Medical Tattooing

Cosmetic Tattoo

Guide

Breast/Scarring Paramedical

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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.

1

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

2 Paramedical Tattoo

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 nonsurgical 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


• 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.


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 welldefined 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.


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 determined 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 .


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 postinflammatory 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


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


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.


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


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 their 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.


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


Anesthet ics I ngredients

B·oouic< A<>esthetic Cream:

15 Grams- Use lafo .. e procedu re apply 15-30 m •nutes before p .-oc.clUt·e.

-10,, Ldou i"le . Aloe Sa-bacer~, leaf Jt..ice, Hvd•ogo:nated Polyi ;ob .. ~ene, Pro::.v e!'e G 'fCO Po vacr•;l al""ice, C13-:4 hoparrafn, La..re:h-7. Glyce~, I S:earatt-, llropvlere Glvcol 0 c~ptylate!Otcaprate, Solu:>le Co ll agen, Hy:h:ly2ec Ela;:in . SociJI"" Hva uronate, ~et •r vl Pall"" otate, TotCO "''e ')' Ace:a:e . Malva Sy i\Oti'S:ris (Mal!o.~ ) E·-.:ract,. Hecera He "· (h-y ) E t ac:, Cut.Jmts SattVUS (Cucwmber) Fru tt E, t-acr., S<Jmbucus \i~ra =ic.,·e E-.:t·act. Arn ea Mo-una Ffn~••r E -ru:, llilr; ttt;w;;a Off c nal s E· t"ll~t. Aloe Sarbad~<ns > L;oaf E··.tract, Sc:liu""' PCA, PEG-:OO Scea·ate , Cety A cnhol. Pc yso•oa:e 20, Trte:htro a,.. he, Oiuol d nyl Urea, Wethv'para!IE "'', Propyl o<Jraben BIJe : . Rec l3,

I nstllnt Nu~b:

B oCa ·e:

Veta Gel:

12 Gr01ms- Aoply durirg ptocedt..te. Pe-c latum. U::iccair 40,•

12 Grams· Apply durirg procedt.. . e. Pet•-olat .. l"", Tetraca•ne :H.

1/ 2 O;z ·Reduces s .. e l ng ilnd b leed.ng.

'Nate r, Alce Bar'::laCe'"ls·s Leaf J ~ice. H )·dro:-;yet~y eel u tose. AJian:o,.,, Sodul"" B ; ~lf1:e, Ph!rylephri ne Hyd"'c•.lorice ~0·>,Pheno·-:yethanol. f•letr ylparaben , Bt.tyloara~e '"l, 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 a~t'\LoS .!..n 'II.US :su'\flo·,.er) Seed Oil, Bo;!!s"•a ,, Jo;o:~a esters. Pa raffh. Suty'OS:le 'T'"Ut~ Park o (S~ea 8.Jtte ) . Carnau.:Ja (Ccoe 'lieta Cerifer:a: Wa•, Eupr o-bia Ce fe-a ( Ca~ae'il 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, ~J'III""'ice 3, Bisaoo o , Vacaca..,,a Te"'" i"':liil Sud Ool. Mert'\a Vo-, :ls (Spearmt't) Lea' Oi Bct'Or Nt~r ce . BHT

1/ :l. O;z • Reduces f'.eali ng t ome and locks tn color.

Wate r. Aloe Sarbadens•£ lea' Ju'ce Soco~om B·ca-bo1a:e. Be1=a kcn·u.., Ch ori de, Ca lci~m Crlon<le, SoC: il.m P--ospha te . Xan:r:ar Gum. Pota:ssi ..;l""' C~lorice 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 .... ................. .


Female Full Body Template Front and Rear

Patient Name:

Procedure Report:

Patient Signature:


Male Full Body Template Front and Rear

Patient Name:

Procedure Report:

V

Patient Signature:


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.


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.


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


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


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 injured 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.


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


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.


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


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


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


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 vitalights 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.


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 postinflammatory 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


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

38 Paramedical Talloo

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.


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.


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


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.


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.


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.


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.


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.


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


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.


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 paramedical 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.


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.


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.


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.

Mastectom~ 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.


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


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.


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.


Measuring tor Nipple Flacement

Note the difference where each breast starts above the ribcage.


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.


-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

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Areola Shaping

Note irregular shape in SE quadrant of areola


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.

59

Enlarged

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.


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.


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.


U nilateral 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.


notes


Medical Tattooing

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Transcript of Medical Tattooing