Medica Centar

TETOVAZA - LASERSKO UKLANJNJE - LASERSKO SKIDANJE

Tetoviranje ili promena izgleda trajnim ucrtavanjem slika na razlicitim delovima tela je stara kultorolosko-socoloska pojava. Moze se reci da je stara koliko i ljudska civilizacija iz jednostavnog razloga sto su ljudi od svojih prapocetaka imali potrebu za ulepsavanjem tela, isticanjem pojedinih delova tela, nekom vrstom obelezavanja i konacno unosenjem neke vrste promene u izgledu. Naravno da su koreni sminkanja i bojenja koze u raznim prilikama ujedno koreni pojave moderne tetovaze. Istorijski gledano, privilegiju nanosenja boje ili slike na kozi su imali pre svega ratnici, svestenici, vracevi i ostali koji su to sebi mogli i smeli da priuste. U svakom slucaju cilj nosenja tetovaze je postizanje nekog efekta na druge ljude (prijatelje i neprijatelje) i jedan od nacina da se slikom obratimo ljudima koje ne poznajemo ili cak ne primecujemo u svojoj okolini. Efekti koji su ocekivani zavise od motiva tetovaze i njene lokalizacije. To moze biti strah, divljenje, privlacenje paznje, ljubav, erotski signali, sazaljenje itd.

Sa napretkom tehnologije i kulturolosko/socioloskog "relaksiranja" ljudske zajednice tetovaze su postajale trajnije, lepse, prihvatljivije i dostupnije sve vecem broju ljudi. Procenjuje se da u tzv. zapadnom svetu 10% ljudi ima bar jednu tetovazu, sto je ogroman porast u odnosu na stanje pre 20 godina.

Sa napretkom tehnike tetoviranja i pojavom sve lepsih tetovaza ova sfera ljudske aktivnosti je dobila i prikladno ime - BODY ART ili PERMANENT MAKEUP. U isto vreme, pojavila se i potreba za skidanjem i uklanjanjem nepozeljnih tetovaza. Motivacija ljudi da uklone svoju tetovazu je razlicita i skoro da je nemoguce nabrojati sve razloge. Medju najcescim razlozima za skidanje tetovaze nalazimo potrebu da se tetovaza zameni lepsom, kolornijom, motivima i detaljima bogatijom tetovazom. Ponekad je potrebno ukloniti istetovirano ime osobe koja je nosiocu tetovaze emotivno nesto znacila. Starosne promene na kozi u smislu opustanja kolagenih vlakana dovode do znacajnih promena u izgledu i konacnom efektu tetovaze. Sam pigment dugogodisnje tetovaze trpi izvesne promene u granulaciji i koloritetu pa moze da dodje do izbledjivanja, gubitka preciznih ravnih linija i delimicnog ili potpunog gubitka forme tetovaze. Promene u kilazi takodje dovode do deformisanja prvobitne forme tetovaze, bilo da se nosioc tetovaze ugojio (najcesca situacija) ili izgubio na kilazi. U svakom slucaju zeljeni psiholoski efekat stare tetovaze moze biti potpuno izgubljen. Ovo moze da bude motiv za skidanje stare tetovaze koja bi bila zamenjena novom koja je prikladnija godinama nosioca tetovaze i trenutnim trendovima.

Proces tetoviranja je u stvari postupak unosenja pigmenta odredjene granulacije u kozu. Dubina plasiranja pigmenta moze biti razlicita ali u proseku iznosi 2 mm. Dimenzije pigmentnih granula se takodje razlikuju i mogu biti od 0.1-10 mikrona. Vrsta, boja, granulacija i dubina plasiranja pigmenta su odlucujuci faktori za metodu skidanja tetovaze, uspesnost procedure i moguce komplikacije. U ne manje vazne faktore spadaju i starost tetovaze i osobe, kao i regija tela sa koje se tetovaza skida.

Postoji vise metoda za skidanje tetovaze. Hirurska ekscizija je efikasna, ali je nazalost primenljiva samo na tetovaze manjih povrsina. Kao sto znamo, u poslednje vreme ljudi se odlucuju za tetovaze na velikim regijama tela koje sadrze puno detalja. Hiruska ekscizija tetovaze na vecim povrsinama je skoro nemoguca bez transplantacije koze sa drugih regija, a oziljne promene su neizbezne.

Tzv. abrazivna metoda skidanja tetovaze se zasniva na uklanjanju svih slojeva koze do nivoa pigmenta. Izvodljiva je mehanickim putem i ultrazvicnim kavitronom. Komplikacije u smislu krvarenja, stvaranja oziljaka, infekcije i nepotpuno skidanje tetovaze su vrlo ceste kod ove metode.

Postoje i metode kada se postojeca tetovaza pokriva neutralnim pigmentom (re-tetovazom) ili tretiranjem specijalnim kremama ciji bi krajnji efekat bio depigmentisanje pigmentnih granula u makrofazima i narozito fibroblastima.

Metoda koja se zasniva na koriscenju fokusiranih ultrazvucnih talasa za "razbijanje" (slicno razbijanju kamena u bubregu) fibroblasta i pigmentnih granula u njima ima svoju perspektivu. Radi se o relativno skupoj metodi koja ima najneinvazivniji karakter po pitanju bola, stvaranja oziljaka i promena koloriteta koze. Mehanizam dejstva ultrazvicnih talasa u ovom slucaju se objasnjava "pucanjem" celija u kojima je pigment "zarobljen" i "usitnjavanju" pigmentnih granula koje se posle raspadanja celije oslobadjaju u medjucelijski prostor.

Lasersko skidanje tetovaze je danas najpopularnije zbog relativne puzdanosti i efikasnosti, kao i zbog malog broja laksih komplikacija koje se mogu javiti. Mehanizam dejstva laserskog zraka je slican kao kod ultrazvucnih talasa, a to je "razbijanje" celija u kojima je pigment deponovan. Osim toga, svetlosna energija lasera utice na sam pigment u tom slislu da intenzitet kolorizacije pigmenta slabi. Ovo su samo osnovna "pravila" dejstva lasera na tetviranu kozu. Preciznije receno, dejstvo laserskog zraka dovodi do "kljucanja" vode u fibroblastima i makrofazima (najvaznije celije u kojima je pigment deponovan) sto dovodi do njihovog pucanja i oslobadjanja pigmentnih granula. Pod uticajem laserskog zraka deo oslobodjenih pigmentnih granula se razbija, jedan deo "izbledi", jedan deo biva evakuisan medjucelijskom "cirkulacijom" do limfnih cvorova i najzad preostali deo bude ponovo fagocitovan od strane makrofaga i fibroblasta. Rezultat ovog procesa je bledja i "razlivena" tetovaza. Ujedno ovo je razlog zbog cega lasersko skidanje tetovaze mora da se izvede u nekoliko tretmana.

Vreme do konacnog nestajanja tetovaze zavisi od svih dosad pobrojanih faktora i nikada nije krace od 12 nedelja.

Skidanje tetovaze ultrazvucnim talasima ili laserom se izvodi u lokalnoj anesteziji. Anestezija se aplikuje kao gel ili injekcija. Upotreba leda tokom i posle intervencije u znacajnoj meri umanjuje neprijatan osecaj.

Komplikacije skidanja tetovaze laserom su bol, crvenilo, formiranje oziljaka, povecana ili (znatno cesce) smanjena pigmentacija koze na mestu dejstva lasera. Infekcije i veliki oziljci su prava retkost posle skidanja tetovaze laserom.

Postintervencijski tretman podrazumeva upotrebu leda i antibiotskih masti. U redjim slucajevima je potrebno previjanje i parenteralna antibiotska terapija.

Literatura sa abstraktima:

1. Paradoxical darkening of unperceived tattoo ink after relatively low fluence from a Q-switched Nd:YAG (1064-nm) laser in the course of treatment for melasma.
Clin Exp Dermatol. 2009 May 26.
Chung WK, Yang JH, Lee DW, Chang SE, Lee MW, Choi JH, Moon KC.
Department of Dermatology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Summary Although Q-switched (QS) lasers are the mainstay of modern tattoo removal, paradoxical darkening of tattoo ink may occur. This darkening of tattoo ink is dependent on laser wavelength, pulse duration and fluence, with high-energy, nanosecond-pulsed lasers more prone to induce tattoo-ink darkening. Laser toning, consisting of multiple-passed QS neodymium:yttrium-aluminum-garnet (Nd:YAG), 1064-nm laser treatment with low fluence, short pulse duration (< 10 ns), and a repetition rate of 10 Hz has been successful in the treatment of melasma. A mistake commonly made during laser toning is to scorch scalp hair, eyebrows or eyelashes, but this phenomenon is reversible. A more problematic error is caused by treatment of eyeliner or eyebrow tattoos. We report a patient who experienced changes in unperceived, skin-coloured tattoos, turning them blue after QS Nd:YAG laser treatment of melasma.

2 . Removal of an amalgam tattoo using a subepithelial connective tissue graft and laser deepithelialization.

J Periodontol. 2009 May;80(5):860-4.
Campbell CM, Deas DE.
10th Dental Squadron, U.S. Air Force Academy, Colorado Springs, CO.
Background: A 56-year-old female presented for periodontal treatment with a large amalgam tattoo located in alveolar mucosa on the facial aspect of her maxillary central incisors. The lesion had been present for 42 years since having endodontic surgery at teeth #8 and #9 after a traumatic childhood incident. Methods: A two-stage surgical approach was used to eliminate the lesion, beginning with a subepithelial connective tissue graft to increase tissue thickness subjacent to the amalgam tattoo. After 6 weeks of healing, the overlying pigmented tissue was removed using laser surgery to expose the underlying grafted connective tissue. Results: After 2 months of healing following laser surgery, the amalgam pigmentation was completely removed, with good color match and an increased width of keratinized tissue at the surgical site. Conclusion: A relatively large amalgam tattoo in the esthetic zone can be adequately removed by a two-stage procedure using grafted palatal connective tissue and laser deepithelialization.

3. Computer-assisted laser tattoo removal: a proposed prototype system - biomed 2009.
Biomed Sci Instrum. 2009;45:214-9.
Barrett SF, Wright CH.
University of Wyoming, Laramie, WY.
It is estimated that there are 7-20 million tattooed people in the United States. This number will probably grow as evidenced by reported increases in the number of tattoo studios and the sales of tattoo related supplies. Consistent with this growth in tattoo placement is anticipated increase in the demand for tattoo removals. Studies by Armstrong et al. indicate that many people want to have tattoos removed. Most participants in the studies indicated they had "impulsively obtained their tattoos for internal expectations of self-identity at an early age and were still internally motivated to dissociate from the past and improve self-identity [1]." Currently there are several lasers approved for tattoo removal: the Q-switched ruby (694 nm), the Q-switched Nd:YAG (532 nm, 1064 nm) and Nd:YAG pumped dye lasers at 585 nm and 650 nm.. A technique called Selective Photothermolysis is used to remove the tattoos. The goal of this project was to investigate the feasibility of a computer-assisted laser tattoo removal system to limit damage to collateral areas and scarring while significantly reducing the length and the number of treatment sessions. This was accomplished by characterizing the absorption properties of common tattoo inks, reviewing the limitations of current laser tattoo removal systems, and proposing a prototype system configuration.

4. Recurring mistakes in tattoo removal. A case series.
Dermatology. 2009;218(2):164-7. Epub 2008 Dec 6.
Wenzel S, Landthaler M, Baumler W.
Department of Dermatology, University of Regensburg, Franz Josef Strauss Allee 11, Regensburg, Germany.
In the Western world, more than 10% of the population have at least 1 tattoo. If the tattoo is removed, the tattoo pigment particles in the skin can be selectively destroyed by means of selective photothermolysis. This treatment requires laser pulses of short durations (nanoseconds) and high intensities. We report on 12 patients who received treatments with improper treatment parameters. In all patients, we diagnosed hypo- or hyperpigmentations and scar formation at the treatment site. In particular, the pulse duration of the light sources or lasers applied were considerably longer than those required by the principles of selective photothermolysis. The light intensities of those devices are normally not sufficient to destroy the pigment particles. Instead of destruction, the pigment particles in the skin are heated up and the heat is conducted to the adjacent tissue causing unspecific tissue injury. Lasers or intense pulsed light sources with millisecond pulses and low light intensities are clearly not suitable to be applied for tattoo removal. Copyright (c) 2008 S. Karger AG, Basel.

5. Facial scars after a road accident--combined treatment with pulsed dye laser and Q-switched Nd:YAG laser.
J Cosmet Dermatol. 2008 Sep;7(3):227-9.
Martins A, Trindade F, Leite L.
We report the case of a woman who presented with several facial scars following a road accident. Treatment was carried out using combined laser treatment with pulsed dye laser (PDL) and Q-switched neodymium:yttrium-aluminum-garnet laser (QS Nd:YAG laser). No side effects or complications from treatment were noted or reported. The patient had very good cosmetic results with this combined technique. A variety of facial scars - erythematous, pigmented, atrophic, and hypertrophic - may occur as a result of trauma, surgery, burns, and skin disease. Surgery with other adjunctive methods including radiotherapy, intralesional steroids, and pressure therapy have shown variable results. Laser treatment has been attempted for scar revision since the 1980s. The PDL is the optimal treatment for reducing scar bulk and symptoms. It also decreases erythema and telangiectasia associated with scars, normalizes the skin surface texture, and improves the scar pliability. The QS Nd:YAG laser (1064 nm) is highly effective for traumatic tattoo removal, resulting in complete clearance in the majority of cases.

6. Motivation for contemporary tattoo removal: a shift in identity.
Arch Dermatol. 2008 Jul;144(7):879-84.
Armstrong ML, Roberts AE, Koch JR, Saunders JC, Owen DC, Anderson RR.
School of Nursing, Texas Tech University Health Sciences Center, TTU-Highland Lakes, 806 Steven Hawkins Pkwy, Marble Falls, TX 78654, USA. myrna.armstrong@ttuhsc.edu
OBJECTIVE: To compare the results of a 1996 study of tattoo possession and motivation for tattoo removal with those of a 2006 study, in light of today's current strong mainstream tattoo procurement and societal support within the young adult population. DESIGN: Descriptive, exploratory study. SETTING: Four dermatology clinics in Arizona, Colorado, Massachusetts, and Texas. PARTICIPANTS: The 2006 study included 196 tattooed patients (66 men and 130 women). MAIN OUTCOME MEASURES: Incidence of purchase and possession risk, as measured by a 127-item survey and factor analysis. RESULTS: In contrast to the 1996 study, more women (69%) than men (31%) presented for tattoo removal in 2006. Women in the 2006 study were white, single, college educated, and between the ages of 24 and 39 years; they reported being risk takers, having stable family relationships, and moderate to strong religious beliefs (prayer and closeness to God). Commonly, tattoos were obtained at approximately 20 years of age, providing internal expectations of uniqueness and self-identity. Tattoo possession risks were significant, cited when the quest for uniqueness turned into stigmata (P < .001), negative comments (P < .003), and clothes problems (P < .004). CONCLUSIONS: In both the 1996 and the 2006 studies, a shift in identity occurred, and removal centered around dissociating from the past. However, in the 2006 study, more women than men were notably affected by possession risks. Societal support for women with tattoos may not be as strong as for men. Rather than having visible tattoos, women may still want to choose self-controlled body site placement, even in our contemporary society.

7. Tattoo removal--state of the art.
J Dtsch Dermatol Ges. 2007 Oct;5(10):889-97.
[Article in English, German]
Pfirrmann G, Karsai S, Roos S, Hammes S, Raulin C.
Laserklinik Karlsruhe, Germany.
Tattooing has been around since the early beginnings of modern civilization. The discovery of selective photothermolysis at last has made it possible to remove tattoos without leaving a scar. Q-switched neodymium: yttrium-aluminum-garnet, alexandrite, and ruby lasers with pulse durations in the nanosecond domain fulfill this need. Argon or cw-CO(2) lasers as well as intense pulsed light sources should not be used since they often produce significant scarring. This article provides an overview of current laser systems. Developments leading to new tattoo inks, feedback systems to detect the absorbance characteristics of tattoo inks, dermal clearing agents, and perhaps even lasers with shorter pulse-durations might improve the results in the future.

8. Pain inhibition in Q-switched laser tattoo removal with pneumatic skin flattening (PSF): a pilot study.
J Cosmet Laser Ther. 2007 Sep;9(3):164-6.
Lapidoth M, Akerman L.
Laser Unit, Department of Dermatology, Rabin Medical Center, Golda Campus, Petah Tikva 49372, Israel. alapidot@netvision.net.il
BACKGROUND: Tattoo removal with a Q-switched laser is often a painful procedure. The sensation of pain associated with the treatment is immediate and acute. Application of topical anesthesia to the treated area of the skin is time-consuming, with only very moderate pain relief. OBJECTIVE: To determine the efficacy of pneumatic skin-flattening (PSF) technology which utilizes an evacuation chamber that generates skin compression and activates tactile neural receptors in the skin, resulting in afferent inhibition of pain transmission in the dorsal horn (the 'gate theory'). METHODS: Eleven young patients aged 17-25 years old (nine females, two males) who were treated for tattoo removal were enrolled in the study. The patients were treated by a Q-switched Nd:YAG laser. Acute pain evaluation was performed on all 11 patients: one to two sites per patient with PSF and one to two control sites without PSF. When patients were treated with PSF, they knew they were being treated with a device that might reduce pain. This may have influenced patients' perception of pain. The evaluation was based on a modified McGill pain questionnaire. RESULTS: All 11 patients completed the study. A lower pain score with PSF was observed in all but one patient (10/11 or 91%). The average reduction of pain is by two levels: from very painful to very mild pain. The energy transmission of the PSF window is 95%, resulting in essentially identical efficacy of the PSF treatment and the regular non-PSF treatment. CONCLUSION: This pilot study indicates that PSF technology may reduce pain in tattoo removal with medium energy density Q-switched lasers (3-5 J/cm(2)).

9. Tattoo removal.
Clin Dermatol. 2007 Jul-Aug;25(4):388-92.
Burris K, Kim K.
Department of Dermatology, State University New York Health Science Center at Brooklyn, Brooklyn, NY 11203, USA. kburris11@yahoo.com
Tattoos have been a part of costume, expression, and identification in various cultures for centuries. Although tattoos have become more popular in western culture, many people regret their tattoos in later years. In this situation, it is important to be aware of the mechanisms of tattoo removal methods available, as well as their potential short- and long-term effects. Among the myriad of options available, laser tattoo removal is the current treatment of choice, given its safety and efficacy.

10. Treatment modalities for allergic reactions in pigmented tattoos.
J Dtsch Dermatol Ges. 2007 Jan;5(1):8-13.
[Article in English, German]
Zwad J, Jakob A, Gross C, Rompel R.
Department of Dermatology, Kassel Hospital, Germany.
Decorative tattoos have become very popular. As a result, a higher number of hypersensitivity reactions are seen, caused by the mostly undeclared tattoo dyes. If local and intralesional therapy with corticosteroids is not effective, total excision was formerly considered the best approach. Selective laser therapy offers an alternative approach for removing the offending pigment. Case reports are used to illustrate the individual treatment options for removal of tattoos.