Commentary on "Use of tattooing for camouflaging various scars".

As a practicing cosmetologist and tattooist, I have personally performed many restorative and reconstructive tattooing procedures over the years, and would like to commend Dr. Kim and his colleagues [1] for their openmindedness in embracing this modality. While surgical revision and other treatments such as dermabrasion and laser may be quite efficacious in refining scar contours and reducing hyperpigmentation, I believe that tattooing serves as an excellent adjunctive therapy for restoring color in cicatricial tissues. As Dr. Kim elegantly illustrates in his article, the technique is most useful in flat, hypo-pigmented scars, to emulate the melanin in surrounding normal skin, as well as the hue of adjacent hair follicles. Tattooing is also quite beneficial in replacing the crimson tones of the lip mucosa. For surgeons wishing to incorporate this skill set into their practice, I would like to share some key clinical observations that I have made in the performance of restorative tattooing to enhance the satisfaction of both the patient and the practitioner. I offer these remarks as a supplemental commentary to the article by Dr. Kim et al. In regard to anesthesia, the authors suggest that ‘‘Local anesthetic mixed with (a) vasoconstricting agent is useful because bleeding makes colors indistinct.’’ They go on to say that ‘‘pigments should be mixed before the injection or topical application of anesthetic agent, and after the patient’s complexion is fully stabilized.’’ While I do agree with the latter statement, I generally avoid using a vasoconstricting agent in scar correction since it blanches the skin and, in my experience, can make the treatment area difficult to precisely situate without intricate preprocedural markings. This is of particular significance when working near the lip vermillion as it may virtually obliterate the intrinsic coloring. Also, surgeons performing these procedures may wish to consider the use of nerve blocks rather than the local infiltration of anesthetics. This method potentially avoids variation of dermal moisture content and the subsequent alteration of tissue characteristics in the proposed area of treatment. I have found tattooing on infiltrated tissues to be less than optimal, as needle penetration and depth become less predictable. The article additionally voices the valid concern that ‘‘black pigment looks bluish when imbedded too deep.’’ This is certainly true, but I believe that ‘‘bluing’’ occurs in many of the darker pigments over time, regardless of the depth of implantation. Consider, if you will, the decorative tattoos of elderly individuals, which had been performed perhaps 40 or 50 years ago. It seems that the darker outlines uniformly undergo a blue-tinged transformation as they age within the skin. To counteract this tendency, at least in the short term, I have used small amounts of orange-based tint added to the pigment batch. This seems to have prevented bluing in the vast majority of cases at approximately 1 year, without substantially altering the color of the originally implanted material. Again, I would like to congratulate the authors on their innovative work and hope that restorative tattooing will make its way into the armamentarium of mainstream reconstructive surgery. I am most honored and greatly W. Lampeter (&) Greenwich Hospital—Yale New Haven Health, 2 1/2 Dearfield Drive, Suite #102, Greenwich, CT 06831, USA e-mail: walterlampeter@aol.com