HOW I DO IT Tattoo removal

How I do it

TATTOO REMOVAL

JON D. PERENACK MD, DDS

Adjunct Associate Clinical Professor and Fellow Director of Facial Cosmetic Surgery, Department of Oral and Maxillofacial Surgery Louisiana State University-New Orleans,

EXAMPLES OF VISUAL ARTISTIC EXPRESSION were present present in the excavations of the earliest sites of human culture. While etchings in stone have tremendous longevity, less stable human remains from as early as 5000BC have revealed tattooed skin, which is an artistic expression. Tattooing of the skin continues to have popularity and significance across all cultures today. As it might be expected, there are times when individuals might wish to remove a tattoo, possibly due to a change in meaning to the individual, an association with an unpleasant memory or a relationship, in order to make “space” for another tattoo, or just a casual whim.

Contemporary tattoo removal typically involves the use of quality-switched (QS) lasers capable of delivering pulses of chromophore directed energy in the nanosecond range. These are QS Nd-YAG, QS Ruby, and QS Alexandrite lasers. These short pulse durations allows the pigment of the tattoo to be heated causing fragmentation, while being less than the pigment’s thermal relaxation time, thus minimizing heat transmission to the surrounding tissues. Fragmentation of pigment then allows the pigment particles to be removed by the patient’s activated inflammatory response. The control of heat dispersal aids in avoidance of blistering, hyper and hypopigmentation, scarring, and thickening of skin. The most recent QS Nd-YAG lasers that came to market, are capable of delivering energy in the

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Patient preop: Fitzpatrick two, professionally performed tattoo displaying primarily black/blue coloring, but also sub-levels of red and green pigment.

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Tattoo after 3 treatments with pico QS Nd-YAG laser on 1064nm setting. Plan for treatment with pico QS Nd-YAG with KTP on 532nm setting.

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One day post-op after pico QS NdYAG with KTP on 532nm setting. Mild erythema is present haloing tattoo, with no crusting or blisters.

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Patient with completed new tattoo in area.

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Note residual pigment from previous tattoo present at detail near skull’s mouth. Treatment of tattoo with pico QS Nd-YAG with KTP on 532nm setting. Note frosting formation, representing gas and vacuole formation within the epidermis from heating.

“Generally, tattoos can be considered one of five types: professional, amateur, cosmetic, medical, and traumatic.”

picosecond range. Picosecond delivery appears to create considerably less heat than nanosecond Nd-YAG lasers at similar fluence energies, possibly by causing fragmentation through photo-acoustic vibrations. This decrease in heat generation provides a safer therapy and easier recovery. Additionally, the larger spot size of the pico laser handpiece allows a deeper penetrance of energy, minimizing damage to the epidermis.

While QS Ruby, Alexandrite, and Nd-YAG lasers are all capable of clearing multiple pigments, the wavelength/ chromophore characteristics of each laser may make one better than another in clearing different pigments. The QS Ruby laser 694nm red light is ideal for dark black and blue pigments. The QS Nd-YAG 1064nm beam clears blue and black pigments, and through a KTP crystal, emits a 532nm light that more effectively clears red, yellow, and orange pigments. The QS Alexandrite laser emits a 755nm beam that clears black and blue pigments and is particularly effective for green pigments. Not uncommonly, multiple lasers may be required for clearance of different pigment aspects of one singular tattoo. Surgical removal of the entire tattoo, or multiple excisions of residual uncleared pigments after laser therapy is always a possible option depending on tattoo size and location. Occasionally, an ablative CO2 laser (10,200nm) may be used to potentiate a QS laser or to remove

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Before and after 8 sessions with pico QS Nd-YAG 1064/532nm a tattoo by surface skin removal. The high cost of technology to perform tattoo removal is perhaps the greatest impediment to provide the service by new practitioners.

Generally, tattoos can be considered one of five types: professional, amateur, cosmetic, medical, and traumatic. The pigments found in amateur and traumatic tattoos are usually easily cleared owing to their simple nature. Professional, cosmetic and medical tattoos may contain complex layering and pigment techniques that may result in incomplete clearance. Yellow, red, and orange colors are particularly difficult. Titanium dioxide used to create a white base pigment is rarely cleared and may paradoxically darken with treatment. Surgical excision is occasionally the only option for this pigment. Adding to the difficulty in assessing a tattoo, professional tattoo artists may layer a darker pigment on top of white or red colors for various visual effects. Only after clearing the dark pigment, the lighter pigment is revealed, often with the undesired side effects of paradoxical darkening.

Evaluation of the patient desiring tattoo removal relies not only on the nature (color) of the tattoo, but also on the Fitzpatrick skin type of the patient. As QS lasers target a chromophore ink pigment, the higher melanin concentrations in darker skin types may also inadvertently absorb laser energy. Excessive energy absorption can lead to hyper or hypopigmentation and increases the risk of blistering and scarring. To avoid these complications, darker skin types can be treated but require more treatment sessions at a lower fluence energy setting. The Nd-YAG lasers is preferred for darker skin types as it penetrates deeper with less energy deposited in the epidermis. The Pico QS NdYAG offers even greater safety due to its short pulse duration and larger spot size, both of which reduce superficial heating of tissue. Patients of all skin types may be instructed to cover the area to prevent tanning for several weeks before treatment. There may also be a benefit to treat the area with topical 0.05% tretinoin/1% hydrocortisone/ 4% hydroquinone twice daily, for 4 – 6 weeks prior to laser therapy.

“Evaluation of the patient desiring tattoo removal relies not only on the nature (color) of the tattoo, but also on the Fitzpatrick skin type of the patient.”

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Before and after 8 sessions with QS Alexandrite 755nm

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“The patient should be informed that typically 6 to 10 sessions will be required break of not less than 4 to 6 weeks between sessions. Incomplete clearance is always a possibility, and the patient should be prepared for this as well.”

Before and after 10 sessions with pico QS Nd-YAG 1064/532nm

The tattoo should be examined for any signs of skin reaction to the ink. An eczemous or pruritic nodular development overlying a tattoo suggests a possible allergic reaction to the pigment used. Red and yellow pigments are the most allergenic. Laser treatment in these instances may be contraindicated as it could precipitate a systemic allergic response.

The patient should be informed that typically 6 to 10 sessions will be required with a break of not less than 4 to 6 weeks between sessions. Incomplete clearance is always a possibility, and the patient should be prepared for this as well.

The tattoo site is sterilely prepped and often anesthetized with local anesthetic or a tumescent solution, depending upon its size. (Tumescent solution: 500cc NS, 25cc 1% lidocaine, 1cc 1:1000 epinephrine) Use of a cooling instrument may also be used.

The patient and technician wear protective eyewear. The appropriate laser, wavelength and an initial fluence energy is chosen. For most patients, we recommend starting with a Pico QS-Nd-YAG laser at 1064nm, if available. A test spot is checked for an appropriate reaction. The area treated should turn white and have a “frosted” look. This represents vapor and gas bubbles from the fast heating of the tissue. This should resolve within 20 minutes. After the tattoo is treated it is not uncommon to see petechia or mild ecchymosis of the area. Crusting of the area may be present for 7 to 10 days. During this time the patient is instructed on proper cleaning and dressing of the wound. Pico lasers often create little to no crusting and require no dressing. Tattoos that are quite large are best treated in segments to minimize risk of infection.

For multi-colored tattoos we treat darker colors at the first 2 -4 sessions, with a Pico QS Nd-Yag set at 1064nm. Follow-up sessions to treat reds, yellows and orange pigments with the same laser using a KTP filter at 532nm. If green pigment remains, a QS Alexandrite laser is helpful for clearance.

While complications are rare, the most common are: lack of pigment clearance, transient or permanent hyperpigmentation or hypopigmentation, and skin thickening and scarring. Superficial fungal or bacterial infection can occur secondary to inadvertent damage caused by excessive fluences and should be treated with topical and systemic antimicrobials. Thickening tissue or signs of a stimulated allergic response may be treated with local injection of steroids. ■