Apply another coat of gel medium over the tissue paper and crumple up more tissue paper and press into the card with more gel medium. Create as many or as few creases/crumples as you desire.
Either while the gel medium is wet, or allow it to dry, then brush on acrylic paints as desired. I brushed on a mixture of blue and white acrylic paints while the gel medium was still wet. Added blue paint to the edges. Bernie states that you can embed small objects into the wet tissue paper if you desire.