Eyebrow Microblading: Science, Art, and Complications

Abstract

Background

Eyebrows are a distinct facial feature and any shift in their appearance impacts self-perception of external beauty attributes. There may be loss of hairs, or changes in pigment and texture due to primary or secondary causes.

Summary

A surge in demand for microblading in recent years, majorly for aesthetic value, has driven curiosity and requests for the procedure. This has translated to subjective dissatisfaction with cosmetic outcomes while also increasing the risk of complications and immunogenically driven adverse events.

Key Messages

Understanding the nuances of the technique and undertaking basic precautions will enable safe and desirable results in this common procedure.

Introduction

The modern human cranial anatomy today is characterised by a vertical and relatively smooth frontal bone, as opposed to the large brow ridges recorded in our immediate ancestors [1]. The placement of eyebrows corresponding with the supraorbital ridges plays a role in communicative and dynamic signals. Eyebrows are highly mobile units, capable of inducing very many forms of expression, ranging from subtle notes to gregariously emotive styles. Through many centuries, eyebrows have been highlighted in art and popular culture, with well-recognised “brow rebellion” in Frida Kahlo, in the Renaissance period, and through motion pictures. It has been stylised in various differing patterns, from thin and stringy, to deliberate, thick arches. Known as the master line of the face, eyebrows are used as a focal reference point for assessment of face contours and as a guide for various injectable techniques in aesthetics [2]. Highlighting its appearance by darkening it and adding optical contrast by filling in pigments is achieved through the process of microblading. Its utility is placed not just for cosmesis alone but as an aesthetic adjuvant in selected clinical cases.

Method

A comprehensive literature search was conducted using PubMed and MEDLINE (Medical Literature Analysis and Retrieval System Online), using studies and articles discussing eyebrow microblading and cosmetic brow tattooing. Search terms included “brow microblading,” “microblading complications,” “cosmetic brow tattooing,” and “madarosis.” Relevant information was collected and framed to explain brow anatomy and function, microblading and eyebrow tattooing, causes of madarosis, procedure, and possible complications.

Brow Anatomy and Function

The eyebrows are arched, hairy eminences bilaterally placed above the orbital regions [3, 4]. The hairs of the eyebrows are short, thick, and oriented obliquely. The diameter of individual follicles, degree of pigmentation and overall thickness exhibits individual differences and ethnic variations [5]. It may be roughly divided into three parts: the medial third below the orbital margin with hairs placed somewhat vertically, and a gradual shift in orientation of hairs, being set obliquely in the medial third and horizontally towards the lateral third (above the orbital margin) [3]. It tends to be most dense physiologically at the medial margins, as opposed to the lateral sides, and any loss of brow cilia is reflected earliest at the lateral third margins. This is also known as Queen Anne’s sign (loss/truncated lateral eyebrows); it is a nonspecific marker of hypothyroidism, and may be observed in multiple conditions such as lepromatous leprosy and severe atopic dermatitis [6].

The appearance of various brow shapes is influenced by gravity, repeated muscle movements, interactions, and actions of supporting ligaments and muscles such as the frontalis muscle, orbicularis oculi, and corrugators [7]. If the dynamic balance between these anatomical features is altered, eyebrows can appear asymmetric, contributing to an overall lopsided facial profile.

Microblading

It is a procedure to cosmetically create/increase the density of eyebrow hair by making nicks into the dermal skin, using a handheld microblade with needles, and placing the required pigment. The indications for eyebrow microblading are conditions where brows are scanty or missing because of primary (physiological) reasons or secondary to injury/disease. Table 1 lists the dermatological conditions where partial or complete loss of eyebrows is seen.

Table 1.

Causes of brow madarosis [8]

Physiological	Genetic and familial “scant brows,” ethnic variations
Trauma	Injury/friction/rubbing, mechanical epilation/alopecia artefacta, trichotillomania, burn injury, post-irradiation
Inflammatory dermatoses	Atopic dermatitis, seborrhoeic dermatitis, endogenous dermatitis, contact dermatitis (cosmetics, irritants, and allergens)
Autoimmune conditions	Alopecia areata, discoid lupus erythematosus, scleroderma, morphea
Infectious	Leprosy, post-infectious bacterial or viral sequelae
Systemic disorders	Hypothyroidism, hyperthyroidism, syphilis (secondary/tertiary), sarcoidosis
Genetic disorders	Ectodermal dysplasia, Netherton syndrome, Vogt-Kayanagi-Harada syndrome, Hereditary Hypotrichosis
Nutritional deficiency	Zinc, iron, Vit. B12, hypoproteinemia
Neoplasms	Mycosis fungoides (folliculotropic), squamous cell carcinoma

Eyebrow Tattooing and Microblading

While microblading can be viewed as a form of, or analogous to tattooing, it is a more refined and temporary method of simulating an actual eyebrow. Handmade and feathery strokes at a relatively superficial depth, achieved by utilising water-soluble pigments, give more natural looking results. Tattooing, on the other hand, is a permanent method of inking pigments, commonly with motorised equipment, and the final outcomes often lack a natural appearance as linear and parallel strokes are absent, and tattooed skin appears as a homogeneous, coloured patch [9, 10]. The side effect profile of both procedures is often similar and tends to overlap as the basic principles of tattooing are similar to both. Table 2 lists the differences between brow microblading and tattooing.

Table 2.

Eyebrow microblading vs eyebrow tattooing

Eyebrow microblading	Eyebrow tattooing
A row of linear needles is attached with a handheld blading pen, where pigment is deposited at the depth of papillary dermis [9]	Mechanical strokes are given with conventional tattooing machines at the level of superficial dermis [10]
The final outcome is a more natural looking “hair” which mimics the appearance of physiological brows [9]	Tattooed eyebrows do not closely resemble the natural state of brows; it can feather at the edges appear as artificially constructed [9]
It is temporary; it can last for up to 3 years, depending on the nature of pigment used. Retouches are needed as the pigment is deposited in relatively superficial layers of the skin and is gradually cleared by dermal lymphatics [9]	Tattooing inks can last from 2 to 8 years, or even permanently, although pigment is not deposited as deep as in conventional tattoos; up to reticular dermis and subcutis
	Fading ink can take many decades to disappear; retouches are needed in a few [10]

Patient Selection for Microblading

The aim of microblading is to restore the appearance of eyebrows to a state of physiologic normalcy, from primarily an aesthetic viewpoint. This suggests that candidates most suitable for the procedure are those presenting with mild to moderate sparness of brows, and with no pre-existing dermatoses causing brow madarosis. Appropriate selection and work-up of cases is essential to address the underlying aetiology. In cases such as Hansen’s induced madarosis (long-standing), it is vital to complete treatment, prior to procedure, and is best avoided. For conditions of cicatricial madarosis, thorough counselling and care is needed. Therapeutic aesthetics remains a challenge. Contraindications to brow microblading are acute conditions of auto-inflammatory and infectious origin.

Pre-Procedure Evaluation

Determining the right shape of eyebrows as desired by the patient remains a challenge in terms of delivering therapeutic artistry in dermatology. Some of the demands are influenced by changing trends, where narrow and slim dimensions were popularised in the past, alternating with arched shapes and less defined, angular “designs.” In a study of 652 respondents, it was observed that an arch shaped brow, such as the Anastasia shape, was the preferred eyebrow shape, from a choice of five different brow shapes [11]. However, determining eyebrow shape preference is variable based on individual preferences, and should be discussed during cosmetic consultations.

Procedure

It is frequently done under topical anaesthesia. Local infiltration with injectable anaesthesia can be employed in rare cases; however, tumescence interferes with the exact depth needed to deposit the pigment. The technique involves making uniform and precise carves with a certain “needle blade.” It is akin to slit skin smear for Hansen’s disease. The ink is then applied on the fresh wound and slightly brushed/massaged into the cuts to deposit the pigments in the skin.

Post-Procedure Care

Precautions following procedure is a crucial step for optimal recovery and in avoiding certain complications. It is often recommended by aestheticians to avoid washing the bladed area for 24–48 h. In our opinion, regular twice-daily washing/cleansing of procedural areas is to be encouraged to prevent excessive crust build-up and for timely removal of physiological debris. Systemic antibiotics are unnecessary for infection prophylaxis. On Day 3–5, early desquamation sets in after the inflammatory phase. This can incite pruritus, and oral antihistamine agents may be prescribed to control itch. Use of other “post-procedure” formulations and antioxidant serums should not be used due to the risk of cross-sensitisation. Pigment retention is incomplete in microblading and a fair bit of fading is noted around Day 7–10. This frequently necessitates a follow-up procedure to fill out the missing strokes and check for symmetry. Similar post-procedure precautions are advisable at the second sitting.

Complications

Asepsis should be maintained during the procedure. Pre-existing infection at the site of procedure, and personal history of keloids are contraindications. Viral markers including HIV and HbsAg, and HCV are desirable. Biomedical waste guidelines need to be followed as per standard operating protocol.

Asymmetry

Unequal placement of strokes can cause asymmetry in arch appearance, or overall shape. It may also be due to the fading out of pigments, leading to the apparent difference on both sides. Careful calibration and marking of sites ensure parity and symmetry.

Short Lasting Efficacy

Semi-permanent pigments are poorly retained in individuals with high sebaceous gland density or activity. In our experience, the history of excessively seborrhoeic skin is a poor candidate for the procedure. The pigment can fade out in a span of a few weeks. Adequate counselling is required for its short-term effects.

Skin Colour Changes

The incorrect use of permanent inks for tattooing can lead to pigmentary changes over a period. It may also occur in cases where semi-permanent colours are used by mixing pigments, causing unmasking of associated shades. Clinically, it presents as a greenish hue or discoloration/smudging/spread beyond outlined strokes and is dependent on depth of deposition and nature of colour. There may be occasionally paradoxical darkening of brows as well [12, 13].

Infection

Infection in the bladed area is a rare and unwarranted adverse effect. Few cases of severe infections following permanent makeup of eyebrows have been reported, including mycobacterial infections [14]. A rare case of preseptal or periorbital cellulitis induced by blading was reported by Akoh et al. [15] Delayed healing, discharge at procedure site, and constitutional symptoms should arouse suspicions of infectious aetiology. Swab culture, imaging, and laboratory tests for inflammatory markers enable early detection and intervention.

Risk of Bloodborne Pathogen Transmission

Brow microblading is essentially the same as tattooing in other areas, causing breaches in the skin barrier and carrying the risk of transmission of blood borne viral conditions like HIV. Standard precautions if not followed can lead to unfortunate incidents particularly in unlicensed centres such as spas.

Granulomatous Reactions

Many reports of acute and chronic granulomatous reactions after eyebrow microblading procedures have been documented. A trial of intralesional triamcinolone acetonide 5 mg/mL was tried when topical corticosteroid did not yield clinical improvement [13]. Ruling out different causes of granulomas is essential. More than 20 cases of cutaneous sarcoidosis, post-cosmetic eyebrow tattooing have been reported. Chest X-ray and serum levels of ACE are prerequisite work-ups in suspected sarcoidosis [16, 17].

Contact Dermatitis

Inflammatory reactions due to contact allergy may occur, causing erythema, pruritus, oozing, and swelling. A case of allergic contact dermatitis in a person with prior nickel sensitisation has been reported [18].

Koebnerization

Trauma at the site of the procedure ups the risk of the Koebner phenomenon in individuals with pre-existing disorders such as psoriasis, vitiligo and lichen planus. One such report of vitiligo lesions in the tattooed area where patients of active vitiligo underwent treatment has been documented [19].

Conclusion

There is a lack of standardisation and FDA approval of pigments used for eyebrow microblading. Pigments should ideally be non-carcinogenic, non-mutagenic, and non-toxic, with minimal risk of immunogenicity [20].

With the rise in demand for microblading, so is the associated risk of complications such as poor aesthetic outcomes, permanent pigmentary changes, hypersensitivity reactions, and granulomas. We view it as a medical adjuvant in selected cases, and each case needs evaluation and follow-up to minimise adverse outcomes in an otherwise safe and effective procedure.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This review was not supported by any sponsor or funder.

Author Contributions

M.S.: literature search, conceptualisation, ideation, and writing. M.K.: editing, literature search, formatting, suggestions, and modifications.

Funding Statement

This review was not supported by any sponsor or funder.