What are the guidelines for tattoo removal using a ruby 694 laser?

Guidelines for Tattoo Removal Using Ruby 694 Laser

Q-switched ruby laser (694 nm) is the state-of-the-art method for tattoo removal, particularly effective for blue-black and green pigments, with treatment intervals of at least 4 weeks between sessions to minimize risk of permanent pigmentary changes. 1

Mechanism of Action and Effectiveness

• The Q-switched ruby laser operates at a wavelength of 694 nm with pulse duration of approximately 40 nanoseconds, allowing for selective photothermolysis of tattoo pigments 2
• The laser pulse causes extremely rapid heating (up to 900°C/1652°F), leading to fragmentation of tattoo pigment particles without damaging surrounding tissue 1
• Particularly effective for removing blue-black and green pigments, with variable effectiveness for other colors 2, 3
• Amateur tattoos typically require fewer treatment sessions than professional multicolored tattoos 3

Treatment Protocol

• Treatment intervals should be at least 4 weeks apart to allow for phagocytosis and clearance of fragmented pigment particles 1
• Immediately after laser pulse, the epidermis appears white due to water vaporization in the skin 1
• Free pigment becomes intracellular again within 4 weeks, necessitating the waiting period between treatments 1
• Longer intervals between treatments may reduce the risk of permanent pigmentary changes 1
• Local anesthesia (injection or topical) may be used prior to treatment as the procedure can be painful 3

Safety Considerations and Required Training

• Proper training in Q-switched laser use is essential; significant burns can occur within tattoos after improper treatment, leading to scarring and poor outcomes 1
• Providers should be aware of potential toxicologic risks associated with cleavage products formed during laser-assisted tattoo removal 1
• Tattoo particles can be found in regional lymph nodes following treatment 1
• Patients should be informed that tattoo removal is expensive, with costs ranging from $49-$300 per square inch per treatment 1

Expected Outcomes and Complications

• Complete removal may require multiple sessions; one case report documented significant improvement after 47 treatments for large, multicolored tattoos 1
• Common adverse effects include:
  • Transient hypopigmentation and hyperpigmentation (most common) 2, 3
  • Textural changes (less common) 3
  • Scarring (rare with proper technique) 3, 4
• Allergic reactions (both localized and generalized) are unusual complications 3

Patient Selection and Considerations

• The Kirby-Desai score can help estimate the number of sessions needed based on skin type, tattoo colors, and complexity 1
• Patients should be counseled that tattoo removal is expensive, time-consuming, and may not result in complete clearance 1
• Patients with history of keloid formation should be advised of potential scarring risks 1
• Patients should be informed that removal is difficult, expensive, and only partially effective in many cases 1

Special Considerations

• The ruby laser is also effective for removing traumatic tattoos (accidental pigment deposition in skin) 5
• Melanocytic lesions are generally not treated with ruby laser due to risk of incomplete removal and uncertain malignant potential 2
• For multicolored tattoos, combination therapy with different Q-switched lasers may be necessary as no single wavelength can effectively remove all ink colors 3