Journal of Cutaneous and Aesthetic Surgery
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Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 191-192
Preoperative site marking in dermatosurgery

Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany

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Date of Web Publication24-Sep-2019


Dermatosurgery is a growing subspeciality due to increasing numbers of skin cancer and aesthetic procedures. Patient safety is a major issue in dermatosurgery. Quality management, education, and organization are the backbone of patient safety. A simple measure to support patient’s safety and to avoid wrong site surgery is preoperative skin marking. Permanent skin markers offer a painless and cost-effective option. To ensure optimal results, the following problems need careful consideration: good viability after disinfection, sterility of the operation field, no sensitization, or toxic effects of the ink. These issues are discussed in detail to allow a safe and successful procedure.

Keywords: Dermatosurgery, hygiene, patient’s safety, skin marking, viability

How to cite this article:
Wollina U. Preoperative site marking in dermatosurgery. J Cutan Aesthet Surg 2019;12:191-2

How to cite this URL:
Wollina U. Preoperative site marking in dermatosurgery. J Cutan Aesthet Surg [serial online] 2019 [cited 2021 Oct 24];12:191-2. Available from:

   Introduction Top

Implementation of surgery safety protocols is of major importance to prevent wrong-site surgery (WSS). In a recent study from California, all cases that have been reported to the Department of Public Health between 2007 and 2014 were analyzed. The most common erroneous procedure was WSS (60 cases) that made up 62% of all reports.[1]

Preoperative skin site marking is a simple but effective measure to prevent WSS, a “never event.”[2],[3]

   Skin Marking Top

There are three possible problems arising with skin marking, which need consideration.

Visibility after disinfection

Skin marking must be visible after disinfection of the surgical field. Masud et al.[4] investigated this aspect in a prospective study covering 500 surgeries. The results showed that 59% of markings were visible in theater after sterile draping, 40.4% markings were not visible, and 0.6% (3/500) were not marked. They recommended to use an arrow with an indelible marker pen for skin marking. Appropriate marker pens were used on 88% of patients. Skin marking must be sufficiently permanent to remain visible after completion of the skin preparation. To improve correct site surgery, skin markings should be recognizable and understood by all members of the staff in the unit.[4]

In a review about surgical skin marking, Edding® 400 (3mm diameter) and Edding® 3000 (1.5mm) have been recommended, because they can withstand disinfection procedures (Edding, Ahrensburg, Germany). Alternatives are Pentel® (Pentel GmbH, Hamburg, Germany) and Paper Mate® (Sanford, Ontario, Canada). Viscot® (Viscot Medical, LLC, East Hanover, NJ) with blue ink is an alternative to mark dark skin.[5]

In another study, marked skin sites were prepared with chlorhexidine followed by chlorhexidine, Betadine followed by chlorhexidine, and Betadine followed by Betadine in five volunteers. The visibility of the marks was rated after disinfection. In this trial, Sharpie® W10 black (Newell Rubbermaid, Dandy Springs, GA), Dual Tip (Purple Surgical), and Easimark modern regular tip (Leonhard Lang, now Skintact, Fannin, Ireland) were the best those with best visibility across all skin types.[6]

Visibility of skin markings depends also on the disinfectant. In a study with 20 patients, who had a primary total hip arthroplasty, chlorhexidine-based solution for skin preparation resulted in significantly greater erasure of the surgical site marking than did the use of the iodine-based solution.[7] As chlorhexidine solution is superior to iodine-based solutions for the prevention of surgical site infections, chlorhexidine-resistant pens have been developed such as Viscot 1450XL-200 Mini XL presurgical skin marker, fine tip, and Viscot 1449XL-50 XL presurgical skin marker, bold tip (Viscot Medical, LLC, East Hanover, NJ).[8]


Skin marking and sterility should not exclude each other. In a study with volunteers, surgical site marking with a non-sterile surgical marking pen did not contaminate the surgical site. The marking was performed both forearms. Microbiology swabs were taken before, and after, skin sterilization with 10% povidone-iodine. After sterilization, no bacterial growth was observed in culture on marked arm and controls.[9],[10]

However, marker pens have to be considered as vehicles for nosocomial infection. An experimental study with 26 permanent skin markers demonstrated that ethanol-based ink in permanent marker pens is bactericidal against methicillin-resistant Staphylococcus aureus (MRSA) that starts within seconds, and they are likely to be safe to use with a gap of at least 2min between patients. On the other hand, old or dried out marker pens may harbor pathogens and should be discarded. Disposable markers are recommended for immunocompromised patients and patients with a positive MRSA status.[11] Another study in the operation theater demonstrated that skin site marking does not increase the risk of operative field contamination.[12]

In contrast, skin marking with alcohol-based solvent surgical marking pens (Devon Surgical Skin Marker, Regular Tip; Covidien, Dublin, Ireland) for anterior cruciate ligament reconstruction in orthopedic surgery showed contamination of 15% of pens with Staphylococcus spp.[13]


Ingredients of inks may have a sensitizing potential. This is known from permanent inks used in cosmetics and tattooing.[14],[15] Azo pigments and quinacridones, such as Violet 19, Red 122, and Pigment Red 181 (CI 73360), have been identified as substances responsible for hypersensitivity reactions.[16],[17] Azo dyes have been identified in inks of permanent markers for the general use.[18] Allergic contact dermatitis has been reported after skin marking with henna containing p-phenylenediamine.[19]

   Conclusions Top

Patient safety is a major issue during dermatosurgery. WSS is the most common thread. Preoperative skin marking is a useful tool to increase patient’s safety and to avoid WSS. Permanent skin markers provide a painless and cost-effective option. The markers should provide good viability after disinfection and ensure sterility of the operation field, and the inks should be non-sensitizing. Skin marking is a safety measure in dermatosurgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Moshtaghi O, Haidar YM, Sahyouni R, Moshtaghi A, Ghavami Y, Lin HW, et al. Wrong-site surgery in California, 2007-2014. Otolaryngol Head Neck Surg 2017;157:48-52.  Back to cited text no. 1
Tatla T, Lafferty K Making your mark again in surgery. Ann R Coll Surg Engl 2002;84:129-30.  Back to cited text no. 2
Anoushiravani AA, Sayeed Z, El-Othmani MM, Wong PK, Saleh KJ High reliability of care in orthopedic surgery: are we there yet? Orthop Clin North Am 2016;47:689-95.  Back to cited text no. 3
Masud D, Moore A, Massouh F Current practice on preoperative correct site surgical marking. J Perioper Pract 2010;20:210-4.  Back to cited text no. 4
Kneilling M, Breuninger H, Kastl A, Heeg P, Häfner HM, Röcken M, et al Methods of labeling skin surgical specimens. J Dtsch Dermatol Ges 2009;7:871-6.  Back to cited text no. 5
Bathla S, Nevins EJ, Moori PL, Vimalachandran D Which pen? A comparative study of surgical site markers. J Perioper Pract 2018;28:21-6.  Back to cited text no. 6
Thakkar SC, Mears SC Visibility of surgical site marking: a prospective randomized trial of two skin preparation solutions. J Bone Joint Surg Am 2012;94:97-102.  Back to cited text no. 7
Marsland D, Kamath MY, Mears SC, Belkoff SM Letter to the editor an update: does the type of skin marker prevent marking erasure of surgical-site markings? Eplasty 2010;10:e50.  Back to cited text no. 8
Cronen G, Ringus V, Sigle G, Ryu J Sterility of surgical site marking. J Bone Joint Surg Am 2005;87:2193-5.  Back to cited text no. 9
Rooney J, Khoo OK, Higgs AR, Small TJ, Bell S Surgical site marking does not affect sterility. ANZ J Surg 2008;78:688-9.  Back to cited text no. 10
Tadiparthi S, Shokrollahi K, Juma A, Croall J Using marker pens on patients: a potential source of cross infection with MRSA. Ann R Coll Surg Engl 2007;89:661-4.  Back to cited text no. 11
Cullan DB 2nd, Wongworawat MD Sterility of the surgical site marking between the ink and the epidermis. J Am Coll Surg 2007;205:319-21.  Back to cited text no. 12
Ridley TJ, Rud CT, Krych AJ, Macalena JA Bacterial contamination of a marking pen in anterior cruciate ligament reconstruction. Orthop J Sports Med 2018;6:2325967118772043.  Back to cited text no. 13
Wollina U Severe adverse events related to tattooing: an retrospective analysis of 11 years. Indian J Dermatol 2012;57:439-43.  Back to cited text no. 14
Shashikumar BM, Harish MR, Shwetha B, Kavya M, Deepadarshan K, Phani HN Hypersensitive reaction to tattoos: a growing menace in rural India. Indian J Dermatol 2017;62:291-6.  Back to cited text no. 15
Gaudron S, Ferrier-Le Bouëdec MC, Franck F, D’Incan M Azo pigments and quinacridones induce delayed hypersensitivity in red tattoos. Contact Dermatitis 2015;72:97-105.  Back to cited text no. 16
Wenzel SM, Welzel J, Hafner C, Landthaler M, Bäumler W Permanent make-up colorants may cause severe skin reactions. Contact Dermatitis 2010;63:223-7.  Back to cited text no. 17
van der Werf ID, Germinario G, Palmisano F, Sabbatini L Characterisation of permanent markers by pyrolysis gas chromatography-mass spectrometry. Anal Bioanal Chem 2011;399:3483-90.  Back to cited text no. 18
Espasandín-Arias M, Vázquez-Osorio I, García-Martínez FJ, Fernández-Redondo V, Toribio J Allergic contact dermatitis due to a surgical marker. Contact Dermatitis 2014;71:57-8.  Back to cited text no. 19

Correspondence Address:
Uwe Wollina
Department of Dermatology and Allerhology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Friedrichstrasse 41, 01067 Dresden
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCAS.JCAS_178_18

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