Reinforce commitment to patient care with respectful management of tattoos during surgery

April 20, 2022

3 min read

Romeo reports receiving royalties from, being on the speakers bureau and a consultant for, and doing contracted research for Arthrex.

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Our patients are at the center of health care. Decisions regarding care consider many factors.

We emphasize the importance of a good history and thoughtful physical examination, supplemented by radiographic studies and results of previous treatments. We also inherently work toward developing trusting relationships with patients, so shared decision-making leads to the best outcomes. This process requires true listening to provide culturally competent care.

Anthony A. Romeo
Anthony A. Romeo

These lofty principles can be sabotaged by factors we cannot control, such as the patient’s mistrust of the health care system. Factors in our control include efforts to ensure patients you care about them as a person, not just as an orthopedic condition. It begins when you first enter the room to listen to their concerns. Subtle influences, such as direct eye contact, being relaxed and interested, and reflecting on their comments, help build a trusting relationship. The process does not end with the first encounter.

Build trust

Although it may seem trivial, attention to managing a tattoo within the surgical site is another opportunity to build trust. The appearance and meaning of a tattoo may not be apparent. However, most tattoos have a deep, personal meaning to patients.

The meaning and motivation behind tattoos are often more significant than patients are willing to share. The tattoo can be so personal that even loved ones present are unaware of the depth of its importance. Tattoos are often linked to events and beliefs that have profoundly affected a patient’s life. A tattoo can confidentially express and memorialize a patient’s thoughts without the need to provide an explanation. Patients express personality, identity and experience without words. Patients are unlikely to share the magnitude of a tattoo’s importance. Every tattoo should be positively acknowledged and respected.

Unfortunately, there may be situations in which the best surgical approach requires an incision through the tattoo. Accepting that the tattoo has importance should encourage a thoughtful approach to managing the conflict between the incision site and tattoo. Needlessly ruining a tattoo with a poorly conceived incision and lack of concern for the postoperative appearance may lead the patients to believe you do not respect them, care is only focused on your perspective and you cannot be trusted in the shared decision-making process. The trust you worked toward can be destroyed along with their tattoo.

Ideal incision

Ideally, managing the conflict between tattoo and the surgical site begins outside the OR, with the patient awake and participating in the decision. Take time to draw the surface anatomy with a surgical site marker carefully. Then draw or dot the standard incision used for the procedure. Identify whether the incision can be made entirely outside of the tattoo without affecting the exposure and results. This may be easier with arthroscopic procedures or those done with small open incisions with a different angle of approach.

If the best answer is to make the incision within the boundaries of the tattoo, look for the dark black ink lines close to the ideal incision – plan on making the incision within those lines even if these are curvilinear. If there are some changes with a healed incision within the center of a black ink line, the tattoo artist can usually resolve the appearance to resemble the original tattoo.

Every effort should be made to avoid a diagonal or perpendicular incision to the tattoo line. This includes arthroscopic portals. Even with the best measure of aligning the tissues properly at the end of the procedure, the line edges may not match perfectly, or the scar may discolor or widen at the incision site. These changes are complicated for a tattoo artist to correct.

After the procedure, a careful multilayered closure with subcuticular stitches supported by Steristrips, not staples or sutures tied perpendicular to the incision, provides the best environment for healing without complications. If the tattoo requires touch-up, patients should be advised to wait a minimum of 3 months. More extensive changes should be delayed until 6 months postoperatively to allow full maturation of incision healing.

Taking care of people can be complicated. Every effort should be made to develop a foundation of trust. Theodore Roosevelt stated, “Nobody cares how much you know, until they know how much you care.” You can reinforce your commitment to the highest level of patient care through respect, thoughtfulness and management of tattoos during surgery.