Eyebrow-raising complications of microblading

By Warren R. Heymann, MD, FAAD
May 1, 2024
Vol. 6, No. 18

One of the most significant challenges of being a medical dermatologist is that patients assume you are well-versed in all aspects of dermatology, including cosmetic procedures. It is a reasonable expectation that dermatologists have at least a rudimentary knowledge of cosmetic procedures and their risks, even if not performing them. Recently I have been asked for my opinion about the microblading technique for tattooing hairstrokes that simulate natural hair, used chiefly for eyebrows. Knowing nothing about this technique served as the impetus for this commentary with the sole purpose of not offering a blank stare to future patients who inquire about it.

As with any cosmetic procedure, art and science is essential in achieving an optimal outcome. Scrupulous attention to detail and technique is mandatory. The risk of complications can be minimized by appropriate training and experience. For those who want to learn about this procedure in depth, I encourage you to read the article by Marwah et al that is summarized in the following abstract. (1)

Eyebrows have been known to be an importance aspect of facial aesthetics and eyebrow restoration is now a part of anti-ageing procedures too. Microblading is a new technique in the field of permanent cosmetics for eyebrow restoration. Currently, it is one of the most sought- after treatments in aesthetic procedures due to the curiosity and awareness raised by social media. Microblading is a form of superficial micropigmentation, wherein pigment is deposited till the papillary dermis, with the help of a manual device and a blade consisting of stacked needles. The resultant crisp, discrete hair like incisions simulate the eyebrow hair to give a natural look. The results are semi-permanent and last only 12-18 months. In the recent years, with the advancement in the instrumentation of microblading there have been several modifications in this procedure. Microblading has now found its applications not only in cosmetic treatments but also in dermatological conditions such as alopecia totalis, hypothyroidism, chemotherapy induced madarosis, etc. It is a vital tool in any dermatology or cosmetic practise for its extensive applications. But with the rise in popularity of microblading, there is also a rise of untrained professionals performing it leading to a rise in its side-effects. This article aims at not only guiding on the instrumentation and procedure of microblading but also its pre and post procedure care, interaction with other aesthetic procedures and treating its complications.

Microblading use has grown exponentially; perhaps the focus on eyes when wearing masks for COVID-19 contributed to its popularity. (2,3)

As stated by Leight-Dunn et al, “Despite the intended superficial implantation, microblading carries the same risks as permanent tattoo procedures, including infections, allergic dermatitis, and granulomatous or autoimmune inflammatory reactions.” (4)

Akoh et al presented the case of a 39-year-old woman with a history of sickle cell disease who developed a purulent facial infection a day after microblading for her eyebrows — this was initially managed by telehealth and cephalexin and mupirocin were prescribed. Worsening of the condition required intravenous antibiotics with a subsequent diagnosis of preseptal (or periorbital) cellulitis, mandating empiric antibiotics to cover common organisms such as methicillin-resistant Staphylococcus aureus, Streptococcus spp., and anaerobic bacteria (see image). (5) A striking case of PCR-confirmed microblading-transmitted monkeypox (mpox) in a 47-year-old woman developed 4 days after her procedure has been reported; the ulcerative lesion healed with scarring. The authors note that mpox may be transmitted by direct skin contact or fomites. (6)

Microblading utilizes metallic nano-needles containing 6–8% nickel, depending on the grade. Lahouel et al reported the case of a 50-year-old woman, with a history of intolerance to fake jewelry who presented with bilateral, symmetrical, itchy, erythemato-edematous lesions on the eyebrows. The lesions appeared 2 days after the application of microblading to her eyebrows. She was successfully treated with topical steroids. Patch testing confirmed nickel allergy. (7)

The most frequently reported adverse reaction to microblading are granulomatous reactions, which may appear months to years after the procedure. The granulomas may be sarcoidal histologically — although this reaction may be skin-limited, an evaluation for systemic sarcoidosis is warranted. (4,8,9) In their review of 21 cases of microblading-induced granulomatous reactions, Ibraheim found that 10 were foreign body granulomas and 11 sarcoidal, 7 of whom had systemic sarcoidosis. Treatment of granulomatous reactions is with the usual litany of agents for granulomatous disease (steroids [topical, intralesional, systemic], tetracyclines, antimalarials, calcineurin inhibitors, azathioprine, methotrexate, adalimumab, etc. (10)

How will I advise my patients who ask for my opinion of microblading for eyebrow enhancement? Just as I do for any other cosmetic procedure — explain that microblading may offer real benefits but is not risk-free; I will then refer them to a colleague with procedural expertise.

Point to Remember: Microblading is a new and increasingly popular technique primarily used for eyebrow restoration. As with all procedures, practitioner knowledge and experience will help minimize attendant risks.

Our experts’ viewpoints

Manjot Marwah, MBBS, MD

Since microblading is a relatively new procedure, the maximum complications that I see are usually due to incorrect technique or using the wrong pigment ink. These usually include effects such as the pigment wearing off too soon, asymmetry, changing colour of the pigment, and the creation of unnatural hair strokes. Most of these effects can be corrected by focusing on learning improved technique. Microblading also gives varied results based on geographical climactic changes. Pigment wears off faster and changes colour in the tropics due to humid weather and sun exposure. Excessive secretion from sebaceous glands near the eyebrow areas washes off the pigment early during the healing phase, hence advising patients to avoid working out and participating in outdoor activities is very important. Microblading inks are synthetic gel-based and are thicker in consistency than tattoo inks, hence their intradermal dispersion and removal by macrophages is lesser, so choosing the right ink consistency is vital. Change of the ink shade occurs because of oxidation of the pigment in sunlight, giving a greyish tone over a period of time. The reddish tone that can be seen in tattoo inks due to higher percentage of iron oxide does not happen because these are not used in microblading.

Adverse side effects like infections and granulomas can be avoided by proper technique and maintaining sterilization around the procedure area. I prefer giving a topical antibiotic ointment for all patient post procedure, which helps with the healing of the tattoo. To date there are very few case reports of infections and granulomas, or studies on microblading in general, so it can be considered a safe procedure, however more reporting and multicenter studies are warranted.

Marina Kristy Ibraheim, MD
Dermatology Resident, PGY-3
Loma Linda University

Interest in cosmetic procedures has surged in recent years due to a number of factors including mainstream exposure through social media and an increased desire to modify of one’s appearance in order to conform to societal norms. (11-13) Curiously, the COVID-19 pandemic may have contributed to this boom as well — studies by Rice et al and Pikoos et al suggest that prolonged exposure to one’s own (distorted) appearance over video conferences may have contributed to self-identification of cosmetic concerns, thereby increasing interest in cosmetic interventions. (14,15) Procedures have also become more readily accessible now than in previous years; interested parties can receive treatment from board-certified dermatologists and plastic surgeons or seek out non-physician operators, such as those in medical spas, who may offer shorter wait times and competitive pricing with minimal physician oversight. (16,17)

Microblading is one such procedure that non-physician operators can conduct in the United States, and individuals in the general public may not fully understand the risks and benefits the modality poses. Indeed, patients may not even consider discussing the matter with their dermatologists during a routine visit before pursuing treatment, thinking that its ubiquity is indicative of its safety. Concerted efforts to educate ourselves and our patients regarding cosmetic interventions of interest is certainly key. Increasing residents’ exposure to cosmetic interventions and educating them on prevention and management of complications that arise from them is equally important, but curricular interventions in this realm are still suboptimal. (18) Finally, it should be noted that in countries such as Japan, microblading is considered a medical intervention. (19) Learning proper technique cannot be overemphasized.

1. Marwah MK, Kerure AS, Marwah GS. Microblading and the Science Behind it. Indian Dermatol Online J. 2021 Jan 16;12(1):6-11. doi: 10.4103/idoj.IDOJ_230_20. PMID: 33768017; PMCID: PMC7982014.

2. Hvas D, Serup J. Microblading Technique for Tattooing of "Hairstrokes" That Simulate Natural Hair: Eyebrow Tattooing and Correction of Medical Conditions. Curr Probl Dermatol. 2022;56:141-154. doi: 10.1159/000529810. Epub 2023 Jun 1. PMID: 37263228.

3. Kim J, Kwon KH. Trends in eyebrow makeup after COVID-19 and long-COVID era. Health Sci Rep. 2023 Apr 13;6(4):e1181. doi: 10.1002/hsr2.1181. PMID: 37064315; PMCID: PMC10100688.

4. Leight-Dunn H, Lemly V, Chapas A. Delayed Granulomatous Reaction After Eyebrow Microblading. Dermatol Surg. 2022 Jan 1;48(1):142-143. doi: 10.1097/DSS.0000000000003236. PMID: 34537782.

5. Akoh CC, Akintilo L, Shankar S, Lo Sicco K. A rare case of microblading-induced preseptal cellulitis. JAAD Case Rep. 2021 Aug 24;16:98-100. doi: 10.1016/j.jdcr.2021.08.014. PMID: 34553011; PMCID: PMC8441103.

6. Castaño-Fernández JL, Grau-Pérez M. Microblading-transmitted Monkeypox (mpox) infection: fomites matter. Br J Dermatol. 2023 May 24;188(6):e40. doi: 10.1093/bjd/ljad063. PMID: 36899480.

7. Lahouel I, Salah NB, Machghoul S, Belhadjali H, Youssef M, Zili J. Allergic contact dermatitis post-microblading eyebrow tattooing: A manifestation of pre-existing nickel sensitization. J Cosmet Dermatol. 2022 Oct;21(10):5270-5271. doi: 10.1111/jocd.14920. Epub 2022 Apr 5. PMID: 35290705.

8. Spurr A, Hanna N, Colantonio S. Cutaneous sarcoidosis in eyebrows cosmetically pigmented with microblading method: A case report and review of the literature. SAGE Open Med Case Rep. 2022 Aug 11;10:2050313X221117720. doi: 10.1177/2050313X221117720. PMID: 35991955; PMCID: PMC9382064.

9. Kluger N. Delayed Granulomatous Reaction After Eyebrow Microblading. Dermatol Surg. 2022 Apr 1;48(4):472-473. doi: 10.1097/DSS.0000000000003361. PMID: 34935749.

10. Ibraheim MK, Desai M, Tawfik M, Elsensohn A, Furukawa B. Microblading-Induced Granulomatous Reaction: Case Report and Review of the Literature. Am J Dermatopathol. 2023 Jul 1;45(7):487-491. doi: 10.1097/DAD.0000000000002449. Epub 2023 May 2. PMID: 37130196.

11. Hopkins ZH, Moreno C, Secrest AM. Influence of Social Media on Cosmetic Procedure Interest. J Clin Aesthet Dermatol. 2020;13(1):28-31.

12. Rippee DB, Hudson HT, Tarabishy S, Herrera FA. Social Media Marketing of Cosmetic Services in the United States: Examining Gender Disparities. J Plast Reconstr Aesthet Surg. 2022;75(8):2831-2870. doi:10.1016/j.bjps.2022.06.029.

13. Pearlman RL, Wilkerson AH, Cobb EK, et al. Factors Associated with Likelihood to Undergo Cosmetic Surgical Procedures Among Young Adults in the United States: A Narrative Review. Clin Cosmet Investig Dermatol. 2022;15:859-877. doi:10.2147/CCID.S358573.

14. Pikoos TD, Buzwell S, Sharp G, Rossell SL. The Zoom Effect: Exploring the Impact of Video Calling on Appearance Dissatisfaction and Interest in Aesthetic Treatment During the COVID-19 Pandemic. Aesthet Surg J. 2021;41(12):NP2066-NP2075. doi:10.1093/asj/sjab257.

15. Rice SM, Siegel JA, Libby T, Graber E, Kourosh AS. Zooming into cosmetic procedures during the COVID-19 pandemic: The provider’s perspective. Int J Womens Dermatol. 2021;7(2):213-216. doi:10.1016/j.ijwd.2021.01.012.

16. Gibson J, Greif C, Nijhawan RI. Evaluating Public Perceptions of Cosmetic Procedures in the Medical Spa and Physician’s Office Settings: A Large-scale Survey. Dermatol Surg. 2023;49(7):693-696. doi:10.1097/DSS.0000000000003811.

17. Valiga A, Albornoz CA, Chitsazzadeh V, et al. Medical spa facilities and nonphysician operators in aesthetics. Clin Dermatol. 2022;40(3):239-243. doi:10.1016/j.clindermatol.2021.11.007.

18. Nielson CB, Harb JN, Motaparthi K. Education in Cosmetic Procedural Dermatology: Resident Experiences and Perceptions. J Clin Aesthet Dermatol. 2019;12(8):E70-E72.

19. Tomita S, Mori K, Yamazaki H, Mori K. Complications of permanent makeup procedures for the eyebrow and eyeline. Medicine (Baltimore). 2021;100(18):e25755. doi:10.1097/MD.0000000000025755.

---