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Original Investigation |

Dermatography (Medical Tattooing) for Scars and Skin Grafts in Head and Neck Patients to Improve Appearance and Quality of Life FREE ONLINE FIRST

Brigitte H. Drost, MD1; Rick van de Langenberg, MD, PhD1,2; Olivia R. Manusama, MD2; A. Soe Janssens, MD, PhD3; Karolina Sikorska, PhD4; C. Lot Zuur, MD, PhD1; Willem M. C. Klop, MD, PhD1; Peter J. F. M. Lohuis, MD, PhD1,2
[+] Author Affiliations
1Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam
2Center for Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Diakonessen Hospital, Utrecht, the Netherlands
3Department of Dermatology, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam
4Department of Biometrics, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam
JAMA Facial Plast Surg. Published online September 22, 2016. doi:10.1001/jamafacial.2016.1084
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Published online

Importance  Dermatography (medical tattooing) is often overlooked as an adjuvant procedure to improve color mismatch in the head and neck area, and its effect on patient satisfaction and quality of life has not been evaluated, to our knowledge.

Objective  To analyze the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and the quality of life in head and neck patients.

Design, Setting, and Participants  Case series of patients undergoing dermatography at the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, between July 1, 2007, and April 1, 2015. Participants were invited to respond to 2 questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors.

Intervention  Use of dermatography.

Main Outcomes and Measures  Two questionnaires evaluating a visual analog scale score (range, 0-10) and multiple questions on a 5-point scale focusing on satisfaction with the appearance and the quality of life.

Results  Among 76 patients, 56 (74%) were included in the study. The mean (SD) age of the study cohort was 56.5 (16.0) years, and 42 (75%) were female. The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography.

Conclusions and Relevance  Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients.

Level of Evidence  4.

Figures in this Article

Dermatography (medical tattooing), first documented early in the 19th century, is performed most often for nipple reconstruction after mastectomy.13 Despite its popularity in breast reconstructing procedures, dermatography is used by few medical professionals as an adjuvant to enhance the appearance of scars and skin grafts after head and neck surgical procedures, which is unfortunate considering the wide range of applications and advantages this type of treatment has to offer. Indications are numerous for primary treatment (eg, postburn scar, vitiligo, alopecia of eyebrow or scalp, and port-wine hemangioma) but also as an adjuvant to previous surgery (eg, scar, skin graft, or free flap).415 In addition to its use in improving the appearance of lesions, another well-appreciated outcome of dermatography is its smoothening effect on scars.16 Compared with surgical options to improve scar or skin transplant appearance, dermatography is minimally invasive, and complications seldom occur.4,6,8,17,18

Although well documented in the literature, most studies of dermatography have been observational.4,6,9,10,12,13,16,17,19,20 To our knowledge, this study is the first to statistically evaluate patient satisfaction with the final result and their related quality of life after dermatography in the head and neck area.

Box Section Ref ID

Key Points
  • Question What is the effect of scar and skin graft dermatography in the head and neck area on patient satisfaction and quality of life?

  • Findings In a case series of 56 patients, the mean improvement in scar or skin graft perception on a visual analog scale (score range, 0-10) was 4 points. All answers to patient satisfaction and quality-of-life questions in 2 modified questionnaires improved significantly.

  • Meaning Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients.

Patients

Institutional review board approval was not necessary for this study because all research was done retrospectively after treatment. All patients included in the study provided oral informed consent.

In this case series, all patients receiving dermatography at the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, were analyzed. Patients were eligible for inclusion in the study if they underwent dermatography for scars or skin grafts or other reconstruction in the head and neck region between July 1, 2007, and April 1, 2015.

Dermatography Technique

All dermatography procedures were performed by one of us (B.H.D.). The pigments used for the technique include ferri- and ferro-oxide, ferrohydroxide, titanium dioxide, tartrazine, and carbon. Mixing these pigments with 80% alcohol yields a suspension. A series of 64 predeveloped standard colors, varying in intensity from 10% to 100%, constitutes the reference by which a sliding color scale can be made.16

Disinfection of the skin is performed with 80% alcohol.16 Local anesthetic may be infiltrated to provide numbing and reduce bleeding during treatment. However, an anesthetic is rarely used because it may result in dilution of the pigment and therefore fading of color.13

Dermatography is performed using a modified tattooing machine (Van der Velden Derma-injector; Medicer) consisting of an electromechanical motor and a needle holder that is moved up and down in a stainless steel tube (Figure 1) at a speed between 500 and 3500 rpm.10,13,16 The number and arrangement of the needles vary depending on the required color intensity.13 The needles are disposable, with a length of 36 mm and a diameter of 0.36 or 0.41 mm.16

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Figure 1.
Postoperative Dermatography of a Scar

The patient had undergone a right-sided Blair incision for a parotidectomy (arrowhead).

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The optimal level of pigment insertion is the upper and midpapillary dermis.6 With the vertical movement of the needles, an alternating effect of pressure and suction is initiated by which the pigment suspension is deposited along the needles. Depending on variations in anatomy, the depth of the punctures varies between 0.6 and 2.2 mm.13 The angle of the needle varies as well, from 10° to 90°. During the procedure, the skin is stretched with the thumb and index finger, and hemostasis is maintained by applying pressure.6,16 To enable the underlying skin color to be visible and to follow seasonal variations, the pigment does not cover the skin completely but is injected to create a raster of punctures.

A pressure dressing, prophylactic antibiotics, and anti-inflammatory drugs may be used after dermatography. If needed, consecutive sessions may be scheduled at intervals of 3 weeks or more until an optimal match with the surrounding skin color is reached.13,17 Touch-up procedures may be needed if color fading occurs over time. Coloring of skin can be combined with treatment of hypertrophic scars (intracicatricial keloidectomy). The cutting action of several needles placed in a row reduces tissue volume and smoothens the scar, making it level with its surroundings.16

Questionnaires

Two previously validated questionnaires21,22 were modified to make them applicable to this study (Figure 2 and Figure 3). First, the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty21 was altered for use in patients with scars and skin grafts. The modified Utrecht questionnaire consists of one question assessing scar or skin graft appearance on a visual analog scale (VAS) ranging from 0 to 10, with 0 as “very ugly” and 10 as “very nice.” Five subsequent questions assess the quality of life in relation to the scar or skin graft, with 1 indicating “not at all” concerned and 5 indicating “very much or often” concerned. Second, a selection of 9 questions from the Patient Scar Assessment Questionnaire22 was used. These questions focused on patient appearance, scar consciousness, and satisfaction with appearance on a 5-point scale.

Place holder to copy figure label and caption
Figure 2.
The Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty

The questionnaire was answered twice. First, patients were asked retrospectively about their situation before dermatography. Next, the patients answered the questions regarding their current situation after dermatography.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
The Modified Patient Scar Assessment Questionnaire

The questionnaire was answered twice. First, patients were asked retrospectively about their situation before dermatography. Next, the patients answered the questions regarding their current situation after dermatography.

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Each questionnaire was answered twice. First, patients were asked retrospectively about their situation before dermatography. Next, the patients answered the questions regarding their current situation after dermatography.

Statistical Analysis

The results of the questionnaires are summarized as means, medians, and interquartile ranges. In addition, the mean (95% bootstrap CI) and median differences in scores before and after dermatography are provided. Some of the differences were not normally distributed. Wilcoxon signed rank test for paired observations was used to test differences in within-patient scores. To account for multiple comparisons, the Bonferroni-adjusted significance level was set at P < 3.3 × 10−3. A software program (R, version 3.2.3; R Foundation for Statistical Computing) was used for the statistical analysis.

Seventy-six patients undergoing dermatography were identified as eligible for this study. Among them, 56 were willing to participate, for a response rate of 74%. Among the 20 excluded patients, 16 could not be contacted, 3 declined to participate, and 1 had died. Among the 3 patients who did not want to participate, one immediately refused (with no explanation), another stated that she was unable to “quantify” her views, and the third regretted the dermatography because it was interfering with diagnostic imaging (confocal microscopy) for a new primary lesion.

The mean (SD) age of the study cohort was 56.5 (16.0) years. Most patients had been treated for cutaneous malignant disease of the head and neck before receiving dermatography (Table 1).

Table Graphic Jump LocationTable 1.  Baseline Characteristics Before Surgery in 56 Patients Who Underwent Dermatography

Almost all patients had a significant improvement on the VAS. The mean difference on the VAS was −4.0 (95% CI, −4.6 to −3.3; P = 1.1 × 10−9). After dermatography, the mean VAS score was 7.8. For the 5 remaining questions, a decrease in patient concern was observed, with all P values significant after Bonferroni correction (Table 2). The same was true for the modified Patient Scar Assessment Questionnaire, with uniform improvement of approximately 1 point across the 9 questions (range, P = 5.6 × 10−6 to P = 1.5 × 10−9).

Table Graphic Jump LocationTable 2.  Results of the Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty and the Modified Patient Scar Assessment Questionnaire Before and After Dermatographya

Scar and skin graft color abnormalities can result in impaired physical, psychological, and social well-being.23,24 In such cases, secondary reconstruction may be necessary to improve the function or appearance of the postoperative site. Well-known established adjuvant procedures to enhance scar or skin graft appearance are dermabrasian, scar excision, W-plasty, geometric broken line repair, or corticosteroid injections. As demonstrated herein, dermatography is also a valuable nonsurgical alternative to improve appearance and occasionally to also enhance function. Unfortunately, the use of this adjuvant procedure is often overlooked. Otolaryngologists and head and neck surgeons may be less familiar with the technique than plastic surgeons who routinely use this procedure for nipple reconstruction after mastectomy.1,2

Dermatography has numerous advantages, including no donor-site morbidity, availability of a wide range of colors, no requirement for hospitalization or general anesthesia, permanent camouflage, and well-preserved sensation.8,17 Moreover, coloring of scars can be combined with intracicatricial keloidectomy, in which the volume of hypertrophic scars is reduced by the cutting action of the needles.16 This action smoothens the scar and reduces scar tension.

Few publications exist on the use of dermatography after head and neck procedures.4,5,12,16,17 These studies were mainly observational and did not focus on patient satisfaction and the related quality of life after treatment. To evaluate these topics in the present study, we searched the literature for validated questionnaires that were simple and short, but no such questionnaires were found. We found 2 validated questionnaires that were usable after slight modification (Figure 2 and Figure 3). The first was the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty,21 in which the word nose was changed to scar or skin graft. The second was the Patient Scar Assessment Questionnaire,22 from which we chose the 9 most relevant questions because we considered 28 questions before and after therapy too long for our group of head and neck patients.

In the Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, dermatography is offered occasionally to patients with hyperpigmented and hypertrophic scars, those with hypopigmented skin grafts, or patients missing a structural organ (eg, hair-bearing skin, vermillion pigment, or eyebrow). Primary treatment, such as surgery, radiotherapy, or chemoradiation, of the underlying disease should be completed before starting dermatography. Especially in the case of skin grafting or flap surgery, the wound is given sufficient time to heal before dermatography to ensure adequate perfusion and healing.17

The results of the present study show that dermatography is a valuable adjuvant treatment option. The scores on the VAS pertaining to the appearance of the scar or skin graft improved after treatment by 4 points on a 10-point scale. One exception was a patient with a history of inflammation and radiotherapy before dermatography, resulting in a more difficult treatment and a worse VAS score after treatment. In all other patients, lesion appearance and quality of life regarding the scar or skin graft improved significantly (Table 2). After this minimally invasive procedure, patients report not only improvement in the appearance of their scar or skin graft but also enhanced quality of life. To visualize the effect of the dermatography procedures, 3 cases are shown before and after therapy (Figures 4, 5, and 6).

Place holder to copy figure label and caption
Figure 4.
Basal Cell Carcinoma of the Left Zygoma and Cheek

The defect was reconstructed with a full-thickness skin graft from the supraclavicular neck. The hypopigmented graft was treated with dermatography, resulting in a more natural appearance.

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Figure 5.
Hypertrophic Scar in a Patient in Whom Dermatography Was Combined With Intracicatricial Keloidectomy.

Note the reduction in tissue volume and the leveled scar.

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Figure 6.
Situation After Commando Operation With Reconstruction of the Oral Vestibule Using a Free Revascularized Double-Layer Radial Forearm Flap

Dermatography was performed by creating the red and vermilion of the lip. In addition, the color of the remaining skin was altered to match that of the surrounding skin.

Graphic Jump Location

The technical aspects of dermatography differ little from those of decorative tattooing. In both disciplines, various tattooing machines and needles are used to inject pigment in the dermis, but the materials injected in the procedures differ, especially relative to the possibility of ink carcinogenesis. Tattoo colorants contain pigments that include inorganic metallic salts, various types of organic molecules, and organic dyes (traditional ink). Some of these components are classified as possible carcinogenic agents.25 Instead of traditional ink that is used in decorative tattooing, inorganic metallic salts (eg, iron oxide dyes) and organic molecules (eg, tartrazine) are used as coloring agents in dermatography because of their structure that gives a more precise result.17 The association between tattooing and skin cancer is most likely multifactorial, including trauma induced by the procedure, a lifetime inflammatory reaction in an attempt to degrade all foreign material, and the ink content used.25 However, a review by Kluger et al25 concluded that the number of skin cancers arising in tattoos is low and that any association thus far should be considered coincidental. In addition, during 20 years of practicing dermatography, one of us (B.H.D.) has observed no malignant neoplasms in tattooed skin at our institute.

In addition to the colorant used, the final result after dermatography is also influenced by procedural factors, namely, the depth of pigment deposition, pigment density, and number of needles used. Patient factors include thickness and elasticity of the skin or mucosa, natural melanin content, and capillary blood flow.6 Tattooing in scar tissue is less predictable than tattooing in healthy tissue because pigment may appear less vivid and uneven when implanted in scar tissue.18

Dermatography has few contraindications.17 Complications mentioned in the literature are rare. Allergic reactions to tattoo composition have been described and can range from a lichenoid reaction to contact dermatitis.6,26 Granulomatous reactions may also occur. Along with local skin reactions, sarcoid granulomas have been described, sometimes occurring years after tattoo placement.6,17,26 Other complications are infections, ranging from hepatitis, human papillomavirus, herpes simplex virus, and human immunodeficiency virus to secondary bacterial infection. These problems mainly result from improper technique or materials and insufficient hygiene, which is not the case in the dermatography setting in a hospital.6,8,17,18,26 No complications occurred in the present study.

Dermatography has few disadvantages, including the need for specialized skills and equipment and the fading of color over time.17 In addition, it may mask the condition of the skin, making clinical follow-up and dermoscopy difficult.27 It may also impede reflectance confocal microscopy, a cellular level in vivo imaging technique.28 Furthermore, tattoos containing metallic elements may interact with magnetic resonance imaging (MRI). Franiel et al29 reported a case of an MRI-induced first-degree burn in a nonferrous tattoo of the eyelids caused by locally induced electric current. Such burns can be induced by any metal (not just ferromagnetic metals). However, another study30 identified dysesthesia in only 2 of 135 patients with tattoos undergoing MRI.

Facial tattooing is offered not only by skin or beauty therapists but also by physicians. Especially in the facial plastic surgical patient population, we believe that medical tattooing is best performed by a trained physician, capable of assessing the skin and able to prescribe medication, if necessary. Anyone interested in this procedure should at least work under the supervision of an experienced dermatographer for some time because medical tattooing requires a certain amount of knowledge and skill. To our knowledge, there is no international list of physicians offering this service.

This study has some limitations. First, selection bias may have occurred because those who benefited most from dermatography were more likely to participate in the study than those who did not. However, most of the exclusions were individuals who were unreachable, and only 3 of 20 exclusions were due to refusal to participate in the interview. Second, the retrospective nature of this study may have resulted in recall bias, especially for the questions relating to the condition before dermatography. However, patient report of the difference before and after treatment expressed a positive change. Third, we did not use photographs before and after treatment. Such photographs can speak for themselves but may be difficult to compare because of differences in angle and lighting or may represent only temporary results.31 On the other hand, a patient’s own subjective appearance is more meaningful and ultimately is the most important measure of a successful outcome.

Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients. Therefore, the use of dermatography is warranted in the routine workup of patients with problematic scars and skin graft pigments after head and neck surgical procedures.

Corresponding Author: Rick van de Langenberg, MD, PhD, Center for Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Diakonessen Hospital, Bosboomstraat 1, PO Box 80250, 3508 TG Utrecht, the Netherlands (rvdlangenberg@diakhuis.nl).

Accepted for Publication: July 5, 2016.

Published Online: September 22, 2016. doi:10.1001/jamafacial.2016.1084.

Author Contributions: Drs van de Langenberg and Lohuis had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Drost, van de Langenberg, Manusama, Janssens, Lohuis.

Acquisition, analysis, or interpretation of data: Drost, van de Langenberg, Manusama, Sikorska, Zuur, Klop, Lohuis.

Drafting of the manuscript: van de Langenberg, Manusama, Lohuis.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: van de Langenberg, Sikorska.

Administrative, technical, or material support: van de Langenberg, Janssens, Zuur, Lohuis.

Study supervision: Drost, van de Langenberg, Klop, Lohuis.

Conflict of Interest Disclosures: None reported.

Previous Presentations: This study was presented at the 228th Dutch Biannual Otolaryngological Society Meeting (228e Keel-Neus-Oorheelkunde Vergadering); April 22, 2016; Nieuwegein, the Netherlands; and at the 8th World Congress of Facial Plastic Surgery; May 13, 2016; Rio de Janeiro, Brazil.

Boccola  MA, Savage  J, Rozen  WM,  et al.  Surgical correction and reconstruction of the nipple-areola complex: current review of techniques. J Reconstr Microsurg. 2010;26(9):589-600.
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Figures

Place holder to copy figure label and caption
Figure 1.
Postoperative Dermatography of a Scar

The patient had undergone a right-sided Blair incision for a parotidectomy (arrowhead).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
The Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty

The questionnaire was answered twice. First, patients were asked retrospectively about their situation before dermatography. Next, the patients answered the questions regarding their current situation after dermatography.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
The Modified Patient Scar Assessment Questionnaire

The questionnaire was answered twice. First, patients were asked retrospectively about their situation before dermatography. Next, the patients answered the questions regarding their current situation after dermatography.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Basal Cell Carcinoma of the Left Zygoma and Cheek

The defect was reconstructed with a full-thickness skin graft from the supraclavicular neck. The hypopigmented graft was treated with dermatography, resulting in a more natural appearance.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
Hypertrophic Scar in a Patient in Whom Dermatography Was Combined With Intracicatricial Keloidectomy.

Note the reduction in tissue volume and the leveled scar.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.
Situation After Commando Operation With Reconstruction of the Oral Vestibule Using a Free Revascularized Double-Layer Radial Forearm Flap

Dermatography was performed by creating the red and vermilion of the lip. In addition, the color of the remaining skin was altered to match that of the surrounding skin.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Baseline Characteristics Before Surgery in 56 Patients Who Underwent Dermatography
Table Graphic Jump LocationTable 2.  Results of the Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty and the Modified Patient Scar Assessment Questionnaire Before and After Dermatographya

References

Boccola  MA, Savage  J, Rozen  WM,  et al.  Surgical correction and reconstruction of the nipple-areola complex: current review of techniques. J Reconstr Microsurg. 2010;26(9):589-600.
PubMed   |  Link to Article
Spyropoulou  GA, Fatah  F.  Decorative tattooing for scar camouflage: patient innovation. J Plast Reconstr Aesthet Surg. 2009;62(10):e353-e355. doi:10.1016/j.bjps.2008.01.043.
PubMed   |  Link to Article
Pauli  G.  Application of tattoo cures moles [in French]. Siebold J. 1835;15:1.
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