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The prevalence of tattoos has increased dramatically over the past several years With continued improvement in colors, including fluorescent and glowing inks, this trend should be expected to continue The more tattoos placed, the more that will need to be removed In the past, laser tattoo removal involved the nonspecific ablation of the skin overlying the tattoo, resulting in removal, but also pigment alterations, and even scarring Nonselective removal devices/procedures include the CO2 laser, the argon laser, and dermabrasion Currently, tattoo removal is performed primarily via selective photothermolysis, using the tattoo ink as the target chromophore for the laser Each color of ink is absorbed by a different wavelength of light, and hence the more ink colors in the tattoo, the more difficult it is to remove With
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the recent introduction of new inks and new colors, complete removal of modern tattoos is becoming more and more difficult Cosmetic tattoos are usually a blend of several different inks, rendering them extremely challenging to remove with laser Professional tattoos typically place ink in the mid-dermis, requiring a device that can penetrate to this depth in order to achieve adequate treatment Amateur tattoos typically use less ink and placement is more superficial, making them easier to remove Just as in removal of melanosomes from the skin, removal of tattoo ink must be achieved with a very short pulse-width system, in the nanosecond range These systems are the Q-switched laser devices, of which three are currently available on the market: the Q-switched ruby, the Q-switched alexandrite, and the Q-switched Nd:YAG The ruby was the first Q-switched system available, and at a wavelength of 694 nm, it is good for removing blue and black pigments3 The alexandrite (755 nm) is also very effective at removing blue and black tattoo pigments4 In addition, it has the unique ability to remove green, which is historically one of the most difficult colors to eliminate The alexandrite is the gold standard for removal of green tattoos, in fact, as the other two Q-switched lasers tend to perform inadequately in this area5 The Nd:YAG (1064 nm) is the workhorse for professional tattoo removal because of its capacity for deep penetration It is used for the basic black ink seen in both amateur and professional tattoos The frequency-doubled Nd:YAG (532 nm) can be used for red pigments Generally a combination of these lasers is needed for successful removal of a tattoo Even then, residual ink or a shadow of the tattoo may persist despite numerous treatment sessions The most important aspect of tattoo removal is setting realistic expectations for the patient from the beginning Laser tattoo removal is not an eraser, as many tattoos will not be completely removed no matter how many treatments are performed In addition, there are reports of some tattoo inks actually darkening because of oxidation of the tattoo particles This may result in an ink that is unremovable Test spots are important especially in cosmetic tattoos For the removal of professional tattoos, six to ten treatments, spaced at least 6 weeks apart, may be required For amateur tattoos, three to five treatments are generally effective6 In patients with darker skin types, tattoo removal may result in scarring or dyspigmentation Many authors
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advocate the use of topical bleaching agents prior to sunscreen to reduce the competing chromophores (skin melanosomes) With every patient, regular use of sunscreen in the treatment area is essential Any patient with a tan in the area of treatment should not be treated Wound healing and postoperative care are also essential parts of laser tattoo removal Moist wound healing via topical emollient creams and a dressing are recommended for all patients for 1 to 2 weeks after laser treatment Straying from this regimen will increase the risk of postinflammatory changes and scarring, and delay additional treatments The future of tattoo removal may be represented by Q-switched devices that emit picosecond pulses, which would be even shorter than the currently used nanosecond devices In addition, the introduction of dissolvable inks or more easily removed inks may improve the treatment of tattoos
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