Introduction
Tattooing has been around since the dawn of time, so has the propensity for humans to change their minds, so not surprisingly methods of removal have been around for as long as tattoos themselves.
Recent studies indicate as many as one in four tattooed Australians want to have at least one removed. The question is: What is the best method to remove tattoos without leaving a scar? We examine what a scarring is, six ways of removing a tattoo and each of their risks for scarring below.
What is a scar?
A scar is: “A mark left on the skin or within body tissue where a wound, burn, or sore has not healed completely, and fibrous connective tissue has developed” (https://en.oxforddictionaries.com/definition/scar)
Who is at most risk of scarring and why?
As a general rule, the risk of scarring increases in thin skin. The location of the wound is therefore important when considering the potential for scarring. For example, you would expect there to a greater risk of scarring on your chest than on the palm of your hand.
It is worthwhile keeping in mind that all treatments which break the skin carry with them a risk of scarring. The risk increases if the wound transects a joint (for example a shoulder), skin creases, (for example at the back of the knee), or major muscle groups, (for example the lower abdomen). Scars may also result from an infection in a wound.
Young children and young adults are prone to scarring from traumatic injuries because their bodies usually heal more vigorously. As a result, these individuals can develop thick, pink scars; however, these will often fade as the young person ages.
Adults do not tend to scar in the same way as children. Their wounds are not likely to be as affected by skin tension. Scars in adults do, however, tend to react more to UV rays, which can lead to noticeable pigment changes.
Abnormal scarring
Visible scarring is a natural part of the body’s healing process when there has been an injury to the skin. Scar types can vary over a broad spectrum; however, abnormal scars can cause psychological distress, are often aesthetically displeasing and can cause impediments in physical functioning.
In general, people with very fair and very dark skin tones may be prone to abnormal scarring.
One of the more well-known types of abnormal scars is a keloid scar. Keloid scars can occur in individuals of all ages. Keloids develop due to an overgrowth of collagen in the wound site which causes dense, fibrous scar tissue to grow outside the borders of the original wound. Keloid scars tend to take on a red or purplish tone. There is some evidence that keloid scarring is hereditary, so people who have family members with keloid scars are at greater risk than the general public. Studies have found that individuals with darker skin types are more prone to keloid scarring, as are people between ten and thirty years of age.
Wounds which reach deep into the dermis may result in hypertrophic scarring. Like keloid scars, hypertrophic scars are caused by an overgrowth of collagen. They appear raised and red. However, unlike keloid scars, they are confined to the original wound site.
6 ways to remove a tattoo and their risks for scarring
1. Micro Dermabrasion
Therapists using this technique use an abrasive device, such as a brush or a diamond wheel, to sand down the skin until the epidermis and the ink-containing layers of the dermis are removed.
People can achieve dermabrasion at home using substances such as brown sugar crystals, powdered pumice and ground down apricot kernels.
This treatment is incredibly painful. Patients are given strong anaesthesia when the procedure is performed in a clinical situation.
Due to the aggressive nature of the treatment, more than one session is required to remove the tattoo. This technique is not suitable for large tattoos and is limited in its ability to remove tattoos with heavily impregnated ink or tattoos with complex colours or shades.
There is a massive risk of scarring and infection, compared with other tattoo removal techniques, due to the sheer volume of exposed flesh resulting from treatment. Healing time is also longer than other treatment methods. Aftercare is therefore critical to avoid infections which can lead to scarring.
The treatment provider's skills and abilities are paramount for a successful outcome from this procedure. The method is not precise. It is very easy for the abrasive brush or diamond wheel to take away more skin than is required to remove the tattoo.
This technique is not recommended for people prone to abnormal scarring, as most people experience scars in the treatment area as a result of this procedure.
Microdermabrasion is not a preferred method among tattoo removal professionals. We do not recommend this technique if you are worried about scarring.
2. Salabrasion
The technique is similar to microdermabrasion, however granular salt and water are used instead of a diamond wheel or an abrasive brush.
In-clinic professionals blast a salt and water mix onto the skin.
People also achieve salabrasion at home by using salt and a sponge.
Salabrasion strips away the outer layers of skin. The technique is repeated every few days until the scarred tissue sloughs off, supposedly leaving healthy tissue underneath. Salabrasion, like dermabrasion, is incredibly painful and as such professionals use robust local anaesthesia when performing treatment in a clinical situation.
Like dermabrasion, there is a substantially elevated risk of scarring and infection, compared with other tattoo removal methods, due to the stripping away of the dermis and part of the epidermis, which forms the body’s protective cover.
Like microdermabrasion, this technique is not recommended for people who may be prone to abnormal scarring because most people scar as a result of this procedure.
Again, this is not a preferred removal method among professionals in the tattoo removal industry. We do not recommend this technique if you are worried about scarring.
3. Chemical/Acid peel
This procedure involves using acid or other chemicals to burn away the layers of skin holding the tattoo ink pigments. This procedure has the advantage of removing the tattoo in one session. The disadvantage is this technique will almost certainly result in a scar which looks like a burn. The nature of this treatment does not make it suitable to remove large tattoos.
There is a substantially increased chance of infection and hence greater scarring, due to the depth of the wound and the exposed flesh. Aftercare is therefore critical to minimise the appearance of scarring.
Chemical/ acid peels are not a preferred methods to remove tattoos due to the highly aggressive nature of the treatment, which is certain to leave a scar and presents a greater risk of infection during the aftercare period.
At the risk of sounding like a broken record, we do not recommend this technique for people prone to abnormal scarring or for those worried about scarring as a result of their tattoo removal procedure.
4. Surgical excision
Surgical removal was a viable and popular method to remove tattoos before the new breed of lasers was released.
While the treatment is extremely invasive, it is effective. A medical surgeon completely cuts away the tattooed skin and stitches up the resulting wound. At one stage surgical removal was the only guaranteed way of achieving a successful removal.
This technique is not suitable for large tattoos. While we have heard of examples where large tattoos have been removed using this method, we don’t recommend it. In one case a patient was subjected to several surgeries because the tattoo was so large the surgeon had no option but to break the removal process up into sections. In this case, the surgeon excised a section of the tattoo and then stitched up the wound. He allowed time for the wound to heal and the skin to stretch, before performing the process all over again. The surgeon repeated this procedure until the tattoo was completely removed. As you can imagine, the process left large, angry scar on the patient.
The effectiveness of surgical removal depends on the size and location of the tattoo. For example, tattoos removed from an area of the body with stretched skin, for example, the scalp, may not be as suitable for the procedure, or enjoy the same results, as other regions of the body, such as the forearm.
Professional tattoo removalists do not recommend this method. The technique is incredibly invasive and requires the patient to have surgery under a general anaesthetic.
Scarring is almost certain to occur; however, the level of scarring will often depend on the location of the removal, the size of the tattoo, and the skill of the surgeon’s hand with stitching.
5. Other home remedies
There are a variety of sites on the internet espousing their home remedies as "miracle, cure-all" tattoo removal methods. The advantage of these methods is cost, which is just a fraction of what a professional removalist would charge.
As much as we would like these methods to be effective (tattoo removal can take awhile, and the procedures can be painful), the reality is they don't work. Home remedies, such as using compounds of Aloe vera, paederia tomentosa and vitamin E, using lemon juice and even using honey to remove tattoos, are simply not effective.
While these "remedies" may marginally fade tattoos, they will never remove them completely.
6. Laser Tattoo removal
Even though medical research has been conducted into the use of lasers to remove tattoos since the 1960s, it was not really until the new breed of lasers emerged in the early 2000s that it became a popular and viable competitor to the other removal methods discussed above.
Can all lasers safely treat tattoos?
It is important to remember not all lasers are suitable for removing tattoos. If you think of the laser beam as being a key and the ink as being a lock, you need to ensure you have the right key for the right lock.
Unfortunately, in recent years there have been some occurrences of people trying to use improper equipment, such as intense light pulse light (“IPL”) lasers, for tattoo removal. This equipment, in particular, the IPL lasers, simply do not have the correct treatment parameters for tattoo removal. Attempts to use this machine for tattoo removal have resulted in significant scars to a few unfortunate individuals.
The new wave of tattoo removal lasers
While it is true, the first lasers used for tattoo removal had a tendency to leave scars, this is no longer the case. The new breed of lasers, particularly those manufactured after 2006, represent a quantum leap in laser tattoo removal treatment. Nowadays the lasers used for tattoo removal can selectively treat targeted structures without damaging any of the surrounding tissue.
There are several different types of tattoo removal lasers in the market, however Q-Switch Nd: Yag lasers are considered by industry professionals to be the gold standard in tattoo removal modalities. As such we will focus the rest of our discussion on these machines.
It is very rare to develop scarring as a result of treatment from a Q-Switch Nd:Yag laser, however in some rare cases it can occur. It is therefore important to be informed about the risk of scarring and the ways scars could occur as a result of a laser tattoo removal treatment.
Like “Oils ain’t oils”, “lasers ain’t lasers.”
While the Q-Switched Nd: Yag lasers are considered the gold standard in tattoo removal, it is important to remember as with most things there is a sliding scale of quality found in the breadth of machines available on the market.
We recommend you research the types of lasers your local service providers have. Not all tattoo removal lasers were created equal, and it is worthwhile noting the more even the beam profile (which tends to be the case in the European and American manufactured lasers) the less chance you have of getting a scar from the procedure.
Go to a qualified technician, preferably a specialist
Make sure your service provider is trained, qualified and experienced in tattoo removal procedures.
Not all states in Australia are regulated. It is therefore imperative for you to do your research in non-regulated states, such as New South Wales, Victoria and South Australia, on the treatment providers in your area and their skills and experience in this industry.
Thankfully, Queensland, where we are based, is heavily regulated and treatment providers have to undergo extensive training before being certified to treat people without supervision. Of course, not all technicians are equal, however, in Queensland, you can at least rest assured the certified technicians have a decent standard of training and experience.
We also recommend you use a treatment provider who is a dedicated tattoo removal specialist, rather than go to a beauty spa which offers a myriad of services, most of which are not applicable to the practice of tattoo removal.
A specialist knows tattoos and how to remove them efficiently and safely. Given one of the focuses of this article is the risks for scarring, we would say a tattoo removal specialist would be more aware of and attuned to these risks in tattoo removal than, say a beauty therapist who offers an expansive menu of treatments, with tattoo removal only being one of them.
In this regard, it is important to know that over-treatment during your laser session could result in breaks in the skin with pin point bleeding or excessive blistering, both of which can have the potential to lead to scars on the treatment site.
An excellent clinician will often see risks and manage for them. It is our practice to make sure our clients leave the clinic with their treated area in a sterile state (with antiseptic powder or ointment and dressing applied). We think this is just good practice given the greatest risk of scarring from laser tattoo removal treatments comes from infection in the aftercare phase.
Avoid infections at all costs
To our mind, the biggest risk for scarring comes from any infections following treatment. It is therefore imperative for you to follow any aftercare instructions given to you by your treatment provider.
These instructions should provide you all the information you need to avoid infections, and hence prevent scarring. Make sure you discuss any concerns or queries you may have about the aftercare instructions with your treatment provider.
Aftercare materials are essential
Some treatment providers will offer their clients aftercare packs (we do!). Make sure the packages contain all you need to ensure you have ease of aftercare, for example, our kits typically include, Bepanthan, Saline, Prontosan, tape, dressings, gloves, cream applicators and moisturising cream.
We recommend you make sure you get value for money in your aftercare needs. Sometimes you will be recommended a product which will go out of date before you have finished using it. Where possible, buy small tubes of ointment, because the active aftercare wound management period following treatment should be minimal.
If in doubt talk to your doctor or treatment provider
Finally, if you have any concerns at all, or if you are healing in a way which is not usual for you, make sure you contact your treatment provider or your doctor. Don’t put it off. Just remember, infections can lead to scars.
Conclusion
Of the six methods investigated, laser tattoo removal with a Q-Switched Nd: Yag device is by far the best method for tattoo removal due to its ability to treat and effectively remove tattoos with a minimum risk of scarring.
