Tattoos in the Operative Field: The State of the Art

The number of tattoos in the United States has been rising steadily. In 2019, approximately 30% of the U.S. population had at least one tattoo, up from 21% in 2012.1 Tattooing is especially common among younger generations, with 40% of Americans between the ages of 18 and 34 reporting at least one tattoo.1 Within the medical community, much of the literature has taken a negative view of tattoos with a focus on tattoo removal2–4 and many authors commenting on the association of tattoos with criminality, gang membership, and risk-taking behavior.5–8 Despite historic stigma, in recent decades tattoos have increasingly come to represent expressions of individuality or commemorate highly significant life events and relationships. In line with this cultural shift, the medical community should similarly celebrate tattoos as aesthetic units with their own intrinsic value and prioritize their preservation wherever possible and desired by patients. TATTOOS: THE SURGEON'S DILEMMA Considering the increasing popularity of tattoos, surgical teams must be equipped with the skill set to accommodate tattoos encountered at potential operative sites. A study by Gilliam et al. found that female patients and patients who recently acquired their tattoo are especially likely to report distress about tattoo disruption. Furthermore, the authors note that 79% of surveyed general surgeons have come across a tattoo at a proposed abdominal incision site and 61% have altered their surgical approach to avoid a tattoo.9 Despite the frequency with which tattoos are encountered, there are currently no well-established best practices for managing tattoos in the operative field. To date, proposed techniques for tattoo management include moving the incision wherever possible,9,10 using minimally invasive techniques to reduce the incision size,9,11 and hiding incisions within the contours of tattoos.10–17 Most literature has described tattoos within the abdominal9,10,13,15 and lumbar regions,11,17 where surgeons have the option of avoiding tattoos by adjusting laparoscopic port sites or retractor placement.9,11 There is little information about best practices for tattoos encountered in more complex anatomical regions, such as the upper extremities. Among men, the arms are the most frequently reported sites for tattoos,18 and tattoos in these regions can be highly sentimental, often obtained with the intention of being seen. Tattoos on the upper extremities and other complex anatomical regions present a unique challenge for surgeons and require greater adaptability because they are less amenable to minimally invasive approaches or significant alterations to the location of a surgical incision. We draw on our experience operating around tattoos of the upper extremity to offer guidance on how to design incisions in a way that preserves the integrity of these highly meaningful symbols. RECOMMENDATIONS FOR TATTOO MANAGEMENT All preoperative consultations should start with careful inspection of the potential operative field. If a tattoo is encountered at the ideal incision site, surgeons should first determine the tattoo's sentimental value to the patient. Although minimizing disruption of tattoos should be prioritized in all cases, it is important to set expectations and discuss the risk of tattoo distortion during the consent process. In line with other authors, we recommend that surgeons change the location of the incision wherever possible.10 However, if operating at the site of the tattoo is unavoidable, we recommend one of the following 2 approaches. Approach 1: Incision Made Along the Contours of Tattoo In the authors' experience, the appearance of surgical scars can be minimized by treating the tattoo as a discrete aesthetic unit and concealing the incision along the interface of the tattooed and normal skin. If the tattoo's margin is located too far from the ideal incision site, the incision can instead follow a line or border between 2 colors within the tattoo itself, as demonstrated in Figure 1. Our team has successfully used this method to camouflage scars within intricate sleeve tattoos, including along the silhouette of the images of a patient's children and around the elaborate boundaries of flowers to conceal the surgical scar. Given the sensitive nature of such tattoos, we were unable to obtain patient consent to include images from these complex cases.Fig. 1.: Patient undergoing reconstruction of a ruptured tendon transfer. Preoperative view of the tattoo at the surgical site (left). An incision is designed to follow the contour of the tattoo and closed using a running subcuticular stitch (center). Surgical scar is minimally perceptible at 4-week follow-up (right).Approach 2: Incision Dividing the Tattoo into Planes If there is no line within the tattoo that would lend itself to an incision, the surgeon can instead design an incision that bisects the tattoo (Fig. 2), ideally along a plane of symmetry if one exists. However, this approach should be taken as a last resort because even with careful reapproximation of the tattoo edges, the scar may discolor or become hypertrophic. Figure 2 demonstrates the case of a patient who presented for removal of symptomatic hardware and was noted to have 2 preexisting surgical scars through an overlying tattoo. Hypopigmented "railroad-track" scars were also present within the shaded portions of the tattoo. An incision was designed at the prior surgical site, and the preexisting scars were excised. At the end of the case, the silhouette was realigned and closed with a running subcuticular stitch.Fig. 2.: This patient presented with 2 prior surgical scars and hypopigmented railroad-track scarring at the surgical site (left). Prior scars are excised, and at the end of the case, the edges are carefully reapproximated with a running subcuticular stitch (center). The scar is healing well with improved tattoo alignment at 3-week follow-up (right).In our experience, skin closure with Monocryl suture in a running subcuticular stitch yields the best cosmetic outcome and avoids potential railroad-track scars as occurred after the initial operation described above. Despite the best intentions, a degree of discoloration along the scar may be unavoidable; however, this can often be corrected by tattoo artists after the scar has healed. A summary of our recommendations is presented as an algorithm in Figure 3.Fig. 3.: Algorithm for designing incisions around preexisting tattoos.Tattoos can carry tremendous personal value to patients. Every effort should be made to handle these highly meaningful symbols thoughtfully out of respect for patients and their bodies. Accordingly, it is the surgeon's duty to solicit patients' preferences regarding their tattoos as part of the shared decision-making process and minimize the disruption of these works of art wherever possible. We believe that optimizing the surgical management of tattoos in the operative field will enhance patients' confidence in their surgeon and ultimately improve patients' satisfaction with their surgical outcomes. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and a research grant from Sonex to study carpal tunnel outcomes. The remaining authors have no financial interests to report. PATIENT CONSENT Patients provided written informed consent for the use of their images.