How Safe Is Permanent Makeup?


Adding permanent makeup to your skin may sound easy and convenient, but like any surgical procedure, there are risks.

Beautiful red lips, nicely formed brows, and an eyeliner that flatters. Permanent makeup ensures that you can work all day, go to the gym, and dance all night, and still wake up with your makeup in place. Nothing seemed to be able to deter these cosmetic tattoos.

The treatments are typically safe when performed by a trained individual. However, state regulatory authorities have not kept up with the industry’s expansion, and there are several untrained individuals wielding needles.

Permanent makeup is comparable to tattoos in that it is called micro-pigmentation. It entails injecting colored granules beneath the skin’s top layers with a needle. Tattooing and medical restoration, which corrects scars and vitiligo (abnormal skin pigmentation), are related treatments. “They are identical operations that are utilized for different objectives,” explains ophthalmologist Charles S. Zwerling, MD, who developed the term micro-pigmentation.

The most popular cosmetic improvement is permanent eyeliner, followed by eyebrows and lip color. While some practitioners give blush and eye shadow, Zwerling, president of the American Academy of Micropigmentation (AAM) in Goldsboro, North Carolina, is adamantly opposed. “What I’ve seen has been quite amateurish. You have no way of knowing what the color will do, and if you do experience an allergic reaction, you are dealing with a vast surface area. You’re referring to extensive facial reconstruction surgery.”

The majority of operations begin with the application of an anesthetic to the skin. According to Zwerling, touch-ups may be necessary following the original treatment, but no sooner than one month and up to three months later. Dermatologists, cosmetologists, aestheticians, nurses, and tattooists are all practitioners. Before you rush to the Yellow Pages in search of a practitioner, experts suggest conducting preliminary research.

Adverse Reactions

“Allergic responses to pigments are very uncommon, but removing the irritant is challenging,” says FDA spokesperson Stanley Milstein, Ph.D., in Washington, D.C. “Any time a foreign body is implanted into the skin, unexpected consequences may occur. Years later, the response may manifest as a rash or an allergic reaction of the immune system.”

According to Zwerling, pigments such as iron oxide seldom induce allergic responses. “Iron oxide has been demonstrated to be the safest pigment,” he explains. “Anything vegetable-based, organic, or natural poses the most danger. Natural components of vegetables and plants can trigger severe allergic responses.”

Additionally, granulomas, which are lumps that form within tissue around a foreign object, and keloids, which are overgrowths of scar tissue or a raised scar, are possible adverse effects. Keloids occur more frequently when permanent makeup is removed than when it is applied.

The FDA issued a public notice in July 2004 regarding a number of adverse occurrences observed in patients who had undergone specific micro-pigmentation treatments. The adverse occurrences are believed to be related to certain hues of the Premier Pigment brand of permanent cosmetic inks, which are manufactured in Arlington, Texas, by the American Institute of Intradermal Cosmetics, doing business as Premier Products.

As of July, the FDA was aware of over 50 adverse occurrences and is now reviewing further reports submitted to the company. Swelling, cracking, peeling, blistering, and scarring have all been described, as well as the development of granulomas around the eyes and lips. In other cases, the claimed consequences resulted in severe deformity, impairing eating and speaking.

Photo by Element5 Digital
Photo by Element5 Digital


A jury in San Antonio convicted the proprietor of a permanent cosmetics business guilty in December 2003 of infecting a lady with hepatitis C during a series of lip color touch-ups. They awarded the lady more than $500,000 in damages.

“I am aware of perhaps ten cases of hepatitis transmission via permanent cosmetics and one case of AIDS in Canada,” Zwerling says. “Tattooists made up the bulk of practitioners.” Tattooing equipment and needles that are not sterile can spread infectious illnesses such as hepatitis.

‘FDA-Approved Colors’ — a Red Flag

Avoid being swayed by advertisements suggesting that a practitioner utilizes FDA-approved colors. “Remain away,” Zwerling advises. “They are attempting to defame themselves and their profession.” The FDA only allows colors for certain end purposes.

When someone claims “FDA-approved colors,” there is no way to tell if the approval is for cosmetics, food, or automotive paint. However, one thing is certain: no color additive has ever been FDA-approved for injection beneath the skin.

“The FDA is undoubtedly considering certain health and safety implications,” Milstein adds.

Complicating matters is the fact that certain pigments are composed of many elements and are not required to list their constituents because they are not marketed to customers. “These combinations may be quite complicated, making it extremely difficult for tattoo artists to determine what they’re using,” he explains.

The FDA encourages consumers and health care professionals to report adverse reactions to tattoos and permanent cosmetics, as well as issues with removal, via its Cosmetics Adverse Reaction Monitoring program (CARM). Contact the FDA district office for your area, which is located in the blue pages of your phone book.

MRI Complications

“A problem you should be most concerned about is what will happen if you get an MRI year from now,” Milstein adds. “There will be swelling or burning in the pigmented region as a result of the magnetic field’s interaction with the pigment, which may impair the quality of the MRI picture.”

Zwerling agrees that some individuals may feel redness or irritation following an MRI, but believes this should not be used as an excuse to avoid permanent makeup. “There is a magnetic interaction between the pigment’s iron oxide and the air.

It vibrates and initiates a moderate inflammatory response that can be alleviated with the use of a topical steroid cream or Benadryl.” He adds that as long as the radiologist is aware of the permanent makeup, the response will not impair the imaging quality. “You must inform them so that they do not misunderstand it.”

How Permanent Is Permanent?

“Consider permanent makeup to be permanent,” Zwerling advises. “Be certain, for it is unlikely that it can be changed.”

Each person is unique, but he believes that in the great majority of instances, considerable fading happens each year. “Some of the patients I treated 20 years ago look fantastic now, while others I treated a year ago require another operation.”

Certain hues may migrate over time, which can be rather scary. According to Zwerling, this is most likely to occur when a practitioner uses black India ink, which is not recommended for micro-pigmentation.

“Because the particles are so tiny, it’s almost like coloring the skin,” he explains. “Iron oxide pigments are inert, which means they do not undergo metabolic reactions. With iron oxide, migration is negligible.”

He adds that there is an unexpected benefit to permanent makeup in that it appears to help with wrinkles and also aids in the breakdown of scar bands, resulting in scars that are slightly flattened. “However, that cannot always be guaranteed,” he adds.

Disappointing Results

What if you enter a salon looking for Jennifer Lopez’s brows and leave with Ben Affleck’s? “The primary danger associated with any cosmetic procedure is dissatisfaction with the outcome,” Zwerling explains. “Get it right the first time, because the chances of getting it right the second time are difficult, and the chances of getting it right the third time are much more complicated. You may be required to travel. I am aware of only a handful of masters in the United States who are capable of correcting errors.”

“While the majority of people believe laser treatments may erase tattoos or permanent cosmetics, they can also leave behind adverse effects such as lighter skin color,” Milstein explains. Other techniques of removal include dermabrasion, surgical removal, and occasionally further tattooing to conceal the issue. “Some procedures leave a scar in the area where the makeup was applied,” he explains.

Do It With Your Eyes Wide Open

Is it legal for someone whose only training consists of a correspondence course to inject pigment into your skin? Or is there no training? Absolutely. “Some states have no rules at all, which is terrifying,” Zwerling says. “Anyone can open a business.”

So what’s a consumer to do?

  • Ascertain if the salon has a business license and a certificate from the local board of health indicating that it has been examined.
  • Ascertain whether the practitioner has been evaluated and determined to be competent. The AAM is an accrediting authority that demands accreditation through a written, oral, and practical examination. “Several states have designated us as their certifying body,” Zwerling explains. “We make every effort to ensure that practitioners are at the very least competent in terms of understanding the proper processes and how to sterilize.”
  • How many operations have the practitioner performed and for how long?
  • Inquire about meeting patients on whom the practitioner has done operations. “Do not depend just on testimonies or photographs,” Zwerling advises. “Anyone may establish a portfolio by appropriating images from another website.”
  • Consider the aesthetics, the level of safety, and the level of comfort. “Physicians are not always the best practitioners,” Zwerling asserts. “They may be knowledgeable about science, but not about art.” The greatest option may be to work as a nurse or cosmetologist under the supervision of a physician. Additionally, if comfort is a priority, keep in mind that the topical anesthetics used by a cosmetologist or tattooist are not as effective as injections administered by a medical practitioner.
  • To avoid infection, see the practitioner remove a new needle from its packaging and open a new bottle of pigment. Additionally, follow any post-operation instructions for how to care for the treated region in the days and weeks after the surgery.
  • Bear in mind that cosmetic trends fluctuate. Avoid adopting a fashionable appearance that will appear antiquated in five, ten, or twenty years.

A final piece of advice. “Ask yourself how willing you are to wear someone else’s mistake,” says Milstein. “Changing tattoos or permanent makeup is not as easy as changing your mind.”