I don’t wear eye makeup, and it’s not only because I’m a guy. The thought of using a pointy instrument to apply pigment so close to my eyeballs every morning sounds especially daunting. So I can understand how some women consider taking advantage of a permanent solution to avoid this potentially perilous and time-consuming daily chore. Plus, there’s the added benefit of never worrying about reapplying makeup later in the day after swimming or sweating at the gym. So, what can go wrong?

Well, plenty it seems.

Micropigmentation, or cosmetic tattooing, has been employed to create “permanent makeup” since the early 1980s. It was originally developed to address alopecia of the eyebrows. The technique has since evolved to include cosmetic solutions for cancer survivors and burn victims, as well as for patients with Parkinson’s disease, arthritis, or other conditions that make it difficult to apply makeup. It has also become popular with women who simply want to shorten the time spent getting ready in the morning. The most common form of permanent makeup involves eyelid tattooing, where eyeliner or eye shadow is simulated by the injected ink.

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Eyelid tattooing is not very different from ordinary tattooing. It involves inserting pigmented granules under the upper layers of the skin using a needle, typically after anesthetizing the area. The initial procedure for creating permanent eyeliner or eye shadow takes about 1 to 2 hours. It is usually followed by several sessions 1 to 3 months later for refinement and touching up, as the intensity of the color tends to fade after the initial application. Practitioners of this procedure most often include dermatologists, nurses, aestheticians, cosmetologists, electrologists, and tattoo artists. The cost can range from $300 to $900, depending on geographic location and the extent of the tattooing.

Because of the increased risks of working near the eyes and on such thin skin, practitioners should be specially trained and very adept at controlling their tools. Unfortunately, whereas the inks used in these procedures are subject to approval by the FDA, regulations related to applying permanent makeup vary from state to state, and practitioners often are not required to receive any specialized training at all in order to perform the procedure. This means that the stylist cutting your hair has spent hundreds of hours obtaining a license to legally practice, whereas in the next room, the person holding an electric needle a few millimeters from some unsuspecting customer’s eyeball might be insufficiently trained, or not trained at all. In addition, some practitioners employ devices sometimes referred to as cosmetic or permanent makeup “pens.” Most experienced tattoo artists agree that these devices are essentially just poorly constructed tattooing gadgets.

What Can Go Wrong?

Beyond the immediate side effects of mild redness and swelling, adverse events from these procedures do occur, especially when the practitioner is not highly experienced. Severe skin reactions, including swelling, cracking, burning, blistering, and the development of papules and granulomas, have been reported. In addition, there is also a risk of full-thickness eyelid penetration. These effects can cause serious disfigurement, resulting in the need for extensive corrective cosmetic surgery. Also, infection is a serious concern. There have been documented reports of the transmission of HIV, hepatitis, staph, and strep from unsterilized equipment, as well as allergic reactions to the permanent ink. Regarding the ink, customers should be wary of ads claiming that a practitioner uses “FDA-approved colors” because the FDA only approves colors for specific end uses. These spurious claims don’t specify whether the dyes have been approved for food, cosmetics, or house paint. In fact, the FDA has never approved a color additive for injection under the skin.

Another possible side effect can occur years later when the patient is getting an MRI. The iron oxide in the pigment could vibrate during the procedure and cause mild redness and inflammation, although this can be controlled by a topical steroid. It’s important for the patient to let the radiologist or MRI technician know about the permanent makeup prior to the MRI so that image quality is not compromised.

Fortunately, several professional societies, including the American Academy of Micropigmentation, have been established to address the inconsistencies in training through accreditation. Anyone interested in undergoing permanent eyelid makeup procedures should look for experienced, well-trained, and certified practitioners who work out of licensed places of business. Safety concerns can be assuaged if a physician is chosen to perform the procedure, but aesthetics should also be given considerable thought. It is the face that we’re talking about. A doctor is much more likely to follow proper techniques regarding anesthesia and sterilization, but a cosmetologist or a nurse working under the supervision of a physician might be the best choice. Note also that the topical anesthetics employed in a physician’s office will be more potent and effective compared with those used by practitioners who are not health care professionals.

As with all things not related to tattooing your face, get recommendations from friends and family, thoroughly research the qualifications and certifications of potential practitioners, and remember that this is not the tiny rose you got tattooed on your ankle while in college.


  1. American Academy of Micropigmentation. http://www.micropigmentation.org/.
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