Over the past two decades, body art has become mainstream, and this trend shows no signs of slowing down. As people of all ages seek to express themselves and commemorate special people and moments in their lives through permanent tattoos, the demand for tattoo removal also rises. Traditionally, treatment options were less than optimal, requiring up to a dozen sessions with poor clearance of multi-colored tattoos.
But there is good news for those who want to help patients obscure painful reminders of past relationships or perhaps just poor judgement. New picosecond lasers with multiple wavelengths, longer wait times between sessions and multi-modal treatment regimens are providing faster, more complete clearance of both black ink and multi-colored tattoos.
Multi-Wavelength Advantages
Multi-color tattoos require a range of wavelengths to target the specific chromophores in the ink. And, although lasers are the No. 1 treatment option for tattoo removal, some pigments such as flesh-colored, tan or rust inks that are composed of iron oxide or titanium dioxide, should not be treated with the oft-used Q-switched or picosecond lasers due to a chemical reaction that causes the tattoo ink to darken. “Instead, it is recommended that these tattoos either be treated with microneedling or CO2lasers that vaporize the skin,” says Tina Alster, MD, founding director of the Washington Institute of Dermatologic Laser Surgery in Washington, DC.
Red and infrared wavelengths, including 755nm alexandrite and 1,064nm Nd:YAG lasers, are used for black, blue-black and some green inks, according to Dr. Alster. Green wavelengths, such as 532nm Nd:YAG, are effective in removing red, orange and yellow inks.
In addition to wavelength, energy and pulse duration significantly impact the effectiveness of devices. For years, Q-switched lasers were the gold standard for tattoo removal due to their short (nanosecond) pulses and large spot sizes. Today picosecond lasers have significantly improved outcomes. “Instead of breaking down pigment from big to small like the Q-switched lasers, the PicoSure turns them to dust,” Jeffrey Dover, MD, of Skincare Physicians in Chestnut Hills, Massachusetts told MedEsthetics back in May 2014 following the introduction of the first picosecond laser, Cynosure’s PicoSure.
Originally these devices were available with 532nm and 1,064nm wavelengths. Now, new picosecond lasers, such as the PicoWay (Syneron Candela), are offering up to four wavelengths to tackle a variety of colors—including the notoriously difficult-to-treat greens, blues and purples. “With the addition of the 755nm and 785nm picosecond wavelengths, we can now successfully treat these colors,” says Paul M. Friedman, MD, director of Dermatology & Laser Surgery Center in Houston.
A study published in the September 2018 issue of Lasers in Surgery and Medicine revealed that lead author Eric F. Bernstein, MD, owner of Main Line Center for Laser Surgery in Ardmore, Pennsylvania, was able to remove 74 percent or more of blue, green and purple tattoos using the PicoWay’s 785nm wavelength.
He performed a total of four treatments sessions using only the 785nm picosecond wavelength (2mm to 4mm beam diameter and fluences ranging from 1.1 to 3.1J/cm2). Outcomes were assessed through blinded review of digital, cross-polarized photographs taken approximately eight weeks following the last treatment.
Fourteen subjects (21 tattoos) completed all study visits. The tattoos contained black, green, blue, yellow, purple and red inks. Blinded assessment of photographs found 85, 81, 74, 61, 11 and 5 percent clearance from baseline photos for purple, blue, green, black, red and yellow pigments, respectively. “As expected, red and yellow inks were not well treated with the 785nm laser wavelength and would have presumably been removed better using 532nm. Black ink would also have more likely cleared more completely if treated with the 1,064nm Nd:YAG laser,” the authors wrote.
“Shorter picosecond pulse duration devices with sufficient energy to enable large spot sizes, which results in greater depth of penetration, are key,” says Dr. Friedman. “Picosecond lasers allow for better clearance with fewer treatments and also allow us to treat all colors, including stubborn greens and blues. The lower fluence compared to Q-switched technology also allows for safer treatment in skin of color.”
Dr. Alster uses both the PicoWay and PicoSure in her practice. “With briefer pulse durations, they can blast tattoo inks into smithereens and provide for their more rapid removal by the body than older Q-switched laser systems,” she says. “With a picosecond laser, the number of treatments sessions needed is reduced by half: from 9 to 12 with a Q-switched to 4 to 6 with a pico laser.”
Back to Black
So which devices do you need in your practice to offer tattoo removal? The most common tattoo color is black so, first, you need a laser that is optimized for the treatment of black ink. “Since black ink is such an important tattoo target, the primary wavelength of a tattoo-removing laser should be at 1,064nm,” says Dr. Bernstein. “There is always loss of energy when converting from one wavelength to another, and I want all the energy I can get for the largest spot sizes at 1,064nm.”
He notes that both the 1,064nm Nd:YAG laser and Q-switched ruby laser target the black ink, but the 1,064nm Nd:YAG is the gold standard because it has a lower risk of adverse events. “This wavelength can see the black ink, and it does the best job of ignoring melanin pigment in skin,” says Dr. Bernstein. “The Q-switched ruby laser also does a good job of removing black ink but can lead to more side effects in darker skin types.”
When looking at multi-wavelength systems, he prefers laser-pumped-lasers with a primary wavelength of 1,064nm versus a 1,064nm laser that uses dye cartridges to offer additional wavelengths. “In my experiences, I have found that these cartridges don’t emit laser-precise wavelengths but instead emit ranges of wavelengths that can drift from the primary wavelength stated on the cartridge,” he says.
Evolving Protocols
In 2010, Dora Kassida, MD, introduced the R20 technique, which involves performing four laser passes spaced 20 minutes apart in the same treatment session to achieve faster clearance of black ink tattoos. The technique was further improved with the introduction of the Describe PFD patch (Merz), which allows practitioners to re-treat the tattoo within seconds of each pass. The perfluorodecalin-infused silicone patch acts as an optical clearing agent, resolving the white steam bubbles that form after laser treatment and also helping absorb some of the heat from the epidermis, which is especially valuable when treating darker skin types.
“Research at our center has shown that picosecond laser tattoo removal with the PFD patch decreases the risk of complications in skin of color,” says Dr. Friedman.
Roy Geronemus, MD, director of the Laser & Skin Surgery Center of New York, uses the R20 method with PFD patch for not only black ink tattoos but color as well. First he selects the wavelengths needed to address the various colors in the tattoo. “I perform multiple passes in the same session for most tattoos using the PFD patch to allow for immediate retreatment,” he says. “Sometimes we add ablative fractional lasers for resistant tattoos.”
When treating multi-colored tattoos with different wavelengths, Dr. Alster advocates treating red, orange and yellow inks prior to the darker black or blue inks. “The intense skin disruption that occurs upon laser impact of the darker inks can interfere with adequate visualization of the lighter inks,” she says.
The total number of sessions required for clearance depends on the tattoo, notes Dr. Friedman. “In general, professional tattoos require more treatments than amateur, cosmetic or medical tattoos,” he says. “The ink of professional tattoos is typically more concentrated and placed deeper in the skin.”
Sessions are best scheduled at monthly, or longer, time intervals in order for complete wound healing (and ink clearing) to take place, says Dr. Alster.
Dr. Friedman typically recommends eight to 12 weeks between laser treatment sessions. His practice has also been investigating the use of acoustic shock wave therapy in conjunction with picosecond lasers and a PFD patch to accelerate tattoo removal.
In June 2018, he and co-authors Ramya Vangipuram, MD and Selina S. Hamill, MD, published the results of a study combining picosecond laser with a PFD Patch and acoustic shock wave therapy (Zwave, Zimmer Medizin Systems) for tattoo removal in Lasers in Surgery and Medicine. The subject was a 28-year-old woman (Fitzpatrick Skin Type V) with a six-year-old professional black tattoo on her left ventral wrist. She underwent three treatment sessions at six to eight week intervals with a 1,064nm picosecond Nd:YAG laser (PicoWay) and the Describe PFD patch (Merz). At each treatment session, the investigators made two passes with the laser (4mm spot size, 2.8 to 3.2J/cm2 and laser repetition rate of 2Hz). Between laser passes and following the final laser pass, the medial portion of the tattoo was treated with the Zwave device (90mJ, 22Hz, and 1,200 pulses).
After three treatment sessions, there was 80 percent clearance of the medial portion of the tattoo that received the acoustic shock wave therapy compared with 60 percent clearance of the lateral portion treated with picosecond laser and PFD patch alone. In addition, the area treated with the Zwave had less edema, erythema and epidermal crusting in the days following treatment.
Addressing Faded Tattoos
With the new picosecond lasers, Dr. Bernstein no longer performs multiple passes in a single session. He believes that if you are using an adequately powered laser, a single pass per treatment session should yield maximal results with the least side effects.
“In the past when using an underpowered laser, I often treated a tattoo using two passes to the entire tattoo with both 1,064nm and 755nm laser energy, while also using 532nm wavelength to treat reds and yellows,” he says. “With newer lasers, I believe a single treatment yields the best results. Interestingly, the best pearl for removing a tattoo in the fewest treatments is the lowest tech—waiting longer between treatments.”
He finds that extending the interval between treatment sessions reduces the total number of treatments necessary to remove a tattoo, particularly toward the end of treatment when the tattoo becomes increasingly faint. “Waiting is a critical necessity when treating faint tattoos,” he says. “Simply cranking up the energy when a tattoo is very faint and almost completely removed, without waiting at least a few months between treatments, will often increase side effects without significantly improving results.”
Future developments
Dr. Bernstein is excited to see future laser developments including additional wavelengths to target pigment, smart lasers and those that offer even shorter pulse durations moving into the femtosecond-domain. “It was originally thought that picosecond-domain lasers may remove pigment independent of color,” he says. “While this hasn’t been the case so far, yellow ink that was previously not removable in the U.S. is now removable with picosecond-domain lasers operating at 532nm, while their nanosecond-domain cousins are far less effective.”
This has been shown with at least two different picosecond-domain lasers, and indicates that something qualitatively different may be occurring with some pigments at shorter pulse-durations. “Newer lasers with even shorter pulse-durations may offer unexpected effects as well. I can’t wait to see,” says Dr. Bernstein.
Daniel Casciato is a freelance writer based in Pittsburgh
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