ANNOUNCING OUR NEW PICOSECOND LASER
RESULTS-
BEFORE and AFTER
BEFORE and AFTER
LASER TATTOO REMOVAL
Effective treatment for all tattoos.
Tattoos are created by injecting colored pigment into small deep holes made in the skin. Regardless of whether a tattoo artist or an untrained individual injects the pigment, the marks or designs are relatively permanent. When people subsequently want their tattoos removed, laser surgery is the best method. The Q-switched Nd:YAG is the most frequently used laser for tattoo removal. During treatment, pulses of light from the laser are directed onto the tattoo, breaking up the tattoo pigment. Over the next several weeks the body's own macrophages remove the treated pigmented areas. The Q-switched Nd:YAG laser is available to treat dark tattoo inks, specifically black (which accounts for more than half of all tattoos), blue and green. Patients should expect to come back for several treatments to achieve fantastic results. Tattoo ink and natural pigmentation like melanin absorb short pulse duration/high peak energy Q-switched pulses so quickly that they create a photo-acoustic effect within the pigment clusters. This effect actually breaks down the ink into much smaller particles that can be more easily removed by the body's natural filtering system.
Tattoo removal has been performed with various tools during the history of tattooing. While tattoos were once considered permanent, it is now possible to remove them with treatments, fully or partially. Tattoo removal by laser is performed with Q-switched lasers, which became commercially available in the early 1990s. Today, "laser tattoo removal" usually refers to the non-invasive removal of tattoo pigments using Q-switched lasers. Typically, black and darker-colored inks are the most easily removed, but all colors can be removed more completely.
Tattoo removal is most commonly performed using lasers that break down the ink in the tattoo. The broken-down ink is then absorbed by the body, mimicking the natural fading that time or sun exposure would create. All tattoo pigments have specific light absorption spectra. A tattoo laser must be capable of emitting adequate energy within the given absorption spectrum of the pigment to provide an effective treatment. Certain tattoo pigments, such as yellows, greens and fluorescent inks are more challenging to treat than darker blacks and blues and require a different type of laser with a special wavelength frequency to most efficiently remove the tattoo ink.
Widely considered the gold standard treatment modality to remove a tattoo, laser tattoo removal requires repeat visits. The amount of energy (flounce/joules/jcm2) is determined prior to each treatment as well as the spot size and treatment speed (Hz/hertz). During the treatment process the laser beam passes harmlessly and safely through the skin, targeting only the ink resting under the dermis. While it is possible to see immediate results, in most cases the fading occurs gradually over the several week healing period between treatments.
Tattoos consist of thousands of particles of tattoo pigment suspended in the skin. While normal human growth and healing processes will remove small foreign particles from the skin, tattoo pigment particles are permanent because they are too big to be removed. Laser treatment causes tattoo pigment particles to heat up and fragment into smaller pieces. These smaller pieces are then removed by normal body processes.
Laser tattoo removal is a successful application of the theory of selective photothermolysis (SPTL). However, unlike treatments for blood vessels or hair removal, the mechanism required to shatter tattoo particles uses the photomechanical effect. In this situation, the energy is absorbed by the ink particles in a very short time, typically nanoseconds. The surface temperature of the ink particles can rise to thousands of degrees without effect upon the surrounding skin structures, but this energy profile rapidly collapses into a shock wave. This shock wave then propagates throughout the local tissue (the dermis) causing brittle structures to fragment. Hence tissues are largely unaffected since they simply vibrate as the shock wave passes. For laser tattoo removal the selective destruction of tattoo pigments depends on four factors:
Several colors of laser light (measured as wavelengths of laser energy) are used for tattoo removal, from visible light to near-infrared radiation. Different lasers are better for different tattoo colors. Consequently, multi-color tattoo removal almost always requires the use of multiple laser wavelengths. Tattoo removal lasers are usually identified by the lasing medium used to create the wavelength:
Spot size, or the width of the laser beam, affects treatment. Light is optically scattered in the skin, like automobile headlights in fog. Larger spot sizes slightly increase the effective penetration depth of the laser light, thus enabling more effective targeting of deeper tattoo pigments. Larger spot sizes also help make treatments faster.
Fluence or energy level is another important consideration. Fluence is measured in joules per square centimeter (J/cm²). It is important to get treated at high enough settings to fragment tattoo particles.
Repetition rate helps make treatments faster but is not associated with any treatment effect.
Complete laser tattoo removal requires multiple treatment sessions, typically spaced several weeks apart. Treating more frequently increases the risk of adverse effects and does not necessarily increase the rate of ink absorption. At each session, some but not all of the tattoo pigment particles are effectively fragmented, and the body removes the smallest fragments over the course of several weeks. The result is that the tattoo is lightened over time. Remaining large particles of tattoo pigment are then targeted at subsequent treatment sessions, causing further lightening. The number of sessions and spacing between treatments depends on various parameters, including the area of the body treated, amount of ink, quality of ink, tattoo colors, and skin color. Tattoos located on the extremities, such as the ankle, generally take longest. As tattoos fade, clinicians may recommend that patients wait between treatments to facilitate ink resolution and minimize unwanted side effects.
The amount of time required for the removal of a tattoo and the success of the removal varies with each individual. Factors influencing this include: skin type, location, color, amount of ink, scarring or tissue change, and layering. In the past, health care providers would simply guess on the number of treatments a patient needed, which was rather frustrating to patients. A predictive scale, the "Kirby-Desai Scale", was developed by Dr. Will Kirby and Dr. Alpesh Desai, dermatologists with specialization in tattoo removal techniques, to assess the potential success and number of treatments necessary for laser tattoo removal, provided the medical practitioner is using a quality-switched Nd:YAG (neodymium-doped yttrium aluminum garnet) laser incorporating selective photothermolysis with six weeks between treatments.The Kirby-Desai Scale assigns numerical values to six parameters: skin type, location, color, amount of ink, scarring or tissue change, and layering. Parameter scores are then added to yield a combined score that will show the estimated number of treatments needed for successful tattoo removal. Experts recommend that the Kirby-Desai scale be used by all laser practitioners prior to starting tattoo removal treatment to help determine the number of treatments required for tattoo removal and as a predictor of the success of the laser tattoo removal treatments.
Multiple factors contribute to the success of laser tattoo removal, one of which is a patient's own immune system. Moreover, treatment on some patients with immune systems problems are contraindicated.
Pain management during treatment. Laser tattoo removal can be uncomfortable but is very tolerable in most cases. The pain is often described to be similar to that of hot oil on the skin, or a "slap" from an elastic band. Depending on the patient's pain threshold, and while some patients may forgo anesthesia altogether, most patients will require some form of local anesthesia. Pre-treatment might include the application of an anesthetic cream under occlusion for 45 to 90 minutes prior to the laser treatment session. In very rare cases, if complete anesthesia is necessary, it can be administered locally by injections of 1% to 2% lidocaine with epinephrine. Anecdotal reports, however, have noted that patients receiving anesthesia by local injection may require additional treatment as the injection causes mechanical edema, a spreading out of the tattoo ink. This makes it more difficult for the laser light to act on specific ink particles, so experts in the laser tattoo removal field caution against injecting anesthetic, as these injections may also increase the risk of scarring and/or additional treatment.
Post-treatment considerations. Immediately after laser treatment, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed. This white color change is thought to be the result of rapid, heat-formed steam or gas, causing dermal and epidermal vacuolization. Pinpoint bleeding represents vascular injury from photoacoustic waves created by the laser's interaction with tattoo pigment. Minimal edema and erythema of adjacent normal skin usually resolve within 24 hours. Subsequently, a crust may appear over the entire tattoo, which sloughs off at approximately 14 days post-treatment. As noted above, some tattoo pigment may be found within this crust. Post-operative wound care consists of simple wound care and a non-occlusive dressing. Since the application of laser light is sterile there is no need for topical antibiotics. Moreover, topical antibiotic ointments can cause allergic reactions and should be avoided. Fading of the tattoo will be noted over the next 4-8 weeks and re-treatment energy levels can be tailored depending on the clinical response observed.
Side effects and complications. About half of the patients treated with Q-switched lasers for tattoo removal will show some transient changes in the normal skin pigmentation. These changes usually resolve in 6 to 12 months but may rarely be permanent. Hyperpigmentation is related to the patient's skin tone, with skin types IV, V and VI more prone regardless of the wavelength used. Twice daily treatment with hydroquinones and broad-spectrum sunscreens usually resolves the hyperpigmentation within a few months, although, in some patients, resolution can be prolonged. Transient textural changes are occasionally noted but often resolve within a few months; however, permanent textural changes and scarring very rarely occur. If a patient is prone to pigmentary or textural changes, longer treatment intervals are recommended. Additionally, if a blister or crust forms following treatment, it is imperative that the patient does not manipulate this secondary skin change. Early removal of a blister of crust increases the chances of developing a scar. Additionally, patients with a history of hypertrophic or keloidal scarring need to be warned of their increased risk of scarring.
Local allergic responses to many tattoo pigments have been reported, and allergic reactions to tattoo pigment after Q-switched laser treatment are also possible. Rarely, when yellow cadmium sulfide is used to "brighten" the red or yellow portion of a tattoo, a photoallergic reaction may occur. The reaction is also common with red ink, which may contain cinnabar (mercuric sulphide). Erythema, pruritus, and even inflamed nodules, verrucose papules, or granulomas may present. The reaction will be confined to the site of the red/yellow ink. Treatment consists of strict sunlight avoidance, sunscreen, interlesional steroid injections, or in some cases, surgical removal. Unlike the destructive modalities described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. Oral antihistamines and anti-inflammatory steroids have been used to treat allergic reactions to tattoo ink.
Studies of various tattoo pigments have shown that a number of pigments (most containing iron oxide or titanium dioxide) change color when irradiated with Q-switched laser energy. Some tattoo colors including flesh tones, light red, white, peach and light brown containing pigments as well as some green and blue tattoo pigments, changed to black when irradiated with Q-switched laser pulses. The resulting gray-black color may require more treatments to remove. If tattoo darkening does occur, after 8 weeks the newly darkened tattoo can be treated as if it were black pigment. Protective eye-wear may be worn if the laser operator choose to do so.
The use of Q-switched lasers could very rarely produce the development of large bulla. However, if patients follow post care directions to elevate, rest, and apply intermittent icing, it should minimize the chances of bulla and other adverse effects. In addition, health care practitioners should contemplate the use of a cooling device during the tattoo removal procedure. While the infrequent bulla development is a possible side effect of Q-switched laser tattoo removal, if treated appropriately and quickly by the health care practitioner, it is unlikely that long term consequences would ensue.
Risks. Although laser treatment is well known and often used to remove tattoos, unwanted side effects of laser tattoo removal include the possibility of discoloration of the skin such as hypopigmentation (white spots, more common in darker skin) and hyperpigmentation (dark spots) as well as textural changes - these changes are usually not permanent when the Nd:YAG is used but it is much more likely with the use of the 755 nm Alexandrite and the R20 method. Very rarely, burns may result in scarring, but this usually only occurs when patients don't care for the treated area properly. Rarely, "paradoxical darkening" of a tattoo may occur, when a treated tattoo becomes darker instead of lighter. This seems to occur more often with flesh tones, pink, and cosmetic make-up tattoos.
Tattoos are created by injecting colored pigment into small deep holes made in the skin. Regardless of whether a tattoo artist or an untrained individual injects the pigment, the marks or designs are relatively permanent. When people subsequently want their tattoos removed, laser surgery is the best method. The Q-switched Nd:YAG is the most frequently used laser for tattoo removal. During treatment, pulses of light from the laser are directed onto the tattoo, breaking up the tattoo pigment. Over the next several weeks the body's own macrophages remove the treated pigmented areas. The Q-switched Nd:YAG laser is available to treat dark tattoo inks, specifically black (which accounts for more than half of all tattoos), blue and green. Patients should expect to come back for several treatments to achieve fantastic results. Tattoo ink and natural pigmentation like melanin absorb short pulse duration/high peak energy Q-switched pulses so quickly that they create a photo-acoustic effect within the pigment clusters. This effect actually breaks down the ink into much smaller particles that can be more easily removed by the body's natural filtering system.
Tattoo removal has been performed with various tools during the history of tattooing. While tattoos were once considered permanent, it is now possible to remove them with treatments, fully or partially. Tattoo removal by laser is performed with Q-switched lasers, which became commercially available in the early 1990s. Today, "laser tattoo removal" usually refers to the non-invasive removal of tattoo pigments using Q-switched lasers. Typically, black and darker-colored inks are the most easily removed, but all colors can be removed more completely.
Tattoo removal is most commonly performed using lasers that break down the ink in the tattoo. The broken-down ink is then absorbed by the body, mimicking the natural fading that time or sun exposure would create. All tattoo pigments have specific light absorption spectra. A tattoo laser must be capable of emitting adequate energy within the given absorption spectrum of the pigment to provide an effective treatment. Certain tattoo pigments, such as yellows, greens and fluorescent inks are more challenging to treat than darker blacks and blues and require a different type of laser with a special wavelength frequency to most efficiently remove the tattoo ink.
Widely considered the gold standard treatment modality to remove a tattoo, laser tattoo removal requires repeat visits. The amount of energy (flounce/joules/jcm2) is determined prior to each treatment as well as the spot size and treatment speed (Hz/hertz). During the treatment process the laser beam passes harmlessly and safely through the skin, targeting only the ink resting under the dermis. While it is possible to see immediate results, in most cases the fading occurs gradually over the several week healing period between treatments.
Tattoos consist of thousands of particles of tattoo pigment suspended in the skin. While normal human growth and healing processes will remove small foreign particles from the skin, tattoo pigment particles are permanent because they are too big to be removed. Laser treatment causes tattoo pigment particles to heat up and fragment into smaller pieces. These smaller pieces are then removed by normal body processes.
Laser tattoo removal is a successful application of the theory of selective photothermolysis (SPTL). However, unlike treatments for blood vessels or hair removal, the mechanism required to shatter tattoo particles uses the photomechanical effect. In this situation, the energy is absorbed by the ink particles in a very short time, typically nanoseconds. The surface temperature of the ink particles can rise to thousands of degrees without effect upon the surrounding skin structures, but this energy profile rapidly collapses into a shock wave. This shock wave then propagates throughout the local tissue (the dermis) causing brittle structures to fragment. Hence tissues are largely unaffected since they simply vibrate as the shock wave passes. For laser tattoo removal the selective destruction of tattoo pigments depends on four factors:
- The color of the light must penetrate sufficiently deep into the skin to reach the tattoo pigment.
- The color of the laser light must be more highly absorbed by the tattoo pigment than the surrounding skin. Different tattoo pigments therefore require different laser colors. For example, red light is highly absorbed by green tattoo pigments.
- The time duration (pulse duration) of the laser energy must be very short, so that the tattoo pigment is heated to fragmentation temperature before its heat can dissipate to the surrounding skin. Otherwise, heating of the surrounding tissue can cause burns or scars. For laser tattoo removal, this duration should be on the order of nanoseconds.
- Sufficient energy must be delivered during each laser pulse to heat the pigment to fragmentation. If the energy is too low, pigment will not fragment and no removal will take place.
Several colors of laser light (measured as wavelengths of laser energy) are used for tattoo removal, from visible light to near-infrared radiation. Different lasers are better for different tattoo colors. Consequently, multi-color tattoo removal almost always requires the use of multiple laser wavelengths. Tattoo removal lasers are usually identified by the lasing medium used to create the wavelength:
- Q-switched Frequency-doubled Nd:Yag: 532 nm. This laser creates a green light which is highly absorbed by red and orange targets. Useful primarily for red and orange tattoo pigments, this wavelength is also highly absorbed by melanin (the chemical which gives skin color or tan) which makes the laser wavelength effective for age spot or sun spot removal.
- Q-switched Ruby: 694 nm. This laser creates a red light which is highly absorbed by green and dark tattoo pigments. Because it is more highly absorbed by melanin this laser may produce undesirable side effects such as pigmentary changes for patients of all but white skin.[15]
- Q-switched Alexandrite: 755 nm. The weakest of all the q-switched devices and somewhat similar to the Ruby laser in that the Alexandrite creates a red light which is highly absorbed by green and dark tattoo pigments. However, the alexandrite laser color is slightly less absorbed by melanin, so this laser has a slightly lower incidence of unwanted pigmentary changes than a ruby laser.[16] This laser works well on green tattoos but because of its weaker peak power it works only moderately well on black and blue ink. It does not work at all on red, orange, brown, etc.
- Q-switched Nd:YAG: 1064 nm. This laser creates a near-infrared light (invisible to humans) which is poorly absorbed by melanin, making this the only laser suitable for darker skin. This laser wavelength is also absorbed by all dark tattoo pigments and is the safest wavelength to use on the tissue due to the low melanin absorption and low hemoglobin absorption. This is the wavelength of choice for tattoo removal in darker skin types.
Spot size, or the width of the laser beam, affects treatment. Light is optically scattered in the skin, like automobile headlights in fog. Larger spot sizes slightly increase the effective penetration depth of the laser light, thus enabling more effective targeting of deeper tattoo pigments. Larger spot sizes also help make treatments faster.
Fluence or energy level is another important consideration. Fluence is measured in joules per square centimeter (J/cm²). It is important to get treated at high enough settings to fragment tattoo particles.
Repetition rate helps make treatments faster but is not associated with any treatment effect.
Complete laser tattoo removal requires multiple treatment sessions, typically spaced several weeks apart. Treating more frequently increases the risk of adverse effects and does not necessarily increase the rate of ink absorption. At each session, some but not all of the tattoo pigment particles are effectively fragmented, and the body removes the smallest fragments over the course of several weeks. The result is that the tattoo is lightened over time. Remaining large particles of tattoo pigment are then targeted at subsequent treatment sessions, causing further lightening. The number of sessions and spacing between treatments depends on various parameters, including the area of the body treated, amount of ink, quality of ink, tattoo colors, and skin color. Tattoos located on the extremities, such as the ankle, generally take longest. As tattoos fade, clinicians may recommend that patients wait between treatments to facilitate ink resolution and minimize unwanted side effects.
The amount of time required for the removal of a tattoo and the success of the removal varies with each individual. Factors influencing this include: skin type, location, color, amount of ink, scarring or tissue change, and layering. In the past, health care providers would simply guess on the number of treatments a patient needed, which was rather frustrating to patients. A predictive scale, the "Kirby-Desai Scale", was developed by Dr. Will Kirby and Dr. Alpesh Desai, dermatologists with specialization in tattoo removal techniques, to assess the potential success and number of treatments necessary for laser tattoo removal, provided the medical practitioner is using a quality-switched Nd:YAG (neodymium-doped yttrium aluminum garnet) laser incorporating selective photothermolysis with six weeks between treatments.The Kirby-Desai Scale assigns numerical values to six parameters: skin type, location, color, amount of ink, scarring or tissue change, and layering. Parameter scores are then added to yield a combined score that will show the estimated number of treatments needed for successful tattoo removal. Experts recommend that the Kirby-Desai scale be used by all laser practitioners prior to starting tattoo removal treatment to help determine the number of treatments required for tattoo removal and as a predictor of the success of the laser tattoo removal treatments.
Multiple factors contribute to the success of laser tattoo removal, one of which is a patient's own immune system. Moreover, treatment on some patients with immune systems problems are contraindicated.
Pain management during treatment. Laser tattoo removal can be uncomfortable but is very tolerable in most cases. The pain is often described to be similar to that of hot oil on the skin, or a "slap" from an elastic band. Depending on the patient's pain threshold, and while some patients may forgo anesthesia altogether, most patients will require some form of local anesthesia. Pre-treatment might include the application of an anesthetic cream under occlusion for 45 to 90 minutes prior to the laser treatment session. In very rare cases, if complete anesthesia is necessary, it can be administered locally by injections of 1% to 2% lidocaine with epinephrine. Anecdotal reports, however, have noted that patients receiving anesthesia by local injection may require additional treatment as the injection causes mechanical edema, a spreading out of the tattoo ink. This makes it more difficult for the laser light to act on specific ink particles, so experts in the laser tattoo removal field caution against injecting anesthetic, as these injections may also increase the risk of scarring and/or additional treatment.
Post-treatment considerations. Immediately after laser treatment, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed. This white color change is thought to be the result of rapid, heat-formed steam or gas, causing dermal and epidermal vacuolization. Pinpoint bleeding represents vascular injury from photoacoustic waves created by the laser's interaction with tattoo pigment. Minimal edema and erythema of adjacent normal skin usually resolve within 24 hours. Subsequently, a crust may appear over the entire tattoo, which sloughs off at approximately 14 days post-treatment. As noted above, some tattoo pigment may be found within this crust. Post-operative wound care consists of simple wound care and a non-occlusive dressing. Since the application of laser light is sterile there is no need for topical antibiotics. Moreover, topical antibiotic ointments can cause allergic reactions and should be avoided. Fading of the tattoo will be noted over the next 4-8 weeks and re-treatment energy levels can be tailored depending on the clinical response observed.
Side effects and complications. About half of the patients treated with Q-switched lasers for tattoo removal will show some transient changes in the normal skin pigmentation. These changes usually resolve in 6 to 12 months but may rarely be permanent. Hyperpigmentation is related to the patient's skin tone, with skin types IV, V and VI more prone regardless of the wavelength used. Twice daily treatment with hydroquinones and broad-spectrum sunscreens usually resolves the hyperpigmentation within a few months, although, in some patients, resolution can be prolonged. Transient textural changes are occasionally noted but often resolve within a few months; however, permanent textural changes and scarring very rarely occur. If a patient is prone to pigmentary or textural changes, longer treatment intervals are recommended. Additionally, if a blister or crust forms following treatment, it is imperative that the patient does not manipulate this secondary skin change. Early removal of a blister of crust increases the chances of developing a scar. Additionally, patients with a history of hypertrophic or keloidal scarring need to be warned of their increased risk of scarring.
Local allergic responses to many tattoo pigments have been reported, and allergic reactions to tattoo pigment after Q-switched laser treatment are also possible. Rarely, when yellow cadmium sulfide is used to "brighten" the red or yellow portion of a tattoo, a photoallergic reaction may occur. The reaction is also common with red ink, which may contain cinnabar (mercuric sulphide). Erythema, pruritus, and even inflamed nodules, verrucose papules, or granulomas may present. The reaction will be confined to the site of the red/yellow ink. Treatment consists of strict sunlight avoidance, sunscreen, interlesional steroid injections, or in some cases, surgical removal. Unlike the destructive modalities described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. Oral antihistamines and anti-inflammatory steroids have been used to treat allergic reactions to tattoo ink.
Studies of various tattoo pigments have shown that a number of pigments (most containing iron oxide or titanium dioxide) change color when irradiated with Q-switched laser energy. Some tattoo colors including flesh tones, light red, white, peach and light brown containing pigments as well as some green and blue tattoo pigments, changed to black when irradiated with Q-switched laser pulses. The resulting gray-black color may require more treatments to remove. If tattoo darkening does occur, after 8 weeks the newly darkened tattoo can be treated as if it were black pigment. Protective eye-wear may be worn if the laser operator choose to do so.
The use of Q-switched lasers could very rarely produce the development of large bulla. However, if patients follow post care directions to elevate, rest, and apply intermittent icing, it should minimize the chances of bulla and other adverse effects. In addition, health care practitioners should contemplate the use of a cooling device during the tattoo removal procedure. While the infrequent bulla development is a possible side effect of Q-switched laser tattoo removal, if treated appropriately and quickly by the health care practitioner, it is unlikely that long term consequences would ensue.
Risks. Although laser treatment is well known and often used to remove tattoos, unwanted side effects of laser tattoo removal include the possibility of discoloration of the skin such as hypopigmentation (white spots, more common in darker skin) and hyperpigmentation (dark spots) as well as textural changes - these changes are usually not permanent when the Nd:YAG is used but it is much more likely with the use of the 755 nm Alexandrite and the R20 method. Very rarely, burns may result in scarring, but this usually only occurs when patients don't care for the treated area properly. Rarely, "paradoxical darkening" of a tattoo may occur, when a treated tattoo becomes darker instead of lighter. This seems to occur more often with flesh tones, pink, and cosmetic make-up tattoos.
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