Permanent Makeup Tattoos Gone Wrong. Removal of a Double Eyebrow Tattoo

Eyebrow Tattoos Gone Wrong

As you can see from previous posts, removal of eyebrow tattoos is a pretty common request.  People go in expecting model-perfect arches and often come out with a style that is too thick, too thin, too arched, too flat, the wrong color, or maybe, over time the style of eyebrows has changed from thin to thick...etc, etc.

So what do you do if you have a permanent makeup tattoo you don't want anymore?

DON'T....

• Don't let the permanent makeup technician try to correct it by putting a flesh colored tattoo on top. These technicians learn this technique as part of their training, but listen to me, DON'T DO IT!!  Not only does it NOT correct the situation, but it can make laser tattoo removal impossible.  
• Don't let the permanent makeup technician place another tattoo over it, leaving the old one on place
• Don't get a new color placed over it

DO

• Do spend the money to do the right thing and get laser tattoo removal. Laser tattoo removal, while an expensive process, will not scar and will gradually fade the pigment so that you can either cover it up with makeup or get another permanent makeup tattoo to your liking.

Here is an example of a bad case of Permanent Makeup Eyebrow Tattoo Gone Wrong.

Figure 1.

1/31/2007. This patient came to us after getting 3 different permanent makeup eyebrow tattoos as well as a flesh colored/white color correction tattoo.  FIRST, The first one she had done was the lower (faded) brow. SECOND, she got a flesh color/white tattoo to try to cover it up.  THIRD, she got a tattoo one above the old one.  FOURTH, because the color wasn't right, had  another color tattooed right on top of the upper brow (one on top of the other). FINALLY she came to us requesting laser tattoo removal.  I quoted her 6-10 sessions for full removal.  

Figure 2.

1/31/2007. Closeup of Right Brow before treatment began

Figure 3.
2/8/2007. One month after 1st treatment. Significant fading achieved on lower brow, revealing the flesh colored tattoo. Upper brow faded but not too much because it is actually two tattoos (one on top of the other)

Figure 4.

2/8/2007. Closeup of Right Brow. Notice the brown color on the top brow starting to peek through. On the bottom, the flesh color is starting to peek through.

Figure 5.

4/25/2007.Two months after 2nd treatment session. Lower tattoo still fading gone, upper tattoo still fading to reveal brown colored tattoo.

Figure 6.
4/25/2007. Two months after 2nd treatment session. Closeup of Right Brow. The flesh color is more noticeable in the lower brow, the brown color is more apparent in the upper brow. Noticeable fading.

Figure 7.

9/25/2007. 5 months after 3rd treatment session.  Both tattoos are significantly faded. Note that the lower brow appears grey (where before it was flesh colored). This is because flesh colored tattoos have a tendency to change colors during treatment. In any case, patient was satisfied with result as she can now cover the area with makeup. She did not want to continue treatments after this, although I recommended she continue. 

Figure 8.

9/25/2007. 5 months after 3rd treatment session. Closeup of Right Brow

Total cost of laser tattoo removal treatment:  3 treatment sessions, $200 each, for a total of $600. Prior to that, patient spend $800++ on permanent makeup and tattoo removal creams (three times and attempted correction with flesh colored tattoo).

Video!

Below is a video of me performing laser tattoo removal of the eyebrow on someone who had more 2 permanent makeup eyebrows on top of each other. You will see that different colors appear on parts of the tattoo because of the different colors mixed into one.

For more videos, please visit my youtube channel, Happymmm, by clicking on the link below.  http://www.youtube.com/user/happymmm

Laser Tattoo Removal of an Amateur Tattoo on the Breast - Before and After photos

Amateur Tattoos

Amateur tattoos are of the home-made variety.  You may have gotten one done when you were younger.  A friend did it for you.  A lot of prisoners get these while in prison. Generally speaking, these types of tattoos are easier to remove than professionally done tattoos you would get in a parlor because there is usually less ink and they are usually more shallow.  The average number of treatment sessions needed to remove an average amateur tattoo is 4-6.

I have one case here with exceptionally good results. She didn't have much ink, it was amateur, and it was 15+ years old.  I estimated it would take 4 treatments and it did.  Here are the before and after pictures from her laser tattoo removal sessions.

Figure 1.

9/24/2007.  Before Treatment.  Amateur Breast Tattoo, 15+ years old, Latina patient (darker skin type 4)

Figure 2.  

9/24/2007.  Immediately after treatment. You see whitening of the tattoo ink, indicating adequate energy absorption by of the laser, and a little bit of redness and slight swelling

Figure 3.

1/21/2008, After 4 sessions, tattoo ink is gone.  You see a bit of "whiter" skin where the tattoo used to be. This is because the patient has a darker skin tone (she is Latina) and to remove the residual ink, sometimes the patient's natural pigment is also removed as part of the process. The patient was extremely happy with the result and one year later, the skin color is blended and natural looking. 

Figure 3.
5/17/2009. More than 1 year later...skin has blended in and looks normal to the naked eye, with no previous evidence of tattoo. Patient very very happy.

Video!

While I don't have a video of the above patient, I have similar video of a laser tattoo removal of an amateur tattoo on the breast. Enjoy!

To view more laser tattoo removal videos, please visit my youtube channel, Happymmm at:

http://www.youtube.com/user/happymmm

Thanks for watching!

Laser Tattoo Removal of Permanent Makeup Eyebrow - Before and After Photos

"Why don't you post before and after photos?"

People are always asking to see before and after pictures on my Youtube channel, happymmm. I post the video of the treatment, people want to see what it looks like afterwards and they complain that I don't post.   But getting good before/after photos is hard to do. That's why most of the websites you go to post what's called "stock photos,"  photos purchased from someone else for commercial use, or photos provided by the laser company. You can tell a photo is a stock photo because of the quality of the photo.  It's usually small and/or grainy, and oftentimes the ones I see have a yellowish tinge. Many of them use plain light in one photo and flash in the after photo, drowning out the actual result.

I want good before and afters, and I do it right. I use the same lighting, no flash, and a macro lens. Still it's not easy to get good befores and afters, mainly because the process is so long (about 1 -2 years ) and because of patient compliance.  It's not sufficient for me to post the "after photo" because I know you guys don't want the immediate after photo - you want the photo of that shows the result at the end of the entire treatment package. So the REAL photo you want to see the one that usually comes from a SERIES of SEVERAL treatment sessions. Why is this hard to get?  Getting a good after photo depends a lot on patient compliance. He/she has to be compliant and has to finish the series of treatments. The reality is that people don't often commit to full removal. Most of my patients do it until it fades a enough so they can go cover it up with another tattoo.  The fact that the entire series can take a 6 months to 2 years to fully complete means that people fall by the wayside due to that thing called life that often gets in the way.  If people want to finish the treatment, they need to keep coming every month until it's gone.  But oftentimes several months will go by before someone comes back to retreat. This has nothing to do with the efficacy of the procedure, and everything to do with the fact that people have other priorities in life.  I had a girl come to me every month for 3 months up until her wedding. After her wedding, it was another year before she returned. That is the reality my friends: people have other priorities so they just come whevever they want or whenever they get the chance.  I suppose I could post some in-progress photos (and I have) but then people don't get the "in progress" bit and gripe that it's not working.  It's a catch 22.

So I hope this little diatribe clears up the reasons why I don't always post the before and after pics - it's because I'm still doing treatment!!!

Nonetheless, as a reward for reading my little rant, I will post  you a couple good sets of before and after photos of Laser Tattoo Removal of the Eyebrow. This is laser tattoo removal of what's considered "cosmetic permanent makeup."

Figure 1.

Case 1.  Here is a 10+ year old permanent makeup eyebrow tattoo.

The tattoo ink is a plain black tattoo that has already started to fade on its own.

This picture was taken before treatment on 4/21/07

Figure 2.

Case 1. Below is the "immediate" after photo. This picture was taken immediately after the procedure was performed. The skin is red and angry, and the tattoo ink is white in some areas and blotchy.  If you don't understand the procedure you may think that the skin is "burned" when in fact this is not true. The "whitening" is some temporary heat bubbles that are given off when the laser light is absorbed by the ink - it goes away within minutes.

Figure 3. 

Case 1. After photo, 1 month after first procedure.  The ink has faded more than 50% but she will need another 2-3 treatments for complete removal. The skin is intact, there is no burning or scarring.

Figure 4.

Case 2.  Before photo. this is also a 10+ year old permanent makeup eyebrow tattoo.

Figure 5.

Case 2.  This is taken immediately after i completed the procedure. Again you see the whitening, blotchiness, which is temporary.

Figure 6.

Case 2.  After photo, 1 month after first treatment. 80% of the ink is gone.

Figure 7.

Case 2.  Before Treatment

Figure 8.

Case 2.  Immediately After Treatment - whitening of ink and red irritation

 

Figure 9.

Case 2.  One Month After Treatment

Figure 10.

Case 1.  Before Treatment

 

Figure 11.

Case 1.  Immediately After Treatment

Figure 12.

Case 1.  After Photo, 1 Month Post-Treatment

 

Discussion

The sets of pictures shown above show significant fading after 1 treatment. These results are not typical. Sometimes, you won't see any fading after the first treatment at all.  The reason these tattoos responded so well have to do with 1) the age of the tattoo (these are very old 10++ years);  2)  the type of ink (there are more than 300 types of inks - permanent makeup ink tends to bind less tightly to the skin)  3)  The depth of ink placement & amount of ink.  If you look at Figure 12, you'll see that some areas faded completely while some areas did not.  This has to do with the the tattoo artist placing the more ink deeper in some areas. Usually this happens at corners and edges of the tattoo - tattoo artists tend to go over the out edges a bit more. 

Video!

I hope these pictures help you understand the laser tattoo removal process better.

If not, then here is a video of me performing laser tattoo removal of the eyebrow to better illustrate. Note, we applied topical numbing cream for 30+ minutes, and I used
ice immediately before shooting the laser to minimize pain.  Entire procedure is
over in less than 1 minute.  Enjoy.

For more laser tattoo removal videos, please visit my Youtube channel, Happymmm (click on link below)

http://www.youtube.com/user/happymmm

Do the tattoo removal creams work?

Probably not, but they're cheaper than laser tattoo removal, so why not try it, right? Um, WRONG.  
More often than not I get patients who have tried stuff (not knowing what's in it but buying it because of the advertisement) and damaging their skin.  Possible problems with these tattoo removal creams: they could irritate the area, scar the area, damage the area, or make it impossible to remove via laser.


So yeah, I'm pessimistic. These creams are topical, so you apply them and they are supposed to make the ink fade. But how does it do this?  Tattoo ink sits in the upper dermis, (the layer skin below the outer skin layer, the epidermis) -  which means that the cream has to penetrate deep to get to its target. I am sorry, but I would be surprised if any cream could penetrate that deeply.
The popular and heavily advertised cream is Wrecking Balm (about $150-$200), a combination of hydroquinone (a skin bleaching agent) and an exfoliator.  Hydroquinone suppresses expression of melanin, making your skin lighter, but it does nothing for the ink.
The exfoliator is probably some sort of acid (glycolic, salicylic, etc).  One of my patients tried this and ended up with red, flaky, irritated skin, so she ended up coming in for laser tattoo removal anyway.


So bottom line - to cream to not cream?  Save your money and don't spend it on unproven substances that can harm rather than help.
Anyone with experience is welcome to post, but everything I've read on this subject tells me that the creams don't do what they are hyped to do...

Managing laser tattoo removal pain

Does it hurt?
"That looks so painful"
"I've heard it's more painful than getting the tattoo itself."
"It's the most painful thing I've ever had to endure."

The number one question associated with laser tattoo removal is: "does it hurt?"  In a nutshell, the answer is "yes."  But it doesn't have to be excruciatingly painful, and there are ways for the laser operator to minimize the pain.  Some places don't offer these options up front because they can be time consuming and costly. My motto:  make the procedure as painless as possible and make people happy.


So what do I do to minimize pain for patient?
1. Ice, Ice, and more ice
For small tattoos, I usually use ice.  Because I have the fastest and most powerful laser available,  my patients have the benefit of a super quick procedure, which can be completed in less than a minute. For small tattoos 4 inches or less, I simply ice down the area until it feels cold to the touch before I begin the procedure. When I ask the patients what the pain level is from 1-10, most people report somewhere between 2 and 6.  The average reported pain level is 5, which means it hurts but it's not killing anyone.


Here I'm removing an ankle tattoo. The patient says "it feels like bee stings."



The other benefit of ice is that it minimizes epidermal heating, which reduces blistering. 80% of my patients do not get blisters thanks to me and my friend, Ice.


I use ice for large tattoos as well, but ice is just one in my arsenal of pain management tools.


2.  Zimmer cooling (a machine that blows cold air)
Any office performing laser tattoo removal should have one of these devices (but some won't because it's an added cost). What is a Zimmer cooler?  It's a large machine that has a hose blowing cold air.  The cold air blow chills the skin (much in the same way as the ice) , reducing the pain.  Whenever I do a large area on a patient's arm or somewhere the patient can see, I let the patient hold the hose and blow the air wherever they want.  If it's somewhere the patient can't reach, I hold the hose in my left hand and blow it over the tattoo while my right hand holds the laser and performs the procedure.


Here is a video of me using a Zimmer cooler. Notice I have a blue ice pack on
the side (which I've already used to pre-cool the area). The grey hose you see
in my left hand is the Zimmer device.



3.  Numbing cream
For small tattoos, I personally think that ice works better than numbing cream.  But for large
tattoos, numbing cream is an absolute must.  It does take a good 30-40 minutes, however, for the numbing cream to take effect, so it's a bit time consuming.  We put the numbing cream on in the office and ask the patient to either wait or come back to the office in 30 minutes.  I've tried giving numbing cream for patients to apply at home before coming to the office, but I find it just doesn't work as well, so generally if patients want numbing cream I tell them they need to be in the office for 30-40 minutes longer.


Another reason I don't like giving numbing cream to patients is that I don't know what's going to happen. For those of you who are die-hard do-it-yourselfers, beware: It is possible to have a lidocaine overdose (when too much lidocaine enters the system at once, it can cause anaphylactic shock), just like any other drug. So to be on the safe side, get the numbing cream applied in the office so a professional can monitor your progress, and you will be safe.


Numbing creams aren't made the same either.  They come in different strengths and many are prescription only. The most common is EMLA (2.5% lidocaine and 2.5% prilocaine), available by prescription, which works just ok but is relatively economical (about $30-$40/30 grams).   Beware however, that it does contain lidocaine so applying too much at once is not a good thing.  4% lidocaine cream is also common, and the typical branded version is called ELA-Max.  A doctor's office may use a high strength compounded prescription numbing cream called a BLT (betacaine, tetracaine, lidocaine).  The BLT is by far the strongest, but also the highest strength (and therefore most dangerous) and should only be applied under professional supervision.


When I use numbing cream in combination with ice and zimmer on large area tattoos, the patient generally reports a pain level of 4-7 on a 10 point scale.  The main discomfort being that large tats take longer, per session, to remove (15 minutes - 45 minutes per session).


4.  Local anesthetic injection
Another option for pain management is injection of a local anesthetic to the area. In our office, we don't do this, but local injection can be used in conjunction with any of the aforementioned methods to reduce pain of laser tattoo removal.


Final thoughts
So maybe you've been thinking about laser tattoo removal but are afraid of the pain. Now you know that while it is painful, the laser operator can significantly reduce the pain the pain you feel by any number of methods.  So to dispel the myths, let me just say that MOST of my patients say the laser tattoo removal is not that bad.  In fact, most of the time, during the first procedure when I do a test spot and ask them how it feels, they tell me "It's not as bad as I thought."


You can see for yourself by visiting my Youtube channel: happymmm. You can hear the dialog in most of the videos and most of the time I'll ask the patient how much pain they are feeling.  Even patients with tattoos on the breast tell me it's not too bad.
Just click on the link below to visit my youtube channel:
http://www.youtube.com/user/happymmm

So how many laser tattoo removal sessions will I need?

• "So how many sessions will I need, exactly?"

• "So, do you think that by the end of 8 sessions, the tattoo will be completely gone?"

• "So, do you think that if I come every month for 6 months, the tattoo will be gone by the time of my wedding in June?" (asked by someone in December)

People are always trying to pin me down to get an exact number, but no matter how the question is asked, I will always be giving the same answer: I can give you an educated guess based on my experience, but I can't predict the exact number of sessions you'll need.

"Why not?"  they ask.  Well, mainly because all tattoos are different, and there are many variables that influence how quickly a tattoo will fade.

Here is a list of factors that will make a tattoo easier (less sessions) or more difficult (more sessions) to remove.

Things that make a tattoo easier to remove: (less overall sessions)

1) Tattoos 10 year old or more.

2) Tattoos that have already begun to fade

3) Black tattoos that are starting to look greenish

4) Amateur tattoo (if you had yours done at home instead of a tat parlor)

5) Shallow ink placement (this has to do with your tat artist and how deep/heavily they used that tattoo pen/needle

6) Lighter skin color.  If you have lighter skin color, we can use stronger power settings which can translate into less overall number of treatments

7) Plain black tattoo. If it's a plain black tattoo it will be easier than a colored tat to remove

8) The type of ink. Some inks don't bind as tightly as others. There is also a new type of ink,

by a company called Freedom2, that was designed to be removed within 1 or 2 sessions.

Things that make it more difficult to remove:  (more overall sessions)

1) New tattoos 3 years old or less

2) Professionally applied tattoos done in a tattoo parlor

3) Multi-colored tattoos

4) Very dark skin color. If you have dark skin, the laser does not differentiate between pigment in the skin and pigment in the tattoo.  To treat dark skin while minimizing adverse pigment change, we must keep the energy/power settings low - this translates into more number of treatments overall

5) Very large tattoos. Sometimes the tattoo is so large, we cannot treat the entire tattoo in one session and must break it up into several sessions. This is because large tattoos take a long time to treat, which may be too painful to take in one sitting.

6) A lot of ink. Sometimes people will come in with a tattoo that is literally a bit raised where the ink is (if you look closely, the skin where the tattoo is slightly higher raised). In other words, there is so much ink in the tattoo that it causes the skin to slightly puff up. These types of tattoos can take 20-30+ sessions to remove.

7) Ink that is placed deeper in the skin.

8) The type of ink. Some inks bind tighter to the skin and are more difficult to remove.

So how many sessions will it take? I really don't know. It's the nature of the beast.  I can give you a best guesstimate but that's about it.  The bottom line is that it takes several sessions to remove a tattoo and the process usually takes 6 -18 months total, sometimes longer, for complete removal.  So if you are planning a wedding, start your treatments as early as possible...

How much does laser tattoo removal cost?

Is it expensive?

Sorry, I wish I could tell you otherwise, but let's face it, laser tattoo removal is expensive. Someone came into my office complaining that he paid $100 for his tattoo but it was going to cost almost $1000 to remove it. This is the reality, my friends. You may pay little for a tattoo that takes 30 minutes to do, but removing it is a long and expensive process. Still, most people are happy to pay to get rid of an unwanted tattoo.

So why does it cost so much?

First of all, the laser devices are expensive, costing $50-$115k per device. So part of the cost of the removal procedure is the technology. Secondly, you are paying for expertise. In many states, where some sort of licensure is required, you are also paying for a professional to perform the procedure. Just think of it this way: if you are uninsured, a typical doctor's office visit is $125 for 5-10 minutes of their time. Laser tattoo removal is basically a visit to the doctor's office a a cosmetic (uncovered by insurance) procedure.

How many times will i have to pay?

You will also have to do many procedures. For amateur tattoos, you are looking at 4-6 visits. For a typical professional tattoo, you will need 8-10 visits, or more, as many as 30 for Multi-colored tattoos and people with darker skin (Indian, African-American, etc) will need more procedures as well. So the cost of tattoo removal is spread out over several sessions.

So how much, realistically, are you looking at spending? It depends on a few things:

1) Geography. Places that have high rent like New York will be more expensive

2) Does the doctor/office own the laser or rent it? Most places that rent the devices have to pay a set cost just to have the laser delivered, so generally a place that rents will charge you more per procedure because it costs them more to rent the device. Case in point, a young lady came to me with a quarter-sized tattoo on her ankle. She told me she had gone to a plastic surgeon's office to remove it, and the per-procedure cost was $250. In our office, we charge a $69 minimum, and then $49/sq inch, with discounts for larger tattoos. So when she came to our office we charged her $69.

3) How big is the tattoo? Is it black or multi-colored? What is the color of your skin? Is it amateur or professional? Does it look like a lot of ink or very little ink is in your skin? All these items are factored in when a quote is given.

Pricing schemes:

Per-procedure pricing. Some places will offer you a flat rate. $100 for a small tattoo, $250 for a medium tattoo, $500 for a large tattoo, and so on, per procedure.

Pricing by size: Some places offer pricing by the square inch. They will measure it and each inch costs a specific amount of money. Square inch pricing ranges from $39-69 per square inch depending on where you go.

General Estimates:

So I've put together a general estimate of the cost of the procedures based on my experience. There's a very wide range of pricing so I'm giving you my best guess so you can get your funds together if you want to have this procedure done.

• Small tattoo (1 sq inch) - $250 to $750 total
• Medium tattoo (5-10 inches) - $1000-2500 total
• Large tattoo (20++ inches) - $3000-$7,000 total
• Xlarge tattoo - $7500+++

What is the best laser for tattoo removal?

What is the best laser for tattoo removal? Before we launch into specific devices, you should have a basic understanding of the types of available systems. This post will offer a brief overview of these types and then discuss my top picks for best tattoo removal laser.

1. Make sure it's a q-switched laser

If you plan to get laser tattoo removal, make sure the laser is a specific type of laser called a q-switched laser. A q-switched laser is the only laser type that should be used for tattoo removal.

2. If you have a multi-colored tattoo, make sure the correct wavelength laser is used.

Q-switched lasers are available in several wavelengths and each of these wavelengths have specific absorption properties that will absorb different color tattoos. All of the available lasers remove black tattoos, so this is the easiest color to remove. It gets a bit tricky with colored tattoos, since a single machine cannot remove all colors. Some colors such as white, yellow, flesh, etc, are not absorbed well by any laser and are very difficult to remove at this time.

If you have black, blue, green, or red tattoo, you are in luck. For blue or green tattoos, you need a 755nm Alexandrite laser or a 694nm ruby laser. If you have a red tattoo, you need to have a 532nm laser. As I just mentioned, if you have a simple black tattoo any of these laser systems will work. Multi-color tattoos may require two or more lasers to be effective.

I've heard people say that laser tattoo removal doesn't work. There are two reasons for this: 1) the laser is the wrong wavelength for that color tattoo, or 2) the laser does not have enough power. If you've gone through a series of laser tattoo removals with no improvement, I would draw the conclusion that the wrong laser is being used, not that laser tattoo removal doesn't work. Trust me, it does.

Laser	Black	Blue	Green	Red
Alexandrite 755nm	XX	XX	XX
Ruby 694nm	XX	XX	XX
Nd:YAG 1064nm	XX	XX
Nd:YAG 532nm				XX
Choice of Laser for Removal of Tattoo Ink by Ink Color.

3. Now to the nitty gritty: the best tattoo removal laser (in my opinion)

Ok this is the info you want. As a disclaimer let me first say that no one is paying me for writing this

and I have no interest in any laser company. So this is my honest to goodness unbiased opinion based on my experience. I make no guarantees as to the outcome of your treatment, which also depends on the experience of the laser operator and several other factors such as the type of ink in your tattoo, your skin color, and the depth of ink placement.

BEST OVERALL LASER

• Hoya Conbio C6 laser
• Hoya Conbo Revlite

Both of these lasers are 1064nm/532nm q-switched lasers. They are the fastest on the market,

shooting at 10 hz (most tattoo removal lasers shoot at 5hz). They are also extremely powerful.

A faster and more powerful laser translates into less overall treatment time (e.g., less than 5 minute treatments in most cases) and less overall number of treatments. It also has a very large 8mm spot size which covers more area quickly. The Revlite is the more sophisticated model with touch screen operation for the operator, but essentially the two machines deliver equal results. They come with dye handpieces that mimic 694nm and 755nm laser light, allowing the operator to remove greens and blues as well as blacks and reds. 
Here is a video of the Hoya Conbio C6 in action:

NOTABLE NEWCOMERS

• Candela Tri-vantage

The Alex Tri-Vantage combines 755nm, 1064nm, and 532nm lasers in one box. It is a very powerful laser as well but the core laser in this system is the 755nm. Candela has been manufacturing the 755nm q-switched laser for some time now, so that laser is perfected. As for the other components of the

system, I am still waiting for more information before I make judgement. This system is also powerful, but it only shoots at 5hz, which is considerably slower than the 10hz of the Hoya Conbio system.

What does it mean when I say it shoots 5 hz rather than 10 hz? The difference is in the total treatment time.

Repeat this out loud: BEEP - BEEP - BEEP. This is the laser shooting at 5 hz. If it were shooting at 10HZ, it shoots like BEEPBEEPBEEPBEEPBEEPBEEP. Does this make sense? For larger tattoos the difference between 5 and 10 is significant. There is definitely some pain associated with this treatment, so the faster the machine the better.

• Cynosure Affinity (1064nm/532nm q-switched)

Cynosure Affinity is a newcomer to this space and is modelled closely after Hoya Conbio's q-switched lasers. It also shoots in the 10hz range (fast). However, the largest spot size is 6mm. This is adequate for smaller tattoos but for larger ones the Hoya Conbio system offers 8mm spot size which will cover more surface area quicker. I personally have not tested this system but reports from colleagues tell me it is almost identical to the Hoya Conbio system and should therefore be just as effective.

• Cynosure Accolade (755nm q-switched)

Cynosure Accolade is a newcomer to this space as well and is good for black green and blue ink, but won't treat red ink. It is also fast, shooting at 10hz and a fair sized spot size of 5mm. I don't have any experience with this device except to say that it's specifications look good in theory and should therefore work well.

OTHER DEVICES

• Palomar Q-yag 1064nm/532nm

Q-Yag is seen on tv shows such as nip tuck with unrealistic results. I watched 1 episode where the tat disappeared after 1 treatment. Not possible with ANY device, this is is the result of Hollywood tv production and nothing more. Don't expect 1 treatment to fully remove any tattoo. The Q-Yag is a decent enough device, but it is not as powerful as the Hoya Conbio devices which I rated as best overall. The laser itself is significantly less expensive than the Hoya Conbio to purchase, so the treatments may be cheaper as well. This is something to consider for those of you on a budget. The caveat though, is that cheaper doesn't necessarily mean better. You may pay less per treatment, but you may end up needing more treatments overall.

• Light-Age Q-clear 1064nm

I am sorry to report that the first tattoo removal laser I used was the Q-clear, and though I had high expectations, I found this laser severely underpowered. As an example, we did a treatment for a patient and nothing happened - we couldn't get any reaction with the ink. The same patient was treated by with the Hoya Conbio C6 and we saw an immediate reaction.

• Sinon (formely Wavelight) 694nm ruby

I have not used this device but their lasers look very robust. This type of laser is good for black, blue, green tattoos, but is NOT recommended for darker skin types such as Indian, African-American skin. If you have white skin or light colored skin this laser should work fine. I don't know enough to say more.

• Laser handpieces (part of a platform system such as Harmony, Starlux, Sciton, etc)

There are many platform devices (devices that house more than one device) which offer q-switched laser handpieces. I have tried a few of these and was not very impressed. I would probably rate them on par with the Q-clear, in that they are q-switched devices but they are underpowered.

4. FINAL THOUGHTS

So what would I do if I wanted a tattoo removed?

First, I would find someone with experience doing tattoo removal. Some places offer tattoo removal but rent the lasers - this means that unless a technician comes with the rented laser, the person doing the treatment will not have consistent experience with removal. So find a place that has a laser onsite. Also ask to see before and after

photos (make sure they are not stock photos supplied by the laser company - you should be able to tell the difference).

Second, I would ask the place specifically what laser they plan to use. The ones I listed above in the BEST OVERALL an NEW AND NOTABLE are safe bets. The others should work too but in my opinion, not as effectively.

Third, if I had a multicolor tattoo, I would make sure the doctor/laser center has the correct wavelength laser for the colors in my tattoo. If I have a multicolor tattoo with hard to remove colors (yellow, white, flesh, etc.), I would have to decide if I was ok with having these colors remain while the others were removed.

Fourth, if possible, I would buy a package of laser treatments 4-6 for amateur, and 8-12 for professional tats to lock in the treatment price. At many places, if you buy a package they will agree to treat the tat until it is 90% gone (even if it goes over the agreed upon number of treatments).