- Email: [email protected]
Q-switched alexandrite laser treatment (755 nm) of professional and amateur tattoos
THERAPY Q-switched alexandrite laser treatment (755 rim) of professional and amateur tattoos Tina S. Alster, MD Washington, D. C
Background: Several laser techniques have been proposed for the removal of decorative tattoos. The lasers that have been used most successfully are Q-switched red or near-infrared systems because of their ability to target tattoo pigment selectivelywith minimal risk of scarring or permanent pigmentary changes. Objectives: The objectives of this study were to determine the clinical effectiveness of the newest Q-switched system, the alexandrite laser, in removing amateur and professional tattoos and to observe side effects. Methods: Twenty-four multicolored professional tattoos and 18 blue-black amateur tattoos were treated with the Q-switched alexandrite laser (755 nm, 100 nsec) at 2-month intervals until total clearing was achieved. The 510 nm pulsed dye laser was used to treat tattoos that contained red pigment. Results: Professional tattoos required an average of 8.5 alexandrite laser treatments for total clearance, whereas only 4.6 treatments were necessary to remove amateur tattoos. Red tattoo pigment was successfully treated with an average of two 510 nm pulsed dye laser sessions. No scarring or long-standing pigmentary changes were seen in laser-irradiated skin. Conclusion: The Q-switched alexandrite laser is highly effective in removing multicolored professional and amateur tattoos without adverse sequelae. The 510 nm pulsed dye laser was useful in eliminating red tattoo pigment. (J AM ACAD DERMATOL1995;33:69-73.) Requests for the removal of decorative tattoos are growing more numerous as the number of persons with tattoos increases. It is estimated that approximately 5% of the North American population has at least one tattoo. Numerous treatments such as surgical excision, 1-3 dermabrasion, 48 chemical therapy,9-11 cryosurgery,12 and electrosurgery13, 14 have been used, but each technique was limited by undesirable scarring or pigmentary alterations. Many laser treatments have been introduced in recent years. The earfier laser systems had less specificity and, therefore, more side effects than the latest technologic advances. 142° The newest Q-switched laser systems, including the ruby, 21-26 Nd:YAG,26, 27 and alexandrite, 28 have shown the greatest promise in treating tattoos because of their ability to preferentially injure structures in the dermis that contain pigment with brief, selectively ab-
From the Georgetown University Medical Center and the Washington Institute of Dermatologic Laser Surgery. Reprint requests: Tina S. Alster, MD, 2311 M St., NW, Suite 504, Washington, DC 20037. Copyright ® 1995 by the American Academy of Dermatology, Inc. 0190-9622/95 $3.00 + 0 16/1/63140
sorbed laser pulses. This process is termed "selective photothermolysis.,,29, 3o Even with their increased selectivity, however, the current Q-switched ruby and Nd:YAG laser systems cannot effectively remove red and green tattoo pigments, respectively. 21"27 In contrast, the Q-switched alexandrite laser is accompanied by a 510 nm pulsed dye system, which, when used in combination, could conceivably eliminate all pigment in a multicolored tattoo. Clinical reports of the response of tattoos to the Q-switched alexandrite laser have been sparse. This study was undertaken to evaluate the clinical effectiveness of the Q-switched alexandrite laser in eliminating amateur and multicolored professional tattoos. In tattoos that contained red pigment granules, the 510 nm pulsed dye laser was also used. MATERIAL AND METHODS
Patients who were willing to enter the study and schedule appointments every 6 to 8 weeks were recruited during a 3-month period and treated during the next 12 to 18 months. None of the patients had received any prior treatment for removal of their tattoos. 69
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Journal of the American Academy of Dermatology July 1995
Alster
Fig. 1. Professional tattoo with blue-black and red pigments before treatment (A), immediately after alexandrite laser treatment at 6.0 J/cm 2 with characteristic tissue whitening (B), 6 weeks after the fourth alexandrite laser treatment (C), and 8 weeks after nine alexandrite laser treatments (mean fluence, 6.75 J/cm 2) and two 510 nm pulsed dye laser treatments (mean fluence, 3.0 J/cm 2) (D). Ability to tan was not affected by laser treatment.
A Q-switched alexandrite laser (Candela Laser Corp., Wayland, Mass.) with a 755 nm wavelength, 100 nsec pulse duration, and 3 mm spot size was used. After informed consent was obtained, a total of 31 patients (19 men and 12 women, ages 18 to 56 years) with 42 tattoos (24 professional and 18 am-
ateur) were treated at 6- to 8-week intervals. At each visit the tattoo was completely covered with adjacent, nonoverlapping laser pulses at energy densities that ranged from 4.75 to 8.0 J / c m 2. The energy fluence used was determined by each patient's threshold response as indicated by characteristic tis-
Journal of the American Academy of Dermatology Volume 33, Number 1
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71
Table I. Tattoo characteristics Type and location
Average size (cm2)
No. of lesions
Amateur Face Chest Forearm Hand Ankle Subtotal Professional Chest Scapula Deltoid Forearm Ankle Subtotal Total/mean
Average duration
(yr)
1 1 l1 4 1 18
8 12 18 (2-36) 5 (2-12) 48 16 (2-48)
27 15 18 (8-30) 19 (7-33) 1 17.5 (1-33)
2 5 10 6 1 24 42
54 (36-72) 56 (40-64) 87 (9-200) 56 (! 6-140) 4 66 (4-200) 44.5
11 (4-16) 10 (2-14) 19 (1- 39) 20 (8-37) 2 16.0 (1-37) 16.5
Numbers in parentheses represent ranges.
Table II. Response of tattoos to alexandrite laser (755 nm, I00 nsec) and pulsed dye laser (510 nm, 300 nsec) Alexandrite laser Tattoo type
No. of lesions
No. of treatments
Amateur Black-blue
18
2-9 (4.6)
Professional Blue-black only + Green + Red + Green and red Subtotal/mean
l0 6 5 3 2--4
6-13 (8.4) 6-12 (7.3) 6-12 (9.2) 8-13 (10) 6-13 (8.5)
Energy (J/em2)
4.75-7.5 (6.25) 5.75-8 (6.5) 5.5-8 (6.79) 5.5-8 (6.85) 5.75-8 (6.75) 5.5-8 (6.75)
Pulsed dye laser
No. of treatments
Energy (J/era2)
N/A N/A N/A 1-3 (2) 2-3 (2.3) l-3 (2.1)
--2.5-3.5 (3) 2.75-3.75(3.85) 2.5-3.75 (3.1)
Numbers in parentheses represent means.
sue whitening. The energy density was reduced if an excessive response such as bleeding or tissue splatter was encountered. In the eight professional tattoos that contained red pigment, a 510 nm, 300 nsec pulsed dye laser (Candela Laser Corp.) with a 5 mm spot size was used in these areas. No intralesional or topical anesthesia was used. Care after laser treatment consisted of twice-daily cleansing with mild soap and water followed by application of a topical antibiotic ointment and a nonstick bandage. Photographs of the tattoos were taken before each laser session by one photographer who used identical lighting, camera settings, and film processing techniques. Although the photographs were used to
document each patient's progress, individual responses to treatment were determined by clinical examination at each visit. Tattoos were considered to be completely cleared when the color within a laser-treated tattoo was found to be indistinguishable from the surrounding normal (or untreated) skin by two independent observers. Particular attention was paid to pigmentary and textural changes and scarring within the laser-treated site. RESULTS
The total elimination of all tattoos in the study was accomplished with use of the Q-switched alexandrite laser. The number of laser treatments necessary ranged from 2 to 13, depending on whether
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Journal of the American Academy of Dermatology July 1995
Fig. 3. Multicolored professional tattoo before (A) and 8 weeks after (B) 12 alexandrite treatments (mean fluence, 7.0 J/cm 2) and three pulsed dye laser treatments (mean fluence, 3.0 J/cm2). No pigmentary alteration or scarring was noted.
This was especially true for the professional tattoos that contained newer organometallic pigments. No adverse responses were observed in any of the laser-treated tattoos, including scarring or textural changes. Transient hypopigmentation, which was seen in two professional tattoos, completely resolved within 3 months after cessation of laser treatment. Fig. 2. Amateur tattoo before (A) and 6 weeks after (B) four Q-switched alexandrite laser treatments at a mean fluence of 6.25 J/cm 2. the tattoo was an amateur or professional tattoo. On average, amateur tattoos were smaller (16 cm 2 vs 66 cm 2) and required fewer laser treatments (4.6 vs 8.5) and lower energy densities (6.25 J / c m 2 vs 6.75 J / c m 2) than professional tattoos (Fig. 1, A-D, Fig. 2, A and B, and Tables I and II). No significant difference existed in the number of treatments necessary to treat professional tattoos that contained green pigment and those that contained only blue-black pigment. Tattoos that contained red pigment required an average of two treatments with the 510 nm pulsed dye laser in addition to the alexandrite laser treatments (Fig. 3, Table II). The mean ages of the amateur and professional tattoos included in the study did not differ significantly enough to permit assessment of any differences in their response to laser treatment (Table I). In general, however, it was noted that the younger or newer tattoos required more laser treatments.
DISCUSSION To remove tattoo pigment completely with any of the available Q-switched laser systems, a series of repeated treatments is necessary. Each successive treatment allows continued removal of remaining pigment in a "layered" fashion. Laser treatments should be spaced at 1 to 2 month intervals to allow appropriate dermal healing, including phagocytosis of tattoo fragments. However, the ultimate fate of tattoo particles after laser irradiation remains unknown. The results obtained with the alexandrite laser in this study (Tables I and II) demonstrate high tattoo pigment selectivity and are in keeping with results obtained with the Q-switched ruby and Nd:YAG lasers. 2127 Removal of amateur tattoos required a mean of 4.6 alexandrite laser treatments, and elimination of professional tattoos required a mean of 8.5 treatments. The increased number of treatments required for professional tattoos has been attributed to the increased pigment content and to the organometallic dyes used. 23, 3t It is important that even green and red tattoo pig-
Journal of the American Academy of Dermatology Volume 33, Number 1
ments can be removed with the combination of alexandrite and 510 nm pulsed dye lasers, because other Q-switched lasers do not have this capacity. 21-27 Approximately one quarter to one third of professional tattoos contain green and/or red pigment that cannot be eliminated by the Nd:YAG and ruby lasers, respectively. The results of this study illustrated several other advantages of the Q-switched alexandrite laser compared with other Q-switched lasers. First, no long-term pigmentary changes were encountered; these changes are common after ruby laser treatment. The slightly longer wavelength of the alexandrite laser allows less melanin absorption and deeper tissue penetration, thereby reducing pigmentary changes and increased absorption by dermal tattoo pigment. Second, no tissue splatter is encountered with the alexandrite laser. In general, much higher energy densities (on the order of 8 to 10 J/cm 2) are required to effect the desired degree of tattoo lightening by the Nd:YAG and ruby lasers. The increased fluences and smaller spot sizes used in Nd:YAG laser treatment, in particular, are responsible for the prominent bleeding and tissue splatter associated with its use. The energies used in this study (average, 6.5 J/cm 2) produced excellent clinical responses without the risks inherent with tissue debris exposure. Lastly, the features of the alexandrite laser allow rapid treatment sessions with minimal discomfort, thereby eliminating the need for anesthesia, which is commonly used with other Q-switched laser systems. REFERENCES 1. Buncke HJ Jr' C°nway H" Surgery °f dec°rative and traumatic tattoos. Plast Reconstr Surg 1957;20:67-77. 2. Bailey BN. Treatment of tattoos. Plast Reconstr Surg 1967;10:361-71. 3. Roenigk HH. Tattooing: history, technics, complications, removal. Cleve Clin Q 1971;38:181-6. 4. Boo-Chai K. The decorative tattoo: its removal by dermabrasion. Plast Reconstr Surg 1963;32:559-63. 5. Clabaugh W. Removal of tattoos by superficial dermabrasion. Arch Dermatol 1968;98:515-21. 6. Crittenden FM Jr. Salabrasion: removal of tattoos by superficial abrasion with table salt. Cutis 1971;7:295-300. 7. Manchester GH. Removal of commercial tattoos by abrasion with table salt. Plast Reconstr Surg 1974;53:517-21. 8. Koerber WA, Price NM. Salabrasion of tattoos. Arch Dermatol 1978;114:884-8. 9. Scutt R. The chemical removal of tattoos. Br J Plast Surg 1972;25:189-94. 10. Penoff JH. The office treatment of tattoos: a simple and effective method. Plast Reconstr Surg 1987;79:186-91.
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11. Fogh H, Wulf HC, Poulsen T, et al. Tattoo removal by overtattooing with tannic acid. J Dermatol Surg Oncol 1989;15:1089-90. 12. Dvir E, Hirshowitz B. Tattoo removal by cryosurgery. Plast Reconstr Surg 1980;66:373-8. 13. Colvcr GB, Cherry GW, Dawber RPR, et al. Tattoo removal using infrared coagulation. Br J Dermatol 1985; 112:481-5. 14. Groot DW, Arlette JP, Johnston PA. Comparison of the infrared coagulator and the carbon dioxide laser in the removal of decorative tattoos. J AM ACADDERMATOL1986; 15:518 -22. 15. Bailin PL, Ratz JR, Levine HL. Removal of tattoos by CO laser. J Dermatol Surg Oncol 1980;6:997-1001. 16. Lanigan SW, Sheehan-Dare RA, Cotterill JA. The treatment of decorative tattoos with the carbon dioxide laser. Br J Dermatol 1989;120:819-25. 17. Reid R, Muller S. Tattoo removal by CO laser dermabrasion. Plast Reconstr Surg 1980;65:717-28. 18. Apfelberg DB, Maser MR, Lash H. Argon laser treatment of decorative tattoos. Br J Plast Surg 1979;32:141-4. 19. Apfelberg DB, Maser MR, Lash H, et al. Comparison of the argon and carbon dioxide laser treatment of decorative tattoos: a preliminaryreport. Ann Plast Surg 1985;14:615. 20. Apfelberg DB, Bailin P, Rosenberg H. Preliminary investigation of KTP/532 laser light in the treatment of hemangiomas and tattoos. Lasers Surg Med 1986;6:38-42. 21. Reid WH, McLeod P J, Ritchie A, et al. Q-switched ruby laser treatment of black tattoos. Br J Plast Surg 1983; 36:455-9. 22. Reid WH, Miller ID, Murphy M J, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plast Surg 1990;43:663-9. 23. Taylor CR, Gange RW, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser: a dose-response study. Arch Dermatol 1990;126:893-9. 24. Scheibner A, Kenny G, White W, et al. A superior method of tattoo removal using the Q-switched ruby laser. J Dermatol Surg Oncol 1990;16:1091-8. 25. Lowe N J, Luftman D, Sawcer D. Q-switched ruby laser: further observations on treatment of professional tattoos. J Dermatol Surg Oncol 1994;20:307-11. 26. Kilmer SL, Anderson RR. Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 nm and 532 rim) lasers for treatment of tattoos. J Dermatol Surg Oncol 1993;19:330-8. 27. Kilmer SL, Lee MS, Grevelink JM, et al. The Q-switched Nd:YAG laser effectively treats tattoos: a controlled, doseresponse study. Arch Dermatol 1993;129:971-8. 28. Fitzpatrick RE, Goldman MP, Ruiz-Esparza J. Use of the alexandrite laser (755 rim, 100 nsec) for tattoo pigment removal in an animal model. J AM ACADDERMATOL1993; 28:745-50. 29. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed irradiation. Science 1983;220:524-7. 30. Anderson RR, Parrish JA. Microvasculature can be selectively damaged using dye lasers: a basic theory and experimental evidence in human skin. Lasers Surg Med 1981; 1:263-7. 31. Taylor CR, Anderson RR, Gange RW, et al. Light and electron microscopic analysis of tattoos treated by Q-switched ruby laser. J Invest Dermatol 1991 ;97:131-6.
Background: Several laser techniques have been proposed for the removal of decorative tattoos. The lasers that have been used most successfully are Q-switched red or near-infrared systems because of their ability to target tattoo pigment selectivelywith minimal risk of scarring or permanent pigmentary changes. Objectives: The objectives of this study were to determine the clinical effectiveness of the newest Q-switched system, the alexandrite laser, in removing amateur and professional tattoos and to observe side effects. Methods: Twenty-four multicolored professional tattoos and 18 blue-black amateur tattoos were treated with the Q-switched alexandrite laser (755 nm, 100 nsec) at 2-month intervals until total clearing was achieved. The 510 nm pulsed dye laser was used to treat tattoos that contained red pigment. Results: Professional tattoos required an average of 8.5 alexandrite laser treatments for total clearance, whereas only 4.6 treatments were necessary to remove amateur tattoos. Red tattoo pigment was successfully treated with an average of two 510 nm pulsed dye laser sessions. No scarring or long-standing pigmentary changes were seen in laser-irradiated skin. Conclusion: The Q-switched alexandrite laser is highly effective in removing multicolored professional and amateur tattoos without adverse sequelae. The 510 nm pulsed dye laser was useful in eliminating red tattoo pigment. (J AM ACAD DERMATOL1995;33:69-73.) Requests for the removal of decorative tattoos are growing more numerous as the number of persons with tattoos increases. It is estimated that approximately 5% of the North American population has at least one tattoo. Numerous treatments such as surgical excision, 1-3 dermabrasion, 48 chemical therapy,9-11 cryosurgery,12 and electrosurgery13, 14 have been used, but each technique was limited by undesirable scarring or pigmentary alterations. Many laser treatments have been introduced in recent years. The earfier laser systems had less specificity and, therefore, more side effects than the latest technologic advances. 142° The newest Q-switched laser systems, including the ruby, 21-26 Nd:YAG,26, 27 and alexandrite, 28 have shown the greatest promise in treating tattoos because of their ability to preferentially injure structures in the dermis that contain pigment with brief, selectively ab-
From the Georgetown University Medical Center and the Washington Institute of Dermatologic Laser Surgery. Reprint requests: Tina S. Alster, MD, 2311 M St., NW, Suite 504, Washington, DC 20037. Copyright ® 1995 by the American Academy of Dermatology, Inc. 0190-9622/95 $3.00 + 0 16/1/63140
sorbed laser pulses. This process is termed "selective photothermolysis.,,29, 3o Even with their increased selectivity, however, the current Q-switched ruby and Nd:YAG laser systems cannot effectively remove red and green tattoo pigments, respectively. 21"27 In contrast, the Q-switched alexandrite laser is accompanied by a 510 nm pulsed dye system, which, when used in combination, could conceivably eliminate all pigment in a multicolored tattoo. Clinical reports of the response of tattoos to the Q-switched alexandrite laser have been sparse. This study was undertaken to evaluate the clinical effectiveness of the Q-switched alexandrite laser in eliminating amateur and multicolored professional tattoos. In tattoos that contained red pigment granules, the 510 nm pulsed dye laser was also used. MATERIAL AND METHODS
Patients who were willing to enter the study and schedule appointments every 6 to 8 weeks were recruited during a 3-month period and treated during the next 12 to 18 months. None of the patients had received any prior treatment for removal of their tattoos. 69
70
Journal of the American Academy of Dermatology July 1995
Alster
Fig. 1. Professional tattoo with blue-black and red pigments before treatment (A), immediately after alexandrite laser treatment at 6.0 J/cm 2 with characteristic tissue whitening (B), 6 weeks after the fourth alexandrite laser treatment (C), and 8 weeks after nine alexandrite laser treatments (mean fluence, 6.75 J/cm 2) and two 510 nm pulsed dye laser treatments (mean fluence, 3.0 J/cm 2) (D). Ability to tan was not affected by laser treatment.
A Q-switched alexandrite laser (Candela Laser Corp., Wayland, Mass.) with a 755 nm wavelength, 100 nsec pulse duration, and 3 mm spot size was used. After informed consent was obtained, a total of 31 patients (19 men and 12 women, ages 18 to 56 years) with 42 tattoos (24 professional and 18 am-
ateur) were treated at 6- to 8-week intervals. At each visit the tattoo was completely covered with adjacent, nonoverlapping laser pulses at energy densities that ranged from 4.75 to 8.0 J / c m 2. The energy fluence used was determined by each patient's threshold response as indicated by characteristic tis-
Journal of the American Academy of Dermatology Volume 33, Number 1
Alster
71
Table I. Tattoo characteristics Type and location
Average size (cm2)
No. of lesions
Amateur Face Chest Forearm Hand Ankle Subtotal Professional Chest Scapula Deltoid Forearm Ankle Subtotal Total/mean
Average duration
(yr)
1 1 l1 4 1 18
8 12 18 (2-36) 5 (2-12) 48 16 (2-48)
27 15 18 (8-30) 19 (7-33) 1 17.5 (1-33)
2 5 10 6 1 24 42
54 (36-72) 56 (40-64) 87 (9-200) 56 (! 6-140) 4 66 (4-200) 44.5
11 (4-16) 10 (2-14) 19 (1- 39) 20 (8-37) 2 16.0 (1-37) 16.5
Numbers in parentheses represent ranges.
Table II. Response of tattoos to alexandrite laser (755 nm, I00 nsec) and pulsed dye laser (510 nm, 300 nsec) Alexandrite laser Tattoo type
No. of lesions
No. of treatments
Amateur Black-blue
18
2-9 (4.6)
Professional Blue-black only + Green + Red + Green and red Subtotal/mean
l0 6 5 3 2--4
6-13 (8.4) 6-12 (7.3) 6-12 (9.2) 8-13 (10) 6-13 (8.5)
Energy (J/em2)
4.75-7.5 (6.25) 5.75-8 (6.5) 5.5-8 (6.79) 5.5-8 (6.85) 5.75-8 (6.75) 5.5-8 (6.75)
Pulsed dye laser
No. of treatments
Energy (J/era2)
N/A N/A N/A 1-3 (2) 2-3 (2.3) l-3 (2.1)
--2.5-3.5 (3) 2.75-3.75(3.85) 2.5-3.75 (3.1)
Numbers in parentheses represent means.
sue whitening. The energy density was reduced if an excessive response such as bleeding or tissue splatter was encountered. In the eight professional tattoos that contained red pigment, a 510 nm, 300 nsec pulsed dye laser (Candela Laser Corp.) with a 5 mm spot size was used in these areas. No intralesional or topical anesthesia was used. Care after laser treatment consisted of twice-daily cleansing with mild soap and water followed by application of a topical antibiotic ointment and a nonstick bandage. Photographs of the tattoos were taken before each laser session by one photographer who used identical lighting, camera settings, and film processing techniques. Although the photographs were used to
document each patient's progress, individual responses to treatment were determined by clinical examination at each visit. Tattoos were considered to be completely cleared when the color within a laser-treated tattoo was found to be indistinguishable from the surrounding normal (or untreated) skin by two independent observers. Particular attention was paid to pigmentary and textural changes and scarring within the laser-treated site. RESULTS
The total elimination of all tattoos in the study was accomplished with use of the Q-switched alexandrite laser. The number of laser treatments necessary ranged from 2 to 13, depending on whether
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Journal of the American Academy of Dermatology July 1995
Fig. 3. Multicolored professional tattoo before (A) and 8 weeks after (B) 12 alexandrite treatments (mean fluence, 7.0 J/cm 2) and three pulsed dye laser treatments (mean fluence, 3.0 J/cm2). No pigmentary alteration or scarring was noted.
This was especially true for the professional tattoos that contained newer organometallic pigments. No adverse responses were observed in any of the laser-treated tattoos, including scarring or textural changes. Transient hypopigmentation, which was seen in two professional tattoos, completely resolved within 3 months after cessation of laser treatment. Fig. 2. Amateur tattoo before (A) and 6 weeks after (B) four Q-switched alexandrite laser treatments at a mean fluence of 6.25 J/cm 2. the tattoo was an amateur or professional tattoo. On average, amateur tattoos were smaller (16 cm 2 vs 66 cm 2) and required fewer laser treatments (4.6 vs 8.5) and lower energy densities (6.25 J / c m 2 vs 6.75 J / c m 2) than professional tattoos (Fig. 1, A-D, Fig. 2, A and B, and Tables I and II). No significant difference existed in the number of treatments necessary to treat professional tattoos that contained green pigment and those that contained only blue-black pigment. Tattoos that contained red pigment required an average of two treatments with the 510 nm pulsed dye laser in addition to the alexandrite laser treatments (Fig. 3, Table II). The mean ages of the amateur and professional tattoos included in the study did not differ significantly enough to permit assessment of any differences in their response to laser treatment (Table I). In general, however, it was noted that the younger or newer tattoos required more laser treatments.
DISCUSSION To remove tattoo pigment completely with any of the available Q-switched laser systems, a series of repeated treatments is necessary. Each successive treatment allows continued removal of remaining pigment in a "layered" fashion. Laser treatments should be spaced at 1 to 2 month intervals to allow appropriate dermal healing, including phagocytosis of tattoo fragments. However, the ultimate fate of tattoo particles after laser irradiation remains unknown. The results obtained with the alexandrite laser in this study (Tables I and II) demonstrate high tattoo pigment selectivity and are in keeping with results obtained with the Q-switched ruby and Nd:YAG lasers. 2127 Removal of amateur tattoos required a mean of 4.6 alexandrite laser treatments, and elimination of professional tattoos required a mean of 8.5 treatments. The increased number of treatments required for professional tattoos has been attributed to the increased pigment content and to the organometallic dyes used. 23, 3t It is important that even green and red tattoo pig-
Journal of the American Academy of Dermatology Volume 33, Number 1
ments can be removed with the combination of alexandrite and 510 nm pulsed dye lasers, because other Q-switched lasers do not have this capacity. 21-27 Approximately one quarter to one third of professional tattoos contain green and/or red pigment that cannot be eliminated by the Nd:YAG and ruby lasers, respectively. The results of this study illustrated several other advantages of the Q-switched alexandrite laser compared with other Q-switched lasers. First, no long-term pigmentary changes were encountered; these changes are common after ruby laser treatment. The slightly longer wavelength of the alexandrite laser allows less melanin absorption and deeper tissue penetration, thereby reducing pigmentary changes and increased absorption by dermal tattoo pigment. Second, no tissue splatter is encountered with the alexandrite laser. In general, much higher energy densities (on the order of 8 to 10 J/cm 2) are required to effect the desired degree of tattoo lightening by the Nd:YAG and ruby lasers. The increased fluences and smaller spot sizes used in Nd:YAG laser treatment, in particular, are responsible for the prominent bleeding and tissue splatter associated with its use. The energies used in this study (average, 6.5 J/cm 2) produced excellent clinical responses without the risks inherent with tissue debris exposure. Lastly, the features of the alexandrite laser allow rapid treatment sessions with minimal discomfort, thereby eliminating the need for anesthesia, which is commonly used with other Q-switched laser systems. REFERENCES 1. Buncke HJ Jr' C°nway H" Surgery °f dec°rative and traumatic tattoos. Plast Reconstr Surg 1957;20:67-77. 2. Bailey BN. Treatment of tattoos. Plast Reconstr Surg 1967;10:361-71. 3. Roenigk HH. Tattooing: history, technics, complications, removal. Cleve Clin Q 1971;38:181-6. 4. Boo-Chai K. The decorative tattoo: its removal by dermabrasion. Plast Reconstr Surg 1963;32:559-63. 5. Clabaugh W. Removal of tattoos by superficial dermabrasion. Arch Dermatol 1968;98:515-21. 6. Crittenden FM Jr. Salabrasion: removal of tattoos by superficial abrasion with table salt. Cutis 1971;7:295-300. 7. Manchester GH. Removal of commercial tattoos by abrasion with table salt. Plast Reconstr Surg 1974;53:517-21. 8. Koerber WA, Price NM. Salabrasion of tattoos. Arch Dermatol 1978;114:884-8. 9. Scutt R. The chemical removal of tattoos. Br J Plast Surg 1972;25:189-94. 10. Penoff JH. The office treatment of tattoos: a simple and effective method. Plast Reconstr Surg 1987;79:186-91.
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