PracticalDermatology

Pitfalls of Pigmentation: A Literature Review of Cosmetic Eyeliner Tattoo Complications

By Sruti S. Akella, MD and Ann Q. Tran, MD

Permanent eyeliner tattooing, or blepharopigmentation, is popular among women and has become more widespread in recent decades. This is a process by which colored pigments are injected into the skin using a round-tip needle. Advantages include cosmesis and the ability to avoid daily application of makeup, especially among the elderly population who may not have the desired vision or dexterity to apply eyeliner in a symmetrical and consistent fashion. However, the use of blepharopigmentation has also resulted in a number of reported complications. Here, we review complications of blepharopigmentation in cosmetic tattooing to guide practice patterns in appropriate counseling and use of these agents.

We conducted a medical literature search for “complications,” “cosmetic tattoo,” and “cosmetic eyeliner” on the PubMed database. There were no language or date restrictions.

A total of 8 articles encompassing 11 patients were found from 1999-2018. The majority of patients were 58.5 years of age (range 46-81), and all of them were female. Severe complications reported included full-thickness penetration of the eyelid, causing permanent pigmentation of the cornea, conjunctiva, or limbus that may result in vision loss and ultimately require additional surgical intervention. Moderate complications included scarring, hyper- and hypo-pigmentation of the eyelash margin, and even migration of pigment. Extensive migration of the pigment from lower eyeliner tattoos traveled to the tear trough and nasojugal folds and ultimately required skin grafts for subsequent repairs. In other instances, late granulomas have developed, necessitating full-thickness eyelid biopsies, masquerading as other eyelid malignancies, or requiring systemic treatment with oral corticosteroids and antibiotics.

Blepharopigmentation is a largely unregulated industry that can result in globe injury, severe scarring, and spread of pigmentation severe enough to require ophthalmic surgery and reconstruction.

Patients suffering from complications related to cosmetic tattooed eyeliner are generally referred to dermatologists, plastics surgeons, and oculoplastic surgeons for management. It is important to be aware of the potential complications and prior management therapies to effectively counsel patients.

For further reading:

Cannarozzo G, Negosanti F, Sannino M, Santoli M, Bennardo L, Banzola N, Negosanti L, Nisticò SP. Q-switched Nd:YAG laser for cosmetic tattoo removal. Dermatol Ther. 2019 Sep;32(5):e13042. doi: 10.1111/dth.13042. Epub 2019 Aug 23. PMID: 31361928.

Goldberg H, Berger Y, Ben Bassat I, Barequet I. Inadvertent corneal pigmentation following cosmetic blepharopigmentation. Am J Ophthalmol Case Rep. 2018 Sep 5;12:52-54. doi: 10.1016/j.ajoc.2018.09.002. PMID: 30211341; PMCID: PMC6134572.

Liao JC, Proia AD, Ely PH, Woodward JA. Late-onset melanopenic hypomelanosis as a complication of cosmetic eyeliner tattoo. J Am Acad Dermatol. 2013 Sep;69(3):e144-6. doi: 10.1016/j.jaad.2013.02.029. PMID: 23957994.

De M, Marshak H, Uzcategui N, Chang E. Full-thickness eyelid penetration during cosmetic blepharopigmentation causing eye injury. J Cosmet Dermatol. 2008 Mar;7(1):35-8. doi: 10.1111/j.1473-2165.2008.00340.x. PMID: 18254809.

Moshirfar M, Espandar L, Kurz C, Mamalis N. Inadvertent pigmentation of the limbus during cosmetic blepharopigmentation. Cornea. 2009 Jul;28(6):712-3. doi: 10.1097/ICO.0b013e318190737b. PMID: 19512894.

Peters NT, Conn H, Côté MA. Extensive lower eyelid pigment spread after blepharopigmentation. Ophthalmic Plast Reconstr Surg. 1999 Nov;15(6):445-7. doi: 10.1097/00002341-199911000-00016. PMID: 10588257.

Vagefi M, Dragan L, Hughes S, Klippenstein K, Seiff S, Woog J. Adverse Reactions to Permanent Eyeliner Tattoo. Ophthal Plast Reconstr Surg. 2006;22(1):48-51. doi:10.1097/01.iop.0000196713.94608.29.

Bee C, Steele E, White K, Wilson D. Tattoo Granuloma of the Eyelid Mimicking Carcinoma. Ophthal Plast Reconstr Surg. 2014;30(1):e15-e17. doi:10.1097/IOP.0b013e31828ad7b7.

Schwarze HP, Giordano-Labadie F, Loche F, Gorguet MB, Bazex J. Delayed-hypersensitivity granulomatous reaction induced by blepharopigmentation with aluminum-silicate. J Am Acad Dermatol. 2000 May;42(5 Pt 2):888-91. doi: 10.1016/s0190-9622(00)90264-0. PMID: 10767697.

Morphea after endovenous cyanoacrylate adhesive embolization: An unusual complication

By Stefanie Altmann, DO; Rachel Murray, DO; Courtney Bernett, DO

Around 24 percent of Americans have visible varicose veins,¹ making them a common medical and cosmetic concern. Endovenous cyanoacrylate (CA) embolization is a relatively new procedure that is becoming a popular treatment option for varicosities due to refluxing great saphenous veins (GSVs). This device has been marketed as a simple outpatient procedure with less pain and bruising, and faster recovery when compared to thermal ablation.^2,3 However, a variety of adverse events have been documented, ranging from benign to serious. Here we report a case of morphea developing after endovenous CA embolization. To our knowledge, this is the first reported case of its kind and represents a previously unidentified adverse event.

Case

A 71-year-old Caucasian female with a past medical history of hypercholesterolemia presented to the dermatology clinic for evaluation of new skin lesions located on the bilateral legs and antecubital fossa. The patient stated the lesions were asymptomatic, were present for several months, and developed after an endovenous CA embolization procedure (VenaSeal, Medtronic) at an outside vein clinic. Notably, this patient had no history of autoimmune or rheumatologic disorders. On exam, symmetric annular, violaceous indurated plaques were present on the antecubital fossa, posterior thighs, and medial legs. A unilateral linear plaque was noted following the course of the left GSV, from the level of the medial knee extending to the mid-calf. This linear lesion was consistent with the site of her prior CA embolization. The annular lesions, however, were present at sites that had not been treated. A 4-mm punch biopsy from her left leg was performed for further evaluation, which revealed the early inflammatory stage of morphea. The patient was started on topical therapy with calcipotriene 0.005% ointment combined with clobetasol 0.05% ointment, alternating every 2 weeks with tacrolimus 0.1% ointment. Due to concern for a possible joint contracture, oral prednisone, methotrexate, and physical therapy referral were offered. Patient declined the use of prednisone due to the COVID-19 pandemic, and she felt physical therapy was not indicated. Phototherapy was initiated with a 308nm excimer laser, administered three times weekly. The patient was noted to have modest improvement on this regimen. She ultimately required initiation of methotrexate 15mg weekly with folic acid.

Figure 1. Morphea. Left lower extremity showing a unilateral linear plaque following the course of the left GSV, status post endovenous CA embolization procedure with VenaSeal.

Figure 2. Morphea. Symmetric annular, violaceous plaques on the bilateral antecubital fossa.

Discussion

Lower extremity varicose veins are a common concern for many patients. Sclerotherapy is considered to be the treatment of choice for small varicose veins,⁴ however larger caliber veins often require more invasive procedures. Several therapies exist, including phlebectomy, endovenous radiofrequency ablation, and laser ablation. Recently, endovenous CA ablation has been introduced as a novel, effective treatment option. This procedure utilizes a closure system device to deliver CA glue to the vein lumen, resulting in occlusion and endovenous closure. While serious complications from vein ablation procedures are rare, reported adverse events include deep venous thrombosis, pulmonary embolism, nerve injuries, stroke, and arteriovenous fistulas. More commonly encountered, benign side effects include phlebitis, post-inflammatory hyperpigmentation, and ecchymosis. The vascular occluding agent (VenaSeal Closure System) was FDA-approved in 2015 for the treatment of symptomatic lower extremity varicose veins through endovascular embolization with coaptation. While non-specific, mild inflammation of the cutaneous and subcutaneous tissue is listed as a potential adverse event, morphea is not mentioned in medical literature as a possible complication. There has been one case series of three patients developing linear sclerodermiform dermatitis after surgical saphenous venectomy reported in the distant literature.⁵

The theorized pathophysiology in both systemic and localized scleroderma (morphea) is underlying vascular injury, dysfunction, or trauma. This could explain the sequential development of morphea as a complication of CA embolization.⁶ The distribution of our patient’s linear morphea was consistent with the areas previously treated with CA embolization, suggesting this particular procedure triggered her morphea. One case of glue rejection after endovenous CA was recently reported.⁷ It is possible that a similar CA hypersensitivity may have played a role in the initiation of our patient’s morphea. Of note, the annular lesions were at sites with no previous vein procedure, indicating the possibility of an underlying systemic reaction. The absence of reported morphea cases after CA embolization could signify that this association may be underrecognized, and therefore, underreported.

Conclusion

Morphea after endovenous cyanoacrylate adhesive ablation represents a rare, previously unidentified complication. Physicians should be aware of this potential adverse event so as not to delay diagnosis and treatment.

Disclaimer: This research was supported in part by HCA Healthcare or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Stefanie Altmann, DO is a recent graduate of Mercer University/Orange Park Hospital. She currently practices dermatology in Florida

1. Mallick R, Raju A, Campbell C, et al. Treatment Patterns and Outcomes in Patients with Varicose Veins. Am Health Drug Benefits. 2016;9(8):455-465.

2. Morrison N, Gibson K, McEnroe S, et al. Randomized trial comparing cyanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. April 2015;61(4):985-994.

3. Proebstle T, Alm J, Dimitri S, et al. Three-year follow-up results of the prospective European Multicenter Cohort Study on Cyanoacrylate Embolization for treatment of refluxing great saphenous veins. J Vasc Surg Venous Lymphat Disord. March 2021;9(2):329-334.

4. Rabe E, Breu F, Cavezzi A, et al.; for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2013;PMID:23559590.

5. French LE, Braun R, Masouyé I, Ramelet AA, Humbert PG, Saurat JH. Post-stripping sclerodermiform dermatitis. Arch Dermatol. 1999 Nov;135(11):1387-91. doi: 10.1001/archderm.135.11.1387. PMID: 10566839.

6. Wolf R, Wolf D, Ruocco V, Ruocco E. The role of skin trauma (isotopic and isomorphic) in the distribution of morphea. J Am Acad Dermatol. 2015; 72(3): 560-1.

7. PS Lew, YK Tan, TT Chong, TY Tang. VenasealTM Cyanoacrylate Glue Rejection Following Endovenous Ablation - Another New Complication. Biomed J Sci & Tech Res 17(4)-2019. BJSTR. MS.ID.003040.

These papers were originally presented in part at the Cosmetic Surgery Forum in Nashville, TN. on December 3, 2021. They were named among the top 10 resident presentations at the meeting. CosmeticSurgeryForum.com