Tattooing, which is defined as the permanent insertion of ink or other pigments below the skin using a sharp instrument, has been used for cosmetic and ritual purposes since the Neolithic era. It has been used to identify criminals, invoke magical powers and, most recently, to adorn the skin with colorful designs in what has become a major trend.

Indeed, a recent telephone survey done by the American Academy of Dermatology reports that 36 percent of people between the ages of 18 and 29 are tattooed, and 24 percent of people between the ages of 18 and 50 have been inked. This represents a 16 percent increase over a similar survey done in 2003!

But what happens when that tattoo you thought was so cool 20 years ago just isn't cool anymore?

Yes, tattooing has been around a long time, and something that has always gone along with tattoos since the very beginning is the desire to remove them. Whether the desire to remove the tattoo is a result of social, cultural, or physical reasons, people go to great lengths to get the job done.

Early techniques for removing tattoos included painful and scarring procedures such as sanding, cutting, and burning the skin. Unless you were willing to go to these lengths, tattoos were seen as permanent and irreversible. However, thanks to medical advances in the field of dermatology, surgeons are now able to remove tattoos safely and effectively.

Methods for tattoo removal today include dermabrasion, surgical excision, salabrasion, chemical peels, and laser surgery. Let's examine how tattoos are removed with each of these methods.

Dermabrasion

With dermabrasion, the surface and middle layers of the skin are "sanded" away with a hand-held scraping or sanding tool. This process removes the pigmented skin and encourages the growth of new skin.

Dermabrasion is not for everyone. If the tattoo is old, or if the ink has been injected into the subcutaneous fat, dermabrasion may not work. Also, if the tattoo was done by an amateur and the ink is deposited at varying depths in the skin, complete removal may be difficult.

Side effects include skin discoloration, infection at the site of the tattoo, and scarring from repeated scraping and sanding. Complete removal of all the ink is not always possible.

Until laser surgery was introduced, dermabrasion was considered one of the most popular and effective ways of removing tattoos.

Surgical Excision

Surgical excision is performed under general anesthesia. During the process, the surgeon literally cuts the tattoo out of the skin, and closes the wound with sutures. This technique is more suitable for smaller tattoos.

This is one of the more invasive tattoo removal procedures, and complications include swelling, infection, and scarring.

Chemical Peel

A chemical peel, during which trichloracetic acid is usually used, progressively removes layers of skin, and eventually the tattoo.

Depending upon the age of the tattoo, and whether the ink is evenly distributed, it is not guaranteed that a chemical peel will completely remove a tattoo. Chemical peels can also cause permanent damage to the skin, such as lightening where the design used to be, or scarring.

Salibrasion

Salibrasion is perhaps one of the oldest methods of tattoo removal, and requires the skin to be "sanded" with salt. A local anesthetic is usually injected around the design, and the skin is aggressively rubbed with salt or a salt sanding block.

Complete tattoo removal can't be guaranteed, and the procedure can leave the patient with raw, red, burned skin. Scarring is also a possibility with this method.

Laser Treatment

Laser treatment was introduced in the 1980s, and presented the best alternative to tattoo removal. The CO2 laser beam was used to vaporize the ink and the overlying skin, and was less painful, safer, and much easier than other techniques. However, the technique was not perfect. The healing process was long, there was considerable risk of scarring, and in almost all cases a faint image of the tattoo was left behind.

Q-Switched Lasers

Q-Switched Lasers were introduced about 10 years ago, and have been shown to be the most effective way to date to remove tattoos. Q-switched lasers emit light in very short but powerful flashes, which pass through the skin and break up the tattoo pigment.

Because the absorption of the laser light affects the energy's ability to break up the pigment, different types of q-switched lasers are best used on different colors of pigment.

There are four different types of q-switched lasers:

1.Q-switched ruby lasers have a red light and are effective on most black, blue, and green pigments.

2. Q-switched alexandrite lasers emit a deep red light and are effective for most black, blue, and green pigments.

3. Q-switched Nd:YAG lasers emit an infrared light and are effective on most black and dark blue pigments.

4. Q-switched frequency-doubled Nd:YAG lasers emit a green light and are effective on most red, black, dark blue, and purple pigments.

While tattoo removal with q-switched lasers is completely safe, patients usually experience discomfort on the same scale as receiving the tattoo. A topical anesthetic can be applied one to three hours before treatment. The more treatments the patient has the less pain he or she will feel, as there will be less pigment to absorb the laser energy.

Antibiotic ointment and a light dressing are applied to the area after treatment and normal activity, including showering, can resume the next day. Light blistering or bleeding following the treatment is normal and should subside within a day or two.

All tattoos will require more than one treatment, the average being between five and 10 treatments depending upon the depth of the tattoo, the colors used, the location of the tattoo, and the health of the patient. Fading of the tattoo should be evident about two weeks after treatment, and another treatment can be done as soon as a month later.

While scarring will not occur as a result of q-switched lasers, mild skin texture changes can occur. Darker skinned patients may also experience some skin lightening, though this is usually temporary.

Is it guaranteed that the tattoo will completely disappear when treated with a q-switched laser? Well, because more than 100 tattoo inks are used today, and none of them are regulated by the FDA, it is impossible to predict how a particular ink will respond to laser treatment. However, in most cases the tattoo will completely disappear.

To find a physician board-certified in laser surgery who removes tattoos look in the yellow pages under Cosmetic or Laser Surgery, and/or Tattoo Removal. Or contact the Ethical Cosmetic Surgery Association to find a practitioner in your area.