Micropigmentation State of the Art

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

1(11111 /)ellllis. 1I111lr/) Oil . Prot/milo".\' '! h,lIIl rilll ..' ,1/.111. {/Jr llotTn.::. ('I '10111.:1,- m.d, \JltIlUf (J'1/lIfl}',..., m1 '/rllt" .'{.;f" !It,' !~ t:,J:.' J .i: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

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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.

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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.

7

CHAPTER

2

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

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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 rl 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

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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 hL . 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 reciproi 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 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

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INSTRUMENTATION

needle, thus eliminating the need for const

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Cost of Disposables per Case

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

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£! 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.

X

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

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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

X

Yes X Yes

X

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

X

Yes

X

Yt>

X

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 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.

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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

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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 arCuperior 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 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.

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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

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CHAPTER

7

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"

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 "ctance 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

7

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 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 intere·t 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

9

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 ped·orming. 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 'lI·ea. 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

o

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 ·, resuILe 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 artistiurgery. 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 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 :lO·second 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 h£1ve 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

3

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 henzodiaz£lpille 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

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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.

c

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

4

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 viti()J1 wi th ice palrucled thupinc 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

5

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) micropigll1cntured 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 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.

5

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 blepharopigmemhine 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

2

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 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

;:r:

0..

COMPANY

(/')

u

~

:-

Procedures Per Company

-l15l

:2159

118

1:)9

1I

20

16

11 7

7911

Eyelash Loss

4

5

0

0

0

12

Penetration of Tarsal Plate

:2

0

0

0

0

5

'.J

!U

0

Cornea I mplalltation

0

0

0

0

0

0

0

Medlanical Scleritis

0

0

0

0

0

()

0

Lid Scarring

2

()

0

0

()

()

()

14

(1

7

2

:\

2

Hematoma

52

Blepharitis Keratitis

."i

1. 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 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 blROCEI)(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 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. 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 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

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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, 1ual 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

J·N

A

P PEN

0

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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.: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