Medical Tattooing

Cosmetic Tattoo
Guide
Breast/Scarring
Paramedical
1 r ~ ~ . .
contents
Chapter 1 Genera/Information
M icropigmentation 27
Scars 1
The Healing Skin 28
Keloid Tissue 2
Wound Healing Post Application 29
Burns 3
Tattooing & Skin Cancer 31
Facts On Burn Survivors 4
Scar Contractures 4
Chapter 3 Pigment &Colour
Vitiligo 5
Camouflage 32
Skin Disorders 7
Corrective Pigment
Hyperpigmentation 9
Camouflage 34
When To Camouflage 11
Colour Skin Tones 39
Scar Relaxation/
Basic Colour Knowledge 41
Skin Needling 12
Mixing Colours 43
Chapter 2 The Client
Colour Trouble-Shooting 43
Consultation 13
Use Of Colour- Pigment
Procedure Day 14
Update 44
Application 14
Tips For Colour Mixing 45
Application Tips 15
Pigment Do's And Don't's 45
After Procedure
Needles 47
Day 16
Glycogel (Remover) 48
CPC After Care 17
Anaesthetic in Cosmetic Tattoo
Chapter 3 Tattooing The Breast
Procedures 18
The Technician 49
"Left Side" 19
The Cl ient 50
Bio Touch Anaesthetic
Surgeries 51
Ingredients 20
Drawing The Areola 54
Client Details Form 21
Areola I Nipple 55
Female Full Body Template 22
Nipple Artistry 58
Male Full Body Template 23
Needle Technique 59
Chart Notes 24
Colour Technique 61
Interpreting Client History Forms 25
Medications That Effect Blood
Coagulation During
CHAPTER 1
GENERAL INFORMATION
SCARS
o A scar is the direct result when dermal tissue is lost and replaced. This represents
the final stage of the healing process. A superficial scar is said to be atrophic like
a smallpox vaccination. If tension is placed on a scar it will become thin and
elliptical (oblong) rather than linear (longitudinal).
o All scars need specific application treatments with special attention to meticulous
technique.
o Hypertonic (raised), red scars are thickened scars usually resulting from deep
surgery, accidental injury, chemical or heat burns. They usually remain within the
perimeter of the original wound.
o When a scar is raised or jagged, it may be excised. The type of surgery should be
considered 6-12 months post initial injury depending upon the patient's own
healing process.
o Scars usually heal within 6 months to a year.
a The Z-plasty and Y-plasty is a technique used to reposition scars, usually to an
existing crease or facial line so they are less noticeable. The scar is removed and
several incisions are made on each side, creating small triangular flaps of skin.
The flaps are rearranged and interlocked to cover the affected area. The new
scar will be thinner and much less visible.
a Tanning beds and sun bathing may increase scarring while the wound is healing.
o You should not apply pigment into the skin of a patient whose scar is less than 6
months old. Ideally you should wait at least 1 year before beginning any CPC
application.
a Scars should be kept moist. Dense scabs can impede the cellular growth.
a When nerves are damaged, their fibres degenerate toward the spinal cord, then
grow after the scar tissue has formed. The tangle of nerves in a new scar often
gives rise to abnormal sensations, and should disappear in a few weeks. Tangles
nerves in an old scar may, however, cause annoying tenderness.
a The deeper the wound is, the greater the chance the scarring will be.
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o Some scars can be treated with steroid preparations to relieve symptoms such as
tenderness and itching.
o Pressure placed on the wound site may stimulate the fibroblast activity. This may
cause more collagen protein to be secreted, and will increase the size of the scar.
KELOID TISSUE
o According to 2000 Reuters Limited: "Keloid (which is 'cheloide' in French)
was called such in 1835 by a dermatologist named Jean Louis Albert.
According to the Nouveau Petit Robert Dictionaire, the word 'Keloid' was
used in F ranee in the early 1817's.
o A keloid is an abnormal scar that may be hard, smooth and rounded. lt is a
tissue mass of interwoven broad bundles consisting of dense fibrotic tissue.
o Keloid scars occur when a wound scar grows excessively, producing fibrous
protein (collagen) after the wound has healed.
o Keloids are benign tumours.
o Keloids appear shiny and can be shaped like a 'dome' .
o Keloid tissue is hard, dense and often red or darker in colour than the
surrounding tissue.
o Keloids are the most prone on the breastbone, earlobes and the shoulders.
Other locations prone to keloidal scarring are the shoulders, upper chest, and
lower abdomen.
o Keloids occur more often in dark-complected people than fair-complected
people.
o If follicles are lost, the area is predominantly bald; if the glands are lost it is
permanently dry.
o Treatments of Keloidal tissue may include:
Kenalog (a steroid injection that may be injected directly into a scar to
flatten the area)
Cortisone
Silicone gel sheeting
Compression garments
Surgery (scar revision)
Kelo-Cote gel
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BURNS
a The most common cause of burns is fire.
a 80% of accidental burns occur in the home.
a Direct heat (including scalding water), chemicals, electricity, radiation or sun
damage may cause burns.
a First and second-degree burns are classified as partial-thickness burns.
a In a first degree burn, the outer layer of skin is red, injured and will not blister.
a In a second-degree burn, the epidermis is totally injured and much of the
corium. Blisters are formed and there is oedema in the sub-cutaneous layer.
a First and second-degree burns are painful because the nerve-endings have
been injured.
a Third-degree burns are classified as full-thickness burns.
a In a third-degree burn, all layers of the skin are destroyed. Muscles, bones
and blood supply may also be destroyed or injured. The nerves that are
destroyed make the wound painless.
a Burned tissue is usually covered by skin grafts.
a Types of Skin Grafts
Skin grafts are a very common procedure used in reconstructive
surgery:
Autograft: bone, muscle, fascia, fat, cartilage, or nerves that are moved
from one part of the body to another
Allograft I Homograft: tissue that is transplanted from another human
being shortly after their death
Xenografts I Heterografts: tissue from another species
Free Grafting: tissue that is cut from one part of the body and moved to
another part
Thin Split-Thickness Grafts: used to replace mucous membrane and
skin in reconstructive surgery
Full-Thickness Grafts: used primarily to cover small areas where
matching skin tones and texture are important
Pedicle Flap: used when a deep and large defect needs to be covered
FACTS ON BURN SURVIVORS
o "Itching is considered to be a form of pain due to stimulation of nerve fibres
just below the skin surface caused by the release of histamine from the
healed burn," this according to Or Robert Demling.
o Prudoxin is used for the management of moderate itching of atopic dermatitis
and lichen simplex. Prudoxin is now used by burn survivors.
o Prudoxin is nearly 1,000 times more potent than Benadryl and 100 times
more potent than Atarax. See Information below:
SCAR CONTRACTURES
o Skin contractures are one of the most serious long-term complications for a
burn survivor.
o Contractures occur when the skin from the scar pulls the edges of the skin
together. The contractured skin may affect adjacent muscles and tendons
and restrict normal movement.
o There are two major types of contractures.
o Contractures that are caused by joint and muscle stiffening or lack of motion.
o Contractures that occur after skin grafting.
o Early skin grafting can help to prevent contractures because the patient is
mobilised months earlier than would otherwise be possible.
o Chewing gum and blowing balloons will help the patient to prevent facial
contractures.
o Burns that occur on the hand can easily result in contractures, and can be
greatly reduced with 'scar relaxation'.
o Most burn and scar patients have lower self-esteem, social anxiety and fear
of rejection.
o Burn and scar patients that wear a compression garment such as a 'Jobst
garment' will sustain lesser contractions, if they wear the garment faithfully.
a Scar Care "A safe and effective method for managing hypertrophic and keloid
scars. " FDA approved.
a Scar Esthtiqe - "The choice of plastic surgeons and dermatologists for non-
surgical scar care."
a Kelo-cote - a topical silicone wound dressing for the repair, healing and
remediation of damage to the surface of the skin from trauma surgery or
tattooing.
VITILIGO
a Vitiligo (leucoderma) is an autoimmune disease of unknown etiology.
('Leuco' means white and 'derma' refers to the skin.) lt is characterised by
'white areas' (the absence of melanin" in the skin.
a Vitiligo affects 1% to 2% men and women in all races. Peak onset is 20
years of age.
a Approximately 40% of patients have other members in their family who are
also affected with Vitiligo.
a Treatments that may help Vitiligo:
Sinvitil - According to the manufacturer, "Sinvitil is a specially
formulated gel that contains an extract of proteolipids, which gives that
product its main properties. Sinvitil helps the skin to regain its normal
colour by naturally stimulating the pigmentation process, enhancing the
capacity of the skin melanocytes to respond to sunlight (or artificial
ultraviolet light)."
Topical Oxsoralen
Mini grafting
Topical corticosteroid creams
Oral Psoralens and UVA irradiation
Beboquin (bleaching with monobenzylether of hydroquinone 20%
cream)
Vitamin therapies
Excimer laser
Bioskin therapy- is the latest generation in Mictophototherapy.
Irradiation of UVB rays of the affected skin. This treatment is currently
only available in Italy.
Micropigmentation. -adding colour pigment to the skin
Skin Needling
a Common areas for Vitiligo are:
Face
Lips
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Hands
Arms
Legs
Genital areas
o Results and concerns of CPC on Vitiligo patients:
Some patients will keep their pigment for months and then it may
gradually be absorbed by the body.
After the patient has received CPC, others areas of Vitiligo may develop
elsewere on the patient's body. Example - We repigment the areas of
Vitiligo around the mouth. Months later, because of the trauma to the
body, the client may develop Vitiligo around the knees, fingers or
elsewhere on the body.
You must make the patient aware of this potential problem and that this
could happen to them.
o You should not guarantee success or perfect results on any CPC application.
You can only try to make the patients skin appear more normal looking.
o Discuss the terms of application with the patient, making them aware that his
procedure may take many repeated applications. Make sure the patient
initials this information on their consent forms.
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SKIN DISORDERS
Acne Vulgaris
lt is an inflammatory affection of the pilosebaceous apparatus where the comedo
is the primary lesion.
If the comedo causes a perifollicular inflammation, other lesions of this pathology
occur: papule, pustules, nodules and cysts. Severe forms often degenerate into
more or less deep scars appearing as small round depressions with more or less
wide irregular passages similar to bridles or bridges surrounding comedones.
Flat angioma
lt is a red or bluish red birthmark. lt's shape, size and contour vary remarkably.
Senile or actinic keratosis
Small , elevated, rough surfaced patches. They are usually covered by a thin
desquamation and their colour varies from greyish yellow to vivid brown.
Scar
Scars occur when the skin is destructed and then "reconstructed" by the growth of
connective tissue. In this area the epidermis is smooth, thin, pink or whitish.
Scars can be atrophic or exuberant (cheloids).
Chloasma
Pigmentation patches of variable size without traces of sunburn and
desquamation. Their contours are irregular but well defined and symmetrically
distributed (forehead, nose profile, temples and cheeks). They can occur during
pregnancy, but they may be often due to other causes. Only women are affected
by chloasma. This hyperpigmentation can also be caused by exposure to the sun.
Broken veins
Skin imperfection characterised by a congestive condition (erythrosis) or certain
facial regions (cheeks- paranasal areas, forehead- chin) and by telangiectasis.
Dyschromia
The pigmentation activity of the skin can be subject to quantitative pathologic
variations both positive and negative (hyperchromia-achromia). Hyperchromatic
conditions include those due to endocrine disorders (Addison's disease), to oral
intake of drugs (antibiotics, psychotics, hormones) or to the topic application of
cosmetic or pharmacological substances (in particular if based on essential oils
derived from bergamot, perfumes, creams, powders, etc). In the last two cases
pigmentations appear as brown hyperchromatic spots located on photo exposed
areas (face, hands, neck, throat and breast) since this process is stimulated by
solar radiations. They are often preceded by a short sunburn which sometimes
goes unobserved.
Sunburn
lt is an actual allergic reaction catalysed by light. Clinically it appears as
erythemato-exudative itching lesions located on neck, throat, breast, arms and
forehead. However the severest forms can affect any photo exposed region.
Nevoid lesions
Anomalies in the development of melanocytes characterise a number of nevi:
variations in the melanocytes population density and/or melano genetic activity
produce achromic nevi , flat hyperchromatic nevi and freckles.
Psoriasis
lt is an idiopathic chronic inflammatory skin disease.
The primary lesion is an erythemato-squamous patch of variable size with well-
defined regular contours. There are a lot of variations: pustular, palmoplantar, etc.
The traditional form, normally affects the scalp, elbows, knees, while the extensive
forms affect more or less the whole surface of the epidermis including the facial
region.
Rosacea
lt is a skin disease which affects the central regions of the face. lt is characterised
by three symptoms: erythrosis, telangiectases and papulopustular lesions.
Stretch marks
Stretch marks are linear atrophies well-delimited in the dermis and covered by a
corrugate epidermis.
Tattoo
lt is produced by the introduction of indelible monochromatic or multichromatic
pigments into the dermis for creating images, drawings, inscriptions, etc.
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HYPERPIGMENT ATION
One of the most frequent issues I am called upon to address is in regard to the
problem of facial hyperpigmentation after tattooing. The discussion that follows
should answer most of the common questions.
The perceived "colour" of the skin is determined by light reflected from the skin.
The light reflected is determi ned by the skin's chromophores - those molecules
which absorb various colours or wavelengths of white light. The colour of light you
see is white light minus the colours which have been absorbed. There are four
basic chromophores in human skin:
o -Melanin (seen as brown or blue based on the level of melanin in the skin)
o -Carotene (yellow)
o -Oxygenated haemoglobin (red)
o -Deoxygenated haemoglobin (blue)
The intensity of each of these four colours combine to give skin its natural hue. In
general , levels of blood flow determine red and blue tones, skin type and sun
exposure determine browns and diet affects yellows.
Each person has a genetically determined skin colour, termed the "constitutive"
colour, which can be found on habitually non-sun exposed skin. Each person also
has a genetically determined response to sun exposure commonly known as
tanning. The response to sun exposure gives human skin its "facultative" colour.
Varying levels of tanning response have been categorised as skin phototypes,
referred to as Fitzpatrick skin types after the dermatologist who defined them. @
Fitzpatrick skin types range from I to VI as follows:
tfYPE UNEXPOSED SKIN COLOUR TANNING RESPONSE
I White Always burns, never tans
11 White Always burns, tans with difficulty
Ill White Burns minimally, tans gradually
(light
brown)
IV Light Brown Burns minimally, tans well
(moderate brown)
V Brown Rarely burns, tans profusely (dark
brown)
VI Dark Brown or Black Never burns, tans profusely (black)
*Based on 45-60 minutes of sun exposure to untanned skin after winter or no
previous sun exposure.
Why are these skin types important? Because skin types Ill -VI almost always
respond with hyperpigmentation to a variety of insults or injuries to the skin: sun
exposure, acne, picking or scratching, trauma, hormonal changes, chemical peels,
dermabrasion, laser treatments or even tattooing.
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Paramedical Tattoo
Any of these insults cause the pigment cells (melanocytes) to dramatically
increase melanin production in the epidermis and sometimes are associated with
loss of melanin into the dermis, where it is consumed and held in place by
macrophages (melanophages). These result in increased brown colour (epidermal
or superficial dermal melanin) or increased grey-blue colour (deep dermal
melanin). The increased colour of skin resulting from these injuries is termed post-
inflammatory hyper-pigmentation (PIH). In general , PIH will resolve on its own
within weeks to months, once inflammation resolves.
But who wants to wait weeks or months for PIH to fade, or even get PIH in the first
place? Fortunately, PIH can be prevented and/or treated. Broad spectrum
sunscreens, which protect against ultraviolet A and B damage, decrease
melanocyte activity by preventing UV radiation-induced stimulation of melanocytes
to produce more melanin. Retin A can help to inhibit melanin production induced
by various stimuli . Hydroquinone, found in a variety of "bleaching creams", inhibits
the production of melanin in melanocytes. The most recent arrival in treating
pigmentation disorders is kojic acid, a fungal derivative from Japan, also appears
to decrease melanocyte activity. Any of these can be employed to improve
existing hyperpigmentation or prevent PI H. The major disadvantage of prolonged
use of hydroquinone is the possibility of causing increased hyperpigmentation, a
condition known as exogenous ochronosis. Kojic acid does not appear to have
this effect.
When these methods do not satisfactorily prevent or resolve hyperpigmentation,
the extra melanin can be removed more quickly by judicious use of chemical peels
or short pulsed lasers. Superficial (epidermal) chemical peeling agents (such as
glycolic acid or Jessner's solution) allow faster removal of the hyperpigmented
epidermal layers, by speeding the natural sloughing of these layers. The ruby and
green dye lasers all target melanin and therefore can be used to remove
hyperpigmentation. One must remember that chemical peels and laser treatments
are also injuries which may cause hyperpigmentation. Use of these medications
before and after peels or laser should prevent the hyperpigmentation from
reforming.
For those clients who have skin types of Ill or greater or a history of hyper
pigmenting easily, suggest they begin Retin A, sunscreens, and hydroquinone or
kojic acid before tattooing and restart these after the skin has healed from the
procedure (about a week). While Retin A and hydroquinones require
prescriptions, kojic acid is being included in a number of OTC preparations
available through physicians offices. One must be cautious in using these
medications near the eyes or lips as they tend to cause irritation. For
repigmentation of scars which initially have both hyper- and hypo- pigmented
areas, use of these medications may even out the brown tones before
repigmentation work begins.
Whitney Tepe, MD
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WHEN TO CAMOUFLAGE
Camouflage colours are used to cover:
1. birthmarks (nevus)
(note: not all birthmarks accept fill in colour. Always trial a test area before
colouring.)
Suitable colours for dark brown birthmarks are beige, skin and yellow. For
lighter birthmarks try to match the skin tone. This may require 2 or more
applications spaced 4 weeks apart.
Note that strawberry or port wine stain or raised birthmarks or stains are not
suitable.
2. Hyperpigmentation
An over production of pigment can be corrected often with a mixture of skin or
beige with a little water added to thin down the colour.
3. Chloasma (Liver Spots)
Lentigenes (freckles or yellow spots) are both suitable for camouflage in
small areas.
4. Vitiligo (White Spots- loss of pigment)
Small areas are suitable. Begin by mixing a colour identical to the skin ( do
not allow for fading) Many colours when used on the body will not fade. Do
not take on large areas for pigment re-colouring as it will not look natural.
5. Alopecia
Good results have been recorded for hair loss areas. Begin by mixing an
identical hair match, test patch and ask client to return in 4 weeks for further
treatment.
6. Keratoma or Keloids
Do not tattoo keratoma or keloids or very raised scar areas.
7. Nipple- Areola re-pigmentation
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SCAR RELAXATION I SKIN NEEDLING
o Scar Relaxation is the application of repetitive obovoid tattooing to create a
softer skin texture and to soften the fibrous bands of collagen (scar tissue) to
give the patient more flexibility in their movements. Needling is a softer
technique to plump up the collagen in the existing tissue of fine lines and
wrinkles in the skin.
o Scar Relaxation is best accomplished by using a powerful machine like the
Mosaic which is also suitable for Needling is best accomplished with a rotary
machine.
o lt is very difficult to use the manual method or a lightweight machine for Scar
Relaxation. The lightweight rotary machine, as well as using the manual
method does not have enough power to penetrate through the dense bands
of scar contractures.
o If we are using the coil machine, we always use a large needle configuration
and disposable tubes for Scar Relaxation. Needling takes a 3-5 prong round
needle and we usually use a rotary machine.
o We do not find it necessary to patch test the skin when performing either of
these procedures.
o Susan Church, CCPC first introduced 'Scar Relaxation' at the first SPCP
conference in 1991 , after she discovered this and Needling, while working on
several burn survivors in concert with Or Richard Grossman of 'Sherman
Oaks Burn Centre' that was later named Richard Grossman Burn Centre'
o Scar Relaxation and Needling appointments should be scheduled at 4 week
intervals if you will be working on the same area. If you are working on
different areas of the body, you can schedule the appointments at the
patient's convenience.
CHAPTER 2
The client
CONSULTATION
o Discuss correct colour choices for each procedure.
o Decide the amount of risk you are willing to take with each client. Example:
thickness of eyeliner, lip enhancement and so on.
o Lesson and heighten the client's expectations of each procedure.
o Answer all of your client's questions without being condescending.
o By the time the consultation is through the client should feel as though they
have already had the procedure done.
o All proper forms should be completely filled out, signed and dated. Have the
client write out a detailed description of exactly the procedure they desire.
o Thoroughly discuss 'Before and After Care' of procedure with client.
o Take photos of how the client looks with their regular make-up on and without
any make-up on. (Always take more than 1 photo.)
o Do not work on a client if you have any doubts about them.
o Discuss medical considerations, contra-indications and physician's release
statement with your client.
o If a client refuses to accommodate you in any of the above requirements you
should refuse to work on them.
o Clients should pay for all procedures. If you accept cheques, make sure they
have cleared the bank prior to your initial application.
o Write down all of your colour formulas from your patch and sensitivity tests.
Be sure to include the lot number and the expiration date on the pigment
bottle.
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PROCEDURE DAY
o Review all client release forms for total completion and any new medications
prior to application.
o Take photos of client.
o Always make a post-op appointment for 4-8 weeks later. Be sure to give your
client a number you may be reached at after hours in case of an emergency.
o Always give client After Care Instructions
o Recommend a tube a tube of Protat or Bepanthen.
o Complete client file with necessary notes, consent and release forms, photos
and so on ...
o Check desired colour with client prior to application.
APPLICATION:
o Cleanse the area to be treated with an alcohol wipe.
o Apply Bio Quick allow 20mins unless working on a Breast with no feeling due
to nerve damage
o Work in concert with the patient.
o Have the patient turn their body to show you exactly where the scar
contractures are the worst. Gently start your procedure application in this
area.
o Topical instant numb and bio gel may be applied once the skin surface is
broken open.
o Start with a 7 prong needle (Mosaic or a Shader if using Nouveau Digital
Medical Machine) If the machine bogs down, switch to a smaller needle
cluster. Depth 2mm
o Go over the area as many times as needed to create manoeuvrability by the
scar relaxation.
o Clean the area as many times as needed to create manoeuvrability by the
scar relaxation.
o Clean the area and apply Vira Gel to assist healing and colour retention then
a smear of either Protat or Bepanthen.
a Cover the area lightly with a gauze dressing to protect the abrasion from free
radicals.
a The dressing should be kept on the procedure area for the first 24 hours
APPLICATION TIPS
a For the best application, your machine or hand tool should be held as though
you are writing.
a All cosmetic applications should be applied 'straight' into the skin as possible
to create even, clean lines.
a Settings for rotary, coil or digital machine should be obtained from the
manufacturer.
a Skin will vary in thickness and texture. Adjust your needle and speed
accordingly.
a If the pigment is not being inserted into the skin because of thickness:
Stretch the skin more taut
Slow the speed of your machine down
Hold the needle in the skin longer
o Needle should be flush with the tube or tip when you first learn your
applications. As you become more proficient, you may extend your needle
out further.
o Always check your needle for burrs or corrosion prior to application.
o If your client has thick skin (avid sun worshipper, dark complexions and oily
skin) consider using a hot compress or a very light glycolic peel prior to your
application to soften the skin.
o Other options to soften the skin. One week prior to permanent cosmetic
application, the client may choose one of these services:
Microdermabrasion
Glycolic peels
Enzyme peels
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AFTER PROCEDURE DAY
o Phone the client the day after their procedure to see how they are feeling.
o If a client phones you with an immediate concern, speak with them as soon
as possible.
o If they are concerned about the procedure, answer all of thei r questions.
o In certain circumstances problems may occur. If you are in doubt, consult
with your physician.
o Send your clients a thank you note. Remember: They selected you!!
o Ask your clients for referrals.
The more you pamper your clients the more your business will
grow!!
CPC AFTER CARE
Instructions should be explained in detail.
o Before showering or bathing, apply a light coating of Vaseline to the
procedure area. This will enable the water to bead off of the damaged tissue.
(Follow this advice for at least 1 week post procedure.) Apply Protat or
Bepanthen cream twice daily.
o After the procedure area has healed, the patient must apply a sun block daily
to prevent future pigment fading.
o If crust appears on a procedure area do not pick or peel it off! Pigment will be
removed along with the crust.
o No sun, soap, sauna, Jacuzzi , swimming in pools or the ocean for two weeks
post procedure. This also applies to each touch-up application.
o To prevent infection- do not touch pigmented area with your fingers until it is
completely healed. Use clean cotton tips to apply ointments.
o You may not donate blood for one year following any procedure.
o Follow regular after care instructions as well.
Hopefully this series on CPC will help you to understand the psychology of beauty
that is created to present unique concepts of thinking about beauty that extends
beyond traditional basic value.
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ANAESTHETIC IN COSMETIC TATTOO PROCEDURES
Any non-physician practitioner involved in semi-permanent makeup knows the
number one problem we face is effective anaesthesia. Some of us probably
remember being told we were learning a "painless" procedure to later discover the
only pain-free person in the room was the Practitioner. Some Educators have
tried to convince us ice cubes are the only anaesthetic we would ever need.
Anyone with experience quickly learns otherwise.
Needling is very much a non invasive treatment so usually apply a topical
anaesethetic only and normally no further application is required.
In an environment of increasing regulation, using prescription drugs without
medical supervision can lead to charges of practising medicine without a licence
and possible loss of your permanent makeup malpractice insurance, if a claim
should arise from the improper use of a prescription anaesthetic. Worse yet, you
might end up with a medical emergency you or your facility are not equipped to
handle. If you do not work in a doctor' s office, develop a relationship with a
nearby, reasonably priced physician who can examine your client, prescribe for
them as needed, and/or administer a local anaesthetic, after which the client can
return to our office for her cosmetic tattoo treatment.
If your client is going to take any kind of oral medication with analgesic or sedative
properties, you might suggest she take one at home the day before to make sure
she can tolerate the dosage with no adverse side effects.
Anaesthetics
o Bio-quick Anaesthetic Cream (4% Lidocaine)
Pre-numbing for unopened skin. Apply cream 15 to 20 minutes on skin
before any pigmentation procedures. Can be applied suitable for all
procedures
INSTANT NUMB (4% Lidocaine)
To be used after the procedure has begun
Lidocaine is a substance that effectively penetrates the skin to numb the
effected area and works to control pain.
o Bio Gel ( 1% Phenylephrine Hydrochloride)
Apply gel on skin when bleeding or swelling occurs. lt will stop the
bleeding and swelling immediately. Can be applied during all
procedures.
"LEFT SIDE"
When pain is afflicted to a part of the body the brain will direct endorphins, the
body's natural pain killers, to that area. When the pain is abruptly switched to
another area it seems to be more painful than the first was for two reasons. First,
if you have applied a topical anaesthetic that is made for unbroken skin to both
sides at the same time, it will have peaked and lost it's efficacy by the time the
second side is started. The fact that most of us are also using a topical designed
for broken skin makes the area a little more numb each time we apply it. That
combined with the body's natural endorphins directed to that area make it more
comfortable. When the opposite side is started it can be a shock to the client as
they were expecting no more pain than they were experiencing on the first side.
This often leads to them shying away from you and flinching more. For this reason
a new technician (and often a seasoned one too) will repeatedly get one side that
takes and one that doesn't. lt's usually the second side, where you were trying to
inflict less pain, that didn't take.
I have found a solution that, for me, is quite simple and works very well. I apply
the topical (for non broken skin) for the appropriate amount of time. I then make a
pass, clean the tissue and apply the topical made for broken skin. I immediately
proceed to the second side and repeat the procedure. By the time I get back to
the first side it is normally quite comfortable to work on. I only work on that side a
short time before I apply more topical and switch back to the second side. By the
time I finish the procedure, the client has maintained the same amount of pain
control bilaterally and, I normally have not overworked any one area. By the time
you've read this far you already realise that this will also help prevent one of the
banes of the technician's existence, the side that didn't take. If you've not already
figured this out on your own by just trial and error, then try it. Modify it, make it
work for you and then let me know how you've improved!
By DIXIE MEDFORD
19
Paramedical Tattoo
Anesthet ics I ngredients
Boouic< A<>esthetic Cream:
15 Grams- Use lafo .. e procedu re apply 15-30
mnutes before p .-oc.clUte.
-10,, Ldou i"le. Aloe leaf Jt..ice, Hvdogo:nated Polyi ;ob ..
Pro::.v e!'e G 'fCO Po vacr;l al""ice, C13-:4 hoparrafn, La..re:h-7.
I S:earatt-, llropvlere Glvcol 0 Solu:>le Coll agen,
Hy:h:ly2ec Ela;:in. SociJI"" Hva uronate, Pall"" otate, TotCO"'' e ')' Ace:a:e .
Malva Syi\Oti'S:ris E-.:ract,. Hecera He " (h-y) E t ac:,
Cut.Jmts SattVUS (Cucwmber) Frutt E, t-acr., S<Jmbucus =ic.,e E-.:tact.
Arn ea Mo-una E -ru:, llilr; ttt;w;;a Off c nal s E
Aloe > L;oaf E.tract, Sc:liu""' PCA, PEG-:OO Sceaate, Cety A cnhol.
Pc ysooa:e 20, Trte:htro a,.. he, Oiuol d nyl Urea, Wethv'para!IE "'', Propyl o<Jraben
BIJe : . Rec l3,
I nstllnt
B oCa e:
Veta Gel:
12 Gr01ms- Aoply durirg ptocedt..te.
Pe-clatum. U::iccair 40,
12 Grams Apply durirg procedt.. . e.
Pet-olat .. l"", Tetracane :H.
1/ 2 O;z Reduces s .. e l ng ilnd bleed.ng.
'Nater, Alce Bar'::laCe'"lss Leaf eel utose. AJian:o,.,,
Sodul"" B Ph!ryl ephri ne Hyd"'c.lorice
fletr ylparaben,
Prooy pi!l'llt>en, Etry pari!ben a"ld lsob.Jtvioa"iiben
4 Grams Soot.,es & moistur.zes. pt events b'isters.
Ca"''c la o,., Polvb.Jter e He .!..n 'II.US :su'\flo,.er) Seed Oil, Bo;!!s"a ,,
esters. Paraffh. Park o 8.Jtte ) .
Carnau.:Ja (Ccoe 'liet a Cerifer:a: Wa, Eupr o-bia Ce fe-a a) wa, ,
Mtcrocrystalhr e wa .. O'ea Eu"''paa 'Olive ) Fru t 01l. Aloe Barbadeos3 Ln" E' t -ace,
Ret nyl Pa mltate, Toce>pl" ery Acetate, Phytonad O'le. Cro acalc fe-ol, Alo1r,
3, Bisaoo o , Vacaca..,,a Te"'"i"':liil Sud Ool. Mert'\a Vo-, :ls (Spearmt't) Lea' Oi
Bct'Or BHT
1/ :l. O;z Reduces f'.eali ng t ome and locks tn color.
Water. Aloe Sarbadens lea' Ju'ce Bca-bo1a:e. Be1=a kcnu.., Ch ori de, Crlon<le,
SoC: il.m P--osphate. Xan:r:ar Gum. Pota:ssi ..;l""' Scdi.JIT' Cl-lorce, S.oci_.,.. Hvero:ide
CLIENT DETAILS- COSMETIC TATTOO (PARAMEDICAL)
(The information supplied below is confidential and for professional use only)
NAME ... .................................. ... ..... .. .... .. ... .......... ............ ..... ... ..... .. .... DATE ...................................... ... .
ADDRESS ........... .......... ... .. .... .. .. ..... ............ ............ ............ ......... ........ .... .. .. ......... .... .... ............ .. ......... .
... ........ ... .............. .... ..... .......... ........ .................... ... .... .......................... Postcode .. .... ......... ..... ........ .... . .
PHONE(Bus) .. .... .... ..... .. .. ..... .. ...... .. . (Res) ...... ..... ....... ..................... .. .. .. (Mob) .................. ....... ..... .... ... ..... .
HAVE YOU EVER HAD ANY OF THESE HEALTH CONCERNS PAST OR PRESENT?
0 Diabetes OHeart Palpitations O Hepatitis 0 Any Blood Clotting Problems
0 Currently on Blood Thinners such as aspirin, lbuprofin 0 Consumed Alcohol with 24 hours
CONSENT
I understand that this treatment is for cosmetic purposes only
That no guarantees have been made to me regarding the results
I am responsible for the "at home care" which may have risk of infection if not carried out fully
I will not hold the Student/Therapist responsible in the event of any damage and shall not be entitled to take
action against her at Law or in Equity for such treatment
I consent to before and after photographs of this procedure which is at the Student/ Therapist's discretion.
I cannot donate blood for 6 months from today
I am over 18
I am not pregnant
I have had the opportunity to ask questions relating to this treatment
I am aware that latex gloved are used and consent to their use.
I am not allergic to latex.
I am aware that the topical anaesthetic used contain contains Lignocaine I give my approval for these
creams and lotions to be used before and during my procedure.
PROCEDURE ...... ................. ....... .... .. .................... . ........ COLOUR .... ... ......... .. .. ...................... .. ........... .
NEEDLE SIZE .. ....... .. ....... .. .................. THERAPIST ... ........... .... ... .............. .... ................ ..... ........ .... ..... .
COST $ ......... .. ........... . ............... .. ... ... FOLLOW UP VISIT ........................................... ..
CLIENT SIGNATURE (Pre Procedure) .......... .. .......... .. ........... ........ ............ ....... .
I am satisfied with the results obtained from this procedure and I have been informed that colour may vary as the skin
heals.
CLIENT SIGNATURE (Post Procedure) ............................................. DATE .... ................. .
21
Paramedical Tattoo
Female Full Body Template Front and Rear
Patient Name:
Procedure Report:
Patient Signature:
22
Paramedical Tattoo
Male Full Body Template Front and Rear
Patient Name:
Procedure Report:
V
Patient Signature:
23
Paramedical Tattoo
CHART NOTES
Successful professionals in our industry keep a precise record of all their cl ients
and the issues around work done on them. These Chart notes are referred to
each time the client comes in. They help the Practitioner learn what colours work
best to avoid both mistakes with that client in the future and with a particular
colour. When a client comes back for an adjustment, the Chart notes provide the
record of what happened at the last appointment so the proper follow-up treatment
will be provided. Also, these notations provide a record of what occurred in the
event of a lawsuit. lt is impossible to run a successful semi permanent cosmetic
tattoo business without keeping accurate notes.
There are many ways to keep Chart notes. Each Practitioner learns what best
suits them over time. Chart notes are not to be confused with Informed
Consent/Releases or Medical Questionnaires. Chart notes are detailed notes
made during and after each procedure. These notes can include the following:
o Date of Procedure
o Client Name, Address, Phone
Area of Treatment- Some people have outlines to show where the work
was performed
o Machine- Which machine was used and how it worked for the procedure.
o Needles- What grouping and size of needles were used and who
o manufactured the needles.
o Pigments- Brand of pigments, colour and recipe if pigments were mixed.
o Amount of time spent on the procedure.
o Cost- How much the client spent and what method of payment was used.
o Topicals- If a topical was used and what kind.
o Photos taken -This is a reminder to always take photographs.
o Remarks - This is the space to add details such as skin condition, skin
reaction, sensitivity of client, special requests of the client, and any post-op
phone contacts and their purpose.
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Paramedical Tattoo
INTERPRETING CLIENT HISTORY FORMS
Section 1- Demographic information: Self explanatory.
Section 11 - Allergies: We would all rather no one in our offices ever have an
allergic reaction, but they do occur. This list is an effort to head off reactions to
common allergens.
Tetracaine and lidocaine are anaesthetics which may cause reactions when used
topically
Latex protein is found in latex gloves and can cause immediate hives (urticaria) or
a more delayed contact dermatitis. Since you use gloves, your clients will be
exposed to this protein.
Metals, especially nickel and foods are other common allergens. With the
increased marketing of organic pigments, those allergic to fruits or vegetables
could conceivably react if these plants are used as pigments.
lt is important to know the type of reaction your client has - localised hives, allergic
contact dermatitis, or generalised hives with difficulty breathing and/or fainting.
Obvious agents which cause reactions should be avoided.
Section -Skin: Skin issues should always be considered.
Any scar that remains pink or red has not completely matured and is therefore
subject to further change. You should only work on mature, pale white scars.
While rare, tattooing could result in a hypertrophic scar or keloid in a high risk
individual or body location. If you choose to work on these individuals, they should
be followed closely and referred to a physician if signs of hypertrophic scarring
occur.
Individuals with a history of poor healing should be followed closely. If healing is
slower than normal, consider a physician referral for antibiotics to promote proper
healing.
Section VI - General Medical: On every client, medical issues should be
analysed.
Blood thinning drugs, clotting disorders, pregnancy and high blood pressure may
cause excessive bleeding.
Diabetics and those with autoimmune disorder may manifest poor wound healing.
For diabetics this is especially true if their blood sugar is poorly controlled.
25
Paramedical Tattoo
Clients with mitral valve prolapse, artificial heart valves or artificial joints are often
placed on prophylactic antibiotics during dental or surgical procedures to prevent
these valves and prosthetics from becoming infected. If your client uses
antibiotics when visiting the dentist, s/he should be on antibiotics for cosmetic
tattooing as well. If in doubt, call your client's physician and ask what they would
like to do in this situation.
"Palpitations" is a layman's term for cardiac arrhythmias. Generally, those who
have significant arrhythmias are aware of this and may be on medication. Others
may simply feel pounding in their chest, which may happen with stress or pain.
Make an extra effort to help these cl ients relax and minimise their level of stress.
Accutane has been reported to increase the risk of hypertrophic scar formation
after chemical peels and dermabrasion. Allow 6 months before tattooing these
clients.
26
Paramedical Tal/vu
MEDICATIONS THAT EFFECT BLOOD COAGULATION
DURING MICROPIGMENTATION
Blood Thinners: Coumadin, Heparin, Aspirin, NSAID's
1. Anti-histamines: Bendryl , OTC Hayfever remedies, etc.
Please comment on effect on the eyes (dry eyes), driving restrictions
2. Blood Pressure Medications and diuretics: Beta Blockers (dry eyes,
anaesthetic effect on eyes)
3. Diabetes Medications: Insulin, Oral Hypoglycemics
Stress diabetic problems with delayed healing, increased risk of infection and
potential for hypoglycaemic attack during procedure.
4. Pain Killers: Narcotics, (can't drive; decreased awareness of symptoms of
complications from semi-permanent makeup such as corneal abrasions, etc)
5. Tranquilizers:
pigmentation
Valium, Librium etc (can't drive}, Thorazine-melanin
6. Sleeping Pills: Halcion etc (Exposure keratitis if eyes don't close completely)
7. Dermatological: Accutane, any type of chemical peel
8. Hormone replacements: some side effects on skin pigmentation can occur
with hormones
9. Antibiotics: Tetracycline and sunlight
10. Arthritis: Gold-chrysiasis, Plaquenil
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Paramedical Tattoo
THE HEALING SKIN
Whenever the surface of the skin (the epidermis) is injured, the result is
compromised barrier integrity. This may be from a cut, burn, or a puncture such
as the application of permanent make-up. The protective barrier for the body- the
skin - has in some way been rendered impaired.
In minor wounds, such as we deal with during the process of applying colour to the
client, the body's circulatory system and it's partner the lymphatic system rush to
the area in response. The lymphatic system's function is to prevent infection,
while the main circulatory system is providing blood and nourishment to implement
the healing process. This extra blood in the area results in mild reddening and
warmth.
The first phase of this healing process is to recreate barrier integrity. This
happens with scab formation. Size and extent of the scab are dependant on the
injury. In tattooing these may only be lymph involved, resulting in a minute clear
form of scab or there may be droplets of blood. If the client receiving the
procedure is mature, the epidermis is more fragile and prone to bruise or tear
easily. Greater caution must be exercised to avoid these problems.
Once the skin has reformed its surface barrier then, via some method of
communication, the basal cells speed up reproduction,. The skin at and below the
basal layer seems intently focused on replacing the damaged tissue. When these
new cells reach the surface healing is complete.
How long this takes depends on several factors. The primary ones are the age
and health of the client. Cellular rejuvenation is at its peak during the body's
growth years, birth to approximately age 25. By the time a person reaches the age
of 30, the speed with which cells reproduce has already started to slow.
With each additional decade of life the rate of cellular turnover continues to
decrease. Instead of epidermal cells being produced on a daily basis and it taking
28 days for those cells to reach the surface of the skin, the process may extend to
55 days or more.
The permanent cosmetic practitioner can use this knowledge to plan follow-up
work. Clients in their 20s heal very rapidly, so follow-up work could be scheduled
in two weeks. As rejuvenation starts to slow down by the age of 30, wait at least
three weeks for clients in their 30s. For each decade of age, add another week
tag time before rescheduling the follow-up visit. Four weeks is a good time
to wait.
The benefit of waiting may be you find yourself working on more thoroughly healed
skin with a more accurate representation of the finished colour.
By extrat Judy Gulp
28
Paramedical Tattoo
WOUND HEALING POST APPLICATION
Tissue repair proceeds through four stages:
Coagulation
After each perforation is made in the skin, the body's platelets gather to form a
clot. This is considered to be the beginning stage of the body's restorative
mechanism. As the clots dehydrate, a crust is formed that will serve as a
protective covering for the wound. The degree of tissue maceration will determine
the scab density, creating a potential loss of pigment in the procedure area. In the
initial hours after the C.P.C. procedure the body begins to react to the superficial
skin trauma that is caused by the tattoo application.
Inflammation
The inflammatory is the second stage of the body's restorative mechanism. This
response quickly and effectively destroys bacteria. Classic symptoms may range
from redness, heat, swelling, pain and lymph drainage. Patient will not typical
wheal and flare reaction of the procedure area much like a bee sting or mosquito
bite. This tissue releases histamine, serotonin and bradykinin, which creates an
increase in blood flow to the injured tissue. Macrophages (infection fighting cells)
begin to migrate out of the capillaries and small blood vessels in the skin into the
surrounding tissue. Agitation to the skin causes the macrophages to migrate to
the injured tissue, secreting a digestive enzyme to moisten and ingest dead and
irreversibly damages tissues and debris. This activity also causes increased blood
flow to the immediate area. The procedure area will be a bit sore, swell slightly to
moderately within the first 24 hours, may possibly be very tender and be slightly
pink to red. Infected tissue may cause inflammation, pus and swelling to the
inj ured site.
Regeneration
The third phase is the generation of new tissue consisting of reconstruction and
contraction. The basal layer cells divide and grow, which produces a continual
epithelial layer beneath the crust. If there is no crusting, the epithelial tissue will
appear as a raised area. To add support to the new tissue the fibroblasts multiply
and produce collagen that will inflate the injured site.
Maturation
The fourth phase is the maturation of the injured tissue. To strengthen the tissue it
is structurally reorganised several times over the next few years. (Scars lose
about one-third of their original strength.) As scars mature they emerge to be
more of a pinkish/white tone and thin out.
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Paramedical Tattoo
NUTRIENTS THAT AID IN THE HEALING PROCESS.
a Vitamin K is necessary for blood clotting.
a Carbohydrates provide energy to the cells and aids in the antibacterial of
white blood cells.
a Vitamin A helps to block anti-inflammatory impact of steroid agents on the
cellular membrane.
a Zinc will help to strengthen the membranes of the cells.
a B Complex helps to aid in the formation of white blood cells.
Vitamin C helps to strengthen capillaries and is essential for collagen synthesis.
30
Paramedical Talloo
TATTOOING AND SKIN CANCER
lt would seem obvious tattooing over a skin cancer would not be an advisable
thing to do. There are medical case reports of skin cancers, including basal cell
carcinoma, squamous cell carcinoma, and melanoma, arising within tattooed skin.
These events are coincidental and probably unrelated. In other words, tattooing
the skin did not lead to the skin cancer.
Fortunately, while skin cancers can be subtle to detect in their early stages, most
skin cancers are clearly distinct from normal skin and should be easily avoided.
Skin cancer is now the most common cancer in human beings. The American
Cancer Society estimates over 1 million new skin cancers are diagnosed in 1997.
Of these skin cancers about 75% are basal cell carcinoma, 20% squamous cell
carcinoma and 5% melanomas.
Most people know from public education programs to recognise melanoma. They
typically appear as flat or raised pigmented lesions. Melanomas usually have
irregular or notched borders, multiple colours (red, white, blue, black, brown ,
pink), are large (greater than 6mm in diameter) , and asymmetrical in shape. All of
these features would make it fairly difficult not to recognise a potentially cancerous
pigmented lesion. Basal cell carcinoma is most commonly characterised by a
papule growing on the skin. The papule is usually pearly white or translucent with
fine telangiectasia growing over it. This type of tumour may frequently ulcerate in
the centre. The most common site for basal cell carcinoma is the nose, but they
also commonly occur on the head and neck, and may be anywhere on the body.
Since basal cell carcinomas are generally soft in consistency, tattooing over one
would likely cause skin breakdown and bleeding which would be obvious at the
time. Since this cancerous skin is distinctly different in character from the normal
skin, it should be reasonably straightforward to recognise basal cell carcinoma as
well.
Squamous cell carcinoma may have a variety of appearances. Frequently these
start as persistently red and scaly flat lesions. As the tumour begins to grow
deeply into the skin, the skin becomes raised versus the normal adjacent skin.
Typically the consistency is quite firm when squamous cell carcinomas become
raised. Squamous cell carcinoma may also ulcerate. Common sites for
squamous cell carcinoma are the head, neck and arms.
When in doubt about a particular skin change, it is appropriate you refer clients to
a dermatologist for diagnoses. If no specific lesion is felt to be present by the
dermatologist, they should feel comfortable writing you a letter stating this and it
would then be safe to tattoo the area. If you want to become better at recognising
skin cancers, look for an atlas of dermatology in your local library or order one on
loan from a medical facility through your public library.
Whitney Tepe, MD
31
Paramedical Tattoo
CHAPTER 3
PIGMENT & COLOUR
USING PIGMENT TO CAMOUFLAGE
Basic Technique for Colour Correction and Minor Mistakes
o Use Magic or or "Skin" Double Drop. If requiring a thinner/paler look add a
few drops of purified or distilled water, depending on how dark the area is to
be concealed or corrected.
o Too much beige can result in white patches, and too little may require more
touch ups, so it is best to really evaluate the colour and dilution.
o Use a 7 prong round needle and use a circular, shading method of blending.
o To get good coverage, concentrate on the area to be corrected by layering
lightly, adding additional layers as needed. Then gradually spread out to
blend in the edges with the rest of the client's skin tone.
o Concentrate on the blending! Even with conventional makeup, concealers
have a tendency to look too thick or blotchy if not blended properly. This is
essential when doing correction with permanent makeup for a natural
appearance.
o After the first procedure, when the skin has healed, you should see great
results and coverage. However, if you determine that the camouflage is not
satisfactory, it is most likely due to the following:
Not enough pigment was used, so the original demarcation is showing
through. A second application will be required.
Too much pigment was used, causing a caked blotchy appearance. If
this occurs, take an empty needle, allowing the area to bleed a little, and
the patchy colour will eventually peel off.
Loss of pigmentation on the skin, whether caused by accidents, medical
procedures, birthmarks, or a multitude of other skin irregularities, are frequent
problems that can be helped with permanent makeup and an experienced
technician. Keep in mind there are constant changes in body temperature, such as
sun exposure, etc. that can cause subtle changes in the colouring in the skin. The
colour you select to use for camouflage should best represent the skin tone in its
most common or day-to-day colour.
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Paramedical Tattoo
Important Considerations:
Some considerations and corrections are best handled by a laser doctor or
medical advisor. Permanent, pigment camouflage cannot disguise extremely
elevated scarring, or texture of the skin, nor can it ever restore a person to what
they were before the loss of pigment or scarring occurred. This would include burn
victims, cancer patients, breast reconstruction or scar tissue.
Remember:
o Evaluate the skin type before using permanent pigment.
o Perform a skin patch test before a procedure.
o Do NOT work on individuals with keloid formations known to have medical
conditions
COLOUR CORRECTION TECHNIQUES USING:
YELLOW - lightens
ORANGE - neutralises darker shades of bluish or grey tones,
ROSE RED- neutralises medium shades of bluish or grey tones
TAUPE - neutralises darker shades of purple or pink brows
BEIGE - camouflages and covers small mistakes
WHITE - only mix with a pigment for a lighter shade on body only contains
titanium dioxide which may turn black under laser.
NEW COLOUR CHOICE FOR CAMAFLAGE:
MAJIC- For All skin tones
SKIN - For all skin tones
33
Paramedical Tattoo
CORRECTIVE PIGMENT CAMOUFLAGE
o Evaluate each area to be re-pigmented. Discuss colour tones from
consultation applications. Check patient's medical file; refer back to course of
treatment from consultation day. Ask patient if any information on their
Procedure and Consent or Medical Forms has changed since their initial
application.
o Before application, check patient for gradient skin tones. Inspect the
procedure area to ensure there are no open lesions, rashes or other
irregularities. To prepare wipe with an alcohol wipe before start of procedure.
o Apply correct colour. We usually wait until the 2 nd or 3 rd appointment to apply
any nuances ie. Beard simulation, freckles, capillaries. Adjust colour if
necessary.
o Post procedure appointments should be scheduled at 4-8 week intervals.
The patient may return sooner if you are re-pigmenting various areas, but you
can not work on the same procedure area until it is completely healed.
Touch up appointments are critical for any fine detail work the patient may
request or to create any subtle additions or corrections in pigment colour.
o Technicians should always be concerned about excess tissue maceration
when performing any type of cosmetic tattooing or CPC Tissue repair
proceeds through four stages, coagulation, inflammation, regeneration and
maturation.
After each perforation is made in the skin, the body's platelets gather to
form a clot. This is considered to be the beginning of the body's
restorative mechanism. As the clots dehydrate, a crust is formed that
will serve as the body's restorative covering for the wound. The degree
of tissue maceration will determine the scab density, creating a potential
loss of pigment in the procedure area. In the initial hours after the CPC
procedure the body begins to react to the superficial skin trauma that is
caused by the tattoo application.
The inflammatory response is the second stage of the body's restorative
mechanism. This stage may last from 4-6 days. This response quickly
and effectively destroys bacteria. Classic symptoms may range from
redness, heat, swelling, pain and lymph drainage. Patient will note
typical wheal and flare reaction of the procedure area much like a bee
sting or mosquito bite. This tissue releases histamine, serotonin and
bradykinin, which creates an increase in blood flow to the injured tissue.
Macrophages (infection fighting cells) begin to migrate out of the
capillaries and small blood vessels in the skin into the surrounding
tissue. Agitation to the skin causes the macrophages to migrate to the
injured tissue secreting digestive enzymes to moisten and ingest dead
and irreversibly damaged tissues and debris. This activity also causes
increased blood flow to the immediate area. The procedure area will be
34
Paramedical Tattoo
a bit sore, swells slightly to moderately within the first 24 hours, may
possibly be very tender and be slightly pink to red.
The third phase is the generation of new tissue consisting of
reconstruction and contraction. The basal layer cells divide and grow
which produces a continual epithelial layer beneath the crust. If there is
no crusting, the epithelial tissue will appear as a raised inflamed area.
To add support to the new tissue the fibroblasts multiply and produce
collagen that will inflate the injured site.
The fourth phase is the maturation of the injured tissue. To strengthen
the tissue it is structurally reorganised several times over the next few
years. (Scars lose about one-third of their original strength.) As scars
mature they emerge to be more of a pinkish/white tone and thin out.
a After the application is completed, apply Bepanthen cream and cover the
area to keep it exempt from free radicals and pollution for 12-24 hours. We
use Bepanthen to promote rapid healing. The patient should apply a thin
coating of Vaseline over the procedure area while showering I bathing to
protect it from moisture. We phone the patient the next day, 2 weeks later
and 4 weeks later to check on their progress and status of colour application.
a Be sure to work in concert with the patient's physician. As the physician
performs ongoing surgeries, the patient's C.P.C. may need to be adjusted.
One cosmetic tattooist was working with a burn specialist to reconstruct and
tattoo burn patients eyebrows, eyelash enhancement and full lip colour. After
a few months Or G. needed to perform a scar revision to release the bands of
scar tissue in the lip area. After the patient's bottom lip vermilion healed it
was very asymmetrical. The cosmetic tattooist re-tattooed skin tones on the
left bottom vermilion to create a more even lip line.
a We, as technicians, fine-tune and complete the finishing touches on the work
the plastic surgeon has accomplished. Cultivate relationships with plastic
and reconstructive surgeons, dermatologists, oncologists and cosmetic
surgeons. If you do not presently work in concert with a physician, here are a
few tips to help you find one. Phone the physicians you are interested in
working with, describe what services you can provide for their patients and
invite them to visit your clinic. Show them your portfolio and or video of
patients you have performed various procedures on. To insure you will be
able to work with the physician, discuss philosophies. Also, ask yourself,
would you feel comfortable asking the physician any type of question? Is the
physician knowledgeable about alternative treatments? Will they work
evenings and or weekends to inject patients for you? How are referrals
handled? Is the office staff friendly?
a Arranging fees, renting a treatment room and or referrals with a physician can
be very confusing. Many technicians rent space from the physician or pay a
percentage while others may just pay various fees for services. Patients pay
the physician directly for their injections and office visits while paying you (the
technician) for the actual CPC procedure. We have found that in the
35
Paramedical Tattoo
technician's best interest, agree to a 30-day trial period when first working
with a new physician. After a few days or even weeks you may not like the
way the physician conducts his/her business, handles the patients or other
aspects of how they may even run their every day office in relationship to
policy and procedures.
o Look for organisations that advocate comprehension of concerns of the
disfigured I burn patient. Support research that will impact the lives of the
disfigured patient. Join burn and cancer support groups. Phone local
hospitals. Talk to local fire fighters. Work pro-bono. Remember the old
adage- 'What goes around comes around.'
o Patient Assessment includes two phases: collection and analysis of
information. This is achieved through the interview and examination. Most
burn and scar patients have lower self-esteem, social anxiety and fear of
rejection. The patients past and present medical records contain data helpful
to your overall assessment. These records should include a complete
medical history including allergies to food, anaesthesia, drugs, chemicals,
metals, etc. and any diseases or disorders (psychological or physical).
Always establish a rapport with the patient, identify their needs and agree on
goals. Thoroughly discuss their perception of their present situation and what
CPC can do. Clients must be made aware that this procedure is a multi-step
process and final results cannot be determined until all applications are
completed.
o Write out a detailed description of your treatment plan and discuss it with the
patient.
o For accurate colour results, apply a patch and sensitivity test directly into the
procedural area 4-8 weeks prior to the first application. Insert 7-8 implants of
pigments into the epidermal tissue. To ensure an optimal outcome, perform
several different colour tests for variegated skin tones. Modify the colour
value as needed. Pigment should be placed into the epidermis (for minimal
colour retention) so it should be sloughed off within 4-8 weeks.
o This method of application is used in case of inappropriate colour choices.
Even if the appropriate colour match is known, a patch test is still advised as
changes or additions in any medication may alter the chemistry of the body
rendering an earlier patch and sensitivity test inaccurate. Before inserting
pigment, take the patient outside to the natural daylight, to provide optimum
visual clarity of the pigment colour chosen.
o Natural daylight should be used for selecting a correct colour match for CPC
application. The next best type of lighting is a daylight bulb followed by vita-
lights and true white lights.
o After every application of CPC, the pigment will revert back to its original dry
state. Only then will there be accurate final colour results. All procedures are
combinations of pigment colour plus the patient's skin undertones. This
combination will equal the final colour result.
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o Skin may become very thin with the use of steroid creams, while collagen can
make the skin very tough.
o Always check with the patient's physician before you begin any
repigmentation work.
o Before Application Discuss:
Pain factor, topicals and injections.
The total cost of all procedures involved. (Billing, insurance and
discounts.)
Cancellation policy.
'Before and After Care' instructions.
Photos and video taping of all procedures.
Medical considerations and contra indications.
If a client refuses to accommodate you in any of the above requirements
you should refuse to work on them.
o Burn and keloid tissue may be very difficult to tattoo
o Use flat shader needles when possible if an experience cosmetic tattooist
only. Your application will appear to have a smoother texture and softer
colour balance.
o Do not use shader needles sideways. You will macerate the tissue and
create possible scarring. Use the obovoid technique for best results.
o Use a colour wash for all CPC applications. Blend %or less of your desired
colour mixture with rewetting solution or anaesthesia.
o Be cautious of post-inflammatory hyper-pigmentation when applying pigment.
Do not tattoo over an area more than once. This may cause post-
inflammatory hyper-pigmentation especially in darker skin. This condition
may dissipate with time. Usually normal skin colour will return slowly over a
period of months. Bleaching agents such as Kojic Acid or Hydroquinone may
be used. Hyper-pigmentation occurs in Caucasian skin occasionally,
although it will most likely occur on clients with heavy concentrations of
melanin in their skin. The normal skin tone should return slowly. Bleaching
agents may also help the hyper-pigmented area. The patient should avoid
sun exposure and friction to the affected area.
o Always stretch the skin for easier and smoother penetration.
o For easier penetration, steam your clients skin for 10-20 minutes prior to
application.
o Many technicians are familiar with utilising soft music to relieve pain and
stress by distracting the client. The music should draw the client's
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concentration away from the application or sensation that is unpleasant or
painful. Use headphones or surround sound. This relaxation effect is
attained on an emotional level. The right side of the brain is activated by
music, which also involves imagery, feelings and the unconscious mind.
Yanni or Enya are two artists that are very soothing to listen to.
o Create 'holidays' for realistic skin tones in your CPC.
o Clients that receive CPC have gained self-confidence after their application.
a When repigmenting a large area of tissue, switch to your largest needle for
faster coverage and easier penetration.
a Always use separate metal tubes or disposables for CPC. Even if you use
an ultrasonic cleaner and scrub the tubes out thoroughly there is always the
chance that there is one speck of colour left in the tube. If you use this tube
on a person for CPC that one speck of pigment may find its way into the
patient's skin, ruining your CPC procedure. lt is much more productive to use
plastic tubes for all of your applications. You never have to worry about tube
colour separation. Simply throw away the tube after each patient visit.
a Keloid scar tissue that does not have normal pore activity requires a longer
time to force the pigment into the skin.
o Skin that has been dermabraded has been chemically peeled or damaged
and thinned by some type of burn absorbs the pigment at a much higher rate.
o You cannot guarantee success on CPC. You can only make the patient's
skin look more normal.
o Make sure the patient knows this procedure may take many repeated
applications.
Points to Remember!
o CPC lasts approximately one to seven years before a touch-up application
may be needed.
o You cannot guarantee results because of individual skin tone, medications
the patient may be on when the first procedure application was applied,
improper after care or when medications are started while procedure is
healing.
o Always check the base colour of your pigment before you begin application.
Do not look at the colour through the bottle. Many bottles pick up certain
hues of colours and look misleading. To check a colour's base, shake the
bottle well and place a drop of pigment on a white piece of paper. Place a
drop of water on the pigment and let it run down the page. When the drop of
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pigment and water reach the bottom of the page you should be able to tell
what the base of the colour is.
COLOUR- SKIN TONES
o Skin tones are made up from combinations of pink, brown, yellow, blue,
purple and white. Skin tones come from 3 pigments, melanin (brown),
carotene (yellow) and haemoglobin (red).
o Skin acts as a filter. The tone under the surface will determine if you are
warm (yellow) or cool (blue).
o We all have blue and yellow undertones in our skin. Blue or yellow will
predominate to different degrees in each of us.
o Sallow Skin: Is yellow, warm and cool, may also appear yellow-green and
yellow-orange.
o Translucent skin: Is blue, extreme white or black.
o Olive skin: Is blue-green, green and may also be variegated.
o Rosy-Red skin: Is ruddy, spotty, pink or red.
o Transparent skin: Is violet, blue-violet or red-violet.
a To determine your skin's undertones, look at the back of your wrist. Skin with
predominantly yellow undertones will appear more beige, slightly yellow to
olive. A bluish complexion may have veins close to the surface and appear
slightly pink or ruddy.
o People with blue undertones tend to have whiter coloured teeth. People with
yellow undertones tend to have creamier coloured teeth. (Always ask your
client if they bleach their teeth.)
o Winters and Summers, which are the cool seasons, have a blue or greyish
undertone.
o Autumns and Springs, which are the warm seasons, have gold or peach
undertones.
o Cool undertones will tan to a reddish bronze.
o Warm undertones will tan to a golden bronze.
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o Winter's can either wear blue-based colours of true colours that have a base
of yellow and blue, black and white. Their colours are clear, vivid or ice with
blue undertones.
o Summer's can wear either blue, rose or grey undertones. Their colours are
cool and soft with blue undertones.
o Autumn's colours have strong orange and gold undertones.
o Spring's colours have clear, bright or delicate yellow undertones.
o Winter's and Summer's have cool palettes, while Autumn's and Spring's have
warm palettes.
o Winter's are the only season to have pure black and white in their palette.
o Autumn's alone can wear very dark brown and bright orange.
o Sping's can wear almost any colour except black and pure white.
o Cool undertones usually prefer white metals such as silver, platinum and
white gold.
o Warm undertones usually prefer gold tone metals such as gold, brass,
copper, wooden jewellery and tortoise shell.
o White hair on a winter undertone person will be a beautiful salt and pepper or
silver grey.
o White hair on a summer undertone person will be a platinum, blue-grey or
pearl white.
o White hair on an autumn undertone person will be a dove grey or creamy
white.
a There are more Winters than any other season.
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BASIC COLOUR KNOWLEDGE
a There are 3 primary colours: Blue, Red and Yellow. The order of dominance
of the primaries determines our pigment colour results.
o Blue is the darkest colour and the only cool primary. lt heals the darkest in
the skin. Blue will cool any colour.
o Red is a medium colour and a warm primary. Red adds warmth.
a Yellow is the lightest colour and is also a warm primary. lt heals the lightest in
the skin. Yellow is the only primary colour that has both cool and warm
properties. Yellow will cool red and warm blue.
a True primary colours cannot themselves be created from other colours, but
are used to mix other colours.
o Law of Newton:
When white light is reflected through a three-sided mirror the visible
Spectrum of colour will separate into six colours:
Red- Orange- Yellow- Green- Blue- Violet
a Primary colours are red, yellow and blue.
o Mixing two primary colours together in equal proportions creates secondary
colours. The secondary colours are orange, violet and green.
a Mixing a primary and secondary colour together creates intermediate colours.
o Intermediate colours are yellow green, yellow orange, red orange, blue
green, blue violet and red violet.
o Tertiary colours are created by mixing two secondary colours together.
Tertiary colours are dull or low in intensity. This is the result of there being
three primaries involved in the mixtures.
o Direct complimentary colour will create a high or low contrast that depends
on the colour value and contrast.
a Split compliments: Select a colour; and the colour on each side of its
compliment on the colour wheel.
a Complementary colours are located diametrically opposite from each other
on the colour wheel. Example:
Orange and blue -
Red and green - think of Christmas colours
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Yellow and violet -
o Monochromatic colours are variations of any shade, tint or tone of one
colour. lt counterbalances by eliminating an existing colour or it may
strengthen it by recreating a colour, making a colour more apparent.
o Triadic colours are 3 colours at the end of each point of an equal triangle on
the colour wheel.
o Analogous colours are any one chosen colour on the wheel with two colours
to the right or two colours to the left of your chosen colour. These are colours
that resemble one another but are slightly different.
o Reciprocal colour harmony is when the opposite is the same. An example
would be blue and orange. These colours are complementary to each other.
o Relative temperature of a hue is the amount of warmth or coolness that it
maintains.
o Achromatic colours use a colour scheme of blacks, whites and greys.
o All 3 primaries are blended together naturally in natural hair. The three
primaries cannot work together without browning out. All natural hair pigment
contains three primary colours.
Pigment Colour:
o Orange is the strongest warm colour and is made up of red and yellow. The
red establishes the pigment depth. The yellow establishes the warm light
reflection.
o Violet is formed from the strongest cool and strongest warm primary colours,
red and blue. Blue is the dominant colour and transforms the red into its own
class, it is still considered to be warm.
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MIXING COLOURS
Mixing 2 primary colours makes secondary colours.
The first colour will neutralise the last colour.
Weakest Yellow Brown Violet Weakest
Warm Cool
Primary Secondary
Colour Colour
Weakest Yellow Brown Blue Violet Weakest
Warm Orange Oool
Intermediate Intermediate
Colour Colour
Strongest Orange Brown Blue Strongest
Warm Cool Primary
Secondary Colour
Colour
Strongest Red Orange Brown Blue Green Strongest
Warm Cool
Intermediate Intermediate
Colour Colour
Darkest Pure Red Brown Green Coo lest
Warm Secondary
Primary Colour
Colour
'
COLOUR : TROUBLE SHOOTING
a Yellow will always lightens a dark brow. Allow 28 days before going over the
previous colour, this will allow the skin to heal and for you to see the final
colour, before trying to lighten, as time will fade the colour.
a Taupe neutralises darkers shardes of purple or Pink Brows
a Orange neutralises darker shades of bluish or grey in brows or lips
a Rose Red neutralises medium shades of bluish grey in brows or lips
a Olive Neutralises lighter shades of purple or pink in brows
a Beige or Skin covers small mistakes or will matt down a lip colour
a If a client complains about colour changing check to see if the client has:
While the procedure is healing:
Followed the after care instructions exactly.
Picked off crust I scabs.
Been ill , started medication.
Used any product containing AHA's.
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After procedure has healed:
Got a tan.
Lost a tan.
Changes jobs and they are working under different lighting conditions.
Taking medications.
Has been using a total sun block.
Used any product containing AHA's.
o Black and some brown pigments will heal in the skin with a blue/grey cast.
To prevent problems:
4-8 weeks prior to application to check for blue
undertones.
Use warm undertone colours.
Use cool undertone colours add Pumpkin, Coral or Burnt Orange to
pigment.
USE OF COLOUR: PIGMENT UPDATE
When purchasing pigment choose only a reputable manufacturer of iron oxide
pigments. Ideally particle size is the diameter of 6-8 microns. Dyes are by
definition much smaller and tend to be easily dispersed. le. Black ink has a micron
count of 3 and has the capacity of migrating years later following the cosmetic
tattooing application. Vegetable based dyes may cause severe allergic reaction in
some clients and tend to fade much faster than iron oxide pigments. If pigment is
not placed into the dermis it will be sloughed off leaving only the base colour ie.
Brown pigment fading away leaving a pinkish cast in the skin. To ensure optimum
results for all procedures, your client must be aware of the daily use of sunblocks
on the procedure area. Proper after care is essential for successful results.
After pigment has been implanted into the papillary and reticular layers of skin,
and the cosmetic tattooing procedure(s) heals, the suspended solution (glycerine,
alcohol , distilled or sterile water) evaporates and the oxides return to dry particles.
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TIPS FOR COLOUR MIXING
When inserting pigment, a certain sequence must be followed. Pigment should
be applied from the darkest colour to the lightest colour. The proper sequence
should be: Black, darK purple, blue, green, light purple, brown, red, orange,
yellow, beige and white.
Never reuse or save used pigment, it may contain bacteria.Keep all pigment in a
dark area with bottles tightly sealed.
Each application of colour builds colour volume in the skin.
PIGMENT DO'S AND DON'TS
Pigment Do's
o Store pigment tightly sealed and in a cool dark cabinet. Always shake bottles
well for proper disbursement of colour.
o Determine if your pigment is a 'Cool' or 'Warm' based pigment prior to use.
o Using multi colours on one procedure will create a much more realistic effect,
but will take more time.
o Mix colours using your lightest colour first, followed by your darker colours.
You will mix less pigment.
a Each application of pigment builds colour volume in the skin i.e. gets darker
with each application
o Use pigments with a macron range of 6-8 this should ensure against possible
migration of the pigment in the skin. All Bio touch pigments are in this
category,
o The undertones of all black pigment starts out blue based. But with True
black there is red and violet added to counteract this happening therefore this
colour will always stay black. Wet black has red added to give more of a
shine effect whereas True Black is matt.
o 'Patch test' clients with known sensitivities/allergies to cosmetics, drugs etc.
o We prefer not to use lip pigments that contain titanium dioxide. Do not add
white to lighten pigments on the face (only use white on petite body tattoos) if
your clients ever has laser on the face the white will turn black.
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Pigment Don'ts
Colours from the same manufacturer can be mixed together. Try to keep
organics to organics and iron oxide to iron oxide. DO NOT mix colours
together from different manufacturers unless specified by the manufacturer.
Never reuse or save used pigment, it may be contaminated with bacteria
and/or body fluids.
Do -not use a 'Red Brown' pigment around the eye area, as the eyes will
appear bloodshot looking. Never use lighter colour than a Choc Brown which
is % black % brown.
Do not use body tattoo colours purchased from internet or from regular
tattooist as they are different as those used for semi-permanent cosmetics.
However, semi-permanent cosmetic pigments may be used for body
tattooing.
Do not look at your colour through your pigment bottle. Plastic bottles tend to
pick up a yellow or greenish cast from the plastic. To view correct colour,
open the bottle and view colour.
If your client wants a 'blue-toned' healed colour, do not add any other colour
to their 'cool' pigment formula.
If you are concerned about blacks 'appearing' blue, patch test the client and
wait 4-8 weeks for a final assessment of colour.
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NEEDLES
FLAT NEEDLES
Flat needles can be used, like to get the crispness of a single needle but working
much quicker.
A 2 - 4 - 6 flat is used, in a sewing machine style (as back and forth on some
skins can cause tearing ) creates a wonderful thin line.
This is particularly good when doing fine lines then turning the needle head to gain
thickness.
Also flat needles are ideal for shading/filling in. Obervoid motions or shading from
outside in can be achieved really well using the 4 and 6F Also a 2F is good as a
hairstroke, heavier at the base going lighter at the end giviJQg the "hair illusion".
ROUND NEEDLES
Round Needles can be used for all paramedical work from 3-5-7- sizes
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USING GL YCOGEL
Used alone without the use of a needle for penetration, GlycoGel can be used as a
topical gel that works with the skin's pH balance, causing problem areas to be
exfoliated off at the surface.
Needle Procedure: With a dry needle, break open the skin enough for deep
penetration. The properties in the gel can enhance camouflage procedures in the
following ways:
o As a pre-treatment before getting a camouflage procedure done. Will help to
begin the lightening and exfoliation process. Helps prepare the area by giving
the technician a cleaner "beginning" tone to match.
o As an "after-care" treatment to promote more peeling and fading of the
procedure area if the pigment used for camouflage turned out to be too dark
or the wrong colour after a month or so of healing.
IMPORTANT CONSIDERATIONS:
Some skin conditions and corrections are best handled by a laser doctor or
medical advisor. Permanent, pigment camouflage cannot disguise extremely
elevated scarring or texture the skin, nor can it ever restore a person to what they
were before the loss of pigment or scarring occurred. This would include burn
victims, cancer patients, breast reconstruction or scar tissue.
Remember:
o Evaluate the skin type before using permanent pigment.
o Do NOT work on individuals with keloid formations or persons known to
have medical conditions.
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CHAPTER 3
TATTOOING THE BREAST
THE TECHNICIAN
Are you as concerned with learning, as you are with making money? If money is
your main objective, this may not be the work for you. This work is time
consuming, with little profit, but it is the most rewarding of any cosmetic procedure.
Things You Should Know
1. Every client is a new canvas and every scar is unique.
2. Unevenly coloured skin is the easiest to work with, while evenly coloured skin
is the hardest.
3. Colour in scar tissue will not last forever.
4. Most permanent make-up colour theory will not apply to this work.
5. Some scars grab pigment while others will not retain colour at all.
Things You Should Consider
1. Have you been trained in breast reconstruction tattooing? Breast skin and
the scar tissue that comes with it, are not for the novice or the untrained. Get
all the facts and experience you can. Do your homework.
2. Again, this is a process, not a procedure. Some clients may require multiple
sittings to gain the desired results. Be willing to spend the time.
3. Know your colour in the healed form. Test colours and tints on your client
with at least a four-week time frame for healing before you start.
4. Documentation is one of the most important steps for success in para-
medical tattooing. Photos and a clearly printed description of every aspect of
your procedure will aid in educating yourself with this type of work. lt is a
must for a multi-visit procedure.
5. Don't make promises you can't keep. You are a technician, not a magician.
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THE CLIENT
Your First Consideration
Is your client looking for perfection? We as professionals cannot remove all signs
of scarring or return a breast to its appearance "before surgery". However, we
have found that most women are thrilled to have their areola pigment restored,
and to exercise options that were not open to them in the past; colour, size and
shape. I have made pretty pink areolas where the client always disliked the darker
ones she was born with.
Qualifying your client:
1. Has it been at least9 months since her last surgery? To work prematurely is
to chance further damage to a scar or reconstructed area. Some Doctors do
recommend their clients have their recolouring done sooner check with the
Dr.
2. Beware of hyper-pigmentation. You will not be able to minimise a dark scar
by tattooing it. You will only make it worse.
3. Is the scar bumpy or lumpy or irregular in nature? Tattooing will not improve
the nature of the skin, it will only add colour.
4. Breastwork should be looked upon as a colouring process, not a one-time
procedure. Prepare your client and yourself to follow through with this
process if more than one sitting is needed.
Remember .... Honesty is the best policy. These women have accepted a cancer
diagnosis. They can surely accept what you have to tell them.
The Consultation
Schedule at least one hour for the first appointment with your client. You can
incorporate a consultation and also get some of the preliminary test work and
documentation out of the way. Your evaluation of her condition, photographs and
health history can be discussed and completed. Colour testing and some design
work can also be done. This is a confidence builder for the client, and she easily
commits to you as her technician.
Remember .. .Documentation is one of the most important steps in Para-medical
tattooing. If is a must for a multi-visit procedure.
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SURGERIES
Every client is a new adventure. The types of surgeries or requests you will come
in contact with vary considerably; from just darkening an areola for vanity sake, to
a full-blown reconstruction of the chest.
With an understanding of the medical terms, surgical procedures and how they are
accomplished, the better you will understand the nature of the tissue you will be
working with.
The Augmentation
Breast enlargement can be done in many different ways. The implants can be put
in form under the breast (lnframammary incision) or by an incision made around
the areola (Periareolar incision). Both of theses procedures leave visible scars.
F eriareolar E:>reast Augmentation
Note visible scarring around areolas
The Reduction
This surgery (Mastopexy) entails the removal of breast tissue and the replacement
of the areola. You may see a "T" shaped scar on the breast mound and scarring
around the areola.
Latissimus Dorsi
The tissue is taken from the client's back and used to build the breast mound.
Scar shape will vary. This may also include a graphed or non-graphed type
areola.
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The Tram
Tissue is taken from the abdominal area and transferred to the breast. An
indentation from the client's previous belly button may be visual somewhere on the
breast mound and may include a graphed or non-graphed type areola.
The Tram
Note client's previous belly button
Mastectomy
Removal of breast. Unilateral, one breast and Bilateral, two breasts. The most
common reconstruction technique is done with tissue expanders. They are placed
under the chest muscle and filled with fluid over a period of time to expand the
skin. When the tissue has stretched enough, the expander is replaced with the
implant. The horizontal; scar across the breast mound may have a graphed or
non-graphed type areola.
with Expanders
With an understanding of the medical terms, surgical procedures and how they are
accomplished, the better you will understand the nature of the tissue you will be
working with.
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Nipple Replacement
A Star flap or Skate flap are made from small cuts in the breast mound and
sutured into an extension. The Pedicle technique is one, which inserts a small
stint to create the extension. Both lack pigment.
Nipple Replacement
With a Star Flap
Nipple Replacement
With a Grafted Areola
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DRAWING THE AREOLA
Bilateral
If you are lucky enough to have a client with bi-lateral mastectomy (both breasts)
the chances are that your client will leave with a matched set. Any shape, size,
style or colour is possible and can be duplicated without much trouble. We have
found that by offering the client a choice in design and placement, she was able to
relax and take part in the process.
Unilateral
A unilateral (one side) mastectomy is a little harder to deal with, as the main
objective will be to match the healthy breast. You must make your first step:
OBSERVATION, followed by the documentation of what you saw. Develop an eye
for what you are looking at, in detail. If you wish to duplicate the healthy breast, the
smallest detail is important. A pre-printed evaluation sheet is helpful for these type
of procedures and can be used in addition to your general health and release
forms.
At least 6 good "before" photos, of both breasts should be taken. Make it 10, just
to be on the safe side. You will want to study your task. You may note something
you hadn't considered, while looking at the photos during the tester colour healing
period. Take your photos in different locations of your office to make sure you
have some good ones. Take at least 2 body angles, front facing and % view, with
different lighting situations. You will be surprised at the different perspective you
will gain from these photos.
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AREOLA/NIPPLE
Placement Designing
My preference is not to use a drawing implement as they will
always give a false full circle look. I get my client to stand in front
of me and I sketch the areola ensuring it is not a circle, take a
look at photos in Cosmetic Surgery Magazine to see the various
sizes and colours.
There are many acceptable ways to draw on a nipple and areola, from circle
pasties to using a calibre tool for exact measurements. lt is up to the individual
technician what to use. Regardless of the tool , one must OBSERVE, as well as
measure. The breasts are often not the same, and exact measurements will not
look correct. OBSERVE where the nipple should be placed.
Does the underside of the breast (or the breast mound) starts at the same place
on the rib cage? This is important on the bilateral reconstruction as well as the
unilateral. Dependant on the available tissue and its ability to stretch, the surgeon
may not be able to duplicate the implant placement of both sides. This affects
where you place the nipple. Stand back and look. If measurement on one side is
not the same on the reconstructed side, the areola and nipple will not be in the
same place, and appear to be unbalanced. With this in mind, you will come to
depend on your ability to OBSERVE an unbalanced look and make the proper
corrections. See photos below.
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Measuring tor Nipple Flacement
Note the difference where each
breast starts above the ribcage.
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Start with locating the placement of the nipple. What is the distance from the
centre breastbone to the nipple on the normal breast? This is important because
most nipples do not hit dead centre like headlights, but rather face in or out a little.
Whether it is reconstruction, or working with a bilateral mastectomy, the choices
for placement design are open to you artistically.
Pick a level line anywhere on the upper chest. We use the line of the armpit.
Measure down to the nipple. Make sure your client is standing straight and has
her weight evenly distributed on both feet.
Next, measure the distance from where the arm meets the nipple. This is often
the smallest measurement.
-r---:------r
t..,-+ ( I
I
I
Measuring tor Nipple flacement
Place a small dot with your marking tool, to reflect these measurements, on the
breast to be tattooed. Note the size and shape of the nipple you wish to duplicate.
You may measure the diameter of the healthy side or just draw it on. OBSERVE:
Is it the size of a pea? A pencil eraser? Or larger? Stand back and try to look
artistically as well as technically at your work. Once you have determined the
placement of the nipple, the rest is an easy task.
Drawing the areola
Using the nipple as your centre point, measure out, in four directions, to the edge
of the areola on the normal breast. Transfer your findings to the side to be
tattooed. These measurements will vary from top to bottom and side to side. To
have equal measurements all around, will indeed create a target effect. See top
photo next page
Important Note:
Areola and nipples react to sensations such as hot, cold, touch or even breath. An
areola that shrinks in size on contact will not provide an accurate measurement.
Give your client the opportunity to adjust to the room temperature, your touch, and
the use of your measurement tool.
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-r ---i - - - -r --
I
< I )I o
Measuring tor Areola Flacement
Areola Special Effects
Not only is the size of an areola important, but also it is the un-symmetrical and
broken shapes of it that make the areola personal and unique. Visually paint a
north, south, east and west line across the nipple of the healthy breast. Focus on
the four areas of skin this creates. Check each section for shape variations and
uneven lines. OBSERVE the shape of the areola. Round, oval , or any
abnormalities to the shape. lt is common to have an oval shape that appears to
have one side cut off. This occurs naturally in nature, but would not look right if
duplicated.
N
I
I
w--Q- E
I
Areola Shaping
Note irregular shape in SE quadrant of areola
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NIPPLE ARTISTRY
Many of the women who had hoped that surgery would provide a nipple, are
disappointed. Even though an extension was made with a star flap or by other
means, many do not hold up to the healing process and within a few months, the
nipple extension has collapsed. Artistry in recreating a nipple is important and with
a few tricks, you can increase this extension or build the illusion of an erect
protrusion.
Existing Nipple
Even if your client is lucky enough to have a nipple already in place, chances are it
does not match her normal breast. lt may be larger around or not as high off the
breast mound. To better create the illusion of matching nipples, we revert back to
a basic art principle. That which you want to bring forward is lighter and that which
you want to fall behind is darker. An artist trick is to squint your eyes to see what
should be dark and what needs to be light. Look at the healthy breast. Squinting
takes out the shades of grey, so you can see the lights and darks more easily.
To bring a nipple forward, try making the tip a lighter colour than the sides. If the
normal nipple is white, creamy, or in the red family, make the sides of the nipple a
darker red or something from the brown family. Refer to the natural nipple for your
direction in colour.
Non-Existent Nipple
Unfortunately, we cannot add skin where there isn't any. We can however give
the illusion of a protrusion, with colour.
Non-E_xistent Nipple
Note the dark crescent moon shape
under the nipple to bring it forward.
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Paramedical Tattoo
NEEDLE TECHNIQUE
Technique can be defined in many ways but for the sake of this publication, we will
define it as the use or movement of your tool in regard to colour application and
your performance.
I consider each technique as a tool in my toolbox. There is a time and place for
each and almost every one of them. lt is part of the fun when working with
breasts. Even what we consider poor technique, can be useful in breastwork.
Pointillism, the Dot Technique
There are those who have perfected this technique to a masterful form and can
colour a lot of skin in no time at all. Pointillism can be done with every needle,
from a single to multi-magnum. This technique works well to simulate the little red
or white dots scattered across the areola (Montgomery's gland) or to fine tune the
tip of the nipple.
Obavoid, or Circle Technique
This technique consists of small continuous circles that overlap. I use obavoid
almost exclusively to colour any skin. The tighter the circle, the more intense the
colour is deposited. A poor obavoid would be one that is loose and eclectic, but
even this type of movement works well to create spotty colour such as found in a
healthy areola.
Pendulum, or Back and Forth Movement
This technique has some applications, but is rarely used other than on normal or
un-traumatised tissue. Some technicians have great success with this technique
on full lip procedures.
If you are using an obovoid technique, you must keep all of the needles at the
same depth in the skin, all the way around the circle. lt is common for a technician
to start out OK, but by the end of each circle, they lift the needle. First deep, then
shallow, deep, shallow, deep, shallow: the pigment is placed in the derma layer on
the deep stroke, but as you lift, so does the pigment. lt serves no purpose to poke
holes in the skin if you aren't putting in colour. Learn this technique well before
you try anything fancy with it.
Once you can execute a proper obavoid, you may want to alter your technique by
making loose, larger or more spread-out circles. This, in any other instance, would
be considered poor technique. Your colour will heal in the skin looking spotty but
with substance, like natural colouring. lt will not appear solid like you would want
in a full lip procedure or tattoo design.
A Handy Tip... With breastwork, use an inexpensive lip line pencil. lt marks the
skin without fail and is easy to take off without a lot of rubbing.
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I have been asked why I do not use the Pendulum technique for breasts. I can
best explain it this way. Much like a swimmer doing laps in a pool , the hand must
slow down to change direction. The machine does not. lt continually implants
pigment whether your hand is moving or not. Where your hand slowed down to
change direction, your machine will implant more pigment particles. If you know
the mechanics of this technique, it is easy to see the direction changes in healed
work. This effect can be compensated for with short quick direction changes, but
that can overwork unstable tissues. This technique never worked well for, except
when doing solid black tribal tattooing.
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COLOUR TECHNIQUE
Traditionally, tattoo artists work their colours from dark to light. The reasoning is,
once the skin is open, and a light colour has been tattooed, you would
contaminate the area by using a dark pigment close to it. Some residue from the
dark pigment may leach into the open skin of the light area and distort the colours
of the tattoo design. If you were to get the green pigment of a leaf you were
working on, into a yellow rose you have just tattooed, the rose would be
chartreuse (yellow/green). Not a pretty colour for a rose.
With breast and scar work, it is just the opposite. Because you will be working
with un-predictable tissue, there is a sense of security and safety in using your
light colours first. When you feel confident that the tissue will not grab up
undertones, you can become more intense with full strength pigment, as required.
Believe it or not, there are areas on almost all breasts where straight red or full
strength brown is required to duplicate certain characteristics. With breastwork,
the leaching of colours can be a welcome plus. In fact it is helpful in the natural
blending of your colours.
Although you will be using your light colours and washes first, you should not
attempt to use them to blend edges into the skin, as your first step. Concentrate
on the area between the nipple and the outer perimeter of the areola.
Unilateral Colour Technique
With a unilateral procedure, OBSERVE the breast you wish to duplicate, and
locate the light areas on the areola. Note where the full strength colour and tint is
needed. Mix your colour, according to your text chart notes, in full strength, dark
tint, medium tint and light tint, if required.
Start your procedure anywhere you wish, but continue working 360 degrees
around the areola. Do not jump around from side to side. This will make it
impossible to see your colours in the skin. Work with 'X of the areola and finish
one section at a time. See photo below.
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U nilat eral Calor Techni4ue
Note: work only I /4 of the areola at a time.
Pick the spots for the lightest colour and tattoo it. The second step is to dip into
the next darkest shade. No need to wash out your needle if you have used up
most of the colour in the cap. They will blend together just fine. Work your colours
from light ones to the full strength pigment. Remember, you can always add more
if you find you need to be more aggressive with colour on the second sitting. For a
uniform blend, finish all four sections of the areola before blending your colour into
the breast mound. You can be assured that your colour will be the same all the
way around by leaving the edges to the last.
As already stated, scar tissue is unpredictable. Do not spend a lot of time trying to
second-guess the outcome. Believe in what you have learned from your test
colours and let your procedure heal. Most noticeable scar tissue will require a
second visit.
Bilateral Colour Technique
Shear artistry comes from knowledge and research. You cannot create a beautiful
areola if you do not know what this tissue looks like in the natural form. Take a
clinical look at your own areola and note the change in colour throughout the area.
Pay particular attention to colour progression and unique qualities. Get as much
experience with looking at healthy areolas as possible.
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notes
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