CHAPTER 55 Lasers

Tattoo Removal

Decorative tattoos have been a part of human history for thousands of years (Fig. 55-1). The recent discovery of a tattooed, 5000+-year-old, frozen, early European in a glacier in Italy clearly supports this fact. If tattoos have been placed in the skin for over 5000 years, clinicians have likely been trying to remove them for the same amount of time.

Figure 55-1 A, Prison tattoos, Utah State Prison. B, Tattooed pig. C, Tattoo convention, Berlin, 2007.

It is estimated that 50% or more of all people with tattoos will eventually want them removed completely. Approximately 40% of all tattoo removal patients do not want to remove all of the tattoo ink. They in fact desire only to change the existing tattoo and have a new tattoo placed over the old tattoo.

Tattoo Types

Amateur tattoos or home tattoos are usually black tattoos based on “India ink.” The carbon-based India ink dyes are, fortunately, the easiest to safely remove. Amateur tattoos are often placed in the dermis by simply dipping the end of a needle into the ink and then dotting the skin to form a design or pattern. The depth of the ink in the dermis is very imprecise. Therefore the density and uniformity of the ink in the design are often very uneven (Fig. 55-2).

Figure 55-2 Amateur tattoo. Before (A) and after (B) treatment with HOYA ConBio Revlite, 6.5 J, 6-mm spot size, 1064 nm.

Professional tattoos are placed using a repetitively oscillating needle, which in skilled hands will place the ink at a relatively consistent depth in the dermis. Uniform depth can be an advantage for the removal process; therefore, one would think that professional tattoos would have a more consistent removal success rate. However, with professional tattoos, the various colors and the density of the ink complicate the removal process (Fig. 55-3).

Figure 55-3 Professional tattoo. Before (A) and after (B) seven treatments over 18 months with VersaPulse-C, 1 to 3 J, 3-mm spot size, 1064 and 532 nm.

Cosmetic tattoos or permanent cosmetics such as lip liners, eyelid liners, and eyebrow color enhancement pose unique challenges when being removed because of location and variety of mixed colors (Fig. 55-4).

Figure 55-4 Cosmetic tattoo. Before (A) and immediately after (B) one treatment with HOYA ConBio Revlite, 1.5 J, 4-mm spot size, 1064 nm.

Traumatic tattoos are most often the result of an explosion (gunpowder embedded in the skin) or a bicycle or motorcycle accident (asphalt/tar embedded in the skin). Scar tissue often surrounds the embedded particles. The particles are not too deep and can usually be easily removed with a quality-switching (QS) laser (Fig. 55-5).

Figure 55-5 Traumatic tattoo. Before (A) and after (B) 18 treatments over 24 months with VersaPulse-C, 1 to 3 J, 3-mm spot size, 1064 nm.

(Courtesy of Richard Burmeier, MD, Perfect Skin Laser Center, Tempe, Ariz.)

New Tattoo Pigments

Ink recently developed by Freedom-2, Inc., LLC,* if accepted by the tattoo community, will be much easier to remove. In my area, there are approximately 500 tattoo artists. Many have expressed their reluctance to make tattoos a temporary expression of their art, but may use it for some tattoos (e.g., for names). Freedom-2 ink’s microencapsulated biocompatible materials address concerns related to adverse skin responses, allergic reactions, infections, inflammation, and adverse systemic reactions. The application of Freedom-2 ink is consistent with today’s tattoo technology. However, Freedom-2 ink consists of safe, resorbable pigments microencapsulated in clear, stable polymer beads. Freedom-2 ink can be easily and quickly removed using current laser technology in a much more effective manner than current permanent ink options (see later).

Former Treatment Methods

Until recently, all tattoo removal modalities resulted in disfiguring scars. In the past, the most popular options included salabrasion (salt-based dermabrasion), mechanical dermabrasion, CO₂ laser ablation, and infrared photocoagulation.

Laser Treatment and Removal

Fortunately, the majority of tattoos are still predominantly composed of black ink. However, vibrant colors are becoming more popular and are more difficult to remove. There are three common QS lasers that are frequently used for removing tattoos: the q-switched ruby laser (QSRL; 694-nm red), the q-switched Nd:YAG laser (QSYL; both 1064-nm infrared and 532-nm [FD-QSYL] green wavelengths), and the q-switched alexandrite (QSAL; 755-nm red) laser. Quality-switching (QS), sometimes known as giant pulse formation, is a technique by which a laser can be made to produce a pulsed output beam. The technique allows the production of light pulses with extremely high (gigawatt) peak power, much higher than would be produced by the same laser if it were operating in a continuous-wave (constant output) mode.

All three of these lasers have strong absorption by black ink. The color of the ink will determine the wavelength of laser needed (Fig. 55-6). The amount or density of the ink and the depth of the ink will determine the approximate number of treatments required. The QSYL has been the dominant laser used for removing tattoos. QSYLs, by design, produce shorter, higher peak power pulses than either QSRL, and the QSYL can also produce two very useful output wavelengths. The MultiLite Dye Laser Handpieces, compatible with HOYA ConBio Revlite and C6 lasers, convert the 532-nm wavelength to either 585 nm or 650 nm, effectively offering two additional wavelengths. Candela’s AlexTriVantage offers the “Laser-Pumped-Laser” technology with new handpieces that convert the 755-nm wavelength to 532 nm or 1064 nm to improve removal of “all tattoo colors.” The choice of an appropriate laser may depend on the prevalence of the type/color of the majority of the tattoos seen in the practice. The QSYL has become popular because of its ability to treat black, red, orange, and blue inks. The QSYL pulses faster than the ruby- or alexandrite-based laser, so more surface area can be treated in less time.