Introduction
Permanent make-up, also known as micropigmentation, is a cosmetic procedure used to create a long-lasting eyeliner, lipliner or eyebrow make-up.
The technique can have both aesthetic and medical purposes. In this second case it is called “medical tattooing” or “dermopigmentation ” and is used when the area to be treated is affected by a health condition.
In 1984, Doctor Giora Angres published a 2-year research on eyelid tattoo or permanent eye-liner including 250 eyelids of women with impairment who could therefore not make themselves up. His study defined, perfected and established the technique to create a long-term eye-liner, thus giving birth to the concept of medical permanent make up (PMU) as it is known today.
PMU eye-liner can help people affected by disease or impairment to recover their mental and physical well-being. It suits subjects affected by alopecia, also caused by medicaments, women with paraplegia or skin that reported traumas, scars and burns.
In ordinary make-up, the eye-liner is used to frame the look, make the colour of the iris stand out and enhance the lash line. The use of the eye-liner can change the tilt of the eye and correct asymmetries of the face for a more balanced result.
The eye-liner tattoo ought to be performed by well trained professionals who should master perfectly materials and equipment, and know in details the eye and eyelids anatomy and any related disease, beside having good knowledge of aesthetics.
Instruments
Pigments need to be sterile and their formulation should avoid any form of bioresorption. Over time, the colour will gradually fade. This ought to be considered a fundamental and distinctive characteristic of the treatment as it enables to eventually change the colour and shape of the eye-liner to adjust it to any change of the face, such as ageing.
The tool used is an electrical rotary device, called dermograph. It is loaded with a cartridge containing one or more sterile and disposable needles made of surgical stainless steel whose diameter and number change according to the technique.
A second option is the manual technique but, considering the difficulty and precision required, the professional needs to have an extensive expertise.
The right speed of the dermograph and depth of the needle are crucial for the final result, as the skin of the eyelids is thinner than that of any other part of the body. In this area, the skin is thinner than 50 micron (0,05 mm) and, for this reason, non-invasive needles ought to be preferred.
The needles to be chosen for the various techniques can be the following: 1 tip 0.25 medium taper, 1 tip 0.30 medium taper, 3 tips liner 0.20, 3 tips liner 0.25 long taper. The release of the colour depends on the speed of the device and the movements of the hand. The higher the speed, the more shaded will result the mark; conversely, the lower the speed, the thicker will result the mark.
There are several modes of execution delivering different results, from a very natural infracillary eye-liner to suit also men to a more graphic eye-liner with a more defined mark on the upper eyelid to enhance and frame the external outline of the eyes. Experienced professionals may also be able to perform shaded eye-liner with colourful and trendy effects, as if it was an eyeshadow.
Procedures
Here follow the steps involved, such as advisory, informed consent, indications and contraindications of procedure, and expectations of the customer.
Advisory This is a crucial preliminary step. It is advisable to fix an appointment before the treatment to exchange information with the customer, exclude any existing disease and make a realistic test in front of the mirror to understand their expectations and show which is the actual result that can be achieved.
Informed consent It is a crucial moment implying an exchange of information between the professional and the customer. The operator explains to the customer the procedures and its side effects or complications. The customer has to declare any medications he or she is taking or any existing disease impeding the treatment. The professional has to carefully inform the customers and find out any problem which may potentially threat their health.
After the final approval, the customers sign the informed consent in all its parts. This will contain: all the personal details of the professional and the customer, a description of the treatment procedures and additional notes.
Furthermore, the eye pressure ought to be checked and, if in doubt, the customer should be addressed to an ophthalmologist.
While informing the customers, the professional should use this time to carefully observe the morphology, expressions and mobility of the muscles of the person’s face. In addition, the professional should observe how they act, smile, squeeze their eyes, and so forth, in order to opt for the best treatment to enhance their specificities. The professional shall make sure that all the elements of the face are in harmony and any action should be taken with the awareness that it will be permanent.
Subsequently, the professional explains the customer the different steps of the treatment, from equipment to colours, and the specific hygiene and technical protocols. In this phase, the customer should be reassured but also informed correctly. In the end, the professional explains the healing steps, including: oxidation and darkening of the colour and eventual exfoliation of the skin.
To conclude, he or she gives specific instructions for the after-treatment care at home, specifying what to avoid: makeup, going to the swimming pool or seaside, sauna, gym, Turkish baths and, in general, any activity causing excessive sweating for the first 10 days.
Physical Examination
Any minor skin alteration must be adequately investigated before the treatment by sending the customer to the relevant specialist (ophthalmologist or dermatologist).
Assessment of the eyelids anatomy, detection of dermatitis, extremely dry skin, reddened or irritated eyes, exclusion of any diseases or drugs that may prevent or interfere with the treatment.
A complete eye examination with Schirmer test evaluating tear function is recommended.
Such procedures should not be performed in presence of the following eye conditions:
CORNEA
– previous corneal ulcers
-recurrent herpetic keratitis
– keratoconus
– Corneal transplants
– problems related to tearing, such as Sjogren’s syndrome
– previous anterior segment surgery: refractive and cataract surgery
OCULAR ANNEXES
– Chalazion
– Severe blepharitis
-Eyelid conditions such as: ptosis, entropion, ectropion
AUTOIMMUNE DISEASES
– Episcleritis
– Keratouveitis
GLAUCOMA
– patient treated for glaucoma with hypotonic eye drops, especially prostaglandins that may lead to chronic inflammation
ENDOCRINOLOGICAL DISEASES
– hyperthyroidism (Basedow’s disease) with severe exophthalmos, which can result in problems to the tear film and corneal exposure
– diabetes, often associated with tear deficits.
Photography
Photographs should be attached to the informed consent, namely: a photo of the whole face to identify the presence of any asymmetry, often not visible to the naked eye, and a detailed picture of the area to be treated. Such photos should be taken before and after the treatment.
Executive project: after the asepsis with isotear disinfectant, eyedrops are used to protect the eyes. A few minutes before the start of the treatment a drop of sterile liquid containing tocopherol acetate (vitamin E and/or ialuronic acid), is applied to create a protective, long-lasting and even film that helps to keep the eye surface hydrated during the session.
Then the shape and characteristics of the eyelids, eyes and face as a whole are carefully observed. With a sterile coloured tip, of the same colour of the final eye-liner, or a sterile disposable dermographic marker, the professional draws the eye-liner.
The executive project should be in line with what was previously agreed and the customer has to approve it again and suggest adjustments, if needed.
Description of the procedure
The professional washes his or her hands for the first time with antiseptic soap. Then he/she prepares the sterile field wearing sterile gloves. He/she pours the ink in a cup ink and, in case of colour mixes, the mix should be blended with a sterile needle. Then, the professional washes his/her hands again this time wearing the personal protection devices: cap, mask, gloves, and sterile gown.
The professional leaves some time to the customers to go to the restroom and drink before making them lay down on the bed. In the room, the customers should find the most comfortable conditions for them, from the temperature to their position on the bed. There should be no reason for discomfort, as the more relaxed they are, the less likely they are to make sudden movements during the session.
The customers need to find a comfortable position on the bed. Their neck and back should be relaxed, without any tension, to help them remain comfortably laid down for as long as it is needed, even up to two hours. The positions were approved by a physiotherapist and a posturologist. The positions taken by the operator and suggested during the training were also assessed and evaluated by specialists.
A sterile sheet is placed under the head of the customers and wrapped around them. If any blanket is needed to keep them warm on the bed, then these should be disposable.
The colour is applied on the eyelids by means of a cartridge needle inserted in a dermograph (number and thickness of the needles depending on the chosen treatment). The operator carries out the work steadily and slowly according to the approved project. The needle needs to be kept vertical on the area to be treated.
The eyelids should remain closed. The operator should keep the eyelids closed with a firm and delicate hold to avoid any movement. The skin should be comfortably tensed.
It is advisable to give the customers a stress ball to help them avoiding sudden movements. The professional should instruct the customers to raise their hand if they need a break, thus avoiding that they speak during the session.
The operator shall place him or herself on the right side of the customer both when treating the right and left eye. If the operator is left-handed, the positions should then be switched.
The operator shall take a comfortable position, with his or her forearm at rest and the wrist relaxed to allow the hand to move smoothly and lightly.
The slower the movements, the more colour is released, thus achieving a more a solid colour effect. On the contrary, faster, lighter and repetitive movements are used to create shades and coloured nuances.
A good exercise to help operators to perfect their technique consists in practising on a balloon with the objective of deflating it gradually (avoiding bursting it). In doing so, the operator gets a feeling of what is like working on the delicate skin of the eyelids and can learn and memorize the movement, finding his or her own rhythm and vibration.
A sterile glove can be filled with ice and placed on a sterile gaze to give a fresh and nice soothing effect to the skin.
During the session the following can be used for cleaning the eyes: sterile water with sterile gauzes, sterile kosher glycerine and sterile emollient wipes specific for the ocular isotear area (with vitamin E and ialuronic acid). The area should be cleaned gently.
To avoid any rubbing, the operator should prefer viscose and oily products containing sterile water or compatible lipid solutions.
Post-treatment care
At the end of the treatment, it is advisable to apply single-dose eye drops with a soothing and calming action During the following 24/48 hours, the eyelids may look slightly swollen and reddened.
The customer should receive complete post-treatment instructions as it follows: for the first 5/8 days clean delicately the area, once or twice a day, with lukewarm/fresh water and a delicate soap; apply twice a day a modest quantity of soothing gel (E vitamin); avoid exposition to the sun/lamps during the first 15 days; don’t touch the eyes with dirty hands; avoid scratching/rubbing; do not apply other substances, medications or makeup during this period.
In the end, the professional takes the post-treatment photos and attach them to the customer’s folder.
Healing takes about 4 weeks.
Possible complications
– Chemical complications triggered by the anaesthetics and aggressive detergents (Emla). The treatment can be performed safely without using anaesthetics, which alter the pH, thus leading to irritations and even lesions, including serious ones.
– Anatomical complications (meibomial glands, medial angle of the eye)
The operator should work exclusively on the wet line to avoid damaging the Meibomian glands. If not, he or she can cause long term complications, such eye dryness.
The operator should not go close to the medial or lateral angle of the eye where the tear ducts are.
– Technical complications triggered by manipulation, excessively invasive needles, excessive pressure, thin needles used wrongly.
– Colour migration: excessively deep tattoo or Ph alterations.
Given the thin skin of the eyelids, if the first two sessions are well executed, no retouching is needed before 7/8 years. If the operator’s movements are not delicate and soft, this leads to the formation of scar tissue and eventually colour migration and, in the most serious cases, even cornea damages.
Cover up strategies
An old eye-liner can be retouched to change both its colour and shape. The most requested treatment is the camouflage of an old eye-liner that has turned bluish or greenish.
In these cases, camouflages made using skin colours or invasive treatments ought to be avoided.
Rita Molinaro
Chairwoman of Clinita
Rita Molinaro PMU Factory
A special thanks to:
Antonia Pirrera, Researcher National Center TISP Istituto Superiore Sanità
Dr. Davide Allegrini, ophthalmologist, Humanitas University, Italy
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