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Dealing with tattoos in plastic surgery. Complications and medical use
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ANNPLA-1278; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
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GENERAL REVIEW
Dealing with tattoos in plastic surgery. Complications and medical use Autour du tatouage en chirurgie plastique. Complications et ´ dical tatouage me L. Boulart *, M. Mimoun, W. Noel, N. Malca, M. Chaouat, D. Boccara ˆ pital Saint-Louis, 1, avenue Claude-Vellefaux, Plastic, Reconstructive and Aesthetic Surgery Unit, ho 75010 Paris, France Received 22 July 2016; accepted 8 September 2016
KEYWORDS Tattoo; Complications; Dermatography; Reconstruction; Art
MOTS CLÉS Tatouage ; Complications ; Dermopigmentation ; Reconstruction ; Art
Summary Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing, whether in terms of its medical application or its complications. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands. # 2016 Elsevier Masson SAS. All rights reserved. Résumé Le tatouage est une pratique parmi les plus anciennes et intégrée la médecine depuis l’antiquité. Les chirurgiens plasticiens sont de plus en plus confronté au tatouage, qu’il concerne ses complications et son application médicale. # 2016 Elsevier Masson SAS. Tous droits réservés.
* Corresponding author. E-mail address: [email protected] (L. Boulart). http://dx.doi.org/10.1016/j.anplas.2016.09.004 0294-1260/# 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Introduction
The guiding principle
It was in the South Pacific islands that tattooing became widely developed. In 5th century Europe, tattoos were used as punishment for criminals. Only in the 18th century did tattooing reappear on the old continent, via navigators in contact with tribes from faraway lands [1,2]. Up until recent times, when it became overexposed by the media, the practice remained relatively clandestine; nowadays, however, it has reached a prevalence approximating 10% of the overall population [3].
Tattooing consists in implanting exogenous pigments under the epidermis at various degrees of depth and thereby producing coloration. Dermograph needles cross the papillary and/ or reticular dermis at a depth approximating 1 to 2 mm. The tattoo pigments are absorbed in the macrophages; subsequent to scarring, they remain inert [12] (Fig. 1).
A historical overview
According to the literature, tattooing complications involve 2% [13,14] to 20% [15,16] of tattooed subjects and their etiologies are diversified [13,17,60—64] (Table 1). Though they are less frequent in medical applications, which take place under sterile conditions, they are hardly non-existent. Among these complications, allergic reactions predominate [18]. Particularly frequent occurrence with red pigments, chronic reactions are explained as an attempt by macrophages to eliminate the foreign body [19]. In addition to purely dermatological complications requiring medical treatment, a plastic surgeon may in some rare instances be confronted with situations necessitating primarily surgical treatment. While infectious complications seldom appear, their prevalence is likely to be underestimated; more often than not, they are associated with asepsis [20]. Recourse to surgery
Its medical applications are highly ancient. The first traces of tattoos were discovered on the mummified body of a Neolithic hunter (5300 B.C.). Stylized signs next to the osteoarthritic joints may constitute indexes of a precursor of acupuncture [4]. Moreover, tattooing of the corneal opacities has existed since ancient Greece [2,5—7]. In 1911, Kolle used cinnabar pigments to tattoo the Cupid’s bow of scarified lips [8]. In 1920, in a pioneering step towards permanent makeup, Bettman tattooed a patient’s eyebrows and eyelids after disappearance of the cilia following maxillo-facial surgery [9]. In 1944, Louis Byars was the first surgeon to propose the tattooing of secondary dyschromic scars to skin grafts or flaps [10]. In 1974, Buchman was the first to suggest tattooing of the areola mammae [11].
Tattooing complications and surgical treatment
Figure 1 Schema: distribution of the pigments in the dermis (from top to bottom: epidermis, papillary dermis, reticular dermis, hypodermis).
Table 1
Complications and skin diseases after tattooing.
Complications
Clinical presentation
Time before occurrence of symptoms
Bacterial infections
Impetigo, erysielas, cellulitis, sepsis Leprosy, tetanus Molluscum contagiosum, hepatitis B and C, HIV
First days Weeks to years Weeks, months
Dermatitis Granulomatous reactions, lichenoids Psoriasis, pseudolymphoma, lupus, Pyoderma gangrenosum
Months Days, weeks Weeks to years Weeks to years
Viral infections Mycoses Allergies Dermatoses in the tattooed area Tumeurs
Lymphoma, basal cell and spinocellular carcinoma, keratoacanthoma, melanoma, dermatofibrosarcoma
Years
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Dealing with tattoos in plastic surgery. Complications and medical use
Figure 2 Complication: a case of massive pseudo-carcinomatous hyperplasia on red tattoo pigments and outcome one year after excision (collection of Dr F. Fournier, Nîmes) [24,51].
following an abscess is quite rare, and somewhat astonishingly, risk of secondary bacterial infection is exceptional; only a few cases were described by a military surgeon at the end of the 19th century [21]. In our times, only two recent studies have reported severe multibacterial necrotizing fasciitis, one of which had a fatal outcome, following traditional ritualized tattooing in Australia [22] and New Zealand [23]. In cases involving allergic reactions [24,25], particularly warts with major pseudo-carcinomatous hyperplasia (Fig. 2), exeresis is indispensable inasmuch as it not only treats a lesion of which the resistance to local treatments is patent, but also positively eliminates any diagnosis of epidermoid carcinoma or keratoacanthoma [18]. While treatment of chronic allergic reactions generally necessitates high-dose corticosteroid therapy as first-line treatment, surgery should definitely be considered as an option in small-sized tattoos in an area presenting pronounced cutaneous slackening [26]. A Danish team [27] systematically proposes dermatome shaving as first-line Table 2
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treatment for these types of chronic reactions, especially insofar as studies offer divergent, and not necessarily reassuring, conclusions on the harmlessness of laser [18,28]. As a form of minimal tangential excision (thickness of 0.25 to 1 mm), shave biopsy can be performed under local anesthesia and under visual control until the visible pigment has disappeared. As for residual pigments, they should be expelled within 2 months through local alginate therapy, but there exists a risk of pigmentation disorders and hypertrophic scarring [25,29]. The literature contains numerous cases of cancers associated with tattooing [30—32] that a surgeon is called upon to manage by implementing usual procedures, even though he is called upon to deal with an additional technical conundrum: how can reconstruction most effectively optimize the remaining tattoos [26]? That much said, no etiopathogenic connection has provided a convincing demonstration of the risk of benign, much less malignant tumors on tattoos [33,34]. Given the current state of knowledge, it would seem inaccurate to speak of ‘‘tattoo-induced tumors’’ in a context where skin cancer prevalence has nonetheless been markedly increasing, as has the popularity of tattoos in Western societies, and the just-mentioned risk has been rising correspondingly [35]. One may also note that the traumatic factor repeatedly invoked in dermafibrosarcomas and keratoacanathomas suggests a causative factor concerning the contact of a needle with the dermatome. As a variant and differential diagnosis of epidermoid carcinoma [36], keratoacanthoma has been reported in numerous tattoo-associated cases, with a time lapse of one year before symptom occurrence in the overwhelming majority of cases [30,35—39].
Dermatography in medicine Dermatography has drawn inspiration from Japanese tattooing, in which inks are implanted during consecutive sessions until their color is in perfect correspondence with that of the neighboring skin. This technique is characterized by the subtle interplay of shadows, in view of recreating reliefs [40,41].
Medical indications Over a long period of time, dermatography has been applied with excellent results following a wide range of indications including congenital hyperpigmentations or depigmentation, dermatological diseases, traumatology and the aftermath of reconstructive surgery (Table 2) [24,25,42—52].
Dermatography indications.
Medical indications
Surgical indications
Alopecia areata [43—45], trichotillomania Depigmentation, hyperpigmentation
Burn sequelae Hypertrophic or atrophic scars, keloids; scar correction [25,49,50] Cleft lip sequelae [29,52] Nipple-areola reconstruction [55—59,65] Eyebrow reconstruction
Endoscopic marking of digestive tumors Radiotherapy Hemangioma, Klippel-Trenaunay, Weber syndrome [24,46] Vitiligo [47,48], xanthelasma, scleroderma Corneal leukomas
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Figure 3
Figure 4
Dermopigmentation on dyshromic scars.
Decorative tattoos more and more widely used to camouflage scarring (Taratatou, Paris).
Surgical applications Even though the covering of scars is a matter of central concern, a plastic surgeon will hesitate to use tattoos. As for beauticians and professional tattooers, they have a shared interest in the medical application of tattooing known as dermography, and it has been noted that the material used by tattooers is of higher quality and offers a more clear-cut result than the equipment utilized by laboratories for medical purposes.
Figure 5
By means of this procedure, invalidating depigmented scars on the face and in black-skinned persons (Fig. 3) have been successfully treated [25,50]. Due to pigment lability in scar tissue, perfect color correspondence is difficult to achieve. Alterations are frequently required and have got to be preliminarily mentioned to the patient; that much said, supplementation consisting in Xylocaine 1% with adrenaline limits the bleeding that blurs distinctions between the colors of the pigments [29,41]. Spyropoulou has gone so far as to suggest decorative tattooing as a means of obtaining scar
Nipple and areola reconstruction by dermopigmentation associated with Little’s skate flap and skin graft.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Figure 6 Hyper-realist tattoos. Left: Steve Butcher, New Zealand. Right: Patricia Guinguel, Taratatou, Paris. Patricia is specialized in medical tattooing.
camouflage [29] (Fig. 4). As a final pragmatic step in plastic surgery aimed at diminishing induced scars, subsequent to treatment for cleft lip dermatography has finalized a successful outcome by redesigning the philtrum and the ‘‘cupid’s bow’’, and it can also help to camouflage the residual scars on the scalp that persist following a hair transplant or a frontal face lift [43,53]. As regards, mammary areola reconstruction, it is an essential step in overall breast reconstruction (Fig. 5) [54—56] and has provided substantial quality-of-life benefits and improvements [57]. Numerous refinements of the technique have been proposed for consideration in view of achieving three-dimensional nippleareola and Montgomery tubercle reconstruction [58,59,65]. Some of today’s tattooers perfectly master depth effects (Fig. 6). They have amassed several years of experience and dispose of material enabling them to measure striking power, skin depth and quantity of ink to be introduced. As for surgeons specialized in skin treatment, they are in no position to reinvent themselves as tattooers! If our tattoo results are not wholly up to expectations, it is not because the technique employed is deficient, but rather on account of the fact that the conditions of application are far from ideal, and because we have much to learn from tattooers as we attempt to optimize the results of our reconstructions. It should be added that in France, nipple-areola tattoo is a reimbursed procedure, so it is not legitimate to leave it in the hands of non-physicians. Moreover, as we are in a position to alleviate discomfort by applying local anesthesia, it would be unfortunate for patients to find themselves deprived of our active professional engagement.
Conclusion During his career, a plastic surgeon will almost certainly be confronted with tattoos, whether they be dealt with in the operating theater or, more peculiarly, in cases where complications render it necessary to tattoo. He will be called upon to intervene in situations involving chronic allergic reactions proving themselves resistant to medical treatment
or spectacular hyperplasia. His objective will be not only therapeutic but also, and especially, diagnostic, given the pronouncedly high prevalence of keratoacanthoma. And finally, as concerns reconstructive tattooing, which represents the final step of a frequently painful process involving both scar corrections and nipple and areola reconstruction, it is contingent not simply on know-how, but also, and importantly, on a highly developed artistic sense that a plastic surgeon would be wrong to neglect. Indeed, as he proceeds with reconstructive tasks the practitioner must endeavor to combine an aesthetic sensibility with a technically irreproachable approach. To sum matters up: in order to achieve conclusive and enduring success, he must place tattooing at the intersection of art and surgery.
Disclosure of interest The authors declare that they have no competing interest.
Acknowledgments The author wishes to thank private and hospital practitioners for having shared their photos for this article, and wishes to offer special thanks to Dr. Nicolas Kluger for his valuable advice.
References [1] Pesapane F, Nazzaro G, Gianotti R, Coggi A. A short history of tattoo. JAMA Dermatol 2014;150(2):145. [2] Levy J, Sewell M, Goldstein NII. A short history of tattooing. J Dermatol Surg Oncol 1979;5(11):851—6. [3] Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55(3):413—21. [4] Spindler K. The man in the ice. The preserved body of the Neolithic man reveals the secrets of the Stone Age. Weidenfeld & Nicolson; 1994.
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L. Boulart et al.
[5] Hirsbein D, Gardea E, Brasseur G, Muraine M. Corneal tattooing for iris defects. J Fr Ophtalmol 2008;31(2):155—64. [6] Paik J-S, Lee Y-K, Doh S-H. A patient with combined corneal and ingrowing conjunctival tissue tattooing by micropigmentation method. J Craniofac Surg 2014;25(2):e170—2. [7] van der Velden/Samderubun E, Drost BH, den Dulk LD, Kok JH. Corneal tattooing and safety. Cornea 1999;18(4):498—9. [8] Kolle FS. Plastic and cosmetic surgery. Appelton & co; 1911. [9] Bettman AG. Plastic surgery about the eyes. Ann Surg 1928; 88(6):994—1006. [10] Byars LT. Tattooing of free skin grafts and pedicle flaps. Ann Surg 1945;121(5):644—8. [11] Bunchman HH, Larson DL, Huang TT, Lewis SR. Nipple and areola reconstruction in the burned breast. The ‘‘double bubble’’ technique. Plast Reconstr Surg 1974;54(5):531—6. [12] Garg G, Thami GP. Micropigmentation tattooing for medical purposes. Dermatol Surg 2005;31(8 Pt 1):928—31 [discussion 931]. [13] Cuyper C de, Pérez-Cotapos SML. Dermatologic complications with body art: tattoos. In: piercings and permanent make-up. Berlin, Allemagne: Springer; 2010 [viii+110]. [14] Kazandjieva J, Tsankov N. Tattoos: dermatological complications. Clin Dermatol 2007;25(4):375—82. [15] Caucanas M, El Hayderi L, Lebas E, Richert B, Dezfoulian B, Nikkels A-F. Dermatological complications of temporary and indelible tattoos. Ann Dermatol Venereol 2011;138(2): 161—2. [16] Khunger N, Molpariya A, Khunger A. Complications of tattoos and tattoo removal: stop and think before you ink. J Cutan Aesthet Surg 2015;8(1):30—6. [17] Kluger N. Cutaneous and systemic complications associated with tattooing. Presse Med 2016;45(6 Pt 1):567—76. [18] Kluger N. Tattoo skin reactions: management and treatment algorithm. Dermatol Surg 2016;143(6-7):436—45. [19] Abel EA, Silberberg I, Queen D. Studies of chronic inflammation in a red tattoo by electron microscopy and histochemistry. Acta Derm Venereol 1972;52(6):453—61. [20] Kluger N. Complications infectieuses cutanées associées au tatouage permanent. Med Mal Infect 2011;41(3):115—22. [21] Beerman H, Lane RA. Tattoo; a survey of some of the literature concerning the medical complications of tattooing. Am J Med Sci 1954;227(4):444—64. [22] Korman TM, Grayson ML, Turnidge JD. Polymicrobial septicaemia with Pseudomonas aeruginosa and Streptococcus pyogenes following traditional tattooing. J Infect 1997; 35(2):203. [23] Porter CJW, Simcock JW, MacKinnon CA. Necrotising fasciitis and cellulitis after traditional Samoan tattooing: case reports. J Infect 2005;50(2):149—52. [24] Singh AK, Karki D. Micropigmentation: tattooing for the treatment of lip vitiligo. J Plast Reconstr Aesthet Surg 2010;63(6:): 988—91. [25] Kim EK, Chang TJ, Hong JP, Koh KS. Use of tattooing to camouflage various scars. Aesthetic Plast Surg 2011;35(3): 392—5. [26] Kluger N, Koljonen V, Blatière V. Tattoos and dermatological, plastic and visceral surgery. Dermatol Surg 2012;139(5): 369—74. [27] Sepehri M, Jørgensen B, Serup J. Introduction of dermatome shaving as first line treatment of chronic tattoo reactions. J Dermatol Treat 2015;26(5):451—5. [28] louari S. Réaction inflammatoire aux tatouages de couleur et laser déclenché Nd :YAG. Réaction inflammatoire aux tatouages coul laser déclenché NdYAG. Dermatol Surg 2015;142(12):532. [29] Spyropoulou GA, Fatah F. Decorative tattooing for scar camouflage: patient innovation. J Plast Reconstr Aesthetic Surg 2009;62(10):e353—5.
[30] Goldenberg G, Patel S, Patel MJ, Williford P, Sangueza O. Eruptive squamous cell carcinomas, keratoacanthoma type, arising in a multicolor tattoo. J Cutan Pathol 2008;35(1):62—4. [31] Kluger N, Cotten H, Magana C, Pinquier L. Dermatofibroma occurring within a tattoo: report of two cases. J Cutan Pathol 2008;35(7):696—8. [32] West CC, Morritt AN, Pedelty L, Lam DGK. Cutaneous leiomyosarcoma arising in a tattoo - ‘‘a tumour with no humour’’. J Plast Reconstr Aesthetic Surg 2009;62(5):e79—80. [33] Reddy KK, Hanke CW, Tierney EP. Malignancy arising within cutaneous tattoos: case of dermatofibrosarcoma protuberans and review of literature. J Drugs Dermatol 2011;10(8):837—42. [34] Kluger N, Phan A, Debarbieux S, Balme B, Thomas L. Skin cancers arising in tattoos: coincidental or not? Dermatology 2008;217(3):219—21. [35] Kluger N. Issues with keratoacanthoma, pseudoepitheliomatous hyperplasia and squamous cell carcinoma within tattoos: a clinical point of view. J Cutan Pathol 2010;37(7):812—3. [36] Gon A, dos S, Minelli L, Meissner MCG. Keratoacanthoma in a tattoo. Dermatol Online J 2009;15(7):9. [37] Fraga GR, Prossick TA. Tattoo-associated keratoacanthomas: a series of 8 patients with 11 keratoacanthomas. J Cutan Pathol 2010;37(1):85—90. [38] Kluger N, Minier-Thoumin C, Plantier F. Keratoacanthoma occurring within the red dye of a tattoo. J Cutan Pathol 2008; 35(5):504—7. [39] Kluger N, Plantier F. Pseudo-epitheliomatous hyperplasia, keratoacanthoma and squamous cell carcinoma occurring within tattoos: diagnostic issues. J Am Acad Dermatol 2007;57(5): 901—2. [40] van der Velden EM, Oostrom KA, Ijsselmuiden OE, Hovius SE, Baruchin AM. Dermatography: a new discipline with a wide range of applications. Isr J Med Sci 1994;30(12):897—901. [41] Casadio S. Dermopigmentation en médecine et dermatologie chirurgicale. Cosmetol Dermatol Esthet 2015;1—8. [42] van der Velden EM, Drost BH, Ijsselmuiden OE, Baruchin AM, Hulsebosch HJ. Dermatography as a new treatment for alopecia areata of the eyebrows. Int J Dermatol 1998;37(8):617—21. [43] Rassman WR, Pak JP, Kim J, Estrin NF. Scalp micropigmentation: a concealer for hair and scalp deformities. J Clin Aesthetic Dermatol 2015;8(3):35—42. [44] Park JH, Moh JS, Lee SY, You SH. Micropigmentation: camouflaging scalp alopecia and scars in Korean patients. Aesthetic Plast Surg 2014;38(1):199—204. [45] Brown JB, Cannon B, McDowellF A.. Permanent pigment injection of capillary hemangiomata. Plast Reconstr Surg 1946; 1:106. [46] Conway H. Tattooing of nevus flammeus for permanent camouflage. J Am Med Dir Assoc 1953;152(8):666—9. [47] Halder RM, Pham HN, Breadon JY, Johnson BA. Micropigmentation for the treatment of vitiligo. J Dermatol Surg Oncol 1989; 15(10):1092—8. [48] Van der Velden EM, Wittkampf AR, de Jong BD, van der Putte SC, van der Dussen MF. Dermatography, a treatment for sequelae after head and neck surgery: a case report. J Craniomaxillofac Surg 1992;20(6):273—8. [49] van der Velden EM, Baruchin AM, Jairath D, Oostrom CA, Ijsselmuiden OE. Dermatography: a method for permanent repigmentation of achromic burn scars. Burns 1995;21(4): 304—7. [50] Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented scars. Plast Reconstr Surg 1995;95(3):575—9. [51] van der Velden EM, Van Der Dussen MF. Pseudo-hair formation with dermatography as an adjunctive treatment for cleft lip and palate patients. J Oral Maxillofac Surg 1997;55(4):427—8. [52] van der Velden EM, van der Dussen MF. Dermatography as an adjunctive treatment for cleft lip and palate patients. J Oral Maxillofac Surg 1995;53(1):9—12.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Dealing with tattoos in plastic surgery. Complications and medical use [53] Traquina AC. Micropigmentation as an adjuvant in cosmetic surgery of the scalp. Dermatol Surg 2001;27(2):123—8. [54] Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthetic Surg 2006;59(1):40—53. [55] Hoffman S, Mikell A. Nipple-areola tattooing as part of breast reconstruction. Plast Reconstr Surg Nurs 2004;24(4):155—7. [56] Nimboriboonporn A, Chuthapisith S. Nipple-areola complex reconstruction. Gland Surg 2014;3(1):35—42. [57] El-Ali K, Dalal M, Kat CC. Tattooing of the nipple-areola complex: review of outcome in 40 patients. J Plast Reconstr Aesthetic Surg 2006;59(10):1052—7. [58] Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg 2014;133(5):1073—5. [59] Levites HA, Fourman MS, Phillips BT, Fromm IM, Khan SU, Dagum AB, et al. Modeling fade patterns of nipple areola complex tattoos following breast reconstruction. Ann Plast Surg 2014;73(Suppl 2):S153—6.
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[60] Antal AS, Hanneken S, Neumann NJ, Hengge UR. Considerable variation in the range of time for complications to appear after tattoos. Hautarzt 2008;59(10):769—71. [61] van der Bent Sa, Wolkerstorfer A, Rustemeyer T. Extended abstract cutaneous adverse reactions to tattoos. Ned Tijdschr Geneeskd 2016;160(0):A9808. [62] Kluger N, Plantier F, Moguelet P, Fraitag S. Tattoos: natural history and histopathology of cutaneous reactions. Dermatol Surg 2011;138(2):146—54. [63] Pitarch G, Martínez-Menchón T, Martínez-Aparicio A, SánchezCarazo JL, Muñoz D, Fortea JM. Squamous cell carcinoma over tattoos. J Am Acad Dermatol 2007;56(6):1072—3. [64] Schmitz I, Prymak O, Epple M, Ernert C, Tannapfel A. Squamous cell carcinoma in association with a red tattoo. J Dtsch Dermatol Ges 2016;14(6):604—9. [65] Riot S, Devinck F, Aljudaibi N, Duquennoy-Martinot V, Guerreschi P. [Tattooing of the nipple-areola complex in breast reconstruction: technical note]. Ann Chir Plast Esthet 2016; 61(2):141—4.
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ANNPLA-1278; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
GENERAL REVIEW
Dealing with tattoos in plastic surgery. Complications and medical use Autour du tatouage en chirurgie plastique. Complications et ´ dical tatouage me L. Boulart *, M. Mimoun, W. Noel, N. Malca, M. Chaouat, D. Boccara ˆ pital Saint-Louis, 1, avenue Claude-Vellefaux, Plastic, Reconstructive and Aesthetic Surgery Unit, ho 75010 Paris, France Received 22 July 2016; accepted 8 September 2016
KEYWORDS Tattoo; Complications; Dermatography; Reconstruction; Art
MOTS CLÉS Tatouage ; Complications ; Dermopigmentation ; Reconstruction ; Art
Summary Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing, whether in terms of its medical application or its complications. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands. # 2016 Elsevier Masson SAS. All rights reserved. Résumé Le tatouage est une pratique parmi les plus anciennes et intégrée la médecine depuis l’antiquité. Les chirurgiens plasticiens sont de plus en plus confronté au tatouage, qu’il concerne ses complications et son application médicale. # 2016 Elsevier Masson SAS. Tous droits réservés.
* Corresponding author. E-mail address: [email protected] (L. Boulart). http://dx.doi.org/10.1016/j.anplas.2016.09.004 0294-1260/# 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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Introduction
The guiding principle
It was in the South Pacific islands that tattooing became widely developed. In 5th century Europe, tattoos were used as punishment for criminals. Only in the 18th century did tattooing reappear on the old continent, via navigators in contact with tribes from faraway lands [1,2]. Up until recent times, when it became overexposed by the media, the practice remained relatively clandestine; nowadays, however, it has reached a prevalence approximating 10% of the overall population [3].
Tattooing consists in implanting exogenous pigments under the epidermis at various degrees of depth and thereby producing coloration. Dermograph needles cross the papillary and/ or reticular dermis at a depth approximating 1 to 2 mm. The tattoo pigments are absorbed in the macrophages; subsequent to scarring, they remain inert [12] (Fig. 1).
A historical overview
According to the literature, tattooing complications involve 2% [13,14] to 20% [15,16] of tattooed subjects and their etiologies are diversified [13,17,60—64] (Table 1). Though they are less frequent in medical applications, which take place under sterile conditions, they are hardly non-existent. Among these complications, allergic reactions predominate [18]. Particularly frequent occurrence with red pigments, chronic reactions are explained as an attempt by macrophages to eliminate the foreign body [19]. In addition to purely dermatological complications requiring medical treatment, a plastic surgeon may in some rare instances be confronted with situations necessitating primarily surgical treatment. While infectious complications seldom appear, their prevalence is likely to be underestimated; more often than not, they are associated with asepsis [20]. Recourse to surgery
Its medical applications are highly ancient. The first traces of tattoos were discovered on the mummified body of a Neolithic hunter (5300 B.C.). Stylized signs next to the osteoarthritic joints may constitute indexes of a precursor of acupuncture [4]. Moreover, tattooing of the corneal opacities has existed since ancient Greece [2,5—7]. In 1911, Kolle used cinnabar pigments to tattoo the Cupid’s bow of scarified lips [8]. In 1920, in a pioneering step towards permanent makeup, Bettman tattooed a patient’s eyebrows and eyelids after disappearance of the cilia following maxillo-facial surgery [9]. In 1944, Louis Byars was the first surgeon to propose the tattooing of secondary dyschromic scars to skin grafts or flaps [10]. In 1974, Buchman was the first to suggest tattooing of the areola mammae [11].
Tattooing complications and surgical treatment
Figure 1 Schema: distribution of the pigments in the dermis (from top to bottom: epidermis, papillary dermis, reticular dermis, hypodermis).
Table 1
Complications and skin diseases after tattooing.
Complications
Clinical presentation
Time before occurrence of symptoms
Bacterial infections
Impetigo, erysielas, cellulitis, sepsis Leprosy, tetanus Molluscum contagiosum, hepatitis B and C, HIV
First days Weeks to years Weeks, months
Dermatitis Granulomatous reactions, lichenoids Psoriasis, pseudolymphoma, lupus, Pyoderma gangrenosum
Months Days, weeks Weeks to years Weeks to years
Viral infections Mycoses Allergies Dermatoses in the tattooed area Tumeurs
Lymphoma, basal cell and spinocellular carcinoma, keratoacanthoma, melanoma, dermatofibrosarcoma
Years
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Figure 2 Complication: a case of massive pseudo-carcinomatous hyperplasia on red tattoo pigments and outcome one year after excision (collection of Dr F. Fournier, Nîmes) [24,51].
following an abscess is quite rare, and somewhat astonishingly, risk of secondary bacterial infection is exceptional; only a few cases were described by a military surgeon at the end of the 19th century [21]. In our times, only two recent studies have reported severe multibacterial necrotizing fasciitis, one of which had a fatal outcome, following traditional ritualized tattooing in Australia [22] and New Zealand [23]. In cases involving allergic reactions [24,25], particularly warts with major pseudo-carcinomatous hyperplasia (Fig. 2), exeresis is indispensable inasmuch as it not only treats a lesion of which the resistance to local treatments is patent, but also positively eliminates any diagnosis of epidermoid carcinoma or keratoacanthoma [18]. While treatment of chronic allergic reactions generally necessitates high-dose corticosteroid therapy as first-line treatment, surgery should definitely be considered as an option in small-sized tattoos in an area presenting pronounced cutaneous slackening [26]. A Danish team [27] systematically proposes dermatome shaving as first-line Table 2
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treatment for these types of chronic reactions, especially insofar as studies offer divergent, and not necessarily reassuring, conclusions on the harmlessness of laser [18,28]. As a form of minimal tangential excision (thickness of 0.25 to 1 mm), shave biopsy can be performed under local anesthesia and under visual control until the visible pigment has disappeared. As for residual pigments, they should be expelled within 2 months through local alginate therapy, but there exists a risk of pigmentation disorders and hypertrophic scarring [25,29]. The literature contains numerous cases of cancers associated with tattooing [30—32] that a surgeon is called upon to manage by implementing usual procedures, even though he is called upon to deal with an additional technical conundrum: how can reconstruction most effectively optimize the remaining tattoos [26]? That much said, no etiopathogenic connection has provided a convincing demonstration of the risk of benign, much less malignant tumors on tattoos [33,34]. Given the current state of knowledge, it would seem inaccurate to speak of ‘‘tattoo-induced tumors’’ in a context where skin cancer prevalence has nonetheless been markedly increasing, as has the popularity of tattoos in Western societies, and the just-mentioned risk has been rising correspondingly [35]. One may also note that the traumatic factor repeatedly invoked in dermafibrosarcomas and keratoacanathomas suggests a causative factor concerning the contact of a needle with the dermatome. As a variant and differential diagnosis of epidermoid carcinoma [36], keratoacanthoma has been reported in numerous tattoo-associated cases, with a time lapse of one year before symptom occurrence in the overwhelming majority of cases [30,35—39].
Dermatography in medicine Dermatography has drawn inspiration from Japanese tattooing, in which inks are implanted during consecutive sessions until their color is in perfect correspondence with that of the neighboring skin. This technique is characterized by the subtle interplay of shadows, in view of recreating reliefs [40,41].
Medical indications Over a long period of time, dermatography has been applied with excellent results following a wide range of indications including congenital hyperpigmentations or depigmentation, dermatological diseases, traumatology and the aftermath of reconstructive surgery (Table 2) [24,25,42—52].
Dermatography indications.
Medical indications
Surgical indications
Alopecia areata [43—45], trichotillomania Depigmentation, hyperpigmentation
Burn sequelae Hypertrophic or atrophic scars, keloids; scar correction [25,49,50] Cleft lip sequelae [29,52] Nipple-areola reconstruction [55—59,65] Eyebrow reconstruction
Endoscopic marking of digestive tumors Radiotherapy Hemangioma, Klippel-Trenaunay, Weber syndrome [24,46] Vitiligo [47,48], xanthelasma, scleroderma Corneal leukomas
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Figure 3
Figure 4
Dermopigmentation on dyshromic scars.
Decorative tattoos more and more widely used to camouflage scarring (Taratatou, Paris).
Surgical applications Even though the covering of scars is a matter of central concern, a plastic surgeon will hesitate to use tattoos. As for beauticians and professional tattooers, they have a shared interest in the medical application of tattooing known as dermography, and it has been noted that the material used by tattooers is of higher quality and offers a more clear-cut result than the equipment utilized by laboratories for medical purposes.
Figure 5
By means of this procedure, invalidating depigmented scars on the face and in black-skinned persons (Fig. 3) have been successfully treated [25,50]. Due to pigment lability in scar tissue, perfect color correspondence is difficult to achieve. Alterations are frequently required and have got to be preliminarily mentioned to the patient; that much said, supplementation consisting in Xylocaine 1% with adrenaline limits the bleeding that blurs distinctions between the colors of the pigments [29,41]. Spyropoulou has gone so far as to suggest decorative tattooing as a means of obtaining scar
Nipple and areola reconstruction by dermopigmentation associated with Little’s skate flap and skin graft.
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Figure 6 Hyper-realist tattoos. Left: Steve Butcher, New Zealand. Right: Patricia Guinguel, Taratatou, Paris. Patricia is specialized in medical tattooing.
camouflage [29] (Fig. 4). As a final pragmatic step in plastic surgery aimed at diminishing induced scars, subsequent to treatment for cleft lip dermatography has finalized a successful outcome by redesigning the philtrum and the ‘‘cupid’s bow’’, and it can also help to camouflage the residual scars on the scalp that persist following a hair transplant or a frontal face lift [43,53]. As regards, mammary areola reconstruction, it is an essential step in overall breast reconstruction (Fig. 5) [54—56] and has provided substantial quality-of-life benefits and improvements [57]. Numerous refinements of the technique have been proposed for consideration in view of achieving three-dimensional nippleareola and Montgomery tubercle reconstruction [58,59,65]. Some of today’s tattooers perfectly master depth effects (Fig. 6). They have amassed several years of experience and dispose of material enabling them to measure striking power, skin depth and quantity of ink to be introduced. As for surgeons specialized in skin treatment, they are in no position to reinvent themselves as tattooers! If our tattoo results are not wholly up to expectations, it is not because the technique employed is deficient, but rather on account of the fact that the conditions of application are far from ideal, and because we have much to learn from tattooers as we attempt to optimize the results of our reconstructions. It should be added that in France, nipple-areola tattoo is a reimbursed procedure, so it is not legitimate to leave it in the hands of non-physicians. Moreover, as we are in a position to alleviate discomfort by applying local anesthesia, it would be unfortunate for patients to find themselves deprived of our active professional engagement.
Conclusion During his career, a plastic surgeon will almost certainly be confronted with tattoos, whether they be dealt with in the operating theater or, more peculiarly, in cases where complications render it necessary to tattoo. He will be called upon to intervene in situations involving chronic allergic reactions proving themselves resistant to medical treatment
or spectacular hyperplasia. His objective will be not only therapeutic but also, and especially, diagnostic, given the pronouncedly high prevalence of keratoacanthoma. And finally, as concerns reconstructive tattooing, which represents the final step of a frequently painful process involving both scar corrections and nipple and areola reconstruction, it is contingent not simply on know-how, but also, and importantly, on a highly developed artistic sense that a plastic surgeon would be wrong to neglect. Indeed, as he proceeds with reconstructive tasks the practitioner must endeavor to combine an aesthetic sensibility with a technically irreproachable approach. To sum matters up: in order to achieve conclusive and enduring success, he must place tattooing at the intersection of art and surgery.
Disclosure of interest The authors declare that they have no competing interest.
Acknowledgments The author wishes to thank private and hospital practitioners for having shared their photos for this article, and wishes to offer special thanks to Dr. Nicolas Kluger for his valuable advice.
References [1] Pesapane F, Nazzaro G, Gianotti R, Coggi A. A short history of tattoo. JAMA Dermatol 2014;150(2):145. [2] Levy J, Sewell M, Goldstein NII. A short history of tattooing. J Dermatol Surg Oncol 1979;5(11):851—6. [3] Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55(3):413—21. [4] Spindler K. The man in the ice. The preserved body of the Neolithic man reveals the secrets of the Stone Age. Weidenfeld & Nicolson; 1994.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
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6
L. Boulart et al.
[5] Hirsbein D, Gardea E, Brasseur G, Muraine M. Corneal tattooing for iris defects. J Fr Ophtalmol 2008;31(2):155—64. [6] Paik J-S, Lee Y-K, Doh S-H. A patient with combined corneal and ingrowing conjunctival tissue tattooing by micropigmentation method. J Craniofac Surg 2014;25(2):e170—2. [7] van der Velden/Samderubun E, Drost BH, den Dulk LD, Kok JH. Corneal tattooing and safety. Cornea 1999;18(4):498—9. [8] Kolle FS. Plastic and cosmetic surgery. Appelton & co; 1911. [9] Bettman AG. Plastic surgery about the eyes. Ann Surg 1928; 88(6):994—1006. [10] Byars LT. Tattooing of free skin grafts and pedicle flaps. Ann Surg 1945;121(5):644—8. [11] Bunchman HH, Larson DL, Huang TT, Lewis SR. Nipple and areola reconstruction in the burned breast. The ‘‘double bubble’’ technique. Plast Reconstr Surg 1974;54(5):531—6. [12] Garg G, Thami GP. Micropigmentation tattooing for medical purposes. Dermatol Surg 2005;31(8 Pt 1):928—31 [discussion 931]. [13] Cuyper C de, Pérez-Cotapos SML. Dermatologic complications with body art: tattoos. In: piercings and permanent make-up. Berlin, Allemagne: Springer; 2010 [viii+110]. [14] Kazandjieva J, Tsankov N. Tattoos: dermatological complications. Clin Dermatol 2007;25(4):375—82. [15] Caucanas M, El Hayderi L, Lebas E, Richert B, Dezfoulian B, Nikkels A-F. Dermatological complications of temporary and indelible tattoos. Ann Dermatol Venereol 2011;138(2): 161—2. [16] Khunger N, Molpariya A, Khunger A. Complications of tattoos and tattoo removal: stop and think before you ink. J Cutan Aesthet Surg 2015;8(1):30—6. [17] Kluger N. Cutaneous and systemic complications associated with tattooing. Presse Med 2016;45(6 Pt 1):567—76. [18] Kluger N. Tattoo skin reactions: management and treatment algorithm. Dermatol Surg 2016;143(6-7):436—45. [19] Abel EA, Silberberg I, Queen D. Studies of chronic inflammation in a red tattoo by electron microscopy and histochemistry. Acta Derm Venereol 1972;52(6):453—61. [20] Kluger N. Complications infectieuses cutanées associées au tatouage permanent. Med Mal Infect 2011;41(3):115—22. [21] Beerman H, Lane RA. Tattoo; a survey of some of the literature concerning the medical complications of tattooing. Am J Med Sci 1954;227(4):444—64. [22] Korman TM, Grayson ML, Turnidge JD. Polymicrobial septicaemia with Pseudomonas aeruginosa and Streptococcus pyogenes following traditional tattooing. J Infect 1997; 35(2):203. [23] Porter CJW, Simcock JW, MacKinnon CA. Necrotising fasciitis and cellulitis after traditional Samoan tattooing: case reports. J Infect 2005;50(2):149—52. [24] Singh AK, Karki D. Micropigmentation: tattooing for the treatment of lip vitiligo. J Plast Reconstr Aesthet Surg 2010;63(6:): 988—91. [25] Kim EK, Chang TJ, Hong JP, Koh KS. Use of tattooing to camouflage various scars. Aesthetic Plast Surg 2011;35(3): 392—5. [26] Kluger N, Koljonen V, Blatière V. Tattoos and dermatological, plastic and visceral surgery. Dermatol Surg 2012;139(5): 369—74. [27] Sepehri M, Jørgensen B, Serup J. Introduction of dermatome shaving as first line treatment of chronic tattoo reactions. J Dermatol Treat 2015;26(5):451—5. [28] louari S. Réaction inflammatoire aux tatouages de couleur et laser déclenché Nd :YAG. Réaction inflammatoire aux tatouages coul laser déclenché NdYAG. Dermatol Surg 2015;142(12):532. [29] Spyropoulou GA, Fatah F. Decorative tattooing for scar camouflage: patient innovation. J Plast Reconstr Aesthetic Surg 2009;62(10):e353—5.
[30] Goldenberg G, Patel S, Patel MJ, Williford P, Sangueza O. Eruptive squamous cell carcinomas, keratoacanthoma type, arising in a multicolor tattoo. J Cutan Pathol 2008;35(1):62—4. [31] Kluger N, Cotten H, Magana C, Pinquier L. Dermatofibroma occurring within a tattoo: report of two cases. J Cutan Pathol 2008;35(7):696—8. [32] West CC, Morritt AN, Pedelty L, Lam DGK. Cutaneous leiomyosarcoma arising in a tattoo - ‘‘a tumour with no humour’’. J Plast Reconstr Aesthetic Surg 2009;62(5):e79—80. [33] Reddy KK, Hanke CW, Tierney EP. Malignancy arising within cutaneous tattoos: case of dermatofibrosarcoma protuberans and review of literature. J Drugs Dermatol 2011;10(8):837—42. [34] Kluger N, Phan A, Debarbieux S, Balme B, Thomas L. Skin cancers arising in tattoos: coincidental or not? Dermatology 2008;217(3):219—21. [35] Kluger N. Issues with keratoacanthoma, pseudoepitheliomatous hyperplasia and squamous cell carcinoma within tattoos: a clinical point of view. J Cutan Pathol 2010;37(7):812—3. [36] Gon A, dos S, Minelli L, Meissner MCG. Keratoacanthoma in a tattoo. Dermatol Online J 2009;15(7):9. [37] Fraga GR, Prossick TA. Tattoo-associated keratoacanthomas: a series of 8 patients with 11 keratoacanthomas. J Cutan Pathol 2010;37(1):85—90. [38] Kluger N, Minier-Thoumin C, Plantier F. Keratoacanthoma occurring within the red dye of a tattoo. J Cutan Pathol 2008; 35(5):504—7. [39] Kluger N, Plantier F. Pseudo-epitheliomatous hyperplasia, keratoacanthoma and squamous cell carcinoma occurring within tattoos: diagnostic issues. J Am Acad Dermatol 2007;57(5): 901—2. [40] van der Velden EM, Oostrom KA, Ijsselmuiden OE, Hovius SE, Baruchin AM. Dermatography: a new discipline with a wide range of applications. Isr J Med Sci 1994;30(12):897—901. [41] Casadio S. Dermopigmentation en médecine et dermatologie chirurgicale. Cosmetol Dermatol Esthet 2015;1—8. [42] van der Velden EM, Drost BH, Ijsselmuiden OE, Baruchin AM, Hulsebosch HJ. Dermatography as a new treatment for alopecia areata of the eyebrows. Int J Dermatol 1998;37(8):617—21. [43] Rassman WR, Pak JP, Kim J, Estrin NF. Scalp micropigmentation: a concealer for hair and scalp deformities. J Clin Aesthetic Dermatol 2015;8(3):35—42. [44] Park JH, Moh JS, Lee SY, You SH. Micropigmentation: camouflaging scalp alopecia and scars in Korean patients. Aesthetic Plast Surg 2014;38(1):199—204. [45] Brown JB, Cannon B, McDowellF A.. Permanent pigment injection of capillary hemangiomata. Plast Reconstr Surg 1946; 1:106. [46] Conway H. Tattooing of nevus flammeus for permanent camouflage. J Am Med Dir Assoc 1953;152(8):666—9. [47] Halder RM, Pham HN, Breadon JY, Johnson BA. Micropigmentation for the treatment of vitiligo. J Dermatol Surg Oncol 1989; 15(10):1092—8. [48] Van der Velden EM, Wittkampf AR, de Jong BD, van der Putte SC, van der Dussen MF. Dermatography, a treatment for sequelae after head and neck surgery: a case report. J Craniomaxillofac Surg 1992;20(6):273—8. [49] van der Velden EM, Baruchin AM, Jairath D, Oostrom CA, Ijsselmuiden OE. Dermatography: a method for permanent repigmentation of achromic burn scars. Burns 1995;21(4): 304—7. [50] Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented scars. Plast Reconstr Surg 1995;95(3):575—9. [51] van der Velden EM, Van Der Dussen MF. Pseudo-hair formation with dermatography as an adjunctive treatment for cleft lip and palate patients. J Oral Maxillofac Surg 1997;55(4):427—8. [52] van der Velden EM, van der Dussen MF. Dermatography as an adjunctive treatment for cleft lip and palate patients. J Oral Maxillofac Surg 1995;53(1):9—12.
Please cite this article in press as: Boulart L, et al. Dealing with tattoos in plastic surgery. Complications and medical use. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.004
+ Models
ANNPLA-1278; No. of Pages 7
Dealing with tattoos in plastic surgery. Complications and medical use [53] Traquina AC. Micropigmentation as an adjuvant in cosmetic surgery of the scalp. Dermatol Surg 2001;27(2):123—8. [54] Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthetic Surg 2006;59(1):40—53. [55] Hoffman S, Mikell A. Nipple-areola tattooing as part of breast reconstruction. Plast Reconstr Surg Nurs 2004;24(4):155—7. [56] Nimboriboonporn A, Chuthapisith S. Nipple-areola complex reconstruction. Gland Surg 2014;3(1):35—42. [57] El-Ali K, Dalal M, Kat CC. Tattooing of the nipple-areola complex: review of outcome in 40 patients. J Plast Reconstr Aesthetic Surg 2006;59(10):1052—7. [58] Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg 2014;133(5):1073—5. [59] Levites HA, Fourman MS, Phillips BT, Fromm IM, Khan SU, Dagum AB, et al. Modeling fade patterns of nipple areola complex tattoos following breast reconstruction. Ann Plast Surg 2014;73(Suppl 2):S153—6.
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[60] Antal AS, Hanneken S, Neumann NJ, Hengge UR. Considerable variation in the range of time for complications to appear after tattoos. Hautarzt 2008;59(10):769—71. [61] van der Bent Sa, Wolkerstorfer A, Rustemeyer T. Extended abstract cutaneous adverse reactions to tattoos. Ned Tijdschr Geneeskd 2016;160(0):A9808. [62] Kluger N, Plantier F, Moguelet P, Fraitag S. Tattoos: natural history and histopathology of cutaneous reactions. Dermatol Surg 2011;138(2):146—54. [63] Pitarch G, Martínez-Menchón T, Martínez-Aparicio A, SánchezCarazo JL, Muñoz D, Fortea JM. Squamous cell carcinoma over tattoos. J Am Acad Dermatol 2007;56(6):1072—3. [64] Schmitz I, Prymak O, Epple M, Ernert C, Tannapfel A. Squamous cell carcinoma in association with a red tattoo. J Dtsch Dermatol Ges 2016;14(6):604—9. [65] Riot S, Devinck F, Aljudaibi N, Duquennoy-Martinot V, Guerreschi P. [Tattooing of the nipple-areola complex in breast reconstruction: technical note]. Ann Chir Plast Esthet 2016; 61(2):141—4.
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