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ORIGINAL ARTICLE
Ahead of print publication  

Is tattoo in the operative field a disadvantage in posterior thoracolumbar surgery?


1 Department of Neurosurgery, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
2 Department of Neurosurgery, Faculty of Medicine, Ege University, Bornova, Izmir, Turkey

Date of Submission21-Apr-2022
Date of Decision22-Jun-2022
Date of Acceptance22-Jun-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Erkin Ozgiray,
Department of Neurosurgery, Faculty of Medicine, Ege University, 35040 Bornova, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nsn.nsn_71_22

  Abstract 


Objective: Tattooing has become more popular, especially in Western culture. We aimed to analyze the impacts of the presence of tattoos in the operative field for posterior thoracolumbar surgery. Methodology: This study was performed using data extracted from the medical files of 15 patients who underwent posterior thoracolumbar surgery between April 2013 and May 2020 in the neurosurgery department of our tertiary care center. Therapeutic, clinical, and cosmetic outcomes after surgery necessitating incision on the tattoo are presented together with a brief discussion of the current literature. Results: Our series consisted of nine women and six men with an average age of 31.03 (range, 17–45) years. The duration of follow-up was 52 (range, 6–90) months. Ten patients underwent posterior spinal stabilization, and a simple discectomy was performed on five patients. The therapeutic outcomes and clinical improvement were satisfactory in all patients. No complications attributed to the presence of tattoos were detected in any patients. Conclusion: Posterior thoracolumbar surgery usually necessitates a midline incision that may unavoidably result in the deformation of a tattoo. Our results yielded that therapeutic and cosmetic results in patients with tattoos in the operative field were acceptable in the vast majority of cases after posterior thoracolumbar surgery.

Keywords: Incision, management, operative field, tattoo



How to cite this URL:
Yilmaz M, Yucesoy K, Ozgiray E. Is tattoo in the operative field a disadvantage in posterior thoracolumbar surgery?. Neurol Sci Neurophysiol [Epub ahead of print] [cited 2022 Aug 17]. Available from: http://www.nsnjournal.org/preprintarticle.asp?id=351548




  Introduction Top


Tattooing is growing more popular in Western civilization, with 10%–16% of adolescents and 3%–24% of the general population getting one or more permanent tattoos. The lower back, shoulder, and ankles are the most popular tattoo placements for women. For men, the most popular tattoo locations are the chest and arms. Patients may assume they are necessary because tattoos typically include names of loved ones, images, or dates to highlight key life events. Tattoos have become more popular as a result of modern media's fixation with image, fashion, and celebrity culture, which has pushed tattooing into the mainstream.[1]

Tattooing on the body with varied features and sizes has exploded in popularity in recent years across the globe. In the surgical sector, tattoos are commonly encountered in spine surgery applications, particularly in posterior approaches. Although various dermatologic and systemic issues associated with tattooing have been recorded in the general literature, there is no established complication associated with creating an incision over a tattoo.[1],[2],[3] The major issue here is that even while we perform all of the neurologic, radiologic, and other preoperative evaluations on the individuals we select to undergo surgery, we often miss the simple examination of the surgical field.[3]

When we place patients on the operating table in the prone position and notice a tattoo in the surgical field, we know they have had general anesthesia and we usually may not have time to talk to them about it. This raises the possibility of medicolegal issues relating to the tattoo that the patient had diligently completed previously. Therefore, all patients on whom we decide to perform thoracolumbar surgery must undergo a thorough inspection of the surgical field.

However, as tattoos become more popular in society, surgeons will be confronted with them at or near the operating site more frequently. Furthermore, because patients value tattoos and patient satisfaction is a major outcome, tattoos may restrict the usual position of surgical incisions.[4],[5]

Skin tattoos can be a problem in plastic surgery settings because the images can be located within the operative field, interfering with the standard placement of surgical incisions, they can also interfere with the scarring process due to granulomatous reactions on some components of the inks used, and they can even hide dermatologic pathologies such as melanomas, altering the operative field.[6] It is important to think about the preservation of tattoos during surgery because they can be rather expensive and might be seen as an important part of a person's identity.[7]

The purpose of this study was to present our experience with patients when a tattoo was present in the operative field for patients scheduled for posterior thoracolumbar surgery. Demographic, clinical, therapeutic, and cosmetic outcomes are introduced together with a brief discussion of the current relevant literature.


  Methodology Top


This retrospective study was performed per the principles of the Helsinki Declaration after receiving the approval of the Local Institutional Review Board (2021/21-07).

All the data were extracted from the medical files of 15 patients with tattoos in the operative field who underwent posterior thoracolumbar surgery in the neurosurgery department of our tertiary care center between April 2013 and May 2020. Demographic, clinical, surgical, and therapeutic outcomes, as well as postoperative complications and complaints, were noted. The population consisted of nine women and six men with an average age of 31.03 (range, 17–45) years. Patients with a history of cutaneous disease, collagen vascular disease, previous trauma, or other surgery at the site of trauma were excluded from the study.

Statistical analysis

Our data were analyzed using the Statistical Package for the Social Sciences program version 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive data are expressed as frequency, mean, standard deviation, median, and minimum–maximum.


  Results Top


Our series consisted of 15 patients (nine women and six men) with an average age of 31.03 (range, 17–45) years. Five patients underwent a simple discectomy, and posterior spinal stabilization was performed on 10 patients. The mean duration of follow-up was 52 (range, 6–90) months. All patients reported good clinical recovery and satisfactory therapeutic outcomes. No surgical complications or tattoo-related problems were detected. Four patients verbally complained about the deformation of their tattoo due to an incision scar, but no medicolegal applications or cases were recorded.

[Figure 1] demonstrates an L5-S1 disc herniation preoperative image on TW2 magnetic resonance imaging.
Figure 1: L5-S1 disc herniation (sagittal and axial views on TW2 magnetic resonance imaging)

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[Figure 2] exhibits the intraoperative site of an incision with a tattoo, as well as the sutured and dressed site of the incision. Preoperative views of incision sites with tattoos are demonstrated in [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. A postoperative view of an incision site including a tattoo for lumbar disc herniation is shown in [Figure 4].
Figure 2: (a) Sutured incision line across the tattoo, (b) dressed incision line across the tattoo

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Figure 3: (a-d) Preoperative view of incision site with a tattoo

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Figure 4: Postoperative view of incision site for lumbar disc herniation with a tattoo

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  Discussion Top


In surgical practice, tattoos are becoming more common. Disrupting a tattoo with surgery can be upsetting, especially for people who have just had their tattoos done.[8] This is especially true in cosmetic surgery when the goal is to improve one's appearance and well-being. Physicians must have full awareness of the different tattoo management options in terms of the surgical site and tattoo placement due to the rise in both esthetic surgery and the frequency of tattoos.[1]

It is vital to establish the value of a tattoo to the patient before surgery to have the best surgical outcome. During the permission procedure, you should inform the patient about the likelihood of the tattoo being deformed by the surgical incision.[1] Surgeons must be aware of the fact that the application of larger tattoos needs more time, and cause more discomfort and pain.[1]

When performing surgery, the goal should always be to inflict as little harm to the patient's body as possible. Competent use of existing anatomy and tissue handling is essential to achieve a desirable cosmetic result in esthetic surgery. The borders between cosmetic units or natural skin folds are used to conceal surgical incisions.[9] Tattoo removal should be performed using the same surgical principles, and tattoos must be considered as separate esthetic entities.[10]

In abdominal and extremity surgery, an incision may be performed around the tattoo; however, thoracolumbar surgery almost always necessitates a midline surgical incision. Therefore, avoidance of the tattoo in the operative field may not be possible if such an incision is performed. Therefore, the possibility of the deformation of the tattoo must be discussed clearly with the patient before surgery. In parallel with recent literature, we did not come across any tattoo-related complications due to incisions at the sites of the tattoos.[11]

Skin tattoos are becoming more fashionable, even though they are still considered taboo in Western society. The first Polynesian cultures wore these archaic art forms to symbolize bravery, leadership, authority, or the completion of a cultural milestone approximately 2000 years ago.[12] Tattoos are today considered a way to express one's individuality and freedom, as well as a way to enhance one's physical beauty.[12]

In the medical field, tattoo techniques have been used to identify nonpalpable tumors in the neck and breast, camouflage various scars for cosmetic improvement or nipple reconstruction after mastectomies, body identification assistant for forensics, field marking radiation in oncology, or as a warning for chronic disease or life-threatening allergy.[13],[14]

According to recent research, 79% of surgeons have discovered tattoos at indicated incision sites, and 61% prefer to change the incision site to avoid patients complaining about tattoo disruption.[8]

Although there is nothing written in the surgical field about how to proceed in the event of a tattoo, the literature mainly agrees on planning the procedure ahead of time and taking into account and respecting the patient's choices. Different preservation solutions have been described based on the size and placement of the tattoo: small tattoos have no restrictions on where surgical wounds can be placed; however, medium and large colored tattoos can be preserved by cutting along the tattoo's edge or inside the tattooed area.[15]

Tattoos may be evaluated as possible incision access wherever tattoos are present in the surgical field, both to preserve the tattoo and avoid visible scars. The tattoo can be used to conceal the incisions and subsequent scars, resulting in a more attractive cosmetic effect while also concealing the patient's and surgeon's satisfaction.[7] In parallel with recent literature, we did not come across any tattoo-related complications due to incisions at the sites of tattoos.[11]

The main limitations of this study include its small sample size, retrospective design, and data being confined to the experience of a single center. Moreover, the impacts of possible confounding factors such as sex, age, and ethnicity must be remembered during the interpretation of our results.

In abdominal or extremity surgery, the performance of an incision around a tattoo may be feasible. However, posterior thoracolumbar surgery incisions are mostly performed in the midline and the tattoo in the operative field is usually affected by the incision.


  Conclusion Top


Our preliminary data demonstrated that incisions performed on the site of tattoos were associated with satisfactory therapeutic and cosmetic outcomes after posterior thoracolumbar surgery. There seem to be no remarkable disadvantages linked with the presence of a tattoo at the site of an incision. However, preoperative information must be provided to the patient about the fate of the tattoo and the likelihood of the possibility of deformation of the tattoo due to an incision.

Patient consent

Written informed consent was taken from patients or their parents for the utility of data for scientific purposes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smit JM, Scheele K, Lapid O, Hoogbergen MM. Management of tattoos in the operative field. Ann Plast Surg 2010;64:125-7.  Back to cited text no. 1
    
2.
Douglas MJ, Swenerton JE. Epidural anesthesia in three parturients with lumbar tattoos: A review of possible implications. Can J Anaesth 2002;49:1057-60.  Back to cited text no. 2
    
3.
Raynaud L, Mercier FJ, Auroy Y, Benhamou D; SOS ALR. Epidural anaesthesia and lumbar tattoo: What to do?. Ann Fr Anesth Reanim 2006;25:71-3.  Back to cited text no. 3
    
4.
Gahm J, Jurell G, Edsander-Nord A, Wickman M. Patient satisfaction with aesthetic outcome after bilateral prophylactic mastectomy and immediate reconstruction with implants. J Plast Reconstr Aesthet Surg 2010;63:332-8.  Back to cited text no. 4
    
5.
Spear SL, Schwarz KA, Venturi ML, Barbosa T, Al-Attar A. Prophylactic mastectomy and reconstruction: Clinical outcomes and patient satisfaction. Plast Reconstr Surg 2008;122:1-9.  Back to cited text no. 5
    
6.
Haber R, Farid S. Granulomatous tattoo reaction confined to red pigment. Ann Dermatol Venereol 2016;143:79-80.  Back to cited text no. 6
    
7.
Velasquez JF, Nele G, Giordano S. Abdominal tattoo can be useful to avoid a midline abdominal incision. J Surg Case Rep 2018;2018:rjy071.  Back to cited text no. 7
    
8.
Gilliam AD, Donnelly L, Gopinath B. Avoidance of tattoo disruption: A further benefit of laparoscopic surgery. Surg Endosc 2009;23:318-20.  Back to cited text no. 8
    
9.
Millard DR. Principlization of Plastic Surgery. Boston, Little: Brown and Company; 1986. p. 229-52.  Back to cited text no. 9
    
10.
Lapid O. Use of an existing tattoo to conceal a surgical incision. Plast Reconstr Surg 1998;102:2515-6.  Back to cited text no. 10
    
11.
Kluger N, Sleth JC. Lumbar tattoos and epidural analgesia in 2018: Time to let it go? Int J Obstet Anesth 2018;34:113.  Back to cited text no. 11
    
12.
Shenefelt PD, Shenefelt DA. Spiritual and religious aspects of skin and skin disorders. Psychol Res Behav Manag 2014;7:201-12.  Back to cited text no. 12
    
13.
Tirelli G, Cova MA, Boscolo-Rizzo P, Da Mosto MC, Makuc E, Gardenal N. Charcoal suspension tattoo: A new technique for intraoperative detection of small tumors of the parotid gland. Ann Otol Rhinol Laryngol 2016;125:529-35.  Back to cited text no. 13
    
14.
DiCenso D, Fischer-Cartlidge E. Nipple-areola tattoos: Making the right referral. Oncol Nurs Forum 2015;42:E376-81.  Back to cited text no. 14
    
15.
Kim EK, Chang TJ, Hong JP, Koh KS. Use of tattooing to camouflage various scars. Aesthetic Plast Surg 2011;35:392-5.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

 
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