Corrective Pigment Camouflage: Part 2 of 3

This information is part 2 in a 3-part series.

This selection will consist of distinguishing skin undertones, patch and sensitivity tests, proper equipment, pigment, technique and time frame from application to application.

Pre CPC and Scar Relaxation

A 33-year old patient has contractures extending from the tip of the left ear, over the zygomatic, to the filtrum. Post-burn scar contractures of cheek and mouth area, including hyper-and hyper pigmented regions. This photos shows her before Corrective Pigment Camouflage (CPC) and Scar Relaxation treatments.


Post CPC and Scar Relaxation

Patient chose to receive Corrective Pigment Camouflage instead of a radial forearm flap procedure because of the scarring and recovery time involved. Photo shows patient 6 months after CPC was applied to facial areas. Skin tones now integrate into one another.

Natural pigments are classified as melanin. Melanin is comprised of molecules that are capable of reflecting color. The perceived color of our skin is caused by the reflection of light on our skin, known as light refraction. Neuromelanin (brown black), and Phomelanin (yellow red) are two types of melanin.

Melanocytes are the main cells responsible for the color of our eyes, hair and skin. These cells are located in the basal layer of the epidermis. They synthesize red, brown and yellow melanin biochromes (melanin) and are the major determinants of skin color. The biochromes include: carotene (which incorporates the yellow or yellow-orange color into the skin), oxygenated hemoglobin (which incorporates the red color into the skin) and deoxygenated hemoglobin (which incorporates the blue color in the skin). Normal differences in our skin colors are determined by the intensity of the pigmentation and melanin production.

The basic undertones of our skin do not change. Certain conditions may affect the appearance of the skin of a patient. Client consultation, as well as each application visit, should include updated information on recent illness, changes in diet and medication, fatigue, excess smoking and alcohol consumption, along with the use of self-tanning creams, tanning beds and natural sun tanning.

I use two easy and reliable methods of determining skin undertones. ‘Color With Style’ by Donna Fujii is one of the best reference publications I have found. I also use an invaluable tool called the ‘Color Undertone Chart’ from IIPC. It has 4- 8×10 pockets of color that represent pink, yellow, olive and blue skin undertones. Actual beads of pigment color are dropped on a sheet of white paper and then laminated. These color charts are then inserted into the cool/warm pockets of simulated skin undertones. This is the best method for determining how the color will look once it is implanted and reverted back to its natural state in the skin. The charts are made to slide in and out of the pockets to check on the difference each skin undertone has on the pigment color. These charts will help you to develop a keen eye in determining the underlying harmony existing between the skin, eyes and hair. This system is based on ‘Munsell Color Theory.’ Munsell recognizes that color has three dimensions: Hue, Value and Chroma. A thorough analysis of skin undertones is vital in order to successfully custom blend colors on an individual patient basis. The reference book, ‘Permanent Cosmetics A to Z,’ gives in-depth definitions of the proper protocol for CPC procedures with reference to proper utilization of pigment and needle cluster application.

For accurate color results always patch test and sensitivity test directly into the procedural area. Using either a rotary or a coil machine and a 3 round needle, we insert 7-8 implants of iron oxide pigments superficially into the epidermal tissue. To ensue optimal outcome, it is always wise to perform several different color tests for variegated skin tones. Modify color value as needed. Pigment should be placed into the epidermis (for minimum color retention) that will be sloughed off within 3-8 weeks. We utilize this method of application to discourage inappropriate color choices. Even if I know I have a valid color match for a patient’s skin tone, I will still patch test them and let the area heal for 4-8 weeks. Changes or additions in any medications may alter the chemistry of the body rendering your initial patch and sensitivity test inaccurate. Before inserting pigment, take patient outside into the natural daylight. This will enable you to have optimum visual clarity, which is the best perception of the pigment color you have chosen. The next best type of lighting is daylight bulbs, vita-lights or true white lights.

When the patient returns 4 – 8 weeks post consultation, evaluate results. Appropriate color choices and necessary changes can now be made. Patient and technician should thoroughly discuss healed colors from patch and sensitivity testing. Does the color look too ash? Too pink? Does it blend into the surrounding tissue? When patient and technician agree on the most flattering skin tones with consideration to color chroma, hue and value, application may begin. If you cannot agree on matching tones, you may repeat patch test application again.

After every application the pigment will revert back to its original state, dry. Only then will we have accurate final color results. All permanent cosmetic and CPC procedures are combinations of pigment color plus the patients skin undertones. These two factors will yield your final color result.

For all CPC applications we use an 8-wrap coil machine. Using a coil machine, you will achieve a smoother and more consistent application. Most rotary machines do not have sufficient power to penetrate scar tissue. Proper application is best achieved with needle groups of 14 rounds and 6 flats. Scar tissue may be void of pores, hair follicles, and glands. This tissue consists mainly of collagen fibers and can be very difficult to penetrate. Different techniques should be utilized according to tissue density. The same techniques used in lipliner, eyeliner and eyebrow hair simulation may be used on grafted tissue that is not scarred. Tissue that has extensive contractures will be very difficult to penetrate.

From previous experience on burn survivors with extensive scar contractures, I have found that patients will experience scar relaxation through repeated perforations with the coil machine. Whether you use metal or plastic tubes for your coil machine, make sure to use them for camouflage application only. Also, you need to mark the tubes for light or dark camouflage work. (You would not use the same tube on a Caucasian and an African-American.) Dark colors can leach into plastic tubes when autoclaved. We prefer to use white disposable tubes for CPC application. This will ensure us that we will never use a tube that could be possibly contaminated with prior use of darker colors. Remember disposable tubes are just that – disposable.

Use products, including pigments and equipment, with high quality. Purchase these products from companies with solid reputations that have strong track records. Ask other technicians for recommendations. There is a plethora of products created for cosmetic tattooing. The base ingredient of most pigments is generally the same. We suggest only using cosmetic grade iron oxide pigments or lakes for all CPC procedures.

We ask patients not to wear perfume on application day and to consume a light meal before application especially if they are going to take any pain medication. We always have soft, melodic music playing. Andrea Bocelli, Enya and Yanni have great soothing CD’s. Patients are given the choice of wearing a disposable gown or they may stay in their street clothes, depending on the procedure area and how extensive our application will be. We diffuse the room with essential oils that will consist of either orange or lavender for relaxation. Other oils that may be used for their sedating properties are sandalwood, chamomile or eucalyptus. These essential oils are absorbed through the lung tissue. For that special touch, offer the patient a calming blend of teas. We prefer Valerian Root Tea for its calming effect. Some technicians prefer to give their patients apple juice, or have them take a Motrin. You might also suggest a sublingual of Valerian Root and Kava Kava. (Technicians may not give patients any medication!) You may also offer your patient a headset or earplugs. Have the patient lie down and make them as comfortable as possible. In the cooler months, we wrap our patients in black sheets with their feet tucked in. We have had positive feedback from our patients that these small gestures help them to relax and feel secure.

Evaluate each area to be re-pigmented. Discuss color tones from the consultation application. Check your patient’s medical file and refer back to course of treatment from consultation day. Ask the patient if any information on their Procedure and Consent or Medical Forms has changed since their initial application. Before application, check patient for gradient skin tones. Inspect the procedure area to ensure there are no open lesions, rashes or other irregularities. To prepare the skin we cleanse the area with a sterile ‘Lid Wipe’. This product is a non-irritating scrub that will destroy bacteria and also remove any make-up left on the procedural area. Apply correct color. We usually wait until the 2nd or 3rd appointment to apply any nuances (ex. beard simulation, freckles, capillaries.) Adjust color if necessary.

Post-procedure appointments should be scheduled at 4-8 week intervals. The patient may return sooner if you are re-pigmenting various areas, but you cannot work on the same procedure area until it is completely healed. Touch-up appointments are critical for any fine detail work the patient may request, or to create any subtle additions or corrections in pigment color.

Informed and educated technicians understand specific needs of the patients.

C.P.C. is an advanced procedure and proper education is essential for satisfactory results.

Susan Church CCPC,CPDA
Director of Education
International Institute of Permanent Cosmetics
This article first appeared in the SPCP April/May 1996 Newsletter

For product information:

IIPC at 800.2820.577 or visit