Original Article Tattoo removal with Q-switched Nd:YAG

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Original Article
Tattoo removal with Q-switched Nd:YAG
laser in a Brazilian population
Remoção de tatuagem com laser Q-switched NdYAG em população
brasileira
ROBERTO CHACUR1*
NÍVEA MARIA BORDIN DA SILVA
CHACUR2
HONÓRIO SAMPAIO MENEZES3
LARISSA DONINI4
MICHELLE GONÇALVES4
KÁTIA BURGI4
MICHELLE GOULART4
RUTH TERESA BIER5
RAPHAELA RAMOS4
TATIANE SALDANHA4
NORDON JUAREZ DE FIGUEIREDO
POITEVIN6
DANUZA DIAS ALVES2
RENATA D’ OLIVEIRA BATAIOLLI7
Institution: Study conducted at Clínica Leger,
Porto Alegre, RS, Brazil.
Article received: November 26, 2013.
Article accepted: August 3, 2014.
DOI: 10.5935/2177-1235.2014RBCP0073
■ ABSTRACT
Introduction: Both dermabrasion and surgery have been used in the practice
of tattoo removal. Currently, laser is also being used. The aim of this study
is to evaluate tattoo removal with Q-switched Nd:YAG laser. Method: This
is a retrospective study on patients treated by using Q-switched Nd:YAG
laser. The data were collected from medical records and patient photographs,
and through phone or e-mail contact. Statistical tests were done through
the analysis of distribution, multivariate regression, and logistic regression.
Results: A total of 304 patients with an average age of 29.8 years (±7.86 years)
were assessed. Of the total, 297 (97.69%) were classified as white (phototypes
I, II, and III), 270 (88.81%) of whom had professional tattoos done. The oldest
tattoo was 360 months old and the most recent was 1 month old, with an
average of 64.56 months (±63.54 months). The tattoo size was, on average,
12.92 cm, with black being the predominant color (i.e., present in 291 [86.51%]
tattoos). The average number of sessions per patient was 3.77 (±2.99), and
the interval between sessions was 49.23 days. The therapist observed that
52.96% of the tattoos were partially removed, 21.38% were not removed,
86.51% showed normal healing, 8.55% developed a hypertrophic scar, and
3.29% developed a keloid. Of the 304 patients, 81 (26.64%) reported being
satisfied and 179 (58.88%) reported being partially satisfied with the outcome.
Hypochromia was present in 102 (33.55%) patients. Conclusions: Q-switched
Nd:YAG laser is a safe and effective method for tattoo removal that results
in a good degree of patient satisfaction and few undesirable effects.
Keywords: Lasers; Tattoo; Nd:YAG Lasers; Scar.
1
MD, General Surgeon, Standing Member of the Brazilian Society for Laser (SBL) and the American Society for Laser Medicine and Surgery (ASLMS),
Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
2
MD, Member of the Brazilian Society for Laser (SBL) and the American Society for Laser Medicine and Surgery (ASLMS), Member of the Leger Research
Center, Clínica Leger, Porto Alegre, RS, Brazil.
MD, PhD, Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
3
Physical Therapist, Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
4
MD, Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
5
MD, Member of the Brazilian Society of Dermatology (SBD), Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
6
Scholarship Student, Member of the Leger Research Center, Clínica Leger, Porto Alegre, RS, Brazil.
7
404
Rev. Bras. Cir. Plást. 2014;29(3):404-409
Tattoo removal with Q-switched Nd:YAG laser
■■RESUMO
Introdução: Na prática da remoção de tatuagem, já foram utilizadas a
dermoabrasão e a cirurgia. Atualmente, se utiliza o laser. O objetivo deste
trabalho foi avaliar a remoção de tatuagens utilizando-se o laser Q-switched
NdYAG. Método: Estudo retrospectivo, com pacientes tratados com laser
Q-switched NdYAG. Foram coletados dados a partir de prontuários e fotos
dos pacientes, e de contato por telefone ou e-mail. A análise estatística foi
feita através da análise de distribuição, regressão multivariada e regressão
logística. Resultados: Foram avaliados 304 pacientes com média de idade de
29,8 anos (±7,86), sendo que 297 (97,69%) foram classificados como brancos
(fototipos I, II e III); destes, 270 (88,81%) haviam feito tatuagens profissionais.
A tatuagem mais antiga tinha 360 meses e a mais recente, um mês, obtendo‑se
uma média de 64,56 meses (± 63,54). O tamanho das tatuagens foi, em
média, de 12,92 cm, sendo preta a cor predominante, estando presente em
291(86,51%) tatuagens. A média de sessões por paciente foi de 3,77 sessões
(±2,99) e o intervalo entre estas foi de 49,23 dias. Com isso, foi observado, pelo
terapeuta, que 52,96% das tatuagens foram parcialmente removidas; 21,38%,
não removidas; 86,51%, cicatrização normal; 8,55%, cicatriz hipertrófica, e
3,29%, queloide. Dos 304 pacientes, 26,64% (81) relataram estar satisfeitos
e 58,88% (179) relataram estar parcialmente satisfeitos com o resultado. A
hipocromia esteve presente em 33,55% (102) dos indivíduos. Conclusões: O
laser Q-switched NdYAG é um método seguro e eficaz, apresentando bom
grau de satisfação e poucos efeitos indesejáveis na remoção de tatuagem.
Descritores: Lasers; Tatuagem; Lasers de Nd-YAG; Cicatriz.
INTRODUCTION
The first attempt at tattoo removal occurred
>50 years ago1. The technique used in the past was
dermabrasion, which involves the nonselective
destruction of tissue and may remove the tattoo
partially or completely2. Surgical procedure is an old
technique that is also currently being used; however,
it only shows good results if there is enough skin and
if it presents an unfavorable condition, due to the
scar as a result of incision3. Intense pulsed light as
well as diode and alexandrite lasers, each with its
own wavelength, are also current technologies used
to remove tattoos4.
The abbreviation LASER means light amplification
by stimulated emission of radiation. All laser equipment
is composed of an active medium, a light delivery
system, and a power source. The active medium,
referred to as lasing medium (located inside the optical
cavity), is the substance that produces the beam of
light and determines the laser wavelength. It can be
gaseous, liquid, or solid. The active laser medium
Nd:YAG is composed of yttrium-aluminum-garnet
and 3% neodymium-doped crystal. The delivery
system determines how light will reach the tissue,
and the power source is responsible for activating
the laser light. After being triggered by the power
source, the light beam needs to be distributed to the
tissue. The distribution system modifies the laser
beam and transports it from the optical cavity to
the patient4.
Rev. Bras. Cir. Plást. 2014;29(3):404-409
In 1980, the selective photothermolysis process
was created to enable the removal of pigments with
minimal injury to adjacent tissue5,6. Q-switched
lasers feature selective photothermolysis. Each skin
chromophore (melanin, water, oxyhemoglobin, and
exogenous pigments) has a preference for different
absorption wavelengths. The energy absorbed by the
chromophore is converted into heat. The smaller the
target, the faster the heating would be; therefore,
very small structures require rapid heating and
smaller pulse duration, i.e., in nanoseconds (ns). The
temperature relaxation time is the time required for
the target to lose 50% of the heat obtained; that is, the
laser exposure time is less than half of the thermal
relaxation time, thus ensuring that the damage will
be done to the chromophore only5,6.
The removal mechanism occurs from the
release of high-power laser beam pulses that have
an extremely short duration (ns). This leads to ink
fragmentation and formation of acoustic waves due
to high temperatures. The propagation of these
waves causes the destruction of adjacent structures
(chromophore)7,8. The pigment stays in the dermis,
within the fibroblasts and macrophages. After exposure
to the laser, the production of CO2 and water vapor
in the dermis causes bleaching of the skin, which
explains the removal of ink in parts. The other part
of the pigment will be phagocytized9.
The removal depends on several factors: anatomical
location and initial color, and if the color change is
permanent or temporary10. The substances that make
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Chacur R et al.
up the pigment ink will influence the result of the
treatment11. Each chemical component is sensitive
to a specific wavelength. In addition, the packaged
inks used for tattoos include no description of their
composition. All these factors result in a removal
process that is not 100% guaranteed3. No method
of tattoo removal is perfect; however, Q-switched
laser is widely used and has been shown to be very
effective12.
There are five types of tattoos: professional,
amateur, cosmetic, traumatic, and medicated.13-16
There are also three types of commercially used
Q-switched lasers: ruby, alexandrite, and Nd:YAG.
Each one is more specific to one color than to
others. In making the choice of laser to be used,
the following factors should also be considered: the
patient’s skin color, spot size, pulse duration, area,
and fluence17,18. In addition to the black pigment,
Nd:YAG is very efficient in lightening red, brown,
and orange pigments9,10. Yellow and white inks are
more resistant, and the therapist may choose to use
ablative lasers for these colors3.
There have been studies on Nd:YAG laser;
however, in the Brazilian literature, the use of lasers
for tattoo removal is scarce. The Brazilian population
differs from others in terms of its high intermixing
of races, variety of habits and customs, and diverse
climate. The aim of this study is to assess tattoo
removal in Brazilian patients submitted to sessions
of Q-switched Nd:YAG laser treatment.
METHOD
This is a retrospective study of patients seen at
the Clínica Leger locations in Porto Alegre and São
Paulo, who were treated for tattoo removal with
Nd:YAG laser (Palomar, Q-YAG 5 TM; no photo was
inserted to avoid conflict of interest). In general, the
wavelength used was 1064 nm for black ink removal
and 532 nm for the remainder of the colors.
Data were collected by analyzing the medical
records and photographs of patients. When necessary,
contact with patients was made through phone calls
or e-mail. Relevant aspects related to tattoo removal
were analyzed, including patient information, tattoo
characteristics, and treatment data, such as age, skin
phototype, tattoo time, size, color, type, number of
sessions, interval between sessions, the therapist’s
opinion and the patient’s satisfaction in relation to
the result, in addition to healing, hypochromia, and
use of isotretinoin (which is a contraindication for
laser if used in the 6 months before treatment).
The degree of patient satisfaction in relation to
the treatment outcome was measured by using the
Likert scale19.
Tattoo size was divided into four groups: small
(1–3 cm), medium (3–6 cm), large (6–10 cm), and
extra-large (>10 cm). The measurements were made
by using the major axis of the tattooed area.
406
The phototype was defined, according to the
Fitzpatrick scale, as white (phototypes I, II, and II)
and black (phototypes IV, V, and VI)20.
The therapist’s opinion was collected and was
based on the last tattoo photograph. The tattoo was
considered to have been removed when no pigment
could be observed.
The interval between sessions for each patient
was defined through the mean of interval days from
one session to the next.
The use of isotretinoin was considered for the
previous 6 months before starting the treatment.
The aspect of the skin after the tattoo removal
was considered according to the coloring (normal,
hyperchromic, or hypochromic) and healing (normal,
atrophic, hypertrophic, or keloid) of the skin.
Statistical analysis was conducted through a
multivariate regression analysis to quantify the data,
except for the Likert scale analysis in which logistic
regression and percentage distribution were used.
The inclusion criteria were as follows: patients
seen at the Clínica Leger locations in Porto Alegre and
São Paulo, treated for tattoo removal with Nd:YAG
laser, who signed an informed consent form and
received treatment from January 2008 to April 2012.
The exclusion criteria were as follows: patients
who have cognitive impairment, abandoned treatment,
started the tattoo removal treatment at a different
clinic, have other nationalities, use substances
that could influence the color of the skin, and had
incomplete data.
The research project was approved by the Research
Ethics Committee of the Institute of Cardiology of
Rio Grande do Sul, under number 052012.
RESULTS
A total of 304 patients were assessed, 181 (59.53%)
women and 123 (40.46%) men, with a mean age of
29.8 years (±7.86 years). In relation to the phototype,
297 (97.69%) persons were classified as white
(phototypes I, II, and III) and 7 as black (phototypes
IV, V, and VI).
Concerning the tattoo types, 272 (89.48%) were
professional, 23 (7.57%) amateur, 8 (2.63%) aesthetic, and
1 (0.32%) traumatic. The oldest tattoo was 360 months
old and the most recent was 1 month old, with an
average of 64.56 months (±63.54 months). The average
size of the tattoos was 12.92 cm. The predominant
color was black, present in 291 [95.72%] tattoos,
followed by red in 89 (29.27%), blue in 64 (21.05%),
green in 58 (19.07%), yellow in 53 (17.43%), orange in
12 (3.94%), purple in 11 (3.61%), white in 9 (2.96%),
pink in 8 (2.63%), brown in 2 (0.65%), and “other”
in 1 (0.32%).
The average number of sessions per patient
was 3.77 (±2.99); the highest number of sessions in
a single patient was 16, whereas the least number
of sessions was 1. Some patients still underwent
treatment after the first tattoo removal session,
Rev. Bras. Cir. Plást. 2014;29(3):404-409
Tattoo removal with Q-switched Nd:YAG laser
whereas others abandoned the treatment. The
average interval between sessions was 49.23 days.
According to the therapist’s assessment,
170 (55.92%) of the tattoos were partially removed
(Figure 1), 69 (22.70%) were removed (Figure 2), and
65 (21.38%) were not removed. Concerning healing,
263 (86.51%) showed normal scarring, 26 (8.55%)
showed hypertrophic scarring, and 10 (3.29%)
showed keloid scarring. Hypochromia was present in
102 (33.55%) of patients and only 12.84% of patients
were dissatisfied with the treatment (Table 1).
Of the patients assessed, five had undergone a
previous tattoo removal treatment with intense pulsed
light therapy and four had used other procedures. Of
those who completed the tattoo removal treatment
with Q-switched Nd:YAG laser, 14 underwent at least
one fractional CO2 laser session after completing
the removal. Clinically, it was observed that colorful
tattoos showed hypochromia after being treated with
Q-switched Nd:YAG laser at a wavelength of 532 nm.
DISCUSSION
YAG laser presents good results in the removal
of the black pigment. Its advantage over the ruby
laser is that, by having a 1064-nm wavelength, it
Figure 1. (A) Initial tattoo (before). (B) Partially removed tattoo
with hypochromic areas (after).
Figure 2. (A) Initial tattoo (before). (B) Fully removed tattoo (after).
protects the epidermis and has minor adverse effects,
such as bubbling and hypochromia. It is therefore
more suitable for higher phototypes21. In this study,
95.72% of the tattoos were black, which may justify
why most tattoos (239 of 304) were considered by the
assessor as removed or partially removed (78.62%).
Kilmer et al.22 treated 39 tattoos by using Q-switched
Nd:YAG laser; of these, 77% had black pigment and
the removal of ink was obtained in 77% of the tattoos.
These data are similar to those found in this study.
Many of the patients assessed were still undergoing
treatment or abandoned the treatment after the
first few sessions, which can be the reason behind
the highest rates of partially removed tattoos and
partially satisfied patients.
Zelickson et al., while comparing the Nd:YAG,
alexandrite and ruby lasers, examined the pigments
histopathologically and noticed a better response in
relation to the removal of red, brown, and orange
inks, with Nd:YAG. In this study, red was found to
be the second most prevalent color in tattoos, which
was also sensitive to the same Nd:YAG laser used
by Zelickson et al. The alexandrite laser was more
effective in removing green and blue inks, and ruby
was better in removing purple and violet inks. In
addition, in relation to the black pigment, the efficacy
of all lasers was equivalent9.
In another study, artificial skin in vitro (by
using water and gelatin) was used with 21 tattoos
in red, orange, pink, brown, yellow, blue, and green.
Moreover, an in vivo model was used with two tattoos
in red and pink. After removing the pigments from
the artificial skins, morphological analyses were
performed on the irradiated areas. The in vitro and
in vivo tattoo models responded with similar efficacy.
The authors realized that more than three pulses
and very high fluencies could darken the ink. With
smaller pulses, there are no bubbles or scars, and the
interval time between sessions is 2 weeks. Fluences
between 0.7 and 1.6 J/cm2 were more effective than
9.0 and 12 J/cm2.23
Of the 304 patients assessed, 102 (33.55%)
presented hypochromia and 263 (86.51%) showed
normal scarring. In addition to the predominant low
phototypes (I, II, and II), another factor that may have
influenced the low rate of hypopigmentation is the
fact that most of the tattoos were treated with the
1064-nm wavelength, owing to the high prevalence of
the black tattoos. It is known that longer wavelengths
can protect the skin, whereas shorter pulses, such
as 532 nm, can increase the absorption of melanin,
Table 1. Degree of patient satisfaction considering tattoo removal.
Satisfaction
% of Patients
n (N = 304)
Dissatisfied
12.84%
39
Rev. Bras. Cir. Plást. 2014;29(3):404-409
Degree of patient satisfaction
Partially satisfied
Satisfied
58.88%
26.64%
179
81
Very satisfied
1.64%
5
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Chacur R et al.
which can lead to hypopigmentation21,24. This fact
was also observed in this study, as the colored tattoos
showed hypochromia after being irradiated with the
Q-switched Nd:YAG laser at 532-nm wavelength.
Selective photothermolysis is known to protect
the skin, as pulses with lasers in nanoseconds reach
only very small structures such as ink particles6.
When tattoos are treated with pulse durations in
the range of milliseconds or with continuous lasers,
heat is not limited to the target. Such heat transfer
causes a nonspecific destruction of the surrounding
tissue and can result in subsequent scarring25.
Scheibner et al. treated 163 tattoos, of which
101 were amateur and 62 were professional tattoos.
Each tattoo received three Nd:YAG laser sessions.
The amateur tattoos were observed to respond
better to treatment26. In this study, 23 amateur and
272 professional tattoos were treated with satisfactory
results.
There were no cases of anaphylaxis, as referenced
by Sacks & Barcaui.27.
Furthermore, concerning the absorption spectrum
of lasers, in particular the 532-nm (as used in this
study) and 752-nm wavelengths, Beute et al.28 tested
the effect of irradiation on 28 pigments and black
from India, mixed into agar plates and analyzed
spectrophotometrically. They observed that the
highest absorption of red was in a complementary
spectrum, whereas blue, yellow, and orange had their
absorption peaks close to the spectrum of visible light.
A large variation was observed in the absorption of
the green pigment. Darkening of the pigment was
observed in the two wavelengths tested, in all of the
pigments containing iron, except black. There was
some variation in pigments containing titanium.
The pigments lightened or darkened in response to
the 532-nm wavelength; however, the response was
more limited at 752 nm. The absorption spectrum
of the pigments can explain why some tattoo colors
are more resistant to laser removal, as also observed
in this study. The 1064-nm Nd:YAG laser, which
decreased adjacent skin lesion and treated black
tattoos better, was also used. Thus, no epidermal
debris or darkening of the ink was observed, as in
the report by Choudhary et al.29.
CONCLUSION
Treatment with Q-switched Nd:YAG laser is
a safe and effective method of tattoo removal that
results in a good degree of patient satisfaction and
few undesirable effects.
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Roberto Chacur
Avenida dos Flomboyantes, 155, bloco 004, apto. 1103 - Rio de Janeiro, RJ, Brazil
CEP 22776-070; Tel.: (21) 8425-7310
E-mail: [email protected]
Rev. Bras. Cir. Plást. 2014;29(3):404-409
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