The Medical Tattoo Assistant: Guidelines for an Emerging Profession : Plastic and Reconstructive Surgery

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The Medical Tattoo Assistant: Guidelines for an Emerging Profession

Becker, Stacie J.; Cassisi, Jeffrey E. Ph.D.

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Plastic and Reconstructive Surgery: November 2021 - Volume 148 - Issue 5 - p 875e-877e
doi: 10.1097/PRS.0000000000008475
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The application of medical tattooing in plastic and reconstructive surgery for scar concealment, nipple-areola complex reconstruction, and other cosmetically restorative processes is supported by a significant empirical literature.1 Patient and physician outcome ratings are very high. A review of the methods used in these studies reveals an accumulation of specialized scientific knowledge concerning applications, equipment operation, and artistic technique. The establishment of the medical tattoo assistant as an allied health profession is necessary to protect the public and to ensure the highest quality service.

The medical tattoo assistant should have accepted treatment guidelines, professional standards, and an essential training curriculum. The medical tattoo assistant is not only concerned with the technical aspects of tattooing but also focuses on artistic techniques. The artistic application of tattoos can simulate three-dimensional structures, as illustrated in Figure 1. There are several existing training programs that have established curriculums for medical tattooing, but they have not been organized as part of a recognized profession.

Fig. 1.:
Nipple-areola complex tattooing. (Left) Before tattooing. (Center) After nipple-areola complex tattooing. (Right) After decorative scar concealment.

We propose an approach to training and a standardized curriculum for the medical tattoo assistant. Admission to such professional training programs should require a license in the jurisdiction of practice and documented traditional tattooing experience with submission of a portfolio. Admission committees should be made up of stakeholders, including physicians and representatives from patient/consumer communities. The proposed standardized curriculum for the medical tattoo assistant is listed in Table 1. This is an interdisciplinary study at the associate in arts degree level. As with most clinical fields, training should recognize that practice is both a science and an art. Public health and safety considerations relevant to the general art of tattooing are reviewed in a recent dermatology textbook2; however, many more course materials need to be developed for prebaccalaureate level training of the medical tattoo assistant. The training curriculum should not be proprietary, and the requirements and core concepts should be transparent and generally agreed upon. New knowledge and information should be disseminated via peer-reviewed empirical literature in professional journals. The goal is to have multiple training programs that meet standards of accreditation from the Accrediting Bureau of Health Education Schools.

Table 1. - Proposed Curriculum for Medical Tattoo Assistant Training*
Area of Study Suggested Courses
Health science Anatomy
Medical terminology
Dermatological concepts for nonphysicians
Skin pathology
Reconstruction techniques (breast, nipple, skin grafting)
Scar causes and types (burns, keloids, surgical, necrosis, trauma)
Prevention of the transmission of communicable diseases (bloodborne pathogens)
Cardiopulmonary resuscitation/first aid
Signs of infection
Health administration HIPAA training
Care settings and communication structures (collaborative, collocated, integrative)
Ethical standards for human service professionals
Psychology Body image/body dysmorphia
Quality of life
Health psychology
Indicators of severe psychopathy
Indicators of unrealistic expectations
Art Drawing fundamentals 1
Drawing fundamentals 2
Color theory
Drawing human anatomy
Painting fundamentals
Tattooing Tattoo history/introduction to tattooing
Tattoo equipment knowledge (needle configurations, tattoo machine mechanics, pigments)
Clinical room setup
Patient prep and aftercare
Tattoo application and techniques (needle depth, needle angles, skin stretching, needle selection)
Supervised application
HIPAA, Health Insurance Portability and Accountability Act.
*Acknowledgment: The Sauler Institute, with locations in Pennsylvania, New York, and New Jersey, offers medical tattoo training in a week-long workshop that covers many of these topics. The curriculum described above is intended to be incorporated at the college level in a multisemester program.

A professional organization for medical tattoo assistants is needed, and this will be facilitated with the support of other medical organizations and societies. The proposed organization will provide advancement of the field, but will also protect the public, ensure quality and performance standards, provide a code of ethics, and actively pursue scientific practice. An ideal board would consist of respected members from across the professions of dermatology, oncology, health psychology, plastic and cosmetic surgery, health administration, and medical tattooing. The organization should also include board members from patient/consumer communities to represent patient interests.

There are three main care settings in which the medical tattoo assistant may be employed. The first is a collaborative/coordinated care setting that occurs in a separate and independent facility from the physician. The medical tattoo assistant is a self-employed practitioner in this setting. The second care setting is described as collocation, in which the physician and the medical tattoo assistant are separate corporations that are located in the same facility. The third care setting is an integrative model, in which the medical tattoo assistant is employed by the physician (e.g., surgeon, dermatologist) and provides services within the practice. One important consequence of making the medical tattoo assistant a formal health service profession is that communication between providers will be governed by Health Insurance Portability and Accountability Act (HIPAA) guidelines. This includes the release of medical information about patients during the referral process, which heretofore has been informal. This requires a business associate agreement between the medical tattoo assistant and the physician in the first two care settings. If the medical tattoo assistant is directly employed by the practice, a standard HIPAA acknowledgement and agreement is required.

The establishment of the medical tattoo assistant profession requires a training curriculum that covers the standards of patient care required of all allied health fields. This profession will require the formation of a national credentialing process and a professional organization to ensure the protection of the public and to support the development of the field.


The patient provided written consent for use of her images.


The authors have no financial interest to declare in relation to the content of this article.


1. Becker SJ, Cassisi JE. Applications of medical tattooing: A systematic review of patient satisfaction outcomes and emerging trends. Aesthet Surg J Open Forum. 2021;3:ojab015.
2. Serup J, Kluger N, Bäumler W., eds. Tattooed skin and health. Curr Probl Dermatol. 2015;48:1–5.


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