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Conservative Thickness Layers to Preserve Tattoo Appearance During Excisional Procedures
Conservative Thickness Layers to Preserve Tattoo Appearance During Excisional Procedures
Practice Gap
Tattoos have become increasingly prevalent in Western culture, with approximately 1 in 4 Americans having at least 1 tattoo. Individuals invest money, time, and even pain in getting tattoos, many of which hold special personal, family, or religious significance.1 Various cutaneous pathologies may arise in areas of the skin with tattoos, including malignancies and inflammatory reactions to tattoo pigment, and in these cases, surgical management may be indicated.2,3
Nonmelanoma skin cancers (NMSCs) such as superficial basal cell carcinomas on broadly sun-damaged areas (eg, trunk, torso), squamous cell carcinomas, reactive keratoacanthomas, and reactive pseudoepitheliomatous squamous hyperplasia diagnosed as squamous cell carcinoma have been reported to occur in or near areas of the skin with tattoos.2 Mohs micrographic surgery (MMS) is the standard of care for removing NMSCs, particularly when they manifest in cosmetically sensitive areas.4 This treatment option allows for careful guided resection of tumors to minimize the risk for recurrence; it also preserves healthy tissue, which typically results in a smaller radial defect after the procedure is complete.
Chronic reactions to tattoo pigment may include granulomatous tattoo reactions and pseudolymphomas.3 Treatment options may include immunosuppressives such as intralesional triamcinolone as well as pigment destruction via lasers5; however, not all tattoos are responsive to these treatments. Surgical excision is an effective and definitive treatment in this context, as tattoo pigment resides in or above the mid dermis to a depth of approximately 400 μm. Intradermal excision effectively removes the antigenic pigment.5
In these clinical scenarios, patients may be hesitant to pursue surgical treatment due to concerns that it may alter tattoo appearance. Many clinicians and surgeons may consider definitive treatment and tattoo preservation to be mutually exclusive, but this is not always the case. We propose a technique that utilizes conservative thickness layers (CTL) to minimize disruption to the appearance of tattoos in MMS for treatment of cutaneous malignancies as well as intradermal excision of tattoo pigment in the setting of chronic inflammatory tattoo reactions.
The Technique
In the appropriate clinical context, CTL can effectively result in defects that heal well by secondary intention and minimize collateral tissue distortion.4 Lesions manifesting in or near tattooed skin often are responsive to treatment with CTL; furthermore, CTL may preserve some deeper tattoo pigment, resulting in only partial loss of the tattooed skin.
Conservative thickness layers are performed intradermally, similar to removing traditional layers in MMS. For treatment of NMSCs, a margin is scored around the lesion, and then the blade is passed carefully under the lesion nearly parallel to the skin through an intradermal plane. It is important to avoid entering the subcuticular fat (Figure 1). The tissue then is processed normally in the Mohs laboratory for complete circumferential margin evaluation. If necessary and possible, subsequent layers also can be performed in the intradermal plane. Once total circumferential margin control is obtained, the wound is allowed to granulate and heal by secondary intention. As these processes occur, we have found that wound contraction is less likely with the dermis intact, resulting in less impact on the overall appearance of the tattoo (Figures 1 and 2). For very thin lesions, resultant defects may retain some residual tattoo pigment. The residual scars also may be responsive to tattoo revision, although a period of monitoring for recurrence should be considered if there is concern that revising the tattoo could obscure early recurrent tumors. From our experience, utilizing CTL for NMSCs that arise within or near tattoos results in favorable preservation of the tattoo appearance and high patient satisfaction.
The procedure is performed similarly for removal of allergenic tattoo pigment, with careful excision to the mid dermis. Since the areas affected by the cutaneous reaction may be relatively large, surgical precision is required to maintain a uniform depth to remove the tattoo pigment and preserve the deep dermis (Figure 2). Once removed, the defect can be left to granulate and heal by secondary intention. If the patient wants to have the tattoo revised in the future, it would be prudent to utilize pigment that the patient has responded favorably to. In our experience, this approach is effective and yields high patient satisfaction and minimizes morbidity.
Practice Implications
Tattoos often hold special meaning for patients; therefore, treatment of pathologies arising in or near tattooed skin should emphasize maintaining the appearance of the tattoo while still being effective. Conservative thickness layers in MMS and intradermal excisions for allergic reactions to tattoo pigment are an effective treatment strategy that clinicians may consider.
One shortcoming of using CTL for MMS is the need for subsequent layers to clear the tumor; however, data suggest that first-stage cure rates are extremely high even with CTL for appropriately selected patients, with clearance of nearly 80% of tumors on the first stage. Tumors that may be most responsive to CTL include exophytic NMSCs and those arising in areas with a thicker dermis, including the back, legs, and scalp, although other locations including the face, hands, shins, ankles, and feet also may be well suited for CTL.4 Another shortcoming of CTL is that skin cancers arising in tattoos may not be considered appropriate for MMS based on the 2012
Conservative thickness layers in MMS and intradermal excisions of tattoo pigment are both effective techniques of minimizing disruption of tattoos while effectively treating patients.
- Roggenkamp H, Nicholls A, Pierre JM. Tattoos as a window to the psyche: how talking about skin art can inform psychiatric practice. World J Psychiatry. 2017;7:148-158. doi:10.5498/wjp.v7.i3.148
- Rubatto M, Gelato F, Mastorino L, et al. Nonmelanoma skin cancer arising on tattoos. Int J Dermatol. 2023;62:E155-E156. doi:10.1111/ijd.16381
- Atwater AR, Bembry R, Reeder M. Tattoo hypersensitivity reactions: inky business. Cutis. 2020;106:64-67. doi:10.12788/cutis.0028
- Tolkachjov SN, Cappel JA, Bryant EA, et al. Conservative thickness layers in Mohs micrographic surgery. Int J Dermatol. 2018;57:1128-1134. doi:10.1111/ijd.14043
- Sardana K, Ranjan R, Ghunawat S. Optimising laser tattoo removal. J Cutan Aesthet Surg. 2015;8:16-24. doi:10.4103/0974-2077.155068
- Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550. doi:10.1016/j.jaad.2012.06.009.
- Amthor Croley JA. Current controversies in mohs micrographic surgery. Cutis. 2019;104:E29-E31.
Practice Gap
Tattoos have become increasingly prevalent in Western culture, with approximately 1 in 4 Americans having at least 1 tattoo. Individuals invest money, time, and even pain in getting tattoos, many of which hold special personal, family, or religious significance.1 Various cutaneous pathologies may arise in areas of the skin with tattoos, including malignancies and inflammatory reactions to tattoo pigment, and in these cases, surgical management may be indicated.2,3
Nonmelanoma skin cancers (NMSCs) such as superficial basal cell carcinomas on broadly sun-damaged areas (eg, trunk, torso), squamous cell carcinomas, reactive keratoacanthomas, and reactive pseudoepitheliomatous squamous hyperplasia diagnosed as squamous cell carcinoma have been reported to occur in or near areas of the skin with tattoos.2 Mohs micrographic surgery (MMS) is the standard of care for removing NMSCs, particularly when they manifest in cosmetically sensitive areas.4 This treatment option allows for careful guided resection of tumors to minimize the risk for recurrence; it also preserves healthy tissue, which typically results in a smaller radial defect after the procedure is complete.
Chronic reactions to tattoo pigment may include granulomatous tattoo reactions and pseudolymphomas.3 Treatment options may include immunosuppressives such as intralesional triamcinolone as well as pigment destruction via lasers5; however, not all tattoos are responsive to these treatments. Surgical excision is an effective and definitive treatment in this context, as tattoo pigment resides in or above the mid dermis to a depth of approximately 400 μm. Intradermal excision effectively removes the antigenic pigment.5
In these clinical scenarios, patients may be hesitant to pursue surgical treatment due to concerns that it may alter tattoo appearance. Many clinicians and surgeons may consider definitive treatment and tattoo preservation to be mutually exclusive, but this is not always the case. We propose a technique that utilizes conservative thickness layers (CTL) to minimize disruption to the appearance of tattoos in MMS for treatment of cutaneous malignancies as well as intradermal excision of tattoo pigment in the setting of chronic inflammatory tattoo reactions.
The Technique
In the appropriate clinical context, CTL can effectively result in defects that heal well by secondary intention and minimize collateral tissue distortion.4 Lesions manifesting in or near tattooed skin often are responsive to treatment with CTL; furthermore, CTL may preserve some deeper tattoo pigment, resulting in only partial loss of the tattooed skin.
Conservative thickness layers are performed intradermally, similar to removing traditional layers in MMS. For treatment of NMSCs, a margin is scored around the lesion, and then the blade is passed carefully under the lesion nearly parallel to the skin through an intradermal plane. It is important to avoid entering the subcuticular fat (Figure 1). The tissue then is processed normally in the Mohs laboratory for complete circumferential margin evaluation. If necessary and possible, subsequent layers also can be performed in the intradermal plane. Once total circumferential margin control is obtained, the wound is allowed to granulate and heal by secondary intention. As these processes occur, we have found that wound contraction is less likely with the dermis intact, resulting in less impact on the overall appearance of the tattoo (Figures 1 and 2). For very thin lesions, resultant defects may retain some residual tattoo pigment. The residual scars also may be responsive to tattoo revision, although a period of monitoring for recurrence should be considered if there is concern that revising the tattoo could obscure early recurrent tumors. From our experience, utilizing CTL for NMSCs that arise within or near tattoos results in favorable preservation of the tattoo appearance and high patient satisfaction.
The procedure is performed similarly for removal of allergenic tattoo pigment, with careful excision to the mid dermis. Since the areas affected by the cutaneous reaction may be relatively large, surgical precision is required to maintain a uniform depth to remove the tattoo pigment and preserve the deep dermis (Figure 2). Once removed, the defect can be left to granulate and heal by secondary intention. If the patient wants to have the tattoo revised in the future, it would be prudent to utilize pigment that the patient has responded favorably to. In our experience, this approach is effective and yields high patient satisfaction and minimizes morbidity.
Practice Implications
Tattoos often hold special meaning for patients; therefore, treatment of pathologies arising in or near tattooed skin should emphasize maintaining the appearance of the tattoo while still being effective. Conservative thickness layers in MMS and intradermal excisions for allergic reactions to tattoo pigment are an effective treatment strategy that clinicians may consider.
One shortcoming of using CTL for MMS is the need for subsequent layers to clear the tumor; however, data suggest that first-stage cure rates are extremely high even with CTL for appropriately selected patients, with clearance of nearly 80% of tumors on the first stage. Tumors that may be most responsive to CTL include exophytic NMSCs and those arising in areas with a thicker dermis, including the back, legs, and scalp, although other locations including the face, hands, shins, ankles, and feet also may be well suited for CTL.4 Another shortcoming of CTL is that skin cancers arising in tattoos may not be considered appropriate for MMS based on the 2012
Conservative thickness layers in MMS and intradermal excisions of tattoo pigment are both effective techniques of minimizing disruption of tattoos while effectively treating patients.
Practice Gap
Tattoos have become increasingly prevalent in Western culture, with approximately 1 in 4 Americans having at least 1 tattoo. Individuals invest money, time, and even pain in getting tattoos, many of which hold special personal, family, or religious significance.1 Various cutaneous pathologies may arise in areas of the skin with tattoos, including malignancies and inflammatory reactions to tattoo pigment, and in these cases, surgical management may be indicated.2,3
Nonmelanoma skin cancers (NMSCs) such as superficial basal cell carcinomas on broadly sun-damaged areas (eg, trunk, torso), squamous cell carcinomas, reactive keratoacanthomas, and reactive pseudoepitheliomatous squamous hyperplasia diagnosed as squamous cell carcinoma have been reported to occur in or near areas of the skin with tattoos.2 Mohs micrographic surgery (MMS) is the standard of care for removing NMSCs, particularly when they manifest in cosmetically sensitive areas.4 This treatment option allows for careful guided resection of tumors to minimize the risk for recurrence; it also preserves healthy tissue, which typically results in a smaller radial defect after the procedure is complete.
Chronic reactions to tattoo pigment may include granulomatous tattoo reactions and pseudolymphomas.3 Treatment options may include immunosuppressives such as intralesional triamcinolone as well as pigment destruction via lasers5; however, not all tattoos are responsive to these treatments. Surgical excision is an effective and definitive treatment in this context, as tattoo pigment resides in or above the mid dermis to a depth of approximately 400 μm. Intradermal excision effectively removes the antigenic pigment.5
In these clinical scenarios, patients may be hesitant to pursue surgical treatment due to concerns that it may alter tattoo appearance. Many clinicians and surgeons may consider definitive treatment and tattoo preservation to be mutually exclusive, but this is not always the case. We propose a technique that utilizes conservative thickness layers (CTL) to minimize disruption to the appearance of tattoos in MMS for treatment of cutaneous malignancies as well as intradermal excision of tattoo pigment in the setting of chronic inflammatory tattoo reactions.
The Technique
In the appropriate clinical context, CTL can effectively result in defects that heal well by secondary intention and minimize collateral tissue distortion.4 Lesions manifesting in or near tattooed skin often are responsive to treatment with CTL; furthermore, CTL may preserve some deeper tattoo pigment, resulting in only partial loss of the tattooed skin.
Conservative thickness layers are performed intradermally, similar to removing traditional layers in MMS. For treatment of NMSCs, a margin is scored around the lesion, and then the blade is passed carefully under the lesion nearly parallel to the skin through an intradermal plane. It is important to avoid entering the subcuticular fat (Figure 1). The tissue then is processed normally in the Mohs laboratory for complete circumferential margin evaluation. If necessary and possible, subsequent layers also can be performed in the intradermal plane. Once total circumferential margin control is obtained, the wound is allowed to granulate and heal by secondary intention. As these processes occur, we have found that wound contraction is less likely with the dermis intact, resulting in less impact on the overall appearance of the tattoo (Figures 1 and 2). For very thin lesions, resultant defects may retain some residual tattoo pigment. The residual scars also may be responsive to tattoo revision, although a period of monitoring for recurrence should be considered if there is concern that revising the tattoo could obscure early recurrent tumors. From our experience, utilizing CTL for NMSCs that arise within or near tattoos results in favorable preservation of the tattoo appearance and high patient satisfaction.
The procedure is performed similarly for removal of allergenic tattoo pigment, with careful excision to the mid dermis. Since the areas affected by the cutaneous reaction may be relatively large, surgical precision is required to maintain a uniform depth to remove the tattoo pigment and preserve the deep dermis (Figure 2). Once removed, the defect can be left to granulate and heal by secondary intention. If the patient wants to have the tattoo revised in the future, it would be prudent to utilize pigment that the patient has responded favorably to. In our experience, this approach is effective and yields high patient satisfaction and minimizes morbidity.
Practice Implications
Tattoos often hold special meaning for patients; therefore, treatment of pathologies arising in or near tattooed skin should emphasize maintaining the appearance of the tattoo while still being effective. Conservative thickness layers in MMS and intradermal excisions for allergic reactions to tattoo pigment are an effective treatment strategy that clinicians may consider.
One shortcoming of using CTL for MMS is the need for subsequent layers to clear the tumor; however, data suggest that first-stage cure rates are extremely high even with CTL for appropriately selected patients, with clearance of nearly 80% of tumors on the first stage. Tumors that may be most responsive to CTL include exophytic NMSCs and those arising in areas with a thicker dermis, including the back, legs, and scalp, although other locations including the face, hands, shins, ankles, and feet also may be well suited for CTL.4 Another shortcoming of CTL is that skin cancers arising in tattoos may not be considered appropriate for MMS based on the 2012
Conservative thickness layers in MMS and intradermal excisions of tattoo pigment are both effective techniques of minimizing disruption of tattoos while effectively treating patients.
- Roggenkamp H, Nicholls A, Pierre JM. Tattoos as a window to the psyche: how talking about skin art can inform psychiatric practice. World J Psychiatry. 2017;7:148-158. doi:10.5498/wjp.v7.i3.148
- Rubatto M, Gelato F, Mastorino L, et al. Nonmelanoma skin cancer arising on tattoos. Int J Dermatol. 2023;62:E155-E156. doi:10.1111/ijd.16381
- Atwater AR, Bembry R, Reeder M. Tattoo hypersensitivity reactions: inky business. Cutis. 2020;106:64-67. doi:10.12788/cutis.0028
- Tolkachjov SN, Cappel JA, Bryant EA, et al. Conservative thickness layers in Mohs micrographic surgery. Int J Dermatol. 2018;57:1128-1134. doi:10.1111/ijd.14043
- Sardana K, Ranjan R, Ghunawat S. Optimising laser tattoo removal. J Cutan Aesthet Surg. 2015;8:16-24. doi:10.4103/0974-2077.155068
- Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550. doi:10.1016/j.jaad.2012.06.009.
- Amthor Croley JA. Current controversies in mohs micrographic surgery. Cutis. 2019;104:E29-E31.
- Roggenkamp H, Nicholls A, Pierre JM. Tattoos as a window to the psyche: how talking about skin art can inform psychiatric practice. World J Psychiatry. 2017;7:148-158. doi:10.5498/wjp.v7.i3.148
- Rubatto M, Gelato F, Mastorino L, et al. Nonmelanoma skin cancer arising on tattoos. Int J Dermatol. 2023;62:E155-E156. doi:10.1111/ijd.16381
- Atwater AR, Bembry R, Reeder M. Tattoo hypersensitivity reactions: inky business. Cutis. 2020;106:64-67. doi:10.12788/cutis.0028
- Tolkachjov SN, Cappel JA, Bryant EA, et al. Conservative thickness layers in Mohs micrographic surgery. Int J Dermatol. 2018;57:1128-1134. doi:10.1111/ijd.14043
- Sardana K, Ranjan R, Ghunawat S. Optimising laser tattoo removal. J Cutan Aesthet Surg. 2015;8:16-24. doi:10.4103/0974-2077.155068
- Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550. doi:10.1016/j.jaad.2012.06.009.
- Amthor Croley JA. Current controversies in mohs micrographic surgery. Cutis. 2019;104:E29-E31.
Conservative Thickness Layers to Preserve Tattoo Appearance During Excisional Procedures
Conservative Thickness Layers to Preserve Tattoo Appearance During Excisional Procedures
