Microblading is a rapidly expanding technique in cosmetic and medical tattooing, used for eyebrow correction and conditions of hair loss. Tattooing is performed by hand using a special blade; tiny cuts in the outer skin are filled with dark pigment to simulate a natural hair. Indications, the technique, and the microblading procedure step-by-step are considered in what follows. Details on client selection and a range of pitfalls are discussed. The leading application of microblading is cosmetic tattooing of the eyebrows adding pigmented "hairstrokes" to the natural brow area. Tattooed "hairstrokes" fade in color over months and a repeated "touch up" procedure may be required. Pretreatment with laser removal of tattoos of the past may be indicated when a client requests a "touch up" with another brow in another style, shape, or extension. Microblading carries the risk of scarring. The combination with conventional machine-driven needle tattooing for background shading the skin of the brow is also discussed. Microblading is also used as a corrective intervention in a range of dermatological and medical conditions. Having grown exponentially for cosmetic purpose in the first phase of microblading parallel to acquired refinement, the method is now mature and ready to make further progress on medical indication in the coming second phase. The medical community should welcome this opportunity for supplementary correction with restoration of the normal brow anatomy added to other achievements in dermatological and medical therapy.

Tattooists and their customers are under special risk of airborne infection because of the short distance during the procedure and the unavoidable exchange of expired and inhaled air potentially containing droplets holding pathogenic germs. Moreover, the manual procedure involves a significant risk of contamination through physical contact. A range of personal protective equipment (PPE) is available, including three-layered disposable surgical masks, cotton masks, respirators without or with expiration valve, visors and shields, goggles, medical gloves and aprons. Disinfectant fluids and wipes are used for skin and physical objects. Alcohol is used but may evaporate too fast and lose biocidal efficiency; it carries risk of fire. Alternatives such as chlorine and a range of new disinfectants listed in the EU biocide directive should be considered as alternatives. PPEs and disinfectants are subject to formal testing and classification. EU and US requirements are visited. No PPE and no disinfectant have 100% efficiency. Efficiency of masks is influenced negatively by the reduced breathability from masks and respirators with leakage of air between mask perimeter and the skin. Gloves have micro-porosity dependent on wear time and already after 30 min become less efficient. The humid microclimate under masks and gloves easily causes skin problems. Thus, there are many pros and cons to consider. Thoughts on ideal aim, sound sense and realistic application of PPE and disinfectants in daily routine in tattoo parlours are provided, the risk and health of the tattooist included.

Furrows, lines and wrinkles with distensibility and retractility are a biological need of skin in the service of skin integrity, plasticity and joint motion. The fundamental segmentation and linearity of skin is genetically coded, manifested early in embryonal life and remarkably constant throughout life. The basic pattern established early in embryonal life when facial segments expand and fuse is confounded by overlapping linearities of different backgrounds. Embryonal skin and skin in childhood, puberty, adult life and senescence undergo a general change in the direction of disturbed structure, nevertheless respecting the originally coded and segmented linearity. The fundamental linearity is expressed as the naso-frontal, maxillary and mandibular segments of the primitive face and the extremity buds forming extremities. The sensory nerves in this phase of morphogenesis follow and invade the segments of the face, trunk and extremities and form dermatomes,replicating the tissue segments. Early on, CREST cells migrate from behind, from the neural crest, and seed a normally hidden linearity in the tissues, which may appear as scleroderma lines, particularly the vertical "en coup de sabre" line(s) in the front. Later in pregnancy, during the phase of volume expansion, the resultant horizontal force applied to the outer skin results in gliding of epidermal structures relative to the underlying dermis, resulting in hair streams and whorls and bizarre V-shaped figures known as Blaschko's lines.Hairs in this process achieve their final distribution and inclination relative to the skin surface, known as Voigt's hairstreams and whorls. The dermatoglyphic lines and whorls of finger pulps share features with the two linearities explained by outer skin gliding. The fibre network of the dermis has uneven pretension, and circular wounds retract and become oval, systematically mapped as Langer's lines. Surgical incision lines influenced by static and dynamic forces to normal skin are described as Kraissl's linesand Borge's linesused to guide surgical incisions.Gravity acts as a constant vertical force on the face and entire body and results over years in gravitational lines, furrows and "hanging" skin. The sun creates its own pattern of disturbed linearity, photodamage lines and patterns that overrule the minute triangularlinearity, with accumulation of elastotic material in the dermis. Poor lifestyle and medical and psychiatric disease are associated with preterm skin ageing and increased furrowing. Skin linearity is complex with overlapping patterns. A broad insight into the essentials of skin linearity from the embryonal state to aged skin and senescence with an understanding and consideration of the ever-active influence of the genetic coding on skin linearities and ageing, including the forceful autoregulation aiming at the restauration of the natural state of the skin organ at any time and irrespective of interventions, is mandatory for professionals working on skin - plastic and aesthetic surgeons, dermatologists, cosmetologists, and cosmetic and decorative tattooists.

Stretch marks (striae distensae) are common dermal scarring associated with weight gain, overweight, and pregnancy. Scarring is caused by overstretching of the skin's dermis with permanent structural alteration of the collagen network fibers. Some individuals have naturally weak connective tissue and may develop major stretch marks without being overweight. Stretch marks can develop during puberty and after physical exercise with rapid muscle growth. Cortisone treatment and anabolic steroids often cause stretch marks. Stretch marks are of major cosmetic concern to many. They are red and swollen in the early sate and white and irregular in texture in the later stage. Many men and women suffer from poor self-esteem caused by stretch marks. Medical tattooing of stretch marks, also known as microneedling, can correct the skin pigmentation color in the normal direction, but not the actual textural change. However, abnormal texture may be modified by microneedling, by nonablative laser treatment, or by microdermabrasion. Treatments can also be combined, e.g., initial use of a method to flatten the skin, followed by tattooing to correct the color. Treatment options and strategies are reviewed.

Cosmetic and medical tattooing is miniaturized tattooing of high precision and thus requires many dedicated utensils including advanced devices for marking and anatomical delineation. Symmetry is a special demand, as is aesthetic outcome, building on perfectionated detail. The artist shall master design and strategy along with advanced technical performance helped by having and using the right tools. This article reviews and illustrates the many special utensils involved in good-practice cosmetic and medical tattooing, exemplified by selected tools used for cleansing, disinfection, pre-operative measurement and marking, and special tattoo machines, cartridges, microblades and needles. Personal protective equipment used to prevent infections among technicians and customers are also illustrated. Educational tools, such as face phantoms and eyebrow mats, are displayed. Mastering cosmetic and medical tattooing is a challenge and involves mastering the many auxiliaries along with needle configurations, machines, inks and the whole setting of the activity. This review is an illustrated practical record and a guideline to good professional practice.

Medical tattoos are used for camouflage of a wide range of disfiguring skin pathologies and conditions. Recently, tattooing of the nipple and areola of the breast has been introduced as a corrective treatment of sequelae from breast cancer surgery and radiotherapy. The psychologic impact of a disfigured nipple and areola can invalidate self-esteem of the sufferer lifelong with major consequences for social life. Medical tattooing can often restore the visual appearance of the nipple-areolar complex back to normality and even improve the 3D impression of the entire breast. High skills of the operator are needed. The article reviews the theoretical background, patient selection and information, technical performance, and aftercare. Close cooperation between surgeon, dermatologist, and medical tattooist is essential. Medical centers treating breast cancer should routinely have access to corrective medical tattooing.

Needles, machines, and techniques used for professional cosmetic and medical tattooing have reached a high level of sophistication. Best utensils are combined with operator's insight - the key to best results. Nowadays, a broad range of different tattoo needles serving different purposes are available. The chapter reviews round, flat, triangular, magnum, nano, polished, textured needles, etc. and their coding and preferred use in practice. The chapter is intended to be the vade mecum for practitioners in the field, the newcomer as well as the experienced, in private setting as well as in hospital.

Cutaneous scars are permanent and the result of physiological wound healing with formation of disorganized collagen instead of the normally structured connective tissue network (or "textile") of the dermis. A scar restores the physical and tensile integrity of skin; skin is a vital protective layer on the body. Scars are of many types and with a broad spectrum of individual variations of color, texture, thickness, furrowing, tension, and contraction. Scars can be red and hypertrophic and, moreover, aggressive and manifested as keloids. White scars can be changed in color into a normal tone and look by the application of medical tattooing. This can help many scar victims regain their quality of life. High level of skill is required by the tattoo artist, who shall be experienced. Tattooing may restore skin color, but it cannot restore textural and structural changes, which may need correction using other methods before the tattoo is ready to correction of color by tattooing. The medical tattooist needs to cooperate with other specialists and develop a consistent strategy of the treatments to be applied including the sequence of treatments with tattooing added at the end for final color correction back towards normal. The medical tattooist from start shall take responsibility and select the clients who are likely to benefit from tattooing and exclude clients, who shall not be offered this treatment.

Perception of skin color in the natural state, or with tattoo pigment installed in the dermis is highly complex and includes both optical requisites and eye and brain functions connected to advanced cognitive and psychological functions. Permanent makeup (PMU) is miniaturized tattooing on critical anatomical location aiming at fulfilment of a person's esthetic ideal. It is a special challenge since a satisfactory outcome depends on perfectionated technique and very critical selection of pigments. The eye can be compared to a digital camera, and the center of central vision in the brain to a computer and color integrator. Color perception is the end product of a complicated brain function. The background theory of color physics and perception is reviewed with emphasis on aspects related to changed skin color created by pigment installed in the dermis with the purpose to tattoo eyebrows, eyeliners, lips, and other locations. The delicate dosing of pigment relative to the natural skin tone is highlighted. The review is relevant for all aspects of PMU including medical tattooing, e.g., areola tattooing after breast cancer surgery. A detailed guidance to PMU artists and medical tattooists on selection and use of tattoo inks and pigments is provided. The guidance is also relevant to laser surgeons and technicians performing tattoo removal.

Medical tattooing aims to restore the normality of skin structures in patients who have skin diseases or suffer sequelae after surgical interventions or hazards. There are numerous applications, with tattooing of vitiligo and the nipple areola complex after breast cancer surgery as leading fields. The use of 3D or realistic tattoo techniques has increased the potential of medical tattooing and improved the aesthetic results. The tattooist must have good technical training combined with artistic and creative talents. In this chapter, two innovative applications of medical tattooing will be presented as examples, i.e. tattooing of the nailbed and the gingiva. Nailbed tattooing reconstructs the normal perception of the nailbed and the nail plate when the nails have previously been removed though a surgical procedure. Tattoo of the gingiva performed after a connective tissue implant of the gum is a new application. These treatments, approved by a physician and performed by a tattooist with proven experience in medical tattooing, also involve the use of specific color nuances that produce an extremely realistic outcome.

Cosmetic tattooing and medical tattooing of the face share basic principles and to some degree types and spectrum of technical and clinical complications known from decorative tattooing of other parts of the body. Cosmetic tattoos recently have grown exponentially in popularity in industrialized countries all over the world. The different complications and their clinical symptoms, pathophysiology, diagnosis, treatment, and prevention are analyzed versus culprit pigments and updated. Eyeliner tattooing is associated with special complications because of the subtle anatomy and the closeness to the eye, and the risk of meibomian gland damage. The spectrum of cosmetic tattoo complications includes early-onset complications (infections particularly with herpes simplex, healing issues, aesthetic and technical mistakes with regret), and late-onset complications (color fading and color shift, "blowout" pigment escape to surrounding skin, papules, nodules, granulomas associated with sarcoidosis, allergic reactions in lip tattoos with lichenoid dermatitis, eye irritation, and fibrosis and scaring especially after microblading); miscellaneous complications include severe burn sensation in tattoos during magnetic resonance imaging later in life. Corneal tattooing and subconjunctival/episcleral tattooing performed on medical indication by ophthalmologists, and for decoration by tattooists carry special risk of intraocular complications. It is recommended for the purpose of research harmonization that terms and diagnostic classification of tattoo adverse events follow the system introduced by the Tattoo Clinic of Copenhagen and already accepted in specialized tattoo clinics in other centers.

Cosmetic tattooing of eyebrow and lips has become very popular and is expected to be paralleled by more frequent complications. We present 4 cases of granulomas in cosmetic tattoos complicated by regional or systemic manifestations of sarcoidosis including affection of the lungs in 2 cases, the activity triggered by the tattoo. Three cases of traditional decorative tattoos on extremities serve as reference. It is noteworthy that cosmetic tattoos despite small size and thereby low relative dose of pigment injected in the skin can trigger fully developed systemic sarcoidosis. It is hypothesized that iron oxide pigments popular in cosmetic tattoo inks of red or brown color may be prone to elicit sarcoid reactions and thus carry a special risk of granuloma. In decorative tattoos, carbon black is the commonest trigger. It is emphasized that the finding of granulomas in tattoos shall be followed by search of other manifestations of sarcoidosis through patient history and diagnostic examinations to exclude pulmonary, ocular, and other organ manifestations. Patients with granulomas in tattoos shall be informed that active sarcoidosis, if not already present, can become manifest later with a latency of months or years and often with abrupt debut when the triggering tattoo may be overlooked by the doctor who is unfamiliar with this less common type of sarcoidosis.

This chapter reviews our present knowledge about equipment used for cosmetic (decorative) and medical tattooing and its function with respect to installation of tattoo ink into the skin. In the following text, the word "tattooing" refers to body tattooing, permanent makeup (PMU), microblading, and medical micropigmentation. The major consumer risks related to unsafe tattoo and PMU equipment are reconsidered. Such health risks mainly include the danger of non-sterile needles or needle cartridges, cross contamination of equipment and lack of biocompatibility. Even though state-of-the-art tattoo equipment will support the tattooist to reduce such health risks, also today unsafe equipment still might affect consumer health due to malpractice advertising and fraudulent CE certificates by questionable manufacturers and suppliers not being transparent to parlors and artists. For artists, it is therefore of growing importance to understand how to distinguish well-made safe tattoo equipment from fraudulent unsafe products.

Cosmetic tattooing dedicated to beautifying the normal anatomy such as the eyebrows, the eyelines, or the lips is in a remarkable growth all over the world. Medical tattooing with reconstruction of the areola and the nipple after breast surgery, correction of the lost color of vitiligo and scars is a spin-off, which has made tattooing cross the barrier and become accepted and used in clinics and hospitals in service of the quality of life of patients. The last years have seen a major development of machinery, inks, techniques, experiences, and services. The overwhelming rise of the activity created by client pressure and business opportunity, however, also has its cons: amateur work and even malpractice. The development is driven by elite technicians, but competence is little transparent to clients, and there is no distinct authoritative recognition of practitioners based on a recognized educational curriculum. National regulations of the industry are highly variable and scattered. Some countries have no restriction and in others cosmetic tattoos shall be performed by medical doctors. The challenge of the coming decades is to parallel the success of the industry with quality assurance to better control practices and safeguard clients, and the patients.