Complication after nipple-areolar complex tattooing performed by a non-medical person: A case report

Abstract

BACKGROUND

Compared to earlier, there has been an increase in the tattoo procedures for cosmetic purposes; and there has also been an increase in the tattoo procedures performed by non-medical personnel. In South Korea, only tattoos performed by a doctor are considered legal; however, there is still some debate over whether tattoo procedures performed by non-healthcare providers should be considered legal.

CASE SUMMARY

A 28-year-old woman visited our hospital with pain in both nipples and heat sensation over the last 4 d. She had a history of a nipple tattoo performed by an unlicensed person. Pinpoint bleeding was noted in both areolar areas, and the exudate mixed with pus and orange color ink was discharged. Oral medication and tulle with foam dressing were performed under the impression of cellulitis and allergic reaction. After 4 wk, nipples remained dark brown in color, resulting in a color mismatch between the nipple and orange-colored areola. The size of the areola was also found to be distinctly asymmetrical after healing. This complication may have been caused by the use of illegal ink or unsanitary procedures, or a problem may have occurred in the post-tattoo management stage.

CONCLUSION

Doctors use approved ink, aseptic procedure and appropriate postoperative care, and appropriate management can be performed in case of complications.

Key Words: Infections; Nipples; Tattooing; Licensure; Case report

Core Tip: Tattoos are restricted in some cultures, or they are regulated by national policies. In the case of South Korea, it is stipulated by law that only a doctor can perform tattoo procedures. Nevertheless, as the accessibility and demand for tattoos increase among the people, illegal tattoo procedures are increasing. The author presents complications that occurred after illegal tattoo procedures. The use of unapproved dyes, unsanitary procedures, and the absence of post-treatment can result in unnatural and ugly tattoos. Tattoos can be performed more beautifully and naturally by a doctor, especially by a plastic surgeon. In particular, tattoos for cosmetic purposes can produce better results than those performed by non-medical personnel. Therefore, doctors' interest and participation in tattoos are necessary, and government regulations are also necessary.

INTRODUCTION

The nipple areolar complex (NAC) is an important landmark in the breast and has a cosmetic significance[1]. Therefore, it is important to preserve the NAC as much as possible during surgeries, such as mastopexy, mastectomy, and breast reconstruction. If the NAC is damaged, it is necessary to restore its shape and color[2]. NAC tattooing is a procedure that can restore the color of the abnormal NAC and make it look more natural. Tattooing is usually performed by using a tattoo machine to insert ink into the dermal layer at a certain depth with a fine needle[3,4]. In South Korea, a tattoo is defined as an invasive procedure in humans; thus, only doctors can legally perform a tattoo. Therefore, tattoos administered by unlicensed non-medical personnel are illegal in South Korea[5]. Nonetheless, illegal tattoo procedures by non-medical personnel are increasing[6]. This is because the overall demand for tattoos has increased compared to the past, and it has become more accessible to the general public[7]. In addition, the purpose of tattoos has expanded in various ways; thus, tattoos are used for permanent makeup, such as eyebrows, eyeliner, and hairline. The perception of tattoos is also changing positively[8].

As mentioned earlier, tattoo procedures performed by non-medical personnel are illegal in Korea and Japan[5]. Also, some countries in Islamic culture do not allow tattoos[9]. Denmark does not allow tattoos on the face, neck, or hands[10]. There are regulations on tattoos in many other countries[11]. In common, most countries restrict unsanitary and illegal ink and tattoo procedures because of the possibility of infection or various side effects[12-15].

The author intends to report the harm and risk of non-medical tattoo procedures by presenting the case a patient who illegally received tattoo procedures from non-medical personnel without a license.

CASE PRESENTATION

Chief complaints

A 28-year-old woman visited the emergency room with pain, swelling, and exudation of both nipples after receiving a tattoo on her areolar area.

History of present illness

Pain and inflammation that occurred after receiving the tattoo three days ago worsened over time; hence, the patient visited our hospital.

History of past illness

The patient had a medical history of breast reduction and NAC reduction 10 years ago. She received a tattoo on both areolas due to dissatisfaction with the NAC color. The patient said she had been given a tattoo by an unlicensed person at an illegal tattoo clinic. The patient showed that both sides of the areolar area were stained with orange color ink.

Personal and family history

The patient denied any family history of similar symptoms.

Physical examination

The type of ink used in the tattoo could not be determined, and the method used for the procedure was not known. Pinpoint bleeding was found in both areolar areas, and the exudate mixed with pus and orange color ink were discharged. The size of both NACs appeared asymmetric. The nipples remained dark brown in color because tattoos were not performed on the nipples, and they did not match the color of the areolar area (Figures 1 and 2).

Figure 1 Initial Photograph of both nipple areolar complex. Scars were seen on both peri-areolar areas and lower pole of the breast after the breast reduction operation. Pinpoint bleeding was found in both areolar areas. The size of the nipple areolar complex (NAC) on the right side appeared larger than that of the NAC on the left side. The nipples remained dark brown in color because tattoos were not performed on that area and they did not match the color of the areolar area. Hypopigmentation was seen in both areolar areas.

Figure 2 An exudate from the areolar area. Red arrow indicated blood clot and bleeding. Yellow arrow indicated orange color ink ejected from the areolar area. Blue arrow indicated an exudate mixed with pus.

Laboratory examinations

The patient refused any laboratory examinations or clinical study.

Imaging examinations

The patient has not undergone an imaging examination.

FINAL DIAGNOSIS

The final diagnoses were cellulitis, allergic dermatitis, and foreign body reactions in the NAC.

TREATMENT

Because the patient did not have medical insurance, she refused any examination or hospitalization, and instead received outpatient treatment. Therefore, bacterial culture tests, blood tests, and biopsy were not performed. In order to control inflammation, cefroxadine antibiotic, a first-generation cephalosporin, was administered orally. Tulle dressing and foam dressing were applied to accelerate epithelialization and control exudation. Two weeks later, inflammation and exudation were controlled. Epithelialization progressed, and edema and pain decreased (Figure 3A). Four weeks later, the wound had completely healed. More than half of the orange ink in the areolar area was lost, and hyperpigmentation and hypopigmentation occurred partially. Asymmetry of both areolar sizes and color mismatch with nipples persisted (Figure 3B).

Figure 3 A photograph taken after treatment. A: A photograph taken after two weeks of treatment. Swelling, discharge, and pain improved, and bleeding stopped. Epithelialization was in progress, but there was still a raw surface on the areolar area. Hyperpigmentation and hypopigmentation were seen. Also, color mismatch and size mismatch of both nipple areolar complex (NACs) were noted, and there was a color mismatch between the nipple and areolar area, which looked unnatural; B: A photograph taken after four weeks of treatment. After treatment, more than half of the ink was lost, leaving only a part. Hyperpigmentation and hypopigmentation had worsened. It was necessary to correct the size and color of both NACs. The areolar tissue had turned into scar tissue and looked even more unnatural.

OUTCOME AND FOLLOW-UP

After the treatment was completed, NAC correction surgery and tattoo were required to correct asymmetry of the NACs, but the patient was lost to follow-up and contact.

DISCUSSION

It can be assumed that the reason for infection after the tattoo procedure was that the safety of ink used had not been assessed, the procedure itself was a septic procedure, or a problem occurred in the post-tattoo management stage. Since biopsy, blood test, or culture test was not performed, the exact cause could not be confirmed. Viruses[16], bacteria[17], and fungi[18,19] can cause infections after the tattoo procedure. As the number of tattoo procedures increase[5-7], various side effects due to infection are also increasing; thus, medical experts need to pay attention.

As non-infectious complications, itching and swelling are the most common, and they occur in 30% of people who have tattoos. Local reactions may include a papulo-nodular pattern, plaque-like pattern, excessive hyperkeratosis pattern, lymphopathic pattern, neurosensory pattern, and various side effects, such as general conditions, may occur[20]. Therefore, continuous and close management from a medical perspective is required even during and after tattoo procedures.

Illegal inks that have not been evaluated for human fitness are likely to contain unknown ingredients and have serious side effects. Mikkelsen et al[21] reported a case of exfoliative dermatitis that occurred after using a home kit tattoo ink purchased in China. The patient had serious side effects showing edema, redness, pus formation, and dry crustation all over the body. It was confirmed that our patient had been tattooed by a Chinese person, and similarly, the procedure was unsanitary with ink that could not be identified. Therefore, it is very important for public health workers to perform the tattoo procedure hygienically using ink approved by the Food and Drug Administration or a national institution.

In a study conducted in Germany based on public search terms for tattoos, the search terms for tattoo bump, raised tattoo, swollen tattoo, itchy tattoo, tattoo fading increased sharply between 2014-2018 compared to 2004-2008, and also the search terms for infected tattoo and tattoo healing increased[22]. Among these search terms were conditions that may require medical management and treatment. Therefore, appropriate counseling and treatment should be provided based on a professional background to patients complaining of side effects of tattoos.

Recently, the scope of application of tattoos has expanded to a permanent makeup procedure, and in this case, tattoos have been used for cosmetic purposes of the NAC. Tattoos are beingly increasingly used to cover up scars or complexes. Like Korea, Japan also restricts tattoo procedures to doctors and nurses with medical licenses. Tomita et al[5] reported the experience of tattoo procedures by medical personnel. In 1352 patients, the rate of overall side effects was 12%, which was lower than the usual rate of side effects; and among them, itching or swelling were the most common. The proportion of infection was very small, with only three cases, and the proportion of satisfaction was high. Therefore, professional background knowledge and procedures for tattooing are essential[23].

Like a permanent makeup tattoo, the NAC can show good results if properly planned and treated by medical personnel. Sowa et al[24] performed medical tattooing on the NAC. Compared to the traditional tattoo, more natural and satisfactory results were obtained through the 3D enhancing technique. Uhlmann et al[25] successfully reconstructed the NAC through a 3D areolar dermopigmentation technique. If our patient had been tattooed by utilizing the above techniques, better results could have been obtained. The process of removing tattoos involves high cost and time, and pain occurs[26]. Therefore, it is essential to plan adequately before getting a tattoo and to get a tattoo hygienically from an expert.

CONCLUSION

Tattoos have a positive meaning for many purposes. There are many possibilities in which tattoos can be used in the medical field. Even for getting cosmetic tattoos for non-medical purposes, a plastic surgeon with professional knowledge should be preferred compared to non-medical personnel. Careful planning, safe ink and legally approved ingredient, hygienic procedures, and systematic management should be performed so that side effects can be reduced and satisfaction can be increased in people.