Tattoo
Removal
Indications
A tattoo is a collection of foreign pigment trapped within
in certain cells in the deeper layers of the skin; these
pigments are permanent and are not susceptible to the body’s
normal mechanisms for removing foreign material.
Tattooing of the skin is an “art” which has
been practised for many thousands of years. There are many
reasons why tattoos are applied, some cultural, others to
do with fashion, social trends and personal statements.
Tattoos are commonly applied by professional tattoo artists;
but many are applied in a “Do-it-youself” fashion
by scratching the skin and rubbing in India ink. The skin
may also be tattooed as a result of traumatic injury when
a foreign pigment becomes permanently embedded within the
skin.
The wish for tattoo removal may be because of loss of definition
in the tattoo due to loss or diffusion of colour; more commonly
tattoo removal is desired because the “owner”
changes their mind about their tattoo or wishes some content
of the tattoo changed, eg. a name. Many individuals come
to regret their tattoos and wish their removal because of
how they are perceived by others. Some occupations, eg.
the armed forces, have regulations about recruiting individuals
with visible tattoos.
Various techniques for tattoo removal have been described;
these can be broken down into three groups: surgical excision,
abrasion techniques and laser removal.
Anaesthetic
Surgical and abrasion techniques for removal of tattoos
require some kind of anaesthesia, most commonly local anaesthetic.
Technique
Surgical Excision
This is especially useful when the affected area is small.
The tattooed area is cut out and the edges are brought together
and stitched to give a straight-line scar; if the tattoo
is very large then the wound may need to be repaired using
a skin graft from another part of the body. An alternative
method for large tattoos is to remove it in stages; in the
first operation the centre is removed and the wound stitched;
the edges are removed at a later date when the skin has
had time to “relax”. The scars produced by these
techniques are often preferable to the tattoo; one should
remember that scarring is occasionally unsatisfactory.
Abrasion
This is a very old technique; table salt is moistened with
water and the area rubbed to abrade the area (salabrasion).
The abrading apparatus may be an electrical abrasion device
or, more traditionally, a wooden block with a cloth wrapped
around it. Modern abrasion technique is known as “dermabrasion”
- this involves abrading the skin with a rotating abrasive
device. All of these techniques rub away the upper layers
of the skin and in so doing remove some of the contained
pigment. There is some bleeding, followed by soreness (like
a graze), a scab forms which separates after 7 - 10 days.
Abrasion techniques for tattoo removal are rarely performed
these days.
Laser Removal
This is the most modern technique for tattoo removal; at
the present time this seems to offer the most effective
removal with the minimum of scarring.
Lasers produce concentrated, high-energy light which penetrates
the skin and heats the pigment used to make up a tattoo.
This heating process is very intense and localised to the
pigment which has absorbed the laser light. The process
fragments the pigment into small particles which are removed
by the body’s scavenger mechanisms. The various colours
of tattoos absorb various wavelengths of light; the degree
to which the light energy is absorbed by a particular colour
will determine how effective a laser is at removing the
pigment. Because lasers produce light of a particular wavelength
different lasers are more or less effective for different
tattoo pigments. Depending on the colours in the tattoo
more than one laser might be used for optimal colour removal.
Lasers commonly used for tattoo removal are Q-switched Nd-YAG,
Ruby and Alexandrite lasers. “Q-switching” means
that the laser delivers a very high amount of energy but
for a fraction of a second; this minimises the risk of scarring
of the skin. The procedure for laser removal of a tattoo
varies from 15 - 45 minutes depending upon the tattoo size
and type of tattoo ink. More than one session may be required,
even for a small tattoo. Professional tattoos place the
pigment at an even depth through the dermis of the skin
- the laser light can reach the pigment relatively easily
and uniformly; these tattoos are usually easier to treat
than amateur tattoos; however, 5 or 6 treatments still may
be needed. Treatments are usually separated by 4 - 6 weeks.
The laser treatment itself can be carried out without anaesthesia;
the procedure produces some discomfort, usually reported
as feeling as if the skin has been flicked with a rubber
band. If this is too unpleasant the skin can be “numbed”
before the procedure with a special anaesthetic cream (EMLA).
The laser device is housed in a machine 2 -3 feet high and
has a probe on the end of a mechanical arm (a little like
a dentist’s drill). There is a pen-shaped attachment
on the end of the arm from which the laser light is emitted.
The doctor, any attendants and the patient have to wear
protective glasses to protect the eyes from stray laser
light. When the laser is operated there is a clicking or
cracking noise and a sting felt on the skin. The laser light
is applied to the area being treated in a series of short
pulses.
Length of Operation
Laser removal of tattoos typically takes 15 - 45 minutes
per session. More than one session may be required.
Time in Hospital
Laser removal of tattoos is an outpatient procedure. Surgical
techniques can usually be done as a out-patient or as a
day-case.
Post operative Discomfort/Limitations
Following laser treatment for a tattoo the treated area
may feel hot and sore; ice-packs or balms (e.g. aloe vera
gel) may soothe the discomfort. Occasionally some crusting,
blistering and scabbing may occur. After treatment the area
may ooze a small amount of blood for a few hours.
Multiple treatments may be required and it may not be possible
to to completely eradicate some tattoos; amateur tattoos,
in particular, may have some very deeply placed pigment
and removal, without significant risk of scarring may not
be possible. Some colours, e.g. yellow may be difficult
to remove.
Time off Work
Time off work is not required following laser treatment
of tattoos.
Risks
and Complications
There is a small risk of eye injury with laser treatments;
eye protection will be worn at all times during laser treatment.
Lasers are designed to have a low incidence of skin injury
and thus scarring, but occasionally, may be 5%, a scar will
result; scarring can occasionally be unsatisfactory.
Laser therapy may cause loss of the normal skin colour in
the site which has been treated; this usually recovers,
but occasionally is permanent. The treated area should be
protected from sun-exposure for up to six months following
treatment. Sun-exposure may cause the area to darken with
brown discolouration. This hyperpigmentation may take months
to fade and rarely is permanent. Rarely the released tattoo
pigments may cause an allergic response and the skin becomes
red, itchy and inflamed.
