There are different types of tattoo removal available, including:
Before your procedure, you’ll meet with a trained, certified physician who’ll evaluate your situation and inform you about the process. They’ll evaluate your skin and may ask questions that could include:
Your provider will also measure the size of your tattoo and they might take a photo of it to record the results of your procedure. Your provider will choose a treatment plan based on the type and color of ink in the tattoo and the depth of the tattoo pigment in your body.
During a laser tattoo removal procedure, you can expect the following to happen:
Smaller tattoos require fewer pulses and larger ones require more. In either case, the tattoo requires multiple visits for treatments. After each treatment, the tattoo should become lighter.
After each session, your healthcare provider will give you instructions about how to take care of your skin.
It takes more than one session to remove a tattoo because when you got your tattoo, your tattoo artist applied the ink in layers. Because lasers break the ink pigment into smaller particles, it then takes some time between sessions for your body to flush out the ink. Your skin also needs time to heal. If you receive laser treatments, the procedure can sometimes cause swelling and blistering and can temporarily alter the color of your skin. Sometimes, superficial scarring may develop or your skin may be permanently discolored.
Each person’s tattoo removal process is different. It’s relatively common for tattoo removal to not remove a tattoo completely. But some tattoo removal procedures will completely remove the tattoo from your body. When tattoo removal isn’t 100% successful, some colors of tattoo dye resist removal, and some pigment is too deep for lasers to reach, for example. Certain colors may be easier to remove than others. Blue or black tattoos respond well to laser treatment because they’re better at absorbing light.
There are some types of at-home tattoo removals that aren’t recommended by healthcare providers because they may damage your skin or cause an infection.
Tattoo removal creams are a type of at-home treatment where you rub a cream on your skin as you would a lotion. Tattoo removal creams claim to break down the permanent ink particles in your skin using strong chemicals. The success of tattoo removal creams varies, and many people experience skin irritation after using the cream.
Another type of at-home tattoo removal process is salabrasion, which is the removal of the top layers of your skin using an aggressive salt rub. This type of tattoo removal can cause pain or lead to an infection.
If you want to remove a tattoo, visit a healthcare provider or a dermatologist and don’t try to remove your tattoo on your own at home.
If you’re interested in tattoo removal, start by visiting a primary care provider. They may be able to recommend a dermatologist or surgeon who specializes in tattoo removal. As there are several different choices for tattoo removal, you may want to consider your options by having a consultation with both a surgeon and dermatologist to get their opinions on what type of removal procedure is best for you.
Each type of tattoo removal takes a different amount of time depending on the size, color and location of your tattoo. It could range from a few minutes for laser tattoo removal or a few hours for surgical excision. You may need several tattoo removal sessions, especially if you choose laser tattoo removal. It can take between six and 12 visits and sometimes more before you see results.
Your healthcare provider or surgeon will discuss instructions on how you should take care of your skin after a tattoo removal procedure.
Immediately after treatment, you can apply an ice pack to soothe the treated area. You may need to apply a topical antibiotic cream or ointment to your skin. You should use a bandage to protect the site.
You can shower the next day, but it’s best to avoid scrubbing the affected area. You should also cover the treated area with sunscreen when you go outdoors. Try not to pick at your skin after treatment because it could lead to scarring.
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Techniques for tattoo removal have evolved significantly over the years. The commonly used Quality-switched (QS) ruby, alexandrite, and Nd:YAG lasers are the traditional workhorses for tattoo removal. Newer strategies using combination laser treatments, multi-pass treatments, and picosecond lasers offer promising results. The tattoo color and skin type of the patient are important considerations when choosing the appropriate laser. Standard protocols can be developed for the effective and safe treatment of tattoos.
Tattoos have fascinated mankind from all cultures and strata of society for centuries. From the ancient Egyptian, Greek, and Roman cultures 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. It has been estimated that up to a quarter of young to middle-aged adults in the United States have at least one tattoo.[ 1 ] Results from an online survey group, Harris Interactive, reported a rise in US adult tattoo prevalence from 16% in 2003 to 21% in 2012.[ 2 ] As more tattoos are being acquired, increasing numbers of people are also seeking their removal. The American Society of Dermatologic Surgery reported carrying out 100,000 tattoo removal procedures in 2011, up from 86,000 in 2010.[ 3 ] Motivation for tattoo removal includes new jobs or careers, the need to portray a certain image at work or in new social circles, and new, negative feelings towards old tattoos.[ 4 ] Unfortunately, the removal of tattoos is generally more costly and time consuming than acquiring them.
Amateur tattoos are usually smaller, lighter in color and applied more superficially using handheld needles or homemade machines, which render them easier to remove.[ 5 ] Cosmetic tattoos are often referred to as permanent makeup, and are increasingly popular. Permanent eyeliners, eyebrows, and lip liners are commonly applied using the process of micropigmentation to save time and enhance facial features. However, the inks used often contains pigments that are red, brown, white, or flesh colored; inks containing titanium dioxide and iron oxide[ 6 ] 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.[ 7 ] Tattoos have also been used in the field of medicine, from corneal tattooing, radiotherapy field marking, to medical alert tattoos, where tattoos etched into the skin replaces medical alert jewellery for the purpose of alerting medical personnel during emergency situations.[ 8 ]
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 trauma. Tattoos can broadly be divided into professional, amateur, cosmetic, traumatic, or medical tattoos. Professional tattoos are applied with a tattoo machine into the deeper layer of the dermis, and are applied to be permanent in nature. They generally require repeated treatments to remove.
Historically, the removal of undesired tattoos included destructive techniques such as dermabrasion, salabrasion, chemical destruction, cryosurgery, electrosurgery, and surgical excision.[9,10,11] Such non-selective destructive modalities often result in incomplete removal, and varying degrees of scarring and dyspigmentation. Advances in laser and light-based technology have revolutionized tattoo removal, using various wavelengths to target different colored pigments with relative ease and fewer complications than before.
Quality-switched (QS) lasers have long been the traditional workhorse for the removal of tattoos. The laser treatment of tattoos is based on the concept of selective photothermolysis, where laser light of different wavelengths is preferentially absorbed by different chromophores. If the target chromophore is heated for no longer than its thermal relaxation time (time required for target to lose 50% of its heat), selective destruction of these chromophores can be achieved.[12] In the case of tattoos, the chromophore is exogenously-placed ink, which is found in membrane-bound granules in macrophages, fibroblasts, or mast cells.[13] Such tattoo pigment is very small, and can reach its thermal relaxation time very quickly. Rapid heating with very short pulse durations, in the nanosecond or picosecond range, is therefore required to cause photoacoustic injury and rupture of these pigment-containing cells. Phagocytosis is subsequently triggered and the tattoo fragments are packaged for lymphatic drainage and further scavenged by dermal macrophages, fibroblasts, and mast cells, leading to lightening of the tattoo.
A thorough history and examination are essential in establishing the type of tattoo and the skin type of patient prior to treatment. Previous isotretinoin treatment, systemic gold therapy, herpes infection, keloidal tendencies, and sun exposure habits should be considered, as additional precautionary measures may be needed. Standardized digital photography is helpful in recording the baseline appearance, and any subsequent improvement. The patient's treatment objective and expectation should be counseled, and treatment options, expected outcome, potential risks, downtime, and postoperative care should be discussed. There should be adequate opportunity for patients to have all their questions answered. Obtaining informed consent with a clear outline of risks and benefits prior to tattoo removal is essential, and protects both the clinician and patient. Establishing realistic patient expectations through good rapport is helpful in achieving a satisfactory outcome.
Multiple laser treatments are usually required to remove a tattoo via selective photothermolysis, with an average number of 7-10 treatments are often needed. Kirby et al. published a scale [ ] to better help clinicians estimate the number of treatment sessions needed, which can be a useful aid during patient counselling.[14] In the scale, numerical values are assigned to six parameters: Fitzpatrick skin phototype, location, color, amount of ink used in tattoo, scarring or tissue change, and ink layering. Parameter scores can then be added up to give a combined score that will show the approximate number of treatment sessions needed for successful tattoo removal, plus or minus 2.5.
In addition to establishing a realistic number of treatment sessions needed, it is important to highlight to patients the potential side effects of tattoo removal.
Patients should be counseled that tattoo clearance is often incomplete and a residual tattoo outline and textural changes may be seen [ ]. An online questionnaire with 157 participants post tattoo removal showed that only 38% achieved complete tattoo removal. Local reactions following tattoo removal occurred in 97% of participants, and include blistering, edema, crusting, erythema, and pain. Permanent side effects can occur, and include scarring, hyper- or hypopigmentation [ ], and color change of tattoo pigment. Patients with darker skin type are at a higher risk of complications.[15] Skin textural changes are not uncommon and follow multiple laser treatments post treatment [ ].
Open in a separate windowOpen in a separate windowStrict sun protection measures must be emphasized to all patients. Melanin in the epidermis can compete for the absorption of laser light intended for tattoo removal. This can cause destruction of the melanin containing cells and manifest as dyspigmentation, blistering or scarring. The use of longer wavelengths such as the QS Nd:YAG (1064 nm) in patients with a tan or patients with darker skin types can reduce such absorption by epidermal melanin and reduce the risk of complications.
The area to be treated should be cleansed thoroughly and free from any residual cosmetics or skin care products. Avoid using potentially flammable cleansing agents such as isopropyl alcohol. As removal of tattoos can be painful for the patient, topical anesthetics such as 5% lidocaine cream (LMX-5) and 2.5% lidocaine/2.5% prilocaine (EMLA) are often applied under occlusion for 45-60 minutes. The anesthetic should be completely removed prior to treatment. Other methods of reducing discomfort for the patient include the use of cool air during treatment, local infiltration of lidocaine, regional nerve block, or a combination of these modalities.
All medical personnel must wear wavelength-specific protective goggles during the laser procedure. The patient must also be provided with protective goggles or external metal eyeshields. If the area treated is on the eyelid or near the orbit, intraocular metal eyeshields should be placed for the patient.
In darkly pigmented patients, test spots can be carried out and evaluated at 4-6 weeks for efficacy and side effects. Test spots should also be considered for cosmetic tattoos where paradoxical darkening is likely to be encountered.[6]
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 approximately 20 minutes, and is a result of rapid heating of the chromophore leading to gas formation.[16] The optimal fluence is the lowest possible setting that elicits this endpoint in order to minimize the risk of thermal injury, such as blister formation and scarring. 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. Different wavelengths of laser can be used, depending on the tattoo color treated, previous response to laser treatment, and also skin phototype of the patient. Laser spots (3-4 mm spot sizes are used usually) are applied with approximately 10-20% overlap, aiming for immediate whitening, and minimizing pinpoint bleeding. Laser treatments can be repeated approximately every 8 weeks.
Open in a separate windowGenerally, black and dark blue pigment respond best to Nd:YAG and alexandrite lasers. QS ruby laser tends to be associated with hypopigmentation in dark skin individuals. Colored pigments are generally less responsive to treatment . Green pigment may respond to the alexandrite lasers but is recalcitrant to Nd:YAG lasers [ ].
Open in a separate windowOpen in a separate windowPatients should be appropriately advised to look after the treated area post-tattoo removal. Immediately after treatment, patients should expect the treated area to become red and swollen. Cold compresses can be used to minimise any discomfort. Antibiotic ointment or simple ointment-based emollients can be applied for 10-14 days after. Patients should be counseled that blisters and crusting might occur. If large blisters occur, these can be pricked with a sterile needle and dressed. Possible longer-term adverse effects such as scarring, hyper- or hypopigmentation [ ], and color change of tattoo pigment should also be discussed with patients.
The QS ruby laser (694 nm) was the first commercially available QS laser for tattoo removal in 1983,[17] followed by the QS Nd:YAG laser (532 nm, 1064 nm) and the QS alexandrite laser (755 nm). These are all still used today in dermatology practices. The tattoo color and patient skin type should be taken into consideration when choosing the appropriate laser for tattoo removal. A summary of the different lasers used for treating different tattoo colors are shown in .
Darkly pigmented black or blue tattoos can be effectively treated by QS ruby, QS Nd:YAG (1064 nm) [ ] or QS alexandrite laser.[18,19] Leuenberger et al. compared the three different lasers and found that QS ruby laser showed more significant tattoo clearing after 4-6 treatments compared to the QS Nd:YAG and QS alexandrite lasers. The authors attributed it to the use of a larger spot size in the QS ruby laser, which would afford greater depth of thermal injury to the targeted chromophore. The smaller spot sizes used in the QS Nd:YAG and QS alexandrite lasers may have led to more scatter and more rapid decrease in fluence, and, hence, less effectiveness. Treatment with QS ruby laser however resulted in the highest incidence of hypopigmentation (38% for ruby, 0% for Nd:YAG and 2% for alexandrite respectively). This is due to increased absorption by epidermal melanin at this shorter wavelength, and their resultant destruction. Treatment with the longer 1064 nm wavelength results in minimal absorption by epidermal melanin and allows light to penetrate greater than 2mm in the skin, making it ideal for the treatment of dermal chromophores such as tattoo pigments.[18] In darker skin types where there is heavy epidermal melanin content, QS Nd:YAG laser is the laser of choice to reduce the risks of post-inflammatory hyper- and hypopigmentation post tattoo removal.[20] The importance of a homogenous beam profile and large spot size in attaining better tattoo removal was further highlighted in another study by Karsai et al.[21]
Jones et al. carried out a study on eight skin type VI patients with 15 amateur tattoos treated with the 1064 nm QS Nd:YAG laser at 8 week intervals. After an average of 3-4 treatments, 8 of the 15 tattoos were rated as 75-95% cleared and 5 tattoos rated 50% cleared. Only 2 of the tattoos were associated with slight lightening of the skin. None of the other tattoos had any pigmentary or textural changes.[22] Lapidoth et al. treated 404 Ethiopian patients (skin types V and VI) with blue/black tattoos with the 1064 nm QS Nd:YAG (380 patients) or QS ruby laser (24 patients), and reported a clearance of 75-100% in 92% of patients after 3-6 laser treatments (average 3.6) at intervals of at least 8 weeks. Most of these tattoos were carbon-based and located on the face or neck. Mild hyperpigmentation [ ] lasting 2-4 months was noted in 44% of patients, and mild textural changes in 2 patients. There were no cases of scarring or permanent pigmentary changes.[23]
QS alexandrite laser has also been found to be safe and effective for tattoo removal in darker skin types. Burkhari et al. treated 20 Arabic women with skin type III-IV and achieved more than 95% lightening in 5 patients, and more than 75% lightening in 10 patients. These patients were given 3-6 treatments at 6-12 week intervals. Pinpoint bleeding was observed in one case but no pigmentary alteration or scarring was seen.[24]
The light emitted from the 1064nm QS Nd:YAG laser may be doubled in frequency to produce light with a wavelength of 532 nm. Red, orange, and red-brown pigments respond well to this wavelength.[19,25] Studies comparing the QS 532 nm Nd:YAG have also found it to be superior to the QS ruby and QS 1064 nm Nd:YAG in the removal of red colors in professional tattoos.[26,27]
Both the QS alexandrite and QS ruby laser are effective for the treatment of green tattoos, although the QS alexandrite laser is considered the modality of choice.[19,25] QS alexandrite can therefore be used effectively for the treatment of black, blue or green tattoos [ ]. In addition to black, blue, and green tattoos, QS Ruby also works well for purple and violet pigments.[19]
Cosmetic tattoos or pale-colored tattoos can be more difficult to treat as they often contain red, brown, flesh-colored, and white inks containing iron oxides and titanium dioxide, which may irreversibly turn black after QS laser irradiation.[28] Chemical reduction of ferric to ferrous oxide is thought to be responsible for such phenomenon. Such paradoxical darkening has been successfully treated with further QS laser treatments, sometimes requiring up to 20 sessions.[29,30] Ablative laser resurfacing with pulsed CO2 and erbium-doped YAG lasers have also been successfully used in cosmetic tattoos.[31,32]