Ask the Doctor: Why should a physician remove my tattoo?

Laser tattoo removal (LTR) has seen enormous growth since the early 1990s.  It's no wonder, since the tattoo industry has been riding a high wave just ahead of the lasers.  Seeing great opportunity in erasing unwanted tattoos, people from all backgrounds--and some with no relevant background at all--have been purchasing Class IV medical lasers and aiming them at tattoos their owners are sometimes desperate to remove.

These days laser tattoo removal is being done mostly by Certified Laser Technicians operating as estheticians, RNs, Nurse Practitioners, and others having no college degrees or advanced training before obtaining their certification.  They can be found in spas, salons, dermatology/plastic surgery practices, esthetic laser centers, stand-alone laser tattoo removal establishments, and tattoo shops.  They can be extremely experienced and competent, especially if they work in a setting that performs only laser tattoo removal, without a long menu of other services.

But experience is only part of the equation.  LTR, done conscientiously, calls upon knowledge of physics, anatomy, physiology, and psychology.  The physics alone can be quite dizzying, but an in-depth knowledge of the physics is essential to understanding any laser's strengths and limitations.  One must also understand the physiologic responses to the kinds of energy to which the tissues are being subjected.  This knowledge not only guides the choice of safe, effective energy, but it also informs patient qualification, personalized aftercare plans--and pain control, a crucial aspect of LTR all too often ignored.

Many states have been slow to regulate LTR and other uses of medical-grade lasers.  Rhode Island and Massachusetts allow persons with no medical background or licensure to perform laser procedures as long as there is a medical director.  The responsibilities of the medical director, however, are poorly delineated.  For example, there is no requirement that he/she be on-site, nor is any supervision required.  Patient cases and charts need not be physician-reviewed.  Indeed, there is no expected standard of medical record-keeping.  Laser technicians are not mandated to carry professional liability insurance, nor are medical directors required to add LTR activities to their malpractice insurance policies.

In addition, there is little to no oversight to ensure that lasers and other devices are being used in the manner for which they were FDA approved.  This point is very important to consumers, since any use outside of a device's FDA approval is tantamount to experimentation, and a patient's skin should not be the target of anyone's experiment, except in a proper research study under full disclosure.

When a licensed medical professional performs your procedure, you benefit from many years of hard-fought, rigorous study.  Prescribing power means better pain control, and therefore greatly improved satisfaction.  Extensive study of biostatistics confers a respect for sound, evidence-based practice.   With a State Licensing Board to answer to, higher quality is maintained through accountability.  Looking beyond that, a physician is ethically bound to take your well-being seriously.

A physician who will perform your procedure personally, while rare outside of the Providence area, is worth the search and will not necessarily cost more than a technician.  It's very important to shop thoroughly and ask the tough questions.

I believe that when a medical-grade laser is being used, a medical procedure is being performed.  Whether State and local regulators agree does not affect the importance of your skin and the knowledgable care it deserves.


Richard Rosol, MD, owns and operates TattooMedics Laser Tattoo Removal, in Providence, Rhode Island.

Ask the Doctor: Does laser tattoo removal hurt?

Yes.*




* But it doesn't have to.

It's on everyone's mind.  The pain.  People have described it as "a rubber band snapping on your skin," and "a spatter of hot bacon grease."  If that sounds harmless enough, imagine it happening ten times per second.  Even though the average tattoo we see here at TattooMedics takes less than one minute to treat, the pain would get old fast if it weren't for the prescription-strength numbing we provide.  It's called EMLA cream, a mixture of two local anesthetics absorbed extremely well into the skin.  EMLA is very safe and is tolerated well by just about everyone.

Does it work?  To answer that question, let's back up a bit to how laser tattoo removal works.  In tattooing, colored mineral crystals are injected 1 to 2 millimeters into the skin's live layer, or dermis.  Most of the crystals are too large for the body to deal with, so there they stay, permanently embedded.  Laser tattoo removal shatters these crystals into fragments small enough to be cleared safely and naturally by the body.  Our PicoSure laser accomplishes this very efficiently and without an excess of heat.  No skin is ever broken in the process, and there's never a burn.

So, if there's no breaking of skin and no burning, why does it hurt?

It's the explosion of ink crystals.  Even though it happens on an extremely tiny scale, there's a lot of it happening at once.  The brisk snap! heard when a tattoo is lasered is literally this summation of minuscule explosions.  That sound--and the sensation associated with it--is proof positive that ink is being destroyed and the tattoo is not long for this world.

The good news is that we can greatly reduce the pain.  With proper application of EMLA and the addition of ice-pack cooling, most patients report anything from trivial to moderate pain.  That's a lot better than "ten times worse than getting a tattoo," and having to stop and take frequent breaks.  With EMLA on board, patients only rarely ask for a break, and the procedure is over before they know it.  They leave smiling every time.

Score another point for EMLA!

Dr. Richard Rosol owns TattooMedics and personally performs all procedures.

Ask the Doctor: What is hypopigmentation?

Sometimes when we remove a tattoo, the underlying skin lightens in a phenomenon called post-inflammatory hypopigmentation. More common in people with darker complexions, the skin can react to even the mildest inflammation with a temporary dormancy of the cellular machinery responsible for production of melanin, the skin's natural pigment.

The photograph above is a textbook example of the hypopigmentation sometimes seen in laser tattoo removal. The process is completely unrelated to that of scarring, which is extremely rare with the PicoSure laser in experienced hands. The affected skin is supple and smooth--only lighter in color. This can actually be beneficial in laser tattoo removal, which works even better when there is less melanin in the treatment area.

Hypopigmentation of this kind does resolve on its own once treatments are completed, but the restoration of natural skin color can take an average of one year. During the wait, a touch-up with the right foundation can make it nearly unnoticeable. For military qualification hypopigmentation is a non-issue: The only thing that matters to recruiters is that all tattoo pigment be gone.

Follow our blog for more answers to frequently asked questions. If you have a question of your own you'd like to see us address, please contact us!

Our story begins in the Italian Alps...

Over five thousand years ago, a Neolithic man, shot through the shoulder by an arrow, apparently escaped his attackers only to die alone on a frozen mountaintop in the Italian Alps.  This man, affectionately named Ötzi, bears on his naturally mummified skin the earliest known symbolic tattoos.  No anchors or mermaids, these tattoos, but bizarre and arcane markings.

The practice caught fire and sprang up on all corners of the globe.  Whether tribal or spiritual ritual, or mere decoration, tattooing has left an indelible mark on human history.  A tattoo became a snapshot of a moment in the life of its host, writ permanent, and taken to the grave.

For most of the tattoo’s history, one can speculate that the same human ingenuity has been working on the problem of removal.  All kinds of frightening and almost unmentionable methods have been attempted to remove tattoos.  To succeed, it seemed, one had to remove the very skin into which the tattoo was embedded.  Most methods were variations on that simple and painful theme.

Then came the laser.

In the 1990s the first lasers developed for laser tattoo removal became commercially available.  Their aim was to fragment tattoo pigment crystals, leaving skin as undisturbed as possible.  Those Q-switched lasers reigned as the first–and only–laser solution to tattoo removal.  Still, the pulse was long, pumping a lot of heat into the pigment and surrounding tissues.  In the wrong hands, burns and scars are easily inflicted.

Enter the PicoSure.

In 2012 technology took its first giant leap forward in decades.  The PicoSure laser, with a pulse 100 times shorter than its Q-switched ancestors, could target tattoo pigment more specifically while drastically reducing the amount of heat released into surrounding tissues.  The PicoSure is especially strong in the black/blue/green and can remove these colors in significantly fewer treatments.

In 2016 tattoos can be removed completely, without scarring or “ghosting.”  Skin is left clear and with normal texture to be displayed proudly–or re-tattooed!  When laser tattoo removal is performed by a physician, comfort becomes a major priority (thanks Hippocratic Oath!), so there is no need to experience the pain so commonly associated with the procedure.

After over 5 millennia of tattooing, we are fortunate to live in the age of complete tattoo removal, where no tattoo is truly an irreversible mistake.