Permanent makeup removal using Q‐switched Nd:YAG laser

Red‐brown tattoos are usually treated with a frequency‐doubled Q‐switched (QS) neodymium : yttrium–aluminum–garnet Nd:YAG laser (532 nm), because red and pink pigments show maximum absorption between 500 and 570 nm. Using a QS laser for red‐brown tattoo removal has sometimes led to paradoxical darkening of the tattoo pigments, and this darkened grey‐black colour may be difficult to remove. A woman with red‐brown cosmetic tattoos on her eyebrows was treated using a QS Nd:YAG laser (1064 nm) initially with low fluence and subsequently with increasing fluences at 6‐weekly intervals. After the first treatment, a slight darkening of the tattoo pigments was seen, but this faded and complete clearance was achieved after five treatments. There was no downtime during every treatment and there were no scars, pigmentary alterations or textural changes.     

Q‐switched Nd:YAG laser for cosmetic tattoo removal

Laser is a widely accepted tool for tattoo removal, with standardized treatment protocols. Nevertheless, cosmetic tattoo removal may be challenging, because tattoos are performed in proximity of “sensitive” areas and because the ink used in cosmetic tattoos may contain substances that are not standardized and may modify their color at a high temperature. In this case series, we aim to evaluate the effectiveness of Q‐switched (QS) Nd:YAG laser for cosmetic tattoo removal. Our study included 20 patients with cosmetic tattoos of lips, eyebrows, and eyeliners treated with QS Nd:YAG laser. Before treatment, an accurate preoperative assessment was performed, taking into account both patient and tattoo characteristics. Complete tattoo removal was obtained in all the cases and no major complications occurred. Adverse events were mild, mostly represented by erythema. All patients reported a high level of satisfaction. Selective photothermolysis enables complete tattoo removal, even in the case of cosmetic tattoos. However, cosmetic tattoos require a personalized treatment based on an accurate preoperative assessment which takes into account both patient and tattoo characteristics. QS Nd:YAG laser may be considered a good choice in the treatment of cosmetic tattoos, because it enables complete removal with acceptable secondary effects.     

A split-tattoo randomized Q-switched neodymium-doped yttrium–aluminium–garnet laser trial comparing the efficacy of a novel three-pass,one-session method with a conventional method in the treatment of blue/black tattoos in darker skin types

Tattoos with blue/black ink show good lightening of pigment after treatment with 1064 nm Q-switched (QS) neodymium-doped yttrium–aluminium–garnet (Nd:YAG) laser. In this randomized trial, we compared the efficacy of a novel three pass, one session procedure (R15 method) with a conventional method for treating blue/black tattoos in darker skin types. Tattoos were treated with 1064 nm QS Nd:YAG Laser with a spot size of 4 mm, fluence of 5 J/cm² and frequency of 5 Hz. The tattoo pigment lightening was comparable with both methods. Thread-like tattoos had significantly better pigment lightening with fewer side effects than the broad band-like tattoos. We would like to recommend the R15 method of the QS Nd:YAG laser for thread-like tattoos, which can save patients’ time, cut short the frequency of their hospital visits and, more importantly, decrease the cost involved in it.     

Tattoo removal by Q-switched Nd:YAG laser: an objective evaluation using histometry

Background: Tattoos have played an important role in various human cultures for thousands of years. The creation of high power, short pulse Q-switched lasers (QS) has provided a tool for considerable therapeutic advances in tattoo removal. Objective: The aim of the study is to correlate the clinical efficacy of QS Nd: YAG laser for tattoo removal with histological as well as histometric findings. Patients and Methods: QS Nd: YAG laser was used for blue tattoo removal in 12 Egyptian patients. Sessions were done every 2 months for about 6–10 sessions (average 7). Skin phototypes of patients ranged from phototype III to V. Photographs were taken before and after every treatment session. Skin biopsies were taken from the patients before treatment and after six sessions to perform histological and histometric analysis. Results: Eight patients (66.7%) showed excellent response and four patients (33.3%) good response. No textural change or scarring was observed in any patient. Histological examination confirmed the clinical response. Haematoxylin and Eosin (H&E) stained sections showed a significant decrease or almost complete disappearance of the tattoo pigment. Meanwhile, histometric study objectively confirmed a significant decrease in ink particle surface area after treatment. Conclusion: QS Nd: YAG laser effectively treats tattoos in dark-skinned Egyptian patients with excellent cosmetic outcome and minimal side effects. The histopathologic and histometric findings significantly correlated with the clinical response.     

Clinical efficacy of the dual-pulsed Q-switched neodymium:yttrium-aluminum-garnet laser: Comparison with conservative mode

Abstract

The quality (Q)-switched neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is one of the first non-ablative lasers to be used for facial resurfacing and photorejuvenation. Recently, the method of low-fluence Q-switched Nd:YAG lasers known as ‘laser toning’ has been used for non-ablative skin rejuvenation and for the treatment of melasma in Asian countries. We report our experience of using a novel Q-switched Nd:YAG laser that was operated as a dual pulse at half fluence and 140-μs intervals compared with conservative mode laser.     

Melasma treatment in Korean women using a 1064‐nm Q‐switched Nd:YAG laser with low pulse energy

The efficacy of a 1064‐nm Q‐switched neodymium:yttrium–aluminium–garnet (QS Nd:YAG) laser with low pulse energy in the treatment of melasma in 25 women was assessed by retrospective analysis of clinical photographs and patient satisfaction rates. Follow‐up results 2 months after the last treatment revealed that, as defined by our grading scale, 11 of the 25 patients (44%) had marked clinical improvement: 7 of these (28%) had near‐total clinical improvement, 5 had moderate clinical improvement and 2 had minimal to no improvement. Our data suggest that the use of a QS Nd:YAG laser with low pulse energy is an effective, easily performed treatment for melasma in selected East Asian patients.     

A rapid tattoo removal technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol

Background: Tattoo removal has evolved over the years and though Q-switched laser is the ‘workhorse’ laser, it invariably requires multiple sittings, which are dependent on numerous factors, including the skin colour, location of the tattoo, age of the tattoo, colour of pigment used, associated fibrosis and the kind of tattoo treated. Though ablative lasers, both pulsed CO2 and Er:YAG, have been used for recalcitrant tattoos, very few studies have been done comparing them with pigment-specific lasers. Our study was based on the premise that ablating the epidermis overlying the tattoo pigment with Er:YAG could help in gaining better access to the pigment which would enable the Q-switched laser to work effectively with less beam scattering. Objective: A study of rapid tattoo removal (RTR) technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol. Materials and methods: This prospective study was undertaken during 2010–13 at a laser Clinic in the Maulana Azad Medical College, New Delhi. A total of 10 patients were recruited, 5 of amateur tattoo and 5 of professional tattoo. After informed consent each tattoo was arbitrarily ‘split’ into two parts. One part was treated with QS Nd:YAG laser(1064 nm) and the other part with Er:YAG laser immediately followed by the QS Nd:YAG. The laser treatments were repeated at 6-week intervals until the tattoo pigment had cleared. On the combination side in subsequent sittings only the QS Nd:YAG was used, to minimize repetitive ablation. To ensure consistency in the intervention methods a trained dermatologist who was independent of the treatment delivery randomly rated 10% of the procedures. Results: The mean improvement achieved by the Q-switched laser (2.93) was less than the combination laser (3.85) side (p = 0.001) and needed more sessions (3.8 vs. 1.6; p = 0.001). There was a statistically significant difference in the improvement on the combination side till the second session. On the combination side patients required a maximum of 2 sessions, while the Q-switched laser required 3–5 sessions for appreciable lightening. Conclusion: From our study it was concluded that use of a pulsed ablative laser may help in rapid removal of tattoos in conjunction with QS lasers with minimal side effects and can be used as a RTR.     

Dermoscopy as a useful tool for evaluating melasma and assessing the response to 1064‐nm Q‐switched Nd:YAG laser

Melasma is a hard‐to‐manage disorder with considerable relapsing behavior. Dermoscopy emerged to help in comprehensive evaluation of pigmentary disorders and melasma. The aim of the study was to evaluate the potential role of dermoscopy in assessing melasma and monitoring the efficacy of 1064‐nm low‐fluence Q‐switched neodymium:yttrium‐aluminum‐garnet (QS Nd:YAG) laser. A total of 31 patients with facial melasma were included. A total of five laser sessions were performed with 2‐week intervals. Patients were evaluated at baseline and 2 weeks after the last session (at the 10th week) by using digital photography, modified melasma area and severity index (mMASI), and colorimetry, as well as dermoscopic score for pigment and vascular elements. Adverse effects were reported. Postlaser sessions, mMASI scores as well as the colorimetric melanin and erythema indices had showed significant improvement. The “dermoscopic score of pigmentary and vascular elements” displayed significant change and confirmed the improvement. Side effects were tolerable. mMASI, colorimetry, and dermoscopy had ascertained the efficacy of low‐fluence 1064‐nm QS Nd:YAG laser in melasma; however, dermoscopy is superior to other assessments as it can help in the diagnosis of melasma besides the follow‐up assessment and can precisely detect the detailed changes in response to treatment.     

Retrospective analysis of melasma treatment using a dual mode of low-fluence Q-switched and long-pulse Nd:YAG laser vs. low-fluence Q-switched Nd:YAG laser monotherapy

Background: Despite the effectiveness of low-fluence Q-switched Nd:YAG laser (QSNY) treatment in melasma, adverse events, including mottled hypopigmentation (MH) and rebound hyperpigmentation (RH) have been reported. Objective: To compare the effectiveness and safety of combination therapy using low-fluence QSNY and long-pulse Nd:YAG laser (LPNY) (Dual toning), with low-fluence QSNY monotherapy (QS toning), in Asian melasma patients. Materials and methods: Patients were treated for 10 sessions at 1-week intervals with QSNY (6 mm spot); 2.5–3.0 J/cm² for QS toning (n = 177) or 2.1–2.5 J/cm² for dual toning (n = 183). The dual toning group was immediately treated with LPNY (7 mm spot, 15–17 J/cm²). The results were evaluated using the modified Melasma Area and Severity Index (mMASI) score and the physician's global assessment. Results: MH or RH were significantly lower (1.1% vs. 14.1%) and the treatment efficacy was improved (median decrease of mMASI, 3.6 vs. 3.0) in the dual toning group compared with the QS toning group. Periorbital melasma showed distinctively high rates of adverse events in the QS toning group (23.9% vs. 5.7%), which were significantly reduced in the dual toning group (2.9%). Conclusion: Dual toning could represent a safe and effective treatment for Asian melasma patients, as it is associated with minimal adverse events and improved treatment efficacy compared with QS toning monotherapy.     

Hypopigmentation Induced by Frequent Low-Fluence,Large-Spot-Size QS Nd:YAG Laser Treatments

The Q-switched 1064-nm neodymium-doped yttrium aluminum garnet (QS 1064-nm Nd:YAG) laser is increasingly used for nonablative skin rejuvenation or "laser toning" for melasma. Multiple and frequent low-fluence, large-spot-size treatments are used to achieve laser toning, and these treatments are associated with the development of macular hypopigmentation as a complication. We present a case series of three patients who developed guttate hypomelanotic macules on the face after receiving laser toning treatment with QS 1064-nm Nd:YAG.     

Paradoxical darkening and removal of pink tattoo ink

It is widely accepted that Q‐switched lasers are the gold‐standard treatment for the resolution of unwanted tattoo ink. Although much safer than other tattoo removal modalities, the treatment of tattoo ink with Q‐switched devices may be associated with long‐term adverse effects including undesired pigmentary alterations such as tattoo ink darkening. Darkening of tattoo ink is most often reported in cosmetic, flesh‐toned, white, peach, and pink tattoos. In this paper, we briefly review a case of pink tattoo ink that initially darkened paradoxically but eventually resolved with continued Q‐switched laser treatments.     

Comparison of Q-switched Nd:YAG laser alone versus its combination with ultrapulse CO2 laser for the treatment of black tattoo

Background: Q-switched lasers are conventionally used for the treatment of black tattoo. However, they require multiple sittings, and the response may be slow due to competing epidermal pigment in dark skin. Objective: To compare the efficacy of Q-switched Nd:YAG laser alone with its combination with ultrapulse CO₂ for the removal of black tattoo. Materials and methods: Sixty patients with black tattoo were randomized into two groups viz., group A and group B. Group A was treated with QS Nd:YAG laser (1064 nm) alone, and group B received combination of ablative ultrapulse CO₂ followed by fixed-dose QS Nd:YAG laser (1064 nm), at 6-week interval for a maximum of 6 sittings. After each sitting, 3 independent physicians noted percentage of improvement that was evaluated using visual analogue scale (VAS) and grading system for tattoo ink lightening (TIL). Results: Combination laser (group B) showed statistically significant improvement in mean VAS score in the last 2 noted visits as compared to 1st session (p < 0.007, p < 0.001) and TIL mean score in last three noted visits as compared to 1st session (p < 0.008, p < 0.020, and p < 0.004). There was no statistically significant difference in the side effect profile of both the groups. Conclusion: For refractory professional tattoos, combination of ultrapulse CO₂ laser and QS Nd:YAG laser is superior to QS Nd:YAG laser alone.     

Comparison of treatment with an Alexandrite picosecond laser and Nd:YAG nanosecond laser for removing blue–black Chinese eyeliner tattoos

Objective: To retrospectively evaluate the efficacy of an Alexandrite picosecond laser versus Nd:YAG nanosecond laser for removing blue–black eyeliner tattoos which have existed more than 10 years.

Methods: A total of 40 patients were treated with an Alexandrite picosecond laser in our department from August 2015 to July 2017, with a fluence of 1.96–6.37J/cm², spot size of 2.0–3.6 mm, and pulse width of 750 ps. Another 32 patients were treated with an Nd:YAG nanosecond laser, with a fluence of 2.80–7.00 J/cm², spot size of 3 mm, and pulse width of 5–20 ns. All analysed patients completed at least one treatment and follow-up.

Results: The median number of treatment for all the patients was 1 (range, 1–4). After a single session, no difference was found between the two lasers for the eyeliner removal (p > 0.05). For the people who achieved an excellent response of tattoo clearance, there was still no difference between the two groups (p > 0.05). Transient side effects were observed in two groups, but neither group had significant adverse reactions.

Conclusions: To treat blue–black Chinese eyeliner tattoos over 10 years, Alexandrite picosecond laser does not provide better clearance than the Nd:YAG nanosecond laser.     

Laser Removal of Tattoos

Tattoos are placed for different reasons. A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of scarring, is needed. Nonspecific methods have a high incidence of scarring, textural, and pigmentary alterations compared with the use of Q-switched lasers. With new advances in Q-switched laser technology, tattoo removal can be achieved with minimal risk of scarring and permanent pigmentary alteration. There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient. Treatment should begin by obtaining a pre-operative history. Since treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anaesthesia cream may be used prior to laser treatment. Topical broad-spectrum antibacterial ointment is applied immediately following the procedure. Three types of lasers are currently used for tattoo removal: Q-switched ruby laser (694nm), Q-switched Nd:YAG laser (532nm, 1064nm), and Q-switched alexandrite laser (755nm). The Q-switched ruby and alexandrite lasers are useful for removing black, blue and green pigments. The Q-switched 532nm Nd:YAG laser can be used to remove red pigments and the 1064nm Nd:YAG laser is used for removal of black and blue pigments. The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Transient hypopigmentation and textural changes have been reported in up to 50 and 12%, respectively, of patients treated with the Q-switched alexandrite laser. Hyperpigmentation and textural changes are infrequent adverse effects of the Q-switched Nd:YAG laser and the incidence of hypopigmentary changes is much lower than with the ruby laser. The development of localized and generalized allergic reactions is an unusual complication following tattoo removal with the Q-switched ruby and Nd:YAG lasers. Since many wavelengths are needed to treat multicolored tattoos, not one laser system can be used alone to remove all the available inks and combination of inks. While laser tattoo removal is not perfect, we have come a long way since the advent of Q-switched lasers. Current research is focusing on newer picosecond lasers, which may be more successful than the Q-switched lasers in the removal of the new vibrant tattoo inks.     

Tattoo ink darkening of a yellow tattoo after Q-switched laser treatment

The popularity of tattoos is burgeoning with 20-30 million tattooed individuals in the Western World. Requests for removal can be expected to rise concurrently with increased applications. Laser removal of tattoos is potentially a more cosmetically acceptable method of removing tattoos than surgical excision or dermabrasion. Nevertheless, complications and side-effects can result from laser treatment and include scarring, hypopigmentation, hyperpigmentation, partial removal, infection, bleeding and tattoo ink darkening. The latter has been reported for flesh-toned and red tattoos. Such a complication has never been reported for the laser treatment of a yellow tattoo in the dermatological literature. We describe a case of tattoo ink darkening of a yellow tattoo after treatment with the 532 nm quality-switched Neodymium : Ytrrium-Aluminium Garnet laser to highlight clinicopathological features. The mechanism by which some tattoos darken after laser treatment is not clearly understood. We review darkening of tattoos after laser treatment to raise awareness of this important complication. This paper will help to facilitate discussions with the patient and in obtaining informed consent prior to commencing treatment. Tattoo ink darkening of a yellow tattoo adds to the growing list of complications resulting from attempts at tattoo removal.     

Efficacy and safety of 1064‐nm Q‐switched Nd:YAG laser with low fluence for keloids and hypertrophic scars

Background Several treatment modalities using laser devices have been used for the treatment of keloids and hypertrophic scars with various therapeutic outcomes. Objective The purpose of this study was to describe the efficacy and safety of 1064‐nm Q‐switched (QS) Nd:YAG laser with low fluence on keloids and hypertrophic scars. Methods Keloids and hypertrophic scars located at 21 anatomic sites in 12 Korean patients (10 men and 2 women; mean age 23.8 years, range 21–33) were treated using 1064‐nm QS Nd:YAG laser with low fluence at 1–2 week intervals. Treatment settings were 1.8–2.2 J/cm², 7‐mm spot size and 5–6 passes with appropriate overlapping. Results Follow‐up data collected 3 months after the final treatment revealed decreases in the mean score for the following lesion characteristics: pigmentation from 1.8 to 1.2; vascularity from 1.4 to 1.0; pliability from 3.0 to 2.0 and height from 2.3 to 1.8. The modified Vancouver General Hospital Burn Scar Assessment score decreased from 8.6 to 5.9 (P < 0.0001). Observed side‐effects were a mild prickling sensation during treatment, and mild post‐treatment erythema, both of which resolved within few hours. Conclusion Our results demonstrate that QS Nd:YAG laser with low fluence may be used for the treatment of keloids and hypertrophic scars.     

Comparison of a single treatment with Q-switched ruby laser and Q-switched Nd:YAG laser in removing black-blue Chinese tattoos

Abstract

Background: Black and blue are two popular colors in Chinese tattooing. Two Q-switched lasers, ruby and Nd:YAG, are effective for tattoo removal. No reference with regard to a comparison of the effects and adverse reactions in Chinese individuals has been made in the literature. Objective: To compare a single treatment of black-blue tattoos with the Q-switched ruby laser and Q-switched Nd:YAG (1064 nm) laser. Methods: A total of 35 Chinese patients with black-blue tattoos at the laser center of the Institute of Dermatology, Chinese Academy of Medical Sciences were enrolled into a self-control study. Tattoos were split into two parts or two nearby tattoos on the same body part were used; one side was treated with the Q-switched ruby laser and the other with the Q-switched Nd:YAG laser. Immediate response, treatment outcome and adverse effects were compared. The statistical significance level was set at p< 0.05. Results: Edema and exudation were more common immediately after ruby laser treatment (p< 0.05). The Q-switched Nd:YAG laser had a significant difference in tattoo lightening versus the Q-switched ruby laser after a single treatment (p<0.05). There was no significant difference in adverse effects between the two lasers. Conclusion: The Q-switched Nd:YAG laser is more effective at tattoo lightening for Chinese individuals. Its immediate response after treatment is slighter than the Q-switched ruby laser.     

Long pulse 1,064‐nm neodymium‐doped yttrium aluminum garnet laser in aesthetic dermatology

Long pulse 1,064‐nm neodymium‐doped yttrium aluminum garnet (Nd:YAG) laser is a very versatile laser due to its deep penetration and absorption by hemoglobin, melanin, and water, which has gained increasing popularity over recent years for the treatment of leg veins and permanent hair removal as well as skin rejuvenation. The long‐pulse Nd:YAG laser was appointed as treatment of choice for the treatment of 0.5–3.0 mm deoxygenated, unsightly leg veins. Hair removal is another application of long pulse Nd:YAG lasers, and decreased light absorption by melanin at 1,064 nm reduces the risk of pigmentary side effects, which makes long pulse Nd:YAG laser the safest laser in darker skin types. The long pulse Nd:YAG lasers are also being employed for skin rejuvenation based on their ability to heat dermal water and stimulate collagen production. We have reviewed the parameters of Nd:YAG laser and shared our experiences in these indications that may be useful for good clinical response with minimal side effects.     

Combination of CO2 and Q-switched Nd:YAG lasers is more effective than Q-switched Nd:YAG laser alone for eyebrow tattoo removal

Background: The eyebrow tattoo removal using Q-switched lasers is usually prolonged. Other modalities may be required to enhance the efficacy and shorten the treatment course. Objective: To compare the efficacy of Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser alone versus combination of Q-switched Nd:YAG and Ultrapulse CO₂ lasers for eyebrow tattoo removal after a single session. Patients and methods: After local anesthesia, the right eyebrow of 20 patients was treated with Ultrapulse CO₂ laser with the parameters of 4 J/cm² and 3.2 J/cm² for the first and the second passes. Both eyebrows were then treated with 1064-nm and 532-nm Q-switched Nd:YAG laser. The spot size and pulse duration were 3 mm and 5 nanoseconds for both wavelengths, and the fluence was 7 J/cm² for 1064 nm and 3 J/cm ² for 532 nm. Results: The side treated with combination of Q-switched Nd:YAG and CO₂ lasers improved 75–100% in 6 of 20 patients versus only 1 of 20 in the side treated with Q-switched Nd:YAG alone. Similarly, the right side in 13 of 20 patients showed more than 50% improvement with combination therapy versus the left side (the monotherapy side), where only 6 of 20 cases showed more than 50% improvement. The Mann–Whitney test was 2.85 for the right side and 1.95 for the left side (P value = 0.007). Conclusion: Using Ultra pulse CO₂ laser enhances the efficacy of Q-switched Nd:YAG laser in eyebrow tattoo removal.     

A retrospective analysis of the influencing factors and complications of Q-switched lasers in tattoo removal in China

Background and objective: Q-switched (QS) lasers are the gold standard for tattoo removal. The purpose of the present study was to gain a more comprehensive understanding of the factors that influence the efficacy of QS lasers and their associated complications in the removal of tattoos in China. Patients and methods: Clinical data of 266 patients were analyzed retrospectively. The tattoo clearance rate was evaluated using the 4-point scale. The Cox regression model was applied to analyze the factors that affected the efficacy of QS lasers in tattoo removal. In addition, treatment-related adverse reactions were analyzed. Results: The results showed that several variables had a statistically significant effect (p < 0.05) on the efficacy of QS laser-mediated tattoo removal treatment, including the patients’ age, the tattoo’s age, type, color, or ink density and the number of treatments. A variety of adverse responses occurred during the laser treatment. The overall incidence of adverse responses was approximately 24.06%, including pigmentation, hypopigmentation, bulla formation, allergic reactions, and skin texture changes or hypertrophic scarring. Conclusion: Some factors may influence the efficacy of QS lasers in the treatment of tattoos and certain adverse reactions may occur during this process.