A simple method of tattoo removal

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Dec 15, 1990 - The treatment ofdecorative tattoos is not new. Many modalities of treatment exist, but none is entirely satisfactory. Our experi- ence with a ...
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SAMJ

VOL 78

15 DEC 1990

A simple method of tattoo removal D. A. HUDSON,

R. U. LECHTAPE-GRUTER

Summary The use of trichloracetic acid in the treatment of decorative ta"oos is described. The technique is simple to perform. No anaesthesia or analgesia is required. Complic~tions are uncommon and usually minor. Trichloracetic acid acts by inflicting a chemical burn. S Atr Med J 1990; 78: 748-749.

The treatment of decorative tattoos is not new. Many modalities of treatment exist, but none is entirely satisfactory. Our experience with a simple method of tattoo removal, which can be performed in any doctor's office, is described. The technique has been described previously;! it involves the use of trichloracetic acid (TCAA), which is painted over the tattoo. No dressings or anaesthesia are required. Complications are uncommon and usually minor. Our results have been satisfactory.

Patients and methods Forty patients (29 men) presented to the Plastic Surgery Outpatients Department at Groote Schuur Hospital requesting tattoo removal during the lO-month period May 1988 - February 1989. There were 3 white, 35 coloured and 2 black patients, average age 34 years (range 18 - 71 years). Tattoos were noted on every part of the body; however, the arms, especially the forearms, were the most common areas (Figs 1 and 2). Two patients had rather unsightly tattoos on their faces. Most of the tattoos had been carried out by amateur tattoo.ists. The reasons for requesting removal varied: 7 patients requested removal for religious reasons (they were of the . Muslim faith); 13 had tattoos indicating affiliation to a 'gang' and wanted to disassociate themselves; and 7 complained of difficulty in obtaining gainful employment. The remainder put forward reasons varying from regret to a desire for an improved cosmetic appearance. The method used for removal was as follows: the area to be treated was initially wiped with a solution of hibitane and then ether, which both cleaned and then removed fatty deposits from the skin - this allowed greater penetration of the TCAA. The tattoos were then 'painted' with a solution of 97% TCAA using an orange stick with a bud of cotton wool on the end. This process was continued until the whole tattoo was covered and the skin assumed a 'white frosting' of hypopigmentation; this occurred irrespective of the ethnic group.

Department of Plastic and Reconstructive Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town D. A. HUDSON, F.R.CS. R. U. LECHTAPE-GRUTER, M.MED. (PLAST. & RECON. SURG.) Reprint requests to: Or R. U. Lechtape-Gruter, Dept of Plastic and Reconsuuctive Surgery, Groot. Schuur Hospital, Observatory 7925, RSA. Accepted 8 May 1990.

Fig. 1. Tattoos before application of TCAA (above). Scar alter two applications of TCAA (below).

The patient usually experienced a tingling sensation for about 20 minutes after applicatiOli. No patient requested cessation of the procedure because of pain. No dressings were applied. The patients were requested to return to the outpatieins department after 1 week for follow-up. Nineteen patients attended outpatients once only. Complications were relatively infrequent and usually of a minor nature. Five patients developed superficial sepsis. Ten patients required a second application of TCAA before tattoo removal was achieved. No patient required a third application. Two patients developed hypopigmented scars. No keloids were noted, despite the variation in ethnic groups. The results were deemed to be satisfactory by 90% of patients. Although the tattoos 'had been satisfactorily removed, a scar was now present, which the patients preferred (Fig. 1, above).

SAMJ

Fig. 2. Tattoos before application of TCAA (above). Scar following over-zealous application of TCAA, which resulted in a deep dermal burn (below).

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Mechanical methods of tattoo removal consist of overtattooing or dermabrasion. 4 This technique requires considerable instrumentation and expertise. Thermic methods include both cautery and cryosurgery "but scarring is unpredictable, often being atrophic and depressed. 5 Furthermore, anaesthesia and analgesia are required. More recently, laser treatment has been reported to be efficacious in tattoo removal. 6 The argon and carbon dioxide laser both yield similar results. The method requires the availability of both expensive equipment and expertise. Chemical methods of tattoo removal have been practised for centuries - way back to the days when pigeon excrement, decomposed urine or mothers' milk were used. 7 TCAA produces a 'controlled' chemical burn - usually a partialthickness burn and this usually heals with eschar formation within 2 - 3 weeks. Tattoo pigment embedded in the epidermis and superficial layers of the dermis is thus removed. Tattoo pigment penetrating into the deep layer of the dermis and subcutaneous fat requires further application of TCAA. In this situation the potential for a full-thickness burn exists with its attendant problems regarding skin cover. In all our cases the burn was small and healed by primary intention. The advantages of this technique are numerous. No anaesthesia or analgesia is required. The technique is easy to perform and no specialised instrumentation is required. No dressings are necessary. Side-effects are uncommon and usually minor. Furthermore, the cost is low, especially as the procedure can always be performed on an outpatient basis. Most of our patients (90%) reported satisfactory results. Even the 2 patients with facial tattoos were satisfied with the outcome. This is consistent with other results using this technique. l There are also disadvantages with TCAA. In 28% of our series a second application was necessary. Repeated application of TCAA may lead to a full-thickness skin burn and the necessity for skin grafting may arise. As stated, we did not encounter this problem, but in another reported series, less than 1% of the patients required a skin graft. 1 Sepsis is another complication and occurred in 8 patients (12,5%). In all cases the sepsis was superficial and responded to the conservative measure of regular dressing with povidone iodine. No keloids formed in the patients in our series. This is surprising, since there were 37 patients with darkly pigmented skins. This group have an increased tendency to keloid formation. However, pigmentary changes did occur. Where a superficial burn was created the patients were often left with a hyperpigmented scar (Fig. lB). In contrast, when a deep dermal or full-thickness burn occurred, a hypopigmented scar was often present (Fig. 2B). The application of TCAA is a simple and effective method of tattoo removal. Disadvantages are usually minor and most patients report satisfactory results.

Discussion _ Numerous methods for the removal of decorative tattoos exist. There is no ideal method and some techniques are both timeconsuming and/or expensive. Surgical removal is a common method. Small linear tattoos· can be excised and closed primarily, whereas larger tattoos may require serial excision. 2 Excision and split-thickness skin grafting is often employed for the large tattoo that has completely penetrated the dermis. Surgical excision, however, can result in considerable morbidity3 and may also be expensive. Often a general anaesthetic is required and, if skin grafting is undertaken, the patient may need to be admitted to hospital for a few days.

REFERENCES 1. Piggot TA, Noms RW. The treatment of tanoos with trichloracetic acid: experience with 670 patients. Br J Plasr Surg 1988; 41: 112-117. 2. Bunche HJ jun., Conway H. Surgery of decorative and traumatic tanoos. Plasr Reconscr Surg 1957; 20: 67-77. 3. McDowell F. Tanoo erasing (Editorial). Plasr Reconscr Surg 1974; 53: 580. 4. Oaburgh W. Tanoo removal by superficial dermabrasion. Plasr Reconscr Surg 1975; 55: 401-405. 5. Apfelberg DB, Manchester GH. Decorative and traumatic tanoo biophysics and removal Clin Plan Surg 1987; 14: 243-251. 6. Apfelberg DB, Maser MR, Lash H. Argon laser treatment of decorative ranoos. Br J Plasr Surg 1979; 32: 141-144. 7. Shie MD. A study of tanooing and methods of removal. JAMA 1928; 90: 94-96.