Permanent Eyeliner - Avoiding Complications

Important: This article is not intended as a 'how to guide' it is a general discussion of the potential complications with eyeliner tattooing and the possible causes.


Anatomy

The skin on the eyelid is the thinnest on the body, in fact the thickness of the epidermis of the upper eyelid is less than 50μm (0.05mm) and the dermis is less than 800μm (0.8mm), notably combined epidermis and dermis eyelid skin is thinnest near the ciliary margin 320±49 μm (as measured in Korean subjects)¹. Average skin thickness of the upper eyelid increases gradually as you move upwards away from the ciliary margin; 7mm above the eyelashes 860±305 μm, and just below the eyebrow 1.127±238 μm.

It is worth noting that some previous research (Barker²) indicates that overall average skin thickness of the upper eyelid is even thinner 330–355 μm in Caucasians than the average thickness found in Koreans 521±115.8 μm (Hwang¹).

Also there is hardly any sub-cutaneous fat within the eyelid particularly near the lid margin, obviously these factors mean it is essential to select the precise needle depth if eyeliner tattooing is being performed.

As you can see it is crucial for technicians to have a clear understanding of anatomy of the eyelid and its key structures, with that in mind the short video below provides a quick recap.

Complications & Their Causes

Considering the popularity of eyeliner tattooing the number of reported complications that we found within the medical literature were lower than we expected, in most of those instances only sparse information was provided about the exact nature of the service that was provided. Previously the potential benefits of cosmetic tattooing including eyelid tattooing for both medical³ and aesthetic⁴ reasons has been reported, however the potential for complications/adverse outcomes should not be ignored.

 Potential complications can be grouped into 6 main areas;
 

• Chemical injury to the eye and or supporting structures
   
• Mechanical injury to the eye and or supporting structures
   
• Pigment migration
   
• Infections
   
• Short term irritation to the eye and or supporting structures
   
• Chronic eye/lid irritation

Chemical injury to the eye and or supporting structures

The most likely cause of a chemical injury caused during eyeliner tattooing would be due to inappropriate use of alkaline topical anaesthetics during the procedure such as Emla cream (pH 9.0-9.2) or other commercial or privately compounded preparations with undisclosed pH. Due to the chemical properties of anaesthetics such as lignocaine and tetracaine many commercial preparations are often too alkaline to be used near the eye⁵.

Poorly manufactured cosmetic tattoo pigments and pigments not intended for use in cosmetic tattooing (such as body art pigments) may also have a pH that is not safe for use near the eye⁶.

Our Position:

• Alkaline/Acidic topical anaesthetics and pigments should not be used near the eye⁵.

Mechanical injury to the eye and or supporting structures

Excessive trauma can be caused to the eyelid due to the use of inappropriate (rotary, coil) or outdated (rotary pen) devices, in comparison high quality modern microprocessor controlled digital cosmetic/medical tattoo equipment provides far more accuracy and control over; penetration speed, power (force) to needle, and better needle quality.

Overworking the skin due to using high penetrations speeds, excessive passes over the same area of skin, using incorrect angle for the specific needle and moving over the skin surface too slowly can all result in excessive trauma and bruising.

Incorrect needle depth or careless technique can result in full thickness eyelid penetration and or injuries to the eye surface⁷.

Tattooing over the lachrymal drainage ducts or puncta could potentially lead to impairment or closure of the lachrymal drainage apparatus resulting in chronic tear overflow problems.

During an eyeliner procedure it is not uncommon for small flecks of pigment to splash into the eye, this is far more likely with; the use of coil machines and rotary pens, tattooing with the eye open, overfilling the needle tip, or due to the use of watery pigments. If pigment is left in contact with the eye surface for too long or if the client/patient rubs the eye when pigment is still present it can result in corneal abrasions⁸.

The above picture is the worse case of bruising following eyeliner that I have ever seen, possible causes are; poor quality equipment, overworking the skin or perhaps anticoagulant therapy or clotting disorder (bleeding tendencies).

Our Position:

• Standard coil machines and older style rotary pen devices should not be used for eyeliner tattooing.
• All clients should be provided single use, sterile, preservative free, tear replacement drops (a brand that is pH stabilised >6 & <8) and written advice following eyeliner tattooing.

Pigment migration

The majority of clients who contact me requesting correction of eyeliner tattooing involve some degree of pigment migration, there are several potential causes of pigment migration;

• Anticoagulants/clotting disorder - if a client/patient is currently on anticoagulant therapy (e.g. heparin/warfarin), using analgesics with anticoagulant side effects (e.g. aspirin, ibuprofen) or if they have any clotting disorders (e.g. haemophilia, Von Willebrand Disease), or if they are taking mega doses of certain supplements such as Omega 3 fatty Acids (Fish Oil/Flaxseed Oil), Vitamin E, Vitamin C, Coenzyme Q-10, Ginseng, Ginkgo Biloba, Garlic, Saw Palmetto and Glucosamine; then there is a higher risk of pigment migration caused by bleeding during or after the procedure.
  
  This emphasises how important a Client Pre-Treatment Screening Questionnaire is prior to performing any form of cosmetic tattooing.
  
   

• Poor quality pigments - Use of body art pigments or poor quality cosmetic pigments can lead to pigment migration.
  
  

The above client requested assistance after she experienced pigment migration following eyeliner tattooing by a technician with a commonly used brand of cosmetic tattoo pigment, I have seen several clients who have experienced pigment migration associated with this particular brand. Possible causes are small colourant particle size (e.g. <6µm)⁹, excessive glycerine content or pH related issues¹⁰.

• Diluting pigments - Diluting pigments with saline or pigment dilutant increases the risk of pigment spread once it has been implanted.
   

• Alkaline topical anaesthetics - We have previously demonstrated that alkalising the skin with topical anaesthetics such as Emla cream (pH 9.0-9.2) has the capacity to change the structure and behaviour of tattoo pigment particularly carbon based pigments¹⁰. For the same reasons I would urge caution with topical anaesthetics that do not disclose their pH e.g. some commercial and privately compounded anaesthetics unless the pH is clarified by the manufacturer.
   

• Tattooing near the canthus - incorrect training can result in technicians tattooing too close to the medial or later canthus, epidermal and dermal skin is very thin in this region and pigment migration is a high probability.
  
  

The above client requested assistance after she experienced pigment migration following eyeliner tattooing by a technician far too close to the lateral canthus.

The above client requested assistance after she experienced pigment migration following eyeliner tattooing by a technician directly over the lateral canthus.

• Over traumatising the skin - if excessive trauma and bleeding is caused during eyeliner tattooing then pigment migration is a high risk.
  
  

The above picture is secondary to extreme bruising and bleeding following eyeliner, possible causes are; poor quality equipment, overworking the skin or perhaps anticoagulant therapy/clotting disorder.

In most circumstances pigment migration cannot be rectified effectively with cosmetic tattooing, tattooing over with skin coloured pigments is likely to compound the problem and make tattoo removal more difficult.


Our Position:

• Topical anaesthetics such as Emla, and those with undisclosed pH (some commercial, privately compounded) should not be used prior to cosmetic tattooing.
• High risk anatomical structures should be avoided when performing eyeliner tattooing.

Infections

Previously we have discussed the Potential Causes of Nosocomial Type Infections in the Salon-Clinic Setting ¹¹.

Infections following eyeliner tattooing do not appear to be particularly common; possible causes of infections are un-sterile or contaminated pigments, failure to use standard non touch aseptic technique (e.g. not using sterile gloves), clients/patients who are immunocompromised.

Provided that none of the previous circumstances apply then the most likely cause of infection post eyeliner tattooing is poor hand hygiene or failure to follow the aftercare on the part of the client/patient, hence the reason why emphasising aftercare advice is crucial.

Our Position:

• A Client Pre-Treatment Screening Questionnaire should be completed by all clients prior to cosmetic tattooing.
• All clients should be provided aftercare advice and supplies sufficient to care for their eyeliner tattoo.

Short term irritation to the eye and or supporting structures

Minor or transient irritation to the eye and eyelid is not uncommon for a few hours following eyeliner tattooing, ongoing or excessive irritation could indicate that that a corneal abrasion has occurred or there is a reaction to the tattoo pigment or other products and supplies used during the procedure.

There are a few reports of transient tingling, burning, irritation of eyeliner tattooing during MRI¹² however it is possible that some cases related to pigments containing diametric magnetic properties¹³.

Our Position:

• Ongoing or excessive eye irritation following eyeliner tattooing should be referred to a medical practitioner.

Chronic eye irritation

Tattooing over the conjunctiva of the eyelid (wet-line) to create a kohl pencil look could cause damage to meibomian glands, interfere with normal eye surface lubrication, and result in chronic eye irritation. Also pigment implanted into the eyelid mucosa is likely to result in continuous pigment shedding directly onto the eye surface, it has previously been reported that frequent use of standard eye makeup can become permanently imbedded in conjunctiva resulting in chronic eye irritation¹⁴.

There are a small number of cases within the literature of chronic eyelid inflammation/granulomas following eyeliner tattooing¹⁵ it is quite plausible that these cases involved pigments that contained ingredients that are known to have higher incidences of allergic skin reactions such as heavy metals and some of the organic colourants that are often used in body art pigments and poor quality cosmetic tattoo pigments that may yield aromatic amines¹⁰.

We have seen comments by some cosmetic tattoo trainers that lash enhancements would lead to permanent loss of eyelid hair due to infiltration of pigment into the hair follicle and its root sheath.

However, histopathological reports that we found within the medical literature do not appear to support that belief; excised tissue from the eyelid examined microscopically via electron microscope eight weeks after eyelid tattooing found "no pigment detected within the lymphatics, epidermis, or hair follicles"¹⁶ . Also with "three patients with implantation of iron oxide pigment into the margin of the lateral eyelid followed by excision of that region 1 hour later in one patient, 5 days later in the second and 18 months later in the third" the finding was that "there were no substantial deleterious effects on the treated tissues"¹⁷. In both reports the implanted pigment particles were found to be predominantly residing within the cytoplasm of macrophages.

Our Position:

• Tattooing of eyelid mucosa should not be performed.
• Body art pigments and pigments that have not undergone allergy testing should not be used for eyeliner tattooing.

Corrections

As reluctant as the client is to hear it, sometimes the best correction choice is to wait and do nothing and permit the tattooing to fade over time, this is often the best choice with minor areas of pigment migration, however if body art pigment has been used the tattoo may take many years to fade.

For some unknown reason some cosmetic tattoo trainers persist with teaching technicians to use skin coloured pigments to correct eyebrow and eyeliner tattooing. In most instances tattooing skin coloured pigments over previous tattooing will compound the problem by creating blue/green/grey colour results, can spread the unwanted colour within the skin, tends to emphasise the unwanted appearance even more, and can make tattoo removal even more challenging.

The above client had poor quality eyebrow and eyeliner tattooing performed by one technician resulting in pigment migration and irregular lines and then the problem was compounded by the tattooing of skin coloured pigment by another technician.

Correction of eyeliner tattooing is best managed via the following 3 options;

1. Minor Irregularity / Patchiness / Colour Issues - Corrective cosmetic tattooing.
    

2. Small Area of Pigment Migration - wait 1-2 years and permit natural fading to reduce the visibility and then review.
    

3. Large Area of Pigment Migration / Gross Irregularity - Refer to a very experienced dermatologist/cosmetic physician for evaluation of removal options.

Most clients who have sought our assistance with pigment migration problems from treatments by other technicians have been referred to our preferred dual qualification Dermatologist/Cosmetic Physician who has extensive experience with laser tattoo removal.

NB. Due to the risk of damage to the eye laser tattoo removal of eyeliner should not be entered into lightly, laser removal can also have unusual and unexpected consequences such as permanent leukotrichia¹⁸ (loss of natural eyelash hair pigmentation).

Our Position:

• Skin coloured pigments should not be used in an attempt to correct eyeliner tattooing.
• Laser tattoo removal near the eye should only be attempted by a suitably qualified medical practitioner.

Higher Risk Anatomical Structures

Most of the clients who have contacted us seeking assistance with adverse outcomes from eyeliner tattooing provided by other technicians have either been provided tattooing using poor quality equipment and pigments or have had tattooing near or over higher risk anatomical structures.

Key Structures to Avoid

• Medial & Lateral Canthus - Very thin skin and high risk of pigment migration.
   

• Upper and lower eyelid Conjunctival Mucosa near lid margins (wet-line) - important meibomian glands (oil secretion) if damaged there is the risk of causing hypo-lipid keratoconjunctivitis sicca, and pigment shedding could lead to chronic eye irritation¹⁴.
   

• Lachrymal Puncta/Duct - risk of damage to lachrymal drainage apparatus potentially leading to chronic tear overflow.

Positive Outcomes

In my experience outcomes from eyeliner tattooing are overwhelmingly positive provided that both the technician and the client/patient are following sensible precautions and care is taken with both the procedure and the aftercare.

Above is an example of what to expect immediately after the first treatment for top lash enhancement and bottom eyeliner, a small amount of eyelid swelling is evident which should subside within a short period of time. It is very important that the technician does not attempt to implant too much pigment or overwork the skin during any given procedure, density can be increased and any patchiness experienced after healing is easily improved with successive treatments.

No doubt that some technicians will read this article and state that they have achieved positive outcomes for clients after conducting higher risk procedures. My contention is that our obligation as professional and ethical service providers is to minimise the risk to our client/patient and to engage in Evidence Based Practice.

Acknowledgment

Special thanks to D. Darby RN, Dr. Linda Dixon and my extensive expert advisory network many of whom have contributed to my detailed understanding of crucial aspects related to eyeliner tattooing.
 

References

1. Kun Hwang. Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery. Anatomy & Cell Biology 2013 Department of Plastic Surgery and Center for Advanced Medical Education by BK21 Project, Inha University School of Medicine, Incheon, Korea
2. Barker DE. Skin thickness in the human. Plast Reconstr Surg (1946) 1951;7:115-6.
3. Abbes M1, Boursault C, Conso D, Roméo E. Forum: dermopigmentation or medical tattooing. Dermography in cancerology. Apropos of 220 clinical cases. Ann Chir Plast Esthet. 1992 Aug;37(4):394-401.
4. Tiziano JP. Forum: dermopigmentation or medical tattooing. Dermopigmentation with an esthetic aim. Apropos of 420 cases. Ann Chir Plast Esthet. 1992 Aug;37(4):370-86.
5. Eaglstein, NF. Chemical injury to the eye from EMLA cream during erbium laser resurfacing. Dermatol Surg. 1999 Jul;25(7):590-1.
6. D. Darby RN. Topical Anaesthetics & Cosmetic Procedures. 10/01/2011 (inc revisions).
7. De M, Marshak H, Uzcategui N, Chang E. Full-thickness eyelid penetration during cosmetic blepharopigmentation causing eye injury. J Cosmet Dermatol. 2008 Mar;7(1):35-8.
8. Rudkin AK. Wake up with make-up: complication of cosmetic lid tattoo. Med J Aust. 2011 Jun 20;194(12):654.
9. Dr. Charles Zwerling, Dr. Linda Dixon, Dr. Frank Christensen and Dr. Norman Goldstein. Micropigmentation Millennium;4:44, 2010: ISBN:978-0-615-48414-3
10. D. Darby RN & A. Darby MMT. Why Do Cosmetic Tattoos Change Colour? - Part 1 & 2. CTshop.com.au Educational Articles. 14/09/2013 (inc revisions).
11. D. Darby RN, & Andrea Darby MMT. Potential Causes of Nosocomial Type Infections in the Salon-Clinic Setting. CTshop.com.au Educational Articles 24/04/2013 (inc revisions)
12. Offret H, Offret M, Labetoulle M, Offret O. Permanent cosmetics and magnetic resonance imaging. J Fr Ophtalmol. 2009 Feb;32(2):131.e1-3.
13. A. Darby MMT, D.Darby RN. Cosmetic Tattooing & MRI’s - Diametric Particle Agitation Hypothesis (DPA). CTshop.com.au Educational Articles 19/01/2013 (inc revisions)
14. Stewart, Charles R. CONJUNCTIVAL ABSORPTION OF PIGMENT FROM EYE MAKEUP. American Journal of Optometry & Archives of American Academy of Optometry. 50(7):571-574, July 1973.
15. Vagefi MR, Dragan L, Hughes SM, Klippenstein KA, Seiff SR, Woog JJ. Adverse reactions to permanent eyeliner tattoo. Ophthal Plast Reconstr Surg. 2006 Jan-Feb;22(1):48-51.
16. Farber MG, Lamberg RL, Smith ME. A histologic study of eyelid pigment eight weeks after implantation (eyelid tattoo). Arch Ophthalmol. 1986 Oct;104(10):1434-5.
17. Hurwitz JJ1, Brownstein S, Mishkin SK. Histopathological findings in blepharopigmentation (eyelid tattoo). Can J Ophthalmol. 1988 Oct;23(6):267-9.
18. Liu XJ, Huo MH. Permanent leukotrichia after Q-switched 1064 nm laser tattoo removal. Indian J Dermatol Venereol Leprol. 2011 Jan-Feb;77(1):81-2.

Date of most recent revision: 11/03/2014 (mutatis mutandis)
Original publication date: 11/03/2014

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Disclaimer: The content of this article should be regarded as general information & is provided solely for the purpose of discussion & is not intended to replace cosmetic tattoo training or medical advice in any instance, always check with a cosmetic tattoo master trainer and or a qualified medical practitioner before acting on any information regarding cosmetic tattooing or in relation to any medical condition or medical circumstance.

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