The term tattoo describes the deliberate placement of permanent colors into the skin or the accidental entry of pigmented material. The word tattoo is derived from the Polynesian (Marquesan) word tattoo, and refers to the accidental or volitional acquisition of pigmented particles of the skin. Types of tattoos 1. Decorative amateur tattoos These include tattoos placed by tribal and gang members. The amateur tattoo usually consists of black India colored. Since these tattoos are placed unevenly and superficially in the dermis, they respond well to laser treatment, with fewer treatments and more complete clearance. 2. Professional tattoos In the past, these types of tattoos were commonly seen in military men and bikers. However, with today’s changing trends people of all ages and socioeconomic strata are obtaining professional tattoos. Unfortunately, these tattoos do pose difficulties for the laser surgeon. These tattoos are placed more deeply in the dermis with a greater density of pigment. The colours are very vibrant and diverse in shade. 3. Cosmetic Tattoos Cosmetic tattoos are applied for a variety of reasons including disguising scars, broadening lips, eye and lip liners, covering periorbital pigmentation, or providing rosy cheeks. The colors that are used most frequently are off-white, reddish-brown, red, flesh tones (skin colored), or dull orange. Many of these cosmetic tattoos are made with iron pigments. 4. Medicinal Tattoos These types of tattoos are often placed to designate a radiation port during cancer therapy. After patients are in remission, they are often anxious to remove these signs of illness. Fortunately, these India ink blue-black tattoos are often easily removed in 1 to 2 sessions. 5. Traumatic Tattoos Traumatic tattoos can occur following different types of injury to the skin. This method of introducing tattoo pigment can occur following abrasion or explosion. Gunpowder and particulate matter following motorcycle and bicycle accidents are examples of these types of tattoos. Ink Colors Tattoo ink is remarkably nonreactive histologically, despite the frequent use of different pigments of unknown purity and identity by tattoo artists. Amateur tattoo inks consist of simple, carbon particles originating from burnt wood, cotton, plastic, or paper, or from a variety of inks, including Indian ink, pen ink, and vegetable matter. Along with Indian ink, the classic tattoo dye, formerly used substances include metal salts such as mercury (red), cadmium (yellow), chrome (green), and cobalt (blue). In recent times, instead of these metal salts ,high-quality industrially manufactured organic pigments have been injected (mono- and di-azo dyes, polycyclic pigments of the phthalocyanine, dioxazine, and quinacridone classes of pigments). Even pigments produced for use as automobile paints are used. Treatment of Tattoos Over the centuries, different methods for tattoo removal have been explored. Previously popular methods of removal included excision with primary closure or skin grafting,mechanical dermabrasion ,salabrasion, cryosurgery, application of caustic chemicals such as phenol or a combination of the above, all of which habitually leave noticeable scars which,depending on the anatomica l location could be hypertrophic or keloidal.Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Q switching is a means of producing a very short laser pulse in the nanosecond domain. The earliest attempts at removing tattoo pigment with the Qswitched laser were reported by Goldman. Anderson and Parrish’s principle of selective photothermolysis (1983) revolutionized the use of lasers in dermatology and therefore the treatment of tattoos. This principle proposes that if the used wavelength is well absorbed by the target and the pulse width is equal to or shorter than the target’s thermal relaxation time , the heat generated will be confined to the target. The Q-switched lasers used to remove tattoos are as follows: • Q- switched Ruby Laser (694 nm) • Q-switched Alexandrite laser (755 nm) • Q-switched Neodymium- YAG laser (Nd:YAG laser) ( 532 and 1064nm) Q-switched Ruby Laser (QSRL) The Q-switched ruby is composed of a ruby crystal (aluminium oxide), which has a crystal lattice with a chromium impurity inside of it. The crystal is surrounded by a helical flashlamp. In the Qswitched mode, very high power is achieved by allowing the energy to build up inside the optical cavity. The laser has a wavelength of 694nm, a 28 to 40 nsec pulse width (over 108 W/cm2), and injures to a depth of about 1mm into skin. Q-switched Alexandrite Laser The Q-switched alexandrite laser is a solid-state laser containing a chrysoberyl crystal of aluminum tetraoxide (BeO:A12Q) doped with chromium ions. The crystal is placed within the laser cavity where powerful flashlamps excite the chromium ions to produce red photons with 100 ns pulse durations at a wavelength of 755 nm; this wavelength is between those of the QSRL and the QSNd-YAG lasers. Reflectance studies at 755 nm suggest excellent absorption by black pigment, good absorption by blue and green, and poor absorption by red pigment, as confirmed by preliminary studies performed on tattooed Yucatan minipigs. One treatment session provided excellent results in removal of black ink, good results with blue and green, and poor results with red ink. Efficacy was fluence related. Q-switched Nd:YAG Laser The Q-switched neodymium: yttrium-aluminum-garnet (QSNd:YAG) laser was developed in 1989. It is a solid state, high fluence laser containing a crystal rod of yttrium-aluminum- garnet doped with 1 to 3% neodynium ions. Its emission is in the near infrared range at 1064nm, with a pulse duration of 10 to 20 nsec.The laser emission can be doubled in frequency by placing a potassium titanyl phosphate (KTP) crystal inside the laser cavity and focusing the beam through the crystal, producing a green light at 532nm. The 1064nm option is best suited to black and blue-black tattoos,and the 532nm wavelength is used for red pigment. The Qswitched Nd:YAG laser was explored in anticipation that its longer wavelength (1064 nm) would increase dermal penetration and decrease melanin absorption, thus improving the response of QSRL-resistant tattoos and avoiding pigmentary changes. Number of Treatments Required In skin city, the average number of treatments required for Indian skin type is 6-8 sittings. It is very common to get scars after tattoo removal in Indian Skin. So safe protocol of more sittings with low dose laser is adopted at skin city It minimizes the risk of scarring. Treatment intervals The current recommendation is to treat at 6 to 8 weeks interval unless a longer period is needed for tissue recovery. Recommended treatment parameters The main parameters include pulse duration, wavelength, fluence, and spot size. All of the Q-switched lasers are in the nanosecond range, and pulse width is predetermined by the laser. Wavelength is chosen based on the best available wavelength for the tattoo ink colour For example, red ink is best treated by a green wavelength (510 or 532 nm), and green ink is best treated by a red wavelength (694 or 755 nm). When melanin is present, the 1064 nm wavelength is the best choice to avoid disruption of the epidermis. Fluence should be sufficient to produce immediate whitening without immediate bleeding or blistering. Larger spot sizes provide deeper penetration and should be used as long as sufficient fluence can be obtained. This maximizes the distribution of laser light to the dermal pigment and minimizes cutaneous injury.
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