30 Tattoo Removal with Lasers
WILLIAM KIRBY, DO, FAOCD  •  FRANCISCA KARTONO, DO  • 
REBECCA SMALL, MD
T he growing trend of tattooing has led to increased
numbers of patients seeking tattoo removal. Studies
note that 40% of Americans between the age of 26 and
40 currently have tattoos and 17% of these people are
seeking removal.1,2 With more than 20,000 tattoo
studios in the United States placing tattoos, the demand
for removal is likely to continue to increase in the
coming years.3
Multiple techniques can be used for tattoo removal.
Early removal methods used mechanical destruction
such as dermabrasion, chemical peels, and continuous-
wave lasers. These methods left patients with unsatis-
factory results and were associated with suboptimal
removal and scarring (Figure 30-1). The current stan-
dard of using Q-switched lasers has revolutionized
tattoo removal and offers patients a safe and effective
means for removing tattoo ink.
In this chapter, we describe the physiology of a
tattoo, the latest tattoo removal technology, and the
current standard practice recommendations for tattoo
removal with Q-switched lasers.
TATTOO ANATOMY
During the tattooing process, tattoo ink is injected intra-
dermally. The epidermis and upper papillary dermis are
homogenized and ink particles (ranging in size from 2
to 400 nm) are deposited intracellularly and extracel-
lularly. After 2 to 3 months, the skin layers are reestab-
lished and ink is concentrated in the dermis within
fibroblasts, beneath a layer of fibrotic scar tissue (Figure
30-2).
Numerous chemicals and inks are used in the tattoo
industry and the component ink compounds in a given
tattoo are usually unknown by the patient at the time
of presenting for tattoo removal. The Food and Drug
Administration (FDA) does not regulate tattoo inks and,
therefore, tattoo inks are not evaluated for safety. In
general, amateur tattoos are often carbon based such as
burnt wood or pen ink, and there is a lower density of
pigment particles. Professional tattoos are typically com-
posed of organic dyes mixed with metallic elements that
give the color: red is often made from mercury; yellow
from cadmium; green from chromium; blue from cobalt;
white from titanium dioxide; and flesh color from iron
oxide. Tattoo inks are usually combinations of colors,
so a green, red, or light blue tattoo may also contain
darker colors such as black ink.
LASER PRINCIPLES
Tattoo ink serves as a cutaneous chromophore for lasers.
Certain wavelengths of light are selectively absorbed by
different ink colors.4 In this way, colored inks can be
targeted and removed by laser light with minimal
damage to surrounding tissues. The chromophore
absorption spectrum of the tissue chromophores,
melanin and oxyhemoglobin, as well as wavelengths
used for tattoo removal, are shown in Figure 30-3.
Wavelength selection for different tattoo colors is shown
in Figure 30-4 and is as follows:
• Black and dark blue inks are best treated with a
1064 nm wavelength.
• Red ink (and variations of red such as orange and
yellow) is best treated with a 532 nm wavelength.
• Green ink is best treated with 650, 694, or 755 nm
wavelengths.
• Sky blue is best treated with a 585 nm wavelength.
• Purple is a combination color and can be treated with
585 and 532 nm wavelengths.
Laser parameters including wavelength, pulse dura-
tion, and fluence can be tailored to maximize tattoo ink
destruction and minimize thermal damage to surround-
ing tissue. Short pulsed, Q-switched lasers further
employ photoacoustic vibration to fragment tattoo ink
into smaller particles. These smaller ink particles are
eliminated through epidermal extrusion, lymphatic
drainage, and macrophage phagocytosis. In addition,
laser-treated ink particles have altered optical properties
that render the ink remaining in the skin less visible to
the eye.5
Laser Parameters and
Tattoo Treatments
• Pulse width, or pulse duration (measured in nanosec-
onds) is the length of time that laser light is in contact
with the skin. Q-switched lasers have fixed nanosec-
ond pulse widths and this parameter cannot be
adjusted for treatments.
• The thermal relaxation time (measured in seconds) is
defined as the time required for the absorbed energy
within the target chromophore to cool to one-half its
original value immediately after irradiation. To spe-
cifically target the chromophore ink and reduce
unwanted thermal damage to surrounding tissues,
367
30 SECTION THREE  •  Cosmetic Procedures

Ink particles
Epidermis
Tattoo needle
puncture site
Dermis

Subcutaneous layer
A

FIGURE 30-1  Dermabrasion results for tattoo removal showing

scarring, hypopigmentation, and residual ink. (Copyright Rebecca
Small, MD.)

very short pulse widths (shorter than the target

thermal relaxation time) are used to heat and ablate
the ink faster than heat is conducted to the sur-
Fibrotic layer
rounding tissue.
• Spot size (measured in millimeters) is the diameter of Ink particles
the laser beam on the skin surface. Use of a larger
spot size results in less scatter of the photons and
deeper laser beam penetration. This maximizes the C
distribution of laser light to the dermal ink and FIGURE 30-2  Tattoo placement and dermal incorporation of ink
reduces epidermal injury. Larger spot sizes should be (A) immediately after tattooing, (B) 1 month, and (C) 2 to 3 months
after.
used as long as sufficient fluence can be obtained to
achieve the desired clinical endpoint. A smaller spot
size (e.g., 2 to 3 mm) has greater scattering of
photons, delivers energy less efficiently, and causes

Oxyhemoglobin
650
532 Melanin
694
585
Absorption coefficient (cm–1)

1000
755
1064
100

10

0
400 500 600 700 800 900 1000 1100 1200 1300 1400
Wavelength (nm)

UV Visible light Infrared light

FIGURE 30-3  Chromophore absorption spectra and tattoo removal lasers.

368

1064 nm
Black
585 nm
Sky blue
532 nm
Red
650 nm, 694 nm,
755 nm
Green
FIGURE 30-4  Laser wavelengths used for different tattoo colors.
(Copyright Rebecca Small, MD.)
more epidermal injury than larger spot sizes (e.g., 6
to 8 mm).
• Wavelength (measured in nanometers) is chosen
based on the tattoo ink color. In general, as the wave-
length increases, so does the depth of penetration.
• The energy output is known as fluence (measured in
joules per square centimeter). More specifically,
fluence is defined as the amount of energy delivered
per unit area. Fluence should be sufficient to produce
immediate whitening with tattoo treatment without
bleeding or blistering. The fluence emitted with a
given spot size is dependent on the device used.
Adequately powered tattoo laser devices can main-
tain high fluences (e.g., more than 4.5 J/cm2) with
large spot sizes (e.g., 6 mm).
PATIENT AND TATTOO SELECTION
Lasers may be used for tattoo removal in patients of all
skin types (Fitzpatrick types I through VI). However,
patients with darker skin types (IV through VI) are at
greater risk for side effects, specifically hypopigmenta-
tion and hyperpigmentation. Topical hydroquinone
(2% to 8%) can be used preprocedure, and resumed
once the skin is healed postprocedure, to reduce
the risk of postinflammatory hyperpigmentation in
patients with darker skin types. Additionally, patients
of Asian or African descent have a greater predisposi-
tion to hypertrophic and keloidal scarring. In general,
30  •  Tattoo Removal with Lasers 30
Fitzpatrick skin type VI patients have the greatest risk
of complications with any aesthetic procedure, and pro-
viders should consider treatment of this skin type an
advanced laser application.
Almost any tattoo is indicated for laser tattoo removal.
Multiple treatments are needed to achieve satisfactory
results. Due to great variation in tattoo ink depth,
density, composition, and techniques used for place-
ment, the number of treatments needed for removal
can be difficult to estimate accurately. In general, pro-
fessionally placed tattoos have a high ink density and
require 9 to 14 treatments, whereas amateur tattoos
typically require 4 to 8 treatments. Several other factors
can affect the number of treatments necessary for
removal: faded, older tattoos on paler skin types in
more proximal locations tend to resolve with fewer
treatments than intense, multicolored tattoos on darker
skin types in distal locations.6 Patients should be ques-
tioned about other tattoo removal methods used previ-
ously. Methods that create scar tissue, such as burning
or abrasion, can make tattoo removal with lasers less
successful.
Certain types of tattoos are considered advanced, and
treatment should not be undertaken until the provider
is fully confident in his or her skill with artistic tattoo
removal. Advanced tattoos include cosmetic tattoos,
such as those used for permanent eyeliner or lip liner,
flesh-colored inks, and traumatic tattoos.
INDICATIONS
Laser tattoo removal is indicated for the treatment of
ectopic skin pigment. This pigment is usually from pur-
posefully placed ink in tattoos (both professional and
amateur artistic tattoos) as well as tattoos associated
with medical procedures (e.g., radiation therapy
tattoos). In rare cases ectopic pigment may be the result
of trauma (traumatic tattoos) where materials such as
asphalt are trapped in the dermis.
ALTERNATIVE THERAPIES
The following alternatives to Q-switched laser tattoo
removal methods are not recommended:
• Dermabrasion (not to be confused with
microdermabrasion)
• Salabrasion
• Cryotherapy (liquid nitrogen)
• Continuous-wave lasers
• Chemical acids
• Thermal injury (electrocautery).
The results of using these alternative modalities are
often unsatisfactory to both patients and health care
professionals. These techniques significantly increase
the risk of adverse effects including scarring, hypo­
pigmentation, hyperpigmentation, depigmentation,
incomplete resolution of ink, pain, prolonged healing
time, infection, textural changes, and unpredictable
369
30 SECTION THREE  •  Cosmetic Procedures
outcomes. The advantage of these techniques is that
they are relatively inexpensive and may offer faster ink
resolution when compared to laser tattoo removal
treatments. Some providers use surgical excision as a
method of tattoo removal.
PRODUCTS CURRENTLY AVAILABLE
Q-switched lasers are now widely regarded as the gold
standard for laser tattoo removal. Current Q-switched
lasers available include:
• Q-switched Nd:YAG laser (1064 nm)
• Frequency doubled (532 nm)
• Dye modules (650 nm and 585 nm)
• Q-switched alexandrite laser (755 nm)
• Q-switched ruby laser (694 nm).
The Q-switched Nd:YAG (neodymium-doped yttrium
aluminum garnet) produces a 1064 nm wavelength of
light that is ideal for treating black ink. A primary dis-
advantage is its limited efficacy in removing yellow and
green inks. With some devices, through a process called
frequency doubling, an Nd:YAG laser can also produce
light with a wavelength of 532 nm to treat red, orange,
and yellow inks.20 The Nd:YAG laser has an advantage
of treating darker skinned patients with less risk of
hypopigmentation, hyperpigmentation, and textural
changes.7 This can be attributed to the increased dermal
penetration of this longer wavelength and the lower
melanin absorption. The wavelength of the light emitted
by the Q-switched alexandrite laser is 755 nm. This
wavelength has excellent absorption by black, good
absorption by green and blue, but poor absorption by
red ink. The ruby laser was one of the first Q-switched
lasers, and it emits a 694 nm wavelength. It works well
for darker colors (black, blue-black, and some green),
but poorly on yellow and red ink. Although more effec-
tive for green ink than the Nd:YAG, the ruby laser com-
monly causes hypopigmentation and hyperpigmen­tation
and, although usually transient, may be permanent.5
Recently, a number of lower cost, Q-switched devices
have become available. Although considerably less
expensive, these units have little to no long-term track
records and are of unknown quality. Choosing a device
with a more established company is recommended.
CONTRAINDICATIONS8
• Ink allergy.
Also see Chapter 26, Hair Reduction with Lasers, for addi-
tional laser contraindications.
ADVANTAGES OF LASER
TATTOO REMOVAL
• Considered the “gold standard” for tattoo removal.
• Individual treatments are relatively quick.
370
• Provides the best cosmetic result when compared to
other forms of tattoo removal.
DISADVANTAGES OF LASER
TATTOO REMOVAL
• Expensive.
• Painful.
• Multiple treatments are required.
• The procedure has risks of hyperpigmentation,
hypopigmentation, depigmentation, and textural
changes.
EQUIPMENT
• Q-Switched laser device
• Topical anesthetic
• Tongue depressors to apply anesthetic
• Gauze pads to remove anesthetic
• Sterile wipes or alcohol wipes to cleanse the treat-
ment area
• Protective eyewear for patient and laser operator and
any other personnel in the room
• Appropriate door sign indicating laser usage
• Ice packs
• Nonsterile gloves
• Face shield for laser operator (optional)
• Masks for laser operator (optional).
Although relatively reliable, Q-switched lasers, like
any laser device, are made of sensitive components.
Q-switched lasers should not be transported from loca-
tion to location and all measures should be taken to
move the device as little as possible. To ensure that
calibration and mirror alignment within the laser arm
are adequate, one can aim the laser on a wooden
tongue depressor and observe the formation of concen-
tric circles with a laser pulse. If this pattern does not
appear, the equipment is due for a calibration. When
not in use, the foot pedal should be properly stored and
the key removed. Always take care to not damage the
laser arm.
Q-switched lasers can rupture blood vessels and
aerosolize tissue, so a laser operator may choose to use
a plastic shield or a cone device on the laser tip to
protect from tissue and blood contact as well as a face
shield and mask.
PROCEDURE PREPARATION
1. Review the patient’s medical history to ensure there
are no contraindications to treatment (see Contrain-
dication section). If there is a history of herpes simplex
in or near the treatment area, prophylactic antiviral
medication is used 2 days prior and 3 days after the
treatment. If the risk of herpes is low, antivirals may
instead be started on the day of treatment.
2. Review the tattoo history: amateur/professional/
cosmetic/traumatic, years present, flesh-colored or

FIGURE 30-5  Red tattoo ink dermatitis, prior to laser treatment.
(Courtesy of W. Kirby, MD.)
white ink, “cover-up” tattoo, previous methods used
for removal and scarring at the tattoo site.
3. Determine the patient’s Fitzpatrick skin type (see
Chapter 19, Aesthetic Principles and Consultation).
4. Perform a brief and focused physical examination
to rule out ink allergy. Ink allergy presents with signs
of an allergic contact dermatitis (erythema, edema,
induration, and discomfort in previously tattooed
areas). A severe red ink dermatitis is shown in
Figure 30-5. Examine the tattoo carefully for areas
of scarring; document if present and inform the
patient.
5. Photograph the tattoo.
LASER TATTOO REMOVAL: STEPS
AND PRINCIPLES
The following guidelines are based on treatment of
artistic tattoos using a Q-switched laser (HOYA ConBio
RevLite), which is indicated for all Fitzpatrick skin types
(I through VI). Manufacturer guidelines specific to
the device used should be followed at the time of
treatment.
General Treatment Technique
1. The appropriate wavelength is selected for the tattoo
ink color to be treated. Colored inks are often a
mixture of different colors and it is safest to use a
1064 nm wavelength for initial treatments of multi-
colored tattoos.
• Treatment 1: Use a 1064 nm wavelength regardless
of the color of the tattoo.
• Treatments 2 through 4: Use a 1064 nm wavelength
for multicolored tattoos in the dark areas (black,
blue, purple, green), and a 532 nm wavelength
for red-colored ink areas.
• Treatments 5 and greater: Treat the whole tattoo
with a 1064 nm wavelength first and then treat
30  •  Tattoo Removal with Lasers 30
specific colored areas with the wavelength appro-
priate for the color. For example, the fifth treat-
ment for a green tattoo with red and sky blue
ink would be as follows: 1064 nm to the whole
tattoo, followed by 650 nm to the whole tattoo,
532 nm to the red areas, and 585 nm to the sky
blue areas.
2. Start with larger spot sizes (e.g., 6 to 8 mm) for
initial treatments and progress to smaller spot sizes
(e.g., 4 mm) over the treatment series. Larger spots
penetrate deeper and are less aggressive with fewer
side effects.
3. The laser tip is moved smoothly in a painting motion
over the tattoo and is not in direct contact with the
skin.
4. Universal precautions should be used during and
after the treatment due to possible tissue splatter and
bleeding.
Planning and Designing
Treatment of thinner skinned areas such as the neck,
breast, and below the knees can result in adverse reac-
tions, so conservative settings with lower fluences and
larger spot sizes are advised.
For large tattoos covering an entire extremity, con-
sider performing the dorsal area in one session and
volar area in a subsequent session to avoid circumfer-
ential edema and a possible tourniqueting effect.
“Cover-up” tattoos, in which a second tattoo has
been placed on top of the initial tattoo, have a greater
density of ink and should be treated with very low flu-
ences initially to reduce the risk of overtreatment.
Anesthesia
Tattoo treatments are painful but can be performed
relatively quickly. Some patients may forgo anesthesia
altogether, but many patients require some form of
local anesthesia. A topical anesthetic cream such as
benzocaine:lidocaine:tetracaine (see the Resources list at
the end of the chapter) may be used under occlusion
with plastic wrap for 30 minutes in the office prior to
the laser treatment. If complete anesthesia is desired,
injections of 1% or 2% lidocaine with epinephrine sub-
dermally may be used. Local injection is discouraged by
the authors because clinical experience has shown
increased bleeding and edema at the time of treatment,
rendering treatments less effective.
Performing the Procedure
1. Remove any reflective jewelry that may scatter
laser light.
2. Apply topical anesthetic (such as benzocaine:lidoca­
ine:tetracaine) in the office and remove after 30
minutes of contact time.
TIP: Patients will experience discomfort in spite of
analgesic measures used, and reminding patients
to breathe during treatments will assist with pain
management. Squeezing the treated area is also
a useful distraction technique.
371
30 SECTION THREE  •  Cosmetic Procedures
3. Position the patient on the treatment table in a
comfortable position allowing for exposure of the
tattoo.
4. Cleanse the treatment area with a sterile wipe or
alcohol and allow to dry.
5. Provide wavelength-specific protective eyewear to
all people in the room. If working on the face,
provide the patient with lead extraocular goggles.
6. The laser operator should be positioned comfort-
ably, often sitting, as opposed to leaning over the
patient. This will allow for comfortable manipula-
tion of the headpiece while depressing the foot
pedal that is used with most laser systems.
7. The wheels on the device should be placed in the
locked position to ensure that the unit does not roll
during treatment.
8. Select the appropriate wavelength for the tattoo
color (see the General Treatment Technique section
earlier in this chapter).
9. Select the appropriate spot size based on the
patient’s Fitzpatrick skin type using the manufac-
turer’s guidelines. In general, for initial treatments,
larger spot sizes (e.g., 8 mm) should be selected
for darker Fitzpatrick skin types (V and VI) and
smaller spot sizes (6 mm) for lighter skin types (I
through III).
10. Confirm again that everyone in the room is wearing
appropriate eyewear at all times and all doors are
fully closed.
11. Hold the handpiece at a 90-degree angle to the
skin.
12. Instruct the patient not to move if he or she experi-
ences discomfort and, to inform you if a short rest
is needed during the treatment.
13. Perform a test spot on the darkest area of the tattoo
using the 1064 nm wavelength (regardless of the
tattoo ink color) and observe for clinical endpoints.
The amount of ink present is highly variable and
settings will be determined by the tissue response
to the test spot performed. Desirable clinical end-
points include:
• Whitening of the tattoo ink. Figure 30-6 shows
whitening of a black ink tattoo using a 1064 nm
Q-switched laser (HOYA ConBio RevLite).
• Audible and palpable snapping felt during laser
pulses due to photoacoustic vibration.
• Edema.
• Petechiae are desirable endpoints and indicate
aggressive settings. This is more commonly seen
with shorter wavelengths, such as 532 nm.
TIP: If the tattoo ink appears yellowish or brown
immediately after the laser pulse, increase the
fluence to obtain a white spot.
TIP: Dark tattoos with high concentrations of ink
will require lower starting fluences and larger
spot sizes than lighter faded tattoos.
14. Pinpoint bleeding results from vascular injury and
represents an overly aggressive treatment. The
fluence should be reduced if this occurs. Some of
the newer tattoo laser technologies available have
modified beam profiles, which have reduced the
occurrence of pinpoint bleeding.
372
15. The initial treatment session may be performed
with conservative settings and minimal endpoints
to determine how a patient will respond, particu-
larly with darker skin types and very dark tattoos.
16. At subsequent visits the tattoo ink will lighten and
the fluence should be increased or spot size reduced
for more aggressive treatments to achieve desired
endpoints. Typically, the fluence is increased first,
based on the manufacturer’s recommended treat-
ment parameters. After maximizing the fluence
over several visits, the spot size is then decreased
with an associated reduction in fluence.
TIP: A test spot should be performed at each visit
prior to initiating treatment to determine the
appropriate settings.
CAUTION: Watch for vasovagal signs of light-
headedness, perspiration, and fatigue and discon-
tinue treatment if these occur.
RESULTS
Immediately after a Q-switched laser treatment, the
tattoo will have a white discoloration. Figure 30-6
shows a blue-black tattoo during treatment with imme-
diate whitening. This white color change is thought
to be the result of rapid, heat-formed steam, causing
dermal and epidermal vacuolization. Patients may per-
ceive this as reduction of ink, but this positive change
is only temporary and typically lasts for 20 minutes or
less. Ink color will gradually fade during the month fol-
lowing each treatment. Results from laser treatments
for removal of tattoo ink are cumulative and results
from some treatments will be more noticeable than
others.
Figure 30-7 shows a blue-black professional tattoo
(A) before and (B) after five treatments with a
Q-switched laser using 1064 nm wavelength (HOYA
ConBio Medlite) demonstrating typical tattoo clear-
ance. Figure 30-8 shows a multicolor professional tattoo
(A) before, (B) midway through treatment with light-
ening of the black ink and hypopigmentation, and (C)
after completion of treatment with a Q-switched laser
FIGURE 30-6  Laser tattoo removal treatment showing immediate
clinical endpoint of whitening. (Copyright Rebecca Small, MD, using
HOYA ConBio RevLite™.)
 30  •  Tattoo Removal with Lasers 30

A B
FIGURE 30-7  A blue-black professional tattoo (A) prior to and (B) after completion of five treatments with a Q-switched laser using a 1064 nm
wavelength. (Courtesy of W. Kirby, MD, using HOYA ConBio Medlite™.)

using 1064, 532, and 585 nm wavelengths for black/
blue, red/yellow, and sky blue inks, respectively (HOYA
ConBio Medlite).
Occasionally colored inks may darken with treat-
ment due to darker constituent inks. Figure 30-9A
shows a red ink tattoo prior to treatment. This tattoo
was initially treated with a Q-switched laser using a
1064 nm wavelength (Medlite, Hoya ConBio) and the
tattoo ink darkened and became black in color (Figure
30-9B). Subsequent treatments were performed using
a 1064 nm wavelength for black and a 532 nm wave-
length for red ink areas.
AFTERCARE
Laser tattoo removal treatment normally results in tem-
porary swelling, redness, and tenderness of the treated
area, which may take a few hours to resolve. Ice is
applied immediately after treatment for patient comfort
and for 15 minutes every 1 to 2 hours on the day of
treatment to reduce the risk of blistering.
If the treated skin is fully intact and in an area that
will not be abraded, a broad-spectrum sunscreen (con-
taining zinc or titanium) with an SPF of 30 or greater
can be applied without a dressing. If the skin is not
intact, an occlusive ointment, like Aquaphor, should be
applied and loosely covered with a nonadherent dress-
ing and tape that is changed once daily, for moist wound
healing. Care should be taken not to macerate the
treated area with excessive occlusion. Once the skin is
intact, a daily broad-spectrum sunscreen should be
applied for the duration of the tattoo removal
treatments.
A crust may appear over the treated area that sloughs
off at approximately 14 days post-treatment. The treated
skin appears slightly shiny until the area has fully
healed. Crusts or blisters should not be removed and
patients cautioned against picking, which increases the
risk of scarring. Mild pruritus is part of the healing

A B C
FIGURE 30-8  A multicolor professional tattoo (A) before, (B) midway through treatment with lightening of the black ink and mild hypopigmen-
tation, and (C) after completion of treatment showing resolution of hypopigmentation with a Q-switched laser using 1064, 532, and 585 nm
wavelengths for black/blue, red/yellow, and sky blue inks, respectively. (Courtesy of R. Anderson, MD, and S. Kilmer, MD, using HOYA ConBio
Medlite™.)

373
30 SECTION THREE  •  Cosmetic Procedures
A B
FIGURE 30-9  Red tattoo ink (A) prior to and (B) after treatment with a Q-switched laser using a 1064 nm wavelength demonstrating paradoxical
darkening. (Courtesy of W. Kirby, MD, using HOYA ConBio Medlite™.)
process and is common during the first few weeks fol-
lowing treatment.
Strenuous exercise and exposure to water should be
avoided until the skin is intact. Elevation of treated
extremities can reduce edema.
FOLLOW-UP
A 6 to 8 week interval between treatments is necessary
to allow the skin to heal completely. This interval may
be extended without any reduction in efficacy and, in
fact, treated tattoo ink may continue to fade slightly
over time. The tattoo is appropriate for retreatment
once the skin is fully intact, without a crust and the
shiny appearance to the skin has resolved. Patients
often request more frequent treatment sessions as they
are usually highly motivated to remove their tattoos.
However, treating too frequently, such as every 4 weeks,
may increase the chances of textural changes, scarring,
and hypopigmentation.
COMPLICATIONS
• Hyperpigmentation
• Hypopigmentation/depigmentation
• Blistering
• Bleeding
• Textural changes
• Scarring (including hypertrophic and keloids)
• Prolonged healing
• Infection (e.g., herpes simplex, varicella zoster)
• Paradoxical tattoo darkening (flesh-colored ink or
permanent makeup)
• Allergic reactions with local dermatitis/nodules or
systemic allergic response (rare).
A fine line exists between expected side effects and
true complications from laser tattoo removal treat-
ments. For example, discomfort, swelling, blistering,
and itching are commonly associated with the treat-
ment8 but extreme pain, limb edema, bulla, and in­­
tractable pruritus are rare and indicate treatment
complications.
About half of the patients treated with Q-switched
lasers for tattoo removal will show some transient
374
changes in the normal skin pigmentation (hyperpigmen-
tation or hypopigmentation).5,9 These changes usually
resolve in 6 to 12 months but rarely may be perma-
nent.7,10 The risk of hyperpigmentation and hypopig-
mentation is greatest with skin types IV, V, and VI,
regardless of the wavelength used. Areas that blister
and bleed are more likely to have pigmentary and
textural changes.11 Twice daily treatment with hydro-
quinone and broad-spectrum sunscreens on fully healed
skin usually resolve hyperpigmentation within a few
months, although in some patients resolution can be
prolonged. Shorter wavelengths, such as 532 nm, are
more commonly associated with blistering and hypopig-
mentation than longer wavelengths.
Transient textural changes are common and typically
resolve within a few months; however, permanent tex-
tural changes and scarring can occur.10 If a patient is
prone to pigmentary or textural changes, longer treat-
ment intervals are recommended. Additionally, patients
with a history of hypertrophic scarring need to be
warned of their increased risk of scarring.
Local allergic responses to tattoo pigments have been
reported at the time of tattoo placement, and allergic
reactions to tattoo pigment can also occur after
Q-switched laser treatment.13–18 For example, photoal-
lergic reactions have been reported to yellow cadmium
sulfide, a pigment commonly added to tattoos to bright­
­en red or yellow inks. This reaction is also reported with
red ink, which may contain cinnabar (mercuric sulfide),
green (chromium), and blue (cobalt).21,22 Erythema,
pruritus, and even inflamed nodules, verrucose papules,
or granulomas may occur. The reaction is confined to
the site of the red/yellow ink. Treatment consists of
strict sunlight avoidance, use of sunscreen, intralesional
steroid injections, or in some cases, surgical removal.22
Q-switched lasers mobilize the ink through the lym-
phatic system and systemic allergic responses are
extremely rare complications. Oral antihistamines and
anti-inflammatory steroids may also be used to treat
allergic reactions to tattoo ink.23
TREATING SPECIFIC LESIONS
Caution should be used with cosmetic ink appearing
pink, flesh colored, or peach because these may
contain iron oxide or titanium oxide pigments.25 These
 30  •  Tattoo Removal with Lasers 30

pigments, when treated with a Q-switched laser, may
turn brown or black in a phenomenon known as para-
doxical darkening.9 Although this brown or black color
usually responds well to continued treatment, it can be
disconcerting to patients as the effect of early treatment
will often leave the tattoo looking darker than it did
prior to treatment. If tattoo darkening does occur, after
8 weeks, the newly darkened tattoo can be treated as
if it were black pigment with 1064 nm.
One of the newest forms of tattoo ink is an iridescent
pigment that is only observable under a black light.
Patients refer to these tattoos as “glow-in-the-dark.”
These patients should not be treated because their ink
contains no chromophore for selective absorption.
Occasionally patients will present with tattoos that
are slightly raised. Prior to laser treatment, if a tattoo is
palpable, it will still be palpable when the treatment
series is completed. It is important to remember that
Q-switched lasers only treat ectopic pigment and are
not intended to improve the texture of the skin.
Traumatic tattoos resulting from asphalt or “road
rash” can be effectively treated with laser tattoo removal
methods.24 Obtaining a proper history is imperative
when treating any traumatic tattoo because case reports
of laser ignition from flammable debris have been
reported.12,26
equal to 9 in.2 may be $200; 10 to 25 in.2, $350; and
26 to 49 in.2, $500; with an additional $100 added for
tattoos containing red, sky blue, or green.
CONCLUSION
Tattoo removal has advanced greatly in the past decade
with the advent of highly selective Q-switched laser
technologies compared to early, nonspecific tattoo
removal modalities that relied on thermal and mechani-
cal destruction. Through the process of selective photo-
thermolysis and photoacoustic vibration, Q-switched
lasers can specifically target inks of all different colors
while minimizing damage to the surrounding tissues
and are now considered the gold standard for patients
seeking tattoo removal.
Resources
Tattoo Removal Lasers
Alma Lasers
Phone: 866-414-2562
www.almalasers.com
Asclepion Laser Technologies
www.asclepion.com

LEARNING THE TECHNIQUES Cynosure

Phone: 800-866-2966
Practice by drawing an image on a large grapefruit or www.cynosure.com
orange using a black permanent marker. This will serve
as an excellent model for practitioners new to Q- HOYA ConBio
switched laser techniques. As comfort level increases, Phone: 800-532-1064
practitioners can experiment with other colors until www.conbio.com
they feel their skill level warrants treatment on a
patient. Light Age
Phone: 723-563-0600
www.light-age.com
CURRENT DEVELOPMENTS
Lumenis
A recent development is the advent of a specific type of Phone: 408-764-3000
tattoo ink called Infinitink™. The pigment in this ink is www.aesthetic.lumenis.com
stored in transparent, biocompatible capsules, which
according to the company that produces it (Freedom Syneron (formerly Candela)
2™), require fewer treatments with Q-switched lasers Phone: 800-821-2013
for removal. No studies confirming this claim are avail- www.candelalaser.com
able. Furthermore, because tattoos are meant to be
permanent, it is questionable whether or not the tattoo Topical Anesthetics
artist community will embrace the use of this ink. American Health Solutions Pharmacy
(benzocaine:lidocaine:tetracaine (20 : 6 : 4)
ointment)
FINANCIAL CONSIDERATIONS Phone: 310-838-7422
www.AHSRx.com
Although tattooing of skin may be considered medically
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Additional Reading
Small R. Tattoo removal. In: Small R, ed. A Practical Guide to Cosmetic
Lasers. Philadelphia: Lippincott; 2012.