7)Light-Based Tattoo Removal...Tattoo Results Professional Tattoo - Tattoo had been placed for only two weeks when patient wanted it removed. New tattoos are the most difficult to

©Sharon McQuillan, MD. All rights reserved. 1

Light-Based Tattoo Removal

Sharon McQuillan, MD

Tattoo Removal Sharon McQuillan, MD

The following potential conflict of interest relationships are

germane to my presentation.

Speakers Bureau: Sciton Laser, Allergan, Medicis, Bioform Medical, Hoya Con Bio

Tattoo Incidence

•  3-8% of the general population •  19-23% in the 16-35 year age range •  50% eventually regret getting the tattoo

Goldstein, N. Psychological implications of tattoos. J Dermatolog Surg Oncol 1979; 5:883.


Tattoos and Tissue •  Dermal injection of submicronimeter particles taken

up by phagocytes •  Immediately upon injection, ink found in

keratinocytes, phagocytes, fibroblasts, macrophage, and mast cells

•  At one month, ink particles are present in epidermal basal cells and are surrounded by collagen

•  Fibroblat is responsible for lifespan of tattoo •  Eventually, tattoo ink migrates to deep dermis and

lymph nodes Christensen, He Schmidt, H. The ultrastructure of tattoo marks. Pathol Microbiol Scand 1972; 80A:573.

Pigments Used by Tattoo Artists

•  Black: carbon, iron oxide •  Green: chrome oxide, malachite green •  Red: mercury sulfide, cadmium selenide •  Yellow: cadmium sulfide, curcumin yellow •  Brown: ochre •  Violet: manganese violet •  White: titanium dioxide, zinc oxide •  Flesh: iron oxide Everett, MA. Tattoos: abnormalities of pigmentation. In: Clinical dermatology, vol 2, units 11-21.

Hagerstown, MD: Harper & Row,; 1980.

Tattoo Removal Techniques

•  Mechanical

•  Chemical

•  Thermal


Mechanical Tattoo Removal

•  Salabrasion

•  Dermabrasion

•  Surgical Excision

Salabrasion

•  Abrade superficial dermis past bleeding point with coarse table salt and moist gauze pads

•  Salt then placed on wound and covered with surgical dressing for 24 hours

Dermabrasion

•  Spinning “fly wheel” used to remove skin to papillary dermal depth

•  Minimizes scarring but leaves significant pigment

•  Many treatments required


Surgical Excision

•  Physical cutting of tattooed tissue as a form of removal

•  Often done by incision, scratches, puncture, and criss cross incisions

•  Often accompanied by extensive wound healing, skin grafts

Disadvantages of Mechanical Tattoo Removal

•  High risk of hypertrophic scarring

•  Residual tattoo pigment

•  Tissue distortion

Chemical Tattoo Removal

•  Caustic chemicals –  Tannic acid –  Silver nitrate –  Phenol –  TCA


Disadvantages of Chemical Tattoo Removal

•  Hypopigmented scarring

•  Require repeat applications, increasing the likelihood of burns and skin grafts

Laser Ablation of Tattoos

•  Argon •  Carbon Dioxide •  Pulsed Dye •  Q-switched Ruby •  Q-switched Nd:YAG •  Q-switched Alexandrite

Selective Photothermolysis

Tattoo Ink Example - The specific color of the ink is targeted by the correct wavelength. The high energy, short pulse of light hits only the targeted chromophore, breaking it up into minute particles without harming the surrounding skin. The body’s own natural cleansing system is then able to remove the fine particles.


Argon Laser

•  Results comparable to CO2 •  Low power •  Results in inefficient pigment removal •  Multiple treatment sessions necessary •  High incidence of hypertrophic scarring

Apfelberg DB et al. Argon laser treatment of decorative tattoos. Br J Plast Surg 1979;32:141.

Carbon Dioxide

•  High fluence results in tissue vaporization •  More efficient than argon •  Pigment removed by vaporization, thermal necrosis,

and loss of pigment in healing phase

Bailin PL et al. Removal of tattoos by carbon dioxide laser. J Dermatol Surg Oncol 1980;73:298.

Q-Switched Ruby

•  Effective in removing tattoos with minimal scarring •  Multiple treatment sessions necessary •  Hypopigmentation possible •  High fluences and shorter pulses are more

effective, but cause more nonspecific tissue damage

•  Effective for black, blue-black, and green ink Levine VJ and Geronemus RG. Tattoo removal with the Q-switched ruby

laser: a comparative study. Cutis 1995; 55:291-96.


Q-Switched Nd:YAG

•  Effective for removal of black ink •  More beneficial for darker skinned patients •  Treats tattoos quickly and often in one or two

treatments •  Blistering and purpura can occur

Kilmer SL, Anderson RR et al. The Q-switched Nd:YAG laser (1064 nm) effectively treats tattoos: a controlled dose-response study. Arch Dermatol 1993; 129:971-78.

Q-Switched Alexandrite

•  Effective and safe for removing blue, black, green pigment

•  4-10 treatments required at 1-2 month intervals

•  Transient hypopigmentation common

Alster, T. Q-switched alexandrite (755 nm) treatment of professional and amateur tattoos. Journ Am Acad Dermatol 1995; 33:69-73.

Wavelength Summary

•  Dark blue/black ink –  755 nm Q-switched alexandrite (types I-III) –  1064 nm Q-switched Nd:YAG (types IV-VI)

•  Green ink –  694 nm Q-switched ruby (types I-III)

•  Red ink –  532 nm Q-switched Nd:YAG (types I-III)


Chart courtesy of Sciton Laser Inc.

Laser Absorption vs. Wavelength

532 1064 585 694 810 755

1

10

100 Melanin

Hemoglobin

FD Nd:YAG Pulsed Dye Ruby Alex Diode Nd:YAG

Wavelength (nm)

Absorption

Important for hair removal and epidermal safety

Important for vascular treatments

Patient Selection

•  Fitzpatrick skin type I-III

•  No sun exposure

•  Tattoo present for one year or more

Treatment Considerations

•  Type of tattoo (professional, amateur, cosmetic, medical)

•  Date placed •  Types of ink/dye used •  Use of white in ink in any colorations or mixtures •  Prior attempts at removal/alteration •  History of herpetic outbreak


Contraindications

•  Use of retinoids •  Sun exposure •  History of keloids •  Unrealistic expectations

Pre-Treatment Guidelines

•  Avoid Retin-A, AHA, glycolics one week prior to treatment

•  Avoid sun exposure, tanning, self-tanning products two weeks prior to treatment

•  Use sunscreen SPF 30 or above on treatment areas •  Shave area 24 hours prior to treatment (if

applicable) •  Prophylax with anti-viral if patient prone to herpetic

outbreak

Clinical Endpoint

•  Tissue whitening •  Pinpoint bleeding •  DO NOT DOUBLE PULSE


Post-Treatment Guidelines

•  Apply polysporin ointment and non-stick gauze dressing

•  Wash and change dressing twice daily •  Dry crust will form within 5-14 days •  Bruising and swelling common and will

resolve in 7-10 days •  Follow up treatment 6-8 weeks

Tattoo Removal Before & After Photos

Tattoo Results

Professional Tattoo - Four Treatments


Tattoo Results

Professional Tattoo - Tattoo had been placed for only two weeks when patient wanted it removed. New tattoos are the

most difficult to remove.

Tattoo Results

Images Courtesy of Bruce Saal, M.D., Los Gatos, CA

Tattoo after multiple treatments.

Tattoo Results

Professional Tattoo - No previous treatment. Very good results with several 1064 nm treatments.

Photos Courtesy of Dr. Suzanne Kilmer, M.D., Sacramento, CA


Tattoo Results

Amateur Tattoo - No previous treatment. Very good results with one treatment, patient was satisfied and did not return.

Tattoo Results

Traumatic Tattoo - No previous treatment. Very good results with treatments at 1064 nm.

Photos Courtesy of Dr. Suzanne Kilmer, M.D., Sacramento, CA

Tattoo Results Professional Tattoo - Red & black ink. 90% of clearing was obtained with one treatment at 532 nm, 5 J/cm2. One additional treatment cleared the red. The black was cleared with 3 treatments at 1064 nm.


Tattoo Results

Images Courtesy of David J. Sire, M.D., Fullerton, CA

Typical tattoo after multiple treatments.

Tattoo Results

Amateur Tattoo - No previous treatment. Very good results with one treatment at 1064 nm.

Tattoo Results

Images Courtesy of Larry Weinstein, MD, Chester, NJ


Tattoo Results

Professional Tattoo - Multicolored. This tattoo received 11 treatments of a combination of 532 nm and 1064 nm.

Tattoo Results

Professional Tattoo - Multicolored, no previous treatment. Treated once at 532 nm and 1064 nm.

Tattoo Results

Professional Tattoo - No previous treatment

Before After 4 Treatments at 1064 nm

After one more treatment at 1064 nm

Final results Total of 6 sessions: 5-1064nm treatments 1-532 & 1064nm treatment


Cosmetic Tattoo Removal

1 treatment, 7 months Post Op, 1064nm, 3mm, 2Hz, 7.1-7.7J/cm2"


1 treatment, 11 months Post Op, 1064nm, 3mm, 2Hz, 7.7J/cm2"





1 treatment, 1064nm, 3mm, 5Hz, 7.3J/cm2"


2 treatment, 10 months Post Op, 1064nm, 3mm, 1Hz, 3.8-4.0J/cm2"




Tattoo Removal Side Effects & Complications

Side Effects

•  Pain •  Bruising •  Swelling •  Blisters •  Scabbing

Complications

•  Allergic Reaction •  Hyperpigmentation •  Hypopigmentation •  Tattoo darkening •  Infection


Allergic Reaction

•  Most serious complication •  Localized and systemic reactions can occur

due to ink components –  Metal salts –  Mercury derivatives

Goldberg DJ. Complications in Cutaneous Laser Surgery. Taylor & Francis 2004: p.88.

Pigmentation

•  Transient hypopigmentation common and generally resolves

•  Transient hyperpigmentation common in darker skin types and generally resolves

Kilmer SL et al. Hazards of Q-switched lasers. Lasers Surg Med Suppl 1993; 5:56.


Hyperpigmentation

Treatment with Q-switched Nd:YAG laser



Hyperpigmentation

Tattoo Darkening

•  Seen in tattoos that are red, pink, and flesh colored –  Ferric oxide component in inks converts to ferrous oxide

when reduced resulting in black discoloration •  Also seen in tattoos that have white ink or a mixture

of white and another color –  Titanium dioxide reduction causes blue discoloration

Tope W et al. Tattoo ink darkening: the effect of wavelength, fluence, and pulse duration. Lasers Surg Med 1994; 15:364.

Documents

7)Light-Based Tattoo Removal...Tattoo Results Professional Tattoo - Tattoo had been placed for only two weeks when patient wanted it removed. New tattoos are the most difficult to