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Dealing with tattoos in plastic surgery. Tattoo removal
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ANNPLA-1279; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
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GENERAL REVIEW
Dealing with tattoos in plastic surgery. Tattoo removal Autour du tatouage en chirurgie plastique. ´ tatouage De N. Malca *, L. Boulart, W. Noel, A. de Runz, M. Chaouat, M. Mimoun, D. Boccara ˆ pital Saint-Louis, 1, avenue Claude-Vellefaux, Plastic, reconstructive, aesthetic surgery unit, ho 75010 Paris, France Received 25 July 2016; accepted 14 September 2016
KEYWORDS Tattoo; Tattoo removal; Surgery; Laser; Scar
MOTS CLÉS Tatouage ; Détatouage ; Chirurgie ;Laser ; Cicatrice
Summary Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing — and with tattoo removal procedures, as well. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands. # 2016 Elsevier Masson SAS. All rights reserved. Résumé Le tatouage est une pratique sociétale parmi les plus anciennes au monde et intégrée à la sphère médicale depuis l’antiquité. Les chirurgiens plasticiens sont de plus en plus confrontés au tatouage mais aussi à son retrait. Même si cette pratique est anodine en apparence, tatouage et détatouage ne sont pas dénués de risque et nécessitent d’être pris en charge par des mains expertes. # 2016 Elsevier Masson SAS. Tous droits réservés.
* Corresponding author. E-mail address: [email protected] (N. Malca). http://dx.doi.org/10.1016/j.anplas.2016.09.005 0294-1260/# 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Introduction In parallel with the resurgent popularity of tattooing, requests for tattoo removal have been steadily increasing; this is the case for a number of psychosocial reasons: making a break with a tumultuous past, responding to professional exigencies or enduring a romantic ‘‘split’’. Over the upcoming years, one can expect at least 5 to 10 million tattooed individuals to wish to have their tattoos removed [1,2]. Tattooing consists in implanting exogenous pigments under the epidermis at various degrees of depth so as to produce coloration. Dermograph needles cross the papillary and/or reticular dermis at a depth approximating 1 to 2 mm. The tattoo pigments are placed in the macrophages; subsequent to scarring, they remain inert [3—6] (Figs. 1 and 2).
Tattoo removal techniques Historical background Different techniques have existed since antiquity [7]: the salt abrasion process dates back to the 6th century and remained in use as late as the 1990s [8]. In 1888, Variot developed a new chemical destruction technique [2] involving injection in the dermis of tannic acid and leading to dry necrosis of the tattoo; its implementation was later discontinued due to the extensive resulting keloid scars and hypopigmentation it provoked. In the early 20th century, Lacassagne was the first to propose a dermal abrasion procedure using emery cloth [9]. As for Dubreuilh, he carried out unsuccessful attempts with X-rays prior to publishing details on his
Figure 1
new, so-called decortication technique in 1909, at a time when direct suture for large-scale tattoos was not possible [10], and it yielded controlled wound healing or a skin graft taken from the limbs [11]. Diversified procedures of chemical destruction using potassium bioxalate, zinc chloride and vesicatory ammoniac also saw the light of day, provoking superficial burns and hideous scars.
Thermal tattoo removal techniques The 1970s were marked by the emergence of selective photothermolysis through which laser is enabled to destroy the pigment. Whether or not laser is chosen depends on the color of the pigment corresponding to the therapeutic target. When it is, sufficient knowledge of the inks comprising the tattoos is essential to selection of the wave length most amenable to absorption. Several studies have underscored the wide variety of chemical components to be found in tattoos; some of them have specific colors, and the black and dark inks are the easiest to eliminate. In addition to acquisition of the right wave length, pulse time is of prime importance. Indeed, with nanosecond pulsed lasers only a limited part of laser energy is transformed into an effective photoacoustic effect, especially when the target is minuscule. One consequence of this principle is that small-sized pigmented masses are resistant targets (Fig. 2). Clear, polychrome or compact tattoos are particularly difficult to remove, and some forms of permanent makeup contain non-mineral pigments that change colors on contact with laser [12—16]. Even though some of the thermal procedures outlined above have revolutionized treatment of exceedingly largescale tattoos, they have continued to present several short-
Homogenous distribution of the pigments in the dermis on a tattoo created by a professional.
Figure 2 Localization of the pigments created by an amateur. It is necessary that the pigment be deposited at exactly the right depth. If it is positioned too superficially, the color will fade; if it is positioned too deeply, it will appear bluish due to Tyndall effect. Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Figure 3
3
Superficial tattoo treated by nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon. Good result.
Figure 4 Superficial tattoo treated by nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon. Keloïd scar formation.
comings: incomplete removal of certain pigments, hypopigmentation or hyperpigmentation secondary to faulty parameter setting, changes in skin texture and scarring sequelae according to the depth of the tattoo. Conversely, amateur tattooing using superficially applied or low-quality ink will in all likelihood disappear without sequelae! So much said, thermal removal remains a long-term process (ten sessions spread out over 3 to 4 years) that is at once painful and
Figure 5
expensive, and there is no guarantee of 100% efficacy, the degree of effectiveness often depending on the intrinsic quality of the tattoo [17—21] (Figs. 3—5).
Mechanical tattoo removal methods Administered alone or in association with silver nitrate or gentian violet, dermabrasion by a high-speed drill with a
Tribal tattoo treated using nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Figure 6
Figure 7
First phase of excision, closing by Dufourmentel LLL flap.
Laser failure, positioning of 2 expanders on two sides. Outcome < 1 postoperative month.
diamond burr [22] can successfully remove the upper or superficial layers of tattooed skin, but given its ineffectiveness on deeper layers and risks of hypertrophic scarring or hyper/hypopigmentation, it has been largely given up [1,23]. More precisely, dermabrasion has been eclipsed by surgical removal [24,25] (Figs. 6—8), which systematically leaves scars yet remains the most effective way of eradicating tattoos. Indeed, surgery yields excellent cosmetic results when the tattoo is small-sized and located in a part of the skin characterized by high laxity; on the other hand, it is not indicated in markedly large zones. More generally, it is according to the
Figure 8
width and location of the tattoo that it may be possible to carry out exeresis suture or iterative excisions at intervals of at least 6 months. The complications directly ascribable to this method are scar disunion and keloid scarring (1 case out of 20 in the study by Koljonen) [24]. Lack of cutaneous laxity is liable to lead to difficulties in closing the wound that may finally necessitate a skin graft (Fig. 8); it can also yield anatomic distortion and a cosmetic outcome less acceptable for the patient than the tattoo itself [26]. While loss of soft tissue can in some cases be limited by applying progressive skin traction or dermotraction (presuture/dynamic suture),
Exeresis followed by graft, 1 month after tattooing of the trunk.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Dealing with tattoos in plastic surgery. Tattoo removal which has given promising results on animal models or in other therapeutic applications [25], the most widely used procedure has been cutaneous expansion. It is also possible to use large-sized expanders (Fig. 7), which may be customized and installed on both sides of a tattoo so as to achieve optimal advantage; incision and valve positioning are carried out in the tattoo to minimize the extent of scarring. In some areas, however, such as the lower back, classical tattooing tends to complicate application of this technique, and iterative excision or skin graft are more likely to be recommended. A surgical solution should consequently be adopted only after giving due thought to the risk of major scarring, which has got to be consciously accepted by the patient [25]. Surgery must be oriented according to the depth of the dermis containing the pigments. Very small-sized, posttraumatic tattoos or those secondary to tracking radiotherapy can be removed by skin biopsy punch and will permit direct suture [27]. Small tattoos can be removed by fusiform excision while observing an ideal length/width ratio of 3:1 and respecting the outlines of a main axis parallel to Langer’s lines of skin tension; following adequate detachment, the wound is to be closed in two planes. According to a tattoo’s geometry, flaps can be proposed (Fig. 6) for small ovoid tattoos (O-plasty is preferable to basic Z-plasty), whereas for elongated tattoos, rotation flaps are more suitable [28]. Broader-based tattoos on the limbs or the trunk can be removed by tangential incision or controlled wound healing [29]. On the limbs, application of a tourniquet enables more precise excision and shortens surgical time [30]. Preoperative biopsy can help to assess the depth of the pigment and to optimize excision [16]. In order to improve cosmetic outcome and to facilitate the scarring of these excisions, different methods have been suggested: dermal overgrafting [31], utilization of cells in suspension from the excised area in view of ensuring more rapid reepithelialization [32] and cell culture [25]. Finally and more
Figure 9
5 or less time-consumingly, a Japanese team has proposed to improve wound healing without additional scarring by excising from the dermatome the tattooed epidermis, which are first immersed for an hour in an enzymatic solution and subsequently regrafted [33].
Alternatives Over recent decades, efforts have been concentrated on methods minimizing adverse effects; in 2001, Cheng a published [34,35] his conclusions on 98 patients having used the ‘‘E-Raze Rejuvi tattoo remover’’ a supposedly simple chemical extraction procedure derived from Dr. Variot’s and aimed at softening the pigments so as to detach them from the dermis by means of the usual mechanism of micropigmentation. The rate of success was 100% for permanent makeup, which is superficial, and 92% for other tattoos (body piercing. . .), with a scar at 6 months in 6% of the latter and 0% of the former. Sooner rather than later, the studies reported a sizable number of adverse side effects (chemical burns, dysesthetic or unsightly scar, hypopigmentation. . .) in patients subjected to E-raze by non-physicians, which have raised serious doubts about this innovation [36—38]. For the reasons mentioned above, none of the ablative methods are altogether ideal; all of them entail side effects, while the chemical and mechanical methods, which are more rapid, nonetheless expose patients to the risk of scarring sequelae [7,39]. They must systematically be performed by persons with expertise in the procedure applied. Laser and surgery constitute the currently recognized gold standard [40]. Given the expensiveness of these procedures, more and more persons desirous of tattoo removal have been opting for clandestine methods via products purchased on the Internet that are in no way regulated and have never been
Conduct recommended following request of tattoo removal.
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the object of scientific studies. Tattoo removal creams, for example, may contain salicylic acid or hydroquinone derivatives and are responsible for reactions ranging from simple contact dermatitis to chemical burning; more broadly speaking, they are quack remedies inasmuch as the location of the pigment in the dermis impose a treatment involving, at the very least, an attack on the epidermis [41,42]. As local applications or as variants of the 19th-century Variot method, they are likewise problematic; some examples are tricholoroacetic acid (rarely used today) or lactic acid in ‘‘tatt2away’’ injection solution [43]. And while some chemical methods are potentially effective in expert hands, they present a sizable risk of chemical burns or negative aesthetic sequelae [23,40,44—46].
Conclusion Whether in reconstructive tattooing or tattoo removal, the role of the plastic surgeon is indisputably primordial. The surgeon should remember that as of now, there exists no perfect ablative procedure. While laser is the most widely applied method, it almost immediately reaches its limits, given the fact that many tattoos are colored and far from superficial. From the outset, surgical treatment can be considered as an option, starting with simple or iterative excisions, while more cumbersome treatments (cutaneous expansion followed by skin graft) should be reserved for the most extended and difficultly localized forms (Fig. 9).
Disclosure of interest The authors declare that they have no competing interest.
Acknowledgments The author wishes to thank private and hospital practitioners for having shared their photos for this article, and wish to offer special thanks to Dr. Nicolas Kruger for his valuable advice.
References [1] Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55(3):413—21. [2] Armstrong ML, Roberts AE, Koch JR, Saunders JC, Owen DC, Anderson RR. Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol 2008;144(7):879—84. [3] Garg G, Thami GP. Micropigmentation: tattooing for medical purposes. Dermatol Surg 2005;31(8 Pt 1):928—31 [discussion 931]. [4] Rassman WR, Pak JP, Kim J, Estrin NF. Scalp micropigmentation: a concealer for hair and scalp deformities. J Clin Aesthetic Dermatol 2015;8(3):35—42. [5] Tsur H, Kaplan HY. Camouflaging hairless areas on the male face by artistic tattoo. Plast Reconstr Surg 1993;92(2):357—60. [6] Park JH, Moh JS, Lee SY, You SH. Micropigmentation: camouflaging scalp alopecia and scars in Korean patients. Aesthetic Plast Surg 2014;38(1):199—204. [7] Kluger N. [Tattoo removal at the start of the 20th century]. Ann Dermatol Venereol 2010;137(8—9):582—4.
[8] Horn W. [Effects of tattoo removal and results after salabrasion]. Z Für Hautkrankh 1983;58(5):336—42. [9] Bruno C. Tatoués, qui êtes-vous ?. Bruxelles, Belgique: Éditions de Feynerolles; 1970: 239. [10] Dubreuilh W. Détatouage par décortication (un nouveau procédé). Ann Dermatol Syphiligr (Paris) 1909;10:367—73. [11] Levy J, Sewell M, Goldstein N. II. A short history of tattooing. J Dermatol Surg Oncol 1979;5(11):851—6. [12] Ho SG, Goh CL. Laser tattoo removal: a clinical update. J Cutan Aesthetic Surg 2015;8(1):9—15. [13] Ibrahimi OA, Sakamoto FH, Anderson RR. Picosecond laser pulses for tattoo removal: a good, old idea. JAMA Dermatol 2013;149(2):241. [14] Jimenez G, Weiss E, Spencer JM. Multiple color changes following laser therapy of cosmetic tattoos. Dermatol Surg 2002;28(2):177—9. [15] Shah SD, Aurangabadkar SJ. Newer trends in laser tattoo removal. J Cutan Aesthetic Surg 2015;8(1):25—9. [16] Tammaro A, Fatuzzo G, Narcisi A, Abruzzese C, Caperchi C, Gamba A, et al. Laser removal of tattoos. Int J Immunopathol Pharmacol 2012;25(2):537—9. [17] Bergstrom KG. Tattoo removal: new laser options. J Drugs Dermatol 2013;12(4):492—3. [18] Choudhary S, Elsaie ML, Leiva A, Nouri K. Lasers for tattoo removal: a review. Lasers Med Sci 2010;25(5):619—27. [19] Kluger N, Hakimi S, Del Giudice P. Keloid occurring in a tattoo after laser hair removal. Acta Derm Venereol 2009;89(3): 334—5. [20] louari S. Réaction inflammatoire aux tatouages de couleur et laser déclenché. Ann Dermatol Venereol 2015;142(12):532. [21] Varma S, Swanson NA, Lee KK. Tattoo ink darkening of a yellow tattoo after Q-switched laser treatment. Clin Exp Dermatol 2002;27(6):461—3. [22] Clabaugh WA. Tattoo removal by superficial dermabrasion. Five-year experience. Plast Reconstr Surg 1975;55(4):401—5. [23] Kluger N. The risks of do-it-yourself and over-the-counter devices for tattoo removal. Int J Dermatol 2015;54(1):13—8. [24] Koljonen V, Kluger N. Specifically requesting surgical tattoo removal: are deep personal motivations involved? J Eur Acad Dermatol Venereol 2012;26(6):685—9. [25] Wollina U, Köstler E. Tattoos: surgical removal. Clin Dermatol 2007;25(4):393—7. [26] Burris K, Kim K. Tattoo removal. Clin Dermatol 2007;25(4):388— 92. [27] Köstler E. Tätowierungen als chirurgisch-dermatoligisches problem. Dermatol Monatsschr 1982;168:1—9. [28] Zuber TJ. Fusiform excision. Am Fam Physician 2003;67(7): 1539—44 [1547—8, 1550]. [29] Wheeler ES, Miller TA. Tattoo removal by split thickness tangential excision. West J Med 1976;124(4):272—5. [30] Hull JB, Corner NB, Roberts P, Attwood AI. Tattoo removal by surgery in a bloodless field. J R Army Med Corps 1991;137(1): 5—7. [31] Vecchione TR. Tattoo removal using precise shave excision and dermal overgrafting. Ann Plast Surg 1988;20(5):443—6. [32] Sebök B, Kulik P, Török Z. [Dermabrasion for tattoo removal complemented by cell suspension for wound healing]. Orv Hetil 1991;132(5):245—7. [33] Takushima A, Okazaki M, Harii K. Tattoo removal by grafting enzymatically separated epidermis. Ann Plast Surg 2001;47(4):398—403. [34] Cheng W. A non-laser method to reverse permanent makeup and tattoos. Cosmet Dermatol 2001;14(4):47—50. [35] Cheng W. Chemical extraction technique for tattoo removal. Br J Dermatol 2004;151(6):1282—4. [36] Veysey E, Downs AMR. Adverse side-effects following attempted removal of tattoos using a non-laser method. Br J Dermatol 2004;150(4):770—1.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Dealing with tattoos in plastic surgery. Tattoo removal [37] Snelling A, Ball E, Adams T. Full thickness skin loss following chemical tattoo removal. Burns J Int Soc Burn Inj 2006;32(3): 387—8. [38] Saini R, Winhoven SM, Kaufman J. Hypertrophic scar after chemical tattoo removal. Dermatol Surg 2008;34(11):1599— 602. [39] Goldstein N. Tattoo removal. Dermatol Clin 1987;5(2):349—58. [40] Kluger N, Koljonen V. Chemical burn and hypertrophic scar due to misuse of a wart ointment for tattoo removal. Int J Dermatol 2014;53(1):e9—11. [41] Kluger N. [Tattoo skin reactions: management and treatment algorithm]. Ann Dermatol Venereol 2016;143(6—7):436—45.
7 [42] Kluger N. Cutaneous and systemic complications associated with tattooing. Presse Med 2016;45(6 Pt 1):567—76. [43] All natural non-laser tattoo removal system — Tatt2Away [Internet]. Available from: http://tatt2away.com/ [cited 2016 Jul 19]. [44] Wollina U. Depigmentation and hypertrophic scars after application of a fluid lactic acid tattoo eraser. Wien Med Wochenschr 2015;165(9—10):195—8. [45] Rawlins JM, Austin O. Hypertrophic scar from tattoo dispersion gel. J Plast Reconstr Aesthetic Surg 2008;61(6):709. [46] Karsai S, Krieger G, Raulin C. Tattoo removal by nonprofessionals — medical and forensic considerations. J Eur Acad Dermatol Venereol 2010;24(7):756—62.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
ANNPLA-1279; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
GENERAL REVIEW
Dealing with tattoos in plastic surgery. Tattoo removal Autour du tatouage en chirurgie plastique. ´ tatouage De N. Malca *, L. Boulart, W. Noel, A. de Runz, M. Chaouat, M. Mimoun, D. Boccara ˆ pital Saint-Louis, 1, avenue Claude-Vellefaux, Plastic, reconstructive, aesthetic surgery unit, ho 75010 Paris, France Received 25 July 2016; accepted 14 September 2016
KEYWORDS Tattoo; Tattoo removal; Surgery; Laser; Scar
MOTS CLÉS Tatouage ; Détatouage ; Chirurgie ;Laser ; Cicatrice
Summary Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing — and with tattoo removal procedures, as well. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands. # 2016 Elsevier Masson SAS. All rights reserved. Résumé Le tatouage est une pratique sociétale parmi les plus anciennes au monde et intégrée à la sphère médicale depuis l’antiquité. Les chirurgiens plasticiens sont de plus en plus confrontés au tatouage mais aussi à son retrait. Même si cette pratique est anodine en apparence, tatouage et détatouage ne sont pas dénués de risque et nécessitent d’être pris en charge par des mains expertes. # 2016 Elsevier Masson SAS. Tous droits réservés.
* Corresponding author. E-mail address: [email protected] (N. Malca). http://dx.doi.org/10.1016/j.anplas.2016.09.005 0294-1260/# 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Introduction In parallel with the resurgent popularity of tattooing, requests for tattoo removal have been steadily increasing; this is the case for a number of psychosocial reasons: making a break with a tumultuous past, responding to professional exigencies or enduring a romantic ‘‘split’’. Over the upcoming years, one can expect at least 5 to 10 million tattooed individuals to wish to have their tattoos removed [1,2]. Tattooing consists in implanting exogenous pigments under the epidermis at various degrees of depth so as to produce coloration. Dermograph needles cross the papillary and/or reticular dermis at a depth approximating 1 to 2 mm. The tattoo pigments are placed in the macrophages; subsequent to scarring, they remain inert [3—6] (Figs. 1 and 2).
Tattoo removal techniques Historical background Different techniques have existed since antiquity [7]: the salt abrasion process dates back to the 6th century and remained in use as late as the 1990s [8]. In 1888, Variot developed a new chemical destruction technique [2] involving injection in the dermis of tannic acid and leading to dry necrosis of the tattoo; its implementation was later discontinued due to the extensive resulting keloid scars and hypopigmentation it provoked. In the early 20th century, Lacassagne was the first to propose a dermal abrasion procedure using emery cloth [9]. As for Dubreuilh, he carried out unsuccessful attempts with X-rays prior to publishing details on his
Figure 1
new, so-called decortication technique in 1909, at a time when direct suture for large-scale tattoos was not possible [10], and it yielded controlled wound healing or a skin graft taken from the limbs [11]. Diversified procedures of chemical destruction using potassium bioxalate, zinc chloride and vesicatory ammoniac also saw the light of day, provoking superficial burns and hideous scars.
Thermal tattoo removal techniques The 1970s were marked by the emergence of selective photothermolysis through which laser is enabled to destroy the pigment. Whether or not laser is chosen depends on the color of the pigment corresponding to the therapeutic target. When it is, sufficient knowledge of the inks comprising the tattoos is essential to selection of the wave length most amenable to absorption. Several studies have underscored the wide variety of chemical components to be found in tattoos; some of them have specific colors, and the black and dark inks are the easiest to eliminate. In addition to acquisition of the right wave length, pulse time is of prime importance. Indeed, with nanosecond pulsed lasers only a limited part of laser energy is transformed into an effective photoacoustic effect, especially when the target is minuscule. One consequence of this principle is that small-sized pigmented masses are resistant targets (Fig. 2). Clear, polychrome or compact tattoos are particularly difficult to remove, and some forms of permanent makeup contain non-mineral pigments that change colors on contact with laser [12—16]. Even though some of the thermal procedures outlined above have revolutionized treatment of exceedingly largescale tattoos, they have continued to present several short-
Homogenous distribution of the pigments in the dermis on a tattoo created by a professional.
Figure 2 Localization of the pigments created by an amateur. It is necessary that the pigment be deposited at exactly the right depth. If it is positioned too superficially, the color will fade; if it is positioned too deeply, it will appear bluish due to Tyndall effect. Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Figure 3
3
Superficial tattoo treated by nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon. Good result.
Figure 4 Superficial tattoo treated by nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon. Keloïd scar formation.
comings: incomplete removal of certain pigments, hypopigmentation or hyperpigmentation secondary to faulty parameter setting, changes in skin texture and scarring sequelae according to the depth of the tattoo. Conversely, amateur tattooing using superficially applied or low-quality ink will in all likelihood disappear without sequelae! So much said, thermal removal remains a long-term process (ten sessions spread out over 3 to 4 years) that is at once painful and
Figure 5
expensive, and there is no guarantee of 100% efficacy, the degree of effectiveness often depending on the intrinsic quality of the tattoo [17—21] (Figs. 3—5).
Mechanical tattoo removal methods Administered alone or in association with silver nitrate or gentian violet, dermabrasion by a high-speed drill with a
Tribal tattoo treated using nanosecond Q-switched laser (before/after). Collection of Dr Paul Barbe, Avignon.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Figure 6
Figure 7
First phase of excision, closing by Dufourmentel LLL flap.
Laser failure, positioning of 2 expanders on two sides. Outcome < 1 postoperative month.
diamond burr [22] can successfully remove the upper or superficial layers of tattooed skin, but given its ineffectiveness on deeper layers and risks of hypertrophic scarring or hyper/hypopigmentation, it has been largely given up [1,23]. More precisely, dermabrasion has been eclipsed by surgical removal [24,25] (Figs. 6—8), which systematically leaves scars yet remains the most effective way of eradicating tattoos. Indeed, surgery yields excellent cosmetic results when the tattoo is small-sized and located in a part of the skin characterized by high laxity; on the other hand, it is not indicated in markedly large zones. More generally, it is according to the
Figure 8
width and location of the tattoo that it may be possible to carry out exeresis suture or iterative excisions at intervals of at least 6 months. The complications directly ascribable to this method are scar disunion and keloid scarring (1 case out of 20 in the study by Koljonen) [24]. Lack of cutaneous laxity is liable to lead to difficulties in closing the wound that may finally necessitate a skin graft (Fig. 8); it can also yield anatomic distortion and a cosmetic outcome less acceptable for the patient than the tattoo itself [26]. While loss of soft tissue can in some cases be limited by applying progressive skin traction or dermotraction (presuture/dynamic suture),
Exeresis followed by graft, 1 month after tattooing of the trunk.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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Dealing with tattoos in plastic surgery. Tattoo removal which has given promising results on animal models or in other therapeutic applications [25], the most widely used procedure has been cutaneous expansion. It is also possible to use large-sized expanders (Fig. 7), which may be customized and installed on both sides of a tattoo so as to achieve optimal advantage; incision and valve positioning are carried out in the tattoo to minimize the extent of scarring. In some areas, however, such as the lower back, classical tattooing tends to complicate application of this technique, and iterative excision or skin graft are more likely to be recommended. A surgical solution should consequently be adopted only after giving due thought to the risk of major scarring, which has got to be consciously accepted by the patient [25]. Surgery must be oriented according to the depth of the dermis containing the pigments. Very small-sized, posttraumatic tattoos or those secondary to tracking radiotherapy can be removed by skin biopsy punch and will permit direct suture [27]. Small tattoos can be removed by fusiform excision while observing an ideal length/width ratio of 3:1 and respecting the outlines of a main axis parallel to Langer’s lines of skin tension; following adequate detachment, the wound is to be closed in two planes. According to a tattoo’s geometry, flaps can be proposed (Fig. 6) for small ovoid tattoos (O-plasty is preferable to basic Z-plasty), whereas for elongated tattoos, rotation flaps are more suitable [28]. Broader-based tattoos on the limbs or the trunk can be removed by tangential incision or controlled wound healing [29]. On the limbs, application of a tourniquet enables more precise excision and shortens surgical time [30]. Preoperative biopsy can help to assess the depth of the pigment and to optimize excision [16]. In order to improve cosmetic outcome and to facilitate the scarring of these excisions, different methods have been suggested: dermal overgrafting [31], utilization of cells in suspension from the excised area in view of ensuring more rapid reepithelialization [32] and cell culture [25]. Finally and more
Figure 9
5 or less time-consumingly, a Japanese team has proposed to improve wound healing without additional scarring by excising from the dermatome the tattooed epidermis, which are first immersed for an hour in an enzymatic solution and subsequently regrafted [33].
Alternatives Over recent decades, efforts have been concentrated on methods minimizing adverse effects; in 2001, Cheng a published [34,35] his conclusions on 98 patients having used the ‘‘E-Raze Rejuvi tattoo remover’’ a supposedly simple chemical extraction procedure derived from Dr. Variot’s and aimed at softening the pigments so as to detach them from the dermis by means of the usual mechanism of micropigmentation. The rate of success was 100% for permanent makeup, which is superficial, and 92% for other tattoos (body piercing. . .), with a scar at 6 months in 6% of the latter and 0% of the former. Sooner rather than later, the studies reported a sizable number of adverse side effects (chemical burns, dysesthetic or unsightly scar, hypopigmentation. . .) in patients subjected to E-raze by non-physicians, which have raised serious doubts about this innovation [36—38]. For the reasons mentioned above, none of the ablative methods are altogether ideal; all of them entail side effects, while the chemical and mechanical methods, which are more rapid, nonetheless expose patients to the risk of scarring sequelae [7,39]. They must systematically be performed by persons with expertise in the procedure applied. Laser and surgery constitute the currently recognized gold standard [40]. Given the expensiveness of these procedures, more and more persons desirous of tattoo removal have been opting for clandestine methods via products purchased on the Internet that are in no way regulated and have never been
Conduct recommended following request of tattoo removal.
Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005
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the object of scientific studies. Tattoo removal creams, for example, may contain salicylic acid or hydroquinone derivatives and are responsible for reactions ranging from simple contact dermatitis to chemical burning; more broadly speaking, they are quack remedies inasmuch as the location of the pigment in the dermis impose a treatment involving, at the very least, an attack on the epidermis [41,42]. As local applications or as variants of the 19th-century Variot method, they are likewise problematic; some examples are tricholoroacetic acid (rarely used today) or lactic acid in ‘‘tatt2away’’ injection solution [43]. And while some chemical methods are potentially effective in expert hands, they present a sizable risk of chemical burns or negative aesthetic sequelae [23,40,44—46].
Conclusion Whether in reconstructive tattooing or tattoo removal, the role of the plastic surgeon is indisputably primordial. The surgeon should remember that as of now, there exists no perfect ablative procedure. While laser is the most widely applied method, it almost immediately reaches its limits, given the fact that many tattoos are colored and far from superficial. From the outset, surgical treatment can be considered as an option, starting with simple or iterative excisions, while more cumbersome treatments (cutaneous expansion followed by skin graft) should be reserved for the most extended and difficultly localized forms (Fig. 9).
Disclosure of interest The authors declare that they have no competing interest.
Acknowledgments The author wishes to thank private and hospital practitioners for having shared their photos for this article, and wish to offer special thanks to Dr. Nicolas Kruger for his valuable advice.
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Please cite this article in press as: Malca N, et al. Dealing with tattoos in plastic surgery. Tattoo removal. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/j.anplas.2016.09.005