Tattoo removal has been performed with various tools during the history of tattooing. While tattoos are considered permanent, it is sometimes possible to remove them with treatments, fully or partially. The expense and pain of removing tattoos will typically be greater than the expense and pain of applying them. Some jurisdictions will pay for the voluntary removal of gang tattoos.
Pre-laser tattoo removal methods include dermabrasion, salabrasion (scrubbing the skin with salt), cryosurgery, and excision which is sometimes still used along with skin grafts for larger tattoos. Tattoo removal by laser was performed with continuous-wave lasers initially, and later with Q-switched lasers, which became commercially available in the early 1990s. Today, "laser tattoo removal" usually refers to the non-invasive removal of tattoo pigments using Q-switched lasers. Typically, black and darker colored inks can be removed more completely.



Motivation for tattoo removal
In the United States, about 17% of people with tattoos experience some regret. According to a poll done in 2008, the most common reasons for regret are "too young when I got the tattoo (20%)," it's "permanent" and I'm "marked for life (19%)," and I just "don't like it (18%)."An earlier poll showed that 19% of British people with tattoos suffered regret, as did 11% of Italian people with tattoos. Surveys of tattoo removal patients were done in 1996 and 2006, and provided more insight. These patients typically obtained their tattoos in their late teens or early twenties, and just over half were women. About 10 years later, the patient's life had changed, and more than half of the patients reported that they "suffered embarrassment." A new job, problems with clothes, and a significant life event (wedding, divorce, baby) were also commonly cited as motivations.
Cover-up
Some wearers opt to cover an unwanted tattoo with a new tattoo. This is commonly known as a cover-up. An artfully done cover-up may render the old tattoo completely invisible, though this will depend largely on the size, style, colors and techniques used on the old tattoo. Some shops and artists use laser removal machines to break down and lighten undesired tattoos to make coverage with a new tattoo easier. Since tattoo ink is translucent, covering up a previous tattoo necessitates darker tones in the new tattoo to effectively hide the older, unwanted piece.
Methods
Tattoo removal is most commonly performed using lasers that react with the ink in the tattoo, and break it down. The broken-down ink is then absorbed by the body, mimicking the natural fading that time or sun exposure would create. All Tattoo pigments have specific light absorption spectra. A tattoo laser must be capable of emitting adequate energy within the given absorption spectrum of the pigment in order to provide an effective treatment. Certain tattoo pigments, such as yellows, greens and fluorescent inks are more challenging to treat than the darker blacks and blues. These pigments are more challenging to treat because they have absorption spectra that fall outside or on the edge of the emission spectra available in the respective tattoo removal laser.
Laser tattoo removal often requires many repeated visits to remove even a small tattoo, and may result in permanent scarring. A brand of ink, InfinitInk, was developed to enable easier tattoo removal with a single laser treatment. The newer Q-switched lasers are said by the National Institute of Health to result in scarring only rarely, however, and are usually used only after a topical anesthetic has been applied. Areas with thin skin will be more likely to scar than thicker-skinned areas. There are several types of Q-switched lasers, and each is effective at removing a different range of the color spectrum. Lasers developed after 2006 provide multiple wavelengths and can successfully treat a much broader range of tattoo pigments than previous Q-switched lasers.
Factors contributing to the success of laser tattoo removal
Multiple factors contribute to the success of laser tattoo removal one of which is a patient's own immune system. A healthy patient will get the best results. Adequate hydration, eight hours of sleep a night, maintaining a healthy weight, eating a well balanced diet, exercise, and non-smoking improve results. Treatment on some patients with immune systems problems are contraindicated.
Pain management during treatment
Laser tattoo removal can be quite painful. Prescription strength topical anesthetic creams or injections of anesthetic solutions are usually used to manage pain, although some patients forgo any type of anesthesia.
Depending on the patient's pain threshold, and while some patients may forgo anesthesia altogether, most patients will require some form of local anesthesia. Pre-treatment might include the application of an anesthetic cream under occlusion for 45 to 90 minutes prior to the laser treatment session. If complete anesthesia is desired, it can be administered locally by injections of 1% to 2% lidocaine with epinephrine.
Anecdotal reports have noted that patients receiving anesthesia by local injection will require additional treatments as the injection causes mechanical edema, spreading out the tattoo ink, which in turn makes it more difficult for the laser light to act on specific ink particles. It has been reported that infiltration of local anesthesia will add an additional treatment or two.
Post-treatment considerations
Immediately after laser treatment, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed. This white color change is thought to be the result of rapid, heat-formed steam or gas, causing dermal and epidermal vacuolization. Pinpoint bleeding represents vascular injury from photoacoustic waves created by the laser's interaction with tattoo pigment. Minimal edema and erythema of adjacent normal skin usually resolve within 24 hours. Subsequently, a crust appears over the entire tattoo, which sloughs off at approximately 14 days post treatment. As noted above, some tattoo pigment may be found within this crust. Post-operative wound care consists of topically applied antibiotic ointment and a non-occlusive dressing. Fading of the tattoo will be noted over the next 6 to 8 weeks and re-treatment energy levels can be tailored depending on the clinical response observed.
Side effects and complications
About half of the patients treated with Q-switched lasers for tattoo removal will show some transient changes in the normal skin pigmentation. These changes usually resolve in 6 to 12 months but may rarely be permanent.
Hyperpigmentation is related to the patient's skin type, with skin types IV,V and VI more prone regardless of the wavelength used. Twice daily treatment with hydroquinones and broad-spectrum sunscreens usually resolves the hyperpigmentation within a few months, although, in some patients, resolution can be prolonged.
Transient textural changes are occasionally noted but often resolve within a few months, however, permanent textural changes and scarring very rarely occur. If a patient is prone to pigmentary or textural changes, longer treatment intervals are recommended. Additionally, if a patient forms a blister or crust post treatment, it is imperative that they do not manipulate this secondary skin change. Early removal of a blister of crust increases the chances of developing a scar. Additionally, patients with a history of hypertrophic or keloidal scarring need to be warned of their increased risk of scarring.
Local allergic responses to many tattoo pigments have been reported, and allergic reactions to tattoo pigment after Q-switched laser treatment are also possible. Rarely, when yellow cadmium sulfideis used to "brighten" the red or yellow portion of a tattoo, a photoallergic reaction may occur. The reaction is also common with red ink, which may contain cinnabar (mercuric sulphide). Erythema, pruritus, and even inflamed nodules, verrucose papules, or granulomas may present. The reaction will be confined to the site of the red/yellow ink. Treatment consists of strict sunlight avoidance, sunscreen, interlesional steroid injections, or in some cases, surgical removal. Unlike the destructive modalities described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. Oral antihistamines and anti-inflammatory steroids have been used to treat allergic reactions to tattoo ink.
Studies of various tattoo pigments have shown that a number of pigments (most containing iron oxide or titanium dioxide) change color when irradiated with Q-switched laser energy. Some tattoo colors including flesh tones, light red, white, peach and light brown containing pigments as well as some green and blue tattoo pigments, changed to black when irradiated with Q-switched laser pulses. The resulting gray-black color may require more treatments to remove. If tattoo darkening does occur, after 8 weeks the newly darkened tattoo can be treated as if it were black pigment.
Q-switched lasers can rupture blood vessels and aerosolizes tissue requiring a plastic shield or a cone device to protect the laser operator from tissue and blood contact. Protective eye-wear should be worn at all times during treatment.
Risks
While generally accepted as a safe treatment, rare complications of laser tattoo removal include the possibilities of burning the skin, discoloring dark skin with the laser, hypopigmentation (white spots, more common in darker skin), hyperpigmentation (dark spots), and textural changes. Severe burns may result in scarring. Rarely, "paradoxical darkening" of a tattoo may occur, when a treated tattoo becomes darker instead of lighter. This seems to occur more often with flesh tones and light-colored tattoos and may be avoided by the application of the laser to one or two test sites prior to a decision to treat a full tattoo.
Some of the pigments used (especially Yellow #7) are known to break down into toxic chemicals in the body when attacked by light. This is especially a concern if these tattoos are exposed to UV light or laser removal; the resulting degradation products end up migrating to the kidneys and liver. Laser removal of traumatic tattoos may similarly be complicated depending on the substance of the pigmenting material. In one reported instance, the use of a laser resulted in the ignition of embedded particles of firework debris.
Disclaimer: For general educational purposes only. Information contained in this Web site is general in nature, and should not be relied on for medical treatment. If you need advice or services, please contact the doctor directly.


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