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Ultrapulse Carbon Dioxide Laser Treatment of an Iron
Oxide Flesh-colored Tattoo
GREGORY J. HERBICH, MD
Flesh-colored tattoos darken with traditional tattoo removal lasers. An alternative method was tried. A pulsed carbon dioxide laser was used to remove facial iron oxide flesh-colored tattoo. It resulted in significant clearing without scarring or textural changes. This is a significant improvement over other reported laser treatments. If this laser is used to remove tattoos elsewhere on skin other than the face, an increased risk of scarring may occur.
(Copyright Symbol) 1997 by the American Society for Dermatologic Surgery, lnc. Dermatol Surg 1997;23:60- 61.
Flesh-colored tattoos have been difficult to remove with pulsed lasers utilizing the principles of selective photothermolysis because of adverse darkening of some tattoo inks.(1) These lasers include the Q-switched ruby (694 nm), Q-switched neodymium (N D):YAG (1064 nm/ 532 nm), Q-switched alexandrite (755 nm), and pulsed green dye (510 nm) lasers . Other treatments such as salabrasion, dermabrasion, continuous wave CO2 (10,600) laser, chemical peel, cryosurgery, and excision have been used with varying results but with significant risk of scarring.(2) The Ultrapulse CO2 laser (Coherent Laser Corp., Palo Alto, CA) has not been evaluated previously for the removal of flesh colored facial tattoos.
Case Report
A 46-year-old woman of Japanese decent was given skin-colored tattoos 4 years prior to laser treatment to cover two "liver spots" on her left cheek. A Spaulding Rogers (Voorheesville, NY) iron oxide-based flesh tone pigment was used. Subsequently, she developed "chicken fat" discoloration (Figure 1). The upper tattoo was treated with the Ultra pulse-CO2 laser with three passes using a 7-mm pattern generator at 300 mJ using a pattern density of 5. This was sufficient to cover the entire tattoo. After each pass, saline-soaked gauze followed by dry gauze was used to wipe off any char and water. Immediate whitening of the tattoo occurred and this was present at the completion of the treatment. One month postoperatively she had partial lightening of the tattoo and a red border surrounding it (Figure 2). Two month s postoperatively, she had significant clearing of the tattoo without scarring or textural changes (Figure 3).
Discussion
Flesh-colored tattoos have been difficult to treat with pulsed lasers that target specific chromophores because 1934 Biegeleisen described a microinjection technique for treating telangiectasias. He used sodium morrhuate but frequently complications occurred, such as necrosis, pigmentation, and allergic reaction. Polidocanol was developed in the 1950s as an anesthetic. Its use as an anesthetic was discontinued when it was found to sclerose small-diameter blood vessels through intravascular injection. Its use as a therapeutic sclerosant for varicose veins was first described by Eichenberg in 1969. Foley and Alderman described their experiences with the use of hypertonic saline solution in concentrations of 18% and 20%. Until now, solutions in different concentrations of the two last mentioned solutions are a widely used therapy for telangiectasias in Europe and in North America. Complications of sclerocompression therapy occur frequently. Hyper- and hypopigmentation of the treated areas arc also described after injection of a sclerosing agent. Necrosis is a side effect of the therapy that in most cases leaves scars. It occurs when either the solution is too highly concentrated for injection of small vessels or the injection itself is placed paravasal. Furthermore, necrosis seems to occur more often when areas distal of the ankle region are treated. This phenomenon has been explained by a higher incidence of arteriovenous shunts in this region. As we mentioned above, treatment of telangiectasias is not totally free of undesirable side effects. The three most common adverse sequelae include postsclerotic pigmentation, temporary ankle edema, and telangiectatic matting. Necrosis is a severe side effect and fortunately rarely occurs after injection into an arterial vessel. The most common reason for requesting treatment, however, is for cosmetic improvement. Treatment therefore should be relatively free of any adverse sequelae. Although it is not a common side effect, it should be our aim to find a clinical classification of telangiectases that could make it possible for the dermatologist to avoid necrosis at all. A better knowledge of the pathophysiology therefore is necessary. With additional examination, such as the high frequency 20- and 5O-MHz ultrasound, the localization of telangiectasias in the dermis can be measured. LDPI could reveal an abnormal increased flow, due to an underlying vessel.
The
three most common adverse sequelae include postsclerotic pigmentation, temporary ankle edema, and telangiectatic matting. Necrosis is a severe side effect and fortunately rarely occurs after injection into an arterial vessel." The most common reason for requesting treatment, however, is for cosmetic improvement . Treatment therefore should be relatively free of any adverse sequelae. Although it is not a common side effect, it should be our aim to find a clinical classification of telangiectases that could make it possible for the dermatologist to avoid necrosis at all. A better knowledge of the pathophysiology there fore is necessary. With additional examination, such as the high frequency 2Q. and 5O-MHz ultrasound, the localization of telangiectasias in the dennis can be measured. LOPI could reveal an abnormal increased flow, due to an underlying vessel of reported darkcuing of tattoo ink. Infrared laser beams such as the Ultrapulse CO2 target water in the skin, which is its most abundant molecule. The CO2 laser has been shown to precisely remove thin layers of skin such as the epidermis.(3) Subsequent passes of the epidermis result in progressive degrees of dermal ablation. Recent developments in laser technology such as rapid pulsing or scanning of the laser beam enable reproducible results and are user friendly.(4) Pulsed CO2 lasers utilize high peak energies in a short pulse duration and thermal damage is mostly limited to the target site and heat conduction is minimized to adjacent skin.(5) The Ultrapulse CO2 laser was successful in removing a facial flesh tone tattoo and offers significant improvement over other reported laser treatments.
Caution is advised when using CO2 lasers on areas other than facial skin. Scarring has been reported with CO2 lasers for tattoo removal.(6) It remains to be determined if the Ultrapulse CO2 laser or even shorter pulsed CO2 lasers can be safely used on areas other than the face for tattoo removal.
References
1. Champion RH. Disorder of blood vessels . In: Rook , Wilkinson.
Ebling. Textbook of Dermatology , 1994:1842-9.
2. Ryan 1]. The epidermis and its blood supply in venous disorders
of the leg. Trans St John' s Hoop Dermatol Soc 1969;55:51- 63.
3. Merlen JF. Red teleangtectasl as, blue teleangiectasias. Soc Franc
Phlebolm 1970',22:167.
4, Boeh ler-Sommeregger K, Karne•l F, Schuller-Petrovi c 5, Santler R.
Do telangiectases communicate with the deep venous system? J
DermatolSurg OnooI1992;1!i:403-6.
5. Sedtck N. Treatme nt of telangiectatic leg veins. J Dermetol 5u rg -.
OncoI1990;16:24.
6. Engel A, Johnson ML, Haynes SG. Health ef fects of su nlight
exposure in the United Sla tes : results from the firs t national ;/
he alth and nutriti on I'"'JCamina tion ~;urvey: 1971-1974. Arch Derma
to l l988;12 4:72-9.
8. Go ldman MP. Pat hophys iology of telangiecta sias. In: Sc I~'lUther "'
py. Trea tment 1,1Vari cose lind Telangi ectatic Leg Veins . 1991:86.
9. Bean WB. v ascular Spiders and Related Lesion s of the Skin.
Springfield, IL: Charles C. Thomas. 1958.
to. Altmeyer P, el-Oammal 5, Hoffman n K. Ul tras ound in Derm atology.
Springer Verlag, 1991.
11. Scrup J, [emec GBE. Handbook of non-invasive methods and the
'kin. CRC Preis, 1995.
12. Bodian EL Techniques of sclerotherapy for su nburst Vl;'llOUS
blemishes. J Dl.-rmawl Surg Oncol 1985;11:696- 704.
13. Biegeleisen K. Primary lower extremity l elea ngi~'(:la s ias : rt"la tion'
shi p of size to colour. Ang iology 1987;10:760- 8.
14. de Faria [L, Morucs IN. Htstopethclogy III the telea ngicctasias
associated wi th varicose veins. Dermatulogii1196.1;127:321-9.
15. W(lkaM,; H et al. Morphology and loca lization of sunburst vancosues:
an electron microsco pic and morphometric study. J DermatoI
Surg OnooI 1989;15:149.
16. Van dee Molen HR, Kimper JF. Analyse toocno neue
icooographique de la stase veneuse. Congres International de
Phlcbologi e, Chamberg, 6-8 ma y 1960. Chambe ry, lmprtmertes
Rcurues, 267-n .
17. Goldman MP, Bennett RG. Treatment of tl.'1.1ngiecta!lia, ,1 review.
JAm Acad Dermatol 1987;17:167.
18. Ramelet AA. Die Behend lung der Bcscnreiserva riz cn: indikntion
der Ph lebckte mie nac h Mueller. PhlcboI 1993;22:163-7.
19. Eichenberger H. Resul tate dC'I' varize nverod ung mit hyd roxypolyathoxydodecan.
Zbl Ph lcboll969;8:181- 3.
20. Foley WT. The eradication of venous blemishes . Cu tis 1975;15:
665-8.
21. Alderman DB. Therapy for essential cutaneou s telangiectasia .
Postgrad Moo 1977,61:91-5.
22. Partsch H. Do we need firm com pression s tockin gs exerting high ,..,
pressure? VASA 1984;13:52-7.
23. Thiba ult PK. Trea tm ent of leg telangiectasias. In: Bergan J), Goldman
MP, cds . Varicose Veins an d Telangiectasias. 1993:373-!l6
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References
1. Anderson RR, Geronemus R, Kilmer SL, et al. Cosmetic tattoo ink darkening. Arch Dermatol 1993;129:1010-4.
2. Goldstein N. Tattoo removal. Dermatol Clin 1987;5:349-58.
3. Herbich G. Epidermal changes limited to the epidermis of guinea pig skin by low-power carbon dioxide laser irradiation. Arch Dermatol Clin 1986;122:132.
4. Waldorf HA, Kauvar ANB, Geronemus RG. Skin resurfacing of fine to deep rhytides using a char-free carbon dioxide laser in 47 patients. Dermatol Surg 1993;21:940-6.
5. Hobbs ER, Bailin PL, Wheeland RG, et al. Superpulsed lasers: minimizing thermal damage with short duration with high irradiance pulses. J Dermatol Surg Oncol 1987;13:955-64.
6. Lim JTE, Goh CL. Lasers used in dermatology. Ann Acad Med 1994;23:53.
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