"Which procedure hurts most" is one of the most searched questions about permanent makeup, and it is not one that can be answered honestly. Sensation varies from person to person, and no published data lines the procedures up in a single order.
Two things can be stated clearly: what the anatomical literature says about the relevant area, and what regulators have already documented. Neither produces a ranking, but both help you ask better questions.
What the anatomy says about the lip
The anatomical literature describes the lip — and particularly the vermilion — as densely innervated and especially receptive to touch and temperature (Annals of Anatomy, 2023). Other research reports measurable differences in sensitivity between oral mucosa and facial skin, and between sites within the mouth (reviews of facial and oral pain neurobiology).
That is a fact about nerve distribution in a region. It is not a conclusion about any procedure. It does not tell you that a lip procedure is necessarily more uncomfortable than a brow procedure, and it cannot be used to rank procedures against one another.
Why a ranking does not hold up
- Sensation varies between people and is not visible from the outside.
- The things being compared are not equivalent. Procedures differ in duration, area covered and number of contacts, so lining them up in a single order does not work.
- The first part and the later part of one appointment are not the same thing — worth confirming with your practitioner.
So instead of hunting for a ranking, use the set of questions in section five.
What regulators have documented
This part is not about sensation, but it does bear directly on the decision.
The US Food and Drug Administration (FDA) regulates tattoo and permanent makeup inks as cosmetics, and states plainly: although a number of colour additives are approved for use in cosmetics, none is approved for injection into the skin. In 2003–2004 the FDA became aware of more than 150 reports of adverse reactions to certain permanent makeup ink shades, and the products were voluntarily recalled by the marketer in 2004. The complications the FDA lists include infection, removal problems, allergic reactions, granulomas and keloid formation. The Modernization of Cosmetics Regulation Act (MoCRA), signed in December 2022, requires serious adverse events to be reported to the FDA within 15 business days.
The American Academy of Dermatology (AAD) adds several situations worth raising in advance: a tendency to form keloids, an active skin infection, or a history of severe reaction to cosmetics are all reasons to speak with a doctor first. The AAD also notes that tattooing can trigger or aggravate some skin conditions, such as psoriasis and eczema, sometimes within days of the procedure and sometimes years later.
Topical pain relief: one thing you can use today
In March 2024 the FDA issued a specific warning about these products, stating that consumers should:
- not use over-the-counter pain relief products containing more than 4% lidocaine;
- not apply them heavily over large areas, or to irritated or broken skin;
- not wrap or cover treated skin with plastic wrap or other dressings.
The FDA states that under use patterns that increase absorption, serious injury such as irregular heartbeat, seizures and breathing difficulties can occur. The warning named products from six companies, some labelled at 10.56% to 40% lidocaine.
One behaviour you can change today: do not apply these products heavily to broken or irritated skin and then cover them.
Which product is used during a procedure, who applies it and at what strength is a matter for qualified practitioners and for local rules — ask the practitioner you have chosen, and check with your local regulator if you want to be certain.
Questions to take into a consultation
These five will tell you more than ten rankings will:
- How long does this procedure usually take in your hands, and which part of it usually feels more pronounced?
- How do you plan to pace the session, and will there be breaks?
- Which type of pain relief product do you use, and how is it classified where you practise?
- Given my circumstances — medication, skin history, scarring tendency — is there anything I should check with a doctor first?
- If I have persistent redness, oozing or a rash afterwards, who do I contact, and when do I go to a clinic?
The answers to questions four and five are medical judgement. They belong with a qualified professional, not with an introductory article.
Put attention on what you can control
A common attitude is to treat discomfort as something to endure and be done with. A more practical approach is to put your attention on information: knowing how the session runs, what happens next, and when you can ask to stop.