Medical Applications of Tattooing

 
 
Medical applications of tattooing
Snejina Vassileva, MDa,⁎, Evgeniya Hristakieva, MDb

a Department of Dermatology and Venereology, Sofia Faculty of Medicine, 1431 Sofia, Bulgaria
b Department of Dermatology and Venereology, Medical Faculty, Trakia University, 6000 Stara Zagora, Bulgaria

Abstract Tattooing is an ancient procedure, practiced by humans from all parts of the world for a variety of reasons. However, relatively little is known by the medical audience of the numerous medical conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Tattooing for cosmetic and medicinal purposes, referred to as either micropigmentation, dermatography, or medical tattooing, may ensure permanent camouflage in a wide range of dermatological diseases. It can be a valuable finishing step in several surgical procedures in the fields of craniofacial surgery, plastic and reconstructive operations, cosmetic surgery procedures, and breast reconstruction. Other fields of application of medical tattooing include radiation therapy, endoscopic surgery, and ophthalmology. © 2007 Elsevier Inc. All rights reserved.

Introduction

Tattooing implies the process of implantation of exogenouscolorfast pigments into the skin or mucous membranes leading to a discoloration referred to as a tattoo. In this process, only pigment particles introduced through the skin surface, below the dermal epidermal junction, are retained by the dermal macrophages and fibroblasts where they reside permanently, producing an indelible change of the skin color under the form of a recognizable pattern or design.
The practice of tattooing has been in existence for thousands of years, with origins tracing back to the Stone Age.1 Throughout history, the core characteristic of tattoos, their indelibility, has been used by humans from all parts of the world for a variety of reasons, including decoration, to ensure uniqueness in the self-appearance, to mark a status, or

Corresponding author.
E-mail address: snejina.vassileva@gmail.com (S. Vassileva).
0738-081X/$ – see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2007.05.014

to inflict punishment. Some tattoos are performed to enhance physical beauty, for example, to camouflage pathological skin changes. The importance and meaning of tattooing have changed according to time periods. For many years, ornamental tattooing has been popular not only among seamen and the military but also among criminals.2 The prevailing view on tattooing from the 1950s could not be better represented than the statement by the author Hugh Garner who wrote:

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

During the past several decades, however, the public perception of tattooing has greatly evolved. In both the European continent and in the Americas, tattoos and other types of body art, such as piercing, have dramatically increased in popularity, especially among adolescents and young adults. 3 With all of its prerequisites, tattooing has frequently attracted a great deal of scientific curiosity. From the medical perspective, it is an invasive procedure involving several components that might be potentially hazardous and may threaten the health of the tattooed individual. The unequivocal risk of transmission of several blood-borne and infectious diseases by tattooing has been shown and is a source of unabating public health concern.3 The demographic, psychological, and behavioral aspects of the tattooed have been the focus of extensive research in the mental health field.4,5 As far as dermatologists are concerned, most patients are seeking help in relation to tattoos, either to have them removed or for treating the diverse cutaneous complications reported as a consequence of permanent and temporary tattooing. Relatively little is known by the medical audience of the numerous special conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Examples of such medical applications are endoscopic tattooing, corneal tattooing, as well as the recently introduced treatment of viral warts by means of tattooed cytostatic drugs.

Historical aspects of medical tattooing

Perhaps the history of medical tattooing is as old as the history of ornamental tattooing. Speculation surrounds the tattoo marks seen on the naturally preserved human body from 3300 BCE found in a snowfield in the Tyrolean Alps, near the natural pass called the Hauslabjoch.6 These tattoos, in the form of groups of small parallel lines, were located over the lumbar spine, the right knee, and both ankles of the corpse. Because radiographic studies revealed that the man from Hauslabjoch had osteoarthrosis in these joints, it was suggested that the tattoos might indicate a form of stimulatory treatment similar to acupuncture. Other wellpreserved prehistoric mummies found in Siberia and Peru had both ornamental and nonornamental tattoos. The difference in the tattoos was so obvious that a possible therapeutic importance was attributed to the ones of less aesthetic value.1 Tattoos have been seen on Egyptian mummies dating from about 2000 BCE. 7 In the Bible, Moses warned the Jews against the use of tattooing.8 Although in ancient Greece decorative tattooing was considered as barbaric, a crude way of medical tattooing was practiced in 150 CE by Galen, who attempted to cover leukomatous opacities of the cornea by cauterizing the surface with a heated stilet and applying powdered nutgalls and iron (ferric tannate) or pulverized pomegranate bark mixed with copper salt.9 The Romans used tattooing and

branding with a hot iron to mark prisoners of war, captives, and criminals.10 At the same time, a class of physicians was maintained who specialized in the removal of these marks from the skin of successful gladiators and slaves who were granted their freedom. Interest in tattooing declined with the advent of Christianity. It was banned by a papal edict in 787 CE. 11 In the Middle Ages, it was used essentially for marking criminals, a procedure also practiced in the British Army on deserters.10 Although tattooing was forbidden in Europe, it persisted in the Middle East and in other parts of the world, reaching the highest form of art in the islands of the South Pacific and in Japan.11 During the Age of Exploration, tattooing was reinstated in Europe, possibly as a result of James Cook’s expedition, which brought the old continent into contact with the many cultures practicing tattooing. Tattooed Indians and Polynesians, and later Europeans tattooed abroad, attracted much interest at exhibits, fairs, and circuses in Europe and the United States during the 18th and 19th centuries. Influenced by Polynesians and Japanese examples, tattooing “parlors” were mounted in port cities all over the world where specialized “professors” applied decorative designs on European and American sailors.11 By the mid 1800s, the first papers to document unequivocally medical application of tattooing appeared. In 1835,12 a German physician, Pauli, employed tattooing with mercury sulfide and white lead for the restoration of the natural color to the skin in cases of congenital vascular nevi. In 1850, Shule13 recommended cosmetic tattooing with mercury sulfide after plastic lip procedures. In the 1870s,14 the oculoplastic surgeon Louis Von Wecker put into practice the modern method of corneal tattooing of unsightly corneal scars, which became largely used during the subsequent decades to improve the cosmetic appearance of the “blind eye.” At this time, the pigments used were mainly confined to black powdered charcoal or india ink; red-colored mercury sulfide, also know as cinnabar or vermilion; and green, obtained from chromium salts.7 Until 1891, when the first electric tattoo machine was patented, tattooing was performed by hand, using a single needle or instruments with varying needles configurations. The procedure was long and tedious. By 1900, several social events catalyzed the development of both plastic and aesthetic surgery, regarded at this time as the “serious” and “frivolous” counterparts of what we today know as one and the same specialty: using surgery to improve function and normal appearance at the same time. Feminist movements and socialization of women into a “beauty” culture, along with the relative prosperity and the industrial revolution of the early 20th
century, led to the formation of a consumer society that favored the introduction of new aesthetic surgical procedures, such as rhinoplasty, otoplasty, and blepharoplasty, in which tattooing found a place. In 1911, Frederick S. Kolle,15 a German surgeon practicing in New York, used tattooing with cinnabar to

outline the border of scarred lips; in the 1920s, tattooing of
the eyelids was applied to simulate sparse or missing
eyelashes after ocular surgery.16 Not until the post World
War I period did the specialty of plastic surgery emerge. The
horrifying wounds from the trenches stimulated the undertaking
of various flap- and graft-associated reconstructive
procedures that also needed tattooing to simulate a missing
lip or absent eyebrows. In 1944, Louis Byars,17 a plastic
surgeon at the Washington University in St. Louis, Mo,
presented before the annual meeting of the Southern Surgical
Association the results from postoperative tattooing undertaken
in over 60 cases for the purpose of matching skin grafts
and flaps to adjacent facial tissues.
Some rather strange uses were in vogue during the late
1930s and the 1940s. Based on an interesting observation
reported in 1909 by Sh. Dohi,18 a dermatologist from Japan,
cutaneous syphilis did not involve portions of skin that had
been tattooed red with cinnabar (HgS, mercury sulfide,
hydrargyrum sulfuratum rubrum); thus, the treatment of
chronic localized pruritic cutaneous lesions by tattooing was
recommended. Because the mercurials are antiseptics as well
as spirocheticidal, tattooing of the perianal skin with
mercuric sulfide was successfully employed in cases of
intractable pruritus ani.19,20 This idea was extended to treat
severe itching of the vulva and the scrotum.
By mid century, medical tattooing found a place in the
treatment of port-wine stains (PWS) and leukomatous
corneal lesions. In 1958,21 tattooing of the colonic mucosa
was employed as a novel method to mark the site of
excised colorectal polyps and became a landmark in the
field of endoscopic tattooing. By 1974,22 tattooing was
initiated as an adjunct to the reconstruction of the nipple
and areola in the burn patient, a method that was further
refined in breast surgery. In 1984,23 Giora Angres
perfected tattooing of the eyelids to produce permanent
eyeliner, and thus is the beginning of cosmetic makeup.
A variety of machines are available along with a number
of pigment manufacturers, but the principles of introducing
pigment under the surface of the skin remain the same. Two
terms, micropigmentation and dermatography, were introduced
in the medical literature to convey the use of
tattooing for medical purposes. Although micropigmentation
is the term adopted in the American literature and
evokes the use of tattooing for cosmetic reasons and
permanent makeup,24 dermatography designates the
method introduced by European authors to designate the
art of tattooing applied to permanently correct various
cosmetically disabling disorders.25
Cosmetic tattooing/Micropigmentation
Cosmetic tattooing is the art of improving the appearance
of eyelids, augmentation or replacement of eyebrows,
and improvement of lip contour after trauma or

surgery. Other potential fields of micropigmentation
surgery include permanent eye lining, eyelash enhancement
for sparse lashes, and nipple replacement by tattooing.26
Various types of tattooing equipment are available for such
treatment by aesthetic dermatologists: for example, Cooper
Vision (Natural Eyes); Penmark, Dioptics (Accents);
Vision Concepts (Glamour Eyes); Cosmedyne, Alltek,
and Eyelite.
Eyelid tattooing is achieved by a single-pronged23 or
triple-pronged27 needle coated with ferrous oxide pigment,
moving rapidly in a reciprocating fashion. Before the
surgery, local anesthesia is first applied by subconjunctival
injection of 2% lidocaine with 1:100,000 epinephrine.
Under a microscope or wide-field magnifying loupes (×6
magnifying loupes), the operator implants the pigment at
the base of the eyelashes and between the lashes in dotlike
fashion, from lateral to medial canthus. The dots are
applied sequentially so that they barely overlap, which
provides a subtle, fine line of pigmentation. It is
recommended that both lower eyelids be tattooed first. In
the upper eyelids a heavier line may be obtained by
pigmenting two or more rows of dots that should be
confluent, with the outer edges of each dot overlapping.27
After completing the blepharopigmentation procedure, the
eyelids are cleaned of excess pigment, and steroid
antibiotic ointment is applied to the eyelashes; artificial
tears should be used during the next 48 hours to lubricate
the eyes to prevent any keratitis from eyelid akinesia.
Evaluation of the final result is made at least 1 month after
the initial application of pigment. Although initially
developed to satisfy the need of handicapped women
who wished to have the eyes permanently enhanced,
subsequently, eyelid tattooing or blepharopigmentation
quickly gained popularity in cosmetic medicine as
permanent makeup among the general population. Blepharopigmentation
is a particularly convenient cosmetic
procedure for contact lens wearers as well as people with
presbyopia. Women allergic to conventional eye makeup
have also undergone blepharopigmentation.27 Complications
related to this procedure are mostly reported in the
ophthalmology literature, including long-lasting pigment
spreading, eyelid margin necrosis, cilia loss and secondary
cicatricial entropion, preceptal cellulitis.28 Most commonly,
these appear to be caused by improper technique. To avoid
ocular injury, a protective shield is advised.27,28
The lip liner or full lip color can be done using
micropigmentation to change the size and shape of the lips
as well as to deepen their color.29 It is a simpler and
permanent technique than collagen implants for the
creation of French lips. Lip lining is done in a step-bystep
manner to achieve the desired effect according to the
individual’s choice.26 Many patients need permanent lip
tattooing as a final step in lip rejuvenation surgeries, such
as lip advancement and lip-lift, resurfacing, and autologous
fat augmentation. Red dye is tattooed into the lip mucosa
and over the vermillion border to advance the red color

surgery. Other potential fields of micropigmentation
surgery include permanent eye lining, eyelash enhancement
for sparse lashes, and nipple replacement by tattooing.26
Various types of tattooing equipment are available for such
treatment by aesthetic dermatologists: for example, Cooper
Vision (Natural Eyes); Penmark, Dioptics (Accents);
Vision Concepts (Glamour Eyes); Cosmedyne, Alltek,
and Eyelite.
Eyelid tattooing is achieved by a single-pronged23 or
triple-pronged27 needle coated with ferrous oxide pigment,
moving rapidly in a reciprocating fashion. Before the
surgery, local anesthesia is first applied by subconjunctival
injection of 2% lidocaine with 1:100,000 epinephrine.
Under a microscope or wide-field magnifying loupes (×6
magnifying loupes), the operator implants the pigment at
the base of the eyelashes and between the lashes in dotlike
fashion, from lateral to medial canthus. The dots are
applied sequentially so that they barely overlap, which
provides a subtle, fine line of pigmentation. It is
recommended that both lower eyelids be tattooed first. In
the upper eyelids a heavier line may be obtained by
pigmenting two or more rows of dots that should be
confluent, with the outer edges of each dot overlapping.27
After completing the blepharopigmentation procedure, the
eyelids are cleaned of excess pigment, and steroid
antibiotic ointment is applied to the eyelashes; artificial
tears should be used during the next 48 hours to lubricate
the eyes to prevent any keratitis from eyelid akinesia.
Evaluation of the final result is made at least 1 month after
the initial application of pigment. Although initially
developed to satisfy the need of handicapped women
who wished to have the eyes permanently enhanced,
subsequently, eyelid tattooing or blepharopigmentation
quickly gained popularity in cosmetic medicine as
permanent makeup among the general population. Blepharopigmentation
is a particularly convenient cosmetic
procedure for contact lens wearers as well as people with
presbyopia. Women allergic to conventional eye makeup
have also undergone blepharopigmentation.27 Complications
related to this procedure are mostly reported in the
ophthalmology literature, including long-lasting pigment
spreading, eyelid margin necrosis, cilia loss and secondary
cicatricial entropion, preceptal cellulitis.28 Most commonly,
these appear to be caused by improper technique. To avoid
ocular injury, a protective shield is advised.27,28
The lip liner or full lip color can be done using
micropigmentation to change the size and shape of the lips
as well as to deepen their color.29 It is a simpler and
permanent technique than collagen implants for the
creation of French lips. Lip lining is done in a step-bystep
manner to achieve the desired effect according to the
individual’s choice.26 Many patients need permanent lip
tattooing as a final step in lip rejuvenation surgeries, such
as lip advancement and lip-lift, resurfacing, and autologous
fat augmentation. Red dye is tattooed into the lip mucosa
and over the vermillion border to advance the red color

500 and 3500 rpm. Massive entomological needles, 36 mm
in length and 0.36 or 0.41 mm in diameter, with a conical tip
are used. The number of needles and the distance between
the needle tips can be arranged depending on the required
color intensity. The color pigments used consist of a mixture
of ferric oxides, carbon black, titanium dioxide, and
tartrazine. A series of 64 standard colors varying in intensity
between 10% and 100% serve as a reference for specific
applications and may be mixed to obtain different subtle
shades.35 The pigment suspension is inserted in the skin
along the needles by an alternating effect of pressure and
suction caused by the up-and-down movement of the needles
and skin elasticity. The angle between the skin surface and
the needles also varies between 10° and 90°, depending on
the shape of the skin surface and intensity of the color
wanted. The depth of the punctures is between 0.6 and
2.2 mm. In most cases, local anesthesia is not necessary
because of the low speed of the machine and the spread
between the needles. Another reason not to use anesthesia is
to avoid dilution of the pigments by the local anesthetic,
which is one of the major causes of fading of color.

For the last 15 years, dermatography has been applied
with excellent results in a wide range of indications,
including hyperpigmentation and depigmentation caused
by congenital defects, skin diseases, traumata, and after
surgical interventions in plastic and reconstructive surgery
and craniomaxillofacial surgery (Table 1).25
Port−wine stains are benign capillary vascular malformations
consisting of dilated ectatic blood vessels in
the superficial dermis, clinically manifesting with lightpink
to deep-red sharply demarcated macules. Despite the
recent advances made, it remains difficult to eradicate
PWS fully with the current armory of lasers and
noncoherent light sources.36 For patients resistant to the
previous treatment, cosmetic camouflage or cosmetic
medical tattooing are acceptable solutions to ameliorate
the esthetic appearance of PWS, especially those located
on the uncovered parts. Tattooing of PWS has been
reported in several papers dating from the 1940s to the
1960s.37-39 Over 20 years, Conway et al40 treated more
than 1000 cases, reporting satisfactory results in 84% of
patients (836 of 996 cases), but complications were not
infrequent, including irregular intensity of the pigment
deposited and formation of small cavernous lesions within
the treated areas, which required further surgical excision.
Using dermatography,35 much better results have been
obtained in camouflaging PWS on the face and neck,
without any early or late complications observed at a
follow-up up to 2 years.
Vitiligo is the most common depigmenting disorder,
which affects 0.5% to 1% of the worldwide population.
Although vitiligo is not a physically disabling disease per se,
it may be a major psychosocial problem especially in darkskinned
individuals. Patients partially responding or not
responding to standard medical treatments are prescribed
cosmetic camouflage creams, which, however, have the
disadvantage of rubbing-off on areas where there is friction
and sweating and need to be applied daily. Permanent
tattooing has been introduced in practice to restore a
pigmented appearance of lesional skin in localized stable
vitiligo.41 The results from several reported studies showed
excellent color matching in cutaneous,42,43 mucosal,44 and
mucocutaneous vitiligo.42,45
Piebaldism is an autosomal dominant, congenital, stable
leukoderma characterized by a white forelock and vitiligolike
amelanotic macules. Tattooing was successfully used to
cover hypomelanotic patches on the knees in an 11-year-old
girl with piebaldism.46
Halo nevus or Sutton nevus was permanently camouflaged
by means of tattooing of the depigmented zone
followed by electrocauterization of the nevus part.47
Depigmented postburn scars and scars after plastic
surgery present a cosmetically displeasing problem, particularly
when located on the face and in darker-skinned
individuals. Both tattooing techniques of micropigmentation48
and dermatography49 have been applied to disguise
hypochromic scars.

Alopecia areata (AA) is characterized by patchy hair loss
developing in otherwise normal skin. The scalp is most often
affected, but other sites such as the eyebrows, eyelashes, and
the beard area may be involved, making it a disfiguring
disease. A number of therapies have been developed based
on the concept that AA is an autoimmune disease, but none
of them has been proven to be consistently effective. By way
of camouflage, many patients feel happier wearing a wig,
and tattooing of the eyebrows can be helpful to restore the
esthetic appearance of the face. Van der Velden et al50
applied dermatography to treat 33 patients with AA of the
eyebrows. The results obtained were excellent in 30 patients
and good in 3 patients. In 1 patient with partial alopecia of
the eyebrows, hair regrowth was seen in the treated area,
possibly resulting from the hair follicle stimulation by the
dermatography treatment.
Syringomata, benign appendageal tumors of the
intraepidermal eccrine sweat duct, typically presenting as
small skin- or tan-colored papules on the lower eyelids in
young women, have been successfully treated by means of
tattooing followed by Q-switched Alexandrite laser.51 The
surface of the syringoma lesions was first deepithelialized
by vaporization with a clear pulse carbon dioxide laser,
after which, iontophoresis with black ink was applied,
followed by two-three shots of Q-switched alexandrite
laser on the tattooed papules. The results showed complete
disappearance of most lesions before the first follow-up
week without sequelae. With this method, the black ink
was used as photosensitizer for targeting the ductal
adenomas that allowed the damage to the neighboring
normal tissue to be avoided.
Plastic and maxillofacial surgery
Tattooing may be a valuable finishing step in several
surgical procedures in the fields of craniofacial surgery,
plastic and reconstructive operations, cosmetic surgery
procedures, and in breast reconstruction.25
Dermatography was successfully applied for correcting
the color mismatch and reducing the scars in patients
operated for unilateral and bilateral cleft lip and palate. For
correcting the vermilion border, instead of simply drawing a
red lip contour, color is inserted in the filtrum, thus creating
a natural “countercontour” effect52; in the hairy area of the
moustache in men, natural hairs can be simulated by
insertion of dots of brown-black pigment.53
Micropigmentation has been used to disguise the bald
areas in patients with residual scalp scars after hair
restoration procedures and brow lift surgery.54 Moderate
degree of pigment fading was reported as the only
problem, observed within the first 6 weeks after the
tattooing procedure.
Tattoo marks are placed on the scalp of patients
undergoing scalp reduction surgery for correction of male

pattern baldness; postoperatively, tattoo marks allow
subsequent dynamic measuring of the postoperative
“stretch-back” and help define the etiology of a potentially
enlarging bald spot.55,56
Nipple-areola complex (NAC) reconstruction is an
integral part of breast reconstruction after mastectomy for
breast cancer; no breast is now considered optimal
cosmetically without this pigmented complex.57 Other
conditions requiring NAC reconstruction include congenital
anomalies (athelia, amastia), posttraumatic or burn deformities,
and complications from breast surgery such as
reduction mammoplasty.58 Tattooing is now largely performed
as a final step in NAC reconstruction as a simple,
very effective, safe, and minimally invasive outpatient
procedure.57-63 Using different shades of color, the tattooed
NAC is able to produce a 3-dimensional effect of a projecting
nipple when viewed. The areola is tattooed first working
around the periphery and then filling the center. The rugae
and texture are imitated with a darker pigment, and white
spots are interlaced with lighter tones to resemble Montgomery
glands in a natural areola. The nipple is made
slightly darker, whereafter a highlight and shadows are added
to create a “trompe l’oeil” effect. The edge of the areola is
blended into the surrounding skin, so as not to give a distinct
edge.61 A modified pigment-gel-suspension technique has
been proposed to achieve more natural results by imitating
skin translucency and avoiding an opaque “painted”
appearance.59 The shade chosen for the reconstructed areola
is darker than the normal one, so that over time, the fading
will result in a more appropriate color match.57,59,63
Matching the color s in daylight, the use of a Munsell
color chart,64 as well as objective color assessment using
computer software have been recommended to reduce the
risk of color mismatch.63
Patient satisfaction with NAC tattooing has been reported
to be very high. It is the final stage of an often long
and difficult rehabilitation process and signals the end of
the patient’s illness and disfigurement and return to
“normality.”57,62,63
Radiation oncology
In radiation therapy, patient markings are used for target
localization to ensure accurate and precise treatment setup.
Precise beam alignment, with reproducible and accurate
positioning and immobilization of the patient, is required
during each day of a fractionated course of radiotherapy,
which may last several weeks. Patient positioning is typically
achieved by placing a set of dark pigmented tattoos on the
patient’s skin at selected points, generally along the
treatment axis. Tattooing is commonly performed using a
sterile 18- or 19-gauge hypodermic needle dipped in india
ink. The resulting marks, known as “localization,” “radiation,”
or “positional” tattoos, are small black dots that serve

as visible and reliable localization points during the
prescribed treatment course while also serving as a reference
point later.65 Historically, tattoos were also used to localize
past treatment ports during cancer recurrences, but the
current general practice is to confirm earlier treatment
volumes via imaging of bony anatomy in simulation.
Permanent tattoos, especially those in cosmetically
sensitive locations may be troubling because they daily
remind cancer survivors of their disease and treatments. For
example, patients with breast and lung cancer will have post
radiotherapy one or more tattoos on their neckline where the
marks are easily seen. Semipermanent ink marks66 and
temporary tattooing with pure henna have been proposed as a
marking options to increase patients’ comfort.67
Tattooing has been applied in the advent of combined
planned preoperative irradiation and en bloc surgical
resection for epidermoid carcinoma of the tonsillar area
and tongue to outline the largest margins of resection
before irradiation.68
Endoscopic tattooing
Endoscopic tattooing is a technique where a specific site
in the gastrointestinal tract is labeled by an intramural
injection of a staining agent for future surgical or endoscopic
surveillance. Initially introduced to mark lesions in the colon
before surgical resection,69 endoscopic tattooing is now well
recognized as an effective means to enable subsequent
endoscopic and surgical localization of various subtle
luminal digestive tract lesions, such as flat or small
neoplasms, sites of endoscopically removed polyps, diverticula,
and arteriovenous malformations.70 Colorectal tattooing
is the preferred method for tumor localization before
colorectal laparoscopic resection.71 Tattooing has been used
in the stomach to mark the sites of malignant polyps, to
demarcate antrum from body before highly selective
vagotomy, and to mark areas of acute gastrointestinal
hemorrhage preoperatively.72,73 In the esophagus, tattooing
was used to mark the proximal level of the squamocolumnar
junction in patients with Barrett esophagus ensuring a
longitudinal follow-up of 36 months.74 In a patient with
pancreas divisum, tattooing of the minor papilla has been
performed, allowing its immediate identification for subsequent
attempts at endoscopic therapy.75
India ink is most commonly used as a staining agent.
When appropriately diluted and injected, india ink tattooing
is safe and long-lasting.71 Rare complications associated
with injection of india ink, including phlegmonous gastritis,
inflammatory pseudotumor, itraabdominal and rectus muscle
abscesses, and inflammatory bowel disease, have been
attributed to an inflammatory reaction to substances within
the ink, the diluent, or to bacterial contamination. Other dyes,
such as methylene blue, indigo carmine, lymphazurin, and
indocyanine green have shown disappointing results because
of short duration of the staining compared to the permanency

of staining produced by india ink.76 Recently, a sterile and
biocompatible suspension containing highly purified, very
fine carbon particles (Spot, GI Supply, Camp Hill, Pa) was
developed and is commercially marketed specifically for
endoscopic tattooing.77
Corneal tattooing
Permanent tattooing of the cornea can be performed for
both cosmetic and optical reasons. Although with the
current progress of keratoplasty techniques and contact
lens manufacturing corneal tattooing has lost its popularity,
it may still be a reasonable alternative in high-risk cases of
leukoma or leukocoria where corneal transplantation would
lead to rejection and graft failure or in eyes without visual
potential.78 In cases of eccentric semitranslucent scars and
contact lens intolerance, complaints of visual disability
secondary to light scattering and glare can be managed by
a corneal tattoo, which converts an annoying nebula into
an opaque plaque causing an absolute scotoma.79 Occasionally,
corneal tattooing has been used in seeing eyes to
reduce the glare associated with large iridectomies or
traumatic iris loss.80
The conventional method for corneal tattooing is similar
to dermatography techniques, that is, insoluble staining
pigments (india ink, iron oxide, titanium dioxide) are
imbedded into the corneal stroma by means of multiple
punctures or by means of lamellar keratectomy followed
by insertion of the pigments into the midstromal place.81-83
Another method used is chemical dyeing by placing
metallic salts (gold chloride, platinum chloride) on the
deepitelialized corneal stroma and then chemically reducing
them with hydrazine.80
Significance of tattoos in forensic medicine
Tattooing is of considerable medicolegal import. Tattoos
last for a lifetime and persist into the postmortem period
and may help in the identification of living as well as of
dead individuals, particularly when fingerprints or dental
records are unavailable.84 For example, tattoo marks
played a decisive role in the famous Tichborne case
from the 19th century.85
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