Mucosal tattooing and packed eyeliner cosmetic tattoo treatments are controversial, advocates say they can perform them safely but others are not so sure, this article discusses the current research.
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Eyeliner tattooing has been widely available for several decades and the overwhelming majority of clients who have undergone this service describe satisfaction with the outcomes and no lasting negative effects.
The focus by industry members has been mostly centred on achieving aesthetically pleasing results and some have concentrated on procedural safety with particular emphasis on management of risk factors and avoiding complications.
In spite of the low incidence of adverse outcomes two types of eyeliner services have remained controversial, mucosal tattooing and packed eyeliners (implanting high concentration of pigment) these services are not performed by all cosmetic tattooists, those who do provide these services claim to have numerous clients that have had uneventful recovery and some believe that this is a debate related to the skill of the technician, yet others believe that this is a debate purely related to the eyelid anatomy and the risk profile of the treatment1.
All of the ophthalmologists that we have spoken with have expressed concern about both mucosal tattooing and packed eyeliner treatments stating that the apparent lack of immediate symptomology after these types of treatments is purely anecdotal and should not be construed as evidence of long term safety.
In July 2015 a small scale study involving 40 patients (10 with eyeliner tattooing and a control group of 30 without) was published in Cornea
which is the The journal of Cornea and External Disease. The researchers discovered a marked difference in Tear Film Break-up Time (TBUT) in the tattoo group (4.3 ± 0.9 seconds) compared to the control group (11.0 ± 4.3 seconds; P < 0.001), Meibomian gland loss was higher in the tattoo group (3.4 ± 1.5) compared to the control group (0.9 ± 0.6; P < 0.001) and there appeared to be a direct relationship between the tattoo score/proximity to the Meibomian glands2.
Q: What was the relationship between the eyeliner tattoo and the signs observed by the researchers?
A: The simplest explanation is that the closer the tattoo pigment was to the Meibomian glands and the greater the tattoo score the more likely the patient was to have Meibomian gland loss/dysfunction and consequential effects on their tear film.
Q: What does Tear Break-up Time (TBUT) mean?
A: Each time that we blink the tear film is spread across the eye surface to keep the eye moistened and healthy, the TBUT is a test performed to measure the number of seconds that pass without blinking before the tear film that was spread across the eye surface breaks down and dry spots begin to appear, usually the test is performed with a stain (fluorescein) inserted in the eye and the eye is examined under high magnification (slit lamp) to make the tear film more visible by an ophthalmologist. If the TBUT is too short then it indicates a problem with the quality and or quantity of the tear film, in the study mentioned above2 the results suggested that a reduction in Meibomian gland oil production was adversely affecting the quality of the tear film in some patients.
Q: Would a patient experience symptoms due to their shortened TBUT?
Q: How important are Meibomian glands in relation to the quality of tear film and does this cause a different type of dry eye?
A: Tear film has 3 main layers;
Q: How exactly does impairment of the Meibomian glands cause evaporative dry eye?
A: Tear film is spread across the eye surface by the eyelids when we blink (similar to a windshield wiper spreading a film of rain over a car window) and because the tear film is an extremely thin layer of fluid it is highly susceptible to evaporation.
As depicted in the illustrations above the oil that is produced by the Meibomian glands tends to coat the surface of the tear film which reduces the evaporation rate by decreasing the Water-Air contact surface area and by increasing the viscosity of the tear film.
You can conduct a simple experiment to test how important the oil produced by Meibomian glands is in reducing evaporation by filling two glasses with an equal amount of water and then adding a small amount of cooking oil to one of the glasses, you will notice that the oil floats on the surface. If you mark the level of water in each glass and then leave them for a few days you will discover that the glass without the oil on the surface evaporates much faster than the one with the oil.
A study conducted by Mishima and Maurice in 1961 reached the conclusion that the Tear Film Lipids Layer (TFLL) reduced evaporation rate of the tears by a factor of about 15 times5, some later studies conducted in vitro (in the lab) that tested thin layers of meibum on a beaker of saline found little impact on evaporation rates6 however a more recent study by Bhamla et al. confirmed that TFLL was an effective evaporation barrier particularly on small areas of tear film7 it is now widely accepted that Meibomian glands play a crucial role in reducing evaporation of the tear film and maintaining a normal Tear Film Break-up Time (TBUT)8.
Q: How many Meibomian glands are there in each of the eyelids?
Q: Have other members of the medical community made reference to the 'Eyelid Tattooing Induces Meibomian Gland Loss and Tear Film Instability' in other publications?
The fact that the report has not gone unnoticed by the Ophthalmology and Optometry community and coupled with prior case reports of similar nature14 this should be sufficient for the cosmetic tattoo industry to sit up and take notice. Morrison et al. in their case report "My Tattoos Caused My Dry Eye?10" elude to the possibility that proximity of pigment may also play a role in causation of Meibomian gland dropout.
Q: What importance should cosmetic tattooists place upon the report 'Eyelid Tattooing Induces Meibomian Gland Loss and Tear Film Instability2'?
Q: What type of eyeliner tattooing is most likely to have an effect on Meibomian gland (MG) damage/loss and a reduction in TBUT?
Q: Some manufacturers and trainers advocate the use of high impact force devices, but is there actually scientific support for need for high force devices for cosmetic tattooing?
The force required for the needle to penetrate the skin during cosmetic tattooing has 4 main hurdles;
During cosmetic tattooing the needle impact force dissipates into skin in the form of kinetic energy and heat, if you watched a video of a tattoo needle entering the skin in slow motion you may notice the needle impact force dissipating energy in the form of a cavitation wave.
Needle Impact Force Dissipates Into Surrounding Skin
Extremely small delicate anatomical structures such as Meibomian glands may be susceptible to damage not only from direct injury by a tattoo needle but also due to kinetic energy shock from the use of high force equipment. You can see from the above that with services such as eyeliner tattooing the penetration force required is actually minimal, the main source of resistance relates to skin viscoelasticity15-18 therefore the focus should be on improving technique and preferential use of lower force equipment.
Q: If a few Meibomian glands or their orifices were damaged during an eyeliner procedure due to mucosal tattooing, pigment packing, or high force equipment and the client did not develop any eye symptoms immediately after healing would this mean that any damage caused was not sufficient to ever cause dry eye symptoms?
Illustration of a Shift Below Evaporative Dry Eye Threshold
Q: Which anatomical region of the eyelid has the highest risk of damage to Meibomian glands?
Eyelid Cross Section
Penetrating the lid too deeply (even from outside the lash line) could also damage the tarsal glands from within the inside of the lid or even cross lid. Also pigment packing in or near this region may pose a higher risk, high concentrations of pigment might affect the oil secreting glands due to clogging of ducts and orifices, infiltrating the glands themselves, overcrowding the glands or interfering with blood supply to the gland or via direct contact irritation to the glands and orifices10,25.
Q: Is dry eye a relatively minor problem or can it have an impact on quality of life?
If lipid secretions are impaired even slightly due to dysfunction of Meibomian Glands after eyeliner tattooing as a result penetrating too deeply, excessive trauma, packing pigment or tattooing the mucosa then it may not be until later in life that the clients dry eye symptoms actually manifest as the remaining glands decrease production with advancing age and the gland secretions drop below dry eye threshold.
Special thanks to Dr. Linda Dixon & Dr. Charles Zwerling for Pre-Publication Academic Review.
Date of most recent revision:
03/09/2016 (mutatis mutandis)
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