Tattoo Removal

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Industry News ❚ Meeting Review ❚ Practice Management ❚ Events ❚ Product News July/August 2016

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Volume 6 July/August 2016

❙ Volume 6 Issue 4

Issue 4 ❙ Laser body sculpting and skin tightening INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE taking aesthetic procedures to a new dimension. INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

Dual-wavelength laser procedure combining unique PIANO® and ® TATTOO SMOOTH technologies for deep as well as superficial skin tightening and fat reduction. REMOVAL using a multilayer Q-switched laser

Dynamis Multi-Application Laser System www.fotona.com TREATING choose perfection HYPERPIGMENTATION To learn more about TightSculptingTM and what the SP Dynamis WITH COMBINATION INJECTIONS can do for your practice contact Fotona at [email protected] today. COSMECEUTICALS REVERSING DERMAL INJURY

prime-journal.com THE INFLUENCE Committed to designing, manufacturing and delivering: OF FOOD

97564/1 The Highest Performance, Best Made Laser Systems in the World ON CANCER AND AGEING PEER-REVIEW | TATTOO REMOVAL | TATTOO REMOVAL USING A MULTILAYER Q-SWITCHED LASER Leonardo Marini explains how using sequential, multilayer fractional and full beam Q-switched laser technology can improve tattoo removal results

ABSTRACT multilayer techniques have been proposed to photo-acoustic ablative fractional 1064-nm Laser-assisted tattoo removal has shorten tattoo clearing time. Photo-thermal Q-switched laser technology with a sequence revolutionized the medical approach to ablative fractional laser technologies can of 2-3 full beam Q-switched laser passes eliminate ink particles located within be effectively combined with multiple full has proven effective in reducing multilayer dermal layers. Nano-second and sub- beam Q-switched laser passes during the laser session time as well as the number of nanosecond technologies have proven same session improving the efficiency of sessions required to clear tattoo pigments effective in clearing tattoo pigments with intra-dermal ink particle removal processes. both in ‘virgin’ and resistant tattoos. Skin minimal side-effects and complications Ablative fractional Q-switched laser textural changes related to tattoo procedures when proper treatment parameters are technology has been recently introduced, and previously performed tattoo removal selected. The process of tattoo removal paving the way for a virtually thermal- procedures can be improved by photo- is a lenghty procedure requiring multiple free photo-acoustic tissue ablation and acoustic ablative fractional Q-switched laser sessions spaced 2–4 months apart. Recently remodelling. The idea of combining a tissue remodelling. LEONARDO MARINI MD, Skin Doctors Center, Via dei Bonomo 5/a, Trieste, 34100, ATTOOS AND BODY PIERCINGS HAVE diagnostic and surgical procedures4-5. This side-effect is Italy become popular among young adults in not widely known but public awareness campaigns will email: leonardo.marini@ most developed countries around the presumably contribute to decrease tattoo procedures as skindoctors.it world, and this trend seems to be well as increase tattoo removal in the near future. progressively increasing1. The reasons Short (nanosecond) and ultra-short (picosecond) laser behind the tattoo phenomenon remains systems have revolutionized tattoo removal procedures aT mystery, even if most tattoo bearers confirm a since they represent the perfect technological translation ‘personal’ need for individuality and identity with of the theory of selective photo-thermolysis applied to specific groups2. However, progressive social interactions microscopic targets6–8. Their high peak power, associated and specific working environments may induce tattoo with an extremely short pulse duration, enables these bearers — women more than men — to seek medical laser systems to limit their destructive action to targets as assistance to remove their tattoos. Reasons and small as average tattoo ink particles (40 nm), without — or contributing factors for tattoo removal have been minimally — affecting non-pigmented peripheral cells recently analysed, and include fear of negative and tissue. Single pass Q-switched (Q-S) laser procedures, comments and improving ‘self identity’3. even if progressively effective, usually require an average Additionally, numerous studies have confirmed that of 8–12, and sometimes more, sessions spaced 2-3 months COVER STORY tattoo pigments do not remain in the dermis. With time, apart to clear tattoos. Tattoo removal with this technology they are progressively transferred to regional lymph requires a lot of patience from both patients and KEYWORDS 9 Q-S laser, tattoo removal, nodes through lymphatic vessels. Ink pigments within physicians . pigment, fractional laser lymph nodes might affect medical interpretations during An interesting multilayer, full beam Q-S laser

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Progressive social interactions and specific working environments may induce tattoo ‘bearers’ — women more than men — to seek medical assistance to remove their tattoos.

prime-journal.com | July/August 2016 15 ❚ PEER-REVIEW | TATTOO REMOVAL | | TATTOO REMOVAL | PEER-REVIEW Save 15% on the latest procedure (R-20) has recently been presented with the implemented by different State members. Tattoo inks can aim of reducing the total number of laser sessions10. be easily purchased from international manufacturers Unfortunately, this innovative approach has been and, besides water, contain glycerine, ethanol, and dermatology books considered too complex to be routinely used in sometimes preservatives. Colour particles are clinical practice, since 20 minute intervals composed of organic and synthetic pigments between laser passes was considered and are different in size (Table 1). The smallest excessively long. These intervals were are the black particles and consist of carbon from CRC Press necessary to eliminate sub-epidermal gas Colour particles are particles with a mean diameter ranging from 41 bubbles generated by the Q-S photo-acoustic composed of organic and to 165 nm. Most of the black particles (99.94%) effect, before proceeding with subsequent are less than 100 nm in size. White pigments are synthetic pigments and are laser passes. Topical application of usually the largest and consist of TiO2. Their perfluorodecalin was reported useful in different in size. diameter usually ranges from 317 to 738 nm, but The Art of Skin Health Restoration and Rejuvenation reducing inter-laser-pass intervals and the some inks may contain particles less than Second Edition overall duration of the original R-20 procedure11. The 100 nm in size. Green, blue (phthalocyanines), red and Zein E. Obagi, M.D. author thought to ‘prime’ tattoos with a preliminary yellow (azo-pigments) particles are between black and 19 December 2014 | 424pp | 9781842145968 | £121.00 micro-ablative (2,940 nm Er:YAG or 10,600 nm CO2) white pigments in size . fractional pass or micro-acoustic The biological activity of the • Discusses skin peels, approaches to correcting sun damage, 1064 nm Q-S fractional pass microparticles increases as they control of the pigmentary system, and stimulation of skin collagen before performing two or three Table 1 Tattoo pigments decrease in size. Nanoparticles • Details the scientific thinking behind treatment regimes full beam Q-S laser passes to (NPs) are defined as particles with at • Shows how to integrate skin care into a dermatology practice or spa eliminate gas bubbles through VIOLET Manganese violet, indigoid least one dimension less than • Contains more than 200 color illustrations - both drawings and the many micro-holes created by 100 nm. Traditionally, risk BLUE Cobalt aluminate, phthalocyanine, ferric ferrocyanide, the first pass12. The author was assessment of biological clinical photographs indigoid then able to reduce tattoo interactions related to NPs were pigments by 80% after a single GREEN Chromium oxide, hydrated chromium sesquioxide, performed after inhalation, session and reach an almost malachite green, lead chromate, ferro-ferric cyanide, ingestion, and absorption through curcumin green, phthalocyanine dyes complete pigment clearance in the skin20. Carbon black pigments 4–6 sessions in the majority of YELLOW Cadmium sulphide, ochre, curcumin yellow, azo dyes, are produced by imperfect tattoos treated with this limonite, anthraquinone combustion and are available in a technique. Picosecond laser RED Mercury sulphide, cadmium selenide, sienna (red ochre, wide range of sizes (5–500 nm). systems claim to clear tattoo ferric hydrate and ferric sulphate), azo dyes, hematite Their perceived colour saturation is Mohs and Cutaneous Surgery: Maximizing pigment faster and better than FLESH Iron oxides inversely proportional to aggregate Aesthetic Outcomes Q-S nanosecond lasers but so far, size. Black inks contain high Edited by Alexander Berlin BROWN Ochre fractional multilayer Q-S amounts of polycyclic aromatic December 2014 | 173pp | 9781482221367 | £63.99 procedures seem to produce BLACK India ink, carbon, iron oxide, logwood extract, magnetite, hydrocarbons (PAHs) and even • Covers wound healing, surgical planning, intraoperative quite similar results13–16. graphite, ash phenol. Both can cause complex, immunologically-mediated skin techniques, and complications WHITE Titanium dioxide, zinc reactions21. Black carbon pigments • Details surgical scar revision, dermabrasion, laser scar revision, Tattoo pigment oxide, corundum characteristics are widely used, justifying a world neuromodulators and fillers, as well as topical and Professional tattoos are created production of over 10-million intralesional therapies for the improvement of scars by skilful tattoo artists and a tonnes reported in 2005. Up to 90% • Includes photographs and full-color anatomical drawings variety of pigments contained in of carbon black pigment is used by water-based tattoo inks are used the rubber industry — mostly in • Includes intraoperative surgical techniques and pearls to produce this popular form of tyres22. • Written by distinguished contributors who are experts in body art. Presently, there are few Carbon black has been classified their fields commonly implemented rules by the International Agency for regulating composition, Research on Cancer as possibly distribution, storage, carcinogenic for human and practical use beings — partly based on inhalation applied to tattoo studies in rats22. colour formulations. Biological damage 15% discount on all dermatology & In 2003 and 2008, from carbon black the European and ultrafine TiO is cosmetic science books Progressive social 2 Commission supposedly linked to Visit: www.bit.ly/PRIME-ObagiBerlin publishedinteractions and specific working their inflammogenic specific guidelinesenvironments may induce tattoo properties, through to automatically receive your discount on the chemical induction of reactive ‘bearers’ — women more than 23 composition of oxygen species (ROS) . TiO2 tattoo inksmen — to17-18. seek These medical assistance nanoparticle studies, carried out recommendationsto remove were variably their tattoos. on their potential carcinogenicity, www.crcpress.com 16 July/August 2016 | prime-journal.com prime-journal.com | July/August 2016 15 ❚ ❚ Prime - Obagi and Berlin.indd 1 29/01/2015 14:31:56 PEER-REVIEW | TATTOO REMOVAL |

gave conflicting results, with some authors suggesting Colour particle size seems to influence their local a possible genotoxicity in vivo, but with primary particle distribution within anatomical structures after their size of around 21 nm24. This particle dimension has injection. Larger particles tend to remain in proximity of not been found in tattoo inks so far. Azo- their initial deposition while NPs may reach the blood pigments tend to decompose into circulation and body organs, such as kidneys, liver, known carcinogens when exposed spleen, brain, and lungs. The liver and spleen are to light and laser irradiation25–26. considered the main sites of NP accumulation29. In Carcinogenicity studies have any case, once introduced in the dermis, tattoo demonstrated a possible link pigments are there to stay within the body for a with bladder cancer in lifetime and can induce transient or persistent humans27. In spite of all health problems related to their intrinsic these potentially alarming chemical and physical characteristics, findings, the safety profile injection sites, and tattoo sizes30. of tattoo pigments seems Permanent tattoo pigment accumulation to be very good. within regional lymph nodes can mimic intra-nodal calcium deposits during X-ray Biological diagnostic procedures, making histologic behaviour in the examination necessary when non-benign skin etiologies are suspected31. Intra-operative Tattoo procedures are observation of darkly pigmented tattoo- based on the meticulous related lymph nodes could be interpreted as intra-dermal micro-invasive metastatic disease during sentinel lymph introduction of pigments that node procedures performed on melanoma will inevitably trigger a cascade patients32–36. of reactions aimed at eliminating and/or isolating them from the body. Laser specific interactions Once deposited in the dermis, colour Among the procedures proposed to clear tattoos, short- micro-particles are progressively trapped nanosecond and ultra-short, picosecond laser systems are into lysosomes within phagocytic dermal presently considered the gold standard to remove tattoo cells — mostly fibroblasts, macrophages, and mast cells. pigments37–38 (Table 2). The first non- Up to 32% of freshly injected tattoo pigments have Old tattoos will progressively scarring removal of black tattoo been found to disappear from their original dermal appear as ‘ghosts’ of what they pigment was reported in 1983 by injection sites 42 days after tattoo procedures in mice28. used to be when freshly made. Reid et al., in Scotland using a This finding is the obvious consequence of the attempt Q-switched ruby laser39 (Figure 1). to eliminate foreign particles through the lymphatic Sometimes this lack of definition A greater understanding of laser- system, bloodstream, and trans-epidermal route. Over might be a sufficient motivation tissue and tattoo pigment time, the commonly observed fading of tattoos can be for tattoo removal. interactions have been made explained by a progressive release of colour particles by since, leading to the development apoptotic dermal cells drained by the local lymphatic of innovative technical and system28. Old tattoos will progressively appear as ‘ghosts’ procedural improvements40. Traumatic tattoos and of what they used to be when freshly made. Sometimes tattoos complicated by allergic-reactions have been this lack of definition might be a sufficient motivation for successfully cleared by pigment-blind ablative fractional tattoo removal. lasers41–42. Like any light source, laser wavelengths used to remove tattoo pigments have different penetration Table 2 Short (nanosecond) and sub-nanosecond, depths. Shorter wavelengths penetrate less than longer ultra-short (picosecond) laser systems and their wavelengths in biologic tissue. Short- and sub- pigment targets nanosecond, ultra-short lasers are able to generate a specific photo-mediated light-chromophore interaction NANO-SECOND (NS) 532-nm (5-20 ns) red known as the ‘photo-acoustic effect’. PULSE LASERS 585-nm (5-20 ns) blue A photo-acoustic effect refers to any process where 650-nm (5-20 ns) green absorption of optical radiation leads to the generation of 695-nm (10-20 ns) green-blue sound. It is produced when extremely intense (100 2 755-nm (10-20 ns) green-blue-brown million W/cm ) laser pulses are delivered in an ultra-short amount of time (billionths of a second), producing 1064-nm (5-20 ns) brown-black extremely high temperatures (>300°C) within specific PICO-SECOND (PS) 532-nm (350 ps) red PULSE LASERS chromophores, such as tattoo ink particles. Only high 755-nm (500-900 ps) green-blue-brown peak power laser systems are able to generate a 1064-nm (35-450 ps) brown-black homogeneous top-hat energy distribution on relatively larger spots allowing for a deeper penetration.

gaveThis conflicting particular kindresults, of absorptionwith some authors is able to suggesting generate Colour particle size seems to influence their local aan possible abrupt, genotoxicity extremely in confined, vivo, but photo-thermalwith primary particle effect distribution within anatomical structures after their sizewithin of selectedaround 21 nm targets,24. Thisalong particle with intrinsic dimension chemical has and injection. Larger particles tend to remain in proximity of notultra-structural been found modifications in tattoo inks related so far. to extremely Azo- rapid their initial deposition while NPs may reach the blood pigmentsvolume changes. tend These to decompose effects are also into associated with circulation and body organs, such as kidneys, liver, knownsudden carcinogens mechanical when waves exposed generated by volume spleen, brain, and lungs. The liver and spleen are toexpansion light and to the laser surrounding irradiation tissue25–26. (thermo-mechanical considered the main sites of NP accumulation29. In Carcinogenicityeffect)43. studies have any case, once introduced in the dermis, tattoo demonstratedTattoo particles a possible are fractured link and undergo chemical pigments are there to stay within the body for a withand structural bladder changes cancer leading in to modifications of their lifetime and can induce transient or persistent humansoptical properties.27. In spite Intracellular of all water within pigment- health problems related to their intrinsic thesecontaining potentially cells alarming abruptly reach boiling temperatures chemical and physical characteristics, findings,leading the to safety intracellular profile volumetric expansion, cell injection sites, and tattoo sizes30. ofmembrane tattoo pigments explosion, seems and subsequent release of laser- Permanent tattoo pigment accumulation tomodified be very good. tattoo particles into surrounding dermal within regional lymph nodes can mimic structures. Once free again, part of the fractured tattoo intra-nodal calcium deposits during X-ray Biologicalpigments will be ‘absorbed’ by the local lymphatic diagnostic procedures, making histologic behavioursystem, part will in be theeliminated through trans-epidermal examination necessary when non-benign skin‘extrusion’, and part will be slowly re-phagocytosed by etiologies are suspected31. Intra-operative Tattoodermal cells procedures explaining are the variable degree of pigment observation of darkly pigmented tattoo- basedpersistence on the after meticulous each laser treatment. related lymph nodes could be interpreted as intra-dermalIt is theoretically micro-invasive possible to recognize three aspects of Figure 1 (A) Q-switched laser laser and intensemetastatic pulsed disease light systems, during which sentinel should lymph not introductionlaser-induced of collateral pigments photo-acoustic that tissue interaction: platform with articulated arm be used tonode clear tattoos procedures47–51 (Table performed 3). on melanoma and (B) flat beam profile ■will The inevitably initiation trigger of the a acousticcascade wave — sudden thermal Laserpatients assisted32–36 . tattoo removal might be further adjustable focused handpiece of reactionsexpansion aimed due to at rapid eliminating energy deposition at the improved by increasing trans-epidermal elimination of and/ortissue isolating surface them by optical from absorption;the body. followed by inkLaser particles specific and optimizing interactions lymphatic transport, both Onceexplosive deposited vaporization in the dermis, exceeding colour enthalpy for the willAmong be addressed the procedures later in proposed the article, to and clear by tattoos, delaying short- or micro-particlesphase change are of water progressively to gas; and trappedthen plasma nanosecondblocking and post-laser ultra-short, treatment picosecond re-phagocytosis laser systems52. are intoformation lysosomes due to withinextremely phagocytic strong, non-linear dermal presently consideredCombined the multilayer gold standard Q-switched to remove tattoo laser cells — mostlyoptical absorption fibroblasts, at the macrophages, tissue surface and caused mast cells. procedurespigments have been37–38 ( Tableproposed 2). The to firstimprove non- Upby high-intensity to 32% of freshly laser injectedpulses tattoo pigments have Old tattoos will progressivelytattoo removal.scarring In removal a study of conducted black tattoo by ■been The found propagation to disappear of the acoustic from their wave original dermal appear as ‘ghosts’ of what they Kossidapigment T et al., was up reported to four subsequent in 1983 by ■injection The mechanisms sites 42 days of afterinjury — stress tattoo procedures in mice28. used to be when freshly made. laserReid passes et al., were in performed Scotland using during a Thiscaused finding by is the the extremely obvious consequence steep of the attempt theQ-switched same treatment ruby laser session39 (Figure (R-201). to pressure eliminate gradient foreign of particles acoustic throughwaves, the lymphatic Sometimes this lack of definition method).A greater Twenty-minute understanding inter-pass of laser- system,and cavitation bloodstream, bubbles and44 . trans-epidermal route. Over might be a sufficient motivation intervalstissue and were tattoo considered pigment time,Computer the commonly simulations observed confirmed fading of tattoos can be for tattoo removal. necessaryinteractions to have allow been cavitation made thatexplained tattoo by a inkprogressive particle release break-up of colour particles by since,bubbles leading escaping to the development through processesapoptotic dermal are cells photo-mechanically drained by the local lymphatic ofepidermal innovative layers 10. technicalThis innovative and mediated.system28. Old Minimal tattoos will collateral progressively tissue appear as ‘ghosts’ procedural improvementstreatment,40. Traumatic even if quite tattoos difficult and to damageof what theyis generated used to whenbe when proper freshly laser made. Sometimes tattoos complicated reproduce by allergic-reactions in clinical practice have been due parametersthis lack of definition are used. might Laser be a sufficient pulse motivation for successfully cleared byto pigment-blind its complexity, ablative was fractional able to durationtattoo removal. must be shorter than the lasers41–42. significantly reduce the number of thermal diffusion time across a Like any light source,sessions laser necessary wavelengths to clear used tattoos to characteristic length, linked to particle remove tattoo pigmentswith minimal, have transient different penetrationside-effects. diameter,Table and 2 lessShort than the(nanosecond) stress confinement and sub-nanosecond, depths. Shorter Topical wavelengths application penetrate of perfluorodecalin less than longer timeultra-short of target particles. (picosecond) Laser energy deposition laser systems and their wavelengths has in been biologic proposed tissue. to clear Short- post-QS and laser sub- must,pigment therefore, targets be both thermally and stress nanosecond,epidermal ultra-short whitening. lasers are A able few to seconds generate was a confined in order to physically disrupt tattoo particles45. specificreported photo-mediated to be sufficient light-chromophore in order to interaction clear sub- DisruptiveNANO-SECOND efficiency (NS) seems 532-nm to increase (5-20 ns) with decreasing red knownepidermal as the cavitation‘photo-acoustic bubbles, effect’. significantly decreasing PULSE LASERS laser pulse duration46. 585-nm (5-20 ns) blue A photo-acoustic effectthe refers overall to any R-20 process procedure where In spite of all these 650-nm extremely (5-20 interestingns) light- greenAmong all other absorptionprocedures of optical radiationtreatment leads time 11to. the generation of chromophore interactions,695-nm the single (10-20 pass ns) Q-switched green-blue sound. It is produced when extremely intense (100 proposed to clear tattoos, short-2 laser technique usually 755-nm requires (10-20 an averagens) of 8–12 green-blue-brown million W/cm ) laser pulsesTattoo are delivered removal in an with ultra-short sessions, and sometimes more, to clear tattoos. Recently nanosecond and ultra-short,amount of time (billionths of a second), producing 1064-nm (5-20 ns) brown-black ablative fractional introduced picosecond laser systems seem to require an picosecond laser systemsextremely are high temperatureslaser systems (>300°C) within specific PICO-SECOND (PS) 532-nm (350 ps) red averagePULSE ofLASERS 4–6 sessions to obtain similar results. presently consideredchromophores, the gold such Modern as tattoo ablative ink particles. laser technologies Only high Laser-assisted Q-switched755-nm and (500-900 picosecond ps) laser green-blue-brown peak power laser systemsand pulse are energy able modulation to generate have a treatments are not without1064-nm risks and (35-450 side-effects. ps) They standardbrown-black to remove tattoohomogeneous top-hatrevolutionized energy distribution operator on control relatively on are nevertheless minimal in comparison to millisecond pigments. larger spots allowing forphoto-thermal a deeper penetration. vaporization of

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Wound healing All treated sites followed a three-step dressing strategy aimed at providing a suitable environment to optimise wound healing.

biologicalImmediately tissue after using each 2940 nm laser procedure, Er:YAG and and 10,600 nm during Table 3 Cosmetic tattoos can sometimes be associated with 53–58 COthe2 laserfull duration systems of. Recently, the acute micro-ablative inflammatory fractional healing perceptible textural skin changes due to a variable technologyphase, all treated was tattoo also sitessuccessfully were covered associated with sterile with Tattoo treatment degree of scarring produced by the mechanical Q-switchedparaffin impregnated laser tattoo gauze removal, and aopening thin layer new of horizonsa hydro- perforations of dermal layers during the initial transfer of inactive skin rejuvenation colloid alginate procedures dressing59 . formulation (Flaminal side-effects and tattoo ink into the skin. These thin, irregular scar layers Forte,Ablative Flen-Pharma, fractional Belgium), laser technology with excellent (AFLT) hygroscopic has been are responsible for increased light diffraction during laser successfullyand anti-microbial used in properties. tattoo removal This procedures, specific medical either complications treatments, negatively influencing the overall efficiency alonedevice or enhances in combination trans-epidermal with Q-switched ‘extraction’ laser of systems. tattoo when using picosecond and Q-switched nanosecond (micro-particlesFigure 2) Micro-surgical freed by laser laser ablation procedures, of thin, while vertical creating skin ACUTE non-ablative mode lasers. Lasers using ablative fractional columnsa hostile environment has proven effectiveto microorganisms. in removing portions of technology (AFT) are not affected by dermal scarring Blistering tattooA final pigments cover wasthrough provided direct by destruction a sterile absorbing and external pad when considering their overall efficiency in destroying eliminationand TNT gauze. of microscopic Class 1 compression necrotic debris stockings (MEND). were Bleeding tattoo pigments. They can also contribute to improve the 2940 nmprescribed Er:YAG for tattoos and located 10,600 nm on the CO lower ablative extremities tattoo in textural quality of tattooed skin through progressive 2 Edema removalorder to does help not modify lymphatic the chemical-physical drainage. Patients structure were dermal remodeling41–42. ofinstructed tattoo pigments to remove since their compression stocking at night. Crusting bothDetailed systems written operate instructions wereAs provided in many to Pain Innovative combined laser-assisted withinstandardize millisecond dressing pulse procedures at home. The dressing tattoo treatments ranges.sequence Residual was performed ink 2–3 times other per day, fieldsduring theof Oozing In an attempt to optimize tattoo removal procedures, particlesfirst 3–5 days are partlypost-treatment, re- or untilmodern trans-epidermal laser Infection new innovative laser strategies have recently been phagocytisedoozing stopped. by dermal proposed with variable degrees of clinical success. As in dermatology, Tattoo ink darkening fibroblastsThe second and dressing partly stage, designed to assist the many other fields of modern laser dermatology, sequential Figure 3 (A) Q-switched fractional focused handpieces delivering 25 x 250-micron microspots drainedproliferating by phase the localof wound healing, consisted of a within 5mmAcute x urticaria5mm (left) and 10mmsequential x 10mm (right) combinations square areas. of (B) multiple visual findings laser of passes photo- have lymphatictopical application system of39–40 sterile. siliconecombinations gel (Stratamed, of thermal/photo-acoustic effect observeddemonstrated on blackened better wooden clinicaltongue depressor results than single ThisSwitzerland) particular to provide laser a full contact, surface-conforming,multiple laser LONG-LASTING/ technologies used alone63–65. Focusing our attention on approachsemi-permeable transparentwill film, able to protect the CHRONIC time-honoured Q-switched lasers, it has been significantlynewly formed decrease epidermis the from dehydrationpasses and potential have demonstrated that multiple sequential passes, Reactive overallmicro-environmental quantity irritations. of Oncedemonstrated dried, the thin performed during the same tattoo removal session, immune-mediated regional potentiallysilicone film was dangerous covered by a ultra-thinbetter hydrocolloid clinical lymphadenopathy were able to enormously enhance the efficiency of tattoopad to particles further protect through treatedresults areas bythan involuntary single intra-dermal pigment clearing, without increasing trans-epidermalmechanical trauma. This dressing sequence was Minimal textural changes complications and side-effects10. Sequentially technologies used elimination.performed once a day until a uniform, perfectly flat Hypertrophic scar combining 2940 nm Er:YAG or 10,600 nm CO2 ablative pinkishHigh energyepidermis fractional- was observed. Distally alone.located tattoos fractional resurfacing with full beam Q-switched lasers modeon limbs 1064 nm required Q-S longer laser healing time and patients were Keloid scar has proven more efficient than each laser technique systemspreliminary can informed.produce a relative colour-blinded, controlled Long lasting erythema used alone12,41,52,65. tissueThe last ablation dressing through sequence a combined was studied mechanism to optimise of The author was able to obtain similarly good tattoo Transient and permanent themicro-thermal early remodelling and photo-acoustic phase of wound effects. healingThis unique and clearing responses after a single laser session combining hypopigmentation consistedapproach of has a topical the potential application for of generating a super-potent, a photo- class an ablative 2940 nm Er:YAG laser fractional resurfacing 1,mechanical steroid (0.05% disruption clobetasol of ink particles, associated with a Hypopigmented (AFR) using a SP Dynamis platform (Fotona, Slovenia), propionate)significant trans-epidermal to be continued elimination of pigments12 tattoo (ghost) with two/three full top-hat beam, high peak energy All treated twice(Figure 3 a). Two day of the for three 2–3 main points proposed to Transient Q-switched laser passes performed with a QX Max laser consecutiveimprove the efficiency days ofper laser-assisted sites tattoofollowed removal: a hyperpigmentation unit (Fotona, Slovenia) (Figure 4–5). Five-minute intervals week — withincreasing trans-epidermal the purpose of elimination of ink particles, between laser passes were considered sufficient to stop three-step Depigmentation controllingand optimizing lymphatic excessive transport, will therefore be capillary bleeding. dressing strategy Figure 4 (A) Polychromatic tattoo (right arm). Clinical result (80–90% pigment clearing) after localizedimplemented neo-angiogenesis.52. Persistent/treatment Laser-assisted tattoo removal is not a painless 1 multilayer fractional (one 2940 nm Er:YAG laser ‘priming’ pass) and full flat beam Q-switched (two PulsedAblative steroid fractional treatment laser technology (AFLT)aimed has also at and threeresistant split tattoo tattoos 1064 nm) laserprocedure, passes. (B) Extremely particularly moderate when differences larger anatomical observed areas continuedbeen successfully for used one/two to improve theproviding cosmetic and a between 2 and 3 full beam laser passesand one multiple month post-treatment passes are considered. Therefore, the months.functional A aspects topical of scars wound60–62 . suitable author administered subdermal local anaesthesia to all remodelling cream (i.e. treated tattoo sites (1% mepivacaine plus 1:200,000 Cicalfate-Avene,Figure 2 (A) Heavily France,pigmented or black tattooenvironment on right forearm to(volar aspect). Clinical comparison epinephrine). Epinephrine was chosen to induce a between pre-AFR 2940 nm laser primed area (B–left) and intact skin (B–right) immediately after full Cicaplastbeam Q-switched baume laser (single B5-La 1064 nmoptimise Nd:YAG laser pass).wound Note cavitation bubbles trapped under temporary vasoconstriction able to reduce unnecessary Rocheintact epidermis Posay, and France) gas escape was through AFRhealing. pre treated skin. (C) Better pigment clearance light absorption by haemoglobin during the laser prescribed(80–90%) was toobserved be liberally on combined AFR plus full beam QS site 3 months after a single treatment procedure. Besides laser proof goggles, a suitable form of applied — a minimum of 2–3 times a day — during the ear protection is also required, since the Q-switched same dressing phase and until the next laser session. photoacoustic effect generates a high pitch noise during The author is very keen on the post-tattoo laser operation. treatment dressing sequence since tattoo sites require multiple laser sessions to be cleared. Dermal-epidermal Wound healing tissue needs to fully recover before planning subsequent All treated sites followed a three-step dressing strategy Figure 5 (A) Polychromatic fine-line tattoo (upper back). (B) Clinical result (90-100% pigment laser treatments in order to tolerate repetitive micro- clearing) after six multilayer laser sessionsaimed at(one providing 2940 nm Er a :YAG suitable fractional environment laser ‘priming’ to optimisepass wounding and the subsequent inflammatory response. followed by two 1064 nm full flat beamwound Q-switched healing. laser passes)

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biological tissue using 2940 nm Er:YAG and 10,600 nm Table 3 Cosmetic tattoos can sometimes be associated with 53–58 CO2 laser systems . Recently, micro-ablative fractional perceptible textural skin changes due to a variable technology was also successfully associated with Tattoo treatment degree of scarring produced by the mechanical Q-switched laser tattoo removal, opening new horizons perforations of dermal layers during the initial transfer of in skin rejuvenation procedures59. side-effects and tattoo ink into the skin. These thin, irregular scar layers Ablative fractional laser technology (AFLT) has been are responsible for increased light diffraction during laser successfully used in tattoo removal procedures, either complications treatments, negatively influencing the overall efficiency alone or in combination with Q-switched laser systems. when using picosecond and Q-switched nanosecond (Figure 2) Micro-surgical laser ablation of thin, vertical skin ACUTE non-ablative mode lasers. Lasers using ablative fractional columns has proven effective in removing portions of technology (AFT) are not affected by dermal scarring Blistering tattoo pigments through direct destruction and external when considering their overall efficiency in destroying elimination of microscopic necrotic debris (MEND). Bleeding tattoo pigments. They can also contribute to improve the 2940 nm Er:YAG and 10,600 nm CO ablative tattoo textural quality of tattooed skin through progressive 2 Edema removal does not modify the chemical-physical structure dermal remodeling41–42. of tattoo pigments since Crusting both systems operate As in many Pain Innovative combined laser-assisted Figurewithin 6 millisecond (A) Monochromatic pulse Up to 90% of treated tattoos (20 cases) demonstrated tattooused to completelytreatments cover all tattoo areas. Capillary tattooranges. (right Residual anterior chest). ink almost othercomplete fields pigment of clearing after 5Oozing sessions. Inbleeding an attempt was observed to optimize from tattoo each photo-acoustic removal procedures, micro- (B) Image taken immediately particles are partly re- After these encouraging results the author wanted to newablative innovative spot, confirming laser strategies the author havewas able recently to reach been the after first laser session modern laser Infection performedphagocytised according by dermal to the try a new sequential multilayer tattoo removal technique proposedpapillary andwith upper variable reticular degrees dermis of clinical (Figures success. 6–7). As Five- in dermatology, Tattoo ink darkening author’sfibroblasts protocol. and (C) Clinical partly using a Q-switched laser unit able to deliver its laser manyminute other intervals fields were of modernsufficient laser to stop dermatology, capillary resultdrained (almost by 100% the pigment local beam both insequential fractional and full Acute urticaria sequential combinationsbleeding, of multiple allowing laser thepasses following have clearing) after four multilayer lymphatic system39–40. beamcombinations mode (QX Max, of Fotona, demonstrated better full clinical beam results laser passes than single to be fractional (one 1064-nm laser Presently, time-honoured ‘priming’This particular pass) and full flat laser Slovenia).multiple Local anaesthesia,laser LONG-LASTING/ technologies used alonesafely63–65. Focusing and efficiently our attention performed. on beamapproach Q-switched (two will optical and acoustic protection, CHRONICshort-pulse Q-switchedtime-honoured lasers Q-switched The same lasers, successful it has clearing been 1064significantly nm laser decreasepasses) the and the post-treatmentpasses have dressing demonstrated that multiplerate was observed sequential after the passes, first seemReactive to withstand the challenge overall quantity of sequencedemonstrated were the same as the performed during the laser same sessions tattoo removalin the majority session, of immune-mediatedposed by regional the new generation of potentially dangerous previousbetter treatment clinical protocol. were able to enormouslytattoos enhance (up to 80%). the efficiency Up to 90% of lymphadenopathypicosecond laser systems when tattoo particles through resultsPreliminary than single ‘fractional intra-dermal pigment treated clearing, tattoos without (20 increasing cases) trans-epidermal priming’ was performed with aMinimal texturalused changes as partcomplications of innovative and showed side-effects an 10 almost. Sequentially complete elimination. fractionaltechnologies used Q-switched combining 2940 nm Er:YAGpigment or 10,600 nm clearing CO after ablative 4 Hypertrophicsequential scar combinations. 2 High energy fractional- handpiece, alone. able to generate fractional resurfacing withsessions full beam (Figure Q-switched 8). Interestingly, lasers Keloid scar mode Key 1064 nm points Q-S laser twenty-five 250-µm micro-spots within an area of 5 mm x hasthe author proven was more able efficient to improve than each both skinlaser colour technique and systems can produce a relative5 mm. colour-blinded, A 1,064 nm controlled Nd:YAG wavelengthLong lasting was erythema selected usedtextural alone irregularities12,41,52,65. of difficult-to-treat resistant tattoos, tissue Request ablation for tattoo through a combinedbecause of mechanismits deeper optical of penetration. High energies, afterThe up author to 16 previously was able performed to obtain similarlylaser treatments. good tattoo removal procedures have Transient and permanent micro-thermal and photo-acousticup to 12.7J/cm effects. This2, and unique stacking pulses, between 6–10, were clearingPatient responses compliance after a and single satisfaction laser session levels combining were progressively increased hypopigmentation approachdue to a range has of the potential for generating a photo- an ablative 2940 nm Er:YAG laser fractional resurfacing mechanicalmotivations disruptionincluding fear of ink particles, associated with a Hypopigmented (AFR) using a SP Dynamis platform (Fotona, Slovenia), significantof negative comments trans-epidermal and eliminationReferences of pigments12 tattoo (ghost) with two/three full top-hat beam, high peak energy improving ‘self identity’ (Figure 3). Two of the three main1. Laumann points AE, Derick proposed AJ. Tattoos and to body piercing in Transient13. Ross EV, Naseef G, Lin C, et al.Q-switched Comparison of laser passes23. Jacobsen performed NR, White PA, with Gingerich a QXJ, et al. Max Mutation laser Nanosecond and the United State: a national data set. J Am Acad Dermatol. responses of tattoos to picosecond and nanosecond spectrum in FE1-MUTA (TM) mouse lung epithelial cells improve the efficiency of laser-assisted2006; 55:413-21 tattoo removal: hyperpigmentationQ-switched nedimium:YAG lasers.unit Arch (Fotona, Dermatol. 1998; Slovenia) exposed (Figure to nanoparticulate 4–5). Five-minute carbon black. Environ intervals Mol sub-nanosecond laser 134:167-171 Mutagen. 2011; 52:331-7 increasing trans-epidermal elimination2. Kazandjieva of J. Tattoos ink particles, and piercing. Clin Dermatol. between laser passes were considered sufficient to stop technologies have proven 2007; 25:361 14. Brauer JA, Reddy KK, Anolik R, et al. Successful and 24. Trouiller B, Reliene R, Westbrook A, et al. Titanium 3. Armostrong ML, Roberts AE, Koch JR, et al. Depigmentationrapid treatment of blue and green tattoo pigment with a dioxide nanoparticles induce DNA damage and genetic andeffective optimizing in removing lymphatic transport,Motivation for will contemporary therefore tattoo beremoval. Arch novel picosecond laser. Arch Dermatol.capillary 2014; bleeding. instability in vivo in mice. Cancer Res 2009; 69:8784-9 implementedtattoo ink particles52. from Dermatol. 2008;144(7):879-884 Persistent/treatment148:820-823 Laser-assisted tattoo25. Jamec GB. removal Vomment on:is tattooing not of skin a results painless in 4. Adwani CMJ, Krishnan H. Tattoo pigment in an 15. Saedi N, Metelitsa A, Petrell K, et al. Treatment of transportation and light-induced decomposition of tattoo theAblative dermis fractional laser technologyaxillary lymph (AFLT) node simulating has metastatic also malignant resistanttattoos tattoos with a picosecond alexandriteprocedure, laser – A particularlypigments. when Exp Dermatol. larger 2010; 19:61-2 anatomical areas melanoma. Intern Sem Surg Oncol. 2005; 2:28-30 prospective trial. Arch Dermatol. 2012; 148(12):1360-1363 26. Cui Y, Spann AP, Couch LH, et al. Photodecomposition of pigment yellow 74, a pigment used in tattoo inks. been Conventional successfully single used to improve5. Yactor theAR, Michell cosmetic MN, Koch MS, and et al. Percutaneous 16. Bernstein EF, Schomacker KT,and Basilavecchio multiple LD, et al. passes are considered. Therefore, the A novel dual-wavelenght Nd:YAG picosecond-domain Photochem Photobiol. 2004; 80:175-84 laser pass tattoo removal 60–62 tattoo pigment calcific deposits in axillary lymph nodes functional aspects of scars . Proc(Bayl Univ Med Cent).2013; 26(1):28-29 laser safely and effectively removesauthor multicolour administered tattoos. 27. Golka subdermal K, Kopps S, Myslak local ZW. anaesthesia Carcinogenicity of toazo all is a lengthy procedure Lasers Surg Med. 2015; 47:542-548 colorants: influence of solubility and bioavailability. 6. Anderson RR, Parrish JA. Selective photothermolysis: treated tattoo sitesToxicol (1% Lett. mepivacaine 2004; 151: 203-10 plus 1:200,000 requiring multiple precise microsurgery by selective absorbtion of pulsed 17. Council of Europe Commission. Resolution Figure 2 (A) Heavily pigmented blackradiation. tattoo Science. on right 1983; forearm 220(4596):524-527 (volar aspect). ClinicalResAP(2003)2 comparison on tattoos and permanent make-up. 2003. 28. Engel E, Vasold R, Santarellu F, et al. Tattooing of skin sessions spaced two-four Available at: http://wcd.coe.int/wcd/epinephrine). ViewDoc. Epinephrineresults in transportation was and chosen light-induced to induce a between pre-AFR 2940 nm laser primed7. Choudhary area (B–left) S, Elsaie andML, Leiva intact A. Lasers skin for (B–right) tattoo immediatelyjsp?id=45869 after full decomposition of tattoo pigments – a first quantification beammonths Q-switched apart laser (single 1064 nmremoval: Nd: aYAG review laser Lasers pass). Med Sci. Note 2010; cavitation25:619-627 bubbles18. Council trapped of Europe. under Resolution temporary ResAP(2008)1 onvasoconstriction in vivo using a mouse able model. to reduce Exp Dermatolol. unnecessary 2010; intact epidermis and gas escape through8. Kent AFR KM, Graber pre treated EM. Laser skin. tattoo (C)removal: Better a review. pigment requirements clearance and criteria for thelight safety of absorption tattoos and by19:54-60 haemoglobin during the laser Combination Dermatol Surg. 2012; 38:1-13 permanent make-up. 2008. Available at: http://www.coe. 29. Tang J, Xiong L, Wang S, et al. Distribution, (80–90%)treatments was featuring observed on combined9. AFRKirby W,plus Desai full A, DesaiT, beam et QS al. The site Kirby-Deasi 3 months scale after : int/t/e/social_cohesion/soc-sp/ResAP_2008_1%20E.pdf a single treatment procedure. Besides translocation laser proof and accumulation goggles, aof silversuitable nanoparticles form in of photo-thermal ablative a proposed scale to assess tattoo-removal treatments J 19. Hogsberg T, Loeschner K, Loft D, and al. Tattoo inks in rats. J Nanosci Nanotechnol. 2009; 9:4924-32 Clin Aesthetic Dermatol. 2009; 2(3):32-37 general usage contain nanoparticles.ear Br protection J Dermatol. 2011; is also30. Klugl required, I, Hiller KA, Landthaler since M, theet al. Incidence Q-switched of 10. Kossida T, Rigopoulos D, Katzambas A, et al. Optimal 165:1210-1218 health problems associated with tattooed skin: A skin resurfacing (CO2 tattoo removal in a single laser session based on the 20. Oberdorster G, Oberdorsterphotoacoustic E, Oberdorster J. effectnation-wide generates survey ina German-speakinghigh pitch noise countries. during 2940 nm Er:YAG) and method of repeated exposures. J Am Acad Dermatol. Nanotoxicology: an emerging discipline evolving from Dermatology 2010; 221:43-50 sequential full beam 2012; 66:271-7 studies of ultrafine particles. Environoperation. Health Perspect. 31. Yactor AR, Mitchell MN, Koch MS, et al. Percutaneous 11. Reddy KK, Brauer JA, Anolik R., et al. Topical 2005; 113:823-939 tattoo pigment simulating calcific deposits in axillary Q-switched laser perfluorodecalin resolves immediate shitening reactions 21. Lehner K, Santarelli F, Vasold R, et al. Black tattoo inks lymph nodes. Proc (Bayl Univ Med Cen). 2013; 26(1):28-29 photo-acoustic tattoo and allow rapid effective multiple pass treatment of are a source of problematic substancesWound such as healing dibuthyl 32. Jack CM, Adwani A, Krishnan H. Tattoo pigment in an pigment destruction have tattoos. Lasers Surg Med. 2013; 45:76-80 phthalate. Contact Dermatitis 2011; 65:231-238 axillary lymph node simulating metastatic malignant 12. Marini L, Crisman G. Fractional priming + Q-switched 22. Baan R, Straif K, Grosse Y, etAll al. Carcinogenicity treated sites of followedmelanoma. Int a Sem three-step Surg Oncol. 2005; dressing 2:28-30 strategy further improved tattoo sequential layering tattoo removal. Lasers Surg Med. carbon black, titanium dioxide, and talc. Lancet 2006; 7: 33. Peterson SL, Lee LA, Ozer K, et. al. Tattoo pigment removal efficiency 2013; 45(S25): 9 295-6 aimed at providinginterpreted a suitable as lymph environment node metastasis in ato case optimise of wound healing.

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extremely high, due to the important pigment reduction observed after the first laser treatment, a painless procedure, and standardized dressing sequence. Conclusions Laser-assisted tattoo removal is gaining momentum in the complex scenario of modern dermatologic laser applications. The increasing number of tattoo bearers seeking medical advice to eliminate recent and old tattoos has prompted dermatologists and laser researchers to come up with new, innovative treatment strategies and techniques. Presently, time-honoured short-pulse Q-switched lasers seem to withstand the challenge posed by the new generation of picosecond laser systems when used as part of innovative sequential combinations. Much Figure 7 (A) Monochromatic tattoo (left anterior chest). (B) Central image was taken immediately after has been discovered about the potential hazards linked to first laser session performed according to the author’s protocol. (C) clinical result after four multilayer Figurechemical 6 (A) and Monochromatic ultra-structural characteristicsUp to 90% of treated of tattoo tattoos fractional (20 cases) (one demonstrated1064 nm laser ‘priming’ used pass) to and completely full flat beam Q-switched cover all (two tattoo 1064 areas.nm laser Capillarypasses) tattoopigments, (right and anterior more chest). needs to bealmost studied. complete Even if pigmenttattoo ink clearing after 5 sessions. bleeding was observed from each photo-acoustic micro- (B) Image taken immediately particles remain in the body forAfter life, techniquesthese encouraging able to results the author wanted to ablative spot, confirming the author was able to reach the after first laser session performedeliminate according them, even to the partially, try through a new sequential the skin multilayer could tattoo removal technique papillary and upper reticular dermis (Figures 6–7). Five- author’sreduce protocol. their potential (C) Clinical biological using hazards. a Q-switched Combination laser unit able to deliver its laser minute intervals were sufficient to stop capillary resulttreatments (almost with 100% conventional pigment beam millisecond both in andfractional recently and full bleeding, allowing the following clearing) after four multilayer introduced Q-switched fractionalbeam laser mode systems (QX as Max, well as Fotona, full beam laser passes to be fractional (one 1064-nm laser Presently, time-honoured ‘priming’short- (nanosecond) pass) and full andflat ultra-shortSlovenia). (picosecond) Local full anaesthesia, beam safely and efficiently performed. beamlaser systemsQ-switched seem (two to be a winningoptical combination and acoustic to rapidly protection, short-pulse Q-switched lasers The same successful clearing 1064and nm effectively laser passes) clear intra-dermaland the post-treatment tattoo pigments dressing seem to withstand the challenge rate was observed after the first increasing both their externalsequence elimination were and the internal same as the posed by the new generation of laser sessions in the majority of redistribution within the lymphaticprevious system. treatment protocol. tattoos (up to 80%). Up to 90% of Preliminary ‘fractional picosecond laser systems when treated tattoos (20 cases) Declaration of interest The authorpriming’ declares was no performed potential with a used as part of innovative showed an almost complete conflicts of interest fractional Q-switched sequential combinations. pigment clearing after 4 handpiece, able to generate sessions (Figure 8). Interestingly, FigureKey 1–8 © points Dr Marini twenty-five 250-µm micro-spots within an area of 5 mm x the author was able to improve both skin colour and 5 mm. A 1,064 nm Nd:YAG wavelength was selected textural irregularities of difficult-to-treat resistant tattoos, Request for tattoo because of its deeper optical penetration. High energies, after up to 16 previously performed laser treatments. removal procedures have up to 12.7J/cm2, and stacking pulses, between 6–10, were Patient compliance and satisfaction levels were progressively increased due to a range of Figure 8 (A) Bi-chromatic References motivations including fear References tattoo (right volar forearm). of negative comments and (B) Clinical result after four improvingsubungual melanoma. ‘self identity’ Hand 2008;3:282-285 1. Laumann 45.AE, HoDerick DDM, AJ. London Tattoos R, and Zimmerman body piercing GB, et in al. Laser13. tattooRoss EV, Naseef56. Dierickx G, Lin C, CC, et Khatri al. Comparison KA, Tannous of ZS, et al. 23. Jacobsen NR, multilayerWhite PA, Gingerich fractional J, et al. Mutation (one 34. NanosecondBordea C, Latifaj B, and Jaffe W. Delayed presentationthe United of State:removal: a national a study data of set. the J mechanism Am Acad Dermatol. and optimal responses of tattoosMicro-fractional to picosecond ablative and skin nanosecond resurfacing with twospectrum novel in FE1-MUTA1064 (TM) nm mouse laser lung ‘priming’ epithelial cellspass) tattoo lympadenopathy mimicking malignant melanoma2006; 55:413-21 treatment strategy via computer simulations. LaserQ-switched Surg nedimium:YAGerbium laser systems.lasers. Arch Laser Dermatol. Surg Med 1998; 2008; 40:exposed 113-23 to nanoparticulate carbon black. Environ Mol sub-nanosecondlymphadenopathy. J Plast laser Reconst Aest Surg. 2009;2. Kazandjieva Med. J. Tattoos 2002; 30:389-397 and piercing. Clin Dermatol. 134:167-171 57. Regan TD, Uebelhoer NS, Sattler E, et al. DepthMutagen. of 2011; 52:331-7and full flat beam Q-switched technologies62:e283-e285 have proven 2007; 25:361 46. Ross EV, Naseef GS, Lin CP, et al. Comparison14. of Brauer JA,tissue Reddy ablation KK, Anolik and R, residual et al. Successful thermal damage and caused24. Trouiller by a B, Reliene(two R, 1064 Westbrook nm A,and et al. 5 Titanium32 nm 35. Kurle S, Schulte KW, Homey B. Akkumulation3. von Armostrong responses ML, Roberts of tattoos AE, Koch to picosecond JR, et al. and nanosecondrapid treatmentpixellated of blue and 2,940nm green laser tattoo swine pigment skin withmodel. a Laserdioxide Surg nanoparticles induce DNA damage and genetic effectivetatoo-pigment in imremoving sentinellymphnoten. HautartzMotivation 2009; forQ-switched contemporary neodymium:YAG tattoo removal. lasers. Arch Arch Dermatol.novel picosecondMed laser. 2010; Arch 42:408-11 Dermatol. 2014; instability in vivo inlaser mice. passes). Cancer Res Resistant 2009; 69:8784-9 red 60:781-783 Dermatol. 2008;144(7):879-8841998;134:167-171 148:820-823 58. Bonan P, Campolmi P, Cannarozzo G, et al. Eyelid25. Jamec skin GB. 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Manstein exposures. D, Herron J Am SG,Acad Sink Dermatol. KR, et al. FractionalNanotoxicology: 2004; an emerging6:69-78 discipline evolving from Dermatology 2010; 221:43-50 sequentialinitial treatment full of a beam traumatic tattoo. J Cosmet 2012;Laser 66:271-7 photothermolysis: A new concept for cutaneousstudies of ultrafine64. Alexiades-Armenakas particles. Environ Health M. Rhytides, Perspect. laxity, and31. Yactor AR, Mitchell MN, Koch MS, et al. Percutaneous Ther. 2014; 16:303-305 11. Reddy KK,remodelling Brauer JA, Anolik using R.,microscopic et al. Topical patterns of thermal2005; injury. 113:823-939 photoaging treated with a combination of tattoo pigment simulating calcific deposits in axillary Q-switched43. Park HJ, Wu B,laser Diebold GJ. Effects of exothermicperfluorodecalin Laser resolves Surg Med immediate 2004; 34:426-38 shitening reactions 21. Lehner K, radiofrequency,Santarelli F, Vasold diode R, et laser, al. Black and pulsedtattoo inks light andlymph nodes. 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