Tattoo Removal Comes of Age
Tattoo Removal Comes of Age
Tattoos, or "skin art," are increasingly popular, but along with more tattoos comes a greater demand for removal. William Kirby, DO, a board-certified dermatologist and leading authority on tattoo removal, addresses the vast changes and improvements in tattoo removal of the past decade. He is Clinical Assistant Professor of Dermatology at Western University of Health Sciences and Clinical Assistant Professor in the Department of Internal Medicine, Division of Dermatology, at Nova Southeastern University. He is also an expert reviewer for the Osteopathic Medical Board of California in the field of dermatology and is the medical director of the Dr. TATTOFF, Inc. clinics, which specialize in tattoo removal and laser hair removal. Plastic surgeons also encounter requests for tattoo removals, and Rady Rahban, MD, a board-certified plastic and reconstructive surgeon in Beverly Hills, provides insight into this part of his practice. Both physicians spoke to Medscape's Pippa Wysong about the latest developments and challenges in tattoo removal.
Medscape: Are there different kinds of tattoos?
Dr. Kirby: Tattoos can be divided into 2 basic categories: amateur and professional. Amateur tattoos are usually done in a home setting, sometimes in jail, and use a variety of amateur means, such as scratching the skin and rubbing ashes into it, or using a needle and injecting ink from a pen into the skin. Professional tattoos are much more complex. A steel -- rather than a hollow -- needle is used to inject ink into the dermal layer of the skin. If the ink is not placed into the dermal layer, it won't remain.
Medscape: How common are requests for tattoo removal?
Dr. Kirby: A recent survey showed that tattoos are increasing in popularity, from 16% of the US population in 2003 to 24% of people aged 18-50 in 2006. A parallel increase has been seen in demand for tattoo removal, but exact numbers aren't available.
Medscape: Are all tattoo inks the same?
Dr. Kirby: Tattoo inks vary widely. I wrote the definitive article on ink allergies and included a table about the different colors of ink. Each ink color can be derived from any number of pigment sources. The type of ink affects tattoo removal because although we can see colored ink on the skin, we can't tell specifically what is in the ink. The US Food and Drug Administration considers tattoo ink to be a "food additive," so it isn't well regulated in medicine.
Medscape: How are tattoos removed?
Dr. Kirby: First I'll give you some background. A number of methods are now out of favor. These older methods resulted in unwanted side effects, such as scarring, discoloration, and ink retention. Older methods included salabrasion using acid, thermal destruction, and dermabrasion, in which the skin is just debrided with a rotating metal brush. Because these techniques are nonspecific, they destroy the tattoo colors but can also cause scarring, pain, and delayed healing.
We now have Q-switched lasers (Nd:YAG, alexandrite and ruby) that are being used in an increasing number of clinics. These devices have revolutionized tattoo removal. The laser light enters the skin so that it quickly destroys the ink while minimizing destruction of the surrounding tissue. This process is called "selective photothermolysis." The laser light destroys the ink, and the body breaks it down. The surrounding skin stays intact with few unwanted side effects.
Medscape: How effective is laser treatment?
Dr. Kirby: In most cases it's very effective, and a tattoo can be reduced significantly or removed completely.
Medscape: Do you need a different laser for each ink color?
Dr. Kirby: Yes and no. The most common ink, seen in 90% of tattoos, is black, which responds very well to a 1064-nm wavelength of light. This is the wavelength emitted from an Nd:YAG laser, and it treats black ink very effectively. The next most common ink color we see is red, and using that same laser, through a process of harmonic doubling, we can divide the wavelength in half, to 532 nm. This one device can treat most tattoos composed of black and red inks. The Alexandrite laser has a 755-nm wavelength and is best for green inks. The ruby laser is best for blue inks. The number of colors in a tattoo determines the best devices for removing it.
We occasionally see an ink that won't respond to the laser. The tattoo won't resolve, disappear, or even darken. Some colors don't respond to any form of laser light. Yellow ink sometimes doesn't respond well, although it may fade and blend in with the background color of the skin.
Medscape: Do physicians who remove tattoos have several lasers on hand?
Dr. Kirby: Actually, the more modern Nd:YAG laser is good for black and red, and handpieces can be added to treat blues or greens. Most of the devices have means for treating additional colors. Of course, every device has pros and cons. The ruby device is great for blues, but it also causes the highest rate of hypopigmentation or skin discoloration -- so it's not used very often.
Medscape: How many laser treatments are needed to remove a tattoo?
Dr. Kirby: A colleague and I developed the Kirby-Desai scale to help predict how many treatments a patient needs to remove a given tattoo. It takes much of the guesswork out of estimating how many treatments are needed. This scale is now widely recognized as a necessary tool in the estimation process.
Medscape: How does the scale work?
Dr. Kirby: The scale uses 6 categories. One is skin type, which assigns a score of 1-6 on the basis of how fair or dark the skin is. The next criterion is the location of the tattoo -- head and neck, upper trunk, lower trunk, proximal extremity, or distal extremity. The third criterion is the color of the pigment or pigments in the tattoo. The fourth is the amount of ink -- a subjective assessment that we classify as a mild, moderate, or significant amount of ink. The fifth category is scarring. If scarring is present, the ink is more difficult to remove. The last category reflects layered or covered-up tattoos, meaning there is more ink because someone tried to cover up a tattoo.
You assign a score for each of those 6 criteria, then add the points and the result is the approximate number of treatments needed, plus or minus 2.5. It's a relatively accurate estimate and has been widely accepted by dermatologists.
Medscape: Are there differences in treating fair- vs dark-skinned people?
Dr. Kirby: The fairer the complexion, the more aggressive we can be because we're not worried about discoloration of the surrounding skin. With darker complexions, we have to be more cautious because the chances of discoloration -- either hypo- or hyperpigmentation -- increase.
Medscape: Which tattoos are easiest to remove?
Dr. Kirby: Generally speaking, the closer a tattoo is to the heart, the easier it is to remove because of circulation and vascularity. The way the process works is that the ink is fractionated into microscopic pieces and the body breaks it down on its own. Areas of high vascularity, like the scalp and face, also respond quite well. As you get farther away toward the distal extremities, it becomes trickier.
Editor's Note:
Tattoos, or "skin art," are increasingly popular, but along with more tattoos comes a greater demand for removal. William Kirby, DO, a board-certified dermatologist and leading authority on tattoo removal, addresses the vast changes and improvements in tattoo removal of the past decade. He is Clinical Assistant Professor of Dermatology at Western University of Health Sciences and Clinical Assistant Professor in the Department of Internal Medicine, Division of Dermatology, at Nova Southeastern University. He is also an expert reviewer for the Osteopathic Medical Board of California in the field of dermatology and is the medical director of the Dr. TATTOFF, Inc. clinics, which specialize in tattoo removal and laser hair removal. Plastic surgeons also encounter requests for tattoo removals, and Rady Rahban, MD, a board-certified plastic and reconstructive surgeon in Beverly Hills, provides insight into this part of his practice. Both physicians spoke to Medscape's Pippa Wysong about the latest developments and challenges in tattoo removal.
Tattoo Removal
Medscape: Are there different kinds of tattoos?
Dr. Kirby: Tattoos can be divided into 2 basic categories: amateur and professional. Amateur tattoos are usually done in a home setting, sometimes in jail, and use a variety of amateur means, such as scratching the skin and rubbing ashes into it, or using a needle and injecting ink from a pen into the skin. Professional tattoos are much more complex. A steel -- rather than a hollow -- needle is used to inject ink into the dermal layer of the skin. If the ink is not placed into the dermal layer, it won't remain.
Medscape: How common are requests for tattoo removal?
Dr. Kirby: A recent survey showed that tattoos are increasing in popularity, from 16% of the US population in 2003 to 24% of people aged 18-50 in 2006. A parallel increase has been seen in demand for tattoo removal, but exact numbers aren't available.
Medscape: Are all tattoo inks the same?
Dr. Kirby: Tattoo inks vary widely. I wrote the definitive article on ink allergies and included a table about the different colors of ink. Each ink color can be derived from any number of pigment sources. The type of ink affects tattoo removal because although we can see colored ink on the skin, we can't tell specifically what is in the ink. The US Food and Drug Administration considers tattoo ink to be a "food additive," so it isn't well regulated in medicine.
Medscape: How are tattoos removed?
Dr. Kirby: First I'll give you some background. A number of methods are now out of favor. These older methods resulted in unwanted side effects, such as scarring, discoloration, and ink retention. Older methods included salabrasion using acid, thermal destruction, and dermabrasion, in which the skin is just debrided with a rotating metal brush. Because these techniques are nonspecific, they destroy the tattoo colors but can also cause scarring, pain, and delayed healing.
We now have Q-switched lasers (Nd:YAG, alexandrite and ruby) that are being used in an increasing number of clinics. These devices have revolutionized tattoo removal. The laser light enters the skin so that it quickly destroys the ink while minimizing destruction of the surrounding tissue. This process is called "selective photothermolysis." The laser light destroys the ink, and the body breaks it down. The surrounding skin stays intact with few unwanted side effects.
Medscape: How effective is laser treatment?
Dr. Kirby: In most cases it's very effective, and a tattoo can be reduced significantly or removed completely.
Medscape: Do you need a different laser for each ink color?
Dr. Kirby: Yes and no. The most common ink, seen in 90% of tattoos, is black, which responds very well to a 1064-nm wavelength of light. This is the wavelength emitted from an Nd:YAG laser, and it treats black ink very effectively. The next most common ink color we see is red, and using that same laser, through a process of harmonic doubling, we can divide the wavelength in half, to 532 nm. This one device can treat most tattoos composed of black and red inks. The Alexandrite laser has a 755-nm wavelength and is best for green inks. The ruby laser is best for blue inks. The number of colors in a tattoo determines the best devices for removing it.
We occasionally see an ink that won't respond to the laser. The tattoo won't resolve, disappear, or even darken. Some colors don't respond to any form of laser light. Yellow ink sometimes doesn't respond well, although it may fade and blend in with the background color of the skin.
Medscape: Do physicians who remove tattoos have several lasers on hand?
Dr. Kirby: Actually, the more modern Nd:YAG laser is good for black and red, and handpieces can be added to treat blues or greens. Most of the devices have means for treating additional colors. Of course, every device has pros and cons. The ruby device is great for blues, but it also causes the highest rate of hypopigmentation or skin discoloration -- so it's not used very often.
Medscape: How many laser treatments are needed to remove a tattoo?
Dr. Kirby: A colleague and I developed the Kirby-Desai scale to help predict how many treatments a patient needs to remove a given tattoo. It takes much of the guesswork out of estimating how many treatments are needed. This scale is now widely recognized as a necessary tool in the estimation process.
Medscape: How does the scale work?
Dr. Kirby: The scale uses 6 categories. One is skin type, which assigns a score of 1-6 on the basis of how fair or dark the skin is. The next criterion is the location of the tattoo -- head and neck, upper trunk, lower trunk, proximal extremity, or distal extremity. The third criterion is the color of the pigment or pigments in the tattoo. The fourth is the amount of ink -- a subjective assessment that we classify as a mild, moderate, or significant amount of ink. The fifth category is scarring. If scarring is present, the ink is more difficult to remove. The last category reflects layered or covered-up tattoos, meaning there is more ink because someone tried to cover up a tattoo.
You assign a score for each of those 6 criteria, then add the points and the result is the approximate number of treatments needed, plus or minus 2.5. It's a relatively accurate estimate and has been widely accepted by dermatologists.
Medscape: Are there differences in treating fair- vs dark-skinned people?
Dr. Kirby: The fairer the complexion, the more aggressive we can be because we're not worried about discoloration of the surrounding skin. With darker complexions, we have to be more cautious because the chances of discoloration -- either hypo- or hyperpigmentation -- increase.
Medscape: Which tattoos are easiest to remove?
Dr. Kirby: Generally speaking, the closer a tattoo is to the heart, the easier it is to remove because of circulation and vascularity. The way the process works is that the ink is fractionated into microscopic pieces and the body breaks it down on its own. Areas of high vascularity, like the scalp and face, also respond quite well. As you get farther away toward the distal extremities, it becomes trickier.
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