Types of Tattoo
Just as important as patient selection is evaluation of the lesion itself. Tattoos can be divided into amateur, professional, cosmetic, medical, and traumatic categories.
Decorative tattoos are tattoos placed on the skin as a decoration. These are the most common type of tattoo. Some are homemade with needle and India ink; (amateur), others are professionally applied with a tattoo gun using one or more colors of tattoo ink (professional). Professional tattoos are deeper, contain more ink, and usually need extra treatments. Tattoo artists have been pushing the limits of creativity and design to create fascinating works of art making them unique and special. The classic types of tattoos such as amateur tattoos have paved way to highly complex multi-coloured professional tattoos with the current trend being 3D tattoos, optical illusion tattoos, head mandala tattoos, foot tattoos, miniature portraits, etc.
Cosmetic tattoos are also known as micro- pigmentation or permanent cosmetics. This type of tattoo is used as permanent eyeliner, lip liner, lipstick, and other permanent cosmetic purposes. This type of tattoo is also used to cover skin pigment disorders, scars and other blemishes. Cosmetic tattoos using skin-colored tones are important to distinguish, as are medical tattoos such as those used as radiation markers.
Traumatic Tattoos are foreign substances, such as dirt, that are embedded in the skin through an accidental injury. For traumatic tattoos, it is important to understand the nature of the injury that caused it so as to be aware of the type of material implanted in the skin prior to treatment.
Medical Tattoo is a used to treat a condition, communicate information, or mark a body location. Tattoos have also been used to provide notice to emergency personnel that a person has diabetes mellitus; people with this condition may fall into a diabetic coma and be unable to communicate that information. During breast reconstruction after mastectomy (removal of the breast for treatment of cancer), or breast reduction surgery, tattooing is sometimes used to replace the areola which has been removed during mastectomy, or to fill in areas of pigment loss which may occur during breast reduction performed with a free nipple graft technique.
Are there Treatment Alternatives for Tattoo Removal?
Other methods of tattoo removal include surgical excision (cutting the tattoo out), dermabrasion (scrubbing away the skin), salabrasion (using salt to abrade the tattoo), and chemical peels (using acid to burn away layers of skin). These methods are painful, expensive, and may result in scarring.
Thermal methods of tattoo removal destroy the superficial layers of the skin and result in massive inflammation, with significant scarring. Other types of non-selective lasers such as CO2 laser leaves a significant scar and has a risk of becoming infected post-treatment. Despite the severity of the treatment, often, a significant amount of tattoo pigment can be left behind. Even the modern pulsed CO2 lasers result in hypopigmented scarring when used on non-facial skin to any depth that would affect tattoo removal.
Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Q switching is a means of producing a very short laser pulse in the nanosecond Domain. Unfortunately, some laser Clinics are using devices that deliver pulses in the millisecond range such as intense pulsed light to treat tattoos. These types of devices heat the tattoo granules for too long, allowing heat to spread to surrounding tissue. This results in an unacceptable incidence of scarring in the shape of the tattoo, while still leaving most of the tattoo behind. To achieve optimal cosmetic results, only Q-switched lasers should be used for tattoo removal and in dark skinned people the Q-switched Nd:YAG is the safest.
How does Lasers work on a tattoo?
Q-switched Nd:YAG lasers are capable of emitting two wavelengths of light, 1064- and 532-nm wavelengths. This enables effective treatment of dark tattoo pigments such as black and dark blue using the 1064-nm wavelength, as well as removal of red and orange pigments using the 532-nm wavelength. This laser sends precise pulses of high energy light into the skin, vaporizing some tattoo inks and fragmenting other tattoo inks into thousands of tiny particles which are then safely eliminated from your skin. Our high-power Q-switched laser allows large diameter, deeply penetrating laser beams to be used, and will help to speed up the resolution of your unwanted tattoo.
If the area to be treated has a fresh sun tan or has been treated with self-tanning lotion, it is best to wait a couple of weeks for the tan to fade before having treatment, because the tan will absorb and waste some of the laser energy intended for the pigmented lesion. A fresh sun tan (or color from a recent application of self-tanning lotion) could also absorb enough laser energy to increase the risk of skin irritation or blistering.
That is why Prof. Moawad insists that patients cover tattoos with a bandage or clothing before laser treatment. The laser, being a machine, is indifferent to the reason a patient’s skin is tan and will simply see the extra melanin pigment and possibly hurt the skin, Prof. Moawad explains
Does laser treatment of tattoos hurt?
Many patients find that the discomfort of their first laser tattoo treatment is like the discomfort they had when getting the tattoo. There may be less discomfort after the first couple of treatments because as the tattoo fades there is less pigment to absorb laser energy. The impact of the energy from the powerful pulse of light is like the snap of a thin rubber band, or tiny specks of hot grease on the skin. Most patients do not require anesthesia, but ice packs, anesthetic creams or local anesthetic can be used if necessary. A couple of plain Tylenols can be taken to raise your pain threshold somewhat before laser.
What will happen after treatment?
Skin care after laser treatment of tattoos is quite like skin care after having a tattoo. Gentle cleansing of the skin and application of an antibiotic ointment t will help tattoos heal quickly after treatment.
For the first half-hour after laser treatment the tattoo looks pale or white and may swell slightly. The tattoo may feel hot (like a sun-burn) for a while after laser treatment and it will probably be red and swollen for the rest of the day. There may be pinpoint bleeding for a few hours in areas where there was a lot of pigment. The area may remain reddened for two to four weeks and there may be some flaking or peeling during this time. Sometimes skin or a scab the same color as the tattoo peels off after 5-7 days. This is a normal process as the body works to eliminate the tattoo dyes. Very dark, or large professional tattoos, will remain tender and swollen for a few days.
Watch for unusual redness, pain, or swelling which might be a sign of infection, and please call us right away if you think an infection is developing. Avoid picking or irritating the skin after treatment.
There may be some lightening or darkening of the skin for several months after laser treatment. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal. Your tattoo usually fades over 4-6 weeks. The degree of fading will be easier to see when you compare your tattoo with pre-treatment photographs.
How many treatments are required?
When Prof. Moawad examines your tattoo, he will be able to give you an estimate of the number of treatments, which will be necessary to fade or remove the tattoo. Because there is a great deal of variability in the kinds, mixtures and quantities of ink used in tattoos, and because there is some variability in people’s natural ability to clear away tattoo pigment after laser treatment, it is not possible to “promise” you that a certain result will happen after a fixed number of treatments.
Prof. Moawad will explain what is likely to happen, but he cannot precisely predict or guarantee what will happen in any case. Prof. Moawad will show you photos illustrating the range of results, from fading through to complete disappearance of the tattoo. Some lightly pigmented, black or dark blue, homemade tattoos like the one above can be removed in one treatment.
Amateur tattoos (which usually have a small amount of superficial ink) often clear after two to six treatments. New tattoos usually need extra treatments because they have more ink than old tattoos. Older tattoos have less ink because as a tattoo ages, the body absorbs some of the ink.
Factors which influence laser tattoo treatment success include the kind and color of inks used, the ability of the patients’ immune system to clear away pigment after it has been treated, and location of the tattoo.
Multicolored professional tattoos, especially on the lower legs, tend to respond slowly to laser treatments, and quite a few multicolored tattoos will need 10 or more treatment sessions for satisfactory fading or complete removal. Dark (blue/black) inks and red inks usually fade the best.
Oranges and purples often respond well. Dark inks usually respond quicker than bright colored inks because dark colors absorb laser energy better. Light colors such as light green, yellow and turquoise can be difficult to remove.
Sometimes chemicals like iron oxide or titanium dioxide are added to tattoo ink to brighten the tattoo – but these chemicals make it much more difficult to remove the tattoo. Fluorescent “Day Glow” pigments are almost impossible to remove. Some tattoos are now made with dark tar based ink or “laser resistant ink” and these tattoos (which fortunately are quite rare) can only be removed by cutting them out.
New tattoos usually need a larger number of treatments because they have a higher concentration of ink than old ones. Older tattoos have a lower concentration of ink because as a tattoo ages, the body absorbs some of the ink.
Tattoos on the face and trunk often respond faster to laser treatment than tattoos on the ankles. A professional tattoo (which usually has more ink, deeper ink, and multiple colors) might fade considerably after three to six treatments, but it generally takes between six and ten laser treatments to either completely remove a professional tattoo or to fade the tattoo so that it is barely visible (called a “ghost”). Sometimes complete removal is not possible, or you may find that almost-complete fading of the tattoo is satisfactory.
How long should I wait between treatments?
Quick fading or removal can sometimes be accomplished on black tattoos by using low powered treatments every week or two. In general, however, it is best to wait at least 4 weeks between treatments.
Sometimes it is possible to fade or remove the tattoo with a smaller number of treatments if you are willing to wait 8-12 weeks between treatments, so that your body has a longer opportunity to clear away pigment after laser treatment.
You should think of the fading and eventual elimination of your tattoo as a project which you might work on from time to time over the next year or two.
Will the tattoo completely disappear?
In many cases the tattoo can be made to disappear or fade to the point where you are the only person who can find a trace of it, because you know where to look. Some people choose to over-tattoo (use “cover-art”) to hide an undesirable tattoo.
This is especially common when the original tattoo contains the name of a former lover. If you have one tattoo on top of an older tattoo, extra laser treatments will probably be needed because there is likely to be a large amount of ink (ink from the new cover-up tattoo plus ink from the old tattoo).
Many tattoo artists encourage customers to have several laser treatments to lighten an existing tattoo before covering it with a new one. This will greatly reduce any chance that the old tattoo will be visible through the new tattoo. You should wait a month or two after your final laser treatment before having a new tattoo placed in the treated area.
What are the risks of treatment?
In most cases, the laser treatment leads to satisfactory fading or complete removal of the tattoo without significant side effects. Serious side effects are very unusual.
The most common problem with tattoo treatment is incomplete fading or removal of the tattoo. This is mainly an issue with complicated multicolored tattoos. Not all tattoo inks respond, and rarely certain colors can get worse.
Heavy professional tattoos may not completely fade. In some cases, changing to a different laser may be worthwhile due to the intrinsic differences in wavelengths, pulse durations, and spot sizes.
Cosmetic tattooing is the process of using tattoo ink to enhance the shape of the lips, to augment the appearance of the eyebrow, to accentuate eyelids, or to reconstruct the appearance of the areola following mastectomy.
When a patient desires subsequent removal of this type of tattoo, extreme caution should be exercised, because in most of these situations white ink pigment has been used to achieve the skin-colored tattoo tone.
In non-cosmetic tattoos, the presence of pastel colors such as light blue, turquoise, yellow, light green, lavender, and pink should also raise suspicion of white ink additives. Treatment may result in immediate and permanent tattoo darkening in white and even in red tattoos. The laser pulse can reduce ink from rust-colored ferric oxide (Fe2O3) to jet-black ferrous oxide (FeO).
Similarly, white ink made up of titanium dioxide (TiO2, T4+) can be reduced to blue Ti3+ upon laser treatment. Such post-treatment darkening appears immediately. For this reason, a single small inconspicuous test spot is recommended to ensure that this complication does not occur.
Even after testing, it is appropriate to obtain the patient’s written consent that they understand tattoo ink darkening may still occur during future treatments and that it may be permanent.
The darkening usually becomes apparent once the immediate whitening has faded. For those cosmetic or white tattoos that are refractory to removal with Q-switched lasers, fractional CO2 lasers can also be used to remove these pigments.
If pigment darkening does occur in a decorative tattoo, it may be improved with subsequent treatment with the QS Nd : YAG laser operated at 1064 nm.
Although true scarring is very unlikely there can be some mild change in the texture of the skin (perhaps 1-2% of cases). Sometimes there is pre-existing texture change in the skin caused by the tattooing process itself.
There can also be some loss of natural tanning ability in the treated area, which usually improves with time. You can reduce the chance of irregular tanning by protecting the tattooed area from sun exposure.
Hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin) are quite infrequent and are almost always temporary. Prof. Moawad uses Q-switched Nd:YAG laser which is the safest in the world for dark skin colors.
African, Asian and Mediterranean people can have their tattoos safely treated without changing the surrounding skin color. He recommends using bleaching agents before initiating laser treatment and in between laser sessions to prevent darkening of skin in dark-skinned and tanned patients.
Allergic reactions can occur after treatment, especially if you are already having an allergic reaction (redness and itching) in your tattoo.
Allergic reactions are usually caused by metallic dyes, which contain mercury, manganese, chromium, cobalt, or cadmium. This will necessitate a protocol for effective removal of these pigments. Prof. Moawad treat such reactions with topical or intralesional corticosteroids and avoid laser treatment altogether.
Tattoo granulomas allergic granulomas to tattoo ink are probably most commonly seen to the cinnabar in red-colored inks. In these situations, the use of any of the QS lasers is not recommended as it may worsen the allergic reaction and produce systemic symptoms or even anaphylactic reactions.
The use of an ablative laser, such as the carbon dioxide can be employed to remove the offending ink and destroy the granulomas at the same time. Biopsies should be considered before laser treatment to rule out sarcoidosis, infectious granulomas such as atypical mycobacterial infections, and other entities.
In contrast to drugs and cosmetics, tattoo pigments have never been controlled or regulated in any way, and the exact composition of a given tattoo pigment is often kept a “trade secret” by the manufacturer. In most cases, neither the tattoo artist nor the tattooed patient has adequate information about the composition of the tattoo pigment.
Traumatic tattoos acquired as a result of fireworks or explosives must be treated with great caution. Some of the particles embedded in the skin may be flammable and may reignite after laser treatment. This may result in significant scarring. These tattoos must be approached with care, and a small test spot performed before embarking on removal of large areas.
Newer tattoo inks are being developed that are made up of micro-encapsulated polymethylmethacrylate beads e.g. Infinitink® which are highly laser responsive so that tattoos created with these inks can be cleared in one or a few sessions compared to conventional inks.
To overcome the shortcomings of traditional QSL protocol, technological advancement in the form of development of picosecond lasers and modification of techniques such as R20 (repeated exposure on same day with an interval of 20 mins between sessions for 3-4 times) and R0 (repeated exposure on same day with no waiting period by applying perfluorodecalin, a perfluorocarbon compound after lasing) have been developed which are showing tremendous promise.
Light scattering properties of skin act as a hindrance to laser beam penetration particularly while using shorter WL. Dermal scatter reduction using optical clearing agents such as glycerol enhances the deeper penetration of laser.
Another improvisation is the use of combination of lasers such as the addition of fractional lasers to Q switched and picosecond lasers. Also, combining lasers have aided in treating tattoo complications such as granulomas.
Tattooing has been around since the early beginnings of modern civilization. Tattooing has become increasingly popular in recent times, with an estimated 7–20 million people in the USA with at least one. With advances in laser- and light-based technology, as well as their availability, many patients are not only looking to rid themselves of tattoo ink but also seeking removal of benign pigmented lesions. Modern tattoo artists use a myriad of colors to produce striking designs, resulting in permanent works of body art; however, we humans have been changing our minds since the beginning of time. Times changes, your tastes change, and your life changes. You change your clothes; you change your hairstyle — so why shouldn’t you be able to eliminate unwanted tattoos? Or fade them to prepare the area for a different tattoo. Thanks to the only available tattoo removal specific laser machines at MSI “Q-switched Nd: YAG laser 1064nm infra-red laser ” and frequency doubled 532nm green KTP laser you don’t have to live with an unwanted tattoo.
As tattoo artists are getting smarter to create exquisite works of art, can we the dermatologists be left far behind? Our innovation and improvisation is proving to be a match to counter the tattoo rage. These advances have led to a paradigm shift in laser treatment of tattoos It is important to be patient and remain positive as this promotes better healing and relaxation. It is best not to pass judgment on your progress until the healing process has completed.