The words "I do" can be a little scary for some people, but when it comes to getting your permanent eyeliner done a good technician can ease the client into the procedure and the outcome can be quite stunning as in fig. #1. Here, the healed procedure shows the color Chocolate Truffle that was used for the lash enhancement as well as a smudgy effect surrounding the lashes. There is a lot of skill and knowledge involved in doing a beautiful permanent eye make-up procedure. However, the eyes are so delicate and the safety of the client should be the first priority of the permanent make-up artist when it comes to permanent eyeliner which will include proper use of topical anesthetics, legality of topical anesthetics, pre-treatment instructions, during the procedure considerations, and post treatment care. My special thanks goes to Dr. Charles Zwerling, M.D., an Anesthesiologist, who has helped to pioneer topical analgesics for permanent make-up. Their generous contributions to this article have been greatly appreciated.
Topical Anesthetics
     The use of topical anesthetics for an eyeliner procedure can be wonderful for your client, but only if used properly. The right stuff can relax your client, minimize the discomfort, and help your colors to stay better, thus preventing many unnecessary touch-ups. The question is, just what is the right stuff? When it comes to topical anesthetics, there are specific guidelines that the permanent make-up artist MUST follow.
The FDA on Local Anesthetics
1. Contrary to popular belief, even though the FDA acknowledges the use of topical anesthetics in permanent make-up, the FDA does not approve any topical anesthetics for use in permanent make-up.
2. The FDA does approve use of topical anesthetics for over-the-counter preparations. The FDA has specific guidelines for drug strength levels allowed used in these preparations. The following ingredient levels are allowed for over-the-counter preparations such as for minor cuts, burns and scrapes, non-poisonous insect bites, or poison oak/ivy, etc.:
a. Lidocaine 1-4%
b. Tetracaine .5-2%
c. Benzocaine 20%
d. Pramoxine .5%

3. Many permanent make-up artists use 10 percent Lidocaine or stronger.
Pharmacists make Lidocaine in strengths of 10, 20 and 30 percent for doctors. They should not be used by anyone other than a doctor and certainly not for a permanent eyeliner procedure.
Safe Use of Topical Anesthetics Around the Eye
     When you use a topical anesthetic for a permanent eyeliner procedure, you use it at your own risk. Stronger strengths are not better. They can actually be more harmful. Following are some important guidelines to use when using topical anesthetics around the eye.
     DO NOT Use Liquid Topicals - Liquid topicals can easily flow into the eye, much easier than cream topicals. The idea, of course, is to not get anything in the eye. Therefore, if choosing between a cream and a liquid topical, always choose the cream over the liquid. If a liquid topical gets in the eye, you cannot see it, but you can see the cream topical. This is important because you will need to wash it out if it gets in the eye. Notice that Hurricaine which is 20 percent Benzocaine and comes in both cream and liquid, is only for oral or mucosal use, not for the eyes.
     DO NOT Use EMLA on the Eyes - Topical creams such as EMLA, a prescription only analgesic, and other Eutectic analgesics are not designed for use on the eyes and should therefore not be used. EMLA and other Eutectics have a high alkaline pH of about 9, which can cause a chemical burn to the cornea by damaging the blood vessels. To complicate the matter, permanent make-up artists take it a step further and occlude the eye with Saran Wrap to "help it get numb faster". This is not wise because the brain thinks that a "hot pack" effect is taking place. As a result, vessels are dilated and blood is rushed to the area, swelling it unnecessarily before any implantation of color has even taken place.
     DO NOT Use Topical Anesthetic Eyedrops - Numbing eyedrops should never be used in a permanent eyeliner procedure. These eyedrops mask the burning or stinging sensation to the eye if the topical gets in the eye. This is dangerous because the client is not feeling the burning sensation and they cannot tell the technician to flush it out. Not only is the technician unable to respond by rinsing the eye with eyewash, but since the client is not experiencing a burning sensation the brain is unable to release the proper chemicals to bring tears to the eyes in order to help involuntarily wash it out. Damage to the cornea may continue to occur without the knowledge of the technician or the client. The use of anesthetic eyedrops also allows other harmful substances easier passage to the cornea. A combination of any of the above could really be harmful to the eyes. Imagine a severe alkaline burn from using EMLA on the eyes and then neither the technician nor the client is aware of it until the numbing eyedrops wear off. The eyes burn for a reason. The reason is: whatever got in there doesn't belong there.
     DO NOT Add Topical Anesthetics to Your Pigment - Many permanent make-up artists add topical anesthetic to their pigment. Did you know that this is illegal and can be harmful to the client? There is definitely a difference between putting topical on the skin (externally) and pushing it into the skin with needles (an injection). Doctors should only do injections. Insurance policies will not cover you if any complications arise from adding a topical anesthetic to your pigment. If a concentration of more than 2 percent of Lidocaine is injected into the skin, cells which make up tissue can be severely damaged or even die. Pigment is often unnecessarily lost due to too much damage to the tissue.
Pre-Procedure Considerations
There are several issues that must be addressed prior to doing an eyeliner procedure. Adherence to these issues will help to prevent other problems later on.
     DO NOT Prescribe any Medications for Pain Management - It is very important you do not prescribe to your clients what drugs to take or even worse give them one of your leftover Valium. The prescribing of drugs for pain management needs to be left in the qualified hands of a doctor. However, at the consultation, a warning against using aspirin or drinking alcohol and caffeine (this will put nerves on edge) should strongly be discouraged. The use of alcohol, aspirin and other pain relievers which contain aspirin will promote bleeding because they thin down the blood. The more bleeding that is present during an eyeliner procedure, the harder it is to get your color to stay. Tylenol is a better alternative than aspirin. Again, do not say "Take a Tylenol." This is prescribing. It is better to say, "Some of my clients have said that Tylenol helped them." Also, clients should not be advised to take any medication to prevent watery eyes. We need wet eyes during the permanent eyeliner procedure in order to wash away substances that have gotten into them.
     DO NOT Use India Ink or Pelican® Ink - Many permanent make-up artists use India or Pelican® Ink to achieve a really black look. Although the FDA does not approve any pigments for use in permanent make-up, they do have approved pigments for cosmetic use. The dominant ingredient, carbon, in the Pelican® and India Inks is illegal for use in cosmetics. These inks will burn the eye if they get into it, not to mention that they have been known to migrate. I will never forget one of my students who showed me a beautiful angel that was tattooed across her back. It was monochromatic, in black. I noticed that her skin was raised everywhere the design was. She said that her skin was always raised for about six months after she got a tattoo and then it went back to normal. Curious, I asked her to bring the bottle of pigment that was used. To my surprise, she brought in a bottle of Pelican® Ink and on the bottle it said, "Avoid skin contact." Please remember this in order to protect yourself as a technician as well as the well-being of your clients.
     DO Check for Pre-Existing Eye Conditions - It is wise to do an eye history. Check with the client prior to doing the eyeliner procedure for the following conditions:
1. If a client has had a history of dry eyes, meaning that they wake up with a feeling of sand or discharge in their eyes, it will be very important that you keep the eyes very lubricated during the procedure regardless of whether something gets into the eye or not.
2. Clients who have had eyelid surgery (blepharoplasty) may not be able to completely close their eyes due to the fact that so much skin has been removed, especially on the lower lid. What this means to the technician is to lubricate with artificial tears, lubricate, lubricate!
3. Some people naturally sleep with their eyes slightly open. Here, the same instructions apply. Keep the eyes wet and well-lubricated with artificial tears which can be purchased at your local drug store.
4. For documentation and legal purposes, record when the last eye exam was and whether or not the client has a pre-existing condition of corneal abrasions.
5. If the client wears contact lenses, make sure that they remove them prior to having their eyeliner done. It is best if they refrain from wearing them at least 24 hours prior to having their eyeliner done because if the client removes her contacts and scratches her own cornea just from removing them, you can easily be blamed for the corneal abrasion. If you are doing eyeliner procedures with the contact lenses in the eyes, you are risking damage to the eye. Debris such as pigment, topical, alcohol from pigment, cotton fibers, etc. can get trapped between the contact lens and the cornea, thus abrading it.
6. If a client has a history of lash tinting or perming, do not do eyeliner until at least 72 hours after lashes have been tinted or permed. The chemicals in these products need to subside and it takes about 72 hours for any chemicals left topically on the lids to wash away. You do not want to push any of these chemicals intradermally into the skin. Unfortunately, many technicians are performing lash tints and perms simultaneously as the eyeliner is done. This is not wise at all.
     DO Premoisten the Eyes Prior to Applying Topical on the Eyelids - As an added precaution, it is best to pre-lubricate the eyes with eyedrops prior to beginning any permanent eyeliner procedure even if you do not use topical anesthetic on the eyes. This is a pre-moistening technique, which helps to protect the eye if anything gets in it. A couple of drops in each eye are sufficient. Use a small microbrush (Fig. 6) to apply your topical on the eyelid. This small brush will provide precise placement of your topical and help to prevent it from getting into the eyes.
     DO Check for Allergies - Check to see if the client is allergic to any of the ingredients in the topical anesthetic, pigment, or aftercare product that will be used. One of the questions that should be asked of the client in your release form or questionnaire is: Are you allergic to any drugs such as Benzocaine, Tetracaine, Novacaine, Epinephrine, Adrenaline, Lidocaine, PABA, etc.? If the client is allergic to any of the ingredients that are commonly listed on the label of the topical analgesic then either do the eyeliner without topical or find one that the client is not allergic to. Check for allergies to pigment ingredients such as dyes, organic pigment, titanium dioxide, iron oxides, alcohol, glycerin, etc. Check for allergies to aftercare products you are using for the permanent eyeliner procedure and ask the client if they are allergic to any of them.
Considerations During the Procedure
     DO NOT Let Anything Get Into the Eye - Never, never, never let anything get into the eye. If something does, rinse immediately! If you remember nothing else, remember this. This cannot be emphasized enough. So many things can get into the eye and irritate it. It is very important that the permanent make-up artist does not neglect to immediately use an eyewash for the eyes if anything gets in the eye, such as pigment, topical anesthetic, cotton ball or q-tip fibers, or even an eyelash. It is the responsibility of the technician to do so.
     DO Use a Buffered Eyewash to Rinse the Eyes - Boric acid and borate are buffers used in artificial tears and eyewash. The importance of this is that these buffers will help to neutralize any acid or alkaline substance, which may accidentally get in the eye from the products that are used for the eyeliner procedure.
     DO Wipe the Eyes Gently - Gentle wiping is extremely important in preventing irritation around the eyes. Do not wipe carelessly when cleaning the eyes. The use of damp Q-tips®, foam tipped applicators, or dampened non-cotton woven cloths are acceptable (Fig. 7). They can either be lubricated with Vaseline® or cool water. Dry cotton balls and dry Q-tips® are unacceptable. The cotton fibers can easily get into the eye and scratch the cornea. Some controversy still remains from Opthamologists as to whether petroleum based products are good to wipe with. While some feel that wiping with Vaseline® can "trap" substances and keep it in contact with the eye, others feel that it would protect the eye from substances. If you do lubricate with Vaseline®, then use it sparingly because too much can cause the skin to feel slippery and can cause you to lose your grip. I prefer to use plain water because it is difficult to get Vaseline® off of the skin and I am against implanting anything into the skin except for the pigment. As a final touch, I may use Vaseline® to help me really do a thorough clean up. One thing is for sure, do not wipe the eyes clean with topical anesthetic cream. Overkill on the use of topical anesthetics can bring unnecessary tissue damage without notification to either the client or the technician. A good technician should learn to have gentle hands and only use topical anesthetics if necessary. I do not allow my students to use any topical anesthetic on the brows. By disallowing it, they are forced to have a gentler hand because they are able to receive a true feedback as to how their hands feel to someone else.
Post Treatment Procedure
     DO Lubricate the Eyes Before Sending the Client Home - As one last precaution, check underneath the lid of the eye to make sure that nothing is trapped there such as pigment, cotton fibers, etc. Remove it if there is. Add a drop of a buffered eyewash and a drop of artificial tears to help wash out any substances.
     DO Apply AfterCare Ointment - Do apply aftercare ointment such as a plain Vaseline®, or something with healing properties such as preservative-free antioxidant vitamins A and/or E. Don't forget to give the client a small aftercare packet to continue their post-treatment care. Do not use antibiotic ointment on the eyes. Many people are allergic to them.
     DO Familiarize Yourself With Corneal Abrasions - Knowing the symptoms of corneal abrasions will help you to alert the client to get immediate attention by an Opthamologist, not an Optometrist, in an emergency room. Corneal abrasions can be caused by improper application of substances to the eye by the technician such as topical anesthetics, pigment, alcohol from pigment, soaps, q-tips in the eye, very bright lights, etc. The following symptoms may be signs of corneal abrasion:

Alexis Lawson is the creator of the revolutionary new SofTap method and colors. She is an international speaker and educator and has owned her own state CPPVE approved SofTap Permanent Makeup Academy in San Leandro, Calif. Since 1991 She is a member of the Society of Permanent Cosmetics. Her philosophy for permanent makeup is: "Permanent makeup should be gentle and look completely natural."

a. Pain
b. A gritty, sandy feeling in the eye
c. Sensitivity to light
d. Blurred vision
     If these symptoms occur, do not wait and see. Get immediate attention for your client.
     DO Send Your Client Home With An Ice Pack - Advise your clients to ice up only once per hour for a limit of 15 minutes each hour for the next 12 hours only. Ice on the area for longer periods of time is not more beneficial. After more than 15 minutes of applying ice, the brain is fooled and frostbite may begin to take place. As a result, more blood is rushed to the area, which actually increases the swelling.
     DO Allow Your Clients to Wash Their Face - The old school of thought was to not allow the face to get wet. Cleaner is better. The client may use a mild face wash and avoid scrubbing the eyes, of course. Wearing make-up may be resumed after all healing has taken place.
     DO Advise the Client on Repeated Lash Tinting and Perming - Unfortunately lash tints and perms can strip the permanent make-up color from the skin. This became evident to us when a client that we did three years prior came in for a touch-up on her upper liner. The same color was used for the top and bottom liner. The bottom liner was just as it was three years prior, crisp and beautiful. However, the color on the top eyeliner had been stripped. Why? We discovered that she tinted her top lashes. The chemicals in the tint stripped the color. If clients insist on tinting or perming their lashes, then they will need more touchups. The same goes for repeated uses of alpha hydroxy acids.
     DO Give Your Client a Post-Treatment Instruction Sheet - A sheet containing specific instructions about ice packs, when to resume wearing make-up, washing the face, etc., should be given in writing to the client, the signature of the client should be obtained to verify that she did receive it if this is not already on your client release form that the client filled out and signed prior to the procedure.
     In conclusion, remember that a successful permanent eyeliner procedure is not only what appears pleasing aesthetically, but also following safe procedural practice. Always do for your clients what you would want to have done for you. Follow this motto and you will have happy, satisfied clients and a growing business.