Here we provide an overview of the main tattoo removal treatments currently available, the EU legislation applicable and what is to be expected after this type of aesthetic treatment.
Terminology used, “Tattoo Removal” or “Tattoo Fading”.
Legislation on tattooing and tattoo removal procedures at European level.
Physiological progressive fading of permanent tattoos and inpact of tanning on their brighteness.
Tattoo Resilience and estimating the tattoo fading sessions required.
Why is having a tattoo done perceived to be less risky than removing it?
Tattoo removal techniques introduction, the challenges.
Laser tattoo fading.
Tattoo fading using plasma, or thermal abrasion with or without osmosis.
Tattoo surgical excision.
Tattoo fading using Osmosis or Salation in general.
Tattoo fading using Micro-Dermabrasion.
Tattoo fading using chemical peels.
Tattoo fading using Intense Pulsed Light (IPL).
Tattoo fading using Cryotherapy.
Tattoo removal by replacement.
Temporary adverse reactions.
Discomfort and pain.
Immediate redness and minor swelling.
Swelling and Infections.
Permanent and semi-permanent adverse reactions.
Semi permanent adverse reactions.
Permanent adverse reactions.
Terminology used, “Tattoo Removal” or “Tattoo Fading”.
The procedures we are going to describe are widely referred to as “tattoo removal”. This is mainly because the complete “removal” is the desired end result the clients expect from these aesthetic procedures. In reality most tattoos are very resilient, and most treatments currently available require a number of treatments in order to achieve satisfactory results whenever feasible. Because the most popular tattoo removal procedures rarely lead to the complete disappearance of the tattoo within one session we would rather refer to most types of “tattoo removal” procedures as “tattoo fading” because most of the treatments available can only realistically fade the tattoo slightly after each session instead of removing it. As we will see in some cases complete removal is not feasible without leaving some scars or some sort permanent skin texture modification.
Most of the popular treatments currently available can only fade the tattoo slightly after each treatment. For this reason most procedures advertised as “tattoo removal” should be referred to as “tattoo fading” instead. Currently only very invasive treatments can guarantee complete removal within one procedure or session only. However after making this clear distinction in terminology, we may refer to “tattoo fading” procedures as “tattoo removal” to align to the normal terminology used on the current aesthetic market place.
Sometimes, due to the type of pigments used, it may be detrimental to try and remove the tattoo completely as doing so could require the client to undergo too many treatments. Sustained exposure to some of the most popular treatments for tattoo removal procedures (especially laser treatments) can become detrimental to the skin due to the repeated deep burns caused and therefore if the desired effects are not achieved after a few sessions then it may be advisable to discontinue the aesthetic treatments. In case where the degree of tattoo fading is too low, the likelihood of incurring into the adverse effects of these aesthetic treatments may not be worthwhile and therefore the fading treatments should discontinued or switched for others (e.g. Tattoo Excision or Tattoo Cover-up).
Legislation on tattooing and tattoo removal procedures at European level.
This section was last edited in April 2016. For official references please refer to current legislation and relevant professional legal advisers.
Tattoo drawing although have potential side effects (including infections) and these procedures involve purposely modifying the dermis by injecting the pigments inside it, while causing an open wound, tattoos made for aesthetic and lifestyle choices are not considered to be medical applications (non medical intended uses). Tattooing procedures are currently carried out by tattoo artists who are not required to hold any formal medical qualification.
In case of tattoo removal, although when advertising, several clinics refer to them as “medical procedures” and the client is also often referred to as “patient”, from a mere legislative view point tattoo fading procedures (that do not involve surgery i.e. excision) are considered aesthetic procedures. Furthermore the current interpretation of European legislation considers tattoo fading procedures as cosmetic/aesthetic applications. This is because the main reason behind a tattoo removal procedure is the fact that the client regrets their previous tattoo, and desires to either change it or remove it completely. Of course there are no medical reasons in order to have an aesthetic tattoo drawn in the first place, likewise there are no medical reasons beyond an aesthetic tattoo removal process.
For these reasons in Europe any tattoo removal procedures are widely regarded as mere aesthetic procedure. Since early 2000s, there have been several lobbying pressures in order to modify the legal status classification of tattoo fading (tattoo removal) procedures in general, in order to be regarded as medical applications (Medical Intended Uses). As we know almost any tattoo removal processes do require to inflict a burn or a purposely inflicted injury of tattooed area in some way in order to fade or remove the pigments which reside inside the dermis. In case of tattoo fading techniques, this is done a number of times in order to accomplish the desired effects.
Both tattoo parlours and clinics performing tattoo removal have to comply with local legislations, which may vary from country to country and region to region in each European country.
Therefore as we have seen tattoo removal procedures are considered to be non medical treatments for this reason they are not usually covered by standard health insurance policies and also they are not provided free of charge by the NHS.
Physiological progressive fading of permanent tattoos and the impact of tanning on their brightness.
Tattoos are far more easily drawn than than being removed. This is because the pigments of permanent tattoos are made in a way so that they will withstand to the test of time. However the natural body reaction to tattoo pigments is to try eliminate them, this normal physiological pigmentation absorption is normal and takes place very slowly. In other words, although all permanent tattoos fade over time, their fading rate is so slow that they can effectively be considered permanent.
The rate at which the tattoo fades over time depends on a number of factors and one of them is the type of pigments used by the tattoo artist. Different type of pigments will fade at different rates and in different ways. Also sun exposure and tanning can increase the physiological fading rate. This is because the broad spectrum of sun light also includes a small proportion of infra-red light with penetrates into the skin breaking down the tattoo pigments.
In the figure above we can appreciate the deterioration of a tattoo over time. Sometimes, this natural tattoo fading is accelerated by repeated exposure to sun light (i.e. repeated tanning). It is well known that repeated intense tanning has detrimental effects on the brightness of aesthetic tattoos over time. This is because some lower wavelengths of the broad spectrum natural sun light (in particular red and infra-red) have the effect of breaking down the tattoo pigments, in a similar fashion of lasers and IPL. However the process is much slower than the degree of fading achieved with Laser or IPL treatments. In fact what we are dong with “tattoo fading” techniques is accelerating this natural tattoo fading process one way or another.
Because the tattoo pigments are meant to be permanent and they reside inside the dermis, tattoo removal procedures are normally involving a degree of dermal treatment. Because of this, “tattoo removal” or more appropriately “tattoo fading” procedure cannot be free from inherent risks.
Due to the fact that tattoos are meant to be permanent and be resilient over time, they will generally be far more difficult to remove than having them done. One session is usually sufficient to draw a beautiful medium sized tattoo, however fading it, or even removing it completely can be very challenging and sometimes not worthwhile due to the complications involved in the complete removal of particular resilient tattoos.
Tattoo resilience and estimating the tattoo fading sessions required.
One of the common questions asked by the clients is the number of tattoo fading sessions required in order to achieve their desired result (which is the complete seamless removal). It is important to manage their expectations because in many cases they do expect complete removal without leaving a trace in one or very few session only. In most cases there are no fading techniques currently known which will guarantee complete removal without leaving no trace.
Additionally not all tattoos present the same resilience when trying to fade them. Some types of tattoos can be easily removed in only a few easy fading sessions while others can be far more challenging and sometimes almost impossible to remove completely without leaving a scar, or some sort of trace (i.e. permanent hypo-pigmentation in case of laser removal) due to the aggressiveness of the treatment required for their complete removal. The amount of tattoo fading desired can be accomplished in two ways, either through relatively high number of mild tattoo fading treatments or through a few high intensity treatment sessions. Generally the better the pigment quality used and the better the devices used to draw the tattoos (achieving a relative superficial pigment distribution on the dermal layer) the easier it will be to achieve the desired results while minimising the aggressiveness or intensity of the tattoo fading treatments.
On the other hand low quality pigments or even “not fit for purpose” colours can be almost impossible to remove completely using the most popular tattoo removal techniques. In some cases, the only viable option for the removal of poorly drawn tattoos (with “non fit for purpose” pigments) can be tattoo surgical excision. Also sometimes the tattoo pigments can be injected further into the dermis closer to the hypo-dermis, this can make the removal even more challenging.
Please note that the points below mainly apply to the most common tattoo fading procedures and unless stated otherwise do not refer to tattoo surgical excision. Generally the ease of removing tattoos depends on the following main factors:
- Depth of the pigments. The deeper the pigments inside the dermis the more challenging it will be to fade the tattoo. This applies to any tattoo fading technique. Furthermore sometimes the tattoo pigments could have been injected particularly deeply and may even be located inside or close to the hypo-dermis. In this cases it may be unrealistic to expect complete tattoo removal without leaving any trace.
- Type of pigments. The chemical composition determines the ease of removal. Additionally the better quality the tattoo pigments used the easier it will be to fade them.
- Colour of the pigments (laser tattoo fading only). Certain wavelengths can only fade certain colours. The brighter the colours of the tattoos the more challenging they will be to fade. Conversely the darker the tattoo the easier they are to fade. The wavelength used by the laser will determine the colour it fades and the number of sessions needed. Other tattoo fading treatments are colour-blind (they fade all colours indiscriminately). Most other tattoo fading options are colour blind (they fade all colours indiscriminately).
- Type of the tattoo. A non-professional drawn tattoo is usually harder to fade than professional tattoos. This is because the depth of the pigments distribution may not be uniform throughout the tattoo. Therefore the tattoo may fade in different ways depending on the depth of the pigments.
- Density and amount of the tattoo pigments. The more dense the ink, the more layers of pigments are in the tattoo and the longer it will take to fade the tattoo. What matters is how much ink is in the skin. For example cover-up tattoos have two layers of pigmentation, therefore will be harder to fade than normal tattoos.
- Area covered by the tattoo. The wider the tattoo the more fading sessions will be required to achieve the desired results. Large tattoos cannot be treated in their entirety because the risks associated to the treatment and adverse effects would be too high. In case of tattoo fading treatments which rely on burning the skin (Laser, Electric Plasma, Chemical peels etc). Exposing the body to extensive burns can be detrimental to the individual. This is because the potential risks and the likelihood of adverse reaction can increase dramatically proportionately with the area covered within the session. Additionally other tattoo fading treatments, which use other skin resurfacing principles, should not be used on extensive areas within one treatment, as this can increase the likelihood of their associated adverse reactions. Generally in case of large tattoos, they will be treated in smaller sections to manage the risks of the associated adverse effects. In case of tattoo surgical excision of large tattoos, skin grafting may be necessary to replace the large area of missing skin.
- Position of the tattoo on the body. Some areas are not suitable for certain types of tattoo fading treatments, therefore their removal may be very challenging. These are areas subject to bending and stretching (e.g. knees, elbows, underarms etc). Also those areas with will be inevitably be exposed to the constant rubbing of clothing (e.g. waist-line).
- Skin tone (laser tattoo fading only). One of the side effects peculiar to laser tattoo fading treatments if the likelihood of causing hypo-pigmentation. This is a side effect which does not generally occur after other types of tattoo fading treatments. In general the higher the treatment intensity the higher the likelihood of causing hypo-pigmentation. Conversely the lower the laser treatment intensity the lower the likelihood of hypo-pigmentation. The darker the skin tone the more the likelihood of hypo-pigmentation. Therefore when treating tattoos on dark skin tones the intensity of the treatment has to be lowered, (in order to decrease the likelihood of hypo-pigmentation) therefore increasing the number of sessions required in order to achieve a satisfactory level of tattoo fading.
- Tattoo age (laser tattoo fading only). The older the tattoo the more challenging it may be to fade the pigments. Conversely the fresher the tattoo the easier it may be to fade. This applies to laser tattoo removal, most other fading techniques tend to fade all tattoos approximately in the same way despite of their age.
- Treatment intensity. The treatment intensity of the particular type of tattoo fading treatment determines also the amount pigmentation fading after each session. Generally the higher the intensity the more the tattoo fades after each treatment. Conversely the milder the treatment the less the degree of tattoo fading after the treatment.
Estimating the number of sessions required in order to achieve the desired final results is often difficult if basing the opinion on the the key factors (above). This is because there is seldom reliable information about the way the tattoo was originally drawn, which determines the ease of fading each particular tattoo. Often some assumptions or information about the tattoo may turn out to be incorrect. In other words, the tattoo removal practitioner may not be able to establish the reaction of the specific tattoo to the fading treatment only by looking at the tattoo or asking questions in relation to how the tattoo was drawn (there is seldom reliable information on the pigmentation distribution depth, of the chemical composition of the ink used etc).
Therefore the best option to estimate the number of sessions required in order achieve the desired results is by making an extrapolation based on the degree of tattoo fading after the initial patch testing. From this information the beauty practitioner can provide a more reliable estimation of the number of sessions required to achieve the desired results.
However, even an estimation based on the degree of fading accomplished after the tattoo patch testing may not be very accurate. How much the tattoo fades after each treatment varies from treatment to treatment. The tattoo fades most after the first few treatments, this is because the superficial pigments are the most easily removed. A relative high fading is achieved by removing the most superficial pigments. Therefore those pigments that are left after the previous tattoo fading treatment are more resilient and located deeper inside the dermis.
Therefore in certain cases where the pigments left after a number of tattoo fading treatments, are very resilient and/or located too deep inside the dermis, the amount of tattoo fading will be minor after the initial tattoo fading treatments. This is because as the tattoo fades, generally the remaining pigments are those which are the most challenging to remove. In certain cases of particular resilient pigmentation, removing the fading the tattoo can become so arduous that further attempts to fade it can not only become futile but even potentially counter-productive as it only exposes the client to the adverse effects of the tattoo fading procedure without brining about any substantial improvements. In this case the further steps can be either surgical excision or tattoo cover-up.
Why is having a tattoo done perceived to be less risky than having it removed?
All tattoo removal options carry potential adverse reactions and any risk associated to these aesthetic procedures can be minimised however cannot be completely ruled out even following the right procedures and the after-care protocols. As we have seen, also tattooing present inherent risks, however the perceived likelihood of adverse reactions associated to their removal are generally perceived as higher.
The reason for this is very simple: although the inherent risks of both tattoo drawing and tattoo removal are very similar, tattoo removal are perceived to be riskier procedures because, unlike tattooing, several tattoo fading treatments are often required in order to achieve satisfactory results. On the other hand, the client exposes himself/herself to the inherent risks of a tattooing only once, by contrast they will require to expose themselves to the potential adverse effects several times in order to “remove” (or more appropriately fade) them. Because of this repeated exposure to the inherent adverse effects of tattoo fading treatments, the perceived associated risks are higher in tattoo removal than the tattooing process. The risks associated to each tattoo removal or fading treatment vary dramatically according to the type of fading treatments, the way the treatment was carried out (e.g. the intensity of the treatment) and especially the after-care. Therefore the client has to go through several burns or several resurfacing treatments each time being exposed to similar side effects to those of the tattoo drawing process. It is important to emphasise that most of the permanent adverse reactions to the most popular tattoo fading techniques are usually due to the client’s failure to comply with the after-care procedures.
Tattoo removal techniques introduction, the challenges.
The request for tattoo removal is currently constantly on the increase and the prices charged for this type of aesthetic procedure are high also due to the relative complexity of the tattoo removal procedures. Additionally more and more people are are highly motivated and sometimes willing to pay almost any amount to have their tattoo removed.
In the UK it is not uncommon for some tattoo removal quotes to reach 20 or 30 thousands pounds. Furthermore due to the the inherent complexity of these aesthetic treatments the tattoo removal market provides very conflicting information in connection with each type of “tattoo fading” or “tattoo removal” procedure. This is thought to be due to the several vested financial interests in “tattoo removal” procedures. Some sources point to some treatments types as being extremely risky and focus only to their potential adverse reactions of the specific type of tattoo fading treatment. Other sources emphasise the risks of undergoing tattoo removal procedures from “non qualified” tattoo removal laser practitioners by pointing out and showing only the potential adverse effects of tattoo fading procedures. However as it is well known, no tattoo fading technique potential adverse effects which can be minimised but never completely eliminated. Due to these two factors (vested financial interests and the mere fact that none of the tattoo fading options currently available cannot be considered completely risk free) there are several contrasting information on the public domain suggesting one method to be more effective or safer than others.
There are several options for tattoo removal. In this website we will explore the most popular ones first. Some of the most common tattoo fading treatments involve essentially skin resurfacing techniques (is laser, plasma/electrical arcing, microdermabrasion, cosmetic peels etc). These techniques although sometimes slowly, will lead to a certain degree of tattoo fading, however the problem with skin resurfacing in tattoo removal is that the tattoo pigments are located inside the dermis therefore the resurfacing treatment has to involve the dermal layer in order to be somewhat effective. Any skin resurfacing which involves the dermal layer has intrinsic potential adverse effects including scarring. The type of skin resurfacing dictates the types and prevalence of the potential adverse effects.
Laser tattoo fading.
This is one of the most popular options available on the market. This is heavily advertised the world over and used in several cosmetic clinics. This method relies on skin resurfacing of the dermal layer (by causing a controlled burn). Essentially the tattoo pigments as well as the dermal layer are targeted by the laser causing part of the pigments to be reabsorbed. For more information about laser tattoo removal or laser tattoo fading please Click Here.
Tattoo fading using plasma, or thermal abrasion with or without osmosis..
This a technique which has been used for several years particularly in Italy and Germany and has been in use for several years in many European aesthetic clinics with very good consistent results. It combines the use of salation and thermabrasion. The thermabrasion can be carried out by using devices generating electrical arcing or certain radio frequency devices which have the same ablative (burning) effect. Devices for this intended purpose have been on the market for the past 40 years. Today there are even several more devices on the market and this technique is increasing in popularity throughout Europe. Although very effective, this tattoo fading technique is not as popular as laser tattoo removal (fading). If carried out appropriately this tattoo fading treatment generally accomplishes a greater degree of pigmentation fading than most other techniques. For more information in connection with this type of procedure please click here (link to be later updated, by the 20ieth of September 2016 ).
Tattoo Surgical Excision.
In the video below we can watch a part of the surgical procedure for tattoo excision. The practitioner removes the tattoo using a scalpel and closes the wound with stitches.
Surgical excision, also referred to as “surgical tattoo removal”, is one of the most invasive options for “tattoo removal” when compared to the most popular tattoo “fading” procedures. However, this is the only procedure which can effectively be referred to as “tattoo removal”. This is because only “surgical tattoo removal” can guarantee the complete removal of the unwanted tattoos within one session. All the other non surgical aesthetic treatments are mostly less invasive, however they can only fade the tattoo but seldom remove it completely within one session.
Before suggesting “tattoo surgical excision”, the practitioner assesses the area in order to have a clear appreciation of how the part would look like if the skin where the tattoo resides were removed completely. If the “pulling effects” of the surgery is not dramatic or would not impair normal movements (hence, apart form the scar, the final result would practically look seamless), then the the procedure is carried out under local anaesthetic. This is the only tattoo removal procedure which requires local anaesthetic, for all the other tattoo “fading” treatments topical numbing products usually suffice for the comfort of the client. In some cases where the tattoo covers a large area, this procedure may not be recommendable as removing large portion of the skin could be detrimental and would sometimes require subsequent skin grafting.
Not all tattoos are the best candidates for this type of procedure. If they are located on the face or areas where the skin is subject to bending and stretching (i.e. elbows, knees, shoulders etc) then this procedure may not recommendable. Specifically, this procedure should be avoided close to the major joints were a certain degree of skin stretching is required for normal movement. The main problem with removing large tattoos using surgical excision is the fact that the skin will be “pulled” and the effects of the procedure could be clearly visible long after the removal (non seamless results). One of the disadvantages of this type of procedure is that it will almost inevitably leave a certain degree of scarring caused by the sutures. Therefore if the tattoo is on the face, the skin constriction caused by the surgery and the scar left by the sutures do not make this type of procedure the most recommendable. Small tattoos are the best candidates for this type of procedure especially if they are located in areas where there is a relative amount of loose skin which can be removed without subsequent need for skin grafting or the skin can be removed without causing ad major “pulling” effect which could make the area look awkward.
This surgical technique proves highly effective in removing certain types of tattoos where the presence of a small scar will not bee very important. some tattoos and allows the surgeon to remove the inked areas with great precision and within one sitting only.
Advantages of surgical tattoo excision.
The main advantage of excision is that the tattoo will be gone immediately after the surgical procedure. This is generally the most cost effective option for smaller tattoos. This procedure although invasive, offers the clear clinical advantage of avoiding multiple exposures to burns and other intrinsic adverse effects of most common tattoo fading procedures. Because only one procedure is required for the removal of small tattoos the cost of this type of procedure is typically lower than other tattoo fading procedures.
Side effects are generally minor, but may include:
- Some degree of scarring due to the sutures is to be expected and cannot be avoided.
- Infection could occur if the area is not looked after properly.
- The skin may feel tighter for a while after the procedure due to the missing skin.
- In certain cases, where large tattoos are required to be removed using this surgical procedure, skin grafting may be necessary. The removal may not be seamless if the skin removed is relatively large (also costs could increase dramatically).
The cost of this type of procedure is generally lower than most common tattoo fading treatments. This is mainly because the cost of tattoo fading techniques is cumulative and several treatments are required to achieve satisfactory results. In case of surgical tattoo excision of small tattoos one session will suffice to remove the tattoo. The cost for surgical tattoo removal depends on several factors:
- Country where the procedure is carried out. In certain countries the wide availability of surgeons can make this procedure more cost effective than other most popular tattoo fading treatments. Tattoo fading devices can sometimes be very costly, making the tattoo fading procedures especially “laser removal” more expensive than surgical excision.
- The size of the tattoo. The larger the tattoo the more expensive the procedure may cost due to the likelihood of skin grafting requirement. As pointed out previously, this procedure may not recommendable for the removal of relatively large tattoos.
- The type of anaesthesia used during the procedure. Local anaesthetic is the preferred and most cost effective option for this type of procedure. In case the surgeon opts for total general anaesthesia the procedure can be far more costly. General anaesthetic is the preferred option in case of tattoo surgical excision which also requires skin grafting. Unlike the other most common tattoo tattoo fading procedure topical numbing products will not suffice for surgical procedures.
Tattoo fading using Osmosis or Salation in general.
Due to its effectiveness, the basic principles of salabrasion (combination of osmosis and dermal abrasion) have been used for several hundreds years and this makes it one of the oldest form of tattoo fading procedures currently known. While the efficacy of other methods may be limited by the age of the tattoo, the pigments colours (in case of Laser tattoo fading), the type of tattoo pigments and their distributions inside the dermis, the Saline Method (Osmosis) can remove both old and new tattoos regardless of pigments used. This method is also effective on amateur, professional grade tattoos and permanent make-up, however it cannot fade very deep pigments close to the hypo-dermis.
Additionally, since the saline method does not rely on the destruction of skin layers, the risk of scarring (although always exist and can never be ruled out) is considerably lower than more traditional methods. Finally, pain and wait time between treatments is decreased when compared to laser treatments. Where blistering is a normal inevitable adverse reaction to the burn caused by the Laser, it is not experienced after salabrasion. The evidence of the efficacy of Salation (referred to as salabrasion, or osmosis) is corroborated by fact that the degree of tattoo fading is relatively predictable and the results are repeatable. The efficacy of osmosis is also validated by various scientific research papers (view further reference) and studies carried out by radio frequency devices manufacturers. Reference.
The techniques and protocols used with salation (or osmosis) have evolved throughout the years due to the different skin resurfacing devices that had been placed on the market over time or novel skin abrasion techniques. Also the fact that in Europe and in most parts of the world tattoo removal is a not a heavily regulated procedure have helped develop different protocols for this application. Osmosis (or Salabration) is a tattoo fading technique because it leads to a degree of pigmentation fading after each treatment and complete removal cannot be guaranteed within one treatment.
The main ingredient of this type of tattoo fading technique is Sodium Chloride (salt). The reason for this treatment to be effective is the fact that the osmosis induced when salt (Sodium Chloride) is placed on top of the tattoo pigments, it has the direct effect of drawing not only more water molecules towards it but also the broken tattoo pigments with it.
Applying salt on its own on a tattoo does not have the desired tattoo fading effects. This is because the tattoo pigments are well ingrained inside the dermis and are protected by the epidermis. Therefore merely trying to apply osmosis without another skin abrading treatment which facilitates the osmotic process is not going to produce the desired tattoo fading effects. In other words, if used on its own, the application of sodium Chloride on the surface of the tattoo has very little effects on the tattoo pigments.
For this reason this type of procedure is usually split into two parts:
Abrasion. A form or dermal abrasion is required to allow the dermis to become in contact with the sterile saline solution or fine sterile sodium chloride, this will facilitate the osmotic process to take place. Abrasion can be carried out in many different ways, the most popular techniques use mechanical means, like abrasion by using dermal abrasion devices, micro dermabrasion devices. Thermal dermabrasion by using radio frequency devices or electrical arcing devices are also used to facilitate osmotic tattoo fading. Only these techniques are are explored in this website because these are the most common methods used for this application. However abrasion can be carried out in several other ways to facilitate osmosis. Also thermal abrasion may be possible using other devices including lasers, however they will not be explored here. Local anaesthesia (which is non mandatory) is sometimes administered before the dermal abrasion treatment to avoid discomfort. Good topical numbing products are the preferred option for salabrasion, are more cost effective, easier to use and generally suffice for this purpose. If using dermabrasion devices the tattooed area is abraded until the area becomes red or starts to bleed slightly. Likewise if using thermadermabrasion using radio frequency or Electrical arcing-Plasma devices, the tattooed are is treated until slight bleeding takes place.
Osmosis. The basic active substance used in Osmosis is sterile fine salt. Osmosis can be applied in different ways. Sodium Chloride can be used on its own, made into a thick paste of sterile fine salt and sterile saline solution, or as a saturated or close to saturation sterile saline solution. Sometimes bandages impregnated with highly concentrated saline solution are applied on the abraded tattoo to cause the osmotic effect. The aesthetic practitioner can choose to apply the osmotic effect on the abraded tattoo in different ways and at different intensity (by varying the timing of application) depending on the area where the tattoo is located and the desired effects.
As stated above the osmotic effect can be carried out by applying simply sterile fine salt and bandaging the area, or by applying bandages impregnated with high concentrated sterile saline solution, or applying a dense saline paste on the abraded tattoo etc. The way osmosis is applied is often dictated by the location of the tattoo and the preference of the aesthetic practitioner. For example, when removing permanent make-up, bandaging the area or applying fine salt may not be convenient, whereas applying a thick paste for a few minutes (typically on the tattooed eyebrows) maybe the most convenient option. The osmotic effects depend on the type of abrasion carried out before the osmosis was applied, timing of osmotic application and the type of application (i.e. whether fine sterile salt is applied, a saline paste, saline solution impregnated bandages etc). Varying one of these parameters determines the intensity of the treatment and the amount of pigmentation removal of the specific tattoo fading session.
The duration of the application will also determine the intensity of the osmotic treatment and the degree of tattoo fading. Osmosis can be applied from ten minutes to two hours depending on several factors. In order to stop the osmotic effect, the area is washed using the appropriate antiseptic and re-bandaged. The bandage should be removed a few hours later and the area washed again using the appropriate antiseptic and the bandaging process repeated every 5 to 6 hours for at least 24 hours. Three to four days after the procedure scabs start to develop. The scabs must fall off on their own. Every time the area is treated there will be a degree of discolouration of the tattoo.
There are several factors that contribute to the degree of tattoo fading after each treatment using this technique:
- Depth and type of abrasion. Whether the abrasion is carried out mechanically, using thermal abrasion devices or radio frequency devices. The deeper the abrasion the stronger the osmotic effects. Certain types of abrasion may be more effective than others. Thermal abrasion for instance has the double effect of causing the abrasion but also breaking down some of the pigmentation due to the heat induced into the skin.
- Timing of the osmosis application. The longer the saline solution or the saline paste is kept on the abraded tattoo the better the osmosis effects and the more the eventual discolouration.
- How the osmosis has been applied. Namely it is possible to apply fine sterile salt or sterile paste or a highly concentrated saline solution. Keeping all the other parameters the same (i.e. timing of osmosis application type of and depth of abrasion etc) and changing the way the osmosis is applied, its efficacy in fading the pigments vary.
- Depth of the tattoo pigments. The deeper the pigments the more arduous will the complete removal be or even achieving acceptable results.
- Type of pigments. Like with any other tattoo fading treatment, inevitably the quality of the pigmentation determines the ease of tattoo fading.
Alternative saline treatment.
Certain aesthetic practitioners also utilise traditional tattoo equipment that is commonly used to draw the tattoo. Instead of tattoo pigmentation, a highly concentrated saline solution is injected into the tattoo. The highly concentrated sterile saline solution effectively bonds to the pigment molecules trapped deep below the superficial layers. The body naturally recognizes these bound pigment particles and pushes them up toward the surface of the skin, eventually ejecting them and causing the area to scab and the tattoo to fade.
Tattoo fading using Micro-Dermabrasion.
Dermabrasion has been conceived for other aesthetic procedures, in particular for skin resurfacing used to improve the appearance of fine lines. Sometimes microdermabrasion is used for tattoo fading. There are several types of dermabrasion devices on the market.
This technique when used for tattoo fading, is also referred to as “sanding off” the tattoo. This method uses skin resurfacing in order to fade the tattoo. This aesthetic procedure can be used on its own or combined with other procedures (i.e. salation or osmosis).
On its own, this procedure focuses on stimulating the skin regeneration process by sanding off the epidermal layer, and in case of tattoo removal also the upper part of the dermis where the tattoo resides. This is not a very popular tattoo fading method, particularly due to its immediate gruesomeness (the treated part will in fact immediately start to bleed), the relative low degree of tattoo fading after each session and hence the fact that several treatments are required in order to to achieve the desired results, (consequently exposing the client to the intrinsic associated adverse effects of this treatment several times). Because of these reasons microdermabrasion on its own is not widely used for tattoo fading treatments. After each session scabs will form and the tattoo should have faded slightly.
In the video shown below the resurfacing is carried out mechanically. Bleeding during this type of treatment is a normal and physiological consequence of the treatment and can be gruesome to watch.
Tattoo fading using Chemical Peels.
Like dermabrasion, this is a technique which relies on skin resurfacing. There are several types of chemical peels that can be used for this application. The main problem, like with the use of any other skin resurfacing techniques, is that although the cosmetic peels can remove skin layers as deep as required, the pigments do not fade like the mainstream tattoo fading techniques (Plasma and osmosis, Osmosis on its own, Laser). The reason is that in order for this technique to be effective the ablation should be carried out to remove part of the dermis where the tattoo pigments reside. As we know the deeper the ablation into the dermis the more likely the risk of causing permanent hypertrophic scar formation. Also the fading results are not very consistent using this method as the ablation effects depend on the application of the particular peeling product.
Tattoo Fading using Intense Pulsed Light (IPL).
Intense Pulsed Light devices are mostly used for permanent epilation and they are very rarely used for tattoo fading. The main difference between lasers and Intense pulsed light (IPL ) is that in case of lasers the device can emit one or multiple wavelenths at once, while in case of IPL the device emits a broad spectrum light. The IPL device’s broad spectrum light which penetrates into the skin and can fade the tattoo pigments. This is because the broad spectrum light breaks down part of the tattoo pigments. This is a similar process to laser tattoo fading.
As we have seen previously repeated sun exposure is attributed to the premature fading of tattoos. In case of IPL devices some of the wavelengths used penetrate deeper into the skin than the sunlight does therefore being far more effective than normal sun exposure in the fading of the tattoos. Those particularly prone to developing scars or keloids should not undergo tattoo fading treatments in general, including IPL treatments because of the increased likelihood of permanent adverse reactions. Consult a specialist before undergoing IPL treatments to assess your possible skin reactionm this is usually done by performing a patch test; the test area should be watched for redness, blistering, pigment issues, rashes, later scarring and keloidal formations.
Before performing the IPL tattoo fading procedure, the beauty practitioner may administer a topical numbing product. A cold gel will then be placed on the area and a glass prism is applied to channel the intense light. Several treatments will follow every 3-4 weeks, all more aggressive than the first.
The skin will be pink or red after the procedure. Side effects from IPL include blistering, small bleeding, scarring, swelling and changes in pigmentation. Sunscreen with high SPF must be used on the treated area.
Tattoo fading using Cryotherapy
Cryotherapy uses very cold temperatures to remove unwanted tissue. Like IPL, this is very rarely used for tattoo fading and it is not a mainstream treatment. For tattoo removal, ice crystals form on the skin with tattoo pigments, fragmenting some of them. Cryotherapy can be carried out with liquid nitrogen, carbon dioxide, argon or a combination of dimethyl ether and propane to freeze the skin. The epidermis peels and comes off; some of tattoo ink residing underneath the skin should come off as well. Several cryotherapy sessions will be necessary.
Clients may experience some pain and redness at the site, which can be attenuated by pain relieving products. Blisters go away after a few days. Small white spots may form around the area and are most likely permanent. Risks include nerve tissue damage and scarring.
Tattoo removal by replacement.
As we have seen the complete removal of permanent aesthetic tattoos are sometimes very challenging. Undergoing several tattoo fading treatments can not only be expensive but does expose the client several times to the inherent potential adverse effects of each particular treatment. As we know, the best degree of tattoo fading is accomplished during the first treatments, and as the tattoo fades, the pigments remaining are the most resilient. Especially those located in the deeper part of the dermis, and sometimes even inside the the hypo-dermis. Therefore once the tattoo has faded to a certain extent, in case the further fading treatments do not achieve the satisfactory tattoo fading, than alternative treatments may be more suitable. One option may be cover up.
Tattoo cover up can be used on an existing tattoo, without any prior fading treatment. In fact, an artfully done cover-up may render the old tattoo completely invisible, though this will depend largely on the size, style, colours and techniques used on the old tattoo and the skill of the tattoo artist. Covering up a previous tattoo requires darker tones in the new tattoo to effectively hide the older, unwanted piece. and also can be used as soon as the fading of the particular tattoo removal treatment reduce in effectiveness (becoming not worthwhile) .
Many tattoos are too bright to cover up and in those cases the use of tattoo fading treatments may be advisable to lighten the existing ink to make themselves better candidates for a cover up tattoo.
Generally, the main challenge of all current “tattoo removal” or better “tattoo fading techniques” is that, due to the inherent physiology of aesthetic tattoos, the pigments reside inside the dermal layer, therefore any effective treatment will inevitably affect the dermis in one way or another consequently causing a number of inherent risks including developing scars or other side effects. Despite the type of treatment used to fade the tattoo the inherent risks of scarring and other adverse effects can be minimised but never completely eliminated due to the very nature of these aesthetic treatments. Unfortunately, despite many different claims of selective tattoo pigment targeting, there are not currently known methods that actually allow selective targeting and destruction of the tattoo pigments without also affecting the dermal layer where the tattoo resides. This is proven by the fact that the adverse reaction to the tattoo fading treatment is the same in any part of the body not covered by the tattoo. Additionally the most popular tattoo fading treatments rely on burning the skin (e.g. laser treatment, IPL, Plasma etc), therefore these treatments may carry inherent adverse effects associated to any common skin burn.
There are three types of adverse effects:
- the temporary adverse reactions, those which follow the treatment and cause the so called downtime (most of them will subside on their own accord),
- semi permanent adverse effects,
- and permanent.
Temporary adverse reactions.
The type of temporary adverse reactions vary according to the type of tattoo fading treatment. These are inevitable due to the very nature of the treatments. Most of them will not require any treatment, as they will subside on their own accord. Some of others, like inflammatory infections, will necessitate treatment. These temporary adverse reactions are:
- Discomfort and pain during treatment.
- Frosting (laser treatments).
- Minor bleeding.
- Immediate redness and swelling.
- Swelling and infections.
Discomfort and pain.
While a lot will depend on the individual pain threshold, it is fair to say that the majority of people undergoing the most popular tattoo fading treatments experience discomfort and pain if the appropriate numbing product is not applied on the tattoo in advance. The level of discomfort and pain also depends on where the tattoo is located and the type of tattoo fading treatment; tattoos on more fleshy areas of the body will hurt less as the flesh acts as a cushion, whereas tattoos on areas such as the wrist, feet, face and fingers could be more painful than if the tattoo were on the thigh!
Frosting, (during laser tattoo fading).
Frosting is a normal immediate reaction during tattoo laser fading treatments. The tattooed skin will naturally turn into frosty white colour. This is caused by the carbon dioxide being released as a result of laser burn which surfaces on the upper layer of the skin and usually subsides only after half an hour. The frosting is usually caused by higher frequencies that produce a superficial ablation of the skin. This is not normally caused by very low frequencies used in deep laser sin tightening (i.e. Fraxel laser treatments operating at over 10,000 nm). The frosting effect is also experienced during cryotherapy. Other tattoo fading treatments do not cause frosting.
Minor bleeding is a normal reaction to most professional tattoo fading treatments. In particular Laser, Plasma, surgical excision, Microdermabrasion and IPL. The bleeding is caused by the breakage of the small superficial capillaries in the dermis during the aesthetic treatment. Bleeding during the most popular tattoo fading treatments is minor and lasts only a few minutes. This occurs because any tattoo fading treatment in order to be effective has to include the ablation of the dermis. However in vast majority of cases bleeding is very unlikely to be severe and subsides only after a few minutes.
Immediate redness and minor swelling.
After the use of ablative treatments (i.e. laser, plasma, IPL), the area may turn red and become only slightly swollen a few moments and minutes after the treatment. Also this is the normal physiological immediate reaction to the skin burn caused by the particular tattoo fading treatment. The reddening and minor swelling only last a few hours and will subside on its own accord being replaced by the blistering (in case of laser treatment and IPL). This reaction is not a usually experienced using other types of tattoo fading treatments.
Certain fading treatments like Laser, Plasma, IPL rely on burning the tattoo in order to help fade it. Blistering is a physiological reaction to any type of burns therefore any treatments which cause an intentional burn of the skin will lead to some form of blistering. The blisters usually start forming the day following the treatment replacing the minor swelling and redness caused by the skin burn. Blistering does not require any treatment and will subside on its own accord. In order to reduce the blistering and the downtime associated with the burn caused by the treatment, ice packing and appropriate soothing products can be used to alleviate the adverse effects immediately after the tattoo fading treatment. Ice Packing and other soothing products should not be used after Plasma tattoo attenuation treatments. This is because the blistering experiences is not major after using Plasma.
Therefore blistering is a normal reaction and an indication that the healing process has begun. They might not look too pretty and could be tender to touch, but blisters should take between 3-14 days to heal up completely. Blisters must not be burst. Purposely bursting the blisters can interfere with the physiological healing process including increasing the likelihood of infections and consequently permanent scarring.
Yet another sign that the tattoo removal is working and healing is taking place. Scabbing is a typical part of the healing process after certain types of tattoo fading procedures. The scabbing process starts to develop two to three days after tattoo fading procedures using plasma (voltaic arcing), osmosis and micro dermabrasion. Scabs often contain fragmented ink particles. When the scabs fall off, the top layer of the ink will come off with it. Picking at or peeling off scabs can increase the risk of scarring, so however tempting it must be avoided. A lot will depend on the size, type, intensity of the treatment and location of the tattoo, however most scabs will fall off on their own accord within two weeks, provided there is no inflammatory infection under-way.
This should be seen as a good sign, as the immune system kicks in and starts to heal the affected area, also this is a sign that there is no ongoing infection. An itching sensation is common, but just like any other type of skin irritation, the client must not scratch the treated area. Scratching could impact on the effectiveness of removal and more importantly break the skin and cause a wound, which could increase the likelihood of infection and scarring. Generally, the client should not apply creams or lotions on the treated area. However in case the itching becomes unbearable the client should seek medical advice.
Swelling and Infections.
Our body’s natural defence system will react to things like illness or infection in a number of different ways. But while swelling usually occurs after being bitten by an insect or other inflammatory causes, it can also happen after undergoing tattoo fading treatments especially due to infections. Inflammatory infections can be easily contracted during the healing process due to the fact that the area is an open wound and like any other wound is exposed to several types of bacteria which cause infections.
Inflammatory infections are the main cause of permanent adverse reactions like scarring and permanent change in skin texture. After laser tattoo removal it is very important not to burst the blisters (which form a couple of days after the treatment) because this causes an open wound and puts the client at an increased exposure to infections. Usually the risks of inflammatory infections diminish as soon as the scabs begin to form. The risks of infections can be minimised but never completely avoided. The bast way to minimise the likelihood of contracting an inflammatory infection during the healing process it to keep the area clean and use the appropriate antiseptic products at regular intervals.
Permanent and semi-permanent adverse reactions.
Semi permanent adverse reactions.
The most common semi permanent adverse reactions is a temporary change in skin texture. This is a normal reaction to the skin regeneration process of skin resurfacing treatments. As it is well known, after skin resurfacing treatments the new skin has a pinkish colour and a slight different texture to the rest of the skin. The pinkish colour is due to the lack of pigmentation of the new skin. Over time the skin texture blends in with the rest of the skin and new pigments will form. This applies to all the tattoo fading techniques discussed in this web page including laser tattoo fading.
In other cases, in particular, with the use of Osmosis the common semi-permanent adverse reaction in those cases, especially where an infection has taken place, is a often temporary raised scar. This temporary raised scar usually lasts two to three months and in most cases this will subside over time and the area will blend with the surrounding skin.
Permanent adverse reactions.
The types of permanent adverse reactions can be: Scarring (or permanent change in skin texture), Keloidal formations, hyper-pigmentation and hypo-pigmentation (adverse reaction associate with laser treatments). These types of permanent adverse effects can occur despite the type of tattoo fading treatment carried out. In any case the likelihood of these inherent adverse effects can be minimised but never completely eliminated.
Permanent scarring is an inherent risk of any type of tattoo fading treatments, it can be minimised but never completely excluded. Rarely permanent scarring occurs due to the tattoo fading treatment alone. Permanent scarring is often caused by the damage inflicted by the infections contracted during the healing stage. Also in case of laser tattoo fading treatments the normal blisters must not be purposely burst as this also can increase the likelihood of complications especially infections. If the tattoo fading treatment lead to scabbing, the scabs must not be picked and must fall off on their own. If scarring does occur, it is not usually very noticeable and can be minimised with Vitamin E oil or over the counter silicone patches.
The risks of permanent scarring can never be completely eliminated, even if the tattoo fading procedure is carried out appropriately and the client follows the after-care instructions rigorously. This is because certain individuals are particularly prone to to developing some sort of scarring or permanent difference in skin texture. This is one of the reasons to carry out a patch test at consultation stage. Also some individuals may be prone to developing keloids and some may not even be aware of this predisposition.
Any tattoo fading treatment relies on a form of skin resurfacing, that may be done by means of burning the skin using lasers, electrical arcing, chemical peels etc. Whenever the skin is starting its physiological regeneration process and it is exposed to UV light sources, both natural or artificial, the normal skin reaction can be a hyper-pigmentation. This type of hyper-pigmentation is possible, not only following tattoo fading treatments but also, after any other type of skin resurfacing including cosmetic peels. Therefore cosmetic tattoos and permanent make-up may darken following tattoo fading treatments. Although further resurfacing treatments can fade the hyper-pigmentation away, hyper-pigmentation can be very challenging to resolve at times.
Hyper-pigmentation unfortunately is an inherent risk of any type of skin resurfacing treatment, therefore it can be minimised but never completely ruled out after tattoo fading treatments. The best way to minimise the likelihood of hyper-pigmentation is to avoid sun exposure including any source of UV light. The use of total sunscreen up to two months after the healing process should be mandatory. Please note that sun and UV light exposure must be avoided even while using total sun screen up to two months after the last treatment.
Hypo-pigmentation is a common adverse reaction to aesthetic laser treatments in general (including skin tightening, skin resurfacing etc) . This the potential risks of this permanent change in texture and colour can be minimised but never excluded after laser aesthetic treatments. Hypo-pigmentation is particularly common in darker skin tones (six, five and four) however it has been reported on lighter skin types (including one and two). This type of adverse reaction is prevalent only after tattoo laser fading treatments and they are very rare after other types of tattoo fading treatments.
Hyper-pigmentation is where over production of pigmentation occurs during the healing process, conversely hypo-pigmentation is where the skin’s normal pigmentation has been removed and new melanin cannot either permanently or temporarily be produced. Hence the hypo-pigmentation effect can be permanent or semi-permanent. It can sometimes take months or even years for your skin’s pigment to appear normal again. For some people, the skin texture may never be the same.
As a result of hypo-pigmentation, lighter patches of skin will be visible where the tattoo once was and on the area of the skin was treated by the laser. However, both hyper-pigmentation and hypo-pigmentation are bound to be more tolerable than the unwanted tattoo.
Most of the tattoo fading treatments are currently marketed as tattoo removal treatments. To date, the only procedure which can be correctly addressed as tattoo removal is Surgical Excision. Only tattoo surgical excision can guarantee the complete removal within one sessions only, the other techniques can fade the tattoo, however complete disappearance within one session cannot be guaranteed. In the vast majority of cases several sessions are required in order to achieve a satisfactory tattoo fading. Sometimes, the complete seamless (scar-free) removal of tattoos is not always possible using any conventional tattoo fading techniques currently available. In these case tattoo cover-up may be a good option after fading the tattoo as much as possible using most tattoo fading technique available.
Clients are keen to have an estimation of the number of treatments required to achieve their desired results. The number of sessions required can vary from as few as one in case of permanent make-up removal and can even require up to 10 or more sessions in case of resilient tattoos. The number of sessions required also depends the type of tattoo fading treatment as well as the intensity of the treatment. In order to make a realistic estimation, a patch test should be carried out to extrapolate this information from the degree of tattoo fading accomplished after the patch testing. Patch testing also reveals if the client can be susceptible to any particular type of inherent permanent adverse reactions to the particular tattoo fading procedure.
Although laser tattoo fading currently is the most popular “tattoo removal” procedure, there are also several other effective tattoo fading treatments available (i.e. Plasma, Plasma and Osmosis, Osmosis associated with other dermabasion treatments, microdermabrasion, IPL, Chemical peels, Croytherapy etc). Despite the method used to fade the tattoos, in case after a number of tattoo fading sessions, the degree of tattoo fading is only minimal tattoo removal by replacement may be the best option.