 water, but under no
circumstances should the water come in COnLact with the eyelashes. Bath . .
s hower~ , and sw imll1ing are permitted as long as the face does not become
we\. After two weeks, the p~llient may rcsume all regular activities
involvillg swimming and ballling.
7. [[ marked bruising is present, concealer Of foundation may be used .
Eyeshadow may be used on the second day: however, under no
circumstance should the eyeshadow powder come in contact with the
eyelashes. Mascal~l and eyeliner are not permitted for ule first two weeks.
After two weeks all regular makeup can be resumed without fear.
~. Co ntact lenses may be resumed usually in two or three clays:
Imwever, final clearance l-hould be given by an eye doctor.
lJ . For lhe firSI 24 to 48 hours. it i~ not unnsuul 10 experience some
light sensi ti vity, and (he lise of dark sunglasses is permitted and
recommended . We recommend wearing sunglas),cs for the first week

223

APPENDICES

following micropigmentrtlion: sunbathing \)1' the face is permilled only with


the u:e of protective sunglasses.
10. Judgement of your final results should be deferred until one month
following the procedure. The intensity of the eye liner is most prominent
following the procedure itself. Over the next two to three week . . the
pigment intensity will lighten by approximately 50%. If after one monU,
you feel that certain modifications in the pigmentation need LO be made, we
will be happy to discu s this with you. If you have any further questions or
concerns, please contact our office at any time.

MEDICAL MALPRACTICE COVERAGE


(for physicians)
On
. I attended a microsurgical course on :urgical
implalllation of pigmenls along thc eyelash border. This course wa: given
by the
Company with
Dr.
as course director. The course
covcred and di 'cussed the variOll. aspects of thif' new surgical procedure,
with both the indications and conlrainciications for it. usc. Essentially, the
surgical technique consists of the implantalion of metabolically inert
pigment granules between the eyelash or eyebrow bases in order to create a
more thickencd and natural eyelash enhancement and the effect of an
eyeliner. This surgery is performed under local anesthesia, either in my
office or in an outpatient selling.
The purpose of lhis letter is (0 inform you of my training in Ihis new
procedure and my intent to use this new procedure on patients who elect to
undergo the pigment implantation . The patients are given a complete
writt.en informed consent a~ well as the opportunity 10 watch an infonned
consent video. I am cncl()~ing wilh this letter a copy of the informed
COllselll thai we are cl.IlTemly using. I would apprcciate hearing from you 10
suhstantiate that I alll covered for this new procedure wilhin my practice. I
plan on beginning this procedure on
. Plea. e
nmfirm thar I am covered by you for this new procedure wit.hin my
practice.
Sincerely.
- -- --_._-----Wc recommend Ihal this letter bc sent by regi stered mail and that a
photocopy of the original letter be kept on fil.!. It would also be advisable (0
foliow the Idtcr with a cull to the malpractice office approximatcly one
week after the original kucr is sent.
We know of only a few local malpractilc carriers at thi s timc who arc
not covcring this new procedure. In the vast majority or case~, malpractice
can-iefs throughout the United States are providing coverage for Ihe demlal
pigmentation surgery.

APPENDICES

PROFESSIONAL LIABILITY INSURANCE


FOR
PERMANENT COSMETICS
On December 8, 1992 the Marine Agency Corporation was pleased to offer
professional liabilit y coverage for pemlancnt cosmetics to those graduates
of the Dennoullllgc Clinics. inc.

INSURANCE PROGRAM OUTLINE


For: Graduates of Dermoutlage Cli nics, Inc .
Progl'am: Providing professional liability insurance to g rad uates of
Dermoutlage Clinics, Inc . T he program will utilize a master po li cy. in
which ccrtilicatcs will be issued to participating enrollees.
Limits of Liability: $ 1.000.000 per occurrence
'3.000,000 allllual aggregate
Claims Made Form
Deductible: $5,000 per claim. Thi s will be reviewed at the end of one year
to delcmline the possibility of reducing the deductible to $ 1,000.
Condition: Inl'onncu Consent must be used .
l~xclusiolls: Transmission of AIDS and/or He palitis; sexual acts; product
liahility; guarantee of work performed; pollution; physician, surgeons,
and/or dentists.

Insurance Carrier: Evan ton Insurance Company


E vans tOil, [II i nois
Ratings: Evanston Insura nce Company is raled A by Standard & Poor.
Annual Premium: 950.00

SAMPLE PHOTOGRAPHER'S MODEL


RELEASE
For a consideration mutually agreed upon. and recei ved by me for
(date), I the
posing for photographs hereto, on __
undersigned do hereby assign to you absolutely the copyright and/or tlte
right to c()pyrighl such photogmphy and thc right of re produc tion thereof,
e ithcr wholly or in part, and the unrestricted use thereof in w hatever
manner you or your licensees or assignees may . in your or their absolute
discretion . think fit for all or any advel1i sing, medical teachings. or other
purposes what~oever. including the right of necessary re touch ing and
tinting or work up for reproduction purposes.

- - -- - -------_._----SIGNATURE

DATE

W IT:--IESS

PARENT/GUA RDfAN

225

APPENDICES

PATCH TEST CONSENT FORM


1,,have re<:eived a patch test on
date ____
and no reoulting adverse side effects have occurred.
The patch lest ha~ been received at least 7 day. prior to th~ procedure ,md
releases
from any Ijability related to
any allergies or other reaction to applied pigments.
Witness:_ __ _ _ __ _ __ _ __ _
Client:

Datc: _ __ _ _ __ __________
II' under 18:
(Parent or legal guardian)

226

A P PEN DIe E S
CONSENT TO PROCEDURE
(non-physic ian form)
I. Tbe nature and method of the proposed pro.:edun: has been explained
to me by
. the usual risJ...s .inherent in the
procedure and the possibility of complicatiol1~ during and following its
performance. I llnder~land there maybe a cel1ain amount of pain associated
with the procedure and that other adve rse side effect:- may include minor
and temporary bleeding. brlli~ing, redness or other discoloration. and
swell ing. Fever blisters lllay oecur on the lips following. lip procedures in
indiviuuals prone to this problem. Fading Of loss or pigment may oc ur.
Secondary infection in the area or the procedure may occur rarely .
2. I ahsolutely understand and accept that such procedure is a process,
often requiring multiple applications of color to achieve desirable results.
and that IOoch succes ... cannot be guaranteeJ.
3. It is understood thaI I am to receive a patch test at least 7 days prior
to the procedure. the purpose of which is to detect allergic or other reaction
to the applied pigments. A parch consent rorm is attached.
4. I agree to adh<::rc to preprocedllral and post-proceduwl instructions as
_ _ _ _ _ __

fo llow~:

._ - - - - - - - - - - - - - - - - - -

5. Depending Oil the procedure(s) which I select, I accept responsibility


for determining the color. shape. and position of eyehrow eyeliners. lipliner
and\or flllllip color. and the color of camouflage.
6. I have been advised to not drive a motOr vehicle for 8 hours
following an eyel iner procedure.
(W itllc s~

to signature of client
legally :lllthoriled to give consent)

(Signature of client or per~()n or perso n


giving consent in clients under age I
such as parent or legal guardian)
Dare:

I personally ex.plained the above information to the client or the clients


rcprC~enlal i H:.

W ilncs'i

Signallln: of techniciall

Dat": __________ __ _

227

APPENDICES

Appendix II
UST OF MICROPIGMENTATION
EXPERTS
The following liStS represent in the authors' opinion the notable experts in
the field of micropigmentatiol1. These individuako; have given u: their
permissjon to be listed in our book. The reader is invited to contact them for
any advice or guidance. We appreciate their participation and support of our
book.

RECOGNIZED EXPERTS IN MICROPIGMENTATION:


Patti Wooldridge, R.N.
Samantha Caruthers
The Micropigmenl Center
Permanent Make-up. Inc.
Lee Medical Sculpture Bldg.
2026 Capri COLllt
Wichita, KS 67207
17 J0 Packard
Ann Arbor, MI 48104
(316) 636-1214
(313) 973-6398

Marcia Cohen, R.N.


15233 Ventura Blvd.
Pemhou:e Stc. #3
Sherman Oaks. CA 91403
(818) 995-0918 or (8 18) 780-6542

Marilyn Greenspanll
Electro-Derma Professionals
995 NOt1h Miami Beach, Stc. 110
North Miami Beach. l~L 33162

Tricia Johnston
Salon SCl.:relS By Triciu
106 East 7th Street
Hanford, CA 93230
(209) 582-9050

Susan Sobel Guzick, B.S.N .. R.N.


Certified Makeup Artist
12350 Lake June Ru., Suite 112
Balch Springs. Texas 75180
(214) 234-0945

Steve Blaylock. R.N.


Lasting Crcatiom
2420 Grear Street N E. #8
Salem , OR 9730 I

Larry Kunze
Electrology Laboratory, Inc.
165 South Sherman Street
Denver. CO , 0209

(503) 363-4850

(303) 778-9312

Ro~e Maric Beauchemin


Beau Institute of Permanent
& Correctiw Cosmetic!>
2000 Academy Drive. Sle. 200
Ml. Laurel. NJ 08054

Sharon L. Rane~
Eastside Medical Center
245 NE 36th A venue
Ocala, fL 34470

(609) 727-1411

228

(305) 354-8365

(904) 694-2148

APPENDICES

Gary Roehle
Derma Therapy Cenler
5110 North Summitt
Toledo. Oli 43611
(419) 729-0742

Phyllis Azman. C.A.N.P., R.N.


Division of Plastic Surgery
University of Maryland
Shock Trauma Unit

Sandy Ameck. R.N .

Shcrylc Taffolla
New Age Glamour
72 -880 Fred Waring
Palm Desert. CA 92260
(619) 341-6606

1110 Gulf Breeze Pkwy., Sle. 205


Gulf Breeze. FL 32561
(1)04) lJ32-660 I

Shelia May

Pacific Palisades. CA

Margot Schweifler
Margot's Touch

Baltimore, Maryland

Pati Pavlik
18301 Old Ranch Road
Tchachapi, CA 9:'561
(805) 822-9'43

3541 S. Bentley
Los Angeles. CA 90034
(310) 559-3944

Mary Jane Haake


Dermigraphics
1017 S.W. Morrison Sl.
Ponland, OR 97205
(503) 224-8416

Marline Pelit
Facial Imaging
J 300 East Cypress, H2
Santa Maria. CA 93454
(805) 925-2499

Joyce Gcller
Dermatech, Inc.
One West Ridgewood
ParamusOl, NJ
(201) 444-8810

Dwayne Taylor. R.N.

Tanya Noland
100 South University. Stc. 202
Little Rock, AR 72:205
(50 I) 664-3371'

Dermatology Associates
5555 Peachtree DUllw(lody. 190
Atlanta. GA 30342
(404) 256-4457
Nelson Coombs. R.N.
S(;andinavian Skill Cmc. Inc.
2265 East Mun-ay Holladay Road
Salt Lake City. UT S41 17

Thomas Williamson. R.N ., B.A .. C.D.T.


RR No. 1. Box [73
Pleasant Plains. Illinois 62677
017) 626-1872

(80 I ) 278- 76-+3


Krislanne Matzek
Director of Education
American In~titlllc of
Permanent Color Technology
150 E. Camino Real. Suite 120
Tustin. California 926S0

(714) 5D-44-+R
FAX (714) 544-6171

Nan..:y Crocker
Medical Pigrnt:ntation
525 West Southern Ave .. SIC . 14
Mes~l. AZ 85210
(602) 844-8552

APPENOfCES

Christine Alton
Facets
1004 South 41h Street
Gadsden, AL 35901
(205) 546-0022

Rochelle McCartney
105 Wolf Road
Albany, NY 12205
(518)437-9196

Cathy BuKaty
Orlando Medical Center
1405 South Orange Plaza
Orlando, FL 32806
(407) 648-0879

Jane Strickland
1721 Mayfair Drive
Birmingham, AL 35209

Martha Cleveland
Unique Saloll
330 I Henry Road
Anniston, AL 36201
CW5) 237 -95()9

Carolyn Brown
Cosmetic Applications, Inc.
1860 Thomll!'ville Road
Tallahassee, FL 32303
(904) 224-4427

Elainc Simpson
Facial Derma Graphics Clillic
of Central Ohio
41 West McCreight Avenue
Springfield, 01-1 45504
(513) 323-2237

Elizabeth Finch
Derma Medical, St. Barnabas Hospil.al
Old Short Hills Road
Livingston, NJ 07039
1-800-654-9369

Denise Lctlow
AUract ions
I I 12 1 North Rodney Parhan Road
Little Rock, AR 72212

Letti Lynn
2000 Mississippi Avenue
Kenner, LA 70062
(504) 469-10 I6

(50 I ) 225-954g

Callie Brown
Dcrma Graphics of Asheville,
73 Old Concord Road
Fletcher. NC 28732
(704) 6X7-2807

111C.

Legal
Stcphcn R. Kahn, E).q.
10390 Santa Monica Blvd .. Suil.('.3 10
Los Angeles, CA 90025
(310) 553-5862
(619) 93 1-0700

2.10

Claudine Wright
6260 Butterfield Way
Placerville, CA 95667
(9 16) 973-1611

Financing
Sarah Holden
Allar-Tic Financial Services, Tilc.
223 I Rutherford Road. SIC. 200
Clrbbad. CA 92008

APPENDICES

Insurance
Darryl Stevens
Marine Agency Corporation
191 Maplewood Avenue

Maplewood , NJ 07040
(20 I) 763-4711

Susan Preslon
A. Mason Blodgett
J625 Van Ness Avenue
S;m Francisco. CA 94109
800-442-1977 Inside CA
800-638-4l)10 Outside CA

231

APPEND1CES

Appendix III
Tattoos on Famolls Pcople
Tatto\l~ by "'Professor'" Tom Riley , England (who patented thc first electric
lattooing machine in 18(1):
Cl.ar Nicholas II of Russia
King Oscar of Sweden
Kaiser Wilhelm II
Khedive Abbas II of Egypt
King Edward VlI
King George and Queen OlgH of Greece
Grand Duke Nicholas, Uncle of the Czar and Commander in Chief of
Russian Army in World War I
Lady Randolph Churchill (Jennie Jerome, mother of Winston Churchill)
who had it snab: tattooed around her waist
Tattoos Ily Georgc .Burchette (1872- 1953), England:
King George Vol' England
King Alfoll~o XIII of Spain
King Frederik IX of Denmark
The Great OlTlni
Tattoos by Lyle TuUle, contemporary San Francisco tattoo arti. t:
Jani s Joplin: Small heart on breast and Florenline bracelet on wrist
Petcr Fonda: Two doJphins Oil shoulder and three stars on arm
Joan Bacz: Small blue tlower on low back
Cher: Flower on derriere
Darryl Han (of Hall and Oates): Seven-pointed star on shoulder
Anita Pointer (Or the Pointer Sisters): Flower 011 wri~t
Michael Pollard (actor, "Bunnie & Clyde" and '"The Ru~sians Are
Coming"'): hearl with "Annie", his wife ' ~ name, in it on arm
Gene Simmons (Kiss): Rose on ann
Grace Slick (Jefferson AirplanelSlarship)
Flip Wiboll {comt:dian ): Number 13 with wings on upper ann
Orson Bean : Long stelllmed rose tattooed on wrist during u TV show
Charles Gordone (playwright): Flowers 011 shoulder.
John McVic (Fleetwood Mac): Penguin on lower inner ann
Greg Allman (A llman Brothers): Coyote, forearm
Bonnie Bramlet (s inger): Frog on back
Tattoos by Ed Hardy:
John Paul CiCilY, HI
Werner Herlog , German author/playwright

A PPEN DICES

Tattoos on other contemporary celebrities:


Glen Campbell: Dagger on arm
Ringo Srarr: Half moon and shooling star on arm
Dolly Parton: Tattoo covering an abdominal scar
Pearl Bailey: Heart with "MOUlcr" in it on thigh
Sean Connery: Scotland Forever on forearm
Sen, BaiTY Goldwater: SMOKI. support group for American Indians, on
left hand
Steve Allen: Tattooed on national TV
Charles Conrad (astronaut): eight-day Gemini flight probably the fir t
tattoo in outer space, 1965 )
Rosa lind Elias (MelropoliulIl Opera star): Her name and Social Security
number tattooed on low abdomen
Admiral Hal~ey (U.S. Navy, World War II ): Nautical
Eugene O'Neill (American Playwright)
Walter Winant (railroad magnate, polo player): spent over $50,000 on
talloos over a 3D-year period
Eyelas h/lid tattoos:
Phyllis Diller
Boy George: Cleopatra style mascara tattooed on eyelids in order to ave
two hours daily ill makeup rourine
Joan Riven; ('"to save $6 million a year on eyeliner")
Michael Jackson
Marcy Almy
Jean S, Zwcrling
Goldie Goluon

:?JJ

APPENDICES

Appendix IV
REFERENCES BY CHAPTER
Chapterl: Introduction
I. Zwerling. C. ct (II: Micropigmentution, Slack Publi shin g Co .. New
Jersey. 19R6.
Chaptl'l" 2: History of Tattooing
J. Conway , H., and Dockto)', J.P.: Neutralization of color in capillary
hcm;tngiomas of the face by int.radermal injection (tatlOoing) of
pcrmanent pigments. Surg Gynec ObSlel. 84:866, 1947.
:2. Conway. H., and Montroy. R.E.: Permanrncnt camoutlagc of capillary
hemangiomas of the face by intradermal injection of insoluble pigment
(latlooing): Indications for surgery. New York J Med. 65:876.196~.
3. SnyJennan, R.K., alld Wynn.W.D.: Complete replacement of port wine
stai ns. New York J Med. 66: J 91 O. 1966.
4. Baer. R.L.. and Willen. V.H.: 1955-1956 Year Book of Dermatology and
Syphilology. Chicago, Year Book. 1956.
5. Brown. J.D., Cannon, B., and McDowelL A.: Permanent pigment
injection of capillary hemangiomata. Plast Reconstr Surg J: 106,1946.
6. Pauli: Ucber das Fcuermaal und die clllzig sicherc Methode, disease
cntscullung tU heilen. J Gebruttsh, 15:66, 1835.
7. Hance. G .. Brown, J.D., Byars, L.T .. and McDowell, A.: Color matching
of skin grafts and naps with permanelll pigment injection. Surg Gynec
ObSlel. 79:624. 1944.
8. Byars. L.T.: Tattooing of free skin grafts and pedicle naps. Ann Surg,
] 21-644. 1945.
9. ~1atth ews, D.N .: Technique lind valuc of tattooing in pla~tic surgery.
Pruc Roy Soc Med. 40:8 I. 1947.
10. Winer. C.H.: Hemangiomas: histologic struCllin: and treatmcnt. Calif
Med . 77:242, 1952.
II. Andrews. G.c.: Disc~L<;es or the Skin for Practitioners and Students. 3rd
cd. Philadelphia, W.B. Saunders Co .. 1946. Appendix IV ... 2
12 . Cecil, R.L .. and Loeb. R. F .: A TextbOok of Medicine. 8t h cd.
Philadelphia. W.B . Saunders Co., 1951.
13. M rrill. H.H.: A Textbouk of Ncurology . Philadelphia. la & Febigcr
J 955.
J ..l, Thompson. H.G., Birdsell, D.C.. and Freidling A .: Surgical wllooing: an
expaime ntal srudy. Pla!'t Reconstr Surg, 37:563.1966.
15. Thompson. H.G .. Douglas, L. , and Mumnroe. I. : Surgical tattooing: an
experime ntal study (Part U J. Plast ReCollstr Surg 39:291, 1967.
16. Gifford. SanfoJ'(J R.. and Sreinberg. A.: Gold and silver impregnation of
(he cornea fur cosmetic purposes. Amcr .J OphthaL 10:240-247 (April)
1<)27.
17. Pickrell. Kennelh L., und Clark. Eldoll H .: Tattooing of cOn1cal ~car~

APPENDICES

with insoluble pigl11enr.~. Pia,,! Reconstru Sueg, 2:44-59 (Jan.) 1947.


I ~L Ebenstc, H.: Pierced Heart. and True Love. London, Derek
Verschoyle. 1953, p.73.
19. Giacomctti, L. , and Chiarelli, B.: The skin of Egyptian mummies. A
study in survival. Arch DcrmalOl, 97:712-716, 1965.
20. Armel::.gos, G.L.: DiseaSeS in ancient ubia. Science. 163:255-259.
1969.
21. Post , P.W. , Dan.iels . F., Jr. , and Armelagos, GJ.: Ancient and
mummified skin. Cutis, 1 1:779-781. 1973.
2~. Zarnbucka, K. : Face~ from the Past. The DignilY of the Maori Age.
Melbourne, A.H., and A.W. Reed, 197\.
23. The Oxford English Dictionary. Compact Edition. Volume n. Oxford
niver.ityPress, 1971,p. 2674.
24 . Schmidt. 1-1.: Tatoveringer. Copenhagen. Leo Pharmaceuticals, 1968,
25. Cook. J.: First Voyage , 1776, Diary, in: Price , A.G .. ed.: The
Explorations of Captain James Cook in thc Pacific as Told by
Selections of Appendix 1V .. .3 His Own Journals 176S-1779. New
York, Dover, 1971. p.37.
26. Parry, A.: Taltoo: Secrets of a Strange Art as Practiced by the Natives
of the United State, . ew York, Simon and Schuster, 1933.
27. Collins. L Unpublished manuscript.
28. Tadasu, I.: World of Japanese Tallooing. Japan . Haga, 1973.
29. Dooley. J.: The Mafia - Japanese-style - thrives in isle. Pari I.
Honolulu Ad vertiser (March 20, 1978).
30. Mellen, J.: The Waves at Genji's Door: Japan Through lts Cinema.
New York. Pantheon. Books. 1976, pp. 100- 103.
31. Belishe, M.: The most subtle of Hawaiian arts. Hawaiian Observer
(March 19. 1973), pp. 1-3.
32. Pavlik. Pati.: personal communication 1993
33. Angres, Gium: Surgical maneuvers: Eyelid pigmentation technique and
pretreatment patient consideralions. Ocul Surg New. 4:22, 1986
34. Zwerling, C. et al.: Micropigmentatioll , appendix. "How Tattoo
Machille~ Work," l:ontribulion by Fenzl, Robert, M.D .. Slack
Publi~hing Company. New Jersey. 1986.
Chapter 3: .Instrumentation
I. Zwerling and Chri~lensen: Blepharopigmcl1tation, chapter 47. Surgery
of the Eye. Waltham et al editors, Churchill & Livingston, 1988.
2. Personal Communications: Alcon (Natural Eyes). Diopties (Accents).
La:-.ting Impressions. Dermoutlage, anti Pennark.
3. PalTY, A.: Tattoo: Setrets of a Strange Art As Practiced By the Natives
of the United States. New York, Simon and Schuster. 1933.
4. Lei ghLOn , E: George Burchett: Memoirs of a Tattooist. London.
England. Old Bourne Book Company, 1958.
5. Eldridge, c.: The History of Cosmetic T'-Ittooing. File No.5, lO, and It,
Tattoo Archive, Berkeley, CA, 1986.
6. Walters. c.: Healing Arts: A Look at the Cosmetic and Recon:-.tfllcti ve
Approach to Tallooing. Taltoo Advocate: Journal of International
Talloo Arts. Vol I, No. I, Haledon , NJ, 1988.

235

APPENDICES

7. Tuttle. L. : Collectors: Lyle Tuttle: 40 Years of Tattooing. Tattoo


Advocate: Journal of Imernational Tattoo Arl, Vol I. No. I, Haledon, NJ,

1988.
8. Dwy~r. D.: Construction of Ihe Tattoo Machine. NCTA Quanerly, Voll!,
No. I. National Cosmetic Tattooing AssociaLion, Laguna Beach, CA.
1991 .
9. Pavlik. P.: Pigmcnts/Colors. NCTA Quartcrly. Vol n, No. HI. National
Cosmetic Tattooing Association. Laguna Beach. CA, 1991.
10. Goldstein, N.:Mercury-cadmium Sensilivity in Tattoos. A
PhoroaJlergenic Reaction in Red Pigment. Annals of Internal Medicine,
67:984-989.1967.
I J. O' Brien. E. : Introduction to Intradermal Cosmetics. West Coa t
Academy of Intraderma l Cosmetics, Llguna Beach, CA, 1990.

Chapter 4: FDA and Stllte Regulation'!


I. Federal Food. Drug, and Cosmet.ic Act of 1938. as amended, Sec. . 201702.21 U .S.c. 321-392.
2. Fair Packaging and Labeling Act, Pub. L. 89-755, Secs. 2- 13, 15 U.S .c.
1451 -1460 (November 3, 19(6).
3. Sec. 201(i). 21 U.S.c. 321(i) (see also Ref. 9).
4. Sec. _Ol(g), 21 U.S.c. 321(g).
S. Sec. 509, 21 U.S.c. 359.
6. Sec. 301 ,2 1 U.S.c. 33 1.
7. Sec. 50S, 21 U.S.c. 355 (see also Sec. 201(p). 21 USc. 321(p).
8. Code of Federal Regulations, 21 , Pari 330. Over-the-counter (OTC)
human tlrugs which are generally recognized as safe and e ffective and
not misbranded Sees. 330.1 and .330.10.
9. Sec. 6(H , 21 U.s.c. 361.
10. Sec. 602, 21 USc. 362.
II. Sees. 701. 702, and 704. 21 U.S .c. 37 I. 372, and 374. Appendix IV .. .4
12. Sees. 302. 303. and 304, 21 U.S .C. 3.32, 333, and 334.
13. Sec. 710,21 U.s.c. 371.
14. Secs. 4 anti 5. 14 U.s.c. 1453 and 1454 (see also Ref. 10).
15. Wilson, L.A. , Kuehne. W., Hall. S. W., a nd Ahearn. D.G .: Microbial
contamination in ocular cosmelics. Am J . Ophthalmol, 71: 1298-1302
( 1971).
16. Microbiology Subcommittee on Quality Assurance of the CTFA
Microbiology Commitlee, Microbiological Aspects of Quality
Assurance. CTFA Technical Guidelines , The Cosmetic Toiletry, and
Fragrancc Associations. Inc .. Washington, D.C. ( 1971).
17 . Preservation Subcommincc of the CTFA Microbiological Committee: A
guidel ine for the determination or adequacy of preservation of cosmetics
and toil etry formulations CTPA Technical Guidelines. The Cosmetic,
Toiletry, and Fragrance Association. Inc., Washington, D.C. (1973).
18. Solomon. c.: The Traffic in I-Iealul , New York, NavalTcs. 1938.
19. Goldstein. N. CI. al: Techniques )1' Removal of Tattoos, .Ir Dcm Surg and
Onco!. vol 5 # II. Nov 1979.
20. Zwerlillg. C.S .. Christensen, F.H .. and Goldstein . N: Hi s loriul and
Current Methods of Pigmcnt Removal. Micropigmciltation , Slack and

23n

APPENDICES

Co., Thoroughfare, N.J., 191-194. 1986.


21. Goldstein, N: Tattoo Removal, Advances in Dcrmatologic Surgery,
Dermatology Clinics, Vol 5 #2 1987.
22. Goldstein. N: Tattoo Removal Techniques, Cosmetic and Therapeutic
Talloo. Skin 6th Ed. Saunders. Philadelphia, pg 625. 19R7.
23. Stegman. S., TromQvilch . T . and Glogau, R. : Tattoo Removal
Techniques, Cosmetic and Therapeutic Tattoo, Skin Surgery. 2nd Ed.
Ycmc Book Pub,193-J99.
24. Slide. D., Apfelberg. D.B. Sergott, T: Traumatic Tattoo Removal.
Lasers Med 10(2), 158-164.1990.
25. Groot, D.W .. Arlelle, J.P. , John on, P.A .: Comparison of the lnfarcd
Coagular and the C02 Laser in Removal of Decorative Talloos. J .A.
Acad Derm, 15,516.522, 1986.
26. Ruiz-Esperanza. J. Fitzpatrick, R.E . Goldman, M.D .. Tattoo Removal:
Selecting the Right Altemative. Am .I Cosm Surg 9 #2, 171-176, ] 992.
27. Watts. M.T. eL aI, The Use of a Q-switched Nd: Laser for the Removal
of Permanent Eyeliner Tattoo. Opt hal Plast Recon Surg (4) 292-294.
1992.
28. Scheiber, A. et ai, A Superior Method of Tattoo Removal Using a QS wilch Ruby Laser, J Derm Surg Oncol Dec: 16 (12) 1091-1098, 1990.
29. Goldman, L. et aL Laser Treatment of Tattoos: A Preliminar, of 3
years Clinical Expcrience, lAMA 201. 841-844, 1967.
30. Goodman. L.: HADITH (traditions ascribed to Muhammed)
Authorit.ative Collections, Pe.rsonal communication, June 27. 1985.
3 1. Goldstcin. N.: Laws and Regulations Relating to Tattoos, Journal of
Dermatological Surgery and Oncology 5( II ):813-8 15 (Nov) 1979.
32. BloominglOn Indiana Pres , Vol 19, Junc4, 1985.

Chapter 5: Psycho logical Considerations


I . Spaeth, G., ct al: Ophthalmic Surgery: Principles and Practice, \V.B.
Saunders Company. 1990.
2. Raspa and Cusack: PsychiatJic irnplicarions of tallooS. American Family
Physician, Vol. 41 . pp.14S 1-1486. 1990.
~. Schulman. B. : Chapter on Psychological Consideration,
Micropigmclllation. Slack publishing Co. 1986.
C ha pte r 6:Pr actic.1.I C linical Anatomy
I. Beard. c., and Quicken, M.H.: Anatomy of the Orbit, cd 2 .
Birmingham, Aesculapius Publishing Co. 1977 .
2. DoxanCls. M.T .. and Anderson. R.L.: Clinical Orbital Anatomy.
Baltimore, Williams & Wilkins, 1984.
3. Duke-Elder, S .. and Wybar. K.C. (cds) : The anatomy of the visual
system. in System of Ophthalmology. 51. Louis. C.V. Mosby Co ..
1961. vol 11.
4. Jone s, L.T . , and Wobig, J .L.: Surgery of the Lacrimal System.
Birmingham, Ae~clllapilis Publishing. Co, 1976.
5. Koorn eef, L.: Orbital septa: Anatomy and function. Ophthalmol.
R6:87o-880, 11)79.
6. Koorneel', L.; Sectional Anatomy
the Orbit: A 20-Slide Atlas of
Histological Sections of' Human Orbits Seclioned Frontally Sagittally,

or

237

APPENDICES

and Transversely. Amsterdam. Aerolus Pres" 1981.


7, Silver, B,. et al.: Ophthalmic Plastic Surgery: A Manual Prepared for the
Usc of Graduates in Medicine, ed 3, Rochester. MinJ1csot~l. American
Academy of Ophthalmology and Otolaryngology. 1977,
8. Tessier, P.. et al. : Plastic Surgery of the Orbit ,lI1d Eyel.ids. New York.
Masson Publishing USA, Inc., 1981. pp. I-It.
9. Wolff, E.. and Last. R.: Anatomy of the Eye and Orbit, cd 6. Philadelphia.
W.B. Saunders Co., J968.
10. Bostwick 111,. John.: Aesthetic and Reconstructive Breast Surgery. C.V.
Mosby Co, 51. Loui$, Toronto. London, 1983.
11. Netter. Frank H.: Atlas of Human Anatomy, Ciba-Geigy Corporation.
New Jersey. 1981.).
12. Gray, Henry: Gray's Anatomy, cd. T. Pickering Pick, FRCS, from 15th
English Edition, Bounty Books, New York. 1927.
13. Pauslcy, Bcn. and House, Earl Lawrence: Review of Gross Anatomy.
Second Edition. The McMillan Limited: London, 1969.
14. Smith. Byron C, et al: Ophthalmic Plastic and Reconstructive Surger"
Volume r. c.y. Mosby Co, St. Louis, 1987,
15. Moschella, Samuel and Hurley , Harry, Dermatology volume 1, see-ond
edition, W .B. Saunders Company, Philadelphia. 1985.
16. Fitzpatrick, T.B. , et al.: The mechanism of normal humun melunin
pigmenwtioll and of some pigmentary di. orders. In Kawamura.T.. el al..
(cds): Biolog y of Normal and Abnormal Melanocytes. Tokyo ,
University of Tokyo Press. 1971 p.369.
Chapter 7: Morphology
I. Boswick Ill . John: Aesth-:tic and Recon structive Breast Surgery, c.y.
Mosby Co, Sl. Louis. Toronto, London. 1983,
2. Rces, T.D .. and Astor. S.J.: Aesthetic and Plastic Surgery, Volume 11.
\V.B. Saunders Co, Philadelphia, London and Toronto. Ch 33, 1980.
3. Conver:>e, John M.: Second Edition:ReconSlrllctive Plastic Surgery
Volume. II : Chapter 89: T. Reel> and Hohler M .. W.B. 'aunJers Co,
Philadelphia, London and Toronto, 1983.
4. Gmbb, W.c., and Smith. 1.W .: Plastic Surgery Second Edition . Chapter.
39,40.41 : authors Jo Strombeck, D. Goulian, Jr., and Gilbert B. Snyder.
Lillie Brown: Boston. 1973,
5. Converse. 1.M., MD and .l .G. McCarth y. MD. Reconstructive Plastic
Surgery, Second Edition , WB Saunders Co., Philadelphia. London,
Toronto, Vol 7. Ch. 89. H. Hohler, M.D .. 3711-26.
6. Hartrampf, CR. MD and J.H. Culbenon. MD. A Dermal Flap Graft for
:-.lipplc Reconstruction. Plastic and Recon!>truclive Surgery. June 1994.
Vol. 73. p. 9~Q-986.
7. Bosch . G .. MD and M. Ramirez, MD , Recon struction or the Nipple
Following a New Technique. Ibid., p. 977-981.
X. Kroll , S, MD and S. Hamilton. MD , Nipple Reconstruction with lhe
Double Opposing Tah Flaps, Pla.'tic and Reconstructive Surgery, 1989.
Vol. 84, p. 520-515.
9. Bo ~ [wi c k III. 1. MD. AestheLic anu Recon structi ve Breast Surgery.
CVM(l~hy Co.: SI. Louis. Toronto, London. 1983. Ch. 13, p. 675-720.

APPENDICES

Chapter 8: Photography
I. Eastman Kotlak Company. ( 1972). Clinical Photography. A Eastman
Kodak Mt.'dical Publication . Rochester, ty : Eastman Kodak Company.
2. Han::;c1I, P. (ed) . ( 1979). A Guide to Medical Photography. Baltimore:
University P~u'k Press.
3. Nels01l. G.D. & Kra use. J.L., Jr. (cds). 1988. Clin ical Photography in
Pbstic Surgery . Boston. LillIe, Brown, & Compa ny.
4 . Zarcm. H. Ju ly 1984. Standards of Photography. Pla st ic and
Reconstructive Surgery Journal , 137- 146.
Chapter 9: Patienl Selection
I. Spaeth. G.: Ophthalmic Surgery: Prjl1ciplc~ and Practice, W.B. Saunders
Company, 1990.
2. Rech. M.J . et al : Practical Ophthalmic Pl as ti c and Reconstructive
Surgery. Philadelphia. Lea and Fcbigcr. 1976.
Chal>ter 10: Clinical Evaluation
I. Angrcs. G.: The Angres Permali dliner Method 10 E,nhance the Result of
Co~me ti c Blcpharoplasty. Annals of Ophthalmology J985 17:176- 177.
1. Waltman. S.(ed.): Surgery of the Eye. New York, Churchill Livingstone,
1989,
Chapter 11: Preprocedural Consideration
I. Wilkes. D.: The Complications of Delmal Tattooing. Ophthalmic Pia tic
and Reconstructive Surgery 2(1) 1-6, 1986.
2. Zwcrling and Christensen: Surgery or (he Eye, chapter 47. Waltman ed ..
Churchill and Livingstone, 1988.
Chapler 12: Artistic Technique
I. Ili ff. C.L ct aL: Oc ul op laslic Surgery, Philadelphia, W.B. Sau,nders
Company. 1979.
1. Tessier. P. : Plastic Surgery of the Eye and Orbit. (translated by S.A.
Wolfe) Paris, Mas!->on. 1979. 3. Zwcriillg, C. et al: Micropigmentation.
Slack Publishing Cn .. 1986.
Chapter 13: Anesthesia
I. Angrcs, G ..: A Simplc Approach to Blepharoplasty Using the Ang res 11
Blepharopigmcntati on Lid Clamp. The American Journal or Cosmetic
Surgery. Vol 3. ~o.4. In6.
2. Zwerling. c.. et al: Micropigmelllatio!l. Slack Publishing Co .. 1986.
3. Fox. S.: Ophthalmic Pl astic Surgery. 5th edition l\ew York , Grune and
Stratton. 1976.
Chapter 14: Roh.' of the Assistant
I , Zwcrling. Jean. R.N .: Micropigmem<ltion. Chapter Role of the Nurse,
Slack publishing. New Jersey. 191\6.
Chapter IS: B1er)haropigmentalion
I , Angre~. G .: Angres Pcrrnalidliner Method: A New Surgica l Procedure,
Annals of Ophthalmology 1984: 16: 145- 14g.
2. Angrc!->. G. : The f\ngres pcrmatidliner method to enhance lhe result of
C(\~met ic Blepharoplast y. Annals of Ophthalmology 17 : 17t1-177 .
[1)85.

APPENDICES

3. Bernstein. R.: Automated Mixing during Blepharop igmentation. Letters


to the Editor. Ophthalmic Surg.ery, Vol. ) 7, NoA, April 1996.
Chapter 16: Brow Pigmentation
I . Zweriing. C et al: Micropigmentatioll, Slack publishi ng Co .. New Jersey
chapler on Brow pigmcntation. 1986.
Chapter 17: Lip Pigmcnultiou
I. Angres. G.: Blepharo-and Dermalpigmenlation Techniques for Maximum Cosmetic Rc:-.u lt., The American Journal of Cosmctic Surgery.
Vol 3, No.3, 1986.
'2. Angrc~. G.: Lip Micropigmentation Simple Surgery with Imm edia te
Results, Dermatology Times. December 1986.
Chapter 18: Breast Areolar Pigmentation
I. Zwerling. C, et aI.: Micropigmcnration, Slack Publishing Co .. 1986.
2. Boistwick 111. John, M.D.: Aesthetic and Reconstructive BreastSurgery.
c.c. Mo, by Company. St. Louis, Toronto. London . 1983.
3. Netter. Frank 1-1 .: Atlas of Human Amllomy, Ciba-Geigy Corporation,
New Jersey. 1989.
4. Gray. Henry: Gray's Anatomy, ed. T. Pickering Pick, FRCS. from 15th
English Edi tion, Bounty Books, New York. 1927.
5. Pausky. Ben. Ph.D . and House , Earl Lawrence. Ph.D.: Review of Gross
Anatomy, Seconu Edition. The McMi ll an Limited: London , 1969.
6. Smith , Byron C. et al.: Ophthalm ic Plas tic and Reconstructive Surgery,
vol I. , C V. Mosby COIl1P~U1y , St Louis. 1987.
Chapter ]9: Advanced DermaJpigmenllition
I. Guzick, 5.5., B.S .N. ,R.N. : Para-Medical Camouflage: A sysiematic
approach. Dennascope September/October 1992, pp. 39-4 1.
2. Matzek, Kristannc: American Institute of Permanent Color Technology,
personal communication 1993.
:~. t\ngre,\ , G. , M.D.: Blcpharo- and Dennalpigmentuti oll Techniques. for
Maximum Co sme tic Result s. The American Journal (If Cosmetic
Surg\!ry, VoU. No.3, 1986.
4. Guzick. S.: personal communication 1993.
5. Guzick. S.: Dermatology Nursing. Burn Survivor Case Study a three-part
series February, April, and June Volume 5 Number 1.2. and 3 1993.
C hapter 20: M.mlagement
1. Zwerling and Christensen.: Blepharopigmcntation. chapter 47 of The
Surgery of the Eye. edi tor Waltham el a1. Churchill & Livingston..:: 1988
2. Fraunf'lder and Roy. : Current Ocular Therapy
3. W.B . Saunders Company 19903. Spaeth. G., et <II.: Ophthalmic Surgt::ry:
Principles and Practice, W.B . Saunders Co .. 19l)(l.
4. Armstrong and Gabriel: Tattoos on \V011\e11 : Mark:- of Distinction or
.A bomination . Dermato logy Nursing. Vol. 5 No. '2. Apri l 19<)3.
Chapter 21: Complications of Taltouing
1. Parry, A.: Tattoo Secre ls of a Srrangc An as Practiced Among the
Native~ of th..: LJ nited States. New York. 1933.

APPENDICES

2. Bromberg, W.: Psychological motives in tallooing. Arch NCUJop l


Psychiat. 33:228-232.
3. Lip s chutz. B. : VerhallJlungen del' Wiener dermalOlogischcn
Gescellschaft. Arch r DCI'm Syph. 78:381, 1906.
4. Porritt, RJ .. and Olsen, R.E.: Two ~imultaneous cases of leprosy
developing in tattoos. Am J. Pnthol, 23:805-817. 1947.
5. Smith, B.F.: Occurrence of hepatitis in recently tattooed service
personnel. JAMA, 144: 1074-1076, 1950.
6. Sulzherger, M.B .. Kanof, A., and Baer, R.L.: Complications following
tattooing: sensitization and descnsitization to mercury; report of a case.
US Nav Med Bull, 43:889-894, J 944.
7. Bjornberg, A.: Reactions to light in yellow tattoos from cadmium
sulfidc. Arch Dermatol, 88:267-271. 1963.
8. Buncke. I-I.J . Jr . and Conway, H.: Surgery of decorative and traumatic
tattoos. Plase Rcconstr Surg. 20:66-67, 1957.
9. Bailcy. B.N.: Treatment of tattoos. Plast Recollslr Surg, 40:36 1-371,
1967.
10. Goldman, L.. Rockwell, RJ. , and Meyer, R.: Laser Treatment of
Tultoos. JAMA, 201 :841 -844. 1967.
11 . Crittenden. F.!vL, Jr.: Salabrasion - removal of tatloos by superficial
abrasion wi th table salt. Cutis, 7:295-300, 1971.
12. Janson, P.:Eine Einfache Methode del' Entefertlllng: von
Tmowierungen . Dermal Wchnschr, 29:894-895, 1935.
13. Rosenberg, W.A.: Accidental tattooing of the face ITeated by abrasion
with sandpaper. Arch Derm Syph. 65:466-470, 1952.
14. Slrakosch. E.A .: Sandpaper-abrasion tre'llmenl of taHoos. Arch Derm
Syph. 67:53-55. 1953.
15. Loria, P.R.: Dermabrasion: principle. of planing. 1 Loui~iana Med Soc.
I 12:401-405, 1960.
16. Boo-Chai. K.: The decorative tattoo: it removal hy dermabrasion.
Pla'>t Reconslr Surg. ::12:559-563. 1963.
17. Clabaugh. W.: Removal of latlOos by superficial dermabrasion . Arch
Dermato!. 98:515-521, 1968.
18. Berchon. E.: Histoire Medicalc uu Tutouage. Paris. J.B. Bailliere et
Fils. IS69.
19. Inlernational COlllments. Death after tattooing. JAMA. 222:1194,1972.
20. Beerman. H .. and Lane. R.A .G.: Tattoo : a summary of scientific
literature on the medical complications of tattooS. Am J Med Sci ,
227:444-465,1954 .
21 . Doyle. Sir A.C.: The Red-Headed League. in: The Complete Sherlock
Holmes. Garden City. New York. Garden City Publishing. p. 196.
22. Roenighk. H.H .. Jr.: Tattooing --- history. tt'chniques. complications,
removal. Cleve Clin Q. 31:! : 179- 1R6. 1971.
23 . Ro~tcnbcrg. A .. Brown, R.A., and Caro. M.R. : Discussion of taltoo
reactions with a report of a case showing a renclion to the green color.
Arc h Dermato\ Syph.i1ol, 62:540:547. 1950.
24. Madd.:n , 1.F.: Reactions in tattoos. Arch DerrnaLOI SyphiloL .+0:256262 . IYJ9 .
25. Rook. 1\.1.. and Thomas. PJ.B.: Social and medical aspects of

241

A P PEN D

C E S

lattooing. Praclitioner. 169:60-66. 1952.


26. SCULl. R. and Gotch. e.: Skin Deep. London, Peter Davies. 1974. p.
27. Davis, R.G.: f-hllrtrds of tattooing; report of two cases of dermatitis
caused by sensitization lO mercury (cinnabar). US Armed Forces Med J,
I 1:26 1-280. 1960.
28. HUlin, M.F.: Recherches sur Ie lalOuages. Paris. J.B. Ballier ct Fils. 1853.
29. Josiu:), A.: Prog Med, 5:205, 1877.
30. Arthur. G.: On the infrequency of secondary syphililic contagion. Med
Rec, 30:67-l, I RS6. Cited in Rukstinat. G.S.: Arch Pathol. 31:640-65S.
1951.
31. Maeda. N.: Study on the tattoo mark. Dermatol Tropiea, I: 188-192,
1962.
32. Sehgal, V.N.: Inoculation leprosy appearing after SC\'c n yeurs of
t:mooing. Dermarol, 142:58-61. J 971.
33. News ano Nares. Epidemiology: serum hepatitis. Br Med J. 2: 121 . 1971:\.
3'+. Mowat. :--l.A.G .. Brunt. P.W., Albert-Recht. F., and Walker, W.:
Outbreak or serum hepmiti:- associated with tattooing. Lancet. J :33-34,
1973.
35. Wilde. A.G.: Vaccine-i nfected taLlOO. New Orleans Med Surg J. X2:38S386, 1<)29 .
.,\(1. Fox.. T.e.: Wart~ OCCLltTing in wttooed lines. J Cutan Vcncrol Dis, 2:216,
18R4.
37. Watkins, D.B.: Viral disease in tattoos: verruca vulgaris, Arch Dermatol.
84:306-309. 1961.
38. Tclichevsky. I. : Le phenoene de Koebner a I' enuroit de t<ltouagcs.
DerrnatoJogica. 8 1:98-102. 1940.
.Il). Pilsbury , D.M .. Shelley. W.S.. aod Kligman.A.M .: Dermatology .
Philadelphia, W.B. Saulldcr~ Co .. 1956. p. 732 .
.lO. Sehgal, V.N., and Dhurandhar, M.W.: Tattooing lichen planus. CUli:.
14:93, 1974.
41. Hall , A.F.: lupus erythematosus ill red parl of lalloocd area. Arch
Dennatol SyphiloL 47 :6 10.1943.
42. Rook, A.. and Thomas. P.J.B. : Lupus erythemmosu:. Proc R Soc Med,
.+4:l:\78-X79. 1951 .
..).3. Lubed. G., and Epstein, E. : Complications
tattooing. Cal Med.
76:83-85. 1952.
,,\,4. Lcrchin, E .. Sturman, S., and Lockwood . M.J .: Discoid lupus
erythematosus in red pi gment of tattoos. J Assoc Milil Dcrmatol. I: 18-

or

20. 1975.

45. Fields. J.P .. Little. W.D .. Jr .. and Watson. P.E . Discoid lupu s
erythematosus in red taIlODS. Arch Dennalol, 98:667-669. 1968.
46. Cipollaro. V.A.: Keratoacanthoma developing in a lal(oo. Cutis. 11 :80915 10.1973.
47. Ackerman. A.B.: Personal communication. July t97X .
..1-8. Locwcmhal. L..I.A.: Rcactions in green tattoos. Th~ significance of
valence starc of ehrorniulll. Arch Dcrrnatol. 82:237-243. 1960 .
..\.9. Ror,man, Il .. ct al.: Talloo gr:1l1uloma <Jnd lIvei{i~. Lancet. 2:27-28.
1960.
50. Rorsman, H.: Pc I"(ma I comlllunication to the editor. (June 25. 1969).

2-12

APPENDICES

:) I. Tinuall. J.P., and Smith , J.G., Jr.: Unusual reactions in yellow tattoos:
microscopic studies on hi slOlog.ic sections. South Med J. 55:792-795,
1%2.
52. Ebenslcn, H .: Pierced Hearts and True Lovc. London. Derek
Verschoyle, Ltd. , 1953.
5:\. Goldslein , N . : Mercury -cadmium sensitivity in talloos. A
pholoallerg.enic reaction in red pigment. Ann lnl Mecl. 67:984-989.
1967.
54. Brose. Dr. me et.: Neuc Tatowierungsphanolllenc. Dermatol
Wochenschr, R4:461, 1927.
55. Bonnel l, J.A .. and Russell , B.: Skill reaclions at site of green and red
tattoo marks. Proc R Soc Med, 49:823-825, 1956.
56. R(lv il s. H.F.: Allergic tattoo granuloma. Arch Derrnatol. 86:2 '7-289,
1<)62.
57. Weidman, A.1.. Andrade, R., and Franks, A.G.: Sarcoidosis: Report of
a case of sa rcoid Ie. iOlls in a tattoo and subsequent discovery of
pulmonary sarcoiuosis. Arch Dermatol, 94:321-325. 1966.
58. Lane, R.A.G .. Bcerman, H., and Me:-.con. H. : Mercurial granuloma
OcclllTing in a tattoo. Can Med As:oc J. 70:546- 48, 1954.
59. Biro. L. and Klein . W.P.: Unusual complications of mercurial
(cinnabar) tattoo . Generalized eczematous eruption following
laceration ora tattoo. Areh DermaLol, 96:165-167,1967.
60. Lamh, .I .H. , et a!. : Further studies in light scnsitive eruptions. Arch
Dermarol, 83:568-572, 1961 .
61. McGroulhcr, D.A .. Downie, P.A. , and Thompson. W.D. : Reactions 10
red tattoos. Hr.J Plast Surg, 30:g4-85, 1977.
62. Albert. 1:1 .: Personal communication.

Chapter 22: Pigments


I. Rook. A.J ., und Thomas, P.J .B.: Social and mcdicul aspects of lallooing.
Practitioner. 169:60. 1952.
2. Bro~c: Neue Ta[wierung phanoJllenc. Denn Wschr. 84:46 1. 1927.
3 . Sullberger, M.B .. and Tolmach, LA. : Allergiscne Auflammung srcaktiollen in rolen Tatowierun ge n. Bcobachtungcn uber Entslehen
und AbkJingcn ci ner WuecksilberubercmpfindJichkeit lind uber
allcrgi~che gra nulomato se und sarkoidale Rcaktionen . Hauturzl,
10: 110, 1<)59 .
.:t. Pay. M.F.: The thrcat of laIc on surgeons' gloves. To(\ay's O.R. I LLrse,
p. :; 7-3 1, N() v. 1<) X-l.
5. Pay, M.F.: Clove powders on lrilli. Today's O.R. Nurse. p. 9-12. Nov.
19R3.
6. Kahn, M.H .. el al.: Suture cOlltaminalion by surface powders on ~urgical
gloves. Arch Surg. lI 8:738-739. June 1l)83.
7. Eismnl1, B.. SL'e1ing. M.G., :Jnd Womack , N.A.: Talcum powder
gra nulom a: t\ f"requenl and ~erioLls po:o;toperativc co mplicalion. Ann
Surg 126:820-832. 1l)-l 7.
g. Soloman. 1-1., Golurnan. L., Henderson. B , ('I al.: Hj ~ !()path ology of the
las'r Ireatmelll of port wine les ions . J Invest Dernwtol. 50: 1.+ 1-146.
I %H.

2-13

APPENDICES

9. Apfelberg. D.. Maser, M., and Lash. N.: Extended clin ical use of the
argon laser for ctllancous lesion . . Arch Dermatol, 115:719-721. 1979.
10. Apfclberg. D.B .. Maser. l~YLR ., and Lash. 1-1. : Argon laser treatment of
decorative tattoos. Br J Plast Surg. 32: 141-144, 1979.
J I. Apfclben. D.B .. Raub. D.R.. Maser. M.R., ct a\.: Pathophysiology and
treatment of decorative tattoos with reference to argon laser treatment.
Clin Plast Surg. 7:369-377, 1980.
12. Bou-Chai. K.: The decorative talloo: Its removal by dermabrasion. Plast
Reconstr Surg. 32:559568. 196.'.
13. Angres. G.G. Eye.liner implants : A New Cosmetic Procedure. PIa t
Reeonst Surg, 19):14: 73:833-836.
14. Tse DT, et aL Clinicopathologic con-elate of a fresh eyelid pigment
irnplul1lation. Arch Ophthal 1985; 103:15\5-1517.
15. Palipa. M. et al: Light and Electron Minoscopic Findings with
Permanent Eyeliner. Ophthalmology 19~6 vol ')3 number 10 pp.13611365.
16. MaL-:ek. K.: American In stitute of Permanent Color Technology ,
personal communication. 1993.
17. Zwerling and Christensen: American Society of Micropigmentation
Survey Study of J \)88.
18. Scheibner. A. et aL: A superior method of tattoo removal u.,ing the Qswitched Ruby la~er, Journal of Dermmologic Surgery and Oncology.
voL 16. pp. 1091 - 1098. J 990.

Chapter 23: State of the Art


I. Schwal1l:. A.E., Glick. AW .. and Friedman. E.W.: Tattl)oing of mucosal
sUli'aces in cancer or head and neck with preoperative radiotherapy. NY
State] Med, 71:2187-21t{8. 1971.
2. Baluyot. S.T.. Jr., Shumrick , D.A.: Pre-irradiation tattooing. Arch
Otolaryngol. 96: 151-153. 197_.
J. McColl, A.H., .11'.: Tattooing for preservation of oral and oropharyngeaJ
cancer resection margin);. J Surg Oncol. 9:437-442. 1977.
Chapter 24: Qual.ity Assurance
I. Stephens. D.: per.'.onal commllnication 1993. Marine Insu rallce Company
2. A M.<lson Blougel1 and As,ocialcs: personal comrnunicalion.
3. Walker. George. M.D.: per&onal communications.
4. American Academy of Ophthalmology Code of Eth ics. San Francisco,
1989.
5. Zimlllerman. M.C. : SlIit~ for Malpractice based on allegl:d unsightly
sca r ~ re . ulling from removal or lattoos. Journal of DermalOlogic
Surgery. YoIS. pp. 911 912. I97\).

:3.-14

A P PEN D

C E S

Appendix V
EYESHADOWS
Eyeshadows are produced in essen tially (wo forms: powder and
cream. Rccelllly, a waterproof version has been introduced 011 the market
con~isting of a solvent base of extra minera l spirits added to the standard
eyeshadow formula. In the powder form of eye hadow, tak is Ihe primary
ingredient. usualJy constituting approxima tely 60% of the eyeshadow
base. Next is mixed approximately 209(; of kaolin (clay). To this basic
rormula are added val)'ing amounts (If zinc stearate and/or magnesium
carbonate; occasionally some titanium d ioxide, which will maximize
coverage and prevl:nt caking; occasional l y pre~ervatives and perfume~
pres~ed into powder; and gum or oil. ]n some powucred forms of eyeshadow. occasionally translllcellL~ arc u~ecl to add shine and rellection. In
the cream form of eycshadow, a water base wilh oi l thickeners is used,
along with waxes. perfumes. colors. and preservatives. To gain more of a
waterproof efrecl, a water solvent hase of mineral spirits is added to the
abovt: formu la. Most coslTletologists l:Oday would agree that eye~hadows
. hould compicment ralher than compe te with the pas In'S natural eye
color. There are various guides as 10 the usc of more than one eyeshadow
color in a tri- or bicolor approach, using the various portions of the lid, the
lid crease, und under the brow LO create various illusions and effects. Eye~hadows provide a nice complement to the nalllwi skin tones of the woman
and cun dilllini~h certain structural defects or scars in the eyelid area.

EYE PENCILS
Eye pencils are probably the newest development in the co~meLOlogy
field in the la~t decade. Essentially. the eye pencil represenh a hybrid
between the "hard" eyebrow pencil and the "soft" crcam eye shadow. The
composilion or these rencib is primarily a wax bnse Of hardened oil mixed
with laic as a slifTcnef. The various tcxlllr(;s and hardne~l> can be modified
hy altcring the percentage of talc in the mixture. To this basic composjliun
arc adtkd the various colors, anu then this "lead" is wrapped in CI covering
or wood tu creale the final eye pencil. The advantages or eye pencib are
Iheir versatility and p )rtabi lity. For creation of a ~harpcr line. the new Kohl
pencil oIlers certain advan(age~ as opp(J~ed to the sorter Of ~m u dgier
tcxtuft: or the eye pcncil crayon-like form . Because of the well-known . ide
effects of the red toned carmine-based eye pencils, these are no longcr
a ailablc un the !Harke!. Some problems noted with eye pencils lm~ wa~te.
in that they need ll) he re~harpened hefore lise. anu the potential danger of
scratching the cornea anu abrading the delicate skin along the cyda!>he~.
Some \,",'Olncn have llsed lht:se pencils to line til' inner p(1I1ions of the lid or

?-J5

APPENDICES

t.he mucocutaneous grey line areas to crl!ate a heightened effect of color and
form. However, this delicate mucous membrane tissue is uSlIully greatl y
irriwted by the usc or these pencils, The use of the pencil in this area should
be dist:ouraged.

EYEBROW PENCILS
Eyebrow pencils arc essentially a wax based product Ul<ll can vary in
app lication from a hard penci I-like form to that of a soft powder. Eyebrow
pencils are usua.lly lIsed in a~sociatioll with an eyebrow brush to create a
more feathery, lightened and fuller appearam.:e to the eyebrow areas. Most
cosmeto.logisLs will usually recommend an eyebrow pencil that is one or t\VO
shades darker than the lady 's natural hair color. Of course, if the hair color is
clyed or alt.:red in uny way. the eyebrow pencil is usually chunged. The
correct application 01" the eyebrow pencil should be in soft vertical strokes,
blending in naturally wilh the eyebrow ha.irs. The removal of eyebrow hairs
is uSLI<llly performed with tweezers ancl is done from the inferior po rtion of
the eyebrow extending vert ically. The general purpose of removal of
eyebrow hairs is to create an eyebrow arch cxtending from an imaginary
parallel-vertical linc from the side of ule nose in the inner corner of the eye
and up ou t to the lateral corner of the eye.

EYEliNERS
Eyeliners arc cUITently produced in two general formats: li quid and
pencil applicators. Liquid eye liners can be either wuter- or oil-based. with
the ~o-called waterproof eyeliner usua lly having grealer qua ntities of an oil
substrate. The pencil form 01" eyeliner has the advantage of speed. wheT~al>
the liquid eyeliner can form a more dramatic and sharp linc. However. both
arc extremely difficult to apply and can cause an unevcn clumping.
~mudging, or skip area or applkution.

MASCARAS
Mascaras an: primarily produced in a liquid form packaged in LI lUbe
witil a bru~h applicator. Their c0lJ1p()~iti()11 can con~isl of water. wax
coloring agent. thickeners. rilm formers. prc~ervativcs. anti occasionally
rayon or nyloll fihers to artificial ly augmen t. and lengthen the quality or the
eyelashes. New polymer fonm. of mascara arc no! currently on the market
and arc rather costly.

2.f6

APPEND1CES

EYE MAKEUP REMOVERS


Even though thcre are many eye makeup removers currently available
on Lhe markct, they generally faJl in two classifications: oil-based and non
oil-based removers. The oil-based removcrs consist of mineral oil.
occasionally mixed with perfume fragrance applied to a pad. The use of the
oil pad mixture is ralher successful in the rCllloval of eye makeup including
mascara. However, it leaves a greasy lilm on the eyelids and occasionally
on the eye itself, lhu~ resulting in blurred visioll and occasionally irritaled
cyes. The non oil-based removers are primarily water solutions with boric
acid and other dissolvants, which have the advantage of quicker removal
with less blurring: however. they often cause drying and chafing of the skin
arcas.

EYE CREAMS
After the eyc makeup has been removed. most women wil.! moisturize
and cr('am their eyes before bedtime. The on ly difference between eye
cream moisturizer,' and regular facial creams is tJ1C cenain restrictions that
the FDA has required of the manufacturers to that harmful dyes and other
chemical agent s are kept away from the eye. The moisturizers in these
cre ~IJ11S consist primarily of water. mineral oil. petro latum, lanolin,
vegetable oils and a general oil-grea!>c water-wax formula. To this general
rormula arc often added varioll!> nonessential ingredicms such as vitamin
A. E. collagen. animal protein., almond oil. wheat germ oil, royal jelly,
squalene, or jojoba oil. BeC3tlSe or the dead keratin and sebum protective
layers. very little or all these additives ever arri vc bclow the dead skin
suri'ace. There is the implication that in addition to remoisturizing the skin,
these creams can _olTlctimes remove wrinkles about the eye area.

247

A P PEN D

C E S

Appendix VI
MARKETING CONSIDERATIONS
The nllvice prac titioner will need to consider aspects uf lhis prtlt'cdure
!>cparate from the actual applicution of the pigment. Such factor: include
patient selection and marketing considerations. Chapter 10 discusses at great
length the various aspects of paLient ~clection. This appendix explores the
types of marketing assislance currently available. as well as some of our own
marketing concepts.

Marketing Concepts ofthe Companies


Currently. there arc three companies that provide marketing support (()
physicians considcring micropigl11cntal ion: DERMOUPLAGE CLINICS,
INC., PERMARK, AND ACCENTS . These companies offer u~sistance to
surgeons, nur:-.cs. and/or cosmelojogists. In order for the companies to
realize continued cash flow and profils, it is essential tbat they actively
prol11ote the dennalpigll1cntation procedures. Increased consumer awareness
anu subscquent patienHo-pafi en f referrals will obvious ly bOllst corporate
profits. To a~si~t the practitioner in obtaining paticms. variolls marketing
tools and promotions arc provided. The~c include all or some of the
fol lowing:

Press Kits. The practitioner is usually given some form of a press kit
thaI. typicall y incl udes a prepared press release. qucstions and answer in a
typical intcrview. and ad slicks. The functioIl of the press kit is to stim ulate
publicity for bot h th e practitioncr and the company. All the companies
recommcnd that the practitioner perform a fcw casc~ and become
comfortable with derl11alpigmclll;ttion procedures before taking on the press.
The companics also GlUtion the novicc practitioner about what type of faclS
and policy slateme l1lS in regard to the FDA should be conveyed to the pres~
;lnu the patiellts.
National Media. I n the past, a natiolJal media barrage for
ucrmalpigmelltation was organizcd with the hope of convincing lhe average
American hou~ewire lO consider micropigment<liion as normal u bcauty aid
Car piercing. Plan s for medi a covenge included raelii), television. and
national magazine and newspaper coverage. 'T'his approach did not prove to
be ~ucce~srll l. because the industry was too fractionated. Also {here were too
lJIany pc)orly (rail1eu praclitioller~ performing dermalpigmcntulion . There
wa~ a lac\-; of true educational support and guidance. The c()mpanie~ now
hope tilat the local. well-trained practitioners ,,:i11 Iry a grasi> rooti> approach
with their OWI1 local 11lcuia a:- all adjunct to any national f,)nnul.
Referral Patterns. Some
the companies are providing toll free 800
;1

or

APPENDICES

phone hotlincs so that the consumers and practitioners can call and consull
the companies for advice and information.
Patient Marketing Support. The companies offer the practitioner
various well-prepared brochures for palient education. A simple fol ded
brochure is usually provided as an inexpensive method of stimulating
initial interest in paticnts. either <L~ an in-office handout or a mailing. There
!>hould be a place on the brochure for the practitioner to affix a label with
his name or office address. For those patienLs who have come specifically
to the practitioner's office for a consultation. a more detailed booklet is
available with color graph. , testimonials, and pertinent information about
the procedure. Some of the companies also provide various questionnaires
for patient education and informed consent. For the practitioner who has
Cludiovi:>ual equipment, the companies provide excellenl patient informed
consent vitlcos with patient interviews and testimonials as well as videos
ror the practitioner to review the procedural techniques. Audio casseue
tapes are abo available.
It is quite probable that in the near future, other companies will also
offer comprehensiw marketing SUppOrl to the novice dennalpigmentation
practitioner; however. it i. not necessary to rely lotally on the companies
for all mark.eting needs . There arc certai n credible and ethical avenues
available to the practitioner in his own locaJ area that are ready for bi. u. e.
Cosmetologists: By becomi ng familiar with various beauty products.
tho:! use of a professional eye makeup consult.ant can otTer valuable in. ight
into how the patient should properly approach and evaluate eye makeup,
and can create a ready-made referral source of ideal , motivated patients. A
cosmetologist can be helpful to the practitioner who feels that the patient is
using her makeup improperly. By referring the patient [0 the cosmetologist
ror a second opinion. the practitioner will have support for his views and
establish the atm )sphere of a professional environment for cosmetic
cvuluation. The practilioner will g:lio useful educational experience from
the cosmetologist and help in dealing with palients with lillie or IlO makeup
experience. A cosmelic consu ltant is availahle in 11'10St communities and i.
a good slarting point for anyone who wishes to become knowledgeable in
the area of cosmetic application.
Cosmetologists can help make recommendations to the patient who is
anticipating dermalpigrnentalion procedures. Time is well spent having the
patient become familiar \vith the effect of the eyeli ner when combined with
other makeup. The cosmetologist can act as an advertising vchid for the
pcnnanelll makeup. When talking ancl speaking to local cosmetic advisors,
the practitioner shou ld stress how the procedure complements the usc of
other makeup from both the cosmetic and reconstnr tive points of view.
Initially, the professional cosmctic makeup artist may feel threatened by
the potential competition. We have found that Ihcse procedure:.. aClually
brings cosmetologis[s new clients who previously found that lhe
application of eyeliner was either too curnbersomc, or. because of allergies,
phy ical disahilities, etc., not practical: dermalpigmentation patients
become excited about learning variou s additional way!> to apply eye
makeup. We have a.lso found that women experienced in the application of
makeup \vill (lOW be ahle to :,;pend more time choosing and applying other

JN

P PEN

C E S

cosmetic products. The dermalpigmcntation or permanent make-up is a


foundati.on for the application of the other eye cosmetics.
We recommend Lhat the practitioner offer to speak to local
cosmetologists on an informal hasis and even offer a professional discount or
courtesy to them for the uctual procedure. For the more motivated
practitionas. a se ries of informative lectures could be arranged at local
.;chools and/of technical colleges.

Internal Approach - Patient-to-Patient


Referral
One of the best methods to market and develop uermalpigmemalion in
our local community i~ to have your patients participate as "advertising
:lmbassadors." We perfomlcd our first len procedures free on highly
motivated women who could not afford the usual fee. These patients were
excited at the prospect of being our "amba:sadors" to help stimulate interest
in their friends, relatives and coworkers. They also fell Ihat they could help
the practi lioner by being available for new candidates to il1lerview (studies
by the cl)mpanies clearly demonstrate that new candidates for
rnicropigment:tlion are most intluenced by other women who have had the
procedure). We have found that the initial free procedure was compensated
manyfold by the pyramid effect of patient referral s. as well as hy keeping our
:;kills proficient.
Anolher successful marketing technique is to include the husband in the
preproccdural assessmenl. The discus.'ion of the technique. its purposes,
CIll11plications. elc., will often eliminate or greatly diminish the fears and
anxiety of the husband. Inoeed. many times we have actually found the
hushand La be cxtrcmely supportive of Ihe wife. The alleviation of fears on
the husband' . pal1 will ultimalely help gain acceptance by the wifc and help
him providc positive support for his wife in the immediate postprocedural
period.
Until dcrmalpigrnenlation becolllc!'- more acceptable and commonplace,
the practitioner and Ihe companies will rely heavily 011 markeLing concepts to
stimulaLe pal'icnt interest and acceptance for this new procedure.

250

INDEX
Ac"CCOl\ (~ce Di{lptic~J

ACl'ulan.:. 53. YI
Acclamil)llphcll. 182
Ackerman. 189. 242
r\o.:quired Immune Deficiency Syndrome
(AIDSI.:<, 149. 151. Hlll.1IS. :!25
Adnexa. 1.57.63.101
Adnl\~tI 'ourgery. 96
Alcon. 17.21. 23. 25. 27. 200. 235
Allergy. YO. 105, 190
Allh.:k, 17.2:;.27-28
:\]OP(;<:i;l, 18. 91
t\ Ill":S lIlu tagenic'ity le;;t. 2()O
Amril'illin.182
,\m[JlIlation, 172
Ana lges ia, I S I
Andrade. 191. 243
I\nl"the~i". hl-b3. 103. 106. 1~: 11 Y.
14ti. 153. 160. 163. 167, 171 , 183.
22-1. 239
Aneurysm. 193
Angi(lgraphy. 11-l-85
Angrc,. 1-1, 21.206,235. 23Y-240. 244
Annulu, of Zinno 63
Anticoagulan1 drug. 92
Anxi.:ty. 53-54. RJ. 91-93 . 100. 147. 149.
151. 177. 250
Apfelherg. 196-197.237.244
Ap()neuro~is ('oc<: L..:valor aponcuf()s i ~ .
RClral.:lnr ap()ncuro~is)
Arcola, 30, 65-66. [69172. 11)4
Anhrith. 90
Atrophy. 74. 165. 190
Aurcoll1ycin. 45
Auric!.:. 79
Axilla. 65. [Y:;
l3a.:itr:lci 11 I,'i
Bat:!'. I i{S. ~.l4 . 211
Ikard . 14 .237
[3el1;l(lryl. 105. 123. 128
Benl.dkoniunl ehloride. 127- 128
BCl1wdiru'apilil'. I ~8

B.:rchol1. 1:-:5. 2-11


Ikradil1c. 14g. 15 2
Biro. 191 . ~ ..U
Blepharitis. 52. 1112, 194
I3lt:ph~lropigllle n1ali(Jn. 51 52. 5~ . 62.69.
74. 76. ill. !I 1. ~5 - 1()2. II .:!. 116-117.
124-125. 148 151.153.155.157. 159.
101. 181. IS:>. 197. JY9-200. 20." 206.
~2 .'. 235. 23Y24()
I.llephan>pigl11cnwlion CI;IIlIP, 101, I .n .
160. ~3 9
Hlepharophht y.
99-101. l .W
IJkplw,,~rat , &2, 14~. 153
Ii l(lI,J J y'na;,ia. <)2
Bll nndl. IYI. ~ .t3
13m,c. I\II. 2..U
Brow ('c'" I~} t:br()w)

n.

Iirml, lifl. 64. 108


Brow pigmclIlalioll. 64, I I Y. 163. 240
l3rown. 14, 20. 7ll. 87. 97, 107. 11 2113.
171 , 185, 190. 191), ~OI 2()2,
234.
2.\8-239. 241
Bryson. 192
Bupi vttcaine, 118

:no.

Canalieuli. 61
Cancer. 64, 67, 96. 244
Cannon, 14,234
Canthal tendon. 61, 71,73.99- 100
Canthu:.. 5X-59. 62. 7 I. 73. 100. 114. 116.
159
Capillary. 14. 155. 157. 2J4
Cap~ ul()palpehral fascia. 57
Cafll , J !IS. 241
Caruncle. 71. I 14
Cellulilis. 186- I 87
Cephaloporin. L82
Chalazion. 62
Chalazion damp. 62
Chancroid. 187
Cheiloplasty, 14
Chcn lotaxis. 205
Chloramphenicol . 45
Chloroquille. 189
Chlortetracycline, 45
Ch ri slCl1~(;'n. 14, 126. 182. 194. 235236,
239240.244
Cilia. 98
Cipollaro. 189.242
Circulatory sy\lCrn. 20S
CLIMB , III , 119. 163
Clotting abnormality (sec Ilcrnophi li a)
COla.ine, 125-126
Codeine. I ~2
C(lhen. 194. ~2R
C,)lIa~cn. 30,165. 177.196- 197.203.
205. 247
Color additive, 32.33. 35 , -Ul
Col,.r r\dditive ,\m('ndlllt!nl. 32
Cornpli cation$, 5 1-52. 54-55, 90. 9~. 109.
123. 1 27-128 , 152 153.167.1~2 . 18-1-IS7. 1!o:9. 191 , 193-197.201 -_02,217 .
'227. 2W-2..J.J , 250
C()nlp rl'ht!n~i",:." Drug Abuoe Prevention
ilild Control Act.. 40
(\'Ilg.cnilal puqJIc plaquc". 14
C(lnjunc'tiva. 57-59. 125-126. 128. 2()..j.
C'lnjlln('(iviti~. lSI. l in
COlllac'1Ieus, IN. 1~7 , 14S
Corm ay. I... ~ .'4. 241
CUIJPcrV i,iun (N(ltuml Eye:,). 17, 1 J -23,
2\ 27.7\ qU, llS )41) . 153. 157 .
199-10 1,235
CorJicr. 1-1
('ol'l1.:a. 62. 74, '.IR-<)q, 101. 12 7. 153. 160.
I X2 ISJ , 194.234.2-15
Cll~rlledyn<::. 17.25. 27-2X . 157

251

N D E X

C')~ll1ctic.

Toiletry and Pragrance


SUOCUmll1illt:cs on Qual ity

.-\~s('ciation
As~uralTce,

:'2

Co~rnctic

surgery. 37. 40. 52, 54.76. 101.


117.239-240
C()~Il1<'t<)logy. 2-3. 14.36-37. 41-4J. 165.
211.245
Cmig. 19.1Cranial racial dysn~ t osis. 76
Crows r~d. 58
CryoslIrgery, 196
Crypt> "r Henle. 58
CST (ConcclIlnlled systemati c
trl'pannationL 197
Curet. 204
CYS(otnOlC. 204
CytnLO~icity. 20 I
Dari(!r'~ diseasc. I) I. 187. 189
Darvoll. 182
Da"k 185. 191 ,242
Deltoid. 192
Dcrr<:s~iol1, 5J. 6J, 128
Dermahrasion. 192.11)6- 197, 2 l5 , 241.
244
Dcrillaipigmemalion, 1-3. 15,42.44.60.
64. 1. 89.92. 171.173. 175.177,
240. 2-1S-2S0
Dermal i ti~, 80, 91. 242
Dcnmltochala. i~. 96. 99
Dcrmmofibrom<l.203
[)cnnalographcsis. 91
Dermalolpgy. 229. 23ol. 237-2J8. 240.
242
[)cnnalorm:. 196
Dennis, 21 . 57-58. 60. 64.196.202-203.
205. 208
Dennollfluge. I:. 17-18.2:>.27, 14l1- 149.
153. 201-202.225.235.248
DcsmaIT':~ retrm;tor. 126
D.:Wick,-r, 1.1Diabeles. 106
Diopti..:s (Accents). 17.23-28. 108. 149.
15\ 157. 1\)-1,200-202.135.248
Di>c hotT, 192
Discoid IlIpu~ c-rYlhernatosus, 1-2, 152.
15n. 1~7 , 189.242
Djornhcrg. 191
D(lyk. 185. 2.t J
Drug Anlt'fldnlcnb . .12. 46
Dufonnclltl!!. 14
Duggan. 1-1
Durhal11 -Humphrey Am<: lldl1lcnts. 31
DY<;Cf:bW. 92

EbcnSl.ell. 191. 24.,


ElThymosi,.62. IOc). I S~
E.cl hYllla. 186-187
b:tropion , 99. Il!3
E<lcma, 62. S(l. 96. IOD. 108. 128. 149150. 1(,] . In7, 177. 11l2. IR6

252

EleClmcaulcry, 196
Electrolysis. 195
Enhanc~ r (see Permark)
Entropion. 59 , 100. 183
Ephe<l rinc. 128
Epibkpharon. 59
Epicanthus, 59
Epidermis, 1, 25,57.60.64.108. 125126.186. 197,202.205-_06
Epin~phrine. 105, 124-126. 128. 147-148
Epiphont, JOO
Epithelium. 59.6.1-,78, 197.204
Ep,(cin. 189. 242
Erickson. 1':11
Erysipelas. 186-187
Erythema. 105. 186-187. 193
Erytho::n]<l rnullifonne. 187, 19~
Erythn)myci n, 182
Exudatc. 182.203
Eyc. 3, I 1, 32. 34-35. 60. 62-6J. 70. n.
75,81.,7.89-90, 92. ':15. 'ill- IOO. 102103.1 06-107,114- 11 8.148-149. 152.
161. 171 ,18 1-184.197,212.223. 235,
238-240.245-247 . 249-250
Eye-Lilc. 29. 157
Eyebrow. 20. 57.59.61 -64,71-71.74-76.
95-99, IOI l()2, 107- 108.118- 119.
126, 157. 16J-I64. 167. 176. 224.227.
240, 245-246
Eye l a~ h , 14, 5 1. 58-59. 87. 89-91. 96. 99.
107-108. 11 4,116. 15J-154. 160, 182183. 11)4. 11)7, 204.206-207.224,133
Eyl!i;hh t<luooing. \4
Eyelid. 2-3. 19-20. 29. J~-35. 57-60. fil04.72-73,75-76.86-87.90.96-103.
106.114- 11 8. 124- 128.149-150.15216 1. 182- 183, 194- 195.206208, 223.
233,235. 139.244-245
Eyeliner. 3, )4, 18.20. 2H. 30.36.51-52.
XI. 87. 89-92, 95, 97, JO I. 106-107.
111 - 112.114- 11.5. 12(\. 115.148. 152.
155- [56.160-161. 167, 2()'4. 207. 212,
216,223-124.217.233.237.244.246.
249
Eycshadow. 223, 245
Facial morphology, 2. 14,69.71-73. 75
76.97. 107 108.172
Facia.l nerve. 6 1. 124
Fair Packagi ng Act, 32. 236
Fa,ci'l. 57. 59, 61. 65. 100
Fc'dcral Food, Dmg alld Cosm<:tic Act.
J 1-33. 44-47. 236
F.:ti.:ra l Food and Drug Admini,trallon
(FDA). I H. 26. 31-35, 37,39.4 1.43.
4.5 , 47, 169. 199,2 14, 236.247-248
Fl.'deral Fcl<xI and Drug, Act. 3 1. 45
FCllzl. 2.1. 1,')3. 20 I. 235
Fibrop las ia, 203
Fibrosis. 2m. 20S
Fidds. 43. 1(1 1-102. 17~ . 189. 20t). 21 I.
241

I N D E X

Follicle. 60, 155. 160161, J 83,205-206


Food Additives Arnendrneill. 46
Foramen ovale. 127
Foramen rnlllnclulIl. 126
Fomix. 125
Foundation. 3. 15. I 12. 131. 223, 250
Fox. [IN. 239, 242
Fr:lise, 196
Franks. 191 , 243
Fronlalb. 59. 6 1.63. 102
FTC. 15
FurIJneulosi,. 186187

Keeley. 201
Keloid. 53. 91. 184. 192
Kcratin.247
Keratitis, 157, IS2 183, 194
Keratoacanthoma. 189, 242
Keral()palhy, lOt 127
Kidney disease, 96
Kirsh. 19J
Klein. 191, 243
Knapp. 14
Kochner phenomenon. 189
Kolle. 14

Gangrene, 186
Glamour Ey c~ (sec Vision Concept. )
Clands or Mllll. 59
Glands of Ze is. 59
Globe , 59. 72, 74. 96, \J9-IOI. 116. 125
Glycerol. 20. 28. 90, 148. 195
Gllldstcin. IS. 36. 1~5. 191. 193. 196,

Lacrima l sac, 61
Lagophthalmus, 183
Lamb, 10. 19 1,243
Lnmeliu,57
Lamina papymcea. 64
Lanc, 35.186-187,191,241 , 243
La~ting Impressions, 17.26,201-202,235
Laugh tinc . 58
Lcpro~ y, 187, 195,24 1-242
Lesion, 100
Leva(()r aponcul'osis, 57-59. 98-99
Levator (muscle). 57, 59
Lichen planus. 80, 91. 187, 189, 242
Lid (sec Eyelid )
Lid clamp. 62. 124. 127. 152-154. 159
160, 183.206.239
Lid ptosis, 96
Lid speculum. 149
Lidocaine, 125. 128. 147
Lip. 9. J 8.20, 30. 64, 70-71. 75. 89, 95,
107, III, 114. 116.119.127, 155,
165-168,176.199,202.227.240
Lipschutz , 241
Lisman, 197
Loewcntlllll, IYO, 242
Loupcs (sec Magnifying loupes)
LUflU~ erythcmalllSIl (see Di 'coud lupus
erylhemato s ll~). 1-2. 152. 156
LuYcck , 189
Lymph node, 07. 193
Lymphadcnili,. 193
Lymphadenopathy. 187. 193
Lymphatic sy~tem. 60. 208
Lys.:rgic acid diethylamide. 46

204, 236-::!37. 243


Granuloma. 191. 201 , 242-243
Grunulom ~lIo,i~. 192
Graves disease. 99
GU7.ick, 176.228.240
Hall. 189, 232,236,242
Halothane. 128
Hcrlllilorna. 25, 62.106. 124. 154. 167.
182,194
Heme. 2OJ, 205 -206
Hemophilia. 92
Hemorrhage. 10:'1. 106. 153
Hemostasis. 206
Hepalic necf()~i ~. 185. 188
Hepalili~, '}.7, 185. 187- 188.225,241-242
HCllJCs, 9 I. 187, I 89
Hodgkin's di ca,e. 194
Horner's mu scle. 61
Hulin. 186. 242
Hyperaclivity.53

Hypcrcslltesia. 196
Hypt'ropia, 7}
Ilypcrpigmcnwtion. 80, 196
Hypcr,ensitivity, 90. 105, 190
flypopigme lllalion, 79. 196- 197.207
Hypo, ccrction, 100- 101

Impetigo. 1811- 187


Ini'cctiordl3. 103. 152. 154. 182 IHJ.
i Sf>. 2.13. 223. 227
Infenor rectu.' mu~cle. 59
Inllammuli o n. I H3 . 1l56-187. 203
l)lilllcn/a. 191
Insulin. 31 . .:15
Iri s. 14. 7 () 7 ~. n . 96. I07-IOX. 114. 157 ,
1M, 166

klk,, 1'i7
Jo,i a, . 11)(0, 242

Macrophage, 60. 203, 208


Madden. 185. 189. 241
Maeda. 187. 242
l\bgnify il1g (bi nocul ar) loupcs. 1-2. 152.
156
Marcain.:. 128
Ma~cara , 3, 87 . <)2.102. 106 107.148 ,
IHI. 199,22J.233.246-247
Ma;.[eClolllY . .10.169. 171 - 172
Maudaire. 14

M:l'iilla. 61
MeA (Multilrepannic Collagen
Actival ion). 177
Mc Dowell , 14,234

25J

N 0

E X

rvlcdka l Device Alllendlllcnt~. 32.46


MribolTli:1I1 gi;]nd. 5S
l'.kibumian orifice. 58
Melanin. 9. 77-))0. 11111_. 176-177.218
Mdanonla. 7')-80. 1l/1- 19-t
Menn, 189
Mepi\";lcaine. Il8
Mirropigmcnration, 1-.3, 13. 15. 17- 18.
20.26.19.3335.3').41-44.5153.
55. 60.72. 75. 78-79. 83. 87. X9-9:l,
95-97,102. 10)-109, I II, 113. 119.
121-114. 127 - 129.1 47-148. ISO- IS2.
154-155. 165- 169.175-178.1,'1-182,
IlI4-186. ISi( 194. 1')6. 199-200. 202204.207. 209':! 13.2 15210.21 X. 223n+. 228. 234-2-'7. 2W-240. 24-t, 2.j~.
250
Micrllpigmcl11alitlll su rg..~ry. 52. YO. 182.
194.240
Microscope. 152
:\1ilsut!a. IX7
,\1olluSClIl11 contagio'llll1. 9 I .. 1'1'.7
Mowat. Il'lS. 242
Muc(\lI~ memhrane. 04. lXI, 246
Muller's 11111s..:k. 57. 59, 63
!\lyopia. n. 7-1
Nan;tv:lti.l.:t
70- n. 75. 157. 16-1. 166
Nas:tI colull1dlu. 75. 79
:--ialural Eye (see CooperVlsion)
:--id- Yag. 1')6
"ccro~is. 80, I ~5, 188. 202
;-':colllycin. 182
N~~)sporin. 182
Ncovasculari~ali()n, 204
l'\~umlogy. 134
".:~i. l.:t. 79
Nipple t rCCOll'lrlll:lion i. IliY. 171. 173.
21S
Nilroll~oxide. lOA. 151
No,c. II. 22. 29.63-64.701':',74 76.
Il ~, 154. 197. ~4()
01ar('~.

O'Reilly. 1.1
Ob,c's i"('compubi\'e.55
Ocular ~dn.:xa . I. 57. 101
Oculofucial morphology. (]9-71. 13, 75.
77,79. RI. 166
01<-,'11. 187, 141
Oncology. 39. 237. 24-1

Ophthalrni..: ~urge ry.2 :i7-240


OphthalrlH)l<>gy. [(12.237239.24;1
Optic nerve. 61
OrbiculaJis rnusGk. 2:\ 5X64. 124125,
154,20S.20X
Orbi t. 57. 63. 7273. 91-:. I IS. 237 2:19
Orbital septum. 59. 61,75
(hlcr. 6')
(hllOp;lIhy. 37
Otolaryngology.2:; X

::5-1

Palpcbr:ll f'l~cialfi~su",jfl)ld!1()bc/()pcning.
59-flO. 7'2-75. 98. 100. I I()
Puranuia, 54
Parkinson's Disca~e. 90
P:trry. 195-196, 2:15.240
l"ISSIlt. l .:t
Palhlliogy, 76, 80. 96. 99. 193
Palipa. 19. 125. 244
P~uk}. 14
Puy.24J
Pe nicil lin. 45
PcnlObarbiIIII. 128
Pc'n.:udan. 182
PeriosteulIl. 125
rermad.:rrll. I 5
'\:rmaline. 25. 28
Pl!rrnark lEn hanccr). 17. 19-20.25. '27.
148-149,157, 182.194.201-202,235,
248
Perko, 191
Phaw<')LO~is. 20X
pHi~()Hex. 151
Pilsbur:y , 18'),142
Plaslic surgery. 14.69. n, <),. 193. 229.
234.238-240
Puil1liJli ~tll. 112113. 119. 177
Porrill. 187.241
Port wine ,win, 15. 243
Pre;,byopia. 90
Procerll~. I> I . 63
Proparacaine. 126
Prolhromhin. I ()(,
Protractor. 60
Pwri li~. 1<)'
Psnria,i,. SO. l) I. I X7, 189
PsydlOSi~, 53
P,~yt' holropic Subsfanccs I\CI. 46
Pteryg()id plc,xu~, 63
I'losi .... 62. 64-65. 73, <.)699. 10 1 102.
165. 176,183
Punctum, 100- 10 I. 1141 15. 120. 154.
IS(). 151). 161
PYOdl!frll<l. 91
Q-Swill'hcd Ruby Laser. IQ7.

~04

Rabbitt,. 191
Raphe. 61
Rectus Il1ll.~<.:k (sec In fcrio r rcctu~ rnus.;lc.
Sup-:rior rl!etus Illusck' )
RCl',.23H
R':lina.204
l~elral'l(lr. 57 . 100. 126
Ketraclor JPllnC LIrosi~, 57 -59.9-')')
Rhinoplasty. lOR
Ruhinson, 1')4
R<.'l'nigh..185
RolIl~(hlliqu(:. 117
Rook. 1.'5. I X9. 241-21.\
Ror,mall, 1\/0. 242
R,blt!nbcrg. 185. 190. 241

ABOUT THE AUTHORS


Dr. Charles S. Zwerlillg, MD, f"'ACS, FICS
r.~duralr,J of C"lumhia Co/frgf'. COlUfl:bii.l U nft'eni('j., Nt' \\' York. Nr and L.'nirl'nily tJf
!Joh');ml M,'dim! SrI",o/. 8<,{"8"O, Ilul,,' 11I1<" 'fIsbip III RabertPucker N ospilal, Sal're. PA :
Resid" II('V;II OphtiUlilll%)!y. RilbNt /'''''k", ffospiw[, ""yrr. I'A.

Chief ,,(,he /)"I"/l1f1w" ll~f O;//ahu/lllolu/I.... WaYII" ,t ln//Orial fioSI';I"/. I tlc., 1991. A.<.<il'wnt
Clillical I'fuli,ssor of 0l'ht}lIIlnw/llgy. University of ,vorth Cum/illu Sclt{)(l' of Medicine,
elll1,,,} flill. NCo 1986Prt"<'III. Nl1Iiolla/ Mt'diclll f)il'eerol'. American Sod.", of
Mh T"}'ixmcntclium S"r~cn. IVIi5 P,,'sem. Ft1lo~" Am('(icall College of SIIrg"O/l":
ItUt'rllariOlllll Collt'.gr (~f Phy.\icuJII ... mul SurgeOlls. C(1~/()tllfdr!r un{1 Cha;rmilJt. Amerinm Sociel)' ()f
Mj"ml' i~ ",cMlIIi/)ll. 8"urd C~rI{fied Dil'lomate. illlln-icalt 800rd of Ophlh(/II/l()I(}.~." Allllior,
.tlicropiltlf!t'1l!(Jtion. dldplt!r In Sur~t'r,\' vf I Ill' 1:..~\'~. Churchill and U vilfgSton. 191<7. Author.
{1ctt:dimlti. of Em"rg<'nn 1.(lf n""alt',,,ng Problem.l, Slack fll c.. 1988.

Annette C. Walker, R.N.


Grac1IUlIt. JtiJe'r-wm SrWt' .~c:lI()(I1 of Nu,..,tnK untf FallrioTl Accr,I,'rny.
COffel ,'ttfelo. C(f/~fonrt(l , Cllrr('JtI/r pur,'iuillg (I A1aslt:r'j Ot'grct! in
Xurs;nf!. UUhi"',fUr tJj'Alahmm.l. Dlfl.. wr of l,u el'\'/('f! Educari<m.
Jad.,,\utn'ille H O'ipjwl. )ack10IH'iUc . Alahama, Pt'f'".li./,1lf llnd Dirrcl"r

of [)(lI't/JrJUflage Clinic.,',

111('.

Dr. Normall R Goldstein, MD


CU{lImbi" C"J/eg". N,'w )'I/ rl; City . .v}' (/11(/ SUItt' UlliHT.\ity flf
J)erfJI{(/{//t>s.' Re.\ide/IIT N,'w l tlrk U nil'a.sil.l'. Clill ic<1/ Prt 1<tHor
/)" l'fIl(JII,/('g\ UTllrc/:\i'~' {~lN{nt'lIij SrJul(l/ (if V1f', Iit..'ine. American A ('fldem,'
"r OerttlllflJ{oXV. 1/(,lIn Sil,',:1' tlII'<IIdlOr R~<eolY'" {ji.",,, Ihe f)ntl! otul()gi,'
Sociely IIf (;r,'ul,'r N"1l 1'<11'''). IIl1sik !lIrard/o/' Ol!nnllw/r>gy R" ., elm:!,.
/;'dunllt'd

01

N.. II )i)lI..

01'''' 70 rJIINi,' /:ed ortid", tin Hll'i(lu, tialll(l{o/(lg ic(// ,whj,'c ls.