Research

JAMA Facial Plastic Surgery | Original Investigation

Dermatography (Medical Tattooing) for Scars

and Skin Grafts in Head and Neck Patients
to Improve Appearance and Quality of Life
Brigitte H. Drost, MD; Rick van de Langenberg, MD, PhD; Olivia R. Manusama, MD; A. Soe Janssens, MD, PhD;
Karolina Sikorska, PhD; C. Lot Zuur, MD, PhD; Willem M. C. Klop, MD, PhD; Peter J. F. M. Lohuis, MD, PhD

Author Audio Interview

IMPORTANCE Dermatography (medical tattooing) is often overlooked as an adjuvant
procedure to improve color mismatch in the head and neck area, and its effect on patient
satisfaction and quality of life has not been evaluated, to our knowledge.

OBJECTIVE To analyze the effect of dermatography on the subjective perception of the

appearance of scars and skin grafts and the quality of life in head and neck patients.

DESIGN, SETTING, AND PARTICIPANTS Case series of patients undergoing dermatography at

the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, between
July 1, 2007, and April 1, 2015. Participants were invited to respond to 2 questionnaires
measuring their scar or graft appearance and their quality of life before and after
dermatography as an adjuvant treatment for benign or malignant head and neck tumors.

INTERVENTION Use of dermatography.

MAIN OUTCOMES AND MEASURES Two questionnaires evaluating a visual analog scale score
(range, 0-10) and multiple questions on a 5-point scale focusing on satisfaction with the
appearance and the quality of life.

RESULTS Among 76 patients, 56 (74%) were included in the study. The mean (SD) age of the
study cohort was 56.5 (16.0) years, and 42 (75%) were female. The mean improvement in
scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire
for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4
points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of
approximately 1 point across 9 questions was observed. The answers to all patient
satisfaction and quality-of-life questions on both questionnaires improved significantly after
dermatography.

CONCLUSIONS AND RELEVANCE Dermatography is an effectual adjuvant procedure to improve

the subjective perception of scar and skin graft appearance and the quality of life in head and
neck patients.

LEVEL OF EVIDENCE 4.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Rick
van de Langenberg, MD, PhD, Center
for Facial Plastic and Reconstructive
Surgery, Department of
Otolaryngology–Head and Neck
Surgery, Diakonessen Hospital,
Bosboomstraat 1, PO Box 80250,
JAMA Facial Plast Surg. doi:10.1001/jamafacial.2016.1084 3508 TG Utrecht, the Netherlands
Published online September 22, 2016. (rvdlangenberg@diakhuis.nl).

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 Research Original Investigation Dermatography for Scars and Skin Grafts in Head and Neck Patients

D
ermatography (medical tattooing), first documented
early in the 19th century, is performed most often for Key Points
nipple reconstruction after mastectomy.1-3 Despite
Question What is the effect of scar and skin graft dermatography
its popularity in breast reconstructing procedures, derma- in the head and neck area on patient satisfaction and quality of
tography is used by few medical professionals as an adjuvant life?
to enhance the appearance of scars and skin grafts after head
Findings In a case series of 56 patients, the mean improvement in
and neck surgical procedures, which is unfortunate consid-
scar or skin graft perception on a visual analog scale (score range,
ering the wide range of applications and advantages this 0-10) was 4 points. All answers to patient satisfaction and
type of treatment has to offer. Indications are numerous for quality-of-life questions in 2 modified questionnaires improved
primary treatment (eg, postburn scar, vitiligo, alopecia of significantly.
eyebrow or scalp, and port-wine hemangioma) but also as an
Meaning Dermatography is an effectual adjuvant procedure to
adjuvant to previous surgery (eg, scar, skin graft, or free improve the subjective perception of scar and skin graft
flap).4-15 In addition to its use in improving the appearance appearance and the quality of life in head and neck patients.
of lesions, another well-appreciated outcome of dermatogra-
phy is its smoothening effect on scars.16 Compared with sur-
gical options to improve scar or skin transplant appearance,
Figure 1. Postoperative Dermatography of a Scar
dermatography is minimally invasive, and complications sel-
dom occur.4,6,8,17,18
Although well documented in the literature, most studies
of dermatography have been observational.4,6,9,10,12,13,16,17,19,20
To our knowledge, this study is the first to statistically evalu-
ate patient satisfaction with the final result and their related
quality of life after dermatography in the head and neck area.

Methods
Patients
Institutional review board approval was not necessary for this
study because all research was done retrospectively after treat-
ment. All patients included in the study provided oral in-
formed consent.
In this case series, all patients receiving dermatography at
the Netherlands Cancer Institute–Antoni van Leeuwenhoek
Hospital, Amsterdam, were analyzed. Patients were eligible for
inclusion in the study if they underwent dermatography for
scars or skin grafts or other reconstruction in the head and neck
region between July 1, 2007, and April 1, 2015.
Dermatography Technique
All dermatography procedures were performed by one of us
(B.H.D.). The pigments used for the technique include ferri-
and ferro-oxide, ferrohydroxide, titanium dioxide, tartra-
zine, and carbon. Mixing these pigments with 80% alcohol
yields a suspension. A series of 64 predeveloped standard
colors, varying in intensity from 10% to 100%, constitutes
the reference by which a sliding color scale can be made.16
Disinfection of the skin is performed with 80% alcohol.16
Local anesthetic may be infiltrated to provide numbing and re-
duce bleeding during treatment. However, an anesthetic is
rarely used because it may result in dilution of the pigment and
therefore fading of color.13
Dermatography is performed using a modified tattooing
machine (Van der Velden Derma-injector; Medicer) consist-
ing of an electromechanical motor and a needle holder that
is moved up and down in a stainless steel tube (Figure 1) at a
speed between 500 and 3500 rpm.10,13,16 The number and
arrangement of the needles vary depending on the required
The patient had undergone a right-sided Blair incision for a parotidectomy
(arrowhead).
color intensity.13 The needles are disposable, with a length of
36 mm and a diameter of 0.36 or 0.41 mm.16
The optimal level of pigment insertion is the upper and
midpapillary dermis.6 With the vertical movement of the
needles, an alternating effect of pressure and suction is initi-
ated by which the pigment suspension is deposited along the
needles. Depending on variations in anatomy, the depth of
the punctures varies between 0.6 and 2.2 mm.13 The angle of
the needle varies as well, from 10° to 90°. During the proce-
dure, the skin is stretched with the thumb and index finger,
and hemostasis is maintained by applying pressure.6,16 To
enable the underlying skin color to be visible and to follow
seasonal variations, the pigment does not cover the skin
completely but is injected to create a raster of punctures.
A pressure dressing, prophylactic antibiotics, and anti-
inflammatory drugs may be used after dermatography. If
needed, consecutive sessions may be scheduled at intervals
of 3 weeks or more until an optimal match with the sur-
rounding skin color is reached.13,17 Touch-up procedures
may be needed if color fading occurs over time. Coloring of
skin can be combined with treatment of hypertrophic scars

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 Dermatography for Scars and Skin Grafts in Head and Neck Patients Original Investigation Research

Figure 2. The Modified Utrecht Questionnaire for Outcome Assessment Figure 3. The Modified Patient Scar Assessment Questionnaire
in Aesthetic Rhinoplasty
Modified Patient Scar Assessment Questionnaire.
* = choose the right option
The modified Utrecht questionnaire for scar or skin graft.
* = choose the right option Appearance
A1. How well does the color of your skin match with your skin surrounding it?
I give the following score to the way I like the appearance of my scar/graft*:
Very well matched Well matched A little matched Poorly matched
1 2 3 4
0 1 2 3 4 5 6 7 8 9 10
very ugly very nice
A2. Is your skin darker or lighter compared to surrounding skin?
E1. Are you concerned about the appearance of your scar/graft*? Very much
No Slightly darker Fairly darker Much darker
Not at all A little Moderate Much or often or often
1 2 3 4
1 2 3 4 5

Slightly lighter Fairly lighter Much lighter

E2. Does this concern bother you often? Very much 2 3 4
Not at all A little Moderate Much or often or often
1 2 3 4 5
A3. How flat do you think your scar/skin graft* is compared to surrounding skin?
Flat and level Slightly raised Fairly raised Very raised
E3. Does this concern affect your daily life (e.g., your work)? 1 2 3 4
Very much
Not at all A little Moderate Much or often or often
1 2 3 4 5
Slightly sunken Fairly sunken Very sunken
2 3 4

E4. Does this concern affect your relationships with others? Very much
Not at all A little Moderate Much or often or often Consciousness
1 2 3 4 5 C1. How noticeable is your scar/skin graft* to you?
Very well matched Well matched A little matched Poorly matched
1 2 3 4
E5. Do you feel stressed by the appearance of your scar/graft*? Very much
Not at all A little Moderate Much or often or often
1 2 3 4 5 C2. How often do you think about your scar/skin graft*?
Never Sometimes Often Always
1 2 3 4
The questionnaire was answered twice. First, patients were asked
retrospectively about their situation before dermatography. Next, the patients
answered the questions regarding their current situation after dermatography. C3. Overall, how self-conscious are you of your scar/skin graft*?
Not at all Slightly Fairly Very
1 2 3 4

(intracicatricial keloidectomy). The cutting action of several

needles placed in a row reduces tissue volume and smooth-
Satisfaction with appearance
ens the scar, making it level with its surroundings.16
S1. How satisfied are you with the way the color of your scar/skin graft* matches
with surrounding skin?
Questionnaires Very satisfied Satisfied Dissatisfied Very dissatisfied
1 2 3 4
Two previously validated questionnaires21,22 were modified
to make them applicable to this study (Figure 2 and Figure 3).
First, the Utrecht Questionnaire for Outcome Assessment in S2. How satisfied are you with the texture of your scar/skin graft* (the way it feels
Aesthetic Rhinoplasty21 was altered for use in patients with to touch)?
Very satisfied Satisfied Dissatisfied Very dissatisfied
scars and skin grafts. The modified Utrecht questionnaire 1 2 3 4
consists of one question assessing scar or skin graft appear-
ance on a visual analog scale (VAS) ranging from 0 to 10, with
0 as “very ugly” and 10 as “very nice.” Five subsequent ques- S3. Overall, how satisfied are you with the appearance of your scar/skin graft*?
Very satisfied Satisfied Dissatisfied Very dissatisfied
tions assess the quality of life in relation to the scar or skin
1 2 3 4
graft, with 1 indicating “not at all” concerned and 5 indicating
“very much or often” concerned. Second, a selection of 9
questions from the Patient Scar Assessment Questionnaire22 The questionnaire was answered twice. First, patients were asked
was used. These questions focused on patient appearance, retrospectively about their situation before dermatography. Next, the patients
scar consciousness, and satisfaction with appearance on a answered the questions regarding their current situation after dermatography.

5-point scale.
Each questionnaire was answered twice. First, patients
were asked retrospectively about their situation before der-
matography. Next, the patients answered the questions re-
garding their current situation after dermatography.
Statistical Analysis
The results of the questionnaires are summarized as means,
medians, and interquartile ranges. In addition, the mean
(95% bootstrap CI) and median differences in scores before

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 Research Original Investigation Dermatography for Scars and Skin Grafts in Head and Neck Patients

and after dermatography are provided. Some of the differ-

ences were not normally distributed. Wilcoxon signed rank Results
test for paired observations was used to test differences in
within-patient scores. To account for multiple comparisons, Seventy-six patients undergoing dermatography were identi-
the Bonferroni-adjusted significance level was set at fied as eligible for this study. Among them, 56 were willing to
P < 3.3 × 10−3. A software program (R, version 3.2.3; R Foun- participate, for a response rate of 74%. Among the 20 ex-
dation for Statistical Computing) was used for the statistical cluded patients, 16 could not be contacted, 3 declined to par-
analysis. ticipate, and 1 had died. Among the 3 patients who did not want
to participate, one immediately refused (with no explana-
tion), another stated that she was unable to “quantify” her
Table 1. Baseline Characteristics Before Surgery in 56 Patients views, and the third regretted the dermatography because it
Who Underwent Dermatography
was interfering with diagnostic imaging (confocal micro-
Characteristic Value scopy) for a new primary lesion.
Ratio of men to women 14:42 The mean (SD) age of the study cohort was 56.5 (16.0)
Age, mean (SD) [range], y 56.5 (16.0) [19-86] years. Most patients had been treated for cutaneous malig-
Malignant neoplasm 48 nant disease of the head and neck before receiving derma-
Basal cell carcinoma 18 tography (Table 1).
Melanoma 10 Almost all patients had a significant improvement on
Squamous cell carcinoma 6 the VAS. The mean difference on the VAS was −4.0 (95% CI,
Oral or oropharyngeal cancer 5 −4.6 to −3.3; P = 1.1 × 10−9). After dermatography, the mean
Thyroid carcinoma 2
VAS score was 7.8. For the 5 remaining questions, a decrease
in patient concern was observed, with all P values sig-
Other 6
nificant after Bonferroni correction (Table 2). The same
Unknown 1
was true for the modified Patient Scar Assessment Ques-
Benign neoplasm 8
tionnaire, with uniform improvement of approximately 1
Nevus 2
point across the 9 questions (range, P = 5.6 × 10 − 6 to
Other 6
P = 1.5 × 10−9).

Table 2. Results of the Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty and the Modified Patient Scar Assessment
Questionnaire Before and After Dermatographya

Before After
Mean Difference (95% CI)
Variable Mean Median (IQR) Mean Median (IQR) [Median Difference] P Value
Modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty
Question 0 3.8 4.0 (2.0 to 5.0) 7.8 8.0 (7.0 to 9.0) −4.0 (−4.6 to −3.3)[−4.0] 1.1 × 10−9
Questions 1-5
1 2.7 2.5 (1.0 to 4.0) 1.5 1.0 (1.0 to 2.0) 1.2 (0.8 to 1.6)[1.5] 5.1 × 10−6
2 2.4 2.0 (1.0 to 4.0) 1.4 1.0 (1.0 to 2.0) 1.0 (0.6 to 1.3)[1.0] 3.1 × 10−5
3 1.9 1.0 (1.0 to 3.0) 1.1 1.0 (1.0 to 1.0) 0.8 (0.5 to 1.2)[0.0] 2.3 × 10−5
4 1.6 1.0 (1.0 to 2.0) 1.1 1.0 (1.0 to 1.0) 0.5 (0.3 to 0.8)[0.0] 1.2 × 10−3
5 1.8 1.0 (1.0 to 3.0) 1.1 1.0 (1.0 to 1.0) 0.7 (0.4 to 1.0)[0.0] 1.2 × 10−4
Modified Patient Scar Assessment Questionnaire
Appearance
1 3.6 4.0 (3.0 to 4.0) 2.0 2.0 (1.8 to 2.0) 1.6 (1.3 to 1.8)[2.0] 1.5 × 10−9
2 3.0 3.0 (2.0 to 4.0) 1.7 1.5 (1.0 to 2.0) 1.3 (0.9 to 1.6)[1.5] 2.4 × 10−7
3 2.5 3.0 (1.0 to 3.3) 1.6 1.0 (1.0 to 2.0) 0.9 (0.6 to 1.2)[2.0] 4.0 × 10−6
Scar consciousness
1 3.4 4.0 (3.0 to 4.0) 2.0 2.0 (1.0 to 3.0) 1.4 (1.1 to 1.7)[2.0] 4.0 × 10−9
2 2.7 3.0 (2.0 to 3.0) 1.8 2.0 (1.0 to 2.0) 0.9 (0.7 to 1.1)[1.0] 1.7 × 10−8
3 2.7 3.0 (2.0 to 3.3) 1.8 2.0 (1.0 to 2.0) 0.9 (0.5 to 1.1)[1.0] 5.6 × 10−6
Satisfaction with appearance
1 3.1 3.0 (3.0 to 4.0) 1.8 2.0 (1.0 to 2.0) 1.2 (0.9 to 1.4)[1.3] 2.0 × 10−8
2 2.8 3.0 (2.0 to 3.0) 1.8 2.0 (1.0 to 2.0) 1.0 (0.8 to 1.2)[1.0] 3.5 × 10−8
3 3.1 3.0 (3.0 to 4.0) 1.8 2.0 (1.0 to 2.0) 1.3 (1.0 to 1.6)[1.0] 2.0 × 10−8

Abbreviation: IQR, interquartile range.

a
The means and the medians (IQRs) before and after dermatography are listed. For the mean differences, the 95% CIs were calculated using bootstrapping.

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 Dermatography for Scars and Skin Grafts in Head and Neck Patients
Figure 4. Basal Cell Carcinoma of the Left Zygoma and Cheek
A Before dermatography B After dermatography
Discussion
Scar and skin graft color abnormalities can result in impaired
physical, psychological, and social well-being.23,24 In such
cases, secondary reconstruction may be necessary to im-
prove the function or appearance of the postoperative site.
Well-known established adjuvant procedures to enhance scar
or skin graft appearance are dermabrasian, scar excision,
W-plasty, geometric broken line repair, or corticosteroid in-
jections. As demonstrated herein, dermatography is also a valu-
able nonsurgical alternative to improve appearance and occa-
sionally to also enhance function. Unfortunately, the use of this
adjuvant procedure is often overlooked. Otolaryngologists and
head and neck surgeons may be less familiar with the tech-
nique than plastic surgeons who routinely use this procedure
for nipple reconstruction after mastectomy.1,2
Dermatography has numerous advantages, including no
donor-site morbidity, availability of a wide range of colors,
no requirement for hospitalization or general anesthesia,
permanent camouflage, and well-preserved sensation.8,17
Moreover, coloring of scars can be combined with intracica-
tricial keloidectomy, in which the volume of hypertrophic
scars is reduced by the cutting action of the needles.16 This
action smoothens the scar and reduces scar tension.
Few publications exist on the use of dermatography after
head and neck procedures.4,5,12,16,17 These studies were mainly
observational and did not focus on patient satisfaction and the
related quality of life after treatment. To evaluate these top-
ics in the present study, we searched the literature for vali-
dated questionnaires that were simple and short, but no such
questionnaires were found. We found 2 validated question-
naires that were usable after slight modification (Figure 2 and
Figure 3). The first was the Utrecht Questionnaire for Out-
come Assessment in Aesthetic Rhinoplasty,21 in which the word
nose was changed to scar or skin graft. The second was the Pa-
tient Scar Assessment Questionnaire,22 from which we chose
the 9 most relevant questions because we considered 28 ques-
tions before and after therapy too long for our group of head
and neck patients.
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Original Investigation Research
The defect was reconstructed with a
full-thickness skin graft from the
supraclavicular neck. The
hypopigmented graft was treated
with dermatography, resulting in a
more natural appearance.
In the Department of Head and Neck Oncology and Sur-
gery, Netherlands Cancer Institute–Antoni van Leeuwenhoek
Hospital, dermatography is offered occasionally to patients
with hyperpigmented and hypertrophic scars, those with hy-
popigmented skin grafts, or patients missing a structural or-
gan (eg, hair-bearing skin, vermillion pigment, or eyebrow).
Primary treatment, such as surgery, radiotherapy, or chemo-
radiation, of the underlying disease should be completed be-
fore starting dermatography. Especially in the case of skin graft-
ing or flap surgery, the wound is given sufficient time to heal
before dermatography to ensure adequate perfusion and
healing.17
The results of the present study show that dermatogra-
phy is a valuable adjuvant treatment option. The scores on the
VAS pertaining to the appearance of the scar or skin graft im-
proved after treatment by 4 points on a 10-point scale. One ex-
ception was a patient with a history of inflammation and ra-
diotherapy before dermatography, resulting in a more difficult
treatment and a worse VAS score after treatment. In all other
patients, lesion appearance and quality of life regarding the scar
or skin graft improved significantly (Table 2). After this mini-
mally invasive procedure, patients report not only improve-
ment in the appearance of their scar or skin graft but also
enhanced quality of life. To visualize the effect of the derma-
tography procedures, 3 cases are shown before and after
therapy (Figures 4, 5, and 6).
The technical aspects of dermatography differ little from
those of decorative tattooing. In both disciplines, various tat-
tooing machines and needles are used to inject pigment in the
dermis, but the materials injected in the procedures differ,
especially relative to the possibility of ink carcinogenesis. Tat-
too colorants contain pigments that include inorganic metallic
salts, various types of organic molecules, and organic dyes
(traditional ink). Some of these components are classified as
possible carcinogenic agents.25 Instead of traditional ink that
is used in decorative tattooing, inorganic metallic salts (eg,
iron oxide dyes) and organic molecules (eg, tartrazine) are
used as coloring agents in dermatography because of their
structure that gives a more precise result.17 The association
between tattooing and skin cancer is most likely multifacto-
(Reprinted) JAMA Facial Plastic Surgery Published online September 22, 2016 E5
 Research Original Investigation Dermatography for Scars and Skin Grafts in Head and Neck Patients

Figure 5. Hypertrophic Scar in a Patient in Whom Dermatography Was Combined With Intracicatricial
Keloidectomy.

A Before dermatography B After dermatography

Note the reduction in tissue volume

and the leveled scar.

Figure 6. Situation After Commando Operation With Reconstruction of the Oral Vestibule
Using a Free Revascularized Double-Layer Radial Forearm Flap

A Before dermatography B After dermatography

Dermatography was performed by

creating the red and vermilion of the
lip. In addition, the color of the
remaining skin was altered to match
that of the surrounding skin.

rial, including trauma induced by the procedure, a lifetime
inflammatory reaction in an attempt to degrade all foreign
material, and the ink content used.25 However, a review by
Kluger et al25 concluded that the number of skin cancers
arising in tattoos is low and that any association thus far
should be considered coincidental. In addition, during 20
years of practicing dermatography, one of us (B.H.D.) has
observed no malignant neoplasms in tattooed skin at our
institute.
In addition to the colorant used, the final result after
dermatography is also influenced by procedural factors,
namely, the depth of pigment deposition, pigment density,
and number of needles used. Patient factors include thick-
ness and elasticity of the skin or mucosa, natural melanin
content, and capillary blood flow.6 Tattooing in scar tissue is
less predictable than tattooing in healthy tissue because
pigment may appear less vivid and uneven when implanted
in scar tissue.18
Dermatography has few contraindications.17 Complica-
tions mentioned in the literature are rare. Allergic reactions
to tattoo composition have been described and can range
from a lichenoid reaction to contact dermatitis.6,26 Granulo-
matous reactions may also occur. Along with local skin reac-
tions, sarcoid granulomas have been described, sometimes
occurring years after tattoo placement.6,17,26 Other complica-
tions are infections, ranging from hepatitis, human papillo-
mavirus, herpes simplex virus, and human immunodefi-
ciency virus to secondary bacterial infection. These problems
mainly result from improper technique or materials and
insufficient hygiene, which is not the case in the dermatogra-
phy setting in a hospital.6,8,17,18,26 No complications occurred
in the present study.
Dermatography has few disadvantages, including the
need for specialized skills and equipment and the fading of
color over time.17 In addition, it may mask the condition of
the skin, making clinic al follow-up and dermoscopy
difficult.27 It may also impede reflectance confocal micros-
copy, a cellular level in vivo imaging technique.28 Further-
more, tattoos containing metallic elements may interact
with magnetic resonance imaging (MRI). Franiel et al 29
reported a case of an MRI-induced first-degree burn in a
nonferrous tattoo of the eyelids caused by locally induced
electric current. Such burns can be induced by any metal
(not just ferromagnetic metals). However, another study30
identified dysesthesia in only 2 of 135 patients with tattoos
undergoing MRI.

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 Dermatography for Scars and Skin Grafts in Head and Neck Patients Original Investigation Research

Facial tattooing is offered not only by skin or beauty
therapists but also by physicians. Especially in the facial
plastic surgical patient population, we believe that medical
tattooing is best performed by a trained physician, capable
of assessing the skin and able to prescribe medication, if
necessary. Anyone interested in this procedure should at
least work under the supervision of an experienced derma-
tographer for some time because medical tattooing requires
a certain amount of knowledge and skill. To our knowledge,
there is no international list of physicians offering this
service.
This study has some limitations. First, selection bias may
have occurred because those who benefited most from der-
matography were more likely to participate in the study than
those who did not. However, most of the exclusions were in-
dividuals who were unreachable, and only 3 of 20 exclusions
were due to refusal to participate in the interview. Second, the
retrospective nature of this study may have resulted in recall
bias, especially for the questions relating to the condition be-
fore dermatography. However, patient report of the differ-
ence before and after treatment expressed a positive change.
Third, we did not use photographs before and after treat-
ment. Such photographs can speak for themselves but may be
difficult to compare because of differences in angle and light-
ing or may represent only temporary results.31 On the other
hand, a patient’s own subjective appearance is more mean-
ingful and ultimately is the most important measure of a suc-
cessful outcome.
Conclusions
Dermatography is an effectual adjuvant procedure to im-
prove the subjective perception of scar and skin graft appear-
ance and the quality of life in head and neck patients. There-
fore, the use of dermatography is warranted in the routine
workup of patients with problematic scars and skin graft pig-
ments after head and neck surgical procedures.

ARTICLE INFORMATION REFERENCES 13. Vassileva S, Hristakieva E. Medical applications

Accepted for Publication: July 5, 2016. 1. Boccola MA, Savage J, Rozen WM, et al. Surgical of tattooing. Clin Dermatol. 2007;25(4):367-374.

Published Online: September 22, 2016.
doi:10.1001/jamafacial.2016.1084.
Author Affiliations: Department of Head and Neck
Oncology and Surgery, Netherlands Cancer
Institute–Antoni van Leeuwenhoek Hospital,
Amsterdam (Drost, van de Langenberg, Zuur, Klop,
Lohuis); Center for Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology–Head and
Neck Surgery, Diakonessen Hospital, Utrecht, the
Netherlands (van de Langenberg, Manusama,
Lohuis); Department of Dermatology, Netherlands
Cancer Institute–Antoni van Leeuwenhoek
Hospital, Amsterdam (Janssens); Department of
Biometrics, Netherlands Cancer Institute–Antoni
van Leeuwenhoek Hospital, Amsterdam (Sikorska).
Author Contributions: Drs van de Langenberg and
Lohuis had full access to all the data in the study
and take responsibility for the integrity of the data
and the accuracy of the data analysis.
Study concept and design: Drost,
van de Langenberg, Manusama, Janssens, Lohuis.
Acquisition, analysis, or interpretation of data:
Drost, van de Langenberg, Manusama, Sikorska,
Zuur, Klop, Lohuis.
Drafting of the manuscript: van de Langenberg,
Manusama, Lohuis.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: van de Langenberg, Sikorska.
Administrative, technical, or material support:
van de Langenberg, Janssens, Zuur, Lohuis.
Study supervision: Drost, van de Langenberg, Klop,
Lohuis.
Conflict of Interest Disclosures: None reported.
Previous Presentations: This study was presented
at the 228th Dutch Biannual Otolaryngological
Society Meeting (228e Keel-Neus-Oorheelkunde
Vergadering); April 22, 2016; Nieuwegein, the
Netherlands; and at the 8th World Congress of
Facial Plastic Surgery; May 13, 2016; Rio de Janeiro,
Brazil.
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 Research Original Investigation Dermatography for Scars and Skin Grafts in Head and Neck Patients

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