Radiated Skin: Risks, Retention, and Realistic Expectations

🎀Today, I'd like to talk about radiated skin in breast reconstruction and special concerns regarding mastectomy tattooing. 🎀


🌸 I am not a physician, nor do I want anything I state here to replace information you get from your physician. Everything here is my own opinion from my own experiences. 🌸 I just want to discuss things that I feel can be quite beneficial to not only the client (as is the case with my previous blogs and videos) but also the 🎨 artist. Especially those that do not come from medical background, this information I feel is critically important to understand before you would ever take on the responsibility of tattooing a survivor.


🌸What is radiation used for in the world of medicine?
At low doses, radiation can be used for diagnostic purposes with x-rays and such. At higher doses, it is used therapeutically to shrink tumor masses and kill off cancer cells. This treatment many times is an adjunctive therapy used in addition to chemotherapy, immunotherapy and surgeries to both excise the cancer and reconstructive types of surgery. It can be delivered many ways...
🏵Orally in pill form, for the thyroid gland.
🏵Brachytherapy, which can an implantable form such as seeds which treat prostate, gynecological, and head and neck cancer or Intraoperative (IORT) XRT done directly to a visible tumor bed during surgery before closing. (As a nurse, I took care of a lot of gyn patients that had this done.) IORT can also be done at the time of lumpectomies....
As a restorative tattoo artist, you will many times be seeing the after effects of
🏵External Beam Radiation treatments (XRT) this consists of the beam of radiation originating outside the body and target projected onto the tumor area therapeutically in a series of multiple treatments. This is why you many times see those little blue/gray tattoo dots because they are markers to guide the placement on where to direct the beam.
🌸Note: I only neutralize the markers placed on the midline...I don't try to camouflage the others in case they'd need to be identified in the future for further treatments. Having said that, 2nd Note: there is a cumulative effect of radiation so there is a maximum amount one human can handle in their lifetime. For instance, you may hear a client tell you they had xrt with their 1st episode of breast cancer that was treated with a lumpectomy. Then at the time of their reoccurrence or new primary tumor, they didn't have xrt again or not many rounds the 2nd time because they reached their "max". They also may have previously had
🏵 Full Mantle radiation in the 60's and 70' s for Hodgkin's lymphoma. I personally have tattooed 3 ladies in the past 6 years in which this was the case....so it absolutely does happen.... mantle field xrt hit the neck, chest, and armpits to cover all the upper body lymph nodes they could. A big area. Subsequently, these ladies developed breast cancer in the 90's and had no additional xrt because they maxed out. So when they tell their past history that's the max dose they are referring to so it's good to make yourself familiar with these term if you're going to be treating someone who has experienced this.

🌸 So, what's the takeaway from this? 🌸

🎀 As a survivor, it is important to tell 🗣your artist about your radiation treatments and show👀 them the affected area.❓ Ask questions about their assessment of your skin being "tattooable" . Just because your doctor said it was ok, doesn't mean it actually it safe. I repeat: I've had a few women who were cleared to see me by their surgeon for tattooing and after I closely inspected their skin, I turned them away due to safety concerns with very damaged, thin skin. 💯 not safe to be tattooed in my professional opinion. Note*These docs were not from the Columbus metro area that I typically tattoo for...which is even more concerning because I don't know them and their note to me is not a guarantee that something won't go wrong. Better safe than sorry. Always.
❓Ask the artist how much experience they have with radiated skin. How many clients with a history of xrt have they personally tattooed. ❓How many complications have they had on clients with radiation. ❓ What are the risks? ❓What tattoo techniques do they apply to ensure your safety. ❓ Will or can the radiated skin heal differently? ❓ How many sessions will you anticipate?

As an artist,
💮 It is very important to ASK a potential client if they have ever received radiation treatments in the past.
💮If dealing with a flap, LD, tram or DIEP, it's important to know if xrt was pre or post flap. If pre, the damaged skin may have been removed completely so then it's not an issue but sometimes situations do require a fresh flap to be radiated. Many times the tattoo on an LD will fall part on and part off the flap. So different skin types and radiation can make things tricky.
💮 Be on the lookout for xrt dot marker tattoos which reveal the treated area. 👀
I've had that happen so many times where women even on their health history questionnaires they fill out at my office, will forget to fill in in that spot. Then when I get them disrobed, I see radiation markers which prompts me to ask. Then they say "Yes oh my gosh! I forget to put that on there. I wasn't even thinking about it."
It may have been a long time ago or it's just not fresh on their mind to reveal it without being asked. 💕This treatment can be emotionally traumatic so they may be protectively not thinking about it.
Especially if you are tattooing in a location outside of a medical environment. If somebody is super excited about getting a tattoo and they go to see you at a shop ...their mind is not in medical mode and they may forget to tell you.

🌸 Always ask and always look👀 because it's not like this treated skin will recover and get better over time returning to pre-radition condition. 🌸

I have heard physicians describe radiation therapy as "the gift that keeps on giving" . Giving in the sense of the skin has been forever changed and will sometimes keep changing on down the road.
It is documented that XRT has internal (heart, lung damage/scarring) and external side effects but, for our purposes today, I'll be focusing on just the external. The radiation must travel through the skin to treat cancer beneath so the skin essentially becomes collateral damage. We know xrt causes skin irritation and burns, sometimes extensive burns , thermal tissue type injuries during treatment. Once healed, there can be long term changes that can include hyperpigmentation/ darkened skin color, telangiectasia can be present, skin can be thinner, more fragile, tight, and shiny. The breast or breast reconstruction can sit higher , be firmer and smaller than the other non-radiated side. Capsular contracture of implants is very common as well.

The tattoo ink goes in the dermis as a liquid and the color particles get embedded into the cells by the needles. The body absorbs the liquid component and the cells of the dermis trap and"hold" the color particles in place.
However, because the cells have been forever changed by the radiation, many times they are unable to grasp and retain the ink effectively. So, crisp lines will blur and details will not stand out as you may wish. Additionally, the tattoo can heal lighter compared non-radiated tissue, such as compared to the other reconstructed breast or if the tattoo falls 1/2 on radiated skin and 1/2 on a healthy flap tissue portion of skin, like a DIEP or LD flap.
🗣This is an unpredictable canvas. 🗣You cannot anticipate the end result, so I love the 2 step approach. I am able to respect your skin and tattoo as safely as possible. Then when your return for touch up, it wll reveal how it acts. Sometimes, it heals the same!! Bonus! 🎉

More so in importance than the aesthetic outcome, is the risk of damaging radiated skin. This fragile skin must be tattooed extremely delicately, watching for cues on when it's had enough and stop ✋ when the time is right. I also always start on the radiated breast to see how the tissue will tolerate/accept the tattoo process and proceed cautiously. Remember the skin has been PERMANENTLY CHANGED, damaged really... by the XRT and so has it's ability to withstand trauma and HEAL. I get asked all the time if tattooing can pop an implant. This is not an issue with proper tattooing as our needles are contained in the dermis. However, creating a wound on a radiated breast mound can get infected, can become non healing or even erode and possibly expose an implant.
🗣This is a crucial element to understand when taking on the responsibility of tattooing a cancer survivor. You cannot be heavy handed attempting to pack in a ton of color on these ladies or it will end in heartbreak 💔. I've seen this 1st hand by uneducated staff tattooing this type of skin with an ignorant and cavalier approach and unfortunately the survivor pays the price with nonhealing wounds and compromised or lost breast reconstructions. Wound➡️ non- healing ➡️ erosion ➡️exposure of implant ➡️ possible loss of reconstruction.
I have personally tattooed hundreds of radiated breasts but I examine 🧐 each one's tissue integrity before I decide if it is safe to proceed, then I explain the risks to each person so they understand.

🌸In closing, can radiated breast reconstructions be tattooed? Most of the time, yes with special precautions by an experienced medical tattoo artist. Your physician and tattoo artist together can help safely determine if you're a candidate.

Knowing the risks and understanding there must be realistic expectations regarding the outcome of a tattoo, like healing lighter and having blurred details on radiated skin, can help you decide if it's the choice for you or not. 🌸

Also posted on Blogger June 4, 2021- http://livingstorytattoo.blogspot.com/2021/06/radiated-skin-risks-retention-and.html

#safetyfirst #themoreyouknow🌈 #experiencematters #alittleinkandalotoflove