NOV-DEC 2018

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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© GETTY IMAGES COLOR CORRECTION he selects the wavelengths needed to address the various colors in the tattoo. "I perform multiple passes in the same session for most tattoos using the PFD patch to allow for im- mediate retreatment," he says. "Sometimes we add ablative fractional lasers for resistant tattoos." When treating multi-colored tattoos with different wave- lengths, Dr. Alster advocates treating red, orange and yellow inks prior to the darker black or blue inks. "The intense skin disruption that occurs upon laser impact of the darker inks can interfere with adequate visualization of the lighter inks," she says. The total number of sessions required for clearance depends on the tattoo, notes Dr. Friedman. "In general, professional tattoos require more treatments than amateur, cosmetic or medical tattoos," he says. "The ink of profes- sional tattoos is typically more concentrated and placed deeper in the skin." Sessions are best scheduled at monthly, or longer, time intervals in order for complete wound healing (and ink clear- ing) to take place, says Dr. Alster. Dr. Friedman typically recommends eight to 12 weeks between laser treatment sessions. His practice has also been investigating the use of acoustic shock wave therapy in conjunction with picosecond lasers and a PFD patch to accelerate tattoo removal. In June 2018, he and co-authors Ramya Vangipuram, MD and Selina S. Hamill, MD, published the results of a study combining picosecond laser with a PFD Patch and acoustic shock wave therapy (Zwave, Zimmer Medizin Systems) for tattoo removal in Lasers in Surgery and Medicine. The subject was a 28-year-old woman (Fitzpatrick Skin Type V) with a six-year-old professional black tattoo on her left ventral wrist. She underwent three treatment sessions at six to eight week intervals with a 1,064nm picosecond Nd:YAG laser (PicoWay) and the Describe PFD patch (Merz). At each treatment session, the investigators made two passes with the laser (4mm spot size, 2.8 to 3.2J/cm 2 and laser repetition rate of 2Hz). Between laser passes and following the fi nal laser pass, the medial portion of the tattoo was treated with the Zwave device (90mJ, 22Hz, and 1,200 pulses). After three treatment sessions, there was 80 percent clearance of the medial portion of the tattoo that received the acoustic shock wave therapy compared with 60 percent clearance of the lateral portion treated with picosecond laser and PFD patch alone. In addition, the area treated with the Zwave had less edema, erythema and epidermal crusting in the days following treatment. ADDRESSING FADED TATTOOS With the new picosecond lasers, Dr. Bernstein no longer performs multiple passes in a single session. He believes that if you are using an adequately powered laser, a single pass per treatment session should yield maximal results with the least side effects. "In the past when using an underpowered laser, I often treated a tattoo using two passes to the entire tattoo with both 1,064nm and 755nm laser energy, while also using 532nm wavelength to treat reds and yellows," he says. "With newer lasers, I believe a single treatment yields the best results. Interestingly, the best pearl for removing a tattoo in the fewest treatments is the lowest tech—waiting longer between treatments." He fi nds that extending the interval between treatment sessions reduces the total number of treatments necessary to remove a tattoo, particularly toward the end of treatment when the tattoo becomes increasingly faint. "Waiting is a critical necessity when treating faint tattoos," he says. "Simply cranking up the energy when a tattoo is very faint and almost completely removed, without waiting at least a few months between treatments, will often increase side effects without signifi cantly improving results." FUTURE DEVELOPMENTS Dr. Bernstein is excited to see future laser developments including additional wavelengths to target pigment, smart lasers and those that offer even shorter pulse durations moving into the femtosecond-domain. "It was originally thought that picosecond-domain lasers may remove pigment independent of color," he says. "While this hasn't been the case so far, yellow ink that was previously not removable in the U.S. is now removable with picosecond-domain lasers operating at 532nm, while their nanosecond-domain cousins are far less effective." This has been shown with at least two different picosec- ond-domain lasers, and indicates that something qualitatively different may be occurring with some pigments at shorter pulse-durations. "Newer lasers with even shorter pulse- durations may offer unexpected effects as well. I can't wait to see," says Dr. Bernstein. Daniel Casciato is a freelance writer based in Pittsburgh. 34 NOVEMBER/DECEMBER 2018 | MedEsthetics

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