April 8, 2007

Laser Tattoo Removal

To understand laser tattoo removal, we need to understand both tattoos and lasers. Understanding lasers is not as hard as it might seem and understanding tattoos is not as obvious as most people assume. So let's begin with the tattoo -- dont' skip this part.

By definition, a tattoo is pigment that permanently resides in the dermis, below the epidermis, in the skin. Ink that reaches only the epidermis, the outer most layer of skin, has not penetrated deeply enough and is destined to be sloughed off during the regular process of growth that the skin routinely cycles through. Of course, during a normal tattoo process, much ink will be deposited in the epidermis, just by virtue of the fact that the needle is on the way to the dermis and just passing through. Veteran tattooees know that this colored epidermis will typically peel off and fall away fairly quickly (a few to several days, much like the skin from a sunburn), leaving the actual tattoo, the pigment in the dermis, behind. Despite the body's attempts to remove ink molecules from the dermis (scavenger white blood cells called macrophages have a crack at it, carrying them off in lymph fluid to the local lymph node) much of the ink is either captured or ignored, and stays in the dermis. Likewise, ink that travels too deeply stands a higher chance of being carried away, or being accompanied by scarring, as well as difficult to see well. So, in the molecular world of ink, it is pigment molecules in the dermis that make a tattoo.

How does a laser remove pigment molecules from the dermis?

In reality -- and to be ultra picky -- it doesn't. Instead, it helps the body do what it has always tried to do with the ink, carry it away. A laser is just light, very concentrated light, but just light. When this concentrated light falls on the molecules of pigment, they try to absorb its energy but they simply can't because it's too much. Instead, the bonds of the pigment molecules break, nearly vaporizing them, reducing them to smaller sized molecules. As when the tattoo was first applied, the macrophages rush in, scoop up the smaller molecules, and whisk them away.

Does it all sound too good to be true? In fact, there are some details that complicate matters and which cause laser removal clinics to preface their brochures, contracts, and advertisements with cautionary words to the effect that not all tattoos can be removed and that scarring is always a possible side effect. The American Academy of Dermatology says that there is a low risk of scarring when using lasers to remove a tattoo -- a 5% chance. Then again, there was a low risk of scarring associated with getting the tattoo in the first place. With any of the old style removal techniques (dermabrasion or surgery), scarring was pretty much expected.

Why would scarring occur with lasers? Laser light isn't just concentrated, it's very concentrated and it's amplified. In fact, during the removal process, there is a small popping sound which is the sound of the pigment molecules nearly vaporizing, trying to disband and expel the energy and heat they've absorbed. The laser actually pulses on and off, quickly, to make very short bursts of light, since a sustained laser could cause significant damage. Small circular white patches appear immediately on the surface of the skin and scabbing may occur later. Everybody in the room must wear safety glasses or goggles. It is, according to all accounts and my personal observations, much more painful than getting a tattoo. It is routine for the doctor to offer an anesthetic, in the form of a topical cream or local injection, before the procedure. Because of the nature of the laser treatment and the pain involved, a single session typically lasts only several minutes, if that.

How much of the tattoo ultimately gets removed depends on many different factors: size, location, ability to heal, how the tattoo was applied (amateur or professional) and how long ago it was done. Because there are potentially hundreds of different types of tattoo inks out there, and because we never seem to know which ink was being used, it’s hard to know if it can be removed. Laser removal success is color dependent, to a fairly exact degree when it comes to some colors. The three lasers most commonly used are:

Q-switched Ruby Light from this laser is, not surprisingly, red in color. Because light is absorbed by its opposite color and reflected by its same color, this laser removes most ink colors well, except for red.

Q-switched Alexandrite This laser emits a purple/red light and is therefore best for removing blue-black and green ink.

Q-switched Nd:YAG (pronounced neodymium yag) This laser can emit a green light and removes red and orange ink the best.

Q-switched is just laser talk for high energy that’s delivered in short pulses.

In general you could probably say that an amateur tattoo which uses only black or blue ink is easier to remove. Unfortunately, amateurs also sometimes tattoo too deeply, making the pigment harder to reach. A professional tattooist will often mix colors in the tattoo process for a gradation effect, which is also more difficult to remove, but will tattoo no deeper than the dermis and at a consistent depth throughout the tattoo.

As with getting the tattoo, there will be a minimum three week interval between sessions (usually longer though) to allow the area to heal and to give the body’s immune system time to carry away the broken pigment molecules. And, yes, it is "sessions" plural. An average tattoo that is only 2 x 2 inches takes 6 to 7 months to be removed, with sessions scheduled every six to eight weeks (making that 3 or 4 sessions although ten sessions is not unheard of). And if you thought the process was painful, hold on to your wallet. Competition is rising and prices are falling but it's going to cost way more that getting the tattoo, ranging easily from the low hundreds to several hundred dollars for very small to average sized tattoos.

But with all that said, some of the before and after images of people who have had laser tattoo removal are astonishing. For some tattooed people, removal is the only alternative that they'd realistically consider (as opposed to a cover up tattoo). It becomes important to the point of not being able to feel clean or move on in life without the removal of some tattoos. Choosing a dermatologist for your outpatient procedure is as important as choosing a great tattooist. As with a tattooist, the best referral is a personal one, someone who you know who has had their tattoo removed to their satisfaction. Failing a personal referral, you could ask your personal physician. You can also try The American Society for Laser Medicine & Surgery or the American Society of Dermatologic Surgeons for recommendations. Make sure that you’re getting a medical doctor who specializes in laser surgery and it’d also be fabulous if you found somebody with thousands of tattoo removals behind them. There’s a learning curve just as with tattoo applications and experience does count. Also, be sure that you have in writing how much the total cost to you is going to be at the end of the process. On the bright side, at least you don’t have to tip!

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