How Does Tattoo Removal Work in 2020?
The topic of tattoos is one that’s openly discussed, celebrated, and enjoyed around the world, but tattoo removal in 2020? That’s quite often a different story. We cut through the complicated jargon and false information to break it down for you. We’ll first outline the history of tattoo removal, be it laser removal or other more prehistoric techniques, before moving on to how laser tattoo removal became the norm today and what it entails. We’ll cover everything from the stages of tattoo removal, to the safety of it, along with what we can expect in the future.
History of tattoo removal
Tattooing itself is nothing new - it’s a practise that actually dates back over five thousand years. Over history, tattooing has indicated social ranking in many cultures; often being used to mark or brand slaves and sex trafficking victims, so that they’re identified by their slave owners. It has also been used to show political status, as well as religious authority. While modern laser tattoo removal is a new and innovative process, tattoo removal, in some forms, dates back as far as tattoos themselves. In modern days, these methods would be considered quite barbaric, and thankfully they no longer exist.
One form of removal named ‘Tissue Expanderin’, for example, involved inserting a balloon under the skin and inflating it, to stretch then cut the tattooed area. A skin graft would then be taken to cover the removal; although it’s unlikely this would be done in a sanitized, surgical environment in ancient times!
Other techniques included microdermabrasion (where the face is sprayed with exfoliant crystals to remove dead epidermal cells) and even cryogenics, which involves freezing off the tattooed area. The earliest recorded form of tattoo removal was by Greek Physician Aetius, back in 543 AD. He used ‘Salabrasion,’ which basically saw coarse grains of table salt and a moist gauze pad abrading the skin until it reached the dermis and thus, the ink of the tattoo. As well as being a very painful process, the chances of scarring and pigmentation were extremely high when using this method. In short, ancient techniques were pretty horrendous, and entirely unsafe.
This all began to change with the advent of lasers — and even those have come a long way since their first inception. It all began in 1967, when Dr. Leon Goldman utilised a 694 Ruby laser and an ND: YAG laser to remove a tattoo. This was followed by CO2 lasers in the 1980s (which required general anaesthesia due to how painful they were), and finally short-pulsed lasers in the 1990s, which were far more effective and didn’t result in as many scarring and pigmentation issues. This was in part due to the theory of selective photothermolysis (created by Dr. Rox Anderson M.D. and John A. Parrish, M.D.), which enabled those removing tattoos to select tissue and use a specific wavelength of light to target said specific tissue. Short-pulsed lasers are still widely used today.
Since the ‘90s, laser removal has come on leaps and bounds thanks to increased investment and focus on technology, research, and training. However, as Fraser Watt, a physicist from King’s College London, points out, ‘in general it takes quite a long time for the commercial market to catch up with the latest technology being developed by laser system manufacturers.’ The most advanced and breakthrough technology being developed in scientific labs doesn’t tend to quickly make its way to the commercial market, meaning some laser tattoo removal offerings today are dated.
Types of tattoo removal
While tattoo removal has come far, ‘tattoo regret’ has continued to be a very real and relevant phenomenon. One survey found that a huge 78% of tattooed people regret at least one of their tattoos. To target this regret, there are several forms of tattoo removal available; and by far the most commonly used method is laser tattoo removal. Lasers work by using highly concentrated light waves to break down ink particles in the skin, which are then cleared away by the immune system. (Read more about this here).
Perhaps surprisingly, some older tattoo removal techniques are still around today, as well as the humble lasering approach. Dermabrasion, for example, remains an option. It uses a medical grinding tool to remove the outer layers of skin until the tattoo is also removed. Dermabrasion can be very painful, meaning an anaesthetic of some form is needed. It can also result in considerable scarring. Dermabrasion is now more commonly used as a beauty treatment, in which tiny crystals or other exfoliating substances are used to remove the top layer of dead skin cells on your face. The body then interprets this as an injury of sorts, and replaces the layer with a brand new, fresh one. This can often result in smoother, more radiant skin.
Surgical excision is another extreme method which is still available. It requires some form of anaesthetic, and sees the tattoo being cut out in surgery, before the skin surrounding the area is pulled together. This is actually a technique that is still available today in clinics, but it is perhaps a more extreme method so should be considered carefully. Excision is much more suited to smaller tattoos, as a surgeon can more easily cut the inked area away and patch up the area by stitching the surrounding healthy skin together. Using this method for larger tattoos can be more difficult when it comes to replacing the lost skin; usually a skin graft must be taken making it a more serious, long lasting procedure on the whole.
Lastly, the chemical peel; the premise of this treatment being to exfoliate the upper layers of dead skin to improve texture and luminosity. When it comes to removing ink, the process is slightly more hardcore, using Trichloroacetic acid (TCA) to remove the outer layers of skin, including the inked portion. It’s a hugely painful and unsafe way of removing a tattoo, and can cause blistering, scarring, or severe discolouration of the area. It’s not recommended for those with darker skin tones, as the lightening effects are unpredictable. TCA can even now be bought in pharmacies or online, although it is highly recommended not to try this at home and instead seek a tattoo removal professional first. TCA also isn’t that reliable; over time (between 3-6 treatments, each with 4-6 week intervals in-between), it can gradually lighten a tattoo, but rarely removes it completely.
Laser tattoo removal technology
To understand how lasers work, it’s crucial to get your head around what tattoos actually are first. When you have a tattoo done, molecules of ink are inserted directly into the dermis; the second layer of skin beneath the epidermis. Our bodies’ immune system, being the smart thing it is, quickly detect the ink as a foreign body, and send white blood cells to attack it.
Unfortunately for the white blood cells (but fortunately for tattoo lovers), ink molecules can be up to 100x the size of white blood cells, so the cells don’t really stand a chance. This is how they become permanent - aside from some gradual breaking down and fading over time. Lasers, however, have been developed to effectively break down ink molecules, making them small enough to be processed by the immune system.
‘The overall state of tattoo removal technology is extremely varied,’ explains Watt. In laser tattoo removal, there are a couple of different lasers that are most commonly used, which offer different approaches to removing a tattoo. The most common right now are q-switched lasers, which generate nanosecond pulses (each pulse lasting 0.0000000001 seconds), using very high energies.
The pulses that come from the lasers heat up the ink in a tattoo, often to temperatures of up to thousands of degrees. This energy expands and eventually breaks apart the tattoo ink molecules for the white blood cells in surrounding areas to remove them through the lymphatic system. While this may sound impressive, this excess heat that gets trapped can ‘leak’ out into the surrounding skin, which can cause pain and damage. The laser can also cause what’s known as ‘frosting’: a temporary white bubbling effect on the skin which is caused by bubbles of carbon dioxide produced by the laser’s effect floating to the top layer of skin.
Then there’s the pico-second lasers - slightly newer technology. They also use very fast pulses to transfer energy, but pico-lasers release energy in (as their name suggests) picoseconds, which are the equivalent to 1000 nanoseconds, which Q-switched lasers run at. Therefore with pico-second lasers, energy can be released in a shorter time frame, meaning potentially less time for burning or other side effects. The pulses in pico-second lasers cause shockwaves in the skin (called a photoacoustic effect) to shatter ink molecules, which are then removed by white blood cells in your body.
Watt explains that these ‘generally produce better results’ but that they can also result in skin damage. Unfortunately, this means most people need to take 6-8 week breaks between sessions to allow the skin to recover, so if you’re in need of a speedy removal process, it’s not the one to go for. These lasers can also cause some of the same side effects as q-switched lasers, with burns, pain and frosting being fairly common.
Laser tattoo removal can really vary in price, depending on where you go, who does the procedure, and where you live. In the UK, you’ll usually pay around £150-£800 per session, meaning the longer it takes to remove your ink, the more it can set you back financially.
NAAMA laser tattoo removal technology
NAAMA uses extremely low energy lasers (1000x less energy than some current systems). This may seem like the lasers would therefore be less effective, but NAAMA pairs this with pulsing up to 1000x faster than traditional methods of laser tattoo removal. This means that ink molecules are broken down far more quickly, and with no excess of energy, and this pairing results in far less energy escaping to surrounding areas and causing damage.
NAAMA lasers are also very precise, being able to hone in on specific areas of skin, and deliver energy in a more controlled, uniform way which limits exposure to untattooed skin. The tattooed skin, and only this skin, will be targeted, meaning less pain and a much shorter recovery time overall.
As well as protecting healthy skin, this approach allows the laser beam to interact more effectively with ink, breaking it down faster, and enabling it to work well on even coloured ink too (this is notoriously difficult with other technology).
The main benefits of NAAMA is that it doesn’t result in any long-term damage to skin, protecting your skin from burns and scarring. This allows for more regular treatment, as well as two treatments per removal session. The lasers can actually be used twice in one session, and sessions can be spaced out by as little as 1 week , rather than up to 8 weeks.
Stages of tattoo removal
For all laser tattoo removal, you should expect to first speak to a knowledgeable, trained technician or member of the team prior to having your first treatment. When you’re happy and comfortable with your consultation, the first step is to have your tattoo mapped and photographed with specialist equipment, named dermatoscopy.
Dermatoscopy uses a dermatoscope, which is a diagnostic instrument for observing changes in the skin, and ones that we would usually not be able to see with the naked eye. It is also used to monitor skin lesions and moles, as it is able to magnify the area and uses polarized and unpolarized light to increase the field of view and thus track skin pigmentation.
This ensures there will be a close monitoring of your progress between each session. Sometimes, you will be able to see the difference in your tattoo after a session, however other times, it may not be as clear. The dermatoscopy process will allow you to understand how your tattoo is fading, even if you cannot see it every session to session.
A patch test will be performed with the laser prior to all-over use (just to make sure you don’t suffer any adverse reactions - this is very rare), which is an important step in the whole process. Several spots of your tattoo will be lasered in order to see which colours, lines and shapes will react well.
The entire initial assessment process usually lasts around one hour, and as well as having your tattoo photographed and your patch test, this is an ideal time to ask all the questions you may have about the upcoming process. You can ask about the impact of any medical issues or history which you may have (which you must discuss with the person removing your tattoo), and discuss the estimated removal length, how many sessions, and what you wish your end result to actually be (ie. partly gone, fully disappeared etc?).
After this, and as long as the patch test results are clear, you can begin your removal process 24 hours later.
Here we’ve broken down the steps of the scientific process, from the start of the tattoo’s life to its end:
- Ink is injected into the skin (when you get a tattoo)
Some of the ink particles are small and are quickly cleared away by the body’s immune response, and other ink particles escape from the skin through leakage or shedding (this is why tattoos often initially fade)
The majority of the ink particles are too large to be cleared away and become trapped in the dermis (this is why tattoos are permanent)
Laser tattoo removal breaks down tattoo ink particles by applying intense light to the ink
As ink absorbs this light energy, particles break down, becoming smaller
Smaller particles are then removed by the immune system
It is important that throughout the treatment and after it is finished, you really take care of your tattoo, as well as your health in general to ensure everything heals well and effectively. Staying out of the sun and trying to boost your immune system are two crucial steps that should be followed by all. The sun’s damaging UV rays can alter the process by affecting the pigment of your skin, and the laser process also results in more sun sensitivity, so you should stay in the shade during your treatment, and continue to wear high SPF 30-50 afterwards.
The immune system, as mentioned, plays a huge part in removing the ink particles which are broken down by the laser. For this reason, it’s crucial to take steps such as drinking lots of water, exercising, avoiding smoking, and de-stressing to help things along.
When it comes to aftercare with the tattooed area, ensure you are keeping it clean at all times. Give it a gentle wash with water and a scent-free cleanser twice daily, and apply a hydrating aftercare cream (again, something that is fragrance-free) on gently afterwards. It’s best to wear loose-fitting clothes around the treated area, too, along with applying waterproof dressings and hydrogels that maintain a healing environment for the skin while still allowing air in.
How many sessions does it take to remove a tattoo?
So we know how the whole process works, but in general, how long does it take to remove a tattoo? ‘It varies from person to person and is impossible to predict,’ says Dr Fiona Worsnop, NHS & Harley Street Consultant Dermatologist. ‘It’s affected by both people factors and ink factors. In terms of people factors, each individual is different and will respond differently to the removal process,’ she adds.
The skin of the person undergoing removal is a big factor; things like the skin’s texture (smooth or textured), laxity (whether skin is tight or loose), hydration, and collagen concentration should all be taken into consideration and will cause the session lengths to vary. One step anyone undergoing treatment should take, says Worsnop, is to avoid the sun throughout treatment, and afterwards. ‘This can have a big impact on reducing redness after treatment - and generally improves outcomes,’ she explains.
Then there’s lifestyle factors. Those with weaker immune systems may find it takes longer, as your white blood cells are needed to remove the broken down ink particles. Worsnop recommends trying to quit or reduce smoking while undergoing removal, which can aid wound removal and help your immune system behave more efficiently. Other steps you can take are to maintain a healthy diet and exercise routine, get enough sleep, and drink lots of water, while attempting to live as stress-free as possible!
As well as the person themselves, the length of the removal process undoubtedly depends on the tattoo itself, too; namely the amount of time you’ve had your ink for. ‘It can be more tricky to remove older tattoos,’ explains Worsnop. ‘From the moment you have a tattoo and ink is injected into the dermis of the skin, the body works hard to try and clear it, as it recognises it is a foreign substance. Over time tattoos can fade; the ink which remains may not have cleared as it becomes trapped in cells. The ink can also move deeper in the dermis of the skin, making it harder to reach with the laser.’ This doesn’t necessarily mean that older tattoos are always harder to remove, but this can play a part.
Other factors to consider involve the tattoo itself; its location, ink and the techniques to apply it in the first place. ‘Unfortunately, the ink that can be used in tattoos is poorly regulated, and often a mix of different chemicals, some of which are easier to remove than others,’ notes Worsnop, before adding that different tattoo artists’ ‘techniques’ will also impact the session lengths, particularly if there has been layered shading. Contrary to popular belief, darker inks usually aren’t the problem; it’s the lighter shades and certain colours that lasers can sometimes struggle with.
Finally, there’s which method of laser tattoo removal you go for. Full removal could take as little as 4 months (2-3 months for a fade) with newer, lower energy options, or as long as 1-2 years (10-12 months for a fade) with more traditional options that require more healing time for the skin. Overall, it’s a gradual process that requires a little patience - you won’t see results overnight.
Is tattoo removal safe?
On the whole, tattoo removal is regarded as a safe treatment; a claim which is supported by the NHS: ‘Having a tattoo removed is usually safe if it's done by an experienced and suitably qualified practitioner.’ Newer technology in particular is designed to lessen side effects such as burns or skin damage and is regulated through the CE Mark (in Europe) or FDA approval (in the US). It’s wise to make sure the device you’re treated with has either the CE Mark or FDA approval - the clinic should be able to let you know. This ensures the clinic has done due diligence and is using equipment approved as a very safe form of tattoo removal.
You should also be checking the laser technician who will be treating you has the adequate qualifications to be practising laser tattoo removal safely. They should be trained in laser tattoo removal specifically; not just lasers in general. The NHS recommends the same. Check your technician has an NVQ level 3 for Beauty Therapy and have also completed CPD (Continued Professional Development). At the very minimum, they should have completed 3 days of CPD, although the most reputable technicians will have completed 10 days - we’d recommend looking out for this. The NHS has a guide on choosing who will do your cosmetic procedure which you can find here which details how to find someone reputable for all cosmetic procedures (although it has to be noted, not specifically laser tattoo removal).
Unfortunately, this is not always the case with all laser tattoo removal, which is perhaps the biggest factor to be wary of when researching who to go to to have your tattoo removed. The true dangers of tattoo removal come from badly designed and maintained machines used by poorly trained technicians. When used in this way, machines can cause severe burns, permanent damage and ineffective removal.
The regulations on laser tattoo removal are also widely viewed as dense, and difficult to decipher, meaning they can be interpreted - and thus potentially exploited - in different ways. For example, mistakes can include using the laser too closely to the skin, or on too high of a setting, both of which can cause damage. If not done properly and safely, side effects can be serious, ranging from scarring and blistering, to burns and sickness (but of course, at the many clinics who practise laser tattoo removal safely, this isn’t the case - the treatment is perfectly OK for your skin).
There are certain people for whom laser tattoo removal is generally considered unsafe. This is because of certain health conditions, or prescribed medications, and is defined slightly differently amongst different clinics. NAAMA’s list of those unsuitable for treatment includes:
Active skin infections/disease in the area to be treated
Use of Roaccutane (accutane) or oral Retin A within 6 months
Recent UV exposure of the treated area (including tanning)
There are also groups of people who should exercise caution when considering laser tattoo removal, and will often require a doctor’s note at most reputable clinics:
Pigmentation disorders (Psoriasis, Melasma, Vitiligo, Hypopigmentation or Hyperpigmentation)
Pregnancy and breastfeeding
Heart disease, diabetes, angina
Scarring conditions (ie Keloid scarring)
Bleeding disorders and anticoagulant drugs
Blood borne infections (hepatitis or HIV/AIDS)
Most place importance on avoiding tattoos if you have skin hyper-sensitivity, scarring (keloids), skin infections, or are prone to cold sores (herpes). If you are unsure whether you have a condition which may affect your eligibility to have your tattoo removed, it’s best to contact your doctor to ask first.
For most, however, laser tattoo removal is safe - just make sure you do your research, and choose a clinic with expert, experience, training and up-to-date technology.
The future of tattoo removal
It’s tricky to predict exactly how tattoo removal will advance and change over the years, but with tattooing ever-growing in popularity, and newer low energy lasers making ink removal easier than ever, it’s bound to become far more common. When laser tattoo removal first came to market, it targeted hardcore tattoo regretters who hated their ink - that’s simply not the case today. As the technology, and whole experience, of laser tattoo removal evolves, more people are likely to consider it an option. Not necessarily because more people will suddenly want to remove or change their body art, but because it will be so much easier to do so.
With new businesses launching with game-changing technology, combined with a personalised and premium tattoo removal experience, the global demand for tattoo removal in a safe and fuss-free space will likely grow.
New creations such as removable ink, for example, may even impact the frequency in which we turn to tattoo removal. New York startup Ephemeral aims to develop an ink which will fade within a year, giving a whole new meaning to semi-permanent tattoos. Companies such as this play into the belief that for many of us, our taste and experiences will shape the tattoos we want on our bodies over the years, and make the possibility of change and evolution possible.
Then there’s removal technologies themselves; The Brain Tool Laboratory at Duke University, for example, is looking to develop robots with tiny lasers that can remove your tattoo! These aim to make the laser removal process more precise, as the tiny lasers can target more specific areas, without damaging surrounding skin.
NAAMA is aiming to shape the future of tattoo removal both with different technology, and a different approach to the way we discuss it. The spaces are welcoming, with more of a member’s club feel rather than a clinical doctor’s office, and the staff are non-critical and understanding - they’re non-judgmental, and embrace the evolution of body art, and how it can grow and change with you. It’s hard to predict how the entire world of tattoo removal will evolve over the next few decades, but with NAAMA’s innovate technology so much more advanced than most, removing ink quickly, effectively and in a way that’s damage-free, they’re sure to be a big part of it.