Tattoo removal, an expert opinion

The prevalence of tattoos has steadily increased, and consequently, demand for tattoo removal has also grown. Reasons cited for tattoo removal vary; many patients report career changes, stigmatization, or feelings of embarrassment and low self-esteem. Early tattoo removal methods relied on nonspecific mechanical or chemical destruction such as dermabrasion and chemical peels, often with unsatisfactory results and complications of scarring and inadequate ink removal that left “tattoo ghosts” seen as a permanent haze of ink. Q-switched lasers, which are the current standard of practice, target tattoo ink, and offer a safer, more effective means for removing tattoos.

Laser tattoo removal before and after.

Tattoos

Tattoos are placed by injecting ink particles (ranging in size from 20– 400 nm) into the dermis. During the tattooing process, the epidermis and upper papillary dermis are homogenized, and ink particles are distributed extracellularly and intracellularly. After 2– 3 months, the skin layers reestablish and the ink remains concentrated within fibroblasts beneath a layer of scar tissue in the dermis. Tattoo inks are not regulated by the Food and Drug Administration (FDA), and most patients do not know the constituents of their tattoos. There are many different types of tattoos. Decorative tattoos are the most common and are the focus of this book. They are categorized as either amateur or professional, based on their method of placement.

• Amateur decorative tattoos are typically tapped by hand into the skin using a wire or needle resulting in a low density of ink particles that are located superficially in the skin. These are usually black in color and composed of carbon-based inks such as pen ink or burnt wood.
• Professional decorative tattoos are placed with a “tattoo gun.” These devices have a single needle or group of needles that rapidly oscillate in and out of the skin. Professional tattoos usually contain organic dyes mixed with heavy metals to give vibrant colors. For example, red is often made from mercury, yellow from cadmium, green from chromium, and blue from cobalt.
• Cosmetic tattoos are commonly referred to as “permanent makeup.” They are typically applied to eyelash margins, eyebrows, and lips to simulate makeup, and are usually combinations of colors containing pink and flesh tone inks that may be mixed with white. Flesh tones often contain iron oxide, and white commonly contains titanium dioxide or zinc oxide. When pulsed with a tattoo laser, these inks can turn black or brown becoming darker and more noticeable after the initial treatment.
• Traumatic tattoos result from deposition of pigment in the skin by abrasion. Common causes include trauma from gravel referred to as “road rash,” pencil graphite, or by explosive forces as with shrapnel and fireworks. These materials become lodged in the dermis after reepithelialization of the wound and result in blue/ black tattoos.
• Medical tattoos are placed as markers for radiation therapy. These are usually black, carbon-based inks

Laser tattoo removal before and after.

Laser Principles

Laser tattoo removal is based on the principle of selective photothermolysis, the conversion of laser energy to heat, which selectively destroys tattoo ink. Tattoo ink is the target chromophore in tattoos. Different ink colors are preferentially absorbed by specific wavelengths of light as shown in. When laser energy is applied to skin it is converted to heat within ink particles, causing fragmentation of large particles and rupture of fibrous capsules surrounding the ink. Smaller ink particles are then eliminated through epidermal extrusion, lymphatic drainage, and macrophage phagocytosis . The surrounding skin minimally absorbs energy and remains unaffected. Laser-treated ink particles also have altered optical properties rendering ink that remains in the skin less visible to the eye. Q-switched lasers that generate high-power pulses with very short widths in the nanosecond range (and more recently mode-locking lasers that generate picosecond pulse widths) are used for tattoo removal. In addition to selective photothermolysis, these lasers operate under the principle of photoacoustic vibration where oscillation of ink particles facilitates fragmentation and removal (see also Introduction and Foundation Concepts, Very Short Pulse Lasers section).

Laser Parameters for Tattoo Removal Treatments

Laser parameters (also referred to as settings) such as wavelength, pulse width, spot size, and fluence can be modified at the time of treatment to maximize tattoo ink removal and minimize thermal damage to surrounding tissue (also see Introduction and Foundation Concepts, Laser Parameters section). 

•Wavelength. Wavelength is selected to target the appropriately colored ink. Lasers used for tattoo removal include QS 1064, QS 755, QS 694, QS 650, QS 585, and QS 532 nm. The 1064 nm wavelength penetrates deeply, is less absorbed by epidermal melanin than other wavelengths and is, therefore, the safest tattoo removal wavelength that causes the least epidermal injury.

Patient Selection

Patients of all Fitzpatrick skin types (I– VI) are candidates for laser tattoo removal. However, patients with darker skin types (IV– VI) are at greater risk for side effects, including hypopigmentation and hyperpigmentation. Additionally, patients of Asian and African descent may have a greater predisposition to hypertrophic and keloidal scarring. Fitzpatrick skin type VI patients have the greatest risk of complications with any aesthetic procedure and treatment of this skin type is an advanced laser application, outside the scope of this book. Patient Expectations Multiple laser tattoo removal treatments are needed to achieve satisfactory results. Due to variation in tattoo ink depth, density, composition, and techniques used for placement, estimating the number of treatments needed for removal can be challenging. However, some generalizations about the number of treatments can be made based on patient and tattoo characteristics (Table 1). Professionally placed tattoos have greater ink density and typically require 12– 16 and sometimes up to 20 treatments; whereas amateur tattoos typically require 4– 8 treatments. Faded, older tattoos on paler skin types in proximal locations tend to be removed with fewer treatments than intense, multicolored tattoos on darker skin types in distal locations. A “cover-up” is a tattoo that has one tattoo placed on top of another, rendering a very high density of ink in the skin and requires more treatments for removal. Prior tattoo removal methods that create scar tissue, such as abrasion and caustic chemical agents, can make laser tattoo removal less successful. Q-switched lasers only treat ink and are not intended to improve the texture of the skin. If a tattoo is palpable prior to laser treatment, it will usually be palpable when the treatment series is completed.

We, at Albany and Laser Centre, have the lutronic spectra, the best q-switch laser machine in the industry. We have 4 different wavelengths to be able to deal with all colors. Whether you want to get rid of the tattoo or fade it to get a new one, please do not hesitate to contact us for a free consultation.