Traditional (i.e., decorative) and cosmetic tattoo procedures have been performed for thousands of years. Cosmetic tattoos or “permanent cosmetics” are used to reshape, recolor, recreate, or modify eye shadow, eyeliner, eyebrows, lips, beauty marks, and cheek blush. Additionally, permanent cosmetics are used aesthetically to enhance nipple-areola reconstruction procedures and for other applications.

Unfortunately, there is much confusion regarding the overall safety aspects of permanent cosmetics. For example, based on a few reports of symptoms localized to the tattooed area during MR imaging, many radiologists have refused to perform examinations on individuals with permanent cosmetics, particularly tattooed eyeliner. This undue concern for possible adverse events prevents patients with cosmetic tattoos access to an important diagnostic imaging technique.

While it is well-known that permanent cosmetics and tattoos may cause artifacts and both cosmetic and decorative tattoos may be associated with relatively minor, short-term cutaneous reactions, the frequency and severity of soft tissue reactions or other problems related to MR imaging and cosmetic tattoos is unknown. In 2002, Tope and Shellock conducted a study to determine the frequency and severity of adverse events associated with MR imaging in a population of subjects with permanent cosmetics. A questionnaire was distributed to clients of cosmetic tattoo technicians. This survey asked study subjects for demographic data, information about their tattoos, and for their experiences during MR imaging procedures. Results from 1,032 surveys were tabulated. One hundred thirty-five (13.1%) study subjects underwent MR imaging after having permanent cosmetics applied.

Only two individuals (1.5%) experienced problems associated with MR imaging. One subject reported a sensation of "slight tingling" and the other reported a "burning" sensation. Both incidents were transient and did not prevent the MR procedures from being performed. Based on these findings and additional information in the peer-reviewed literature, it appears that MR imaging may be performed in patients with permanent cosmetics without serious soft tissue reactions or adverse events. Therefore, the presence of permanent cosmetics should not prevent a patient from undergoing MR imaging.

Before undergoing an MR procedure, the patient should be asked if he or she has ever had a permanent coloring technique (i.e., tattooing) applied to the body. This includes cosmetic applications such as eyeliner, lip-liner, lip coloring, as well as decorative designs. This question is necessary because of the associated imaging artifacts and, more importantly, because a small number of patients (fewer than 10 documented cases) have experienced transient skin irritation, cutaneous swelling, or heating sensations at the site of the permanent colorings in association with MR procedures (review of Medical Device Reports, 1985 to 2011). 

Interestingly, decorative tattoos tend to cause worse problems (including first- and second-degree burns) for patients undergoing MR imaging compared to those that have been reported for cosmetic tattoos. With regard to decorative tattoos, a letter to the editor described a second-degree burn that occurred on the skin of the deltoid from a decorative tattoo. The authors suggested that "the heating could have come either from oscillations of the gradients or, more likely from the RF-induced electrical currents". However, the exact mechanism(s) responsible for complications or adverse events in the various cases that have occurred related to decorative tattoos is unknown.

Additionally, Kreidstein, et al. (1997) reported that a patient experienced a sudden burning pain at the site of a decorative tattoo while undergoing MR imaging of the lumbar spine using a 1.5-Tesla MR system. Swelling and erythema was resolved within 12 hours, without evidence of permanent sequelae. The tattoo pigment used in this case was ferromagnetic, which possibly explained the symptoms experienced by the patient. Surprisingly, in order to permit the MRI examination, an excision of the tattooed skin was performed.

The authors of this report stated, "Theoretically, the application of a pressure dressing of the tattoo may prevent any tissue distortion due to ferromagnetic pull". (However, this relatively benign procedure was not attempted for this patient.) The authors also indicated that, "In some cases, removal of the tattoo may be the most practical means of allowing MRI".

Kanal and Shellock (1998) commented on this report in a letter to the editor, suggesting that the response to this situation was "rather aggressive". Clearly the trauma, expense, and morbidity associated with excision of a tattoo far exceed those that may be associated with ferromagnetic tattoo interactions. Direct application of a cold compress (e.g., to the site of a tattoo would likely mitigate any heating sensation that may occur in association with MR imaging. 

Artifacts
Imaging artifacts associated with permanent cosmetics and certain types of eye makeup have been reported. These artifacts are predominantly associated with the presence of pigments that use iron oxide or other type of metal and occur in the immediate area of the applied pigment or material. As such, tattoo- and makeup-related MR imaging artifacts should not prevent a diagnostically adequate MR imaging procedure from being performed, especially in consideration that careful selection of imaging parameters may easily minimize artifacts related to metallic materials.

The only possible exception to this is if the anatomy of interest is in the exact same position of where the tattoo was applied using an iron oxide-based pigment. For example, Weiss et al. reported that heavy metal particles used in the pigment base of mascara and eyeliner tattoos, have a paramagnetic effect that causes alteration of the local magnetic field in adjacent tissues. Changes in the MR signal pattern may result in distortion of the globes. In some cases, the artifact and distortion may mimic actual ocular disease, such as a ciliary body melanoma or cyst.

GUIDELINES AND RECOMMENDATIONS
In consideration of the available literature and experience pertaining to MR procedures and patients with permanent cosmetics and tattoos, guidelines to manage these individuals include, the following:
-The screening form used for patients should include a question to identify the presence of permanent cosmetics or decorative tattoos.

-Before undergoing an MR procedure, the patient should be asked if he or she had a permanent coloring technique (i.e., tattooing) applied to any part of the body. This includes cosmetic applications such as eyeliner, lip-liner, lip coloring, as well as decorative designs.

-The patient should be informed of the risks associated with the site of the tattoo.

-The patient should be advised to immediately inform the MRI technologist regarding any unusual sensation felt at the site of the tattoo in association with the MR procedure.

-The patient should be closely monitored using visual and auditory means throughout the operation of the MR system to ensure safety.

-As a precautionary measure, a cold compress (e.g., ice bag) may be applied to the tattoo site during the MR procedure.

In addition to the above, information and recommendations have been provided for patients by the United States Food and Drug Administration, Center for Food Safety and Applied Nutrition, Office of Cosmetics and Colors Fact Sheet, as follows: " the risks of avoiding an MRI when your doctor has recommended one are likely to be much greater than the risks of complications from an interaction between the MRI and tattoo or permanent makeup. Instead of avoiding an MRI, individuals who have tattoos or permanent makeup should inform the radiologist or technician of this fact in order to take appropriate precautions, avoid complications, and assure the best results."

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