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Surgical Pearl: Q-switched Nd:YAG laser removal of eyeliner tattoo
PEARLS OF WISDOM Surgical Pearl: Q-switched Nd:YAG laser removal of eyeliner tattoo Roy G. Geronemus, MD New York, New York The use of permanent eyeliner has increased because of techniques that facilitate the placement of pigment on the eyelid margin. Removal of eyeliner tattoo pigment has been attempted with surgical excision, carbon dioxide laser vaporization, and cryosurgery. Side effects have included scarring, alopecia of eyelashes, and prolonged postoperative From the Laser and Skin Surgery Center of New York. Reprint requests: Roy G. Geronemus, MD, Laser and Skin Surgery Center of New York, 317 E. 34th St., New York, NY 10016. J Am Acad Dermatol 1996;35:101-2. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0
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morbidity. With the availability of lasers that are capable of selective photothermolysis of tattoo pigment, professional and amateur tattoos can be removed with minimal risk of scarfing and permanent pigmentary change. 1-5 Removal of eyeliner tattoo presents a challenge. The ideal method would avoid damage to the eyelashes, not cause ectropion formation, and not damage the retina. Selective photothermolysis is "a method by which damage to a tissue target can be obtained with the appropriate selection of wavelength and a pulsewidth so that the pulse duration is less than the thermal relaxation time of the target. 6 There are four lasers in clinical use capable of selec-
Fig. 1. A, Black eyeliner tattoo on the right lower eyelid of a 48-year-old woman. B, Eyeliner tattoo after treatment with the Q-switched Nd:YAG laser at 1064 nm. An ocular shield has been placed over the ocular globe for protection. C, Complete removal of the tattoo pigment noted after two treatment sessions. 101
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tire photothermolysis of tattoo pigment. These include the double-frequency Q-switched Nd:YAG at 532 and 1064 nm, Q-switched alexandrite at 755 nm, the Q-switched ruby at 694 nm, and the pulsed dye green light laser at 510 nm. These lasers have different effects on different tattoo colors. Consequently, there are tattoo colors that will respond only to specific wavelengths of light in terms of the degree of absorption and subsequent removal of the pigment. The lasers capable of removing the black tattoo pigment found in most eyeliner tattoos include the Q-switched alexandfite, Q-switched ruby, and Q-switched Nd:YAG laser at 1064 nm. It is important to use a laser that will be least likely to damage the eyelashes. The Q-switched alexandrite and Q-switched ruby lasers deliver light in spot sizes that are a minimum of 3 m m in diameter, as opposed to the Q-switched Nd:YAG laser that can provide a spot size as small as 1.5 m m in diameter. Because most eyeliner tattoos are narrow and because it is necessary to mim'mize absorption of the eyelash hair, the Q-switched Nd:YAG laser at 1064 nm theoretically provides the best option. A 48-year-old woman desired removal of permanent eyeliner tattoo on both lower eyelids that had been placed approximately 4 years earlier (Fig. 1,A). After the application of a topical ophthalmic anesthetic (tetracaine hydrochloride), a Gladstein metal eyeshield was applied over the ocular globe of the right eye. Local anesthetic was infiltrated along the eyelid margin. The contralateral eye was protected with an external shield. With a 1.5 m m beam at 1064 um at 6 J/cm 2, the entire tattoo was treated (Fig. 1, B). Minimal oozing was noticed during the procedure and ophthalmic bacitracin ointment was applied to the wound. Complete healing took place within 5 days. The hair was protected with hydrophilic petrolatum during the procedure to minimize damage to the hair follicle. An eyepatch was placed over the eye that was removed in 3 hours. The patient then returned the next
Journal of the American Academy of Dermatology July 1996
day for treatment of the left eye. Approximately 6 weeks later, an additional treatment was required on both lower eyelids on consecutive days. Two months later, removal of the eyeliner tattoo was essentially complete (Fig. 1, C). This report demonstrates the safe and efficacious removal of eyeliner tattoo with the Q-switched Nd:YAG laser at 1064 nm. The procedure is well tolerated and healing usually takes place within 4 to 6 days. The technique carries minimal risk of ectropion formation. Particular concern for safety must be undertaken by the treating physician and staff. The infrared light of the Nd:YAG laser is capable of penetrating the cornea and can lead to significant damage to the retina. For this reason, the intraoperative use of a metal ocular shield is imperative for the patient' s protection. Wavelength-specific glasses or goggles must also be worn by the medical staff during the procedure. Smart J. Salasche, MD Feature Editor Direct all submissions to Dr. Stuart J. SaIasche, Arizona Health Sciences Center, Section of Dermatology, 1501 N. Campbell Ave., Tucson, AZ 85724. REFERENCES
1. Kilmer SL, Lee M, Grevelink J, et al. The Q-switched Nd:YAG laser (1064 nm) effectively treats tattoos: a controlled dose response study. Arch Dermatol 1993;129: 971-8. 2. Ashinoff R, Geronemus RG. Rapid response of traumatic and medical tattoos with the Q-switched ruby laser. Plast Reconstr Surg 1993;91:841-5. 3. Levhae V, Geronemus R. Tattoo removal with the Qswitched ruby and the Q-switched Nd:YAG lasers: a comparative study. Curls 1995;55:291-6. 4. 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. 5. Fitzpatrick RE, Goldman MP. Alexandrite laser removal of tattoos: a clinical and histological study. Lasers Surg Med 1993;13(suppl 5):54. 6. Anderson RR, Parish JA. Selective photothermolysis: precise rnicrosurgery by selective absorption of pulsed radiation. Science 1983;220:524-7.
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morbidity. With the availability of lasers that are capable of selective photothermolysis of tattoo pigment, professional and amateur tattoos can be removed with minimal risk of scarfing and permanent pigmentary change. 1-5 Removal of eyeliner tattoo presents a challenge. The ideal method would avoid damage to the eyelashes, not cause ectropion formation, and not damage the retina. Selective photothermolysis is "a method by which damage to a tissue target can be obtained with the appropriate selection of wavelength and a pulsewidth so that the pulse duration is less than the thermal relaxation time of the target. 6 There are four lasers in clinical use capable of selec-
Fig. 1. A, Black eyeliner tattoo on the right lower eyelid of a 48-year-old woman. B, Eyeliner tattoo after treatment with the Q-switched Nd:YAG laser at 1064 nm. An ocular shield has been placed over the ocular globe for protection. C, Complete removal of the tattoo pigment noted after two treatment sessions. 101
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tire photothermolysis of tattoo pigment. These include the double-frequency Q-switched Nd:YAG at 532 and 1064 nm, Q-switched alexandrite at 755 nm, the Q-switched ruby at 694 nm, and the pulsed dye green light laser at 510 nm. These lasers have different effects on different tattoo colors. Consequently, there are tattoo colors that will respond only to specific wavelengths of light in terms of the degree of absorption and subsequent removal of the pigment. The lasers capable of removing the black tattoo pigment found in most eyeliner tattoos include the Q-switched alexandfite, Q-switched ruby, and Q-switched Nd:YAG laser at 1064 nm. It is important to use a laser that will be least likely to damage the eyelashes. The Q-switched alexandrite and Q-switched ruby lasers deliver light in spot sizes that are a minimum of 3 m m in diameter, as opposed to the Q-switched Nd:YAG laser that can provide a spot size as small as 1.5 m m in diameter. Because most eyeliner tattoos are narrow and because it is necessary to mim'mize absorption of the eyelash hair, the Q-switched Nd:YAG laser at 1064 nm theoretically provides the best option. A 48-year-old woman desired removal of permanent eyeliner tattoo on both lower eyelids that had been placed approximately 4 years earlier (Fig. 1,A). After the application of a topical ophthalmic anesthetic (tetracaine hydrochloride), a Gladstein metal eyeshield was applied over the ocular globe of the right eye. Local anesthetic was infiltrated along the eyelid margin. The contralateral eye was protected with an external shield. With a 1.5 m m beam at 1064 um at 6 J/cm 2, the entire tattoo was treated (Fig. 1, B). Minimal oozing was noticed during the procedure and ophthalmic bacitracin ointment was applied to the wound. Complete healing took place within 5 days. The hair was protected with hydrophilic petrolatum during the procedure to minimize damage to the hair follicle. An eyepatch was placed over the eye that was removed in 3 hours. The patient then returned the next
Journal of the American Academy of Dermatology July 1996
day for treatment of the left eye. Approximately 6 weeks later, an additional treatment was required on both lower eyelids on consecutive days. Two months later, removal of the eyeliner tattoo was essentially complete (Fig. 1, C). This report demonstrates the safe and efficacious removal of eyeliner tattoo with the Q-switched Nd:YAG laser at 1064 nm. The procedure is well tolerated and healing usually takes place within 4 to 6 days. The technique carries minimal risk of ectropion formation. Particular concern for safety must be undertaken by the treating physician and staff. The infrared light of the Nd:YAG laser is capable of penetrating the cornea and can lead to significant damage to the retina. For this reason, the intraoperative use of a metal ocular shield is imperative for the patient' s protection. Wavelength-specific glasses or goggles must also be worn by the medical staff during the procedure. Smart J. Salasche, MD Feature Editor Direct all submissions to Dr. Stuart J. SaIasche, Arizona Health Sciences Center, Section of Dermatology, 1501 N. Campbell Ave., Tucson, AZ 85724. REFERENCES
1. Kilmer SL, Lee M, Grevelink J, et al. The Q-switched Nd:YAG laser (1064 nm) effectively treats tattoos: a controlled dose response study. Arch Dermatol 1993;129: 971-8. 2. Ashinoff R, Geronemus RG. Rapid response of traumatic and medical tattoos with the Q-switched ruby laser. Plast Reconstr Surg 1993;91:841-5. 3. Levhae V, Geronemus R. Tattoo removal with the Qswitched ruby and the Q-switched Nd:YAG lasers: a comparative study. Curls 1995;55:291-6. 4. 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. 5. Fitzpatrick RE, Goldman MP. Alexandrite laser removal of tattoos: a clinical and histological study. Lasers Surg Med 1993;13(suppl 5):54. 6. Anderson RR, Parish JA. Selective photothermolysis: precise rnicrosurgery by selective absorption of pulsed radiation. Science 1983;220:524-7.