Last Friday, 8/29, Dr. Kaplan came in for his first tattoo removal session.  The tattoo was fresh but well healed.  It was approximately 2 weeks after the tattoo was placed.  Dr. Kaplan had been using the Wrecking Balm on it every 3 days, but notes that it didn’t seem to affect the ink on the balm-treated half of the tattoo.

“I was a bit nervous,” referring to how it would actually feel to get the tattoo removed.  Although we describe laser tattoo removal as a “rubber band snapping-feeling,” it’s hard to know how that will feel until you get it done yourself.  As with all his patients, Dr. K first put anesthetic ointment on the tattoo and occluded it with plastic wrap.  After waiting for 30 minutes to an hour, he was ready to get treatment.

In the photos below, you can see Jeannine, our fabulous physician assistant, performing the treatment.  She holds the cooling device that blows cold air over the tattoo in one hand and the laser handle in the other.  The laser light is invisible except where it hits the skin.  Dr. K compared the feeling of the laser to that of getting the tattoo itself.  “It’s quite similar - the discomfort was about equal in intensity, but went by much faster for the tattoo removal.”

After the treatment, you can see Jeannine applying the Intensive Care aftercare ointment.  Dr. Kaplan will be back for additional sessions of tattoo removal every 4-6 weeks.  Stay posted!

Dr. Kaplan, the medical director of Tattoo MD, got a tattoo placed on his right arm last Monday. This is not something you’d expect from someone who specializes in laser tattoo removal, right? The reason he got the tattoo was not because he really wanted to have that design on his skin. It was to personally experience what it is like to get a tattoo and then what it is like to get it removed. Dr. Kaplan strongly believes in the benefits of laser tattoo removal and in the technology behind it. He has volunteered to go through the process himself in order to demonstrate how it works for others. Each step is being recorded on video for this purpose.

In addition to the planned laser treatment of the tattoo, Dr. Kaplan is doing something unorthodox. He is using Wrecking Balm tattoo removal cream prior to the tattoo healing completely. Only half the tattoo is being treated this way and the other half is left as a control side. We will see if using a topical lotion to try to get some ink out before it sets is useful. This is not a procedure that Wrecking Balm recommends but seemed to Dr. Kaplan like something worth trying since he knew he wanted to remove the tattoo immediately.

Check back with this blog for updates on the progress of Dr. Kaplan’s tattoo removal.

Tattoo regret may set in sooner for some people than for others.  Typically, someone may get a tattoo that is different from what they wanted or expected.  It might be the wrong color, shape, or design, or may contain a mistake, such as a misspelling.

At Tattoo MD, we often get inquiries about what can be done with a brand-new tattoo that is not quite healed yet.  This is a challenging problem since laser tattoo removal is not designed to be used on unhealed tattoos.  What benefit, if any, lasers would provide if used right away on a tattoo is unknown.

There is a lot of advice on the internet on what can be done for a new tattoo.   Some suggest to pick off the scab and pour peroxide in the wound on a frequent basis.  Others recommend the application of salts or creams before the tattoo heals completely. What all these methods have in common is to keep the skin from healing completely over the ink so that as much of the ink as possible will leak out during that time.

This may be somewhat effective.  A tattoo might become lighter or moth-eaten.  However, there is also a risk of causing an infection.  Already, with the placement of a tattoo, there is a foreign body in the wound.  As long as clean technique was used in tattooing, there is a low chance of infection.  If one starts to disturb the tattoo frequently and interferes in the healing process, though, there is a chance of causing an infection.  An infected tattoo can be quite a severe problem and requires treatment with a prolonged course of antibiotics, at the very least.  The potential for scarring may also increase with picking at the wound and the use of destructive solutions, such as peroxide.
In the end, although there may be some benefit in trying to mechanically leach the ink out of an unwanted new tattoo, there is also substantial risk.   No matter how successful this is, additional tattoo removal treatments, e.g. with a laser, will almost always be required.  At Tattoo MD, we recommend allowing a new tattoo to heal for at least 2 weeks prior to beginning laser treatment.

An article titled, “Motivation for Contemporary Tattoo Removal; A Shift in Identity” was released in the  July, 2008 issue of the Archives of Dermatology.  The study surveyed 196 tattooed patients presenting for laser tattoo removal from 2005-2006.  Comparison was made to a similar survey in 1996.

The study made several interesting observations.  It noted that the study subjects had more tattoos than in the 1996 survey (2.8 vs. 2.0) and were older when they presented for tattoo removal.  The mean waiting time for removal also shortened from 14 to 10 years.

In the first study, men outnumbered women, but it was the other way around in 2006.  Women reported more feelings of social stigma and negative comments associated with the tattoo as well as much higher reports of “hiding the tattoo” as a reason for removal.  Women in the study were also pierced more often than men (70% vs. 33%).

The survey appears to reflect general observations that can be made about changes in our society.  It seems that increased risk-taking behavior, such as tattooing, especially when it conflicts with societal expectations of one’s gender is more harshly punished in women than in men.  This may be reflected by the greater number of women getting tattoos and likewise greater number changing their minds later and wanting them removed.

Freedom-2 is the tattoo ink that had recently been developed to be instantly removable with a laser.  The ink is contained in microspheres that are permanent unless disrupted with a q-switched laser.  Once the ink is released from the microspheres with a single tattoo removal session, it dissolves away completely.

So far, there have been press releases that anticipated the launch of this product in 2008.  A recent visit to their website shows that there is a manufacturer of the ink, infinitink.  There is no date listed for availability of the product, but it appears that they are very close to taking orders from tattoo shops.

Naturally, some tattoo artists will be resistant to using the ink.  An artist may not want his or her art to be possibly temporary.  However, the marketplace will decide in the end.  If some clients insist on instantly removable ink, then they will probably find someone who is willing to accommodate them.

Since Tattoo MD works in cooperation with many local tattoo artists, we often share ideas and opinions on everything tattoo-related.   Tattoo artists welcome and appreciate the ability of laser to remove or lighten old tattoos that are difficult to cover up.  They know that in many cases, a cover-up will look much better if the underlying work can be removed.  Usually, if not always, the prior work was done by a different artist.  However, they often express the desire and belief that if someone were to get a new tattoo with them now, it should be permanent.

It is true that there will soon be an instantly-removable ink on the market, called Freedom-2 ink.  This is the ink that takes only 1 laser treatment to be completely removed.  When I ask artists if they plan to use this ink, most of them don’t like the concept of their work being able to be so easily removed.  Many, if not most, feel that this introduces vanity into tattooing and say that they would refuse to use it.  On the other hand, the marketplace may dictate the use of this ink, if enough people demand it and refuse to get any other ink put on.

It’s not just an issue of using Freedom-2 ink, though.  It is also known that certain types of tattoo inks are much harder to remove than others.  Organic charcoal or india-ink based black inks are much easier to laser remove than metal oxide-based black inks.  Some tattoo artists know this and prefer to use the metal oxide inks because they are so permanent.
So the point is, if you are getting a tattoo and are concerned that you may want to possibly have it removed in the future (even a tiny chance), you should consider the kind of ink that your artist is going to use on you.  Agree on the type of ink before they start, as it will be too late once it’s in your skin.

The art of laser tattoo removal involves not just selecting the right laser and wavelength to treat a tattoo. In the last blog entry, we went over the fundamentals of the laser and the importance of using the appropriate wavelength to treat different tattoo ink colors. In this entry, we’ll go over some subtler points.

The amount of energy in a laser shot can be varied from low to high. Most patients think that the higher the energy, also called fluence, the faster their tattoos will come off. This is not quite true. There is a maximum amount of energy that a tattoo can absorb. If additional energy is applied, then it is converted to heat which can injure the skin. As there is less and less remaining ink to absorb the laser energy, the fluence can be increased. The majority of the energy does not encounter tattoo ink and is reflected away. Less heat is generated and thus a higher energy can be safely used. There is of course a limit to how high the energy can be set.

Another aspect is beam profile. The laser beam that hits the skin is ideally completely uniform in energy from outer edge to the middle of the beam. This is not necessarily so. Laser manufacturers have continued making improvements in beam uniformity but this used to be more of a problem. Older lasers sometimes had higher energy in the center of the beam which could cause hot spots and non-uniform tattoo removal.

Some colors of ink absorb the available laser wavelengths very poorly. This makes them more difficult to fade with a laser. Colors such as yellow, pink, and purple are more difficult to remove than colors such as black, blue, red, and green. This does not mean that those colors cannot be removed at all, but that removal is more difficult and expectations should be lower.

Some inks may contain metal pigments, such as iron and titanium, that are much harder to remove than other inks. India ink, for instance, is much easier to remove by comparison. Since patients (and even tattoo artists) almost never know what the inks in their tattoos are composed of, there is no way to predict when this will be a problem.

The current state of the art in laser tattoo removal involves the use of q-switched lasers. The concept is based on “selective photothermolysis” and “photoacoustic effects.”
The ink from a tattoo is generally located within the dermis layer of the skin. The ink may be black, red, or almost any color. A laser light of a particular wavelength, such as 1064 nanometers, is differently absorbed by the particular ink in the tattoo than by the surrounding skin. Thus, the ink particles within a tattoo absorb much more laser energy than the surrounding normal skin. This is referred to as selective photothermolysis.
This difference in absorption though, is not enough to perform successful tattoo removal. The energy must be delivered so fast that it “shatters” the ink particles rather than just heating them up slowly. This is where “q-switching” comes in. The q-switch is like a super-fast shutter on the laser that allows only brief shots of laser light to come out at a time. When something is heated or cooled extremely quickly, it doesn’t have time to expand or contract properly, and so it cracks. This is the photoacoustic effect. If a non-q-switched laser of the proper wavelength were used to treat the tattoo, it would typically cause a burn in the area of the tattoo. This is why laser hair removal is not safe over a tattoo.
These are the two main elements of the mechanism of laser tattoo removal. There are other subtleties that are also important, such as the wavelength of the laser light, the size of the spot, the uniformity of the beam, and the amount of total energy applied to each burst of the laser.

Tattoos are treated with q-switched lasers of various wavelengths. The most commonly and successfully used laser is the q-switched Nd:YAG. It functions mainly at 1064 nm and 532 nm wavelengths. These wavelengths are absorbed by different colored ink pigments. For instance, black absorbs 1064 best while red absorbs 532 best. Other colors of ink may absorb these wavelengths of laser very little. Other lasers or filters, such as the ruby laser, are better for other colors. The ruby laser functions at 694 nm and is best absorbed by sky blue and green. Other colors, such as yellow, do not absorb any readily available laser light well.

These different wavelengths are also differently absorbed by the natural skin pigment, melanin. 1064 nm is virtually not absorbed by melanin., but 532 nm is most strongly absorbed by melanin. That means that a darker-skinned patient has higher risks of skin-pigment lightening, called hypopigmentation, when the shorter wavelengths of laser are used. A red tattoo is best treated with the 532 nm laser. In a caucasian, if there is mild hypopigmentation that may or may not occur, it will not be noticeable. In a darker-skinned patient, such as African-American, the removal of a red tattoo may leave a mark that is more noticeable than the original tattoo.

The hypopigmentation is not necessarily permanent and often returns to normal, but the risk of a persistent light spot where the tattoo used to be has to be considered. Therefore, when getting tattoos removed with a shorter wavelength laser, such as 532, we inform the patient of the risks of hypopigmentation. For dark-skinned patients, this occasionally factors against getting a tattoo removed.

If you are unhappy with a tattoo, you should look at all the options available for getting rid of it. Besides removing a tattoo, another option is to cover it up. If you are simply unhappy with the appearance of the particular tattoo but don’t mind having a tattoo in that area, then this may or may not be a viable option.

Getting a cover-up tattoo is a complex design process in many cases. There are various factors to consider: the color, size, and pattern of the original. Are there open spaces with which to work with? Also, scarring may be present in the area of the old tattoo. Lighter colors are easier to cover up than darker colors or black. The color covering up may need to be black depending on the original color.

One cannot just stroll into a tattoo shop and request any design one fancies. It may be possible to work the old tattoo into a new design, especially when there is a lot of remaining empty space, such as with cursive letters. Even with black cover-up, scarring from the old tattoo may still be visible through the new tattoo, especially when light hits the skin at a certain angle. The cover-up tattoo will usually be twice the size of the old tattoo. In general, large tattoos with wide areas of dark color are very hard to cover up. An attempted cover up may end up looking like a large black blob. A scrupulous tattoo artist will be able to tell you if a cover-up is a good option.

So if you are alright with a larger, darker tattoo in the same area, then a cover-up may be a reasonable option, depending on the characteristics of the original tattoo. However, many people rightly choose to remove the original one than take the chance of getting a larger tattoo that looks just as bad or worse. Laser tattoo removal may be a less risky option for this reason. Once a tattoo has been covered up, there may be much more ink there than originally. This will make it harder, sometimes impossible to remove it completely if you change your mind and decide to get it treated with laser after the cover up.