Case Study: Concealing Scars

By Hina Solanki / 20 Nov 2017

Permanent makeup artist and paramedical tattooist Hina Solanki provides an overview on medical tattooing and details two instances of successful scar concealment

When many people hear the word ‘tattooing’, they probably think of the tattoos people have on their body and not necessarily
that of the medical kind. Medical tattooing can often be referred
to as cosmetic tattooing, micropigmentation, semi-permanent makeup, scar camouflage and paramedical micropigmentation. The procedure can be used to conceal various conditions including alopecia, vitiligo, surgical scars and burns, to name a few.

Medical tattooing can transform the way people feel about themselves and boost their self-esteem and confidence. A person’s skin condition may have affected their work and relationships,
often due to a lack of self-confidence. It’s important for aesthetic practitioners to be aware of medical tattooing as they may be able to refer patients. For example, practitioners or dermatologists who are not able to help with vitiligo should be advising their patients about the possibility of medical tattooing. Additionally, surgeons can reassure patients who may be concerned about the scars following surgery that there can be a solution.

How does it work?

Medical tattooing is a tattooing technique that inserts pigment into the skin with a single-use fine needle, into the chosen procedure site.1 In this technique, the pigment is only implanted into the upper dermal layer. From my experience, if pigment is implanted into the skin as deep as normal body art tattoos are, the colours will not be true enough to mimic traditional makeup, which is important to consider when covering up scars. Pigment is then blended to the skin tone. Several different colours may be blended to build up the skin, to create natural looking skin tones and give the appearance of a natural finish. Freckles may also be implanted to match the patient’s normal skin area. It is very important to remember that this procedure will camouflage the patient’s scar, not make it disappear.

The idea is to make the scar less noticeable and not have the eye drawn to it immediately. The result will also depend on the severity of the scar and may take more than one session. Below are two examples of medical tattooing on patients that I have treated. The first case study is of an areola reconstruction over a scar after a simple mastectomy and the second is a scar camouflage treatment for post- surgery scars to the forearm.

Case study one: areola recreation

For this patient, I recreated an areola over a scar across a newly-inserted implant. The areola and nipple, along with breast tissue, were all removed during the patient’s mastectomy surgery and an implant was inserted by the surgeon to rebuild the breast. If patients have been referred to me from a surgeon, I ensure I liaise with the surgeon and work to the time frames they suggest so that the area heals well.
I recreated the areola and nipple by using three different shades. 

By using a circular movement, with a five-round needle, I was able to create a ripple effect, resulting in a more texturised appearance, which produced a very natural-looking areola. For the nipple, I then used some lighter shades to create a ring with a three-microneedle device, giving the illusion of an outward-projecting nipple. A four- flat needle was then used on the outer edge of the areola. This provided a softened edge, to ensure the areola did not look ‘too perfectly’ circular. All of these needles mentioned vary in thickness and are commonly used for shading work and to create a circle formation on the skin.2

This type of procedure can take two sessions or more. If the scar tissue is dense and tight, then care is needed when inserting the needle, so that the placement of the pigment goes into skin, to achieve the desired results. If too much pressure is used, the pigment could merge out and the resulting colour may appear too grey. If not enough pressure is used, then during the healing process, the pigment may be rejected and leave the skin. In my experience, a scar which is silvery white and flat, with not much tight scar tissue, would retain the most pigment and the best- looking result, however it is important to note that no scar is consistent all the way through.

After the first session, the patient was very pleased, but during healing there was some unevenness in pigment, which is completely normal. In the second session, I went over the area again and evened out the pigment. The first procedure would have broken down some of the scar tissue present in the areola and, from personal experience, it’s almost always easier to get pigment to sit correctly the second time around. The procedure usually takes around two hours. There can be some soreness or swelling to the area, which sometimes lasts up to five days. A light dressing should be applied following the procedure. I normally advise my patients to wear loose, comfortable clothing and most definitely a loose-fitting bra; they normally have their post-surgical bra. The way pigment breaks down in each patient is different but generally, most patients will not need the area retouched for about five years. Overall the patient was happy. In my experience of treating breast cancer patients, this is their chance to fully say goodbye to cancer and frequently provides patients with a sense of closure.

Case study two: self-harm scar camouflage

This patient came to me for a consultation looking for somewhere she could get help covering her scars, but also somewhere where she wouldn’t feel like she was being judged. It’s often very hard for self-harm patients to talk about their problem with anyone and many manage to keep their scars hidden from friends and family for decades. This patient underwent a very successful skin graft procedure by a surgeon to cover self-harm scars to the forearms. Surgery was performed two years prior to having cosmetic tattooing. In my experience, medical tattooing can generally be done one year after having a skin graft however, depending on the case, it may take up to two years. 

Very tight scar tissue meant that the medical tattooing procedure had to be done very slowly using a fine needle, to implant pigment into the skin with a pointillism method, where you hold the needle directly above the skin to create microdots through the whole scar. This technique also helps to break down and loosen the tight scar tissue due to the penetration. Four different shades of pigment were used on this patient, two for the freckled appearance, to create more depth, and the other two shades were used over the whole area that was being treated, to match the patient’s skin colour.

The freckles were done unevenly, in both small and large sizes, to mimic the appearance of true freckles. Pointillism for the freckles could have created too dense a colour tone, so I used a shading needle in small, circular movements to create different sized freckles and used
it to push out the pigment in some areas, so not to create a freckle that was too rounded. This allowed the freckles to blend in better with the rest of the skin. The patient was delighted with the result which took almost four hours to achieve. There was no follow up on this particular procedure as the patient was due to work abroad soon after, otherwise the patient would have come in for a follow up procedure to check the result, which can last up to five years.3 Complications are highly unlikely, however, the patient may have poor pigment retention which would mean that they may need to have more sessions. If the healing is delayed or the area required medical attention, I would advise the patient to visit her general practitioner.

Aftercare

Aftercare for any medical or cosmetic tattooing procedure is very important.4 After the procedure, I provide full aftercare instructions on short-term and long-term care. The aftercare is the same for all procedures. Instructions on dressing the area may vary.

Short-term care

I advise patients to do the following for the first five to seven days after the procedure:

• Keep the treatment area moist with a healing balm containing natural ingredients such as chamomile, lavender and vitamin E, or aftercare ointment, and apply three times per day minimum. Be mindful about not double dipping into the balm pot to prevent cross contamination. To avoid this, advise patients to use the back of their hand as a palette and a cotton bud to place a small amount of aftercare balm on the treatment area. 


• Do not get the procedure site soaking wet for five to seven days and be careful when showering or washing hair. Instead, cleanse the procedure site with damp cotton wool with saline water or tap water. Do not overuse water but use enough to be able to clean the area. Pat dry with a tissue and then reapply the balm. 


• Do not pick, peel or scratch the treatment area. This could result in pigment loss or infection, or worse, scarring. If patients really do get an uncontrollable urge to itch, a light pat to the treatment area with clean hands may help or I advise to apply more balm to lessen the tightening feeling of healing skin. 


Long-term care 


After the initial seven days of healing, patients will need to use a strong SPF to protect the treatment area from fading too quickly. Once a month, I advise to check the healing of the procedure site and apply more balm if need be. In my experience, tattooed skin tends to be drier, so applying some balm will ensure maximum longevity for the treated area. 
If patients regularly swim, I advise to apply petroleum jelly over the treatment area to protect it from the chlorinated water. Chlorine can also fade the enhancement faster.
Patients should inform you if they are having a chemical peel or laser procedure as these can also fade enhancements more quickly. A full four weeks in-between having a cosmetic tattoo and a peel/laser treatment should be left so the skin is given time to heal.

Conclusion 


The patients that were included in both these case studies reported a confidence boost and a sense of liberation after receiving these life-changing treatments. It is important for aesthetic practitioners to consider the possibilities of medical tattooing for their patients and, in circumstances where practitioners may not be able to treat the patient but where medical tattooing may be an option, there should be the opportunity to refer them to professionals. 


References
  1. Breastcancer.org, Nipple Reconstruction (2017) <http://www.breastcancer.org/treatment/surgery/ reconstruction/types/nipple>
  2. Ebay, 5 Tips on Choosing the Correct Size Tattoo Needle (2016) <http://www.ebay.co.uk/gds/5- Tips-on-Choosing-the-Correct-Size-Tattoo-Needle-/10000000177748054/g.html>
  3. Laboratories Biotic Phocea, Medical Tattooing < http://biotic-phocea.com/medical-tattooing/>
  4. East Kent Univerity Hospital, Micropigmentation (medical tattooing): your aftercare (2015) <www.ekhuft.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=7493>
  5. Authority Tattoo, How long after getting a new tattoo can you swim? (2016) <https://authoritytattoo.com/new-tattoo-and-swimming/>


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