Tattoo preservation in upper limb surgery: current practice and a patient-centred decision algorithm

Tattoos are increasingly common and may be encountered overlying planned surgical incision sites. This is particularly relevant in hand and upper limb surgery, where tattoos are frequent and highly visible. Tattoos in standard approach lines raise aesthetic and ethical considerations. Despite this, little is known about current surgical attitudes towards tattoo preservation. We assessed current practice among hand and upper limb surgeons when tattoos lie within the preferred incision.

An electronic survey was distributed to hand and upper limb surgeons trained via plastic or orthopaedic surgery programmes. Respondents reviewed a standardized scenario showing a tattoo over the anterior distal forearm incision for distal radius fixation and selected their preferred approach. Specialty, seniority and level of training were recorded.

There were 225 responses; 175 (78%) were senior surgeons (post-Certificate of Completion of Training/consultant). Orthopaedic surgeons comprised 181 (80%) and plastic surgeons 44 (20%). Overall, 173/225 (77%) would incise directly through the tattoo. Tattoo-preserving options were less common, comprising incision along the tattoo margin 34/225 (15%) and raising a skin flap 7/225 (3.1%).

Upper limb surgeons predominantly favour standard incisions through tattoos rather than preservation. Given limited commentary in the literature and potential aesthetic and psychological implications, we propose the ART algorithm (assess safety-review size-talk to the patient) to structure decision-making and support preoperative discussion of incision placement during consent.