Laser Tattoo Removal. Types of Tattoos

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1 Laser Tattoo Removal Tattooing has been around since the early beginnings of modern civilization. Tattoos are no longer considered permanent and irreversible designs or marks on the skin. Dermatologic surgeons can safely and effectively use different techniques to successfully remove unwanted tattoos. Types of Tattoos Tattoos are created when pigment becomes lodged in the dermis deliberately or as a result of trauma and can be divided into five categories: professional, amateur, cosmetic, traumatic, and medical. Professional tattoos, placed by the vibrating needle of a tattoo machine, are the most common. These tattoos are created with pigments in a variety of colors that are known to withstand the test of time. In comparison, amateur tattoos are composed of substances such as charcoal, pen ink, soot, or whatever pigment the home tattooist has on hand. The pigment is administered using homemade tattoo machines or simply a hand-held needle. Cosmetic tattoos have become increasingly popular in recent years. Colors such as brown, pink, and red simulate makeup when applied to eyes, cheeks, and lips or natural pigmentation such as the areola in breast reconstruction. Traumatic tattoos result when pigment is deposited in the skin by abrasion, as seen in road rash, or by explosive forces. These materials become lodged in the dermis after re-epithelialization of the wound and result in blue or black tattoos, depending on their depth. Tattoos may also be created for medical purposes, such as those used in radiation therapy. Modern tattoo artists use a myriad of colors to produce striking designs, resulting in permanent works of body art; however, we humans have been changing our minds since the beginning of time. Times changes, your tastes change, and your life changes. You change your clothes; you change your hairstyle -- so why shouldn t you be able to eliminate unwanted tattoos? 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 do not have to live with an unwanted tattoo. Are there treatment alternatives? Or Historical methods for tattoo removal!!! Other methods of tattoo removal include surgical excision (cutting the tattoo out), dermabrasion (scrubbing away the skin), salabrasion (using salt to abrade the tattoo), and chemical peels (using acid to burn away layers of skin). These methods are painful,

2 expensive, and may result in scarring. Thermal methods of tattoo removal destroy the superficial layers of the skin and result in massive inflammation, with significant scarring. Other types of non selective lasers such as CO2 laser leaves a significant scar and has a risk of becoming infected post-treatment. Despite the severity of the treatment, often, a significant amount of tattoo pigment can be left behind. Even the modern pulsed CO2 lasers result in hypopigmented scarring when used on non-facial skin to any depth that would affect tattoo removal. Modern Tattoo (Special Considerations) The response of a particular pigment to treatment is dependent on the laser wavelength used and the pigment s absorption spectra as determined by its chemical composition. Generally, very dark amateur tattoos and professional tattoos will respond well to all three of the QS lasers because black objects, by definition, absorb all colors of light in the visible spectrum. It has also been observed that some red and green pigments may be effectively cleared by the QS Nd: YAG (532 nm) However, modern tattoos now exist in a myriad of hues and in vitro analysis of common ink colors have found their composition to be complex and highly variable (Therefore, two inks that clinically appear to be the same color may have very different compositions and absorption spectra. Variability in chemical composition and absorption spectra may result in nonresponse or resistance at best and, in the worst cases, paradoxical darkening. Some colors, such as yellow and orange, are known to be highly resistant to treatment, and colors such as red and green may respond variably. The factors contributing to these phenomena are incompletely understood, but it appears that the inability to deliver the appropriate wavelength to pigment particles plays an important role Unlike the cosmetic industry, there is no Food and Drug Administration regulation of the tattoo industry. Pigments used are not intended for contact with human skin, many being created for automobile paint and printer s ink. As such, inflammatory, allergic hypersensitivity, granulomatous, lichenoid, and pseudolymphomatous reactions after initial tattoo placement occur. Reactions after tattoo treatment with laser light have also been described, including cutaneous reactions and localized lymphadenopathy. Tattoo Laser Treatment

3 Am I Good Candidate? Your Consultation Patient Selection Initial patient evaluation should begin with a thorough medical history, information regarding wound healing and scarring tendencies, and history of infectious diseases. Patients who have received gold salts for diseases such as rheumatoid arthritis should be approached with caution. The use of gold salts and exposure to sunlight or other UV light sources is known to induce chrysiasis. Further hyperpigmentation has been described as a complication of treatment with QS lasers in individuals with chrysiasis. Individuals should also be questioned about the presence of double tattoos because these may be associated with greater risk of scarring after laser treatment. Appropriate pretreatment counseling with regard to realistic expectations, possible adverse outcomes, and cost of treatment is of utmost importance to ensure patient satisfaction. Patients should understand that multiple treatments will be required and that complete clearance cannot be guaranteed. Tattoo removal will take six to 10 treatments or more depending on tattoo color, age, and mechanism of placement. The importance of sun avoidance before the treatment must also be emphasized. Melanin in the epidermis competes for absorption of laser light, causing destruction of pigment-containing cells. This may manifest acutely as blistering and skin sloughing and later as scarring and hypopigmentation. As such, if a patient is suntanned when they arrive for their procedure, treatment should be delayed unless the device employed is the QS Nd:YAG (1,064 nm). Immediate or progressive irreversible darkening of certain tattoo pigments upon treatment with QS lasers is well documented. These color shifts, ranging from mild graying to complete blackening of the treated tattoo were recorded with white, flesh colored, red, brown, yellow, and crimson pigments. The mechanism of these color changes is incompletely understood. Brown, red, and pink pigments, commonly found in cosmetic tattoos, often contain ferric oxide. Ferrous oxide is jet black and appears to be responsible for the color change seen with these pigments. Titanium dioxide, found in white and flesh-colored pigments, has also been implicated in tattoos responding poorly to treatment. White ink, composed of approximately 95% titanium dioxide, is often combined with other colors to enhance their brilliance. The resistance of certain green, blue, and yellow pigments may be partially attributed to its presence. In certain cases, treatment with ablative lasers may be preferred to remove pigments at risk of darkening or those that are altered or treatment resistant. As in treatment of individuals with darker skin types, the longer wavelength of this laser will spare the epidermal melanin as long as excessive fluences are not used. As with all cosmetic procedures, pretreatment photographs are recommended. The Procedure Before the start of the procedure, it is imperative to ensure the safety of the patient and practitioner. All personnel within the room should wear protective goggles with the proper optical density, and the patient should be provided

4 with protective eyewear or intraocular metal shields if appropriate. Cosmetics, lotions, and other skin care products should be removed from the treatment area because they may interfere with the laser light s interaction with the skin. Skin should be dry and free of potentially flammable cleansing agents such as isopropyl alcohol. Inorganic sunscreens or foundation left on the skin may cause a loud pop when the laser is applied, startling the clinician and patient. Although this is not harmful to the patient, it is a sign that cleansing has been inadequate and should be repeated. Because all QS lasers, particularly the Nd:YAG (1,064 nm), are associated with splatter of blood and tissue, the use of a protective shield should be considered.30 Clear hydrogel dressings (Vigilon) or clear occlusive dressings (Tegaderm) can be used Modern tattoo-removal lasers Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Q switching is a means of producing a very short laser pulse in the nanosecond Domain. Unfortunately some laser Clinics are using devices that deliver pulses in the millisecond range such as intense pulsed light to treat tattoos. These types of devices heat the tattoo granules for too long, allowing heat to spread to surrounding tissue. This results in an unacceptable incidence of scarring in the shape of the tattoo, while still leaving most of the tattoo behind. To achieve optimal cosmetic results, only Q-switched lasers should be used for tattoo removal and in dark skinned people the Q-switched Nd:YAG is the safest. PicoSure is the world s first and only picosecond aesthetic laser for multiple aesthetic applications including tattoo removal, skin revitalization, acne scar treatment, removal of pigmented lesions and wrinkle treatment. This unparalleled breakthrough in laser technology delivers ultra-short pulse bursts of energy to the skin in trillionths of a second. Picosecond pulse width is 100 times shorter than nanosecond technology, enabling unmatched photomechanical impact for better clearance with fewer treatments and less fluence. Pulses in the picosecond range may more effectively target pigment particles, with less surrounding tissue disruption. Evidence suggests that the primary mechanism of pigment elimination in laser tattoo removal is through damage of cells harboring pigment by photoacoustic rather photothermal effects. Shorter pulse durations produced by picoseconds lasers cause the target to heat and expand more rapidly than QS lasers, resulting in more substantial locally destructive forces. Tattoo color, origin, and patient skin type will guide laser selection. As discussed, the QS ruby, QS Nd:YAG (1,064 nm), and QS alexandrite lasers have each been shown to be effective when treating blue black tattoos. The carbon containing dark pigments of amateur tattoos also respond well, typically requiring fewer treatments than similarly colored professional tattoos. In more darkly pigmented patients, however, the QS Nd:YAG (1,064 nm) is favored as the longer wavelength interacts less with epidermal melanin, resulting in a lower likelihood

5 of hypopigmentation. Colored tattoos are becoming increasingly common and respond less predictably to treatment. In general, QS lasers will fade most colors, although certain colors may be highly resistant to treatment. Some lasers may treat particular colors more effectively, such the QS Nd:YAG (532 nm) and QS alexandrite lasers for red and green pigments, respectively, but tattoo pigments are complex compounds with variable compositions, and successful treatment of colored tattoos may at times involve a trial and error approach. Because a tattoo s response to laser irradiation cannot be predicted, a test spot in the most inconspicuous area may be done at the discretion of the practitioner before the full treatment. Intra-operatively, the laser will cause an immediate ash-white color at the site of impact. This color appears to be attributable to steam and gas bubbles formed with rapid heating of the tissue and resolves within 20 minutes. It should be considered a treatment endpoint, and if it is not observed, it is likely that the laser exposure dose is not sufficient. Some With the rare exception of some amateur and traumatic tattoos, laser tattoo removal will always require multiple treatments, each increasing the risk of laserinduced side effects and cost to the patient, but recently presented data suggest that multiple treatments spaced only minutes apart may be just as effective as the traditional approach. In a novel approach Prof. Moawad used a technique in which tattoos are treated with Qs Nd:YAG laser and a fractionated carbon dioxide laser. There was greater clearance with the addition of ablative fractional resurfacing. Prof Moawad suggested that,laser ablation of tissue-containing pigment and stimulation of an inflammatory and phagocytic response. Application of imiquimod may also aid in tattoo removal. Tattoo Darkening When color shifts occur, there are a number of options, including continued treatment using a QS laser, treatment using nonselective ablative lasers, and surgical excision. Traumatic Tattoos Traumatic tattoos are created when material becomes embedded in the dermis by explosive forces or abrasion. These particles may consist of gravel, asphalt, dirt, pencil, surgical pen, firework debris, amalgam, or glass. Most often containing carbon and graphite, traumatic tattoos have been shown to respond well to treatment with all three aforementioned QS lasers. If embedded particles are large, the nanosecond pulse duration may not be able to target them effectively. In this situation, removal using an ablative laser may be an option. When traumatic tattoos are created by explosive means, combustible material may become embedded in tissue. Treatment of these tattoos should be approached with caution, because the laser energy delivered is sufficient to ignite these particles.the treatment of explosive traumatic tattoos may endanger patient and practitioner and result in significant scarring. This may result in significant scarring. These tattoos must be approached with care, and a small test spot performed before embarking on removal of large areas

6 How does the Q-Switched Nd:YAG 1064nm and KTP 532nm lasers work on a tattoo? Q-switched Nd:YAG lasers are capable of emitting two wavelengths of light, 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 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. Our high power Q-switched laser allows large diameter, deeply penetrating laser beams to be used, and will help to speed up the resolution of your unwanted tattoo. If the area to be treated has a fresh sun tan or has been treated with self-tanning lotion, it is best to wait a couple of weeks for the tan to fade before having treatment, because the tan will absorb and waste some of the laser energy intended for the pigmented lesion. A fresh sun tan (or color from a recent application of self-tanning lotion) could also absorb enough laser energy to increase the risk of skin irritation or blistering. That is why Prof. Moawad insists that patients cover tattoos with a bandage or clothing before laser treatment. The laser, being a machine, is indifferent to the reason a patients skin is tan and will simply see the extra melanin pigment and possibly hurt the skin, Prof. Moawad explains How much does laser treatment of tattoos hurt? Many patients find that the discomfort of their first laser tattoo treatment is similar to the discomfort they had when getting the tattoo. There may be less discomfort after the first couple of treatments because as the tattoo fades there is less pigment to absorb laser energy. The impact of the energy from the powerful pulse of light is similar to the snap of a thin rubber band, or tiny specks of hot grease on the skin. The use of anesthesia is generally advisable given the high fluences used when treating targets in the dermis. Options include topical anesthetics such as 5% lidocaine cream (LMX-5) and 2.5% lidocaine/ 2.5% prilocaine cream (EMLA), refrigerated air (Zimmer Chiller), local infiltration of lidocaine, regional nerve block, or a combination of these modalities. For very large areas, one may consider treating the tattoo in sections or the use of oral or intramuscular sedation. A couple of plain Tylenol can be taken to raise your pain threshold somewhat before laser What will happen after treatment? Skin care after laser treatment of tattoos is quite similar to skin care after having a tattoo. Gentle cleansing of the skin and application of an antibiotic ointment t will help tattoos heal quickly after treatment. Watch for unusual redness, pain, or swelling which might be a sign of infection, and please call us right away if you think an infection is developing. Avoid picking or irritating the skin after treatment. For the first half-hour after laser

7 treatment the tattoo looks pale or white, and may swell slightly. The tattoo may feel hot (like a sun-burn) for a while after laser treatment and it will probably be red and swollen for the rest of the day. There may be pinpoint bleeding for a few hours in areas where there was a lot of pigment. The area may remain reddened for two to four weeks and there may be some flaking or peeling during this time. Sometimes skin or a scab the same color as the tattoo peels off after 5-7 days. This is a normal process as the body works to eliminate the tattoo dyes. Very dark, or large professional tattoos, will remain tender and swollen for a few days. There may be some lightening or darkening of the skin for several months after laser 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. The degree of fading will be easier to see when you compare your tattoo with pre-treatment photographs. How many treatments are required? When Prof. Moawad examines your tattoo, he will be able to give you an estimate of the number of treatments, which will be necessary to fade or remove the tattoo. Because there is a great deal of variability in the kinds, mixtures and quantities of ink used in tattoos, and because there is some variability in peoples natural ability to clear away tattoo pigment after laser treatment, it is not possible to "promise" you that a certain result will happen after a fixed number of treatments. Prof. Moawad will explain what is likely to happen, but he cannot precisely predict or guarantee what will happen in any particular case. Prof. Moawad will show you photos illustrating the range of results, from fading through to complete disappearance of the tattoo. Some lightly pigmented, black or dark blue, homemade tattoos like the one above can be removed in one treatment. Amateur tattoos (which usually have a small amount of superficial ink) often clear after two to six treatments. New tattoos usually need extra treatments because they have more ink than old tattoos. Older tattoos have less ink because as a tattoo ages, the body absorbs some of the ink. Factors which influence laser tattoo treatment success include the kind and color of inks used, the ability of the patients immune system to clear away pigment after it has been treated, and location of the tattoo. Multicolored professional tattoos, especially on the lower legs, tend to respond slowly to laser treatments, and quite a few multicolored tattoos will need 10 or more treatment sessions for satisfactory fading or complete removal. Dark (blue/black) inks and red inks usually fade the best. Oranges and purples often respond well. Dark inks usually respond quicker than bright colored inks because dark colors absorb laser energy better. Light colors such as light green, yellow and turquoise can be difficult to remove. Sometimes chemicals like iron oxide or titanium dioxide are added to tattoo ink to brighten the tattoo - but these chemicals make it much more difficult to remove the tattoo. Fluorescent "Day Glow" pigments are almost impossible to remove. Some tattoos are now made with dark tar based ink or "laser resistant ink" and these tattoos (which fortunately are quite rare) can only be removed by cutting them out. New tattoos usually need a larger number of treatments because they have a higher concentration of ink than old ones. Older tattoos have a lower concentration of ink because as a tattoo ages, the body absorbs some of the ink.

8 Tattoos on the face and trunk often respond faster to laser treatment than tattoos on the ankles. A professional tattoo (which usually has more ink, deeper ink, and multiple colors) might fade considerably after three to six treatments, but it generally takes between six and ten laser treatments to either completely remove a professional tattoo or to fade the tattoo so that it is barely visible (called a "ghost"). Sometimes complete removal is not possible, or you may find that almost-complete fading of the tattoo is satisfactory. How long should I wait between treatments? Quick fading or removal can sometimes be accomplished on black tattoos by using low powered treatments every week or two. In general, however, it is best to wait at least 4 weeks between treatments. Sometimes it is possible to fade or remove the tattoo with a smaller number of treatments if you are willing to wait 8-12 weeks between treatments, so that your body has a longer opportunity to clear away pigment after laser treatment. 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. Will the tattoo completely disappear? In many cases the tattoo can be made to disappear or fade to the point where you are the only person who can find a trace of it, because you know where to look. Some people choose to over-tattoo (use "cover-art") to hide an undesirable tattoo. This is especially common when the original tattoo contains the name of a former lover. If you have one tattoo on top of an older tattoo, extra laser treatments will probably be needed because there is likely to be a large amount of ink (ink from the new cover-up tattoo plus ink from the old tattoo). Many tattoo artists encourage customers to have several laser treatments to lighten an existing tattoo before covering it with a new one. This will greatly reduce any chance that the old tattoo will be visible through the new tattoo. You should wait a month or two after your final laser treatment before having a new tattoo placed in the treated are What are the risks of treatment? In most cases, the laser treatment leads to satisfactory fading or complete removal of the tattoo without significant side effects. Serious side effects are very unusual. The most common problem with tattoo treatment is incomplete fading or removal of the tattoo. This is mainly an issue with complicated multicolored tattoos. Not all tattoo inks respond and rarely certain colors can get worse. Heavy professional tattoos in particular may not completely fade. Significant and sometimes irreversible darkening of tattoo ink may occur, where the pigment need more treatment sessions. This is mostly a problem with fleshcolored, red, tan, and white inks, and a small test area can be done to detect this problem. For those cosmetic or white tattoos that are refractory to removal with Q-switched lasers, CO2 lasers can also be used to remove these pigments; although the risk of scarring is greater than with the Q-switched lasers. Although true scarring is very unlikely there can be some mild change in the texture of the skin (perhaps 1-2% of cases). Sometimes there is pre-existing texture change in the skin caused by the tattooing process itself. There can also be some loss of natural tanning ability in the treated area, which usually improves with time. You can reduce the chance of irregular tanning by protecting the tattooed area from sun exposure. Hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin) are quite infrequent, and are almost always temporary. Prof. Moawad uses Q-switched Nd:YAG laser which is

9 the safest in the world for dark skin colors. African, Asian and Mediterranean people can have their tattoos safely treated without changing the surrounding skin color. He recommends using bleaching agents before initiating laser treatment and in between laser sessions to prevent darkening of skin in dark-skinned and tanned patients. Allergic reactions can occur after treatment, especially if you are already having an allergic reaction (redness and itching) in your tattoo. Allergic reactions are usually caused by metallic dyes, which contain mercury, manganese, chromium, cobalt, or cadmium. This will necessitate a protocol for effective removal of these pigments. Prof. Moawad treat such reactions with topical or intralesional corticosteroids and avoid laser treatment altogether. In contrast to drugs and cosmetics, tattoo pigments have never been controlled or regulated in any way, and the exact composition of a given tattoo pigment is often kept a "trade secret" by the manufacturer. In most cases, neither the tattoo artist nor the tattooed patient has adequate information about the composition of the tattoo pigment. It is important to be patient and remain positive as this promotes better healing and relaxation. It is best not to pass judgment on your progress until the healing process has completed.