[rev_slider alias=”tattoo-laser-removal” /]

Summary

Why shouldn’t you be able to eliminate unwanted tattoos? Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Or fade them to prepare the area for a different tattoo. Thanks to the only available tattoo removal specific laser machines at MSI “Q-switched Nd: YAG laser 1064nm infra-red laser ” and frequency-doubled 532nm green KTP laser, you don’t have to live with an unwanted tattoo. This laser sends precise pulses of high-energy light into the skin, vaporizing some tattoo inks and fragmenting other tattoo inks into thousands of tiny particles, which are then safely eliminated from your skin. I should also consider test spots for cosmetic, medical, traumatic, or decorative tattoos with light colors. Paradoxical darkening is likely to be encountered in these tattoos. After laser treatment of tattoos, skincare is quite similar to skincare after having a tattoo. Gentle cleansing of the skin and applying an antibiotic ointment will help tattoos heal quickly after treatment. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal. Your tattoo usually fades over 4-6 weeks. Other non-laser methods of tattoo removal include surgical excision (cutting the tattoo out), dermabrasion (scrubbing away the skin), salabrasion (using salt to rub the tattoo), and chemical peels(using acid to burn away layers of skin). These methods are painful, expensive, and may result in scarring.

History of tattoo

Tattoos have fascinated humankind from all cultures and strata of society for centuries. From the ancient Egyptian, Greek, and Roman civilizations to the modern society we have today, skin markings have been used to enhance beauty, demonstrate uniqueness, signify belonging, and sometimes to identify, shame, or punish.  The term tattooing is derived from “tattau,” a Tahitian word which translates essentially as “to mark” and is a process of implantation of permanent pigment granules in the skin.

  • Tattoos date back to 5200 years. The early tattoo was made by cutting the skin and rubbing powdered charcoal in the wound
  • Scientists believe tattoos may have been the first form of medical treatment
  • The tattoo has been found on female Egyptian mummies. Ancient Egyptians believed tattoos prevented complicated pregnancies and births
  • In the 10th and 11th centuries, crusaders had cross-shaped tattoos. If killed, that person would receive a Christian Burial.
  • The tattoo has been to mark slaves and criminals.
  • In many tribal communities, facial tattoos indicated a person’s status and accomplishment
  • In the 5th century, the Japanese developed tattoos in fine art with intricate designs and colors
  • In 19th and 20th century America, tattoos were mostly associated with sailors, fringe cultures, prisoners, and gangs

How is a Tattoo Done?

Tattoos are created by the introduction of exogenous pigment into the dermal skin layer and can be placed with intent or be the result of accidents and injury. Tattoo inks are composed of pigments or dyes combined with a tattoo pigment vehicle which entraps, encases, incorporates, complexes, encapsulates, or is otherwise associated with the pigment to form pigment/vehicle complexes that retain the pigment in the tissue.  Most professional tattoo artists purchase inks pre-made (known as pre-dispersed inks), while some tattoo artists mix their own using a dry pigment and a carrier. Manufacturers are not required to reveal their ingredients or conduct trials, and recipes may be proprietary. Professional inks may be made from iron oxides (rust), metal salts, or plastics. Homemade or traditional tattoo inks may be made from pen ink, soot, dirt, blood, or other ingredients. Heavy metals used for colors include mercury (red); lead (yellow, green, white); cadmium (red, orange, yellow); nickel (black); zinc (yellow, white); chromium (green); cobalt (blue); aluminium (green, violet); titanium (white); copper (blue, green); iron (brown, red, black); and barium (white). Metal oxides used include ferrocyanide and ferricyanide (yellow, red, green, blue). Organic chemicals used include azo-chemicals (orange, brown, yellow, green, violet) and naptha-derived chemicals (red). Carbon (soot or ash) is also used for black. Other elements used as pigments include antimony, arsenic, beryllium, calcium, lithium, selenium, and Sulphur.

Both blacklight and glow in the dark inks have been used for tattooing. Glow in the dark tattoo ink absorbs and retains a light and then glows in darkened conditions by process of phosphorescence. The ingredients in some “glow” inks are listed as: (PMMA) Polymethylmethacrylate 97.5% and microspheres of fluorescent dye 2.5% suspended in UV sterilized, distilled water. Blacklight ink does not glow in the dark, but reacts to non-visible UV light, producing a visible glow by fluorescence. The resulting brightness of both these inks is highly variable. Unsubstantiated claims have been made that some inks fade over time, yielding a “semi-permanent tattoo. The safety of such inks for use on humans is widely debated in the tattoo community.

After Tattooing What Happen?

After initial injection, the pigment is dispersed throughout a homogenized damaged layer down through the epidermis and upper dermis, in both of which the presence of foreign material activates the immune system’s phagocytes to engulf the pigment particles. As healing proceeds, the damaged epidermis flakes away (eliminating surface pigment) while more rooted in the skin granulation tissue forms, which is later converted to connective tissue by collagen growth. This repairs the upper dermis, where pigment remains trapped within fibroblasts, concentrating in a layer just below the dermis/epidermis boundary. Its presence there is stable, but in the long term (decades), the pigment tends to migrate deeper into the dermis, accounting for the degraded detail of old tattoos. Tattoo pigment has been reported both intracellularly and extracellularly, with mild fibrosis and occasional foreign-body giant cell reactions, with allergic granulomas, and with sarcoid reactions.

Tattoo ink is remarkably non-reactive histologically, despite the frequent use of different pigments of unknown purity and identity by tattoo artists. Although it rarely occurs, red (mercury), yellow (cadmium), green (chromium), and blue (cobalt) tattoo pigments have elicited a persistent, localized allergic or photoallergic dermatitis and, more infrequently, systemic reactions. Interestingly, the colors most involved in allergic reactions (red and yellow) often spontaneously disappear from a tattoo without clinical signs of a response. Complex and light absorbing molecules are implanted in the skin. When tattooed skin receives UV radiation or natural sunlight, photochemical cleavage of the pigments may occur. The decomposition products are hazardously showing a potential risk of being toxic or even carcinogenic. At present, a risk assessment is not feasible since the concentration of pigments and their decomposition products in skin are unknown. Sun protection is necessary for successful laser tattoo removal. First, it decreases the number of melanin pigments that competed with laser absorption with tattoo pigments. This means reduced intake with tattoo pigments (reduce efficacy and increase absorption by melanin pigments (epidermal injury and more side effects).

How to Do Safe Tattooing? What are the Complications?

The tattooing should be carried out by trained personnel so that the pigment is placed at the appropriate depth. Thorough cleaning of the surface to be tattooed is mandatory to prevent resident organisms of the skin from being introduced in the dermis. The inks should be sterile and of good quality without external contaminants to reduce the incidence of allergic and granulomatous reactions. Strict aseptic precautions are essential to prevent bacterial, viral, and fungal infections. The instruments should be sterile, and preferably all disposables should be used to avoid transmissible diseases such as Hepatitis B, C, and HIV infection and leprosy. There are regulations that restrict blood donation following a tattoo. The period varies from 4 months to 1 year in different counties.

Who Get a Tattoo?

In the United States, rates of tattooing have increased over the past several decades. It is currently estimated that 21%to 24%of the population in the United States has at least 1 tattoo. Tattoos also seem increasingly common in younger generations. It has been estimated that up to a quarter of young to middle-aged adults in the United States have at least one tattoo. 2 As tattoos become

Who Get Laser Tattoo Removal? Why?

28% of people who get tattoos regret the decision within the first month. The motivation for tattoo removal includes new jobs or careers, the need to portray an image at work or in new social circles, and further, negative feelings towards old tattoos. Various psychosocial reasons, especially when names are tattooed, and patients reconsider or a change of faith in case of religious symbols. Many occupations, such as the armed forces, prohibit the presence of tattoos and seek tattoo removal. It has been rightly sung by Jimmy Buffett, an American singer, that a tattoo is a permanent reminder of a temporary feeling.

How Does Laser Remove My Tattoo?

The mechanism of action of the QSL is through photon absorption by tattoo pigment within fibroblasts. During the 40-nanosecond pulse, temperatures exceeding 1000°C can occur. Gaseous products of pyrolysis or pores created by superheated steam may account for the lamellated appearance of the granules after laser exposure. The reduction in pigment particle size and fragmentation of pigment-containing cells results from rapid thermal expansion, shock waves, and potentially localized cavitation. Fluence-dependent thermal damage to collagen immediately surrounding the irradiated tattoo pigment also occurs. Q-switched Nd:YAG lasers are capable of emitting two wavelengths of light, 1064- and 532-nm wavelengths. This enables effective treatment of dark tattoo pigments such as black and dark blue using the 1064-nm wavelength, as well as the removal of red and orange pigments using the 532-nm wavelength. This laser sends precise pulses of high energy light into the skin, vaporizing some tattoo inks and fragmenting other tattoo inks into thousands of tiny particles which are then safely eliminated from your skin by macrophages immune cells.

How Long Should I Wait Between Tattoo Laser Removal?

The appropriate treatment interval is critical and yet poorly understood. Early on, patients were treated every 4 weeks. Higher fluences and shorter pulse widths remove tattoo pigment more rapidly but may induce excessive shock wave tissue reaction; therefore, they must be balanced with the desire to remove dye without scarring or hypopigmentation. The current recommendation is to treat at 6- to 8-week intervals unless a more extended period of 2-3 months is needed for tissue recovery. For highly motivated patients, I schedule them every 2 weeks if only QS lasers are used. Fractional CO2 or Ultra-pulse CO2 is used every 4-6 weeks to help skin recover. You should think of the fading and eventual elimination of your tattoo as a project which you might work on from time to time over the next year or two.

What are the Types of Tattoo?

Tattoos can be divided into Decorative tattoo (amateur& professional), cosmetic, medical, and traumatic categories.

Decorative tattoos are tattoos placed on the skin as a decoration. The classic types of tattoos, such as amateur tattoos, have paved the way to highly intricate multi-colored professional tattoos. The current trend is 3D tattoos, optical illusion tattoos, head mandala tattoos, foot tattoos, miniature portraits, etc.

Amateur tattoo inks consist of simple carbon particles originating from burnt wood, cotton, plastic, or paper, or a variety of inks, including Indian ink, pen ink, and vegetable matter. A needle is used to deposit ink at various depths of the skin.  The amateur tattoo is easy to remove as it contains a low volume of pigments and superficially place.

Professional tattoos contain more ink, deeper ink, and multiple colors with the help of a hollow needle or a tattoo gun to inject pigments into the dermal layer of skin. The granule depth remains uniform and is located at the bottom of about 400 ums in the upper to mid-dermis. This explains the difficulty in treating these tattoos as compared to amateur tattoos, which are superficially placed.

Cosmetic tattoos are also known as micro-pigmentation or permanent cosmetics. This type of tattoo is used for permanent eyeliner, lip liner, lipstick, and other permanent cosmetic purposes. This type of tattoo is also used to cover skin pigment disorders, scars, and other blemishes. In the hands of professionals, permanent cosmetics can form a practical final step in treating many patients—cosmetic tattoos using skin-colored tones like medical tattoos used as radiation markers.

A medical Tattoo is used to treat a condition, communicate information, or mark a body location. Tattoos have also been used to provide notice to emergency personnel that a person has diabetes mellitus. During breast reconstruction after mastectomy or breast reduction surgery, tattooing is sometimes used to replace the areola or to fill in areas of pigment loss, which may occur during breast reduction performed with a free nipple graft technique. Medical therapeutic tattooing has been used as a camouflage technique in vitiligo, camouflage for permanent hair loss after craniofacial surgery, and scars following plastic and reconstructive surgery. The inks used often contain pigments that are red, brown, white, or flesh-colored; inks containing titanium dioxide and iron oxide are difficult to remove

Traumatic tattoos are deposited in the skin following abrasion, laceration, or explosive injuries. Such pressurized penetration of dark particles into the deep dermis gives rise to black or blue tattoos, depending on the depth of the pigment. Traumatic tattoos acquired because of fireworks or explosives must be treated with great caution. Some of the particles embedded in the skin may be flammable and may reignite after laser treatment. This may result in significant scarring. These tattoos must be approached with care and a small test spot performed before embarking on the removal of large areas.

Your Consultation for Tattoo Laser Removal

A thorough medical history and examination are essential in establishing the type of tattoo and the patient’s skin type before treatment. It is important to note if the patient was ever treated with systemic gold therapy (e.g., rheumatoid arthritis therapy). This is an absolute contraindication to QS laser treatment since the darkening of gold-containing skin is immediate and irreversible. Previous isotretinoin treatment, herpes infection, keloidal tendencies, a tendency toward post-inflammatory hypo- or hyperpigmentation, and sun exposure habits should be considered, as additional preventive measures may be needed. I usually recommend that patients stop tanning, cover their tattoo if possible, and apply bleaching cream 2-4 weeks before the first session, mainly Egyptian patients with the III-IV skin type.

Just as critical as the patient selection is the evaluation of the lesion itself.

  • _ Is it an amateur, professional, traumatic, aesthetic, or medical tattoo?
  • _ How long has it been present?
  • _ What colors of inks/dyes were used?
  • _ Were inks mixed to make the colors?
  • _ Is there any white or skin-colored ink in the tattoo to the patient’s knowledge?
  • _ Has the patient attempted to remove or alter the tattoo previously? If so, what technique was used?

Standardized digital photography helps record the baseline appearance and any subsequent improvement. This applied to a video-dermatoscopy. You can quickly discover the various color components, camouflage (beige color), previous attempt removal, or scars. It is imperative to document these findings before starting treatment for legal purposes. The patient’s treatment objective and expectation should be counseled, and I should discuss treatment options, expected outcomes, potential risks, downtime, and postoperative care. There should be an adequate opportunity for patients to have all their questions answered. Establishing realistic patient expectations through good rapport helps achieve a satisfactory outcome. They obtain informed consent with a clear outline of the risks and the benefits before tattoo removal is essential and protects both the clinician and patient. It is imperative to deliver the message that Multiple laser treatments are usually required to remove a tattoo.

Your Tattoo Laser treatment

The tattoo area is photographed before each session. I should cleanse the area to be treated thoroughly and free from any residual cosmetics or skincare products. Sometimes I use microdermabrasion or micro-needling before the application of topical anesthetic cream. This helps to increase the efficacy of anesthetic cream and laser treatment, as well. Topical anesthetics such as 5% lidocaine cream (LMX-5) and 2.5% lidocaine/2.5% prilocaine (EMLA) are often applied for 45-60 minutes under occlusion.  I should exercise caution if the region is significant, as topical anesthetics can produce toxicity.  Other methods of reducing discomfort for the patient include cold air during treatment, local infiltration of lidocaine, regional nerve block, IV sedation, or a combination of these modalities. I should altogether remove the anesthetic cream before the treatment, and the treatment area is cleansed again.

In the case of cosmetic tattoo laser removal of eyebrows, I advised patients to shave their hair immediately before laser sessions. These hairs turn to ash grey or whitening when a QS laser is applied. Its melanin content will absorb a significant part of laser energy. This will decrease the efficacy of the Qs laser to remove tattoo pigments. All medical personnel must wear wavelength-specific protective goggles during the laser procedure. I must also provide the patient with protective goggles or external metal eye shields. If the area treated is on the eyelid or near the orbit, intraocular metal eye shields should be placed for the patient. High-energy short pulses cause a pressure shock wave that ruptures blood vessels and aerosolizes tissue (with potentially infectious particles), requiring a barrier or a cone device to protect the operator from tissue and blood contact. Lower fluences eliminate this problem but result in more treatment sessions. Scarring or tissue textural changes are also attributable to hot spots within the beam and pulse-to-pulse variability. Maintaining a high-energy output with a more prominent spot size (which decreases fluency) is equally effective, with less hazard to the operator and fewer adverse effects (less epidermal disruption) for the patient. It is essential to wear a mask to prevent inhalation of debris, blood splatter. The presence of forceful smoke evacuation. In some patients, we cover tattoos are with thin plastic sheets for the exact reason.

Test spots can be carried out and evaluated at 4-6 weeks for efficacy and side effects in darkly pigmented patients. I should also consider test spots for cosmetic, medical, traumatic, or decorative tattoos with light colors. Paradoxical darkening is likely to be encountered in these tattoos. The main parameters include pulse duration, wavelength, fluence, and spot size. All the Q-switched lasers are in the nanosecond range, and the laser predetermined pulse width. Wavelength is chosen based on the best available wavelength for the tattoo ink color. For example, red ink is best treated by a green wavelength (510 or 532 nm), and green ink is best handled by a red wavelength (694 or 755 nm). When melanin is present, the 1064-nm wavelength is the best choice to avoid disruption of the epidermis. Fluence should be enough to produce immediate whitening without immediate bleeding or blistering. Larger spot sizes provide deeper penetration and should be used if I can obtain enough fluency. This maximizes the distribution of laser light to the dermal pigment and minimizes cutaneous injury.

The optimal fluence is the lowest possible setting that elicits this endpoint to reduce the risk of thermal injuries, such as blister formation and scarring. The desired endpoint of QS laser treatment (Nd: YAG, alexandrite, and ruby) is immediate tissue whitening, although this may not occur if the tattoo has faded significantly. Such whitening can last 20 minutes and results from rapid heating of the chromophore leading to gas formation. A low starting fluence should be used to attain this desired endpoint during initial tattoo treatment, especially when the tattoo pigment density is very dark.  The fluence can be increased as the tattoo becomes lighter. Frequently, the initial treatment session produces a more dramatic response than in subsequent sessions. Specific sites of clearing, corresponding to laser impacts, are often seen. Other tattoos are highly unresponsive during early treatment phases, although biopsy samples reveal fragmentation of tattoo granules. The response differs from one patient to another involves the efficiency of mobile macrophages in removing fragmented tattoo pigment debris and the density and amount of tattoo pigment present. The speed of the macrophage response and the maximum amount of pigment removed per session varies from patient to patient and from treatment to treatment. The more superficial the tattoo pigment and the less the total pigment volume, the fewer the number of procedures necessary to remove the dye.

If you have light skin, you are lucky as the practitioner has several options. The QS alexandrite (755 nm), the QS ruby (694 nm), and the QS Nd: YAG (1064 nm) lasers are all helpful for dark-blue and black tattoos. On the other hand, the QS Nd: YAG is the laser of choice for patients with dark skin. The optimal laser wavelength for removing red tattoo ink is 532 nm (QS frequency-doubled Nd: YAG). Furthermore, red tattoo ink is often the culprit for immediate and delayed allergic reactions in the tattoo itself. Laser removal of the red ink can cause more dispersion of the antigen resulting in urticaria or systemic allergic response. In these cases, an ablative CO2 or Er: YAG laser can be employed to vaporize the tattoo. If a QS laser is applied, the patient should be covered with systemic corticosteroids and antihistamines, and the laser surgeon should proceed with caution.

What Will I Look Like after Laser Tattoo Removal?

What Should I Do “Skincare” after Laser Tattoos Removal?

In short, it is pretty similar to skincare after having a tattoo. Gentle cleansing of the skin and application of an antibiotic ointment will help tattoos heal quickly after treatment. You should continue this until the area has completely re-epithelialized. A dry crust should never be allowed to form, and if developed, never remove it. The treatment area should improve within 5–14 days. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal. Your tattoo usually fades over 4-6 weeks. The degree of fading will be more comfortable to see when you compare your tattoo with pre-treatment photographs or video-dermatoscopy photos. There may be some lightening or darkening of the skin for several months after laser treatment. For those patients afraid that laser will affect hair regrowth (eyebrows or eyelashes), I prescribed Lumigan (bimatoprost) eyedrops cautiously. The applied in localized areas of pigment loss.