Laser Tattoo Removal

What can you expect in the following essay about Laser Tattoo Removal and what you cannot expect. Sure, we are not objective, as we represent the position of a competitor as we remove tattoos without laser. But this could even be an advantage for you. We focus on details that dermatologists and the laser lobby are aware of but don’t mention it. Simultaneously we try not to judge but talk of aspects of laser tattoo removal, aspects you may never heard before. For to make it clear, we consider that laser technology is not suitable for tattoo removal for many reasons we will expose. On the other hand laser technology never ever removed a tattoo, it only shredders the pigments into little pieces and spreads them all over the blood vessel and lymph system, but more about that later. Below we explain the laser tattoo removal method technically, medically and we show the risk and side effects in words and images. Finally we evaluate the Benefit-Risk Relation of this method.

Today, the most widely practised tattoo removal technique by far involves the use of lasers. Concentrated beams of light are targeted onto the skin for fractions of a second, breaking the ink into smaller fragments while leaving the tissue unharmed. This happens because the highly energised light (which must be in the absorption spectrum of the targeted area) causes an explosive effect in the pigment. The high energy heats the ink to a temperature of 900 degrees Celsius for an extremely short time, causing it to explode. The resulting tiny fragments are either pushed into deeper layers of the skin and then absorbed and removed by the lymphatic system, or remain in the skin but due to their smaller size become less visible – at least until the next treatment, when they explode again due to the application of the laser and become even smaller.

For several decades, there have been multiple different types of laser devices, each of which has its unique qualities. Many lasers are used for treatment of skin abnormalities such as spider veins, port wine stains, changes in pigmentation, liver spots and hair removal. Not every laser used in the dermatological field is suitable for tattoo removal. Although the wavelength of older devices (such as argon lasers, ruby lasers and CO2 lasers) allowed a small range of colours to be removed, the overwhelming choice for today’s treatment is a Q-switched YAG laser, of which there are several varieties including Erbium, Alexandrite and Pico.

To create a better understanding of these frequently misused concepts, here is a short explanation. “YAG” is an acronym for a neodymium-doped “Yttrium-Aluminium-Garnet” laser. Neodymium is a chemical element with the symbol Nd and is a rare earth element. A YAG laser is a form of solid state laser which uses a neodymium crystal to produce a wavelength of 1064 nanometres. The wavelength is essential to ensure that the tattoo ink will absorb the light and thus explode. At a wavelength of 1064 nm, black ink is targeted; at 534 nm red ink is the target and 694 nm is the wavelength to target green and blue colours. The term “Q-switch” refers to the ability to shorten the wavelength of the laser through technical means in order to target lower-frequency dyes, causing them to oscillate and ultimately to burst. IPL (Intense Pulsed Light) flash lamp technology, which is predominantly used by non-physicians, does not technically involve a laser but is comparable in terms of its effectiveness and the risks and side effects inherent in its use. It is mainly used for hair removal. (1)

Lasers are only partially suitable for tattoo removal and require years of experience and a high level of specialist knowledge. In order to achieve a successful treatment, multiple device parameters must be balanced.

  • The operator has to recognise the precise frequency of the colour being targeted using nothing more than the naked eye in order to set the correct wavelength (provided that the laser even supports this frequency – otherwise a different device must be used altogether). If the operator fails to do this, or does not do so correctly, the only result is a dangerous heating of the skin; the ink deposits are not destroyed despite the potentially dramatic side effects. It is often very difficult to achieve the correct wavelength due to the use of mixed inks or multiple components within a single ink (for instance cardinal red alone can contain 50 to 60 different substances), or due to the presence of overlaid inks or intricate designs, all of which require extensive experience if the correct frequency is to be identified and selected.
  • The operator must be able to recognise the depth of the tattoo using non-intrusive, visual techniques. This is far from simple for many reasons, including the fact that ink can be accumulate in multiple layers of the skin, with variable quantities of ink in each layer. Tattoo inks can be found in cell layers of the dermis at a depth of less than 1mm up to 4mm. The operator must therefore specify the precise intensity of the light, which is expressed in watts per square centimetre (W/cm2).
    Tattoo ink is stored unevenly in the cells.

    Tattoo ink is stored unevenly in the cells.

  • A further parameter is the duration of each impulse, which is measured in nanoseconds. This can be configured with some devices. More modern devices such as the Pico Laser have an extremely short clock frequency, allowing them to break down even large deposits over just a few treatments. (Pico refers to the frequency: 1012 is a trillionth of a second; nano = 109 or a billionth of a second).
  • Moreover the size of the light cone (the diameter of the laser beam) can be controlled.
  • “Some tattoo dyes such as iron oxide (black and brown colours) or titanium dioxide (white, pink, orange, red and violet) are used to increase the intensity and coverage of the tattoo. These dyes can only be removed through the use of lasers with difficulty, if at all.” (3)

The best results are achieved when black colouration is removed, with the worst (if any) being achieved in respect of yellow ink. Multi-coloured tattoos present the greatest difficulty. Often nobody knows which inks were used and what they are made of. (2)

The number of treatments can vary depending on the amount and quality of the pigments and the depth at which the tattoo ink is located. (3)

  • Laser treatment can cause reddening of the skin, which is sometimes painful, and which can cause blisters and scabs.
  • In certain circumstances, severe scarring can occur.
    A keloid scarring that occurred as a result of laser treatment covers the entire tattoo. (4)

    A keloid scarring that occurred as a result of laser treatment covers the entire tattoo. (4)

  • Sometimes a colour within a tattoo can transform into a dark pigment that can no longer be removed by laser.
  • Pigmentation disorders can also occur; these are mostly temporary but can be permanent.
    Colour transformation and pigmentation disorders, even pain after laser treatment; right in detail. (5)

    Colour transformation and pigmentation disorders, even pain after laser treatment; right in detail. (5)

  • Certain skin diseases (such as herpes and acne) can be triggered or exacerbated by the use of lasers. Moreover, the possibility of an allergic reaction cannot be excluded, including as a result of impurities contained in the ink. Infections can also occur or foreign body granulomas may develop (6), (7)
  • These allergic reactions may extend as far as an allergic septic shock in isolated cases (8)
  • An extremely high percentage of laser treatments are not concluded, as no improvement is experienced after the sixth session (or at the latest, after the tenth session). Either the laser is not capable of removing the particular ink colour, for instance while no suitable laser is available for the particular wavelength, or the broken-up ink particles have been transported to the deeper layers of the dermis or even into the subcutaneous tissue (fat layer), out of the laser’s reach, where they remain visible as shadows and can only be removed by surgical intervention.
    Photo 1 End result after 10 sessions of laser treatment Photo 2 End result after 19 sessions of laser treatment Photo 3 End result after over 20 sessions of laser treatment Source: (9)

    Photo 1 End result after 10 sessions of laser treatment
    Photo 2 End result after 19 sessions of laser treatment
    Photo 3 End result after over 20 sessions of laser treatment
    Source: (9)

  • “A hitherto completely unexplained side effect is massive itching, mostly in conjunction with swelling. It remains uncertain as to whether this is an allergic reaction.” (7)
  • As the pigmentation crystals are broken down during laser removal, and new components are unleashed, allergic reactions and immune reactions to foreign bodies may also occur. The breakdown of azo-dyes may cause carcinogenic aromatic amines to be formed. The pigments, their decomposition products and their impurities then travel through the entire body via the vascular system and are detectable in the lymph nodes, the spleen and the liver (10).
  • “Scars typically occur as a result of misuse of the laser, e.g., if the depth setting is wrong, causing too much energy to be unleashed, the tattoo does not explode but instead melts, causing the skin to bursts giving rise to extensive blood flow and consequent scarring. This is very painful even after multiple sessions, the tattoo will not disappear.” (11)
  • While nano-particles in cosmetic products are largely forbidden, some so called innovative lasers like the Pico Sure Laser create a big quantity of them by destroying the huge ink molecules and spread them all over the body. Incomprehensible as ink nano-particles are certainly much more dangerous for health than any cosmetic product.

“Complete removal of a standard tattoo occurs in approximately half of all treatments. In around 30 percent a remnant, i.e., a shadow of the tattoo remains lightly visible.” (12)

Although there are successful removals with lasers, the ink often does not disappear completely even after multiple treatment sessions. Instead, shadow tattoos remain, which cannot be removed even by the use of other known methods. Nearly all scientific sources recommend that laser treatments are only carried out by highly trained and experienced dermatologists with sufficient experience with laser devices and who have far-reaching clinical experience of laser tattoo removal. (13)

Dr. Erich Kasten of the University of Göttingen sums up the risk-reward ratio of laser treatment as follows: “Firstly, we don’t know what the ink contains and secondly we don’t know what happens to each ingredient in the ink when a laser is applied to it.” Thirdly, no one knows where the broken-down pigments go within the body and what effects they have. “What that means is: we have no idea of the possible side effects or consequential conditions.” (14)

Tattoo ink in the lymph nodes.  Laser treatment does not remove the tattoo dye; it breaks it down into smaller particles.  It is transported via the blood vessels to the lymph nodes, liver and spleen where it accumulates.  It does not leave the body; instead it builds up around the organs. (15)

Tattoo ink in the lymph nodes. Laser treatment does not remove the tattoo dye; it breaks it down into smaller particles. It is transported via the blood vessels to the lymph nodes, liver and spleen where it accumulates. It does not leave the body; instead it builds up around the organs. (15)

(1) Deutsche Dermatologische Lasergesellschaft e.V., www.ddl.de)

( 2 ) „Vorsicht vor Vielfarbigen Tattoos“ sl Biedersteiner Kolloquium „Haut und Allergie“, München, 2006 zitiert aus ÄP Dermatologie Allergologie 1/2006 S 11-12

( 3 ) Farbverstärker in Tätowiertinte http://www.medizin24.tv/medizin/dermatologie/337-tattoo-entfernung

( 4 ) Australien: „Widened and Hypertrophic Scar Healing Treatment & Management“ Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS

( 5 ) Skinial Kundendatenbank, 445-2013

( 6 ) miomedi Chirurgie 8.7.2012 http://www.chirurgie-portal.de/haut-dermatologie/taetowierung-laser-entfernung.html

( 7 ) Dr. rer. nat. Wolfgang Bäumler, Laserspezialist der Universitätsklinik Regensburg in ÄP Dermatologie Allergologie 1/2006 S 11-12

(8) Dermatologin Dr. Alder, themenportal myNEWSdesk 2012 www.themenportal.de/gesundheit/Tattoolos-Laserbehandlung-Yael-Adler

(9) Skinial Kundendatenbank 301-2012 / 597-2011 / 89-2012

(10) Kommentar u.a. vom vom Helmholtz Zentrum, München und mehreren Dermatologen via OnMedia.de Link: http://www.onmeda.de/g-rat/tattooentfernung-679.html

(11) Presseerklärung der PARA MEDIC UG in Gütersloh vom 2.4.2012 – Einem Produzent von Lasergeräten

(12) Dermatologe Dr. Heiko Grimme „Hautzentrum am Kurpark“ in Stuttgart 15.09.2012 in WELT ONLINE http://www.welt.de/109032744

(13) Tattoo removal by non-professionals – medical and forensic considerations 12.9.2009 – by S. Karsai, G. Krieger, C. Raulin 2009 published in: Journal compilation of European Academy of Dermatolgoy and Venerology

(14) Dr. Erich Kasten vom Institut für Medizinische Psychologie an der Universität Göttingen, „Risiken der Tattoo-Entfernung: Wenn die Jugendsünde weg soll“ (DPA)

(15) „The fate of Tattoo Pigments in the Skin“, entnommen aus dem Vortrag von Prof. Dr. Wolfgang Bäumler, Regenburg anlässlich des BfR Symposiums „First International Conference on Tattoo Safety“ Juni 2013 in Berlin.

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