7 Things That Affect Laser Tattoo Removal
Tattoos can be really beautiful! Unfortunately, time passes and a tattoo you liked when you were younger might not reflect the person you are now. Or maybe you just want to make room for another tattoo. No matter the reason - here's what you need to know about tattoo removal.
What qualifications should the person who does my tattoo removal have?
Ask your provider about his or her qualifications. Make sure you feel good about the answer! At a minimum, look for a certified laser technician to perform your treatment and make sure he/she works with a doctor. A skilled laser operator will adjust your treatment plan to optimize both healing and ink clearance.
A small number of states, including Colorado, have very few regulations for laser tattoo removal. Anyone can operate the laser as long as there is an off-site medical director. In Missouri there are no requirements for either supervision or training of laser operators. Many states are becoming more strict about the qualifications of people doing laser treatments, and this directly affects price. New Jersey only allows doctors to use a laser. California restricts the use of lasers to doctors, nurses and physicians assistants.
The more qualified the operator / provider, the more expensive the tattoo removal will be. As a result, tattoo removal costs about 10 times more in California than in Colorado. Only two states, North Carolina and Texas, require a state license and a state test. Most states fall somewhere in the middle, meaning they require a medical director and a trained and certified laser operator, possibly one that is also a registered nurse, physician's assistant or nurse practitioner.
Will it hurt?
Many patients describe the laser as feeling like a grease splatter or the snapping of a rubber band against the skin. You should look for a clinic with a Zimmer cooling machine which greatly reduces pain before, during and after treatment with the laser. Most patients do not require any additional pain control because the treatments are so quick. However, depending on the location of the tattoo (treatments on thinner skin over bone - like on fingers - can be more painful) and your pain threshold, anesthetics such as topical creams or painkiller injections may be desired.
*Please note: If you feel you might need injections to control your pain, you will need to choose a provider that is qualified to give them, i.e., a doctor or nurse.
Can I have only part of my tattoo removed?
Absolutely! By using certain settings and changing the size of the beam on the laser, the parts of your tattoo that you no longer want can be removed. Additionally, most clinics can work directly with your tattoo artist to help him or her redo part or even all of your tattoo.
How long does it take?
Each removal session is very quick, but depends on the size of the tattoo. A small tattoo may take only a couple of minutes. Most sessions last 15 minutes or less. The number of treatment sessions will depend on the amount of ink used, type and color of ink, your skin tone and your immune system. Amateur tattoos can take as little as a single session. Multi-color, professional tattoos may take 10 or more. Lightening for a cover-up usually takes 3 to 4 sessions.
7 Things That Affect Laser Tattoo Removal:
1. The quality of the laser used affects tattoo removal. The Q switched laser used to be considered the gold standard. Picosecond lasers are quickly becoming the laser of choice for tattoo removal. They take about half the time of Q switched lasers to remove a tattoo, but expect to pay about double the price. Not all lasers remove all ink colors, so look for clinics with lasers that can remove all the colors in your tattoo.
Dr. Mathew M. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston, recommends providers NOT promise a specific number of tattoo removal treatments. Here's why:
“Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in 3 - 5 treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”
2. Your immune system does most of the ink removal. When the laser breaks the ink into particles, it takes time for your body’s lymphocytes to clear the unwanted ink. Your body can only remove the ink so fast. The healthier you are, the more quickly your tattoo will be removed. Exercise regularly, eat a healthy diet, drink plenty of water and don’t smoke. The Wall Street Journal published an Italian study that found smoking reduces the chances of successful tattoo removal.
3. The age of your tattoo affects removal. Older tattoos can be removed with fewer treatments than newer tattoos because newer inks have been formulated to last. A black ink tattoo that is 10 years old may take one or two treatments fewer than a 1 year old black tattoo. A 20 year old tattoo may take two to three treatments fewer than a 1 year old tattoo.
4. Not all lasers remove all colors because not all lasers have all wavelengths. Different wavelengths break up different ink colors.
- Tattoos with many colors are harder to treat than single color tattoos.
- Black and dark blue are the easiest ink colors to remove.
- Light blue, green, and red respond well.
- Purple is hard to treat.
- Yellow and orange clear some, but not completely. To remove these colors, doctors often recommend using an ablative fractional laser (often used to treat wrinkles).
5. The type of ink in your tattoo will affect its removal. Different types of inks respond differently to the laser. The FDA does NOT regulate tattoo inks or the pigments in them. Each tattoo artist / shop chooses ink and decides how that ink is blended and diluted. Different pigments fade at different rates. This means it is impossible to know how your ink will react to the laser until you are treated. Black inks respond the quickest because they absorb all the wavelengths. The depth, color and amount of ink used are all factors that affect how quickly your tattoo will be removed.
6. The tattoo artist and how he or she performed the work of tattooing will affect removal time. If the artist was a professional, the removal time is longer. Amateur work generally takes fewer treatment sessions. Also, the way the artist applied the ink will influence removal time. Again, the depth, color and amount of ink used are factors that determine treatment time.
7. Location of the tattoo on your body determines number of treatments. Generally, when the tattoo is closer to your heart, clearance is quicker. When treatments are performed on thinner skin over bone, patients say the treatments are more painful.
What can I expect after treatment?
Immediately after treatment, you’ll see whitened areas on the tattoo. This is called frosting and will disappear in about 20 minutes. There will be mild redness and swelling over the tattoo which should resolve over several hours. Some people get small blisters or pinpoint bleeding. The treated area will feel like a sunburn. Scarring is uncommon with Q switched lasers and picosecond lasers.
How long should I wait between treatments?
You should wait 8 weeks between treatments. Generally, the longer you wait between treatments, the better the clearance of ink. The added time allows your immune system to move the ink away from the tattoo.
There are patients who want their treatments spaced as closely as possible. While this may work for small tattoos in patients who heal quickly, it's not a good idea on large tattoos or for people with an ink that's resistant to treatment. Large tattoos require more time to heal and the more ink there is to be absorbed, the longer it will take your body to do so. Some studies have shown that the more time between treatments, the faster the removal.
What about for dark skin? Is tattoo removal safe?
Make sure that the laser used on your tattoo has been FDA approved for all skin types, from light (type I) to very dark (type VI). Tattoo removal on dark (or tanned) skin can be difficult because of the risk of hypopigmentation, or skin lightening. The risk is lessened by increasing the number of treatments and using the 1064 wavelength. Dr Avram explains more.
“For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI ."
When the 1064 wavelength is used, the laser’s waves go deeper, passing the pigmented layer of your skin – and less of the laser’s energy is absorbed by your skin's pigment. People with dark skin can expect 12 or more treatments scheduled 8 - 10 weeks apart. The PFD patch may also lower your risk of skin color changes.
Another thing to consider if you have dark skin - different light wavelengths treat different ink colors. So even though this kind of laser is safer for dark skin, it's not as good at treating green, blue or red pigments.
Dr. Avram says some amount of hypopimentation is likely to occur - regardless of your skin type / color.
“Let patients know this is going to happen, but over time, this usually resolves, because you’re (the provider isn't) not destroying the melanocytes (the cells that give your skin color), unless you’re going too strong. It may take a few months. It may take a year or 2, but the pigment should recur.”
If your tattoo is treated too aggressively, people with dark skin may get permanent skin color changes. This happens when the melanocytes, which make the pigment in your skin, are destroyed.
“What you want to see is immediate whitening of the treated area,” says Dr. Avram. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening.
People who are not being treated with the 1,064-nm Nd:YAG - should expect to see immediate skin whitening. If you see epidermal disruption and bleeding during treatment, your laser technician is probably being too aggressive.
Are there any side effects?
Less common side effects:
- an allergic reaction
- darkening of a cosmetic tattoo (cosmetic tattoos like lip liner and blush sometimes darken because of oxidation of ferric oxide or titanium oxide in the pigment)
- an immune reaction
- chrysiasis (a dark blue pigmentation cause by a Q-switched laser used on a patient who has taken gold salts, usually for rheumatoid arthritis)
Dr. Avram explains: “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85. All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”
How should I care for my tattoo after a treatment?
Most clinics will have you apply petroleum jelly and a Telfa dressing to your tattoo after laser treatment. Expect about a week of healing. Keep your tattoo out of the sun and don't allow anything to rub the treated area while it's healing.
Will my insurance cover the cost of tattoo removal?
No, your health insurance company will not pay for tattoo removal. Insurance companies consider it a cosmetic procedure.
Are there any new developments in laser tattoo removal?
The R-20 method of tattoo removal was invented to speed tattoo removal. In this method, 4 consecutive treatments are given 20 minutes apart (to allow the frosting to disappear so the light from the laser can better penetrate the skin). An initial study found the approach led to better outcomes compared to a single treatment per visit, but a follow up study by Dr. Avram contradicted those findings. The R-20 method also has a higher risk of skin color changes and scarring.
In 2015, a patch was approved by the FDA for tattoo removal. It makes laser tattoo removal safer, less expensive and less painful. Read our post, A Tattoo Removal Patch That Works in 6 AMAZING Ways!
There's also a new study (2018) that studied the use of acoustic shock wave therapy (ASWT) used with a picosecond laser and a PFD patch. The study was done on a young woman with dark skin. The authors wanted to see if they could speed up tattoo removal, so they treated part of the woman's tattoo with the patch and the picosecond. Another part was treated with ASWT, the patch, and picosecond.
What happened? After 3 treatments, the part of the tattoo treated with ASWT, the patch and picosecond got 80% clearance with less swelling, redness, and crusting. In comparison, the part of the tattoo treated with the patch and picosecond alone got 60% clearance. So this may be the direction tattoo removal goes. But it's only 1 study on 1 girl, so more research is needed.
Are there any alternatives to laser tattoo removal?
If you have a small tattoo, having it surgically removed is an option.
Some doctors are using ablative fractional resurfacing (like you'd use on your face for wrinkles) either alone or combined with a Q-switched or picosecond laser. Sometimes the ablative fractional laser is used to treat the fibrosis that can develop after multiple treatments on a hard-to-treat tattoo. What's fibrosis? I'm glad you asked. I had to look it up myself! It's the result of a skin injury from repeated chemical exposure or trauma (like the tattoo removal laser). There's an increase of fibrous connective tissues in the skin accompanied by chronic inflammation.
There's also a new kind of tattoo removal called trans epidermal pigment release where the ink is removed through your skin (instead of via your immune system) - but some people are getting scars from it. Read our post, A New Type of Tattoo Removal - Safer Than Lasers to learn more.
What's the difference between a Q-switched laser & a Picosecond laser?
Lasers work by light absorption. When tattooed skin is treated with a laser, plasma is created and gas bubbles form around the tattoo pigments. During treatment, you can see this happening when your skin turns white. It's an indicator to your laser technician that the tattoo pigment reacted with the light from the laser.
Q-Switched lasers:
Q-switched lasers partially destroy ink molecules by breaking them into smaller fragments. They use nanosecond pulses. Here's how they do it:
- Tattoo particles are heated to high temperatures that cause chemical changes within the ink particles and the surrounding cells.
- There's also a mechanical fragmentation of the particles from the rapid changes in temperature. Very high energy is delivered in a very short period of time, which causes a rapid thermal expansion. It creates shock waves that rupture the ink particles.
- Your immune system eliminates most of the pigment. The ruptured ink fragments are directed to the lymphatic channels or to your lymph nodes. Some ink fragments are eliminated through the skin as the post-treatment crust falls off.
- There is also an overall lightening of the pigments from the Q-switched laser.
Q-switched lasers MAY take longer to remove a tattoo than picosecond lasers. But the jury's still out. There are conflicting studies.
- A study published in the Archives of Dermatology in 2012, found that 47% of patients had their tattoo successfully removed after 10 sessions using a Q-switched laser. 75% of the people in the study got successful removal after 15 sessions.
- A 1998 study published in the JAMA Network found that picosecond pulses were more efficient than nanosecond pulses in clearing black tattoos.
- And a 2017 study published in the Journal of the European Academy of Dermatology and Venereology found a statistically significant superiority of picosecond lasers compared to nanosecond lasers for tattoo clearance. HOWEVER, picosecond lasers were not more effective on multicolored tattoos. When side effects of the 2 of lasers were compared, there was a minimal difference with a tendency for picosecond lasers to be less painful.
How much does tattoo removal with a Q-switched laser cost? Do people like it?
NOTE: RealSelf.com puts tattoo removal into one big section. However, it separates picosecond lasers by machine. SO my best guess is that the tattoo removal rating / cost below is mostly for Q-switched lasers, but I can't be sure.
Tattoo removal gets an 89% "Worth It" rating based on 92 ratings over the last 12 months. They list the typical cost as anywhere from $25 - $3,050 with an average cost of $1,225 based on 1,078 reviews submitted on RealSelf.
Picosecond Lasers:
Picosecond lasers work very similarly to Q-switched lasers, but they use a shorter pulse duration. Proponents of the picosecond lasers say they remove tattoos more quickly than Q-switched lasers. Here's their thinking:
Q-switched lasers have a pulse duration that lasts nanoseconds. (In comparison, 1 picosecond is equal to 1,000 nanoseconds.) The pulse duration of Q-switched lasers is too long to break ink into small enough particles to be cleared quickly. Picosecond lasers use shorter duration pulses (in the picosecond range) that are able to heat tattoo ink more quickly and clear the tattoo more quickly.
It's also thought that when this high amount of energy is released in less time, less heat is generated so there's a lower chance of heat damage to the skin (causing side effects). But a 2017 study published in the Journal of the European Academy of Dermatology and Venereology compared the side effects of the picosecond and Q-switched laser. It found that there was minimal difference in the side effects of the 2 kinds of lasers - with a tendency for picosecond lasers to be less painful.
How much does tattoo removal with a picosecond laser cost? Do people like it?
Picosecond lasers are more expensive than Q-switched lasers, and often that expense gets passed on to you.
The PicoSure, a picosecond laser made by Cynosure, gets an 88% "Worth It" Rating on RealSelf.com based on 66 ratings in the last 12 months. Tattoo removal with the PicoSure costs from $75 - $3,075 with an average cost of $1,050 based on 523 reviews submitted on RealSelf.
The PicoWay, another picosecond laser, gets a 100% "Worth It" rating based on 22 ratings over all time. The PicoWay cost ranges anywhere from $150 - $3,000 with an average cost of $1,100 based on 57 reviews on RealSelf.
You should know - laser tattoo removal WON'T make every tattoo disappear completely!
Dr. Avram says, "Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”
And on the RealSelf.com Tattoo Removal Overview, they agree: "Tattoo removals of any kind represent a challenge, and generally involve numerous clinic or office visits, considerable pain, and no guarantee you'll entirely remove the ink."
"We can not say there will be 'complete' removal but the goal is to make it barely visible." - Barry E. DiBernardo, MD, a plastic surgeon in New Jersey
"Your goal, with your black tattoos, should be significant fading of your tattoo over the course of 6-8 treatments spaced at least 2 months apart. Some tattoos may fade completely with enough time and treatment, but generally a good result is 80-90% fading." - Jeffrey C. Poole, MD, a dermatologic surgeon in Metairie, LA
"Complete removal is possible but not every tattoo responds with complete removal." - Daniel J. Ritacca, MD, oculoplastic surgeon in Chicago
If you are in the process of tattoo removal, it’s possible to temporarily cover your tattoo.
DermaBlend Professional Cover Creme
This foundation comes in 21 shades so you get the perfect match.
You have a couple of options. You can use airbrush makeup. I like the Dinair Airbrush system. It's great at covering tattoos, Vitiligo, birthmarks and other skin irregularities. Learn more on our web page, Airbrush Tattoo Cover Up.
There's also a makeup called DermaBlend. It was developed by a dermatologist and his wife, a makeup artist. And this stuff really covers! It's amazing! You can find it on Amazon and DermaBlend.com.
Did you know? Not all states regulate tattoo parlors and not all tattoo artists are licensed.
If you're interested in getting a new tattoo, be sure to read our post, Tattoo Safety - 13 Ways to Stay Healthy When You Get a Tattoo.
You may also enjoy our post, Microblading Eyebrows - How to Find the Best Brow Artist.
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Amy Takken, RN
Amy Takken is a registered nurse with 20+ years of experience helping people improve their health. Her in-depth skincare articles have been featured on Nazarian Plastic Surgery and The Palm Beach Center for Facial Plastic & Laser Surgery. She's also been quoted on Dermascope.com. Amy loves research and constantly watches for new products and treatments to help you improve your skin’s health – because healthy skin is beautiful! To reach Amy, visit our contact page.
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References:
The PicoSure website - What Should I Expect
The Astanza Laser Blog - State Regulations for Laser Tattoo Removal by Opal Taskila
https://www.cynosure.com/product/picosure/
https://www.realself.com/question/laser-tattoo-removal-ink-colors-easy
https://www.drugs.com/cdi/gold-sodium-thiomalate.html
http://www.doctorschierling.com/blog/wikipedia-and-the-scar-tissue-fibrosis-debate
https://ntp.niehs.nih.gov/nnl/integumentary/skin/fibrosis/index.htm
https://theskiny.com/picosure-vs-q-switch-tattoo-removal/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411594/ Laser-Tissue Interaction in Tattoo Removal by Q-Switched Lasers
https://www.linkedin.com/pulse/picosecond-lasers-vs-nanosecond-tattoo-removal-tom-miller
https://emedicine.medscape.com/article/1121212-overview#a4
https://jamanetwork.com/journals/jamadermatology/fullarticle/1358585 Removal of Tattoos by Q-Switched LaserVariables Influencing Outcome and Sequelae in a Large Cohort of Treated Patients
https://www.laserandhealthacademy.com/media/objave/academy/priponke/s09_s10_cencic.pdf
https://www.ncbi.nlm.nih.gov/pubmed/29938802 Accelerated tattoo removal with acoustic shock wave therapy in conjunction with a picosecond laser.
https://jamanetwork.com/journals/jamadermatology/fullarticle/188845 Comparison of Responses of Tattoos to Picosecond and Nanosecond Q-Switched Neodymium:YAG Lasers
https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.14492 Comparison of two picosecond lasers to a nanosecond laser for treating tattoos: a prospective randomized study on 49 patients
https://www.jaad.org/article/S0190-9622(11)00815-2/fulltext Optimal tattoo removal in a single laser session based on the method of repeated exposures
https://www.thepmfajournal.com/features/post/laser-tattoo-removal-results-and-issues
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