MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.
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application allows us to re-treat the tattoo within sec- onds of each laser pass." "In my experience alternative treatment protocols, including the R20 technique and the treatment patch, can help reduce the number of treatments. So the specifi c advantage of these new wavelengths may be less of an issue," say Dr. Zelickson. Dr. Dover agrees: "The R20 method uses four passes over the tattoo every 20 minutes for a total of four. It takes way longer per visit, but it appears to help the tattoos clear faster. So if you don't have a Pico but want to speed the clearance of tattoos, this is the best alternative," he says. THE INK COLOR CONUNDRUM There is no question that many different types and colors of ink present unique challenges. Most laser sur- geons concur that effectively treating the widest range of tattoos and patients requires multiple wavelengths. "The most diffi cult for me are the brown/red fl esh tones used in lip, eyelid and eyebrow liner," says Dr. Zelickson. "These often have white titanium in them so very often one can get a darkening or even a peach type of color after treatment, which can be very diffi cult to get out. Greens, light blues, purples and yellows can also be diffi cult." "Any tattoo ink that is mixed with white ink to get the resulting color, such as light blue, pink or just plain white, is the most diffi cult to remove," adds Dr. Ber- nstein. "Iron and zinc oxides often turn gray requiring many treatments to remove, often proving refractory to removal. Green and blue inks are the next most stubborn colors to remove." Another hurdle is patient compliance. "Compliance is an issue because many patients will see slow progress and become discouraged. In some cases, only the black portion of a tattoo will improve but the remainder will not, leaving a smudge," says Dr. Ross. "Possible side effects, such as loss of skin color, is always an issue for non-black tattoo removal treatments in darker- skinned patients." In addition to ink colors, some tattoo placements are tricky to treat effectively. For example, "To treat eyeliner, we use corneal shields and a brushed metal lid protector to protect the eyelashes," says Dr. Zelickson. Areas that are more painful to treat often require a diverse approach and larger beam diameter spot size. "Large areas can be very painful," says Dr. Zelickson. "For those I use my Revlite, which is very powerful, set on a large spot size and I do several passes. This is much more tolerable and, anecdotally, I seem to get very good clearance with this technique." Dr. Spencer adds that tattoo removal treatments on the lower legs and the back are particularly hard for patients to tolerate. "We use numbing cream, but some people require lidocaine before treatment. Tattoos on the ankle are quite common, but treating them can be very uncomfortable," he says. PRACTICE BENEFITS "If someone is really looking to add this to their practice then they should get all wavelengths to cover the most colors and get the highest-powered device available," says Dr. Zelickson. "Then look closely at the service contracts and any other ongoing costs." The costs and pain involved are always going to be a factor in getting patients to come back to complete a treatment course. "Tattoo removal can be tough because many sessions are necessary, and it's hard to treat non-black tattoos," says Dr. Ross. "The unpredict- ability of responses to treatment make it a hard sell for many patients." "If the treatments are working, and the patient is motivated, then they are compliant. One way to help compliance is to offer package pricing so they pay up- front for a series of treatments," says Dr. Zelickson. Despite the challenges, laser tattoo removal can be a wonderful addition to any practice, according to Dr. Bernstein, who considers it to be a fun proce- dure. "The laser-skin interactions are cool to watch, and patients are often quite happy to remove the name of a no-longer-loved-one. The type of laser to buy will depend upon a number of factors, including the demo- graphics and skin types of those patients presenting for tattoo removal." Wendy Lewis is a New York-based writer specializing in cosmetic medicine and practice management. ERASING THE PAST Compliance is an issue because many patients will see slow progress and become discouraged." 48 MAY/JUNE 2014 | Med Esthetics E r a s i n g t h e P a s t M E D 5 - 6 1 4 . i n d d 4 8 Erasing the Past MED5-614.indd 48 4 / 1 6 / 1 4 4 : 4 5 P M 4/16/14 4:45 PM