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Tattoo Removal

Greg Mennie, PA-C, MSed

PIH-UCI Family Medicine Residency Program

Adapted from S. Murphy M.D. lecture

History of Tattoos

� Traced back to 3300 BC

� Name tattow from Captain Cook after trip to Polynesia (1700’s)

� Western – King Harold II (1022) Edith/England

� U.S. it has been generally regarded as a marker for rebellious or antisocial behavior.

� First tattoo gun invented in 1891

Adolescents

� AB 99 – no piercings under the age of 18

other than ear

� AB 186 – illegal to tattoo or offer tattoo to

anyone under the age of 18

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Demographics� 15% of Americans are tattooed

� 18 to 29 = 36%

� 30 to 40 = 24%

� 40 to 50= 15%

� Sixteen percent had obtained their first tattoo before age18.

� People of lower educational status were more likely to have a tattoo and also more likely to have more than one tattoo than those of higher educational status.

� Drinking alcohol and using recreational drugs were related to having tattoos.

� Tattoos were seen in all ethnic groups but were more common among those with Hispanic ancestry than among all other ethnic groups combined.

“A permanent reminder of a

temporary feeling”

25% had regrets about their tattoo.

5 % percent had already covered a tattoo with a new tattoo

17 % percent said they were considering tattoo removal.

Individuals who were younger than 18 when they were first tattooed

were more likely than older persons to have regrets.

Five types of tattoos:

� Amateur

� Professional

� Cosmetic

� Medicinal

� Traumatic

Middle Class

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Prison/Gang

Numerology� 13 – This tattoo indicates membership with the Mara

Salvatrucha 13 gang.

� 14 – This tattoo indicates membership with the Nuestra Familia, which is a prison gang. This gang is affiliated with the Nortenos, a street gang.

� 88 – eighth ltr of alphabet = HH

� Area codes – Many gang members use the area code to their neighborhood as a tattoo, though this can become outdated as area codes are changed.

� Dates, prison id number, etc?

Symbolism

Teardrop tattoo – This design is worn by the eye. It indicates the wearer has killed someone or that the person had a friend killed. “a mother has lost her son”

Three dots arranged as a triangle – This design is

most commonly found between the prisoner’s

forefinger and thumb. The design stands for “mi

vida loca,” which means “my crazy life.”

Other - lightning bolts, viking horns, chains, locks,

religious

The Art of Tattooing

Artists use a tattoo gun and mix and blend various inks. The ink is placed into

the dermis and thus permanent.

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PrisonTattoos

Amateur Tattoos

Melted plastic

Burned styrofoam

Baby oil, conditioner, shampoo mixed

with smoke carbon

Pen Ink

Guitar strings, pins, sewing needles

Motors from walkmans, fans

Ink Placement in Skin

The World of Inks?.

� 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"

� Cadmium, Chromium, Cobalt, Iron, Lead, and

Mercury all figured prominently in these

pigments, with a high incidence of allergic and

phototoxic reactions, as well as scarring.

History of Tattoo Removal

� Dermabrasion

� Carbon Dioxide Laser

� Surgical Excision

� Q-Switched Ruby Laser

� Q-Switched Nd:YAG

� Other- Infrared Coagulator

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Dermabrasion

Salabrasion

Laser wavelengths break up ink

L.A.S.E.R. is an acronym forLight Amplification by Stimulated Emission of Radiation

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Selective Photothermolysis

Selective - Discriminant

Photo - Light

Thermo - Heat

Lysis - Damage

Chromophore Attraction

Tattoo Removal Lasers

� Currently 4 different Q-Switched lasers are available for tattoo removal:

� Q-Switched Ruby Lasers -Red light @ 694nm> usually effective for most black, blue, and green pigments

� Q-Switched Alexandrite- Deep Red @ 755nm>usually effective for most black, blue, and green pigments

� Q-Switched Nd:YAG-Invisible (infrared) @1064nm>usually effective for most black and dark blue pigments

� Q-Switched Frequency-Doubled Nd:YAG-Green light@ 532nm>usually effective for red, satisfactory for black, dark blue, and purple pigments

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LASER SETTINGS

Q:YAG laser settings

� Wavelength (nm)

� Spot size (mm)

� Fluence (j/c2)

Example: Red: Q532nm 4mm 3.5 j/c2 10hz (1st)

Yel-Green: Blend 4mm 3.2 j/c2 10hz

Black: Q1064 4mm 3.5 j/c2 10hz

Larger beam diameters have better

penetration to treat deeper vessels.

Smaller diameter beams have limited penetration due to scattering.

Q-Switched YAG Laser

•Direct Delivery Handpiece

•Shorter Pulsewidth

• Wavelength Mixing Mechanism

Mixed Wavelengths

Unique Wavelength

Mixing Mechanism

� Allows user to mix 532

nm and 1064 nm

wavelengths

� User can treat multiple

colors simultaneously

� User can treat

epidermal and dermal

lesions simultaneously

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Palomar Q-YAG 5

� Q- Switched Nd:YAG laser will treat:

� Multi colored professional tattoos

� Amateur tattoos

� Pigmented lesions� Age spots

� Café au lait birthmarks

� Becker’s nevus

Laser Removal of Tattoos

� Mechanism unclear

� Lymphatic clearing of tattoo particles,

which are released on laser impact

� Carried off by macrophages

� Pregnancy

� Aspirin, Motrin, Aleve

� Photosensitive meds

� Active Sun exposure

� Herpes pre-medicate

Valtrex 1gm BID

Contraindications to Laser

Side effects of tattoo removal

POTENTIAL

� Hypopigmentation

� Hyperpigmentation

� Infection

� Scarring

� Incomplete clearing

� Sub dermal fibrosis

ACTUAL

• Crusting

• Blood Blisters

• Allergic reaction to

antibiotic cream

• Transient

hyperpigmentation in

dark skinned patients

Always warn patient they may experience all of these side effects.

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Anesthesia in Tattoo Removal

� Tattoo to be treated (right) is

covered with Topicaine Gel (center),

and then occluded with plastic wrap

(left). Topical anesthetics should be

applied at least 1 hour, and

preferably 3 hours before treatment.

Occlusion is essential to keep the

anesthetic cream or gel from drying

and losing effectiveness.

� Topical anesthetics:

� EMLA

� LMX 5% (OTC)

� Betacaine

� Betacaine-Lido-Tetracaine compounds

Apply before coming for treatment

Red bar=Infrared 1064 black

brown blue

Thick end of green bar is

Q: 532/1064 for reds,

yellows

Blend for

Greens, yellows, lavender

Patient Treatment

� Clinician is gloved

� Area prepped

� Goggles on

� Place hand piece perpendicular to the skin

� Treat to tissue response

� Always start with reds

Clinical Endpoints of Treatment

� 1064nm erythema

and edema

� 532/1064nm

whitening, erythema,

edema

� Do not treat until

bleeding occurs

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Caution: Metallic Ink May Oxidize

Test Spot

•Metallic

•Glow in the

dark

•Gold

•Pink

•Whites

Complications of Tattoo Removal

� Blistering ankles

Do not debride

Polysporin BID

� Incomplete clearing

� Infection

� Neosporin Allergy

� Crusting

� Hyperpigmentation

� Hypopigmentation

Difficult colors may lighten

Tattoo Art

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Unless someone like you cares a whole awful lot, nothing is going to get better. It's not.

~Dr. Seuss

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