Short-pulsed laser for the treatment of tattoos,

pigmented lesions, scars and rejuvenation

Emil A Tanghetti, MD;1 Kristina Andrea Hoffmann, MD;2 and Klaus Hoffmann, MD2

The development and commercialization of the quality-switched

■ Abstract Ruby, the neodymium yttrium aluminum garnet (Nd:YAG) and the
This review describes the use of picosecond lasers for Alexandrite laser in the 1990’s with nanosecond technologies pro-
the treatment of tattoos, pigmented lesions, scars, and
vided a practical and affordable means to remove tattoos with ac-
their use in rejuvenation. These devices have delivered
enhanced efficacy for the treatment of tattoos and ceptable downtime and side effects. The pulse durations of these
pigmented lesions when compared to the older 40-50 devices are in the 6-100 nanosecond ranges. All 3 wavelengths are
nanosecond devices. The fractional delivery with the absorbed by black ink. The Ruby and Alexandrite lasers are also
picosecond devices have opened up a new method of absorbed by green and blue. The Nd:YAG with 532 nm light is
rejuvenation for photodamaged skin and the treatment of absorbed by red, and to a lesser extent, yellow. To effectively treat
scars. The delivery of these high-energy short pulses have most colors, the practitioner is best configured for success with an
created zones of injury in the skin referred to as areas of
Nd:YAG and an Alexandrite or Ruby laser. These devices are in a
laser-induced optical breakdown. These areas of dam-
age appear to produce cytokines and chemokines which range that rapidly heats the inks in the skin resulting in rapid steam
result in epidermal and dermal repair and remodeling. The formation both heating and fragmenting these granules and particles.
dual use of these devices with the flat and the fractional The energies required to achieve clearance do result in unwanted
optics have made these devices useful in many ways that side effects when used in the nanosecond domain. Due to the charac-
have been unanticipated. teristics of the pulse duration, there can be unwanted heating of the
Semin Cutan Med Surg 36:148-154 © 2017 Frontline tattoo ink that could result in textural change and hypopigmentation.
Medical Communications Also, total clearance of professional, heavily inked tattoos or tattoos
over tattoos are difficult to achieve. Even with pulses in the nanosec-
ond domain there is a significant difference in the pulse durations

I
n western culture, tattoos have become a common form of expres- between a 5 ns and a 50 ns device (10 x shorter at 5 ns) which will
sion. Their prevalence has dramatically increased over the last result in better thermal confinement and less unwanted side effects.
2 decades, often lead by sports figures and individuals in the art The potential benefits of pulse durations shorter than those in the
world. As with all forms of expression, the individuals and times nanosecond domain were suggested by Jacques.1 It was postulated
change. These forms of body art can become dated, out of fashion, that picosecond or femtosecond pulses would not only lead to deliv-
and a significant social problem for many. The intended permanence ery of heat, but also a rapid delivery of acoustic energy which would
of this ink in the skin poses a challenge to its removal. Nonspecific cause tensile stress leading to fragmentation of the tattoo particles.
destructive methods such as excision, salabrasion, dermabrasion, A simple analogy would be the heating of a cold glass pan where
and ablative carbon dioxide (CO2) lasers have resulted in significant it is placed in a cold oven and both are heated gradually. However;
scarring and an appearance that is often unattractive. when a cold glass pan is placed in a hot oven, there is a very rapid
An understanding of a tattoo ink in the skin is important in devel- temperature change which can lead to rapid fracturing and breakage
oping a strategy for its removal. India ink is a common agent used of the glass (Figure 2). This concept was explored with experimental
in tattoos. It is largely placed in the papillary and reticular dermis picosecond and femtosecond devices in animals and later in humans
with various needling techniques. After a number of days, the ink is with proof that these devices could clear ink.2,3 Based upon these
taken up by macrophages and histiocytes which then migrate to the findings, providers encouraged individuals in industry to build a
perivascular areas of the dermis. In these cells, the ink is contained commercial device with picosecond pulse widths. Modeling data by
in granules which are 400 to 4,000 nm in diameter. These granules Ho suggested that a pulse duration of 10-100 picosecond would be
are made up of loosely packed particles generally in the range of ideal to treat graphite ink particles.4 However, Ross et al cautioned
40-100 nm in diameter (Figure 1). These data suggest that the ink that the creation of a superficial plasma might pose some limitations
could be targeted as granules as large as 4,000 nm to particles as for the deeper delivery of the energy generated by these devices.3
small as 40 nm. The first commercial picosecond laser was an Alexandrite manu-
factured by Cynosure with a pulse duration of 750 picoseconds. The
1
Center for Dermatology and Laser Surgery, Sacramento, California. most dramatic finding was the rapid clearance of blue and green ink
2
Department of Dermatology, Center of Laser medicine NRW, Bochum, which was previously difficult to clear after many treatments with
Gemany. the 40-50 ns Alexandrite lasers.5 Practitioners could finally deliver
Disclosures: Dr Tanghetti reports other from Cynosure, during the conduct
near complete clearance of blue and green ink, in just a few treat-
of the study. Dr KA Hoffman has nothing to disclose. Dr K Hoffman reports
personal fees and other from Cynosure, from Cutera, during the conduct of ments (Figure 3). This study demonstrated greater than 75% clear-
the study. ances after 1 to 2 treatments with two-thirds of patients achieving
Correspondence: Emil A Tanghetti, MD; [email protected] complete clearances with fluences of 2.0-2.83 J/cm2.5

148 Seminars in Cutaneous Medicine and Surgery, Vol 36, December 2017 1085-5629/13$-see front matter © 2017 Frontline Medical Communications
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 Tanghetti et al

A
B

C D

■ FIGURE 1. Tattoo ink in the skin. Electron microscopy. Courtesy of H. R. Jalian, MD

An early comparative study with this new commercially pro- the side treated with picosecond device after 4 treatment sessions
duced picosecond Alexandrite (Picosure, Cynosure, Inc, Westford, (Figure 5).8,9 Another commercially available picosecond 1064 nm
Massachusetts) was presented by Sierra in 2012.6 This device was Nd:YAG laser (Enlighten, Cutera, Brisbane, California) also has a
compared to two commercially available nanosecond devices: the 2 ns pulse duration option which is recommended for heavily inked
Alexandrite laser (Accolade, Cynosure, Inc, Westford, MA; at 50 tattoos in the first few treatments followed in later sessions by 750
ns) and an Nd:YAG 1064/532 nm (RevLite, Cynosure, Westford, ps pulse duration. Picosecond lasers also enable the provider to
MA; at 5 ns). The picosecond device used in this study was able to treat tattoos at significantly lower fluences than nanosecond devic-
achieve similar clearances than the other two devices operating at the es with less discomfort. All these data suggest that the picosecond
manufacturer’s suggested optimal treatment parameters with half the devices are an improvement over the longer-pulse nanosecond la-
number of treatments and at a significantly lower fluence (Figure 4). sers especially as the ink particles size diminishes with more treat-
In a recent study performed by Pinto et al with a 450 picosecond ments, and that 755 nm picosecond devices may be more effective
1064 nm Nd:YAG versus a 5 ns 1064 nm Nd:Yag, there was no than nanosecond lasers. From a practical view, a picosecond device
significant difference with 2 treatment sessions in tattoos which may not deliver dramatically greater clearance of tattoos in com-
had been previously treated 7. Unfortunately, only two treatments parison to 2-6 ns devices. However, our experience and that from
were administered. In another study by Kono that was conducted the literature would suggest that picosecond lasers do offer a dra-
with the 450 picosecond 1064 nm Nd:YAG 50 ns Alexandrite and matic difference in results over 40-50 ns devices.
a 50 ns Nd:YAG, there was greater black pigment clearance on
Challenges to treating tattoos
The proper treatment of tattoos is more challenging than gener-
ally believed. The issue at hand is the lack of a“Standard-tattoo.”
Neither the process of injecting the ink into the skin, nor the tattoo
dye itself is in any form standardized. In Europe, through legis-
lation passed by the European Union, an index displaying which
substances are not to be used in tattoo dyes exists. In the United
States, a comparable list has not been developed.
The tattoo artist places the ink in the skin with various needles
which in themselves can be of different size, grind and thickness.
With a special tattoo gun, the artist can set up the frequency at which
the needle is supposed to penetrate the skin as well as the depth into
which the ink is injected. The pressure applied onto the skin, the
retention time of the needle at a specific location as well as sev-
eral other factors determine how much pigment is injected and into
which depth of the skin they are placed. Appropriate aftercare is es-
■ FIGURE 2. Heating and fragmentation example
sential. If the tattoo is not properly treated, there is a risk of infection

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 ■ ■ ■ Short-pulsed laser for the treatment of tattoos, pigmented lesions, scars and rejuvenation

■ FIGURE 5. 755 nm alexandrite laser (TriVantage TM by Candela

Corporation) using the 50 ns vs 755 nm alexandrite laser (Pico-
sure TM by Cynosure Corporation) using the 550-750 psec. Cour-
tesy of Taro Kono MD

■ FIGURE 3. Courtesy of R. Saluja, MD Before initiating treatment, it is important to determine if the

tattoo is a cover-up over an older preexisting tattoo. These can be
and scar formation. Most tattoo artists, as well as their customers, challenging to treat, especially when the added ink is done by a
are typically unaware of the contents of the color being used; yet, it professional where the placement of the ink is done densely and
is easy to understand that among the population wishing to have a sometimes more deeply. If a variety of wavelengths are available,
tattoo removed, this information can be very important. Tattoo dyes it would be ideal to administer a series of test spots prior to a com-
consist of binders, solvents and excipients in addition to the pigment. plete treatment session.
The tattoo pigment (dye) constitutes less than 30% of what the artist Squares of 1 cm² (1 cm x 1 cm) are treated. Four weeks later we
is transferring from the ampulla into a vial then into the skin. There judge the effect of the test session and recommend the best wavelength
is a strong suspicion that the excipients play a major role in the pro- for further treatments. If we feel that the ink is more deeply situated,
cess of the pigment integration in the skin. we often prefer to use a 1064 nm wavelength due to the increased
depth of penetration and the higher energy available with our device.
Applying the evidence: how we treat patients Overall, we stress to our patients that several treatment sessions are
When we see patients at our institutions, one of the most crucial necessary and that the effects are unpredictable. This sets the stage for
questions is whether it is an amateur or professional tattoo. Tattooists a realistic and ultimately content patient after treatment.
working professionally are usually more precise with the amount of Since each patient has a different threshold for pain, the level of
pigment injected and the depth of placement. The age of the tattoo is discomfort experienced will be different from patient to patient.
also very important. Older tattoos generally fade with time and may While topical anesthetics help minimize the pain, it is important
require less treatment sessions. During the process of degradation that they do not alter the penetration of light through the skin. They
of a colorful tattoo, cleavage products form where the injected dye must be thoroughly removed and the area cleaned before tattoo
splits and the tattoo fades. The ink particles are recognized as a for- removal. We often use forced cool air as an adjunct to tattoo re-
eign body and are engulfed by macrophages and other inflammatory moval primarily for its anesthetic properties. We also use the local
cells, which are distributed perivascularly in the dermis. This entire infiltration of anesthetics with epinephrine to help reduce the pain
process results in an altered faded appearance of the tattoo. and diminish bleeding. Generally, we treat at 4-week intervals.
However, waiting for 2 to 3 months can be helpful in its own right
due to the continued removal of ink in the skin during the healing
process. In our practice, we have found that our picosecond lasers
result in less tissue damage than our older nanosecond devices, and
as a consequence are much better tolerated.

Fractional delivery of picosecond pulses

During the commercialization of the first picosecond Alexandrite
laser for tattoo treatments, the Cynosure team responsible for this
device developed a diffractive lens array to deliver the short-pulsed,
high energy in a fractional manner. The developers hoped that it
■ FIGURE 4. Clinical Results – Benchmarked visibility percentage would be useful as a rejuvenation tool. In our own practice with the
graded by blinded evaluators comparing split treatment clinical Alexandrite laser with diffractive lens array, many of us noted skin
photos vs digitally processed pretreatment photos with 0, 20, 40, lightening, scar pigment and texture improvement, pore size reduc-
60, 80 and 100% pigment removed digitally
tion and improvement in photodamage. These initial findings were

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■ FIGURE 8. Focus lens array

■ FIGURE 6. Brazilian Skin Type:IV MI:27 - 6 mm fractional optic
todamage involving the neck and chest regions with this device
validated in clinical studies by Brauer demonstrating improvement and optic.14,15 In particular, improvement of dyspigmentation, tex-
in acne scars.10 These investigations included patients of all skin ture, and fine wrinkles are seen after a series of 3 to 5 treatments
types demonstrating safety and efficacy in these individuals. The at monthly intervals. Saluja has successfully used the picosecond
darker skin types including skin types IV, V, and VI responded lens array for the treatment of photodamage of the hands with no-
well to multiple passes and sessions without the postprocedural table improvement in dyspigmentation and texture (Figure 8).15
dyspigmentation that was all too common with the other ablative These studies validate the efficacy and safety of this device in the
and nonablative devices.11 In addition to improvements to the acne treatment of conditions of many anatomic areas.
scars, a gradual lightening of the skin was appreciated when treat- The clinical improvements seen with the 755 nm picosecond la-
ing darker skin types (Figure 6). When studied in Asian patients, ser and the defractive lens array appear to be well-correlated with
similar improvement in scars, tone, texture, pore size, and pigmen- the production of new collagen, elastic tissue, and mucin in the
tation were observed.12 The minimal down time and the absence of dermis. This was observed in skin biopsies performed 3 months
postprocedural dyspigmentation made this particularly appealing after 6 treatment sessions.10 The histologic studies performed by
in the Asia-Pacific region.
Furthermore, McDaniel and Weiss investigated this device on
patients with photodamage and demonstrated improvement in fine
wrinkles, mottled hyperpigmentation, lentigines, skin tone, and
texture.13 Generally, improvement is noted over 4 to 5 treatment
sessions. The posttreatment profile of this device is particularly ap-
pealing to patients who require minimal down time. The series of
photos as seen in (Figure 7) by McDaniel is an accurate represen-
tation of the mild postprocedural erythema that usually lasts for a
few hours. There is generally mild discomfort associated with this
procedure, sometimes requiring only topical anesthesia.
The use of the picosecond Alexandrite with the diffractive lens
array has been also used as a rejuvenation tool in areas that are
very sensitive and prone to scarring with more aggressive lasers.
Recent studies have demonstrated significant improvement in pho-

■ FIGURE 9. Intra-epidermal vacuole in skin with FST III, MI = 23

■ FIGURE 7. Clinical appearance with the picosecond Alexan- measuring approximately 60 microns in diameter. Biopsy per-
drite and the defractive lens array formed 10 minutes posttreatment.

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 ■ ■ ■ Short-pulsed laser for the treatment of tattoos, pigmented lesions, scars and rejuvenation

is confined to a very small portion of the epidermis and results in a

very localized area of heating with the formation of a small steam
ball, thereby producing the voids seen on histology (Figure12).
In an attempt to better understand the physiological consequences
of this unique injury to the skin, Tanghetti and Tartar studied the
thermal signatures of the picosecond Alexandrite with the diffractive
lens array over a 24-hour period. There was no significant tempera-
ture rise by pulsing with 4 consecutive passes or 4 passes with 1 min-
ute between each pass when evaluated with a thermal camera.17,18
However, beginning 15 minutes and peaking at 1 hour, there was
a significant temperature elevation of 5.6 degrees centigrade from
baseline which dissipated over 24 hours. The histology of a localized
A B epidermal injury with notable delayed temperature rise all suggest
■ FIGURE 10. (A) Approximately 40 microns below the skin sur- that a well-placed epidermal injury can produce a number of chemi-
face small vacuoles are seen in the epidermis corresponding to cal mediators which could be responsible for the temperature eleva-
the vacuoles noted on microscopic examination. (B) Connecting tion as well as the delayed production of collagen and elastic tissue
these spaces reveals a grid pattern of the fractional optic with that has been described with the use of this device. It is not surprising
similar pitch.
that dermal remodeling can occur without dermal wounding since
Kang and others have reported improvements with long-standing
Tanghetti provided some clues to the type of injury that is respon- acne scars with the use of a topical retinoid.18
sible for the clinical improvement seen with the Alexandrite laser
and a defractive lens array.16 Immediately following the treatment
with this device and optic there are circular voids observed in the
epidermis measuring 40-60 microns in diameter (Figure 9). They
are centered in the granular layer of the epidermis. The surround-
ing keratinocytes are intact. The basement membrane and the stra-
tum corneum are preserved. At 24 hours after the treatment, this
space is occupied by cellular debris which stains positively for
melanin suggesting that melanin is the target of this device. When
studied with a confocal microscopy, these vacuoles are observed
in a pattern that corresponds to the treatment grid of the fractional
diffractive lens array (Figure 10).
This diffractive lens array consists of individual lenses with 500
micron center to center lens distance which results in the delivery
of the short-pulsed laser energy in a low-fluence background and
A B
high-energy micro spots. Approximately 70% of the fluence is de-
livered in these high-energy zones and 30% in a low-energy back-
ground (Figure 11). This high-powered, short-pulsed delivery of
laser light appears to result in a localized area of plasma formation
by the absorption of this 755 nm energy by melanin. This process

C D

■ FIGURE 12. Process of vacuole formation in the epidermis: (A) A

high-intensity portion of the laser beam created by the diffractive
lens array irradiates a region of the skin. A seed electron is eject-
ed from an absorber (melanin); (B) The number of free electrons
grows in an avalanche process. Electron plasma density increas-
es absorbing energy from the beam; (C) The laser beam termi-
■ FIGURE 11. Fluence distribution in the treatment plane on the nates leaving a hot plasma ball.The plasma ball rapidly heats the
skin surface. Treatment spot size 6 mm, average fluence setting surrounding tissue above boiling temperature; (D) Steam expan-
0.71 J/cm² sion creates a vacuole in the epidermis

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 Tanghetti et al

■ TABLE. Wavelength comparison chromophore effects

Wavelength, nm 532 1064 755

Melanin abs, cm-1 555 50 3.0

Blood abs, cm -1
235 3.2 54:1
Melanin: Blood abs, ratio 2.4:1 16:1
Epid. Melanin % 2% 15% 43% 2% 15% 43% 2% 15% 43%
LIOB Thresh, J/cm2 2.8 2.7 2.6 31 30 29 9.5 9.1 8.8
Blood Team rise, °C 172 105 40 28 25 22 7.8 6.5 4.8
Abbreviations: abs, absorption; Epid, Epidermal; LIOB, laser-induced optical breakdown.

•M
 odeling calculation for LIOB threshold fluence and corresponding blood temperature rise for capillaries near the dermal/
epidermal junction.
•M
 elanin and blood absorption at 755nm offer the best compromise and lead to the lowest blood temperature rise at the LIOB
threshold fluence or higher

The introduction of a family of picosecond Nd:YAG lasers with Conclusion

wavelengths at 532 nm and 1064 nm provided an opportunity to in- This review demonstrates that the new high-energy, short-pulsed
vestigate the delivery of this energy to the skin in a fractional man- commercially available picosecond lasers at 755 nm, 532 nm and
ner. There is significant absorption of energy by melanin at these 1064 nm are an important addition to our therapeutic tool chest.
2 wavelengths. Our team first worked on a comparison of 755 nm, These shortened pulse durations have permitted practitioners to ob-
532 nm and 1064 nm picosecond laser light delivered to the skin tain enhanced clearances of tattoos with less textural changes and
with a diffractive lens array.19 We found that there was persistent scarring due to the photomechanical properties of the picosecond
erythema with areas of petechial hemorrhage lasting for several relative to the longer nanosecond pulses. The fractional delivery
days with 532 nm and 1064 nm compared to the transient erythema of energy of this high-energy, short-pulse laser light has opened
lasting 24 hours or less with 755nm. The histological examination up a new avenue of treatment by the creation of a unique epider-
demonstrated focal areas of epidermal necrosis in the form of a mal injury which appears to result in both epidermal and dermal
vacuole with scattered areas of superficial dermal vascular damage remodeling through factors generated during and after treatment.
with extravasation of red blood cells. This was noted across all This type of treatment is particularly well suited for individuals
skin types with the 532 nm and the 1064 nm diffractive lens. This with darker skin types with high epidermal melanin content who
was in contrast to the regularly spaced epidermal vacuoles with the are prone to dyspigmentation with other more invasive devices.
absence of dermal hemorrhage at 755 nm.
These investigations were repeated with a direct histological and References
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