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September 2005 Skin & Aging TATTOOTATTOO REMOVALREMOVAL TECHNIQUESTECHNIQUES 50 SEPTEMBER 2005 SKIN & AGING PART ONE OF OUR TWO-PART SERIES FOCUSES ON THE HISTORY OF TATTOOS 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,Thomas Edison patented a tattoo- 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 tattoo machine 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 James Cook’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 TATTOO INK, COLOR AND PARTICLE SIZE (12,000 BC).2 Tattoo artists use exogenous pigments of Today it is estimated that there are more unknown purity and identity.In both profes- than 4,000 tattoo parlors in the United States sional and amateur tattoos, the location of and more than 5% of the adult population the ink pigment 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 tattoo removal 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 scar- 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 scars.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.
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