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Q: Tattoo Removal ( Answered,   0 Comments )
Subject: Tattoo Removal
Category: Health > Medicine
Asked by: bknowlton-ga
List Price: $100.50
Posted: 09 Aug 2006 09:00 PDT
Expires: 08 Sep 2006 09:00 PDT
Question ID: 754273
I have several tattoos that I would like to have removed. One is very
large and covers my entire left shoulder and upper left arm. I got it
when I was very young and now I have to keep it covered to hide it
from colleagues. I do not know of any lasers that have the power to
remove it effectively. Any info on where to go for effective surgical
removal would be appreciated. Information on other effective removal
procedures and those who provide them would help as well.
Subject: Re: Tattoo Removal
Answered By: crabcakes-ga on 09 Aug 2006 13:35 PDT
Hello Bknowlton,

    One of the problems with removing tattoos, using any method, is
the many different pigment types used in producing the design. Lasers
need to employ different wavelengths to ?zap? each pigment, and this
is a nearly impossible task.  Before lasers, there were other
techniques, such as cryosurgery and abrasion techniques. These have
proven less effective than laser treatment, except in the case of
medical contraindication of laser treatment for some patients.

   ?Depending on the size of the tattoo, a treatment session lasts
about 15 to 30 minutes and sessions are repeated no more frequently
than every two months. Amateur tattoos, which usually consist of a
single pigment color, are typically removed after three to six
sessions. Professional tattoos, which often have more elaborate
designs or use multiple pigments, require about six to 10 sessions to
be removed by laser.

While side effects of laser treatment are generally minimal, they can
include scarring, loss of natural skin pigmentation, and residual
tattoo pigment. ?Anyone considering having a tattoo removed by laser
surgery needs to be aware that it can be a painful, timely and costly
procedure,? said Dr. McBurney. ?However, in the skilled hands of a
dermatologist or dermatologic surgeon, lasers are still the best
option for people who want to safely remove an unwanted tattoo.?

?The older the tattoo, the more likely it is that pigment will have
migrated widely and deeply under the skin. Thus, some "old" tattoos
may not be completely removable by any means other than wide and deep
surgical excision. If surgery is agreed upon as the best treatment,
patient and physician should discuss the probable extent of the
surgical scar and how the scar can be minimized.?

?Color-specific lasers remove tattoos by color-specific absorption of
laser energy by pigments in the tattoo. Destruction is limited to
pigments of the same color (wavelength) of the laser beam, and at
tissue depths were the laser beam can penetrate. It may be necessary
to use several color-specific laser beams over several subsequent
treatments to remove pigment from a multi-colored tattoo. Q-switching
technology that delivers short, powerful laser pulses has improved the
effectiveness of color-specific lasers in tattoo removal.?

   ?The Q-Switched laser has produced the best results. Q-Switched
means that the laser is very quickly pulsed this is why it is able to
dissolve the tattoo ink without destroying the skin. Photo Derm or
multi light systems may fade the tattoo but will almost certainly
leave a scar because the pulse duration is too long which in turn will
cause thermal damage to the surrounding skin. The only visible damage
is absorbed by the ink.?

   ?A good candidate for tattoo removal in a timely fashion without
scarring is medium to fair skin, dark but not dense ink(black/brown),
superficial depth of ink and the preferred locations are the arm,
chest, buttocks, anywhere with good circulation. Medium or fair skin
patients react well because the light will be able to selectively
target the ink instead of the dark skin. Dark ink that is not dense is
favorable because the light is more attracted to darker colors so
darker ink is fragmented better than yellow ink. Density is also a
factor, the more ink, the more there is to fade. Superficial ink is
also favorable because it is closest to the surface of the skin so the
laser doesn't need to penetrate so many skin layers to get to it.
Results are quicker. Areas such as the arm or chest have more blood
flow and are a better vehicle for the immune system which is what
removes the ink. Areas such as the ankle or fingers have poor

  The best removal method depends on several factors; the type of
tattoo (amateur/homemade or professional), the age of the person, the
placement of the tattoo, and skin type. Amateur tattoos are simpler to

  There are three types of lasers currently employed for tattoo
removal, and it?s not unusual for a patient to need two or more
methods for the best removal of all pigments. Q-switched ruby laser,
Q-switched Nd:YAG laser, and Q-switched alexandrite laser are the
three types.

?The Q-switched ruby and alexandrite lasers are useful for removing
black, blue and green pigments. The Q-switched 532nm Nd:YAG laser can
be used to remove red pigments and the 1064nm Nd:YAG laser is used for
removal of black and blue pigments.?

   ?Q-Switched laser treatments make the pigment particles small
enough to be removed much more quickly. Multiple treatments, given
about one month apart are necessary for best results.
The greater the absorption of the laser light, the greater the energy
available to break up the pigment:
?	Black ink absorbs all wavelengths of light 
?	Green and Blue ink absorbs red light best 
?	Red, Orange, and Purple ink absorb green light best 
?	Turquoise responds variably, depending on the pigments in the ink 
?	Yellow tends to reflect light and is difficult to treat. 
The actual absorption of a given tattoo ink may vary considerably
depending on the particular pigments in the ink, which are usually not
known to the patient or tattoo artist. Also, the chemical pigments may
undergo chemical changes after treatment. These factors often leads to
variable and or inconsistent responses of a give color to a given
laser wavelength.?

   ?As with any procedure, certain risks exist with each treatment.
They include but are not limited to temporary pigmentary changes in
the skin (hyperpigmentation or hypopigmentation), infection, and
scarring. Fortunately, complications resulting from laser tattoo
removal are uncommon when performed by an experienced physician and
rarely result in long-term effects.

Treatment with the laser tattoo involes tracing the tattoo with the
laser. This leads to the formation of a thin white crust over the
treated area immediately following and some pinpoint bleeding. In our
office local anesthesia is administered to the area prior to each
treatment to increase the patient's comfort level. The treated area
will then require some daily light wound care to prevent infection
encourage healing. Typically the area is healed in about 8 to 12 days.

Cost of the procedure varies with the size and type of tattoo. Expect
to spend about 5 to 10 times or more to remove the tattoo than it cost
to have it put in your skin.?

   ?Several comparative studies have been performed by using different
lasers on the same tattoos. A comparison of the QSRL and Nd:YAG lasers
found them equally effective in removing black ink; however, the QSRL
was more effective in removing green ink. A second comparison of the
QSRL and Nd:YAG lasers was limited to 1 treatment session, and a
similar response was noted. After 1 month, the Nd:YAG caused more
textural change and hyperpigmentation than the QSRL (possibly related
to the smaller spot size used), and the QSRL caused more
Comparisons between the QSRL and alexandrite lasers revealed that the
QSRL removed more pigment but caused more textural change,
hypopigmentation, and hair loss. A comparison at 2-3 treatment
sessions may not be optimal because only 50-60% of the tattoo has been
removed and the speed and efficacy of tattoo removal, as well as the
avoidance of textural changes, scarring, hair loss, and pigment
alterations, must be examined.

In summary, Q-switched lasers provide a dramatic improvement over
previous modalities for tattoo removal. Appropriate wavelength choice
facilitates clearing of multicolored tattoos. Approach cosmetic
tattoos with caution. In addition, exploration into picosecond lasers
is underway, which may further enhance our ability to treat tattoos.?

   ?A technique for tattoo removal which produces selective removal of
each tattoo pigment, with minimal risk of scarring, is needed.
Nonspecific methods have a high incidence of scarring, textural, and
pigmentary alterations compared with the use of Q-switched lasers.
With new advances in Q-switched laser technology, tattoo removal can
be achieved with minimal risk of scarring and permanent pigmentary

Q-Switched Ruby Laser

  On this clinic?s web site, you can see some before and after tattoo
removal pictures, as well as an illustration on how the Q-switched
ruby laser works.

   ?The ruby laser has been used successfully in over 10,000
treatments and it is the only laser to have received FDA approval and
clearance for the treatment of all benign pigmented skin
discolorations, tattoos, and both dermal (deep) and epidermal
(superficial) skin growths and marks. Scarring is not a significant
risk. In fact, the ruby laser has been named the treatment of choice
for tattoo and pigmented lesion removal by members of the American
Academy of Dermatology. The dermatologists at the Skin Laser Center of
Advanced Dermatology P.C. and The Center for Laser and Cosmetic
Surgery have received specialized training in laser treatments and
have successfully used the Ruby laser on their patients. Some have
even treated their own skin conditions with excellent results.?

?In darker skinned people the area treated by the laser may become
lighter (or occasionally darker) than the surrounding skin for a
period of months. Eventually this area will almost always be restored
to its original color. Scarring is most unlikely.?

   ?Improved self-image and social stigmatization are the main reasons
for removing tattoos from skin. Q-switched lasers are applied to
destroy the tattoo compounds in the skin. The treatment of tattoos
containing ink often gives excellent results, whereas the results of
treatments for coloured tattoos are not predictable and usually are
worse. The chemical structure and the absorption spectra of the tattoo
pigments are usually unknown. However, the efficacy of the treatment
by using light of different Q-switched lasers (wavelengths 510, 532,
694, 755, 1064 nm) is correlated to both the chemical structure of the
tattooed compounds yielding specific absorption spectra and the laser
wavelength used.?

   ?The Q-switched ruby laser was found to be superior in lightening
black dye in both professional and amateur tattoos. A significant
advantage was noted for the ruby laser in the removal of green tattoo
pigment. The differences with the Q-switched ruby laser and the 1064
nm option of the Q-switched YAG laser were not clinically significant
in the lightening or removal of other colors. The 532 nm option of the
Q-switched YAG laser was superior to the Q-switched ruby and the 1064
nm option of the YAG laser in the removal of red tattoo colors in
professional tattoos. Hypopigmentation was found more commonly with
the Q-switched ruby laser, while textural change was noted more
commonly with the Q-switched Nd:YAG laser. One of the patients treated
with the Nd:YAG laser at 1064 nm showed a hypertrophic scar.?

   ?Using identical parameters for professional tattoos, there was
complete pigment removal in two, nearly complete pigment removal in
five, significant pigment removal in 18, minimal pigment removal in
25, and very little pigment removal in 12. Professional tattoos with
red, yellow, and green pigments faded, but required multiple
retreatments. While transient hypopigmentation occurred in many
patients, skin texture and hair growth returned to normal in all cases
and no hypertrophic scarring was seen.?

   ?All of these Q-Switched Lasers cause discomfort during treatment,
similar to being "snapped" with a rubber band, which fades within
minutes. Some areas are more sensitive than others, such as the ankle
and shoulderblade. Most patients equate the pain of removal with the
pain of getting the tattoo. As treatments progress, the pain decreases
because there is less pigment to absorb the laser energy. Anesthetic
creams such as Topicaine, EMLA, or ElaMax, available without
prescription, can be applied between 1 and 4 hours before treatment
for very effective "needle-less" anesthesia.?

   ?The Q-switched ruby laser emits short pulses of intense red light
which pass harmlessly through normal skin where it is selectively
absorbed by the tattoo ink. The laser energy breaks the tattoo ink
into minute particles that are easily removed by your body's immune
system. Any large particles of ink that are not completely fragmented
may require additional treatments, and the tattoo gradually fades.
Normal skin is not harmed by the treatment. Only the ink is removed,
and your skin is left intact.?

Alexandrite laser

   ?Frequently, the initial treatment session produces a more dramatic
response than subsequent sessions. Definite sites of clearing,
corresponding to laser impacts, are often seen. Other tattoos are
highly unresponsive during early treatment phases, although biopsy
samples reveal fragmentation of tattoo granules. The response
difference from one patient to another likely involves the efficiency
of mobile macrophages in removing fragmented tattoo pigment debris, as
well as the density and amount of tattoo pigment present. The speed of
the macrophage response, as well as the maximum amount of pigment
removed per session, likely varies from patient to patient and, to
some extent, from treatment to treatment. The more superficial the
tattoo pigment and the less the total volume of pigment, the fewer the
number of treatments necessary to remove the pigment.

In contrast to anecdotal reports about the QSRL and the Nd:YAG laser,
new Q-switched alexandrite-treated tattoos clear faster, possibly
because the location of newer tattoos is more superficial. New tattoos
have sharp lines with bright colors; whereas, older tattoos are
blurred, with indistinct lines and duller, bluer colors, presumably
resulting from ink movement deeper into the dermis. Further studies
are underway to explore these observations.?

   ?We describe the clinical and histologic effects of the use of a
new Q-switched laser for treatment of tattoos, the alexandrite laser
(wavelength, 755 nm; pulse width, 100 nanoseconds). The results of
treatment of 17 patients with professional tattoos and eight patients
with amateur tattoos are analyzed. Greater than 95% removal of tattoo
pigment averaged 8.9 treatment sessions. Transient hypopigmentation
occurred in approximately 50% of patients, and transient textural
surface changes occurred in 12%. CONCLUSIONS: The alexandrite laser is
a safe and effective treatment modality for removal of black and
blue-black tattoo pigment.?

   ?Different laser intensity should be used for pigments at different
depths in order to minimize the collateral damage to the dermis.
Lasers Surg. Med. 30:389-397, 2002.  2002 Wiley-Liss, Inc.?

Q-switched Nd:YAG laser

?The Q-switched Nd:YAG laser is somewhat more effective in removing
black ink, creating rare textural changes and almost no
hypopigmentation. These improvements are attributable to the longer
wavelength, higher fluence, and shorter pulse width. These same
factors cause more bleeding and tissue splatter during treatment,
making the treatment more cumbersome. The faster repetition rate (1-10
Hz) shortens the treatment session, although this is somewhat
counterbalanced by the smaller beam size (4 mm vs 5-6.5 mm for the
QSRL). Currently, larger spot sizes up to 6 mm are available with new,
higher-powered Nd:YAG laser systems, which also enable deeper
penetration and more effective treatment of deeper, denser tattoos.
Better beam profiles minimize epidermal damage and decrease bleeding,
tissue splatter, and transient textural changes. Often, little wound
care is needed.?

Surgical or Shave Excision
   From my research, it appears that surgical excision works best on
small tattoos, and not of the kind you describe; tattoos that cover a
large area of the body.

?The surgeon removes the tattoo with a scalpel and closes the wound
with stitches. This technique proves highly effective in removing some
tattoos and allows the surgeon to excise inked areas with great

   ?If the tattoo is relatively small and/or easily accessible and
cosmetically in an inconspicuous area, the entire tattoo can be
surgically cut out (or excised), and the skin can be sutured closed
with stitches. This can be done in a single treatment session, or in
several treatment sessions involving a "staged" or serial excision
technique. This surgical technique is done in the office under local
anesthesia. ?

   ?Surgical removal may be an option for small tattoos. Surgery also
can be used for the removal of larger tattoos, but this may involve
the need for multiple surgeries and skin grafting.?

   ?Excision: For a small tattoo, excision involves removing the
tattooed area of skin and then stitching it closed. For a larger
tattoo, the skin is removed and a skin graft from another part of the
body is used to cover the area.?

   ?Question: My name is Ricky and I am wondering if there is any type
of sugery that will remove a 1 1/2 inch tattoo of a green shamrock on
my ankle?
Reply: Consult a plastic surgeon about laser surgery.

   ?Split thickness tangential excision is a simple means of tattoo
removal with very acceptable cosmetic results. The technique has
several advantages. (1) The depth of skin removal may accurately be
controlled as the tattoo pigment is excised with a dermatome. The
major portion, if not all of the remaining pigment, is extruded and
sloughs with the crust. (2) Scar formation, if it occurs at all, is
negligible. (3) No donor site is created. (4) The procedure may be
carried out rapidly without admitting patients to hospital, is
inexpensive for patients and conserves time for physicians.? You can
download the entire article on this site.

   ?Nine patients with tattoos were treated with cultured epidermal
autografts. The tattoos were excised down to the deep dermal layer,
and the wounds were covered with cultured epidermal autografts. The
areas grafted with cultured epidermal autografts were an average of
907 cm2 in size. The average percentage "take" of the cultured
epidermal autografts was 86%. The average time for complete wound
epithelialization was 20 days. The pain at the grafted sites was
minimal. There was minimal scarring and no tendency for scar
contracture. The appearance and elasticity of the grafted sites
resembled those of adjacent normal skin 2 1/2 years after grafting.
These findings demonstrate that cultured epithelium autografting is a
suitable method for coverage of the tangentially excised tattoo

?At 3 months posttreatment, four patients had no significant scarring
and three patients retained only scattered flecks of tattoo pigment.
Each patients demonstrated migration of the deeper dermal pigment to a
more superficial level. CONCLUSION. A superficial, tangential excision
of a professional tattoo by a Brown dermatome is a viable, low-risk,
inexpensive procedure.?

Additional Useful Information:

See page 43

Surgical Excision information

   It appears from my research, that for your larger tattoos, one of
the Q-switched lasers would be your best bet. Still, please check with
your dermatologist, who best knows what type will be best for your
tattoo, skin, age, and medical condition, and who can recommend
someone in your area. (Especially since I don?t know where you live!)

   I would recommend looking for a laser surgeon, and not a
cosmetologist, if you opt for laser. Ask your doctor for someone s/he
recommends.  This website recommends calling 1.800.532.1067 to locate
a laser surgeon in your area.

If you opt for surgical excision, for smaller tattoos, again, ask your
doctor for a cosmetic/plastic surgeon recommendation. If it were me, I
would want a dermatologic surgeons who is board-certified.

Another tattoo removal surgeon site:

   There you go! If I have omitted anything you wanted to know, or if
anything is unclear, please request an Answer Clarification, and allow
me to respond, before you rate.

I wish you the best!

Sincerely, Crabcakes

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