TATTOOTATTOO REMOVALREMOVAL TECHNIQUESTECHNIQUES

50 SEPTEMBER 2005 SKIN & AGING PART ONE OF OUR TWO-PART SERIES FOCUSES ON THE HISTORY OF AND THE EARLY OPTIONS FOR REMOVAL.

BY WILLIAM KIRBY, D.O., TEJAS DESAI, D.O., AND FRANCISCA KARTONO, B.S.

attoos are not new — they’ve been MODERN TATTOOING around since ancient times. In 1991, In 1876, patented a - at the border of Austria and Italy in ing device called the autographic printer, TTthe Alp Mountains, the body of a which he intended to be used as an engrav- man was found. Subsequent carbon dating ing device for hard surfaces. In 1891, Samuel showed that this well-preserved frozen O’Reilly modified Edison’s machine by human had died approximately 5,300 years changing the tube system and incorporating earlier.1 Of note was the fact that he had 59 a rotary-driven electromagnetic oscillating purposely placed skin markings, making this unit, which enabled the machine to drive the discovery one the best-documented cases of needle. tattoo placement in ancient man. The modern is a steel The word “tattoo” is derived from the instrument fitted with needles that puncture Tahitian word “tattau” and the Polynesian the skin at the rate of 50 to 3,000 times a (Marquesan) word “tatu”, which mean “to minute. Powered by a foot switch, the tattoo mark”, and were first mentioned in 1769 by machine uses an up-and-down motion to explorer ’s after his expedition to puncture the epidermis and drive ink parti- the South Pacific. The practice of perma- cles between 0.6 mm and 2.2 mm into the nently decorating the human body,however, dermis. has been in existence for thousands of years with origins tracing back to the Stone Age , COLOR AND PARTICLE SIZE (12,000 BC).2 Tattoo artists use exogenous of Today it is estimated that there are more unknown purity and identity.In both profes- than 4,000 tattoo parlors in the sional and amateur tattoos, the location of and more than 5% of the adult population the ink varies greatly as does the has a tattoo for either decorative or cosmet- size and shape of the ink particles themselves. ic purposes. Amateur tattoo inks consist of simple, carbon particles originating from burnt wood, cot- EARLY TATTOO METHODS ton, plastic or paper, or from a variety of inks, There is a wide variety of means by which including India ink, pen ink and vegetable tattoo ink can be injected into the skin. matter. Professional artists have access to Simple skin pricking with solid needles coat- more than 100 different colors. Black ink is ed in ink, scratching or abrading the skin and the most common color seen in professional then applying ink to the excoriations tattoos, followed by red, blue, green, yellow through mechanical rubbing, or even draw- and orange. More recent tattoos have a ing threads coated with pigmented ashes greater range of colors, including shades of through the skin are some of the many early pink, brown, purple and even fluorescent methods. However, the one thing all tattoo colors. Some tattoo inks are actually a mix- techniques have in common is the depth of ture of colors with a wide range of shades pigment placement; for the ink to become and are thus difficult to classify as a single permanent it must be placed in the dermis. pigment.

SEPTEMBER 2005 SKIN & AGING 51 The FDA currently lists tattoo inks as network of connective tissue is found to skin.The presence of a tattoo may put a “color additives” for use on the skin. surround each fibroblast that contains strain on interpersonal relationships and Truth be told, because ink manufacturers ink particles, effectively entrapping and can sometimes serve as an obstacle to are not required to list the composition immobilizing the cell. This presence of meaningful employment. While most of their products, in the vast majority of ink particles only in dermal fibroblasts people keep tattoo(s) for life, it has been cases, neither tattoo artists nor patients supports the theory that fibroblasts are estimated that 50% of individuals with have any idea of the exact make-up of responsible for the stable intradermal life tattoos regret the decision to decorate the tattoo ink. span of the tattoo.The life span of these their skin. Regardless of the composition of the fibroblasts is unknown and may persist Through the years, various methods of tattoo pigment, the microscopic appear- throughout the individual’s life.7,10 have been attempted. ances of all pigments are similar;Taylor et Clinically, a tattoo may appear duller, Dermabrasion was once the primary al. found black pigment granules in tat- more indistinct, or blurred over time. method of tattoo removal; it removed toos to vary in diameter from 0.5 µm to Kilmer noted that although biopsies pro- tattoos by sloughing off layers of skin 4.0 µm.3 Colored ink granules were vide considerable detail regarding the until reaching the ink. For centuries noted to be larger than black ink gran- dermatopathology of tattoo pigment, individuals have used this method simply ules. Additionally, there is variability in they do not fully explain dermal tattoo using any sharp object. In the 1950s and regard to the size of the pigment clusters ink changes. One proposed theory is that 1960s, a rapidly spinning wheel or a wire formed when pigment granules brush abraded skin frozen with aggregate. For the most part, a refrigerant to produce a hard professional tattoos have smaller A TATTOO MAY APPEAR surface. The procedure tended clusters that are approximately DULLER, MORE to be rather traumatic and the 145 µm while amateur tattoo biological particulates that were have clusters of approximately INDISTINCT, OR BLURRED aerosolized could carry infec- 180 µm.4,5 “ OVER TIME. tious agents. Hypertrophic - ring occurred frequently, post- HISTOLOGY operative pain was significant, Immediately following tattoo and most patients reported a injection, ink particles are found result more unsightly than the within large phagosomes in the original tattoo.12-14 cytoplasm of both keratinocytes Salabrasion was first and phagocytic cells, including described in 543 AD by Aetius, fibroblasts, macrophages and a Greek physician to the mast cells.6 Additionally,the epi- Byzantine court in his 16-vol- dermis, epidermal-dermal junc- ume medical text Medicae Artis tion, and papillary dermis Principes. Salabrasion involves appeared homogenized.6,7 abrading the superficial dermis At 1 month, biopsies show with coarse granules of com- that the basement membrane mon table salt and a moist abra- begins to reform, and aggregates of ink during sun exposure, some Langerhan sive pad. Salt is then reapplied to the particles are noted within basal cells. In cells will undergo apoptosis while others wound surface and left under occlusion the dermis, ink-containing phagocytic migrate into the dermis and a minor for 24 to 36 hours.15,16 Commonly,resid- cells are concentrated along the epider- inflammatory reaction occurs. The ual tattoo pigment remains and textural mal-dermal border below a layer of inflammatory reaction occurs in the epi- changes are noted after the wound granulation tissue that is closely sur- dermis but it also involves the dermis. heals.17 rounded by collagen.6-8 Again, ink parti- Such a reaction causes the recruitment of Liquid nitrogen is commonly used to cles are present in keratinocytes, more phagocytic immune cells to the destroy superficial cutaneous lesions. macrophages, and fibroblasts. area, and it has been suggested that a tat- However, its role in tattoo removal is Additionally, transepidermal elimination too may change clinically through the limited because the destruction leads to of ink particles outward through the epi- action of these phagocytic cells.11 unpredictable results including hypopig- dermis is still in progress 1 month fol- Biopsies of older tattoos demonstrate mentation, scarring and prolonged heal- lowing ink injection. Pigment is not seen pigment in the deep dermis and eventu- ing time.18 within mast cells, endothelial cells, peri- ally ink may appear in the regional In 1888, Variot G. Nouveau trauma- cytes, Schwann cells, in the lumina of lymph nodes. tized the skin surface with punctures and blood and lymphatic vessels, or extracel- incisions and then applied tannic acid lularly.7-9 TATTOO REMOVAL TECHNIQUES and silver nitrate in an attempt to In biopsy specimens obtained at In many cases, patients with tattoos remove tattoo ink.19 This technique 3 months and at 40 years, a prominent regret their decision to decorate their resulted in a less significant scar than that

52 SEPTEMBER 2005 SKIN & AGING from the application of more caustic LASER PRINCIPLES” chemicals but was noted to leave residual he term “laser” is an acronym for light present. The common cutaneous chro- tattoo pigment.20 Tamplification by the stimulated emis- mophores include water, hemoglobin, Phenol solution and trichloracetic acid sion of radiation. The therapeutic action melanin and, for purposes of this article, have been used to treat tattoo ink, but of laser energy is based on complex inter- tattoo ink. When tattoo ink absorbs a spe- they, too, leave hypopigmented .21,22 actions between laser light and biological cific wavelength of light, a photothermal Repeat application is hazardous and may tissues. reaction occurs leading to target destruc- result in a full-thickness burn that The process begins when an energy tion from the conversion of absorbed ener- requires skin grafting. source stimulates the lasing medium gy into heat. (See figure 1 below for the Thermal injury via fire, hot coals, and causing an atom to move from a resting absorption spectra.) cigarettes has been used for centuries to state to an excited state. When the atom Pulse width, or pulse duration (meas- try to remove unwanted tattoos, usually returns to its resting state, a photon of ured in nanoseconds or milliseconds) is with significant scarring. Thermal light energy is released. The released pho- the length of time that laser light is in cautery, electrocautery, and infrared ton collides with atoms still in an excited contact with the skin, and the thermal coagulation are equally unpredictable.21,23 state, leading to light amplification. relaxation time is defined as the time Surgical excision of skin containing The emitted laser light is monochro- required for the temperature generated by tattoo pigment is still common but may matic, meaning it is of a single wave- the absorbed energy within the target result in scarring because of limitations length (measured in nanometers) that is chromophore to cool to one-half its origi- in wound closure. However, tattoos determined by the specific medium nal value immediately after irradiation. located in areas of adequate skin laxity through which the light was passed: crys- In the 1980s, Anderson and Parrish’s may be removed with simple excision tal, liquid dye, or gas. principal of selective photothermolysis with the added benefit of a single, rela- While ordinary light travels in all direc- revolutionized the laser treatment of tat- tively inexpensive treatment.24,25 tions at once, laser light is collimated and toos.29-31 They proposed that if a wave- All of the aforementioned treatments coherent — it has parallel (non-divergent) length was well absorbed by the target offer unpredictable results and may result beams, which gives the laser the ability to chromophore and the pulse width was in scarring, hypopigmentation, pain and maintain the same spot size regardless of equal to or shorter than the target’s ther- incomplete resolution of the tattoo ink. the distance traveled. mal relaxation time, the heat generated When laser light strikes the skin, the would be confined to the target. Selective LASER HISTORY light may be absorbed, reflected, trans- photothermolysis is laser light-mediated Albert Einstein first introduced the mitted or scattered. The Grotthus-Draper damage to very specific chromophores of concept of stimulated light emission in law, the first law of photobiology, states the skin. The application of this theory 1917. Although modern lasers are based that light must be absorbed by tissue for a allows for highly selective destruction of a on his theory, it took many years before clinical action to take place. target in the skin, like a tattoo, with min- a functioning laser was available. In Absorption determines the depth of imal unwanted injury to the surrounding 1959, advancements in technology penetration of laser energy. In general, as area containing other chromophores like allowed Maiman to develop a laser using the wavelength increases, so does the melanin and hemoglobin. a ruby crystal to produce red light, and depth of penetration. Lasers using longer Laser parameters including wavelength, in 1963, Goldman used ruby laser treat- wavelengths of light can penetrate deeper. pulse duration and fluence can be tailored ment for a variety of cutaneous applica- The energy absorbed is known as fluence. to maximize tattoo ink destruction and tions.26 Goldman’s initial report of suc- The amount of absorption is determined minimize thermal damage to surrounding cessful tattoo removal using ruby and by the wavelength and the chromophore tissue. Nd:YAG lasers appeared in 1967.27,28 In the 1970s most cutaneous research focused on argon and carbon dioxide Figure1. Laser absorption spectra of cutaneous chromophores.32 laser use. The ability to remove a tattoo CHROMOPHORE ABSORPTION with a laser with minimal side effects was enhanced greatly when, in the early A 1980s, Anderson and Parrish developed b s Hemoglobin pulsed lasers and the theory of selective o Melanin photothermolysis.29-31 r Water p Scatter t EARLY LASER USE IN TATTOO REMOVAL i The Argon Laser. In 1979 an argon o laser was used for tattoo removal in n 28 patients. Hypertrophic scarring occurred in 21% of these patients and half of the patients had residual tattoo

54 SEPTEMBER 2005 SKIN & AGING pigment while complete removal of tat- can be obtained, because there is no 14. Clabaugh WA.Tattoo removal by superficial der- mabrasion. Five-year experience. Plast Reconstr Surg. 1975; too pigment was noted in 8 patients color selective light absorption, nonspe- 55(4): 401-405. 33 (29%) with acceptable cosmetic results. cific thermal damage to adjacent dermal 15. Crittenden FM. Salabrasion-removal of tattoos by In a subsequent study, 20 of 60 patients structures occurs and, therefore, virtually superficial abrasion with table salt. Cutis. 1971; 7: 295. 16. Koerber WA Jr, Price NM. Salabrasion of tattoos.A experienced complete removal of tattoo all patients have some form of secondary correlation of the clinical and histological results. Arch pigment without scarring, with amateur scar formation making both the argon Dermatol. 1978; 114(6): 884-888. tattoos responding slightly better than laser and the carbon dioxide laser less 17. Colver GB, Dawber RP.Tattoo removal using a liquid nitrogen cryospray. Clin Exp Dermatol. 1984; 9(4): 364- professional tattoos. Unfortunately, than ideal treatment modalities.39-42 366. hypertrophic scarring occurred in 35% 18. Colver GB, Dawber RP.The removal of digital tat- of the patients, and residual tattoo pig- BETTER TREATMENT OPTIONS toos. Int J Dermatol. 1985; 24(9): 567-568. 19.Van der Velden EM,Van der Walle HB, Groote AD, 34 ment remained in 67%. Over time, better laser removal Tattoo Removal:Tannic Acid Method of Variot. Int J The argon laser offers selective options have been discovered. Next Dermatol. 1993; 32(5): 376-380. 20. Fogh H,Wulf HC, Poulsen T, Larsen P.Tattoo removal absorption of energy from its 488 nm month, we’ll look at current treatment by overtattooing with tannic acid. J Dermatol Surg Oncol. and 514 nm wavelengths by tattoo pig- modalities with the Q-switched lasers 1989; 15(10): 1089-1090. ment. Its usefulness, however, is limited and also discuss some possible tattoo 21. Colver GB, Cherry GW,Dawber RP.Tattoo removal using infra-red coagulation. Br J Dermatol. 1985; 112(4): by melanin and hemoglobin absorption, removal techniques for the future. 481-485. resulting in unwanted damage to tissue 22. Piggot TA, Norris RW.The treatment of tattoos with trichloracetic acid: experience with 670 patients. Br J surrounding the tattoo pigment. Thus, Drs. Kirby and Desai are Co-Chief Plast Surg. 1988; 41(2): 112-117. even though the authors demonstrated Dermatology Residents at Western 23. Scutt RW.The chemical removal of tattoos. Br J Plast selective absorption of laser energy by University/Pacific Hospital Long Beach Surg. 1972; 25(2): 189-194. 24. Bunke HJ, Conway H. Surgery of decorative and tattoo pigment, they also noted extensive Dermatology Program in Torrance, CA. traumatic tattoos. Plast Reconstr Surg. 1957; 20: 67. diffusion of heat from all absorbing chro- 25.Wheeler ES, Miller TA.Tattoo removal by split thick- ness tangential excision. West J Med. 1976; 124(4): 272- mophores resulting in non-selective Francisca Kartono is a Medical Student at 275. 35 destruction. Western University of Health Sciences in 26. Goldman L,Wilson RG, Hornby P.Radiation from a The carbon dioxide laser (CO2). The Pomona, CA. Q-switched ruby laser. J Invest Dermatol. 1965; 44: 69. carbon dioxide laser emits a continuous 27. Goldman, L, Rockwell, RJ, Meyer, R, Otten, R, Wilson, RG, Kitzmiller, KW.Laser treatment of tattoos: a beam at 10,600 nm, a wavelength com- preliminary survey of three years clinical experience. References: pletely absorbed by water, and reports of JAMA. 1967; 201:841-844. 1. Hambly WD. The History of Tattooing and Its Significance. 28. Goldman L, Rockwell RJ, Meyer R: Laser treatment successful tattoo removal with the car- Gale Research Co; 1974. of tattoos. JAMA. 1967; 201: 163. bon dioxide laser first appeared in 2. Goldstein N, Sewell M III.Tattoos in different cultures. 29.Anderson, RR, Parrish, JA.The optics of human skin. J Dermatol Surg Oncol. 1979; 5(11): 857-856. 1978.36 The original objective of carbon J Invest Dermatol. 1981; 77:13-19. 3.Taylor CR,Anderson RR, Gange RW,Michaud NA, 30.Anderson, RR, Parrish, JA. Optical properties of skin. dioxide treatment was to vaporize tissue Flotte TJ. Light and electron microscopic analysis of tat- In: Regan, JD, Parrish, JA, eds. The Science of Photomedicine. toos treated by Q- switched ruby laser. J Invest Dermatol. New York,NY: Plenum Press; 1982: 147-194. and remove all tattoo pigment in one 1991; 97(1): 131-136. 31.Anderson RR, Parrish JA. Selective photothermolysis: treatment session. Attempts to confine 4. Christensen HE, Schmidt H.The ultrastructure of tat- precise microsurgery by selective absorption of pulsed the depth of tissue vaporization to the too marks. Acta Pathol Microbiol Scand [A]. 1972; 80(4): radiation. Science. 1983; 220(4596): 524-527. 573-576. precise level of tattoo pigment resulted 32. Herd RM, Dover JS,Arndt KA. Basic laser principles. 5. Silberberg I, Leider M. Studies of a red tattoo: Dermatol Clin. 1997; 15(3):355-372. in a wound of variable depth because Appearances in electron microscope, and analysis by chemical means, laser microprobe and selected-area dif- 33.Apfelberg DB, Maser MR, Lash H.Argon laser treat- tattoo ink is deposited at different depths fraction of tattooed material. Arch Dermatol. 1970; 101(3): ment of decorative tattoos. Br J Plast Surg. 1979; 32(2): even within the same tattoo.37 Histologic 299-304. 141-144. 6. Kilmer SL,Anderson RR. Clinical use of the Q- 34.Apfelberg DB, Laub DR, Maser MR, Lash H. evaluation of the wounds revealed loss of switched ruby and the Q-switched Nd:YAG (1064 nm Pathophysiology and treatment of decorative tattoos with dermis and subcutaneous tissue up to a and 532 nm) lasers for treatment of tattoos. J Dermatol reference to argon laser treatment. Clin Plast Surg. 1980; 7(3): 369-377. depth of 5 mm.38 Because of a prolonged Surg Oncol. 1993; 19(4): 330-338. 7. Lea PJ, Pawlowski A. Human tattoo: Electron micro- 35. Diette KM, Bronstein BR, Parrish JA. Histologic healing time and scarring, most physi- scopic assessment of epidermis, epidermal-dermal junc- comparison of argon and tunable dye lasers in the treat- cians decided against complete pigment tion, and dermis. Int J Dermatol. 1987; 26(7): 453-458. ment of tattoos. J Invest Dermatol. 1985; 85(4): 368- 373. 8. Goldstein AP.VII. Histologic reactions in tattoos. 36. McBurney EI. Carbon dioxide laser treatment of der- removal in one session with the CO2 J Dermatol Surg Oncol. 1979; 5(11): 896-900. matologic lesions. South Med J. 1978; 71(7): 795-797. laser.They instead treated patients more 9. Laub DR,Yules RB,Arras M, Murray DE, Crowley L, 37. Reid R, Muller S.Tattoo removal with laser. Med J conservatively, relying on macrophage Chase RA. Preliminary histopathological observation of Aust. 1978; 1(7): 389. Q-switched ruby laser radiation on dermal tattoo pig- 38. Beacon JP,Ellis H. Surgical removal of tattoos by car- engulfment and transepidermal removal ment in man. J Surg Res. 1968; 8(5): 220-224. bon dioxide laser. J R Soc Med. 1980; 73(4): 298-299. of tattoo pigment during the healing 10. Mann R, Klingmuller G: Electron-microscopic inves- 39.Apfelberg DB, Maser MR, Lash H, et al. Comparison tigation of tattoos in rabbit skin. Arch Dermatol Res. 1981; of argon and carbon dioxide laser treatment of decorative phase. Residual pigment was retreated 271(4): 367-372. tattoos: a preliminary report. Ann Plast Surg. 1985; 14(1): after healing was complete. 11. Dover JS, Margolis RJ, Polla LL,Watanabe S, Hruza 6-15. With the carbon dioxide laser, layers of GJ, Parrish JA,Anderson RR. Pigmented guinea pig skin 40. Bailin PL, Ratz JL, Levine HL. Removal of tattoos by irradiated with Q-switched ruby laser pulses. CO2 laser. J Dermatol Surg Oncol. 1980; 6(12): 997-1001. skin are removed to expose the pigment, Morphologic and histologic findings. Arch Dermatol. 41. Levins PC, Grevelink JM,Anderson RR. Q-switched and the wound is allowed to heal by re- 1989; 125(1): 43-49. ruby laser treatment of tattoos. Lasers Surg Med Suppl. epithelialization from adjacent skin. 12. Boo-Chai K.The decorative tattoo-its removal by 1991; 3: 63. dermabrasion. Plast Reconstr Surg. 1963; 32: 559. 42. Brady SC, Blokmanis A, Jewett L.Tattoo removal Dermal tissue is reconstituted by fibrosis 13. Ceilley RI. Curettage after dermabrasion-techniques with the carbon dioxide laser. Ann Plast Surg. 1979; 2(6): and scar tissue.Although excellent results of removal of tattoos. J Dermatol Surg Oncol. 1979; 5: 905. 482-490.

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