“Ideally, you want a QS Nd:YAG and either a QS alexandrite or QS ruby to at least cover the basics of tattoo removal,” says Richard Fitzpatrick, MD, with Goldman, Butterwick, Fitzpatrick & Groff Cosmetic Laser Dermatology, San Diego. “Some inks will still be difficult to remove. We have found that adding a fractional ablative CO2 or erbium laser treatment can be beneficial. These lasers are attracted to the water in tissue and vaporize it along with the ink.”
Dr. Weiss and his colleagues at the Laser & Skin Surgery Center of New York have been studying the effects of adding fractional treatments to QS laser tattoo removal protocols for about three years. They routinely use nonablative fractional treatments but are cautious with ablative fractional treatments.
“We just completed a study using both QS lasers and Fraxel re:pair and/or Fraxel re:store (Solta Medical, www.fraxel.com) to remove tattoos (E.T. Weiss and R.G. Geronemus, Dermatologic Surgery, January 2011),” says Dr. Weiss. “Adding nonablative fractional laser treatments to the appropriate QS laser treatments helped [to] eliminate hypopigmentation, speed healing and improve clearance. Adding ablative fractional treatments also improved clearance of colors, like yellow, as well as titanium-based inks, including white and flesh colors that often turn dark when treated with QS lasers alone. There was a definite improvement in the end results.” Dr. Weiss continues, “If the patient already has hypopigmentation because of previous attempts to remove the tattoo or if he begins to develop hypopigmentation during treatment, adding fractional treatments can correct this. I routinely do nonablative treatments on all tattoo patients. If I’m working with tattoos that include titanium-based ink or the color yellow, I add a fractional ablative treatment about every third laser treatment. And if the patient has scar tissue from the tattoo itself, fractional treatments can speed the clearance.”
In the research paper cited above, Drs. Weiss and Geronemus identified several possible mechanisms leading to improved outcomes with fractional treatments. In addition to removing any pigment superficial enough to be vaporized in the ablated tissue zones, ablative fractional resurfacing induces a robust inflammatory response that could improve phagocytic removal of tattoo pigment. The wound columns typical with ablative fractional resurfacing allow fluid to escape rather than building up and forming blisters. This allows the skin to heal more quickly. Nonablative fractional treatments may also stimulate melanocyte activity or migration leading to less risk of hypopigmentation.