Magnetic Resonance Imaging and Permanent Cosmetics (Tattoos): Survey of Complications and Adverse Events
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JOURNAL OF MAGNETIC RESONANCE IMAGING 15:180 –184 (2002) DOI 10.1002/jmri.10049 Original Research Magnetic Resonance Imaging and Permanent Cosmetics (Tattoos): Survey of Complications and Adverse Events Whitney D. Tope, MD, MPhil,1 and Frank G. Shellock, PhD2* marks, and cheek blush (1). Additionally, permanent Purpose: To use a survey to determine the incidence of cosmetics are often used aesthetically to enhance nip- complications and adverse events in individuals with per- manent cosmetics (e.g., tattooed eyeliner, eyebrows, lips, ple-areola reconstruction (2). cheeks, etc.) who underwent magnetic resonance (MR) im- Magnetic resonance (MR) imaging is a frequently aging. used imaging modality, particularly for evaluating the brain, head, neck, and other anatomic regions where Materials and Methods: A questionnaire was distributed cosmetic tattoos are typically applied. Unfortunately, to clients of cosmetic tattoo technicians. This survey asked study subjects for demographic data, information about there is much confusion regarding MR safety aspects of their tattoos, and for their experiences during MR imaging permanent cosmetics (3– 6). For example, based on a procedures. few reports of symptoms localized to the tattooed area during MR imaging, many radiologists have refused to Results: Data obtained from 1032 surveys were tabulated. perform MR procedures on individuals with permanent One hundred thirty-five (13.1%) study subjects underwent MR imaging after having permanent cosmetics applied. Of cosmetics, particularly tattooed eyeliner (unpublished these, only two individuals (1.5%) experienced problems observations, F. G. Shellock, 2000). Obviously, this un- associated with MR imaging. One subject reported a sen- due concern for possible adverse events prevents pa- sation of “slight tingling” and the other subject reported a tients with cosmetic tattoos from access to an extremely sensation of “burning”; both sensations were transient in important diagnostic imaging technique. nature. While it is well-known that cosmetic tattoos may Conclusion: Based on these findings and information in cause MR imaging artifacts (3–11) and that both cos- the peer-reviewed literature, it appears that MR imaging metic and decorative tattoos may cause relatively mi- may be performed in patients with permanent cosmetics nor, short-term cutaneous reactions (3,8,11–16), the without any serious soft tissue reactions or adverse events. frequency and severity of soft tissue reactions or other Therefore, the presence of permanent cosmetics should not related problems associated with MR imaging and cos- prevent a patient from undergoing MR imaging. metic tattoos is unknown. Therefore, the purpose of Key words: magnetic resonance imaging, safety; magnetic this investigation was to determine the frequency and resonance imaging, bioeffects; heating; artifacts; magnetic severity of adverse events associated with MR imaging resonance imaging in a population of subjects with permanent cosmetics. J. Magn. Reson. Imaging 2002;15:180 –184. © 2002 Wiley-Liss, Inc. MATERIALS AND METHODS TRADITIONAL (I.E., DECORATIVE) and cosmetic tat- A questionnaire was developed to survey individuals tooing have been performed for thousands of years. In with permanent cosmetics to determine the incidence the United States, cosmetic tattooing or “permanent and severity of complications or adverse events associ- cosmetics” are used to reshape, recolor, recreate, or ated with MR imaging. The questionnaire asked study modify eye shadow, eyeliner, eyebrows, lips, beauty subjects for basic demographic data, information about their cosmetic tattoos, information about their MR im- aging examinations, and their experiences with these 1 procedures relative to the permanent cosmetics. Table Department of Dermatology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota. 1 shows the questionnaire used in this investigation. 2 University of Southern California, Keck School of Medicine, Los Ange- The questionnaire was distributed in the United les, California. States to clients of permanent cosmetic technicians Contract grant sponsor: Society of Permanent Cosmetic Professionals. who were members of the Society of Permanent Cos- *Address reprint requests to: F.G.S., 7511 McConnell Ave., Los Angeles, CA 90045. metic Professionals (SPCP, an international, non-profit E-mail: frank.shellock@gte.net organization of cosmetic tattoo artists). This permitted Received July 18, 2001; Accepted October 11, 2001. individuals with cosmetic tattoos to be contacted con- © 2002 Wiley-Liss, Inc. 180
MRI and Permanent Cosmetics 181 Table 1 individuals ranged from 14 to 93 years old. Caucasians Cosmetic Tattoo and Magnetic Resonance Imaging (MRI) formed the largest racial population (961; 93%) for the Research Survey respondents (14 [1%] Asian; 16 [2%] Latino; six [1%] Part I: Client Information African-American; two [0.2%] Native American; 30 [3%] Age Race Sex State of Residence data not provided). Please check the appropriate response: Eight hundred ninety-seven (897/1032; 87%) study (1) I have cosmetic tattooing, but have never had an MRI. subjects with permanent cosmetics reported that they (2) My doctor recommended that I have an MRI, but the radiologist wouldn’t allow me to have an MRI because never had MR imaging examinations (Non-MRI Group), of potential complications with cosmetic tattooing. while 135 (135/1032; 13%) study subjects underwent (3) I have cosmetic tattooing and have had an MRI. MR imaging after application of permanent cosmetics (MRI Group). The mean age of the Non-MRI Group (50 ⫾ If you checked #1, you have finished the survey. 5 years old) was significantly younger (P ⬍ 0.05) than that of the MRI Group (56 ⫾ 5 years old). For the Non- Part II: If you checked #2, or #3, please answer the following MRI Group, five study subjects (6%) reported that the questions: Site for cosmetic tattoo (check all that apply): MR facility personnel or radiologists would not allow eyelid eyebrow cheeks lips them to have MR imaging procedures due to potential areola other (specify) complications with cosmetic tattoos. Pigment colors used: Unknown: For the MRI Group (N ⫽ 135), tattoo site information was available in 131 subjects (97%). These subjects Approximate date of your cosmetic tattoo procedure? / / reported a total of 210 individual tattoos (i.e., 61 sub- jects, 45%, had more than one cosmetic tattoo). Of Part III: If you checked #3, please answer the following questions: these, 210 permanent cosmetics were applied to the Area of body scanned by MRI: head eye/orbit chest abdomen other following body sites: 85 (41%) eyelid, 75 (36%) eyebrow, (specify) 34 (16%) lip, six (3%) cheek, four (2%) areola, and six Did you have any complications in the area of the cosmetic (3%) trunk. tattoo from the MRI? Yes No Information on tattoo pigment color was available for 112 of the 135 (83%) study subjects in the MRI Group. If yes, please describe the complications you experienced (any Notably, 91 of these study subjects (67%) reported that specific symptoms you experienced and how long they lasted)? they had permanent cosmetics that were applied using Note: to gather as much information as possible, it will be pigment colors (e.g., brown, black, red, and flesh) that important to contact your radiologist about your MRI scan and typically contain iron oxide. permanent cosmetic technician about your cosmetic tattoo. To For the MRI Group (N ⫽ 135), information on the do this, we will need the following information. If you do not wish cosmetic tattoos and body sites for the MR imaging to release this information, simply leave the spaces blank. examinations was available for 133 (98%) of the sub- Thank you for your cooperation. jects and is shown in Table 2. Forty of these subjects had MR imaging examinations involving more than one Name Date of Birth / / Radiologist’s Name Radiologist’s Phone Number anatomic region (i.e., for a total of 173 MR imaging Approximate date of MRI scan / / examinations). Fifty-six (42%) of the subjects in the MRI Permanent Cosmetic Technician’s Name Group had MR imaging examinations that involved the Phone number immediate anatomic site where the permanent cos- metic was applied (Table 2). All of this information will be held in the strictest confidence and One hundred thirty-three (133/135, 98.5%) of the only be used for research purposes. Your signature allows us to MRI Group reported that there were no complications, request access to your MRI report and films, only. adverse events, or other problems associated with MR imaging. Two (2/135, 1.5%) study subjects in the MRI Group reported complications or adverse events asso- fidentially through client lists of members of the SPCP. ciated with MR imaging. One subject experienced The study subjects were assured that the questionnaire “slight tingling” before MR imaging began and the other would be analyzed with anonymity maintained. The subject reported a “burning” sensation that started be- questionnaires were returned to the primary author (W.D.T.) for tabulation, and the results were analyzed fore entering the magnet (i.e., while in the MR system using simple descriptive data techniques. room, in the MR environment) that resolved by the end of the examination. Both of these subjects were women who had blue-black pigment colors used for periorbital RESULTS (i.e., eyelid/eyeliner) tattoos and underwent MR imag- Of a total of 3065 questionnaires that were distributed, ing of the cervical spine. Each tattoo had been applied 1037 (34%) were returned for analysis. Five surveys at least nine months prior to the MR imaging examina- contained insufficient data for inclusion (i.e., the an- tion. In neither case did the severity of symptoms war- swers were incomplete), leaving a total of 1032 ques- rant cessation of the MR imaging. Neither subject re- tionnaires available for tabulation. ported any other problem with the tattooed areas (e.g., The majority (1027; 99.5%) of the study subjects with erythema, edema, irritation, etc.) subsequent to MR permanent cosmetics were women. The ages of these imaging.
182 Tope and Shellock Table 2 According to the findings of our study, there was an Anatomic Sites for MR Imaging Examinations for Subjects With extremely low incidence (1.5%) of complications or ad- Permanent Cosmetics verse events, and the severity of these problems was Anatomic sitea No. of MR imaging examinations relatively minor (i.e., there was no serious, permanent, or life-threatening injury). Of interest is that, for these Head 56 Neck 16 study subjects, one individual reported a “burning sen- Eye/orbit 1 sation” that was unrelated to the actual scanning pro- Chest 15 cedure (i.e., upon entering the MR environment), while Abdomen 12 the other subject’s symptom, a “tingling sensation”, has Lower extremity 26 not been previously reported. Importantly, neither Spineb 11 problem prevented completion of the MR imaging pro- Back 23 cedure. Pelvis 4 Investigations of incidents related to patients experi- Shoulder 5 encing cutaneous or other reactions in relation to the Total bodyc 2 presence of both cosmetic and decorative tattoos re- Site not indicated 2 vealed that there was a tendency for these problems to Anatomic No. of MR imaging Complication/adverse occur whenever pigments that contained iron oxide or sited examinations event other similar metallic substance(s) were used (3–16). Neck 1 Slight tingling The study subject that reported a “burning sensation” Neck 1 Burning had her cosmetic tattoo applied by an ophthalmologist a Subjects with permanent cosmetics that did not have adverse re- using black pigment that typically contains iron oxide. actions (number of subjects, 133; total number of MR imaging ana- Unfortunately, the exact type of pigment that was used tomic sites, 173). could not be verified and there tends to be little quality b Spine refers to cervical, thoracic and lumbar spine spine MR imag- control over tattoo ink (15). Apparently, certain ferrous ing examinations. pigments used for the tattooing process can interact c Total body was the term used by the subjects to describe their with the electromagnetic fields used for MR procedures, examinations. d producing the reported problems (7–11,13,16). Subjects with permanent cosmetics that had a complication or adverse event (number or subjects, 2). Proposed mechanisms to explain tattoo-related prob- lems encountered in the MR environment include mag- netic field related interactions and/or radiofrequency DISCUSSION (RF)-induced induction of heating. The fact that an in- The incidence of complications or adverse reactions and dividual in this study reported symptoms even before severity of these problems for patients with permanent entering the MR system suggests that one possible cosmetics undergoing MR imaging examinations are causative factor is the static magnetic field. Presum- unknown. Unfortunately, many MR healthcare profes- ably, traction or torque from interaction of the ferro- sionals do not fully understand the relative risk of per- magnetic tattoo particles with the static magnetic field forming MR imaging in patients with permanent cos- may be partially responsible for the symptoms re- metics and, as such, may not allow these patients to ported. undergo examinations. (For example, findings from this In a letter to the editor that described a second-degree survey revealed that 6% of the study subjects with per- burn that occurred on the skin of the deltoid from a manent cosmetics were not allowed to undergo MR im- decorative tattoo, the authors suggested that “the heat- aging because of MR safety concerns.) Therefore, the ing could have come either from oscillations of the gra- purpose of this investigation was to determine the fre- dients or, more likely from the RF-induced electrical quency and severity of problems associated with MR currents” (15). However, the exact mechanism(s) re- imaging in a selected population of subjects with per- sponsible for complications or adverse events in the manent cosmetics with the intent of providing guidance various cases that have occurred is unknown. and recommendations based on the results of this Interestingly, decorative tattoos tend to cause worse study and those published in the peer-reviewed litera- problems (including first- and second-degree burns) for ture. patients undergoing MR imaging compared to those To date, only a small number of patients (estimated to who have been reported for cosmetic tattoos be less than 10) that have undergone MR imaging have (6 –13,15,16). For example, a recent publication re- reported transient symptoms that included skin irrita- ported that a patient experienced a sudden burning tion, cutaneous swelling, or a heating sensation at the pain at the site of a decorative tattoo while undergoing site of application of the permanent cosmetics (review of MR imaging of the lumbar spine using a 1.5-Tesla MR Medical Device Reports, 1985 to 1999). Because of system (13). Swelling and erythema resolved within 12 these incidents, the latest MR safety recommendations hours, without evidence of permanent sequelae. The and guidance from the Food and Drug Administration tattoo pigment used in this case was ferromagnetic, (Guidance for Industry Guidance for the Submission of which possibly explains the symptoms experienced by Premarket Notifications for Magnetic Resonance Diag- the patient. Surprisingly, in order to permit completion nostic Devices) states that the performance of an MR of the MR examination, an excision of the tattooed skin imaging examination requires particular caution for with primary closure of the site was performed (13). “patients with permanent (tattoo) eye-liner or with fa- The authors of this report stated, “Theoretically, the cial make-up” (17). application of a pressure dressing of the tattoo may
MRI and Permanent Cosmetics 183 prevent any tissue distortion due to ferromagnetic pull” imaging procedures using standard, MR imaging tech- (13). However, this simple, relatively benign procedure niques and procedures. Additionally, it would be ad- was not attempted for this patient. They also indicated vantageous to evaluate additional subjects with both that, “In some cases, removal of the tattoo may be the cosmetic and decorative tattoos that undergo MR imag- most practical means of allowing MRI” (13). ing. Thus, additional research that acquires specific MR Kanal and Shellock (14) commented on this report in imaging information in a larger group of tattooed sub- a letter to the editor, suggesting that the response to jects is warranted. This may help determine a mecha- this situation was “rather aggressive”. Clearly the nism responsible for the cutaneous reactions that trauma, expense, and morbidity associated with exci- sometime occur in the MR setting. sion of a tattoo far exceed those that may be associated In consideration of the findings of this study and the with ferromagnetic tattoo interactions. A firmly applied available literature pertaining to MR imaging and pa- pressure bandage may be used if there is any concern tients with cosmetic tattoos, the following patient man- related to “movement” of the ferromagnetic particles in agement guidelines are recommended: the tattoo pigment (14). Additionally, direct application of a cold compress to the site of a tattoo would also 1. The Pre-MR Procedure Screening Form should in- likely mitigate any heating sensation that may occur in clude a question pertaining to the presence of per- association with MR imaging. manent cosmetics or decorative tattoos (3–5). A comprehensive search of the peer-reviewed litera- 2. Before undergoing an MR imaging examination, ture supports the results of this present investigation the patient should be asked if he or she has a (8 –10). That is, symptoms rarely occur, the symptoms permanent coloring technique (i.e., tattooing) ap- are transient in nature, and the severity of the symp- plied to any part of the body. This includes cos- toms is relatively minor. Furthermore, when one con- metic applications such as eyeliner, lip-liner, lip siders the many millions of clinical MR procedures that coloring, and decorative designs. have been conducted in patients over the past 15 years 3. The patient should be informed of the relatively and that only a very small percentage of these individ- minor risk associated with the site of the tattoo. uals have had minor, short-term problems related to 4. The patient should be advised to immediately in- the presence of permanent cosmetics, it is apparent form the MR technologist regarding any unusual that this MR safety concern has an extremely low rate of sensation felt at the site of the tattoo in association occurrence and relatively insignificant consequences. with the MR imaging procedure. With regard to artifacts, none of the study subjects in 5. The patient should be closely monitored using vi- this investigation were informed that the MR images sual and auditory means throughout the entire were substandard due to the presence of tattoos and operation of the MR system to ensure safety. none of the examinations had to be repeated. Neverthe- 6. As a precautionary measure, a cold compress (e.g., less, imaging artifacts associated with permanent cos- wet wash cloth) may be applied to the tattoo site metics have been reported (7–10). These artifacts are during the MR imaging procedure. predominantly associated with the presence of pig- In conclusion, because of the relatively remote possi- ments that use iron oxide and occur in the immediate bility of having an incident occur in a patient with a area of the tattoo. As such, tattoo-related MR imaging permanent cosmetic and due to the relatively minor, artifacts should not prevent a diagnostically adequate short-term complication or adverse event that may MR imaging procedure from being performed, especially develop (i.e., transient cutaneous redness and swell- in consideration that careful selection of imaging pa- ing), the patient should be permitted to undergo MR rameters may easily minimize artifacts related to me- imaging. Any problem of performing an MR imaging tallic objects (3,4). procedure in a patient that has a cosmetic tattoo is The only possible exception to this is if the anatomy of unlikely to prevent the examination, since the impor- interest is in the exact same position of where the tattoo tant diagnostic information that is provided by this was applied using an iron oxide-based pigment. For imaging modality is typically critical to the care and example, Weiss et al (7) reported that heavy metal par- management of the patient. ticles used in the pigment base of mascara and eyelin- ing tattoos cause alterations of the local magnetic field REFERENCES in adjacent tissues. These changes in normal signal may result in distortion of the globes. In some cases, the 1. Halder RM, Pham HN, Hreadon JY, Johnson HA. Micropigmenta- tion for the treatment of vitiligo. J Dermatol Surg Oncol 1989;15: distortion may mimic actual ocular disease, such as a 1092–1098. ciliary body melanoma or cyst. 2. Becker H. 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