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Lasers for the removal of tattoos and treatment of pigmented lesions have greatly improved during the last few years. With the advent of picosecond lasers, we now have more options than ever before. We also have newer and more powerful nanosecond lasers. Improved techniques using these devices have also greatly improved our ability to clear tattoos faster and treat resistant colors.

Newer nanosecond lasers such as the QX-MAX (Fotona) have more wavelength options. QX-MAX has four wavelengths: 532nm, 585nm, 650nm, and 1064nm. This is in contrast to two wavelengths available on most other Q-switched lasers. In addition, its higher peak power makes it much more effective on all colors, including resistant colors compared with other traditional nanosecond lasers. The QX-MAX device also comprises a nonablative fractional Nd:YAG handpiece that can be used for priming the tattoo. (This same handpiece is used for photorejuvenation and laser hair removal.)

When used for tattoo removal, the device shatters deep inks, and then the body’s own phagocytes can absorb and remove the particles. The QX-MAX’s single-pulse Q-switched technology generates larger spot sizes that deliver higher fluence deeper in the dermis making it more effective at removing deeper-lying pigment. In sum, large spot sizes at high peak power (short pulse + high fluence) will equal greater success in tattoo removal.

By contrast, low-powered devices will leave a shadow and never fully clear the tattoo, as the laser won’t reach deep enough. The QX-MAX will remove all the colors in half the number of treatment sessions because of the higher peak power compared with other Q-switched nanosecond lasers


•Ablative and Photoacoustic Fractional Priming followed by two to three Full Flat Beam QS passes have proven extremely effective in removing tattoo pigment

•Up to 80 percent tattoo pigment clearing has been achieved three months after a single laser session

•Ablative and Photoacoustic Fractional Priming have shown to be relatively color-blinded inducing consistent pigment reduction in multicolored tattoos

•Positive textural changes have been observed after both Ablative and Photoacoustic Fractional Priming contrib- uting to improve dermal irregularities induced by original tattoo process

•Ablative and Photoacoustic Fractional Priming followed by two to three Full Flat Beam QS passes may be consid- ered the new gold standard in tattoo removal

—M. Christine Lee, MD

Proper Protocol

The R20 method, described by Kossida, et al,1 comprises four treatment passes with an interval of 20 minutes between each pass. I use the R20 method but add a fractional nonablative Nd:YAG or fractional Erbium:YAG prior to beginning treatment with the QX-MAX as described by Marini, et al.2,3 This method of priming the tattoo is called FracTat, which results in pre-drilling of the skin to enable the gases to come out more quickly and thus eliminate the need to wait 20 minutes for frosting clearance. By priming the tattoo with the fractional nonablative Nd:YAG followed by the Q-switched nanosecond 532nm, 585nm, 650nm, or 1064nm wavelengths, an 80 percent reduction of a tattoo after one treatment session is achievable. The R20 method willalways result in faster clearance than the traditional one-pass method but when used with a more powerful laser, such as QX-MAX, this method will result in much faster clearance than it would with a weaker laser.  

Positive textural changes have been observed after both ablative and photoacoustic fractional priming. This contributes to the improvement in dermal irregularities induced by the original tattoo process, and is an added benefit for patients.

When it comes to laser tattoo removal, the QX-MAX is a workhorse. Ablative or photoacoustic fractional priming followed by two to three full flat beam Q-switched passes (R20 method) may be considered the new gold standard in tattoo removal. n

Based on a presentation given at Cosmetic Surgery Forum 2015. Cosmetic Surgery Forum 2016 will be held November 30 to December 4, 2016. For information, visit Dr. Lee has been an advisor for Fotona, Lumenis, Cutera, Syneron, Solta, Ulthera, Cynosure and Iridex.  

Min-Wei Christine Lee, MD is a dermatologic surgeon and director of The Skin and Laser Treatment Institute in Walnut Creek, CA.

1. Kossida T, et al. Optimal tattoo removal in a single laser session based on the method of repeated exposures. J Am Acad Dermatol 2012 Feb; 66:271.

2. Marini, et al. Fractional priming + Q-switches sequential lavering tattoo removal. Lasers in Surgery and Medicine, Supplement 2013 45s25:9

3.Marini, et al. Fractional Er:YAG Skin Conditioning for Enhanced Efficacy of Nd:YAG Q-Switched Laser Tattoo Removal. Journal of the Laser and Health Academy.2012:1

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