The Girl with the Dragon Tattoo (Removed): An Overview of Tattoo Physiology, Reactive Lymphadenitis, Removal, and Scarring

Dr Larsa Al-Omaishi1,2, Dr Ralph Corsetti2

1Greenslopes Private Hospital, Greenslopes, Australia, 2The University of Queensland – Ochsner Clinical School of Medicine, New Orleans, USA


The popularity of tattoos is rising in America and Australia. A 2016 Harris Poll and McCrindle Survey showed that 29% of Americans and 19% of Australians have at least one tattoo, respectively. Furthermore, a quarter of American (23%) and Australian (24%) individuals regret their body art, leading to the rise of laser tattoo removal. Tattoos are also being used as permanent makeup, scar camouflaging, and nipple recreation post-mastectomy.

Tattoos are created by injecting an ink into the dermis using needles that penetrate the epidermis at 50-3,000Hz. Three months after the ink’s deposition, granulation tissue initially created by the traumatic process is replaced by ink-enveloping fibroblasts which cause permanence. However, ultraviolet light can cause pigments to degrade. Phagocytes engulf pigment fragments then migrate deep into the dermis. The pigments then travel via lymphatics, which can result in reactive lymphadenitis mimicking lymphoma, metastatic skin, or breast cancer.

There are no regulatory or safety requirements whatsoever for tattoo ink manufactured in the USA, the largest supplier of tattoo inks worldwide. The process of removal involves using a high energy beam to break apart the ink pigments into smaller particles that can be consumed by macrophages. Pigments that are harder to break apart, such as blues and reds, are more difficult to, “remove,” than smaller black nanoparticles. Because multiple sessions are required to break apart the pigment in larger tattoos, skin can burn and result in scars. Alternatively, scars created by the initial tattoo process may reveal themselves when tattoos are removed.


Dr. Al-Omaishi graduated as a member of the 2017 Ochsner cohort of the University of Queensland. This cohort returns to the US for years 3 and 4 of clinical training. Dr. Al-Omaishi is currently undertaking an internship at Greenslopes Private Hospital and is particularly interested in trauma surgery, surgery in developing countries, and population health research.


ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

Conference Managers

Please contact the team at Conference Design with any questions regarding the conference.

© 2020 Conference Design Pty Ltd