Don't text and drive: you either see the letter or the danger. This is a fantastic example of how clever use of space can make a big impact. An innovative idea that really drives home the dangers of while driving. by Leo Burnett for FIAT
So pretty + fairly easy. In photoshop, type out your letter in helvetica, then reverse it. Fill it with a patterned paper, then print. You could then do the piercing directly on the printed side, leaving this on the reverse.