Magnetic Resonance Imaging and Permanent Cosmetics (Tattoos): Survey of Complications and Adverse Events
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JOURNAL OF MAGNETIC RESONANCE IMAGING 15:180 –184 (2002)
DOI 10.1002/jmri.10049
Original Research
Magnetic Resonance Imaging and Permanent
Cosmetics (Tattoos): Survey of Complications and
Adverse Events
Whitney D. Tope, MD, MPhil,1 and Frank G. Shellock, PhD2*
marks, and cheek blush (1). Additionally, permanent
Purpose: To use a survey to determine the incidence of
cosmetics are often used aesthetically to enhance nip-
complications and adverse events in individuals with per-
manent cosmetics (e.g., tattooed eyeliner, eyebrows, lips, ple-areola reconstruction (2).
cheeks, etc.) who underwent magnetic resonance (MR) im- Magnetic resonance (MR) imaging is a frequently
aging. used imaging modality, particularly for evaluating the
brain, head, neck, and other anatomic regions where
Materials and Methods: A questionnaire was distributed
cosmetic tattoos are typically applied. Unfortunately,
to clients of cosmetic tattoo technicians. This survey asked
study subjects for demographic data, information about there is much confusion regarding MR safety aspects of
their tattoos, and for their experiences during MR imaging permanent cosmetics (3– 6). For example, based on a
procedures. few reports of symptoms localized to the tattooed area
during MR imaging, many radiologists have refused to
Results: Data obtained from 1032 surveys were tabulated.
perform MR procedures on individuals with permanent
One hundred thirty-five (13.1%) study subjects underwent
MR imaging after having permanent cosmetics applied. Of cosmetics, particularly tattooed eyeliner (unpublished
these, only two individuals (1.5%) experienced problems observations, F. G. Shellock, 2000). Obviously, this un-
associated with MR imaging. One subject reported a sen- due concern for possible adverse events prevents pa-
sation of “slight tingling” and the other subject reported a tients with cosmetic tattoos from access to an extremely
sensation of “burning”; both sensations were transient in important diagnostic imaging technique.
nature. While it is well-known that cosmetic tattoos may
Conclusion: Based on these findings and information in cause MR imaging artifacts (3–11) and that both cos-
the peer-reviewed literature, it appears that MR imaging metic and decorative tattoos may cause relatively mi-
may be performed in patients with permanent cosmetics nor, short-term cutaneous reactions (3,8,11–16), the
without any serious soft tissue reactions or adverse events. frequency and severity of soft tissue reactions or other
Therefore, the presence of permanent cosmetics should not related problems associated with MR imaging and cos-
prevent a patient from undergoing MR imaging. metic tattoos is unknown. Therefore, the purpose of
Key words: magnetic resonance imaging, safety; magnetic this investigation was to determine the frequency and
resonance imaging, bioeffects; heating; artifacts; magnetic severity of adverse events associated with MR imaging
resonance imaging in a population of subjects with permanent cosmetics.
J. Magn. Reson. Imaging 2002;15:180 –184.
© 2002 Wiley-Liss, Inc.
MATERIALS AND METHODS
TRADITIONAL (I.E., DECORATIVE) and cosmetic tat- A questionnaire was developed to survey individuals
tooing have been performed for thousands of years. In with permanent cosmetics to determine the incidence
the United States, cosmetic tattooing or “permanent and severity of complications or adverse events associ-
cosmetics” are used to reshape, recolor, recreate, or ated with MR imaging. The questionnaire asked study
modify eye shadow, eyeliner, eyebrows, lips, beauty subjects for basic demographic data, information about
their cosmetic tattoos, information about their MR im-
aging examinations, and their experiences with these
1
procedures relative to the permanent cosmetics. Table
Department of Dermatology, University of Minnesota Hospital and
Clinic, Minneapolis, Minnesota. 1 shows the questionnaire used in this investigation.
2
University of Southern California, Keck School of Medicine, Los Ange- The questionnaire was distributed in the United
les, California. States to clients of permanent cosmetic technicians
Contract grant sponsor: Society of Permanent Cosmetic Professionals. who were members of the Society of Permanent Cos-
*Address reprint requests to: F.G.S., 7511 McConnell Ave., Los Angeles,
CA 90045.
metic Professionals (SPCP, an international, non-profit
E-mail: frank.shellock@gte.net organization of cosmetic tattoo artists). This permitted
Received July 18, 2001; Accepted October 11, 2001. individuals with cosmetic tattoos to be contacted con-
© 2002 Wiley-Liss, Inc. 180MRI and Permanent Cosmetics 181
Table 1 individuals ranged from 14 to 93 years old. Caucasians
Cosmetic Tattoo and Magnetic Resonance Imaging (MRI) formed the largest racial population (961; 93%) for the
Research Survey respondents (14 [1%] Asian; 16 [2%] Latino; six [1%]
Part I: Client Information African-American; two [0.2%] Native American; 30 [3%]
Age Race Sex State of Residence data not provided).
Please check the appropriate response: Eight hundred ninety-seven (897/1032; 87%) study
(1) I have cosmetic tattooing, but have never had an MRI.
subjects with permanent cosmetics reported that they
(2) My doctor recommended that I have an MRI, but the
radiologist wouldn’t allow me to have an MRI because
never had MR imaging examinations (Non-MRI Group),
of potential complications with cosmetic tattooing. while 135 (135/1032; 13%) study subjects underwent
(3) I have cosmetic tattooing and have had an MRI. MR imaging after application of permanent cosmetics
(MRI Group). The mean age of the Non-MRI Group (50 ⫾
If you checked #1, you have finished the survey. 5 years old) was significantly younger (P ⬍ 0.05) than
that of the MRI Group (56 ⫾ 5 years old). For the Non-
Part II: If you checked #2, or #3, please answer the following
MRI Group, five study subjects (6%) reported that the
questions:
Site for cosmetic tattoo (check all that apply):
MR facility personnel or radiologists would not allow
eyelid eyebrow cheeks lips them to have MR imaging procedures due to potential
areola other (specify) complications with cosmetic tattoos.
Pigment colors used: Unknown: For the MRI Group (N ⫽ 135), tattoo site information
was available in 131 subjects (97%). These subjects
Approximate date of your cosmetic tattoo procedure? / / reported a total of 210 individual tattoos (i.e., 61 sub-
jects, 45%, had more than one cosmetic tattoo). Of
Part III: If you checked #3, please answer the following questions:
these, 210 permanent cosmetics were applied to the
Area of body scanned by MRI:
head eye/orbit chest abdomen other following body sites: 85 (41%) eyelid, 75 (36%) eyebrow,
(specify) 34 (16%) lip, six (3%) cheek, four (2%) areola, and six
Did you have any complications in the area of the cosmetic (3%) trunk.
tattoo from the MRI? Yes No Information on tattoo pigment color was available for
112 of the 135 (83%) study subjects in the MRI Group.
If yes, please describe the complications you experienced (any Notably, 91 of these study subjects (67%) reported that
specific symptoms you experienced and how long they lasted)?
they had permanent cosmetics that were applied using
Note: to gather as much information as possible, it will be pigment colors (e.g., brown, black, red, and flesh) that
important to contact your radiologist about your MRI scan and typically contain iron oxide.
permanent cosmetic technician about your cosmetic tattoo. To For the MRI Group (N ⫽ 135), information on the
do this, we will need the following information. If you do not wish cosmetic tattoos and body sites for the MR imaging
to release this information, simply leave the spaces blank. examinations was available for 133 (98%) of the sub-
Thank you for your cooperation. jects and is shown in Table 2. Forty of these subjects
had MR imaging examinations involving more than one
Name Date of Birth / /
Radiologist’s Name Radiologist’s Phone Number anatomic region (i.e., for a total of 173 MR imaging
Approximate date of MRI scan / / examinations). Fifty-six (42%) of the subjects in the MRI
Permanent Cosmetic Technician’s Name Group had MR imaging examinations that involved the
Phone number immediate anatomic site where the permanent cos-
metic was applied (Table 2).
All of this information will be held in the strictest confidence and One hundred thirty-three (133/135, 98.5%) of the
only be used for research purposes. Your signature allows us to
MRI Group reported that there were no complications,
request access to your MRI report and films, only.
adverse events, or other problems associated with MR
imaging. Two (2/135, 1.5%) study subjects in the MRI
Group reported complications or adverse events asso-
fidentially through client lists of members of the SPCP.
ciated with MR imaging. One subject experienced
The study subjects were assured that the questionnaire
“slight tingling” before MR imaging began and the other
would be analyzed with anonymity maintained. The
subject reported a “burning” sensation that started be-
questionnaires were returned to the primary author
(W.D.T.) for tabulation, and the results were analyzed fore entering the magnet (i.e., while in the MR system
using simple descriptive data techniques. room, in the MR environment) that resolved by the end
of the examination. Both of these subjects were women
who had blue-black pigment colors used for periorbital
RESULTS (i.e., eyelid/eyeliner) tattoos and underwent MR imag-
Of a total of 3065 questionnaires that were distributed, ing of the cervical spine. Each tattoo had been applied
1037 (34%) were returned for analysis. Five surveys at least nine months prior to the MR imaging examina-
contained insufficient data for inclusion (i.e., the an- tion. In neither case did the severity of symptoms war-
swers were incomplete), leaving a total of 1032 ques- rant cessation of the MR imaging. Neither subject re-
tionnaires available for tabulation. ported any other problem with the tattooed areas (e.g.,
The majority (1027; 99.5%) of the study subjects with erythema, edema, irritation, etc.) subsequent to MR
permanent cosmetics were women. The ages of these imaging.182 Tope and Shellock
Table 2 According to the findings of our study, there was an
Anatomic Sites for MR Imaging Examinations for Subjects With extremely low incidence (1.5%) of complications or ad-
Permanent Cosmetics verse events, and the severity of these problems was
Anatomic sitea No. of MR imaging examinations relatively minor (i.e., there was no serious, permanent,
or life-threatening injury). Of interest is that, for these
Head 56
Neck 16
study subjects, one individual reported a “burning sen-
Eye/orbit 1 sation” that was unrelated to the actual scanning pro-
Chest 15 cedure (i.e., upon entering the MR environment), while
Abdomen 12 the other subject’s symptom, a “tingling sensation”, has
Lower extremity 26 not been previously reported. Importantly, neither
Spineb 11 problem prevented completion of the MR imaging pro-
Back 23 cedure.
Pelvis 4 Investigations of incidents related to patients experi-
Shoulder 5 encing cutaneous or other reactions in relation to the
Total bodyc 2
presence of both cosmetic and decorative tattoos re-
Site not indicated 2
vealed that there was a tendency for these problems to
Anatomic No. of MR imaging Complication/adverse occur whenever pigments that contained iron oxide or
sited examinations event other similar metallic substance(s) were used (3–16).
Neck 1 Slight tingling The study subject that reported a “burning sensation”
Neck 1 Burning had her cosmetic tattoo applied by an ophthalmologist
a
Subjects with permanent cosmetics that did not have adverse re- using black pigment that typically contains iron oxide.
actions (number of subjects, 133; total number of MR imaging ana- Unfortunately, the exact type of pigment that was used
tomic sites, 173). could not be verified and there tends to be little quality
b
Spine refers to cervical, thoracic and lumbar spine spine MR imag- control over tattoo ink (15). Apparently, certain ferrous
ing examinations. pigments used for the tattooing process can interact
c
Total body was the term used by the subjects to describe their with the electromagnetic fields used for MR procedures,
examinations.
d producing the reported problems (7–11,13,16).
Subjects with permanent cosmetics that had a complication or
adverse event (number or subjects, 2).
Proposed mechanisms to explain tattoo-related prob-
lems encountered in the MR environment include mag-
netic field related interactions and/or radiofrequency
DISCUSSION (RF)-induced induction of heating. The fact that an in-
The incidence of complications or adverse reactions and dividual in this study reported symptoms even before
severity of these problems for patients with permanent entering the MR system suggests that one possible
cosmetics undergoing MR imaging examinations are causative factor is the static magnetic field. Presum-
unknown. Unfortunately, many MR healthcare profes- ably, traction or torque from interaction of the ferro-
sionals do not fully understand the relative risk of per- magnetic tattoo particles with the static magnetic field
forming MR imaging in patients with permanent cos- may be partially responsible for the symptoms re-
metics and, as such, may not allow these patients to ported.
undergo examinations. (For example, findings from this In a letter to the editor that described a second-degree
survey revealed that 6% of the study subjects with per- burn that occurred on the skin of the deltoid from a
manent cosmetics were not allowed to undergo MR im- decorative tattoo, the authors suggested that “the heat-
aging because of MR safety concerns.) Therefore, the ing could have come either from oscillations of the gra-
purpose of this investigation was to determine the fre- dients or, more likely from the RF-induced electrical
quency and severity of problems associated with MR currents” (15). However, the exact mechanism(s) re-
imaging in a selected population of subjects with per- sponsible for complications or adverse events in the
manent cosmetics with the intent of providing guidance various cases that have occurred is unknown.
and recommendations based on the results of this Interestingly, decorative tattoos tend to cause worse
study and those published in the peer-reviewed litera- problems (including first- and second-degree burns) for
ture. patients undergoing MR imaging compared to those
To date, only a small number of patients (estimated to who have been reported for cosmetic tattoos
be less than 10) that have undergone MR imaging have (6 –13,15,16). For example, a recent publication re-
reported transient symptoms that included skin irrita- ported that a patient experienced a sudden burning
tion, cutaneous swelling, or a heating sensation at the pain at the site of a decorative tattoo while undergoing
site of application of the permanent cosmetics (review of MR imaging of the lumbar spine using a 1.5-Tesla MR
Medical Device Reports, 1985 to 1999). Because of system (13). Swelling and erythema resolved within 12
these incidents, the latest MR safety recommendations hours, without evidence of permanent sequelae. The
and guidance from the Food and Drug Administration tattoo pigment used in this case was ferromagnetic,
(Guidance for Industry Guidance for the Submission of which possibly explains the symptoms experienced by
Premarket Notifications for Magnetic Resonance Diag- the patient. Surprisingly, in order to permit completion
nostic Devices) states that the performance of an MR of the MR examination, an excision of the tattooed skin
imaging examination requires particular caution for with primary closure of the site was performed (13).
“patients with permanent (tattoo) eye-liner or with fa- The authors of this report stated, “Theoretically, the
cial make-up” (17). application of a pressure dressing of the tattoo mayMRI and Permanent Cosmetics 183
prevent any tissue distortion due to ferromagnetic pull” imaging procedures using standard, MR imaging tech-
(13). However, this simple, relatively benign procedure niques and procedures. Additionally, it would be ad-
was not attempted for this patient. They also indicated vantageous to evaluate additional subjects with both
that, “In some cases, removal of the tattoo may be the cosmetic and decorative tattoos that undergo MR imag-
most practical means of allowing MRI” (13). ing. Thus, additional research that acquires specific MR
Kanal and Shellock (14) commented on this report in imaging information in a larger group of tattooed sub-
a letter to the editor, suggesting that the response to jects is warranted. This may help determine a mecha-
this situation was “rather aggressive”. Clearly the nism responsible for the cutaneous reactions that
trauma, expense, and morbidity associated with exci- sometime occur in the MR setting.
sion of a tattoo far exceed those that may be associated In consideration of the findings of this study and the
with ferromagnetic tattoo interactions. A firmly applied available literature pertaining to MR imaging and pa-
pressure bandage may be used if there is any concern tients with cosmetic tattoos, the following patient man-
related to “movement” of the ferromagnetic particles in agement guidelines are recommended:
the tattoo pigment (14). Additionally, direct application
of a cold compress to the site of a tattoo would also 1. The Pre-MR Procedure Screening Form should in-
likely mitigate any heating sensation that may occur in clude a question pertaining to the presence of per-
association with MR imaging. manent cosmetics or decorative tattoos (3–5).
A comprehensive search of the peer-reviewed litera- 2. Before undergoing an MR imaging examination,
ture supports the results of this present investigation the patient should be asked if he or she has a
(8 –10). That is, symptoms rarely occur, the symptoms permanent coloring technique (i.e., tattooing) ap-
are transient in nature, and the severity of the symp- plied to any part of the body. This includes cos-
toms is relatively minor. Furthermore, when one con- metic applications such as eyeliner, lip-liner, lip
siders the many millions of clinical MR procedures that coloring, and decorative designs.
have been conducted in patients over the past 15 years 3. The patient should be informed of the relatively
and that only a very small percentage of these individ- minor risk associated with the site of the tattoo.
uals have had minor, short-term problems related to 4. The patient should be advised to immediately in-
the presence of permanent cosmetics, it is apparent form the MR technologist regarding any unusual
that this MR safety concern has an extremely low rate of sensation felt at the site of the tattoo in association
occurrence and relatively insignificant consequences. with the MR imaging procedure.
With regard to artifacts, none of the study subjects in 5. The patient should be closely monitored using vi-
this investigation were informed that the MR images sual and auditory means throughout the entire
were substandard due to the presence of tattoos and operation of the MR system to ensure safety.
none of the examinations had to be repeated. Neverthe- 6. As a precautionary measure, a cold compress (e.g.,
less, imaging artifacts associated with permanent cos- wet wash cloth) may be applied to the tattoo site
metics have been reported (7–10). These artifacts are during the MR imaging procedure.
predominantly associated with the presence of pig- In conclusion, because of the relatively remote possi-
ments that use iron oxide and occur in the immediate bility of having an incident occur in a patient with a
area of the tattoo. As such, tattoo-related MR imaging permanent cosmetic and due to the relatively minor,
artifacts should not prevent a diagnostically adequate short-term complication or adverse event that may
MR imaging procedure from being performed, especially develop (i.e., transient cutaneous redness and swell-
in consideration that careful selection of imaging pa- ing), the patient should be permitted to undergo MR
rameters may easily minimize artifacts related to me- imaging. Any problem of performing an MR imaging
tallic objects (3,4). procedure in a patient that has a cosmetic tattoo is
The only possible exception to this is if the anatomy of unlikely to prevent the examination, since the impor-
interest is in the exact same position of where the tattoo tant diagnostic information that is provided by this
was applied using an iron oxide-based pigment. For imaging modality is typically critical to the care and
example, Weiss et al (7) reported that heavy metal par- management of the patient.
ticles used in the pigment base of mascara and eyelin-
ing tattoos cause alterations of the local magnetic field
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