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Tattoo Removal Procedures and Potential Risks

Tattoos are permanent designs or marks etched on skin, created by injecting pigment directly into the dermis. Cells in the dermis (the deeper middle layer of skin) are more stable than those of the epidermis (top layer), which are continually shed throughout a person’s life. Therefore, the tattoo ink (pigment) stays in place with minimal or no blurring or fading overtime. Tattoo removal is a procedure used to eliminate or diminish these permanent designs.

There are several different techniques, including laser surgery, surgical excision and dermabrasion, performed by dermatologists to safely remove unwanted tattoos or greatly diminish their appearance. Laser surgery is the most popular procedure because of its less invasive nature. However, complete tattoo removal can still be difficult. For example, homemade or amateur tattoos are usually easier to remove with a laser because these are often made with only one type or color of pigment. Professional tattoos are typically multicolored and pigment volume and variety is greater, thus requiring a lengthier removal process. Keep in mind that the cost of tattoo removal can be much higher than the cost of the original tattoo.

People who wish to have their tattoos removed should consult a dermatologist who specializes in tattoo removal. Treatment by non-medical personnel (e.g., in tattoo parlors) is not advised. The dermatologist will evaluate the skin in the targeted area and determine the best procedure for tattoo removal. Photographs are usually taken to help evaluate the amount of improvement after surgery. In case of laser surgery, patch tests are performed to assess the patient’s response to the laser beam and to determine the setting for the laser treatment.

What to Avoid Before the Tattoo Removal Procedure

Tattoo removal should be avoided in people with active skin infections while those with a history of herpes simplex virus may require antiviral medications prior to treatment. Patients with other than skin infections may require antibiotics starting one day prior to surgery. Individuals with certain skin conditions such as psoriasis, eczema or vitiligo have a greater risk of flares following tattoo removal procedures. In addition, people who have used oral isotretinoin in the past 12 months may be at increased risk of atypical scarring. Also, certain medications (e.g., nonsteroidal anti-inflammatory drugs) and dietary supplements (e.g., vitamin E, niacin) must be avoided for several weeks prior to surgery. Since tanning makes the skin less responsive to laser beam, treatment must be postponed until the tan has completely faded.

Types of Tattoo Removal Procedures

Laser surgery. Because of minimal or no scarring, laser surgery is the most widely used method of tattoo removal today. A high-intensity laser beam is used to penetrate the dermis (the skin’s second layer), causing the ink (pigment) to break down or disperse so that it can be removed or flushed out by the body’s lymphatic system. The patient may experience needle-like pain, or a feeling of warmth, or stinging and burning sensation similar to that occurred when they received the tattoo. Redness and sensations of warmth may last for a few hours but also for a few days.

The specific type of laser used will depend on the type and the amount of tattoo ink used. Black, dark blue, some light blues and green inks as well as red ink respond best to laser therapy, while lavender, orange and yellow hues respond the least. In general, the red light or Q-switched lasers are most effective in removing dark ink tattoos. Multi-colored, intricate tattoos typically require treatment with more than one type of laser. In most cases, laser removal requires between six and twelve sessions (with each session lasting between 15 and 45 minutes) over a prolonged period of time. It may take up to a year to fully remove a tattoo.

The person’s skin color and its ability to heal is also a factor. Individuals with fair skin usually respond better to laser therapy than those with darker skin. Additionally, be aware that results vary from person to person depending on the age, size and type of tattoo.

Other common tattoo removal techniques include:

Surgical excision. The affected area is cut away with a scalpel and the wound is closed with stiches. However, if the wound is too large to be closed with stitches, a skin graft may be necessary. Skin grafting involves removing skin from another part of the body and attaching it to the targeted area. As with any type of surgery, surgical excision may result in scarring. This method is used for tattoos that are too deep to be treated with laser.

Dermabrasion. The surface and middle layers of the skin where the tattoo is located are mechanically removed using an abrasive, high-speed rotating device. Dermabrasion gradually helps raise tattoo ink from the dermis to the skin’s surface where it is absorbed into dressing bandages. If the tattoo is deep, skin grafting may be needed to even out the area treated. Dermabrasion may take anywhere from a few minutes to an hour or more, depending on the size and location of the tattoo. Often, several treatment sessions are required to achieve the desired effect and to prevent scarring. However, due to the invasive nature of this procedure, scarring may not always be avoidable.

All tattoo removal procedures are typically performed on an outpatient basis using local anesthetics applied directly to the skin. After tattoo removal surgery, patients may experience pain, swelling, bruising, itching, scabs and numbness in the treated area. The length of recovery varies by procedure, location and size of the tattoo that was removed as well as by patient. However, special emollients and dressings may help to speed the skin’s recovery. Postoperative restrictions may involve changes in a patient’s diet, drinking or behavior (e.g., washing or limiting sun exposure of the treated area for several months). In some cases, antibiotic medications may be prescribed to help ward off potential infections. The new skin that emerges as a result of laser surgery or dermabrasion is often pink. Gradually, the skin will take on a more normal appearance over a period of two to three months.

Potential Risks of Tattoo Removal

Generally, laser surgery that is performed properly by an experienced surgeon tends to deliver the best results with minimal risks. The most common side effects of laser surgery are temporary pigment changes. Increased pigmentation can be treated with bleaching creams. The risk of scarring is typically greater with dermabrasion and surgical excision. Using these two procedures can also result in thickened skin in some areas. Cortisone creams and injections may help the skin return to normal. In addition, fever blisters may appear in patients prone to frequent outbreaks of herpes infections.

Patients with darkly pigmented skin are more likely to experience adverse effects of the treatment such as burning, blistering, crusting or scarring because their own skin pigment melanin competes with the tattoo ink to absorb laser light energy. Therefore, such patients may require multiple treatment sessions and complete tattoo removal may not always be possible.

Other potential risks involve those associated with any surgery (e.g., bleeding, infection) or use of anesthetics (e.g., allergic reaction, breathing difficulties). A doctor should be alerted if clotting disorders are suspected, or bleeding or scarring with keloids occurs, or skin remains red, itchy or elevated after it has healed.