Connecting The Dots: What Your Surgeon Is Doing With That Markup Pen

You’ve likely seen pre-op pictures of cosmetic surgery patients covered in dashes, x’s, and o’s. But what exactly is the surgeon mapping out with their marker? The AEDITION asked the experts.
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Written by Krista Smith
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Connecting The Dots: What Your Surgeon Is Doing With That Markup PenJacob Lund/Shutterstock

At last, it’s here. After all the research, consultations, and the preparations, your cosmetic surgery day has finally arrived. You’re reclining on a gurney in the pre-op area wearing nothing but a surgical gown and a disposable purple hairnet, trying to daydream about how fabulous you’re going to look and feel when all is said and done. But between the bustle of the nurses and anesthesiologists and the buzzing of the unfamiliar sounds surrounding you, it’s tough to find your zen space.

Suddenly your plastic surgeon appears from behind the curtain — smiling and reassuring — asking if you have any last-minute questions. After the small talk and run-through of post-op instructions, your surgeon asks you to stand up, perhaps sans flowered gown. You probably already have butterflies, and now you’re standing there being stared at intently.

As your surgeon scrutinizes the surgical area, he or she is reaching for a package that is sitting on a metal tray beside your bed. They unseal the plastic, pop off the cap, and proceed to draw on you — all. over. you.

Welcome to the wonderful world of surgical markings.

The Purpose of Surgical Markings Before Cosmetic Procedures

“Sometimes patients get a little panicked,” says UCLA board certified plastic surgeon Jason Roostaeian, MD. “I can see it in their eyes. They’re wondering: ‘Is that where you’re going to cut me?’” Dr. Jason often eases his patients’ nerves by cracking a joke about the markup process.

So what, exactly, do all of those circles, x’s, numbers, meandering lines, and dashes of different colors actually signify? “We use marking pens to plan out the surgery and indicate the landmarks,” explains Beverly Hills-based board certified plastic surgeon Leif Rogers, MD.

Because our bodies look different lying down in the operating room than they do normally, creating a surgical roadmap while the patient is standing upright is optimal. “In some cases, the process of numbing the patient or injecting tumescent solution can obscure some of the landmarks,” Dr. Rogers adds.

Markings can signify a multitude of things: incision sites, existing landmarks, areas to be altered, as well as those to be avoided. “We need to make sure we don’t disrupt certain anatomy during surgery,” Dr. Jason shares. But, just as every procedure is unique to the patient, every marking is specific to the provider.

Surgeons use markings in their own unique way, so there’s no standardized system in place. “You go through your training and watch how your attending does it,” Dr. Jason says. “But everyone adopts their own personal style.”

This explains why some surgeons use multiple colors, while others stick to the stereotypical purple pen. Some doctors do use Sharpies, but the markers are usually specially formulated for use on skin — so they’re not exactly surgical Sharpies. As Dr. Rogers notes, the marking pens “tend not to wash off when the patients are being prepped for sterility.” Speaking of sterility, it’s also worth noting that surgical markers are sterile and single-use only.

How Surgeons Markup Common Cosmetic Procedures

While surgeons have their own style, there are some markings that almost always accompany a certain procedure. Below, Dr. Jason shares some of the typical markings he makes for different surgeries. He draws on all of these patients while they are standing, with the exception of rhinoplasty (because the nose position remains relatively unchanged).

Breast Surgery

  • The breast fold
  • Ideal nipple placement


  • The jawline
  • Facial folds for fat grafting

Neck Lift

  • The midline of the neck
  • Extent of skin dissection


  • Position of nasal bones
  • How much of the hump to take down
  • Ideal tip angle


  • Highest to lowest fat concentration

While many procedures require a series of dashes and straight lines, liposuction is illustrated using curved shapes. “We create a topographical map using concentric circles,” says Dr. Jason of the fat removal surgery.

Just as there is no standard markup methodology, there’s also no such thing as a ‘typical’ pre-op patient mindset. “Patients’ reactions are as different as their personalities,” Dr. Rogers says. “Some want smiley faces. Others are ticklish.” And, while some patients can’t wait to scrub off those markings, others happily snap pre-surgery selfies for social media.

How to Remove Surgical Markings Post-Op

As Dr. Rogers shared, markup pens are meant to survive the sterility and surgical process. So, just how does one go about removing those surgical signatures post-surgery? Both docs say alcohol swabs work best — though patience is key. That ink is often stubborn, and it may hang around as you heal. If you’re in a hurry, Dr. Rogers recommends “light scrubbing in the shower” to facilitate removal over the course of a few days.

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KRISTA SMITHis a contributing writer for AEDIT.

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