Tattooing to reconstruct Nipple-Areola Complex after oncological breast surgery: a scoping review

PURPOSE

The dermopigmentation of the Nipple-Areola Complex (NAC) is a safe non-surgical reconstruction technique that can restore psychophysical integrity, representing the final step after oncological surgery. This scoping review aims to identify and synthesize the literature focused on medical tattooing for NAC reconstruction in women who underwent breast reconstruction after cancer surgery. Competence and training, outcomes and organizational aspects were assessed as specific outcomes.

METHODS

The Joanna Briggs Institute (JBI) methodology for scoping reviews was followed. MEDLINE, Embase, Cochrane Library, Clinical Key, Scopus and Cinahl databases were consulted. After title (N = 54) and abstract (N = 39) screening and full-text review (N = 18), articles that met eligibility criteria were analyzed, critically apprised and narratively synthesized.

RESULTS

13 articles were analysed, with full texts (N = 11) and only abstract (N = 2). The overall quality of the literature (N observational studies = 11; N pilot experimental studies = 2) is weak. Nurses were the professionals mostly involved (N = 6), then medical staff (N = 4) and tattoo artists (N = 2). The professional training is poorly described in 6 papers. The most frequently assessed outcome was the satisfaction rate (N = 8). One study explored aspects of quality of life with a validated questionnaire. The management of these services resulted variable. Nurse-led services were implemented in 2 studies.

CONCLUSION

Despite methodological weaknesses, NAC tattooing research is relevant because it helps women redefine their identity after demolitive cancer treatments. Further research on processes and outcomes is needed.

Factors influencing final rendering in areola tattoo reconstruction: a statistical analysis

BACKGROUND AND AIM

Reconstruction of the nipple-areola complex announces the end of breast reconstruction process, sometimes difficult to live for the patient, and significantly improves the perception of body image. In literature there are no studies addressing the possible influencing factors of the final rendering of areola reconstruction with tattoo. The aim of the present study was to evaluate all the factors which could influence the yield and the final result of the nipple areola complex pigmentation.

METHODS

97 patients who underwent areolar tattooing between January 2018 and February 2020 were retrospectively reviewed. Breast reconstruction timing and personal history, as well as surgical details were recorded.

RESULTS

Mean age was 52 years old (range 29-71), almost the totality of cases was women including even 2 men (one with Poland syndrome and one post mastectomy). 27 patients needed bilateral tattooing. 22 had history of adjuvant radiotherapy, 16 received neoadjuvant chemotherapy and 4 adjuvant chemotherapy. In the logistic regression analysis, radiotherapy resulted a risk factor for retattooing (p<0.05) while the autologous breast reconstruction resulted a protective factor for retattooing. Neo - and adjuvant chemotherapy were not statistically significant.

CONCLUSIONS

Tissue thickness, sex, reconstructive technique and history of radiotherapy could influence the final result in areola reconstruction with tattoo, and must be taken into account to obtain the best result, knowing when the pigmentation has to be repeated.

Near-infrared fluorescence tattooing: a new approach for endoscopic marking of tumors in minimally invasive colorectal surgery using a persistent near-infrared marker

INTRODUCTION

Intraoperative accurate localization of tumors in the lower gastrointestinal tract is essential to ensure oncologic radicality. In minimally invasive colon surgery, tactile identification of tumors is challenging due to diminished or absent haptics. In clinical practice, preoperative endoscopic application of a blue dye (ink) to the tumor site has become the standard for marking and identification of tumors in the colon. However, this method has the major limitation that accidental intraperitoneal spillage of the dye can significantly complicate the identification of anatomical structures and surgical planes. In this work, we describe a new approach of NIR fluorescent tattooing using a near-infrared (NIR) fluorescent marker instead of a blue dye (ink) for endoscopic tattooing.

METHODS

AFS81x is a newly developed NIR fluorescent marker. In an experimental study with four domestic pigs, the newly developed NIR fluorescent marker (AFS81x) was used for endoscopic tattooing of the colon. 7-12 endoscopic submucosal injections of AFS81x were placed per animal in the colon. On day 0, day 1, and day 10 after endoscopic tattooing with AFS81x, the visualization of the fluorescent markings in the colon was evaluated during laparoscopic surgery by two surgeons and photographically documented.

RESULTS

The detection rate of the NIR fluorescent tattoos at day 0, day 1, and day 10 after endoscopic tattooing was 100%. Recognizability of anatomical structures during laparoscopy was not affected in any of the markings, as the markings were not visible in the white light channel of the laparoscope, but only in the NIR channel or in the overlay of the white light and the NIR channel of the laparoscope. The brightness, the sharpness, and size of the endoscopic tattoos did not change significantly on day 1 and day 10, but remained almost identical compared to day 0.

CONCLUSION

The new approach of endoscopic NIR fluorescence tattooing using the newly developed NIR fluorescence marker AFS81x enables stable marking of colonic sites over a long period of at least 10 days without compromising the recognizability of anatomical structures and surgical planes in any way.

Aesthetic corneal tattooing/keratopigmentation using tattoo pen machine: choosing suitable method and color

PURPOSE

This article aims to present the corneal tattooing method and how using a tattoo pen machine can improve aesthetic appearance in patients with corneal leukoma.

METHODS

In this study, 42 patients were evaluated who had no visual potential and who had undergone colored corneal tattooing using an automatic tattoo pen machine for aesthetic purposes. The procedure was conducted according to the principles of the Declaration of Helsinki. The commercially available tattoo ink that has traditionally been used on human skin (brown, green, and black) for years was used for all the patients in this study, and 252 corneal photographs (with a Topcon slit lamp imaging device at 16 magnifications, i.e., 16 ×) taken within the last 2 years were evaluated retrospectively. Red, green, and blue (RGB) and hue, saturation, and lightness (HSL) values of the tattooed areas, such as pupils and iris, in corneal photographs were determined online using the Color Code Finder program. The RGB and HSL values of the pupil and iris were compared before surgery on the first day and first week, first month, third month, and twelfth month after surgery.

RESULTS

In the first postoperative month, the mean pupil lightness (L) and iris L values were found to have increased by 10.7% and 5.7%, respectively. Between the first month and the first year, the L value of the mean pupil and that of the iris increased by 1.7% and 5.2%, respectively. The increase in the RGB value of the mean pupil in the first month was statistically significant (p = 0.02). The highest increase in RGB values of the iris was observed in the first week and first month (p = 0.113). This result shows that the majority of fading occurred in the first month. After the first month, the increase in the L value in the black-colored pupil was less than that in the brown- or green-colored iris. These results show that light colors fade faster and more.

CONCLUSION

Esthetically, corneal leukoma causes severe psychological problems. Many patients are unable to use prosthetic contact lenses. Evisceration surgery has many complications, and limbal stem cells are used in evisceration surgery. Corneal tattooing using a tattoo pen machine is an easy, practical, and repeatable method used for aesthetic purposes. Successful results require the use of appropriate methods, ink, and ophthalmologist's experience. All patients in this study had a more aesthetic appearance than the preoperative white eye. Further studies are needed to develop a colored aesthetic tattooing method with a tattoo pen machine.

Preoperative fluorescent clip marking vs. India ink tattooing for tumor identification during colorectal surgery

PURPOSE

Identifying tumor location is important in colorectal tumor resection. Preoperative endoscopic India ink marking is a widespread practice, but local injection of ink is an unstable procedure. Although it is often invisible, the ink may be sprayed into the peritoneal cavity and contaminate the surgical field. At our hospital, we introduced fluorescent clip marking (FCM) using the Zeoclip FS®, an endoscopic clip developed using near-infrared fluorescent resin. We tested the usefulness of FCM by retrospectively comparing cases in which FCM was used with cases in which conventional ink marking was used.

METHODS

We enrolled 305 patients with colorectal tumors who underwent colorectal surgery after preoperative marking from January 2017 to April 2022. We classified the patients into the FCM group (86 patients) and the India ink tattoo group (219 patients). Endoscopic marking was completed in the FCM group by the day before surgery, and fluorescence was evaluated during surgery with a fluorescent laparoscopic system. Patient backgrounds, marking visibility, adverse effects, and early postoperative results were retrospectively compared between groups.

RESULTS

Marking was visually confirmed in 80 patients in the FCM group (93.02%) and in 166 patients in the India ink tattoo group (75.80%) (p = 0.0006). In the group with India ink tattoos, contamination of the surgical field was observed in seven cases (3.20%). No adverse events were observed in the FCM group.

CONCLUSION

In colorectal surgery, FCM provides better visibility than the conventional India ink tattooing method and is a simple and safe marking method.

CLINICAL TRIAL REGISTRATION

Examination of fluorescence navigation for laparoscopic colorectal cancer surgery. Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf .

Intrastromal keratopigmentation: a boon for unsightly corneal scars

PURPOSE

The aim of this study was to improve cosmesis in patients with corneal opacity (CO) using newer organic micronized pigments.

METHODS

Settings: Tertiary Care eye center, Design: Retrospective study.

INCLUSION CRITERIA

Patients with unsightly corneal scars not suitable for keratoplasty, eccentric corneal opacity not requiring keratoplasty, or lenticular opacity/anterior or posterior capsular opacities in non-seeing eyes. Micronized organic pigment was used for keratopigmentation by the intrastromal pocket technique (ISPT) in deep corneal opacities and lenticular opacities, whereas the intrastromal needle puncture technique (ISNT) was used in superficial opacities or corneoiridic scars. The records of 463 patients were reviewed and analyzed for the duration of the past 7 years.

RESULTS

Two hundred and ninety-three (63.2%) patients underwent ISNT, eight underwent combined technique, and the rest underwent ISPT. The postoperative follow-up period showed more watering and redness in the needle puncture technique (p > 0.001), which resolved in 70.4% of patients by the end of 4 weeks. Repeat procedures were required in 5.3% of the patients with ISNT. The patient's satisfaction grading showed excellent levels in 375 (80.9%) patients, 45 (9.7%) had good satisfaction levels, and the rest had average satisfaction levels.

CONCLUSION

Intrastromal keratopigmentation is a boon for unsightly corneal scars and gives respite to the patients from the social stigma.

A Single Electronic Tattoo for Multisensory Integration

Wearable electronics are garnering growing interest in various emerging fields including intelligent sensors, artificial limbs, and human-machine interfaces. A remaining challenge is to develop multisensory devices that can conformally adhere to the skin even during dynamic-moving environments. Here, a single electronic tattoo (E-tattoo) based on a mixed-dimensional matrix network, which integrates two-dimensional  MXene nanosheets and one-dimensional cellulose nanofibers/Ag nanowires, is presented for multisensory integration. The multidimensional configurations endow the E-tattoo with excellent multifunctional sensing capabilities including temperature, humidity, in-plane strain, proximity, and material identification. In addition, benefiting from the satisfactory rheology of hybrid inks, the E-tattoos are able to be fabricated through multiple facile strategies including direct writing, stamping, screen printing, and three-dimensional printing on various hard/soft substrates. Especially, the E-tattoo with excellent triboelectric properties also can serve as a power source for activating small electronic devices. It is believed that these skin-conformal E-tattoo systems can provide a promising platform for next-generation wearable and epidermal electronics.

Fallibility of tattooing colonic neoplasia ahead of laparoscopic resection: a retrospective cohort study

INTRODUCTION

Precise geographical localisation of colonic neoplasia is a prerequisite for proper laparoscopic oncological resection. Preoperative endoscopic peri-tumoural tattoo practice is routinely recommended but seldom scrutinised.

METHODS

A retrospective review of recent consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection as identified from our prospectively maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation.

RESULTS

Some 210 patients with 'tattooed' colonic neoplasia were identified, of whom 169 underwent laparoscopic surgery (mean age 68 years, median BMI 27.8kg/m2, male-to-female ratio 95:74). The majority of tumours were malignant (149; 88%), symptomatic (133; 79%) and proximal to the splenic flexure (92; 54%). Inaccurate colonoscopist localisation judgement occurred in 12% of cases, 60% of which were corrected by preoperative staging computed tomography scan. A useful lesional tattoo was absent in 11/169 cases (6.5%) being specifically stated as present in 104 operation notes (61%) and absent in 10 (5.9%). Tumours missing overt peritumoral tattoos intraoperatively were more likely to be smaller, earlier stage and injected longer preoperatively (p=0.006), although half had histological ink staining. Eight lesions missing tattoos were radiologically occult. Four (44%) of these patients had on-table colonoscopy, and five (55%) needed laparotomy (conversion rate 55% vs 23% overall, p<0.005) with one needing a second operation to resect the initially missed target lesion. Mean (range) operative duration and postoperative length of stay of those missing tattoos compared with those with tattoos was 200 (78-300) versus 188 (50-597) min and 15.5 (4-22) versus 12(4-70) days (p>0.05).

CONCLUSIONS

Tattoo in advance of attempting laparoscopic resection is vital for precision cancer surgery especially for radiologically unseen tumours to avoid adverse clinical consequence.

Assessing the Association Between Endoscopic Tattooing and Lymph Node Yield in Rectal Cancer

INTRODUCTION

Preoperative endoscopic tattooing is an effective tool for intraoperative tumor localization in colon cancer. Endoscopic tattooing in rectal cancer may have unidentified benefits on lymph node yield, making it easier for pathologists to identify nodes during histopathologic assessment. There remains concern that tattoo ink may alter anatomical planes, increasing surgical difficulty.

METHODS

Retrospective chart reviews from 2016 to 2021 of n = 170 patients presenting with rectal cancer were divided into two groups: with (n = 79) and without (n = 91) endoscopic tattoos. Demographics, operative details, tumor characteristics, prior chemoradiation, and pathologic details were collected. Primary outcome was total lymph node yield. Secondary outcomes were rates of adequate (> 12) nodes, margin status, and operative variables including operative time.

RESULTS

No differences between pathologic stage, tumor height, high inferior mesenteric artery ligation, operative times, conversion rate, or surgical approach (open versus minimally invasive) were noted between groups. Receipt of neoadjuvant chemoradiation was less frequent in the endoscopic tattooing group (53.2% versus 76.9%, P ≤ 0.001). Total node number and rate of adequate lymph node yield were higher with endoscopic tattooing (20.5 ± 7.6 versus 16.8 ± 6.6 lymph nodes and 100.0% versus 83.5% adequate lymph node harvest, both P ≤ 0.001). Rates of positive circumferential and distal margins and complete total mesorectal excision were also similar. Regression analysis identified endoscopic tattooing (Incidence Risk Ratio 1.17, 95% confidence interval 1.04-1.31) and operative time more than 300 min (Incidence Risk Ratio 0.88, 95% confidence interval 0.77-0.99) had significant effects on lymph node harvest. Removal of patients with inadequate lymph node yield resulted in similar rates of total and positive lymph nodes.

CONCLUSIONS

Endoscopic rectal tattooing is associated with increased lymph node yield (including after neoadjuvant chemoradiotherapy) without sacrificing oncologic or perioperative outcomes, although this effect is inconsistent when only considering patients with an adequate lymph node yield.

A Colorimetric Dermal Tattoo Biosensor Fabricated by Microneedle Patch for Multiplexed Detection of Health-Related Biomarkers

Detection of biomarkers associated with body conditions provides in-depth healthcare information and benefits to disease management, where the key challenge is to develop a minimally invasive platform with the ability to directly detect multiple biomarkers in body fluid. Dermal tattoo biosensor holds the potential to simultaneously detect multiple health-related biomarkers in skin interstitial fluid because of the features of minimal invasion, easy operation, and equipment-free result reading. Herein, a colorimetric dermal tattoo biosensor fabricated by a four-area segmented microneedle patch is developed for multiplexed detection of health-related biomarkers. The biosensor exhibits color changes in response to the change of biomarker concentration (i.e., pH, glucose, uric acid, and temperature), which can be directly read by naked eyes or captured by a camera for semi-quantitative measurement. It is demonstrated that the colorimetric dermal tattoo biosensor can simultaneously detect multiple biomarkers in vitro, ex vivo, and in vivo, and monitor the changes of the biomarker concentration for at least 4 days, showing its great potential for long-term health monitoring.

Mastectomy tattoos: An emerging alternative for reclaiming self

Recent discourses within breast cancer and gendered studies literature suggest some women are challenging postmastectomy bodies as abject bodies. Tattooing is an emerging body project in contemporary society that can offer women who live disembodied from their postmastectomized body an alternative. We consider embodied health movements, a type of social movement, to explore how acquiring meaningful tattoo art over a mastectomized site can been seen as challenging hegemonic, gendered discourses of the female breast and patriarchal ideals of beauty, post mastectomy. As part of emancipatory practices, tattooed bodies have historically been used to challenge dominant discourses related to identity and is currently evolving into practices of self-expression, healing, and transformation. As an emerging phenomenon among women, it is important for nurses to understand the prevalence and role of tattoos more broadly, and the possible means for women to embody healing and transformation post mastectomy.

Preoperative endoscopic tattooing using India ink to determine the resection margins during totally laparoscopic distal gastrectomy for gastric cancer

PURPOSE

This study was conducted to determine whether establishing the proximal resection line using India ink tattooing can ensure safe resection margins during totally laparoscopic distal gastrectomy.

METHODS

This retrospective study included 81 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer on the lower two-thirds of the stomach. The proximal resection margins were analyzed with respect to the macroscopic type and clinical T stage, and the intraoperative appearance of the stain on the serosa was classified by reviewing surgical videos.

RESULTS

R0 resection was performed in all patients. The rates of the intended margins were 89.2% in patients without a frozen section diagnosis and 84.2% in patients with differentiated type lesions who underwent a frozen section diagnosis; however, most patients with undifferentiated advanced lesions failed to achieve the intended resection margins. Intraoperative appearance revealed that 85.2% of patients had localized type stains, whereas 11.1% had widespread-type stains.

CONCLUSIONS

Our procedure to determine the proximal resection line in totally laparoscopic distal gastrectomy is oncologically safe. However, careful observation of the resected specimen and a frozen section analysis should be performed for undifferentiated advanced lesions.

Endoscopic Preoperative Tattooing and Marking in the Gastrointestinal Tract: A Systematic Review of Alternative Methods

Background: An accurate and reliable localization of endoluminal gastrointestinal (GI) lesions is crucial, particularly during minimally invasive surgery. As an extreme consequence, a misdetected GI lesion can lead to the resection of the wrong segment, especially in colorectal surgery. A preoperative endoscopic marking is recommended in case of GI lesions, which are expected to be difficult to detect from the serosal side. In clinical practice, three preoperative endoscopic marking methods are currently used: India ink, SPOT™, and endoclips with intraoperative fluoroscopy. All of them have substantial limitations. This has encouraged research on alternative solutions. Methods: In the current systematic review, animal and clinical studies about alternative preoperative endoscopic marking methods of GI lesions were analyzed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Thirty studies were found using PubMed/MEDLINE, EMBASE/Ovid, and the Cochrane Library for the qualitative analysis. Conclusion: Although several smart solutions have been proposed and tested successfully, all of them seem to have a substantial drawback related either to scarce stability on the marking site or potential spreading on the bowel wall or diffusion into the surgical planes.

Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery

BACKGROUND

Breast cancer patients with lymph node (LN) metastases at diagnosis often undergo neoadjuvant therapy (NAT). Identification of a LN which regressed after NAT remains a challenge.

OBJECTIVE

To evaluate marking of involved nodes by tattooing with carbon suspension, and identifying these nodes during surgery.

METHODS

A small amount (0.2-0.5 ml) of carbon suspension was injected into one or two axillary LNs under ultrasound guidance at the time of LN biopsy or before or shortly after starting NAT for LN positive breast cancer. During surgery an attempt was made to identify and remove the tattooed LN as a separate specimen. All patients underwent sentinel LN mapping and biopsy and/or axillary LN dissection as mandated by their clinical status.

RESULTS

Sixty three patients underwent tattooing of axillary LNs with no complications or adverse events. At surgery a tattooed node was identified in 60 patients (95%; 95% CI 87, 98). Of 56 patients who underwent sentinel mapping with Tc99, in 51 (91%; 95% CI 81, 96) at least one radioactive LN was identified. Of 50 patients in whom both radioactivity and tattoo were identified in axillary LNs, in 40 (80%; 95% CI 67, 89) LNs were radioactive and tattooed, however in 10 patients (20%; 95% CI 11, 33), the tattooed LN was not radioactive.

CONCLUSIONS

Tattooing of axillary LNs is safe and easily performed. Tattooing was helpful in identifying the marked LN in the majority of cases. This technique helps to ensure that metastatic LNs are identified and removed at surgery after NAT.

Silver nanowire inks for direct-write electronic tattoo applications

Room-temperature printing of conductive traces has the potential to facilitate the direct writing of electronic tattoos and other medical devices onto biological tissue, such as human skin. However, in order to achieve sufficient electrical performance, the vast majority of conductive inks require biologically harmful post-processing techniques. In addition, most printed conductive traces will degrade with bending stresses that occur from everyday movement. In this work, water-based inks consisting of high aspect ratio silver nanowires are shown to enable the printing of conductive traces at low temperatures and without harmful post-processing. Moreover, the traces produced from these inks retain high electrical performance, even while undergoing up to 50% bending strain and cyclic bending strain over a thousand bending cycles. This ink has a rapid dry time of less than 2 minutes, which is imperative for applications requiring the direct writing of electronics on sensitive surfaces. Demonstrations of conductive traces printed onto soft, nonplanar materials, including an apple and a human finger, highlight the utility of these new silver nanowire inks. These mechanically robust films are ideally suited for printing directly on biological substrates and may find potential applications in the direct-write printing of electronic tattoos and other biomedical devices.

Knowledge of potential risk of blood-borne viral infections and tattooing practice among adults in Mandalay Region, Myanmar

Introduction

Tattooing especially gains popularity among both men and women in adulthood from the wide range of socioeconomic groups and is noted as a risk taking behaviour in adults. Especially when tattooing does not perform to the highest standards, it can potentially be the hazardous practice. Myanmar has a paucity of evidence-based information on the estimated prevalence of tattoos and awareness of potential disease transmission from tattooing under insanitary conditions as well as the infection risk. The present research was undertaken to help identify the self-reported prevalence of tattooing among adults (18–35 years) and their knowledge of transmission risk of blood-borne infections and its determinants.

Methods

A community-based cross-sectional study focused on residents aged 18–35 years was carried out in two urban and two rural areas in Mandalay district, Mandalay Region during 2015. Trained interviewers used a pre-tested structured questionnaire for face-to-face interviews with one eligible participant per selected household (n = 401). Bivariate analysis and multivariable analysis using binary logistic regression were done to ascertain the relevant explanatory variables.

Results

The overall self-reported prevalence of tattooing was 19.5% (78/401) (95% CI = 16–24). Nearly 80% of participants (318/401) knew at least one blood-borne viral infection that could be transmitted from tattooing. The persons who had high formal education, manual laborers and those who lived with their families were significantly more likely to cite at least one blood-borne viral infection. Their perceived possibility to remove tattoo independently influenced the practice of tattooing (aOR = 1.91, 95% CI = 1.06–3.45; p = 0.03) compared with participants who reported no perceived possibility. Tattooing was more common in male (aOR = 13.07, 95% CI = 6.25–27.33; p<0.001) compared to female which was independently significant.

Conclusions

This study ascertained the tattoo prevalence as two in ten adults of working age especially among male in central part of Myanmar in the context of lack of registration system for tattoo parlours and the issuance of safety guidelines. Findings have suggested the target groups and risk factors to be included in future health promotion programs. Future research directions should focus on perspectives of tattooists to create and sustain the sanitary practices to reduce the chance of transmission of blood-borne viral infections.

A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft

INTRODUCTION

Nipple-areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola.

PATIENTS AND METHODS

From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple-areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12 months postoperatively. At the final visit, the patient's subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale.

RESULTS

Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12 months postoperatively, respectively. Patients' overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a 'good' satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be 'poor' and 'disappointing' each accounted for 1 and 3 patients.

CONCLUSION

The combination of nipple-areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tattoos: Very Popular, Not So Innocent

Tattooing is a popular practice worldwide. Its origin dates back to the year 5000 BCE with a frozen mummy and travels across time through diverse cultures and places until it reaches the modern occidental world. Inks and materials used for tattooing are poorly controlled and carry potential risks of skin reactions. The procedure itself is also not innocuous. In this review, different types of tattoos are mentioned and associated dermatologic conditions are discussed. Unfortunately, treatment and removal procedures are often poor in effectiveness and lead to unwanted results. Combining different lasers may be a suitable option that requires further investigation.

A randomized control trial evaluating fluorescent ink versus dark ink tattoos for breast radiotherapy

OBJECTIVE

The purpose of this UK study was to evaluate interfraction reproducibility and body image score when using ultraviolet (UV) tattoos (not visible in ambient lighting) for external references during breast/chest wall radiotherapy and compare with conventional dark ink.

METHODS

In this non-blinded, single-centre, parallel group, randomized control trial, patients were allocated to receive either conventional dark ink or UV ink tattoos using computer-generated random blocks. Participant assignment was not masked. Systematic (∑) and random (σ) setup errors were determined using electronic portal images. Body image questionnaires were completed at pre-treatment, 1 month and 6 months to determine the impact of tattoo type on body image. The primary end point was to determine that UV tattoo random error (σsetup) was no less accurate than with conventional dark ink tattoos, i.e. <2.8 mm.

RESULTS

46 patients were randomized to receive conventional dark or UV ink tattoos. 45 patients completed treatment (UV: n = 23, dark: n = 22). σsetup for the UV tattoo group was <2.8 mm in the u and v directions (p = 0.001 and p = 0.009, respectively). A larger proportion of patients reported improvement in body image score in the UV tattoo group compared with the dark ink group at 1 month [56% (13/23) vs 14% (3/22), respectively] and 6 months [52% (11/21) vs 38% (8/21), respectively].

CONCLUSION

UV tattoos were associated with interfraction setup reproducibility comparable with conventional dark ink. Patients reported a more favourable change in body image score up to 6 months following treatment. Advances in knowledge: This study is the first to evaluate UV tattoo external references in a randomized control trial.

Q-Switched Nd:YAG Laser Removal of Facial Amateur Tattoos in Patients With Fitzpatrick Type VI: Case Series

INTRODUCTION

Q-switched neodymium:YAG (Nd:YAG) lasers are reported to be gold standard for laser tattoo removal. In particular, the Q-switched Nd:YAG laser at 1064 nm is widely recognized for the removal of blue/black amateur tattoos. However, treatment modalities in Fitzpatrick Type VI skin carry a greater risk of complications including alterations in pigmentation compared to fairer skin (Fitzpatrick Type I-IV skin). Therefore, the aim of this case series was to describe with the use of the Q-Switched Nd:YAG laser, the removal of carbon-based amateur tattoos on patients with Fitzpatrick Type VI skin as an effective and safe method.

METHODS

Twenty- five patients with Fitzpatrick type VI skin, from Ethiopian origins, with facial tribal tattoos, were treated with the Q- Switched Nd:YAG laser at 1064 nm. Digital images were taken upon every treatment and the clearance rates of the tattoo was evalu- ated by imaging software.

RESULTS

We observed an average tattoo clearance rate of 95% among the 45 facial tattoos in 25 patients presented in the case series with minimal pigmentary and textual changes evident.

DISCUSSION

These positive aesthetic results have a signi cant psychosocial impact on the lives of those with Fitzpatrick Type VI skin, in particular the Ethiopian Jewish population. <em>J Drugs Dermatol. 2016;15(11):1448-1452.</em>.

Preoperative localization of colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Preoperative colorectal tumor localization is crucial for appropriate resection and treatment planning. As the localization accuracy of conventional colonoscopy is considered to be low, several localization techniques have been developed. We systematically reviewed the tumor localization error rates of several preoperative endoscopic techniques and synthesized information on risk factors for localization errors and procedure-related adverse events.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and the grey literature were searched. Studies were included if they reported tumor localization errors in patients with colorectal cancer undergoing resection with curative intent. Using random-effects models, pooled incidence of tumor localization errors were derived for conventional colonoscopy and colonoscopic tattooing. Due to the lack of comparative studies, a direct comparison of the pooled estimates was performed. Procedure-related adverse events, risk factors for localization errors, and the localization outcomes of other techniques such as colonoscopic clip placement, radioguided occult colonic lesion identification, and the use of magnetic endoscope imaging were also synthesized.

RESULTS

A total of 38 non-randomized controlled and observational studies were included in this review (2578 patients underwent conventional colonoscopy and 643 colonoscopic tattooing). The pooled incidence of localization errors with conventional colonoscopy was 15.4 % (95 % CI 12.0-18.7), whereas that of colonoscopic tattooing was 9.5 % (95 % CI 5.7-13.3), mean difference 5.9 % (95 % CI 0.65-11.14, p = 0.03). Adverse events secondary to tattooing were infrequent, and most were cases of ink spillage. Limited information was available for other localization techniques.

CONCLUSION

Conventional colonoscopy has a higher incidence of localization error compared to colonoscopic tattooing for localization of colorectal cancer. Colonoscopic tattooing is safe and leads to fewer tumor localization errors. Given the widespread adoption of laparoscopic resections for colorectal cancer, routine colonoscopic tattooing should be adopted. However, studies directly comparing different localization techniques are needed.

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100 %) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5 %) it was inside the lesion; in two cases (12, 5 %), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76 %) and high percentage of intraoperative detection of marked lesions (100 %) with a low rate of complications.

Camouflaging Agents for Vitiligo Patients

Vitiligo is an acquired condition resulting in patches of depigmented skin that is cosmetically disfiguring and can subsequently be psychologically disturbing. For patients seeking to mask their vitiligo, camouflage options have historically been limited and been designated as a cosmetic, rather than a medical, concern. As research has indicated that proper concealment of vitiligo lesions can vastly improve quality of life, we believe it is essential that dermatologists become aware of all the options available to their patients and that discussions of camouflage options be broached from the first visit. Methods for concealment include cosmetic tattoos, dihydroxyacetone, general cosmetics, and various topical camouflage agents, including the newest product, Microskin™. We conducted a literature review of all of the available options for vitiligo concealment and evaluated their advantages and disadvantages. Ultimately, temporary methods of concealment are recommended; but the particular agent used can come from discussion with the patient based on the location of the lesions, degree of concealment desired, cost, and availability.

Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study

BACKGROUND

A direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients' and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer.

RESULTS

All patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis.

CONCLUSION

This study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.

Micropigmentation: camouflaging scalp alopecia and scars in Korean patients

BACKGROUND

The aim of this study was to identify the usefulness of micropigmentation as a technique for alopecia and scalp scar camouflage in Korean patients.

METHODS

Micropigmentation was performed in 43 Korean patients from November 2011 to October 2012. There were 23 female patients with female pattern hair loss (FPHL), 14 male patients with male pattern baldness, and 6 patients with scalp scars.

RESULTS

The results for one patient with FPHL Ludwig stage I were satisfactory according to the physician's assessment, but the patient was dissatisfied because she did not notice any remarkable changes after the procedure. The results for the other 42 patients were highly satisfactory and there were no adverse effects or complications.

CONCLUSIONS

Micropigmentation appears to be a good method for camouflaging hair loss and scalp scars.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Endoscopic ultrasound (EUS)-guided fiducial placement allows localization of small neuroendocrine tumors during parenchymal-sparing pancreatic surgery

BACKGROUND

Parenchymal-sparing pancreatic surgery is ideal for lesions such as small pancreatic neuroendocrine tumors (PanNET). However, precise localization of these small tumors at surgery can be difficult. The placement of fiducials under endoscopic ultrasound (EUS) guidance (EUS-F) has been used to direct stereotactic radiation therapy for pancreatic adenocarcinoma. This report describes two cases in which placement of fiducials was used to guide surgical resection. This study aimed to assess the feasibility, safety, and efficacy of using EUS-F for intraoperative localization of small PanNETs.

METHODS

A retrospective study analyzed two consecutive patients with small PanNETs who underwent EUS-F followed by enucleation in a tertiary-care referral hospital. The following features were examined: technical success and complication rates of EUS-F, visibility of the fiducial at the time of surgery, and fiducial migration.

RESULTS

In the study, EUS-F was performed for two female patients with a 7-mm and a 9-mm PanNET respectively in the uncinate process and neck of the pancreas. In both patients, EUS-F was feasible with two Visicoil fiducials (Core Oncology, Santa Barbara, CA, USA) placed either within or adjacent to the tumors using a 22-gauge Cook Echotip needle. At surgery, the fiducials were clearly visible on intraoperative ultrasound, and both the tumor and the fiducials were successfully enucleated in both cases. No complications were associated with EUS-F, and no evidence of pancreatitis was shown either clinically or on surgical pathology. This investigation had the limitations of a small single-center study.

CONCLUSIONS

For patients undergoing enucleation, EUS-F is technically feasible and safe and aids intraoperative localization of small PanNETs.

The musculoskeletal abnormalities of the Similaun Iceman ("ÖTZI"): clues to chronic pain and possible treatments

BACKGROUND AND INTRODUCTION

In 1991, a deceased human male was found frozen in a glacier pool in the Italian Alps in north west Italy, and is now carefully preserved in the South Tyrol Museum of Archaeology, in Bolzano, Italy. The bodily tissues of the 5,300 year old male (colloquially referred to as the Iceman or Ötzi) were well preserved despite damage related to freezing, and glacial movement. Associated articles of well-preserved clothing, tools, weapons and other devices were also present and have been studied in detail. Clinical examination and imaging investigations have also shown that the Icemen had experienced possible illnesses in his lifetime and had identifiable areas of arthritis and musculoskeletal injury. This report includes some key observations on the musculoskeletal state of Ötzi and reference to the involvement of tattoo markings. Some aspects about the aetiology of his abnormalities and inflammatory arthritis are considered along with possible treatments that he might have employed.

METHODS AND RESULTS

We (WFK and MK) undertook a clinical musculoskeletal examination of the Iceman, details of which with available photographs and radiographic imaging pertaining to the musculoskeletal findings of the Iceman are reported here. The skin of the Iceman has numerous linear carbon tattoos, which are not of a decorative type. These have been presumed to possibly be "medicinal" tattoos administered for therapeutic reasons and may have been used in acupuncture-like treatment of pain. Spinal imaging identified areas of spinal damage and our observations have provided clues as to possible sites of spinal initiated pain and hence sites for administration of the "medicinal" tattoos. We observed body areas of the Iceman, in which imaging demonstrated arthritis and other forms of long-term musculoskeletal damage, but which do not have adjacent or corresponding "medicinal" tattoos. We contend that the back and leg "medicinal" tattoos correspond directly to sites of chronic right knee and right ankle pain, and left thoracolumbar pain. They also correspond to lower lumbar and sciatic referred radicular pain which may have a contributory cause related to the presence of a transitional lumbar 5 vertebra. Using recent published data (Keller et al. in Nature Commun 3:698, 2012. doi: 10.1038/ncomms1701 ) of the genome structure of the Iceman, we suggest some potential causes of the osteoarthritis or inflammatory joint injury may relate to presence of coronary heart disease (CHD) and Lyme disease (Borrelia burgdorferi) infection. We speculate on possible medical applications of natural products for self-medication.

CONCLUSIONS

These observations highlight several diagnostic features of musculoskeletal conditions in the Iceman with the possibility that tattoos may have been used for diagnosis or location of his painful states. The origins of his musculoskeletal conditions are unclear but there are indications that Lyme disease and CHD may have been factors. The associations or use of natural products may give insights into their applications at the time of the life of the Iceman.

Guerrillero Heroico--a lasting impression

What once was simply a cultural tradition is fast becoming a popular phenomenon amongst Western tourists. Temporary henna tattoo designs performed by street or beach vendors are prevalent throughout the Middle East and Asia, particularly in holiday resorts. The public may be mistaken in thinking that the fashionable trend comes without significant risk. The main ingredient in the temporary tattooing method is henna (Lawsonia inermis), a flowering plant with dyeing properties that takes only several hours to be absorbed but provides an effect lasting around ten to fifteen days on the recipient's skin. The side effects of henna tattoos are well documented in the literature, although it is not clear whether the side effects directly relate to the henna ingredient or the additives used to prolong the designs. The most commonly noted complications include allergic contact dermatitis, infection, hypertrophic and keloid scarring and temporary or permanent hypo- or hyperpigmentation. In very rare cases, type 1 hypersensitivity reactions (angioedema and anaphylaxis) have been reported. The following case report highlights several of these complications and the relevant management.

Vitiligo surgery: its evolution as a definite treatment in the stable vitiligo

Vitiligo is a common pigmentary disorder which causes immense psychosocial impact on the patients. This condition is still an enigma in terms of its pathogenesis and management. Although there are various treatment modalities, till date none of it takes care of the cause. Surgical management has evolved significantly and given a ray of hope in stable vitiligo. The main purpose is to review the various surgical modalities available along with a look on the milestones and an effort to find answers to "why, when, whom and how" of vitiligo surgery. This article is based on the review of medical literature regarding various surgical management of vitiligo and also author's experience in this particular field. In addition with this review authors tried to shed light on the factors affecting the outcome of vitiligo surgery. The outcome any surgical procedure in vitiligo depends on the proper patient selection, a proper knowledge of this condition and also about its mystery, an expertise in the procedure and a dedication towards patient care. It is certain that surgical modality will be chosen by many with the hope that it succeeds where medical modality fails. However, there is lot of scope for improvement. So more research should happen in this field so that our aim will shift from "any repigmentation" to "complete and normal repigmentation" and we can achieve a scar less healing of those "bruised souls".

Case report - "choumps" enamel tattoos revisited

Because all humans have an identity in life, compassionate societies require that this identity be recognized after death. Traits that are incorporated purposefully into the teeth as a result of cultural considerations are common. The positive identification of living or deceased persons using the unique traits and characteristics of the teeth is a cornerstone of forensic science. As an adjunct to the previously published article on "CHOUMPS" Enamel Tattoos, (Journal of Forensic Odonto-stomatology 2007;25:61-2), the present report provides an insight into more patterns of highly individual enamel tattoos, various instruments and procedures to perform it and discusses the myths and beliefs associated with this practice.

Aesthetic quality of the nipple-areola complex in breast reconstruction with a new local graft technique

BACKGROUND

Reconstruction of the nipple-areola complex (NAC) is the last stage of breast reconstruction and represents the search for symmetry in regard to the contralateral breast. The objective of this study was to present an areola reconstruction technique with local skin graft to improve the texture and aspect of the reconstructed areola, searching for a natural look.

METHODS

This technique was performed on 122 patients who in the period from January 2000 to December 2005 were submitted to nipple and areola reconstruction. Once the position of the new nipple was determined, markings were made for the reconstruction of the areola. Then the external limit of the new areola was incised and the skin was centripetally deepidermized up to 85% of its diameter. After this procedure the detached skin was repositioned in its bed as a graft and sutured with 4.0 mononylon thread. Incisions with an 11-blade scalpel were then made in V and C forms associated with the detachment of this skin of the receptor area along the local graft so that at the end of the healing process they would determine alterations in the areolar texture mimicking the texture of a normal areola. All patients underwent tattooing 3 months after reconstruction of the NAC taking into account the different shades of the contralateral areola and nipple colors.

RESULTS

The use of a local skin graft associated with C and V incisions allowed alteration in the texture of the reconstructed areola. The use of different ink shades for tattooing helped to give a tridimensional aspect to this areola. These factors determined a good aesthetic result in these patients.

CONCLUSION

This areola reconstruction using a local skin graft allows change in the areola texture and a tridimensional aspect similar to that of a normal areola without the inconvenience of grafting from a distance.

The establishment and clinical appliance of technique of mucosa marking targeting biopsy

BACKGROUND/AIMS

Mucosa marking targeting biopsy (MTB) technique has been tested and verified in animal model. For multi-focal atrophic gastritis, random biopsy may miss the point of atrophy, intestinal metaplasia or dysplasia. In order to monitor chronic atrophic gastritis on gastroscopy, get the proper biopsy sample is very important.

METHODOLOGY

Fifty-three atrophic gastritis patients were enrolled prospectively in this study. India ink was tattooed at five points of stomach. Endoscopy was repeated at 3, 9, 15 and 24 months.

RESULTS

Tattoos (96.2%) produced with 1:10 concertrations were visible with a good to excellent tattoo persistence at 3 months. Only two patients (3.8%) had poor tattoo persistence and were retattooed at 3-months interval. Tattoos did not disappear in patients who repeated for more than two gastroscopies at 24 months or even long. There were no complications related to India ink tattooing including abdominal pain, bleeding or perforation. At follow-up gastroscopy, no ulcers, inflammation, break in the mucosa, or pain was noted.

CONCLUSIONS

Clinical use of MTB technique is safe and persistence and may be used as an effective method for longitudinal follow-up in atrophic gastritis and other precancerous lesions.

[Corneal tatoo--art or science?]

The permanent colouring of disfigured corneal scars is known for almost 200 years. Because of improvement in surgical reconstructive techniques, corneal tattoing is used today only with a restricted group on carefully chosen patients, and merely for esthetique reasons.

Medical applications of tattooing

Tattooing is an ancient procedure, practiced by humans from all parts of the world for a variety of reasons. However, relatively little is known by the medical audience of the numerous medical conditions where tattooing is employed as a therapeutic modality or a diagnostic method. Tattooing for cosmetic and medicinal purposes, referred to as either micropigmentation, dermatography, or medical tattooing, may ensure permanent camouflage in a wide range of dermatological diseases. It can be a valuable finishing step in several surgical procedures in the fields of craniofacial surgery, plastic and reconstructive operations, cosmetic surgery procedures, and breast reconstruction. Other fields of application of medical tattooing include radiation therapy, endoscopic surgery, and ophthalmology.

The value of ultrasound-guided tattooing localization of nonpalpable breast lesions

Objective

To investigate the value of ultrasound-guided tattooing localization (US-tattoo) using a charcoal suspension for breast lesions.

Materials and Methods

One hundred sixty-four nonpalpable breast lesions in 134 patients (mean age 47 years; range 30-74 years) were marked with a charcoal suspension under US guidance. The medical records associated with the US-tattoo, the pathology results and the follow-up US results were reviewed.

Results

The average size of the localized lesions was 1.0 cm. The procedure time was < 5 minutes (range, 2-10 minutes) per lesion. The US-tattoo was well tolerated in all cases. The only technical difficulty encountered was a needle tip blockage caused by a large charcoal particle (4.9%). The surgeon easily identified the tattoo with the exception one case. In addition, surgery could be safely delayed from one to 57 days after the making US-tattoo. The pathology result was benign in 108 cases, borderline in five, and malignant in 51. The excised specimen was < 4 cm in 76.6% (82/107) of the benign cases (mean; 2.7 cm). The pathologist could identify the mass around the tattoo and was able to make a specific diagnosis in 81.3% (87/107) of benign lesions. The only complication encountered was residual charcoal marking along the incision scar (3.6%). All follow-up US documented the removal of the lesions.

Conclusion

An US-tattoo for nonpalpable breast lesions is a very simple and accurate method that can help surgeons design and schedule an open biopsy.

Tattoo removal--state of the art

Tattooing has been around since the early beginnings of modern civilization. The discovery of selective photothermolysis at last has made it possible to remove tattoos without leaving a scar. Q-switched neodymium: yttrium-aluminum-garnet, alexandrite, and ruby lasers with pulse durations in the nanosecond domain fulfill this need. Argon or cw-CO(2) lasers as well as intense pulsed light sources should not be used since they often produce significant scarring. This article provides an overview of current laser systems. Developments leading to new tattoo inks, feedback systems to detect the absorbance characteristics of tattoo inks, dermal clearing agents, and perhaps even lasers with shorter pulse-durations might improve the results in the future.

Mohs micrographic surgery for an unusual case of keratoacanthoma arising from a longstanding tattoo

This case report seeks to alert the reader to the possibility that the keratoacanthoma (KA) may develop in tattoo sites, specifically in red tattoo sites. We further wish to describe the senior author's treatment of such a lesion using Mohs micrographic surgery and a rotation flap to preserve the integrity of the original tattoo design in an area of minimal skin laxity. We briefly discuss the etiology of the KA and review potential tattoo reactions as presented in the literature.

Review of identification and traceability legislation for pigs in Australia

OBJECTIVE

To assess Australia's capability to trace pig movements in the event of an exotic disease outbreak by highlighting the commonalities and inconsistencies between the various state and territory legislations in defining how pig producers are located; their pigs are identified; and whether movement records are required post-farm gate.

PROCEDURE

A review of the identification and traceability legislation applicable to pigs in Australia was undertaken over a 6 month period. The appropriate legislative Acts and Regulations were downloaded from the Australasian Legal Information Institute internet site (http://www.austlii.edu.au/) and reviewed.

RESULTS

The Australian pig industry currently uses the branding method (tattooing) to identify pigs for sale or slaughter, with each state responsible for its own pig identification and movement control systems. Areas of concern identified included inconsistencies with the minimum weight or age of pigs that require identification; discrepancies between methods of tattoo registration and shortfalls in documentation for recording pig movements.

CONCLUSION

Our findings highlight the flaws in Australia's current state legislative Acts and Regulations for identifying pigs and tracking their movements, which compromise the ability of jurisdictions to meet the endorsed National Performance Standards. Improvements in these areas will enhance security to the pig and other livestock industries in the event of future exotic disease outbreaks.