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WIKIMAG n. 6 - Maggio 2013
Tattoo removal
Text is available under the
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Traduzione
interattiva on/off
- Togli il segno di spunta per disattivarla
Tattoo removal has been performed with various tools during
the history of tattooing. While
tattoos
were once considered permanent, it is now possible to remove them with
treatments, fully or partially.
Pre-laser tattoo removal methods include
dermabrasion, TCA (Trichloroacetic
acid, an acid that removes the top layers of skin, reaching as deep
as the layer in which the tattoo ink resides), salabrasion (scrubbing
the skin with
salt),
cryosurgery and
excision which is sometimes still used along with skin grafts for
larger tattoos. Some early forms of tattoo removal included the
injection or application of wine, lime, garlic or pigeon excrement.
Tattoo removal by
laser was
performed with continuous-wave lasers initially, and later with
Q-switched lasers, which became commercially available in the early
1990s. Today, "laser tattoo removal" usually refers to the non-invasive
removal of tattoo pigments using Q-switched lasers. Typically, black and
darker colored inks can be removed more completely.
Motivation for tattoo removal
A poll conducted in January 2012 by Harris Interactive reported that
1 in 8 (14%) of the 21% of American adults who have a tattoo regret
getting one. The poll didn't report the reasons for these regrets, but a
poll that was done 4 years prior reported that the most common reasons
were "too young when I got the tattoo" (20%), "it's permanent" and "I'm
marked for life" (19%), and "I just don't like it" (18%). An earlier
poll showed that 19% of Britons with tattoos suffered regret, as did 11%
of Italians with tattoos.[1]
Surveys of tattoo removal patients were done in 1996 and 2006 and
provided more insight. Of those polled, the patients who regretted their
tattoos typically obtained their tattoos in their late teens or early
twenties, and were evenly distributed by gender. Among those seeking
removals, more than half reported that they "suffered embarrassment". A
new job, problems with clothes, and a significant life event were also
commonly cited as motivations.[2]
The choice to get a tattoo that is later regretted is related to the
end-of-history illusion, in which teenagers and adults of all ages
know that their tastes have changed regularly over the years before the
current moment, but believe that their tastes will somehow not continue
to grow and mature in the future.[3]
As a result, they wrongly believe that any tattoo that appeals to them
today will always appeal to them in the future.
Cover-up
Some wearers decide to cover an unwanted tattoo with a new tattoo.
This is commonly known as a cover-up. An artfully done cover-up may
render the old tattoo completely invisible, though this will depend
largely on the size, style, colors and techniques used on the old tattoo
and the skill of the tattoo artist. Covering up a previous tattoo
necessitates darker tones in the new tattoo to effectively hide the
older, unwanted piece. Many tattoos are too bright to cover up and in
those cases patients may receive laser tattoo removal to lighten the
existing ink to make themselves better candidates for a cover up tattoo.
Of course, replacing a tattoo with another tattoo does not rectify
issues regarding the stigma (or in some cases discrimination) connected
to having a tattoo in the first place.
Methods
Tattoo removal is most commonly performed using lasers that break
down the ink in the tattoo. The broken-down ink is then absorbed by the
body, mimicking the natural fading that time or sun exposure would
create. All tattoo pigments have specific light absorption spectra. A
tattoo laser must be capable of emitting adequate energy within the
given absorption spectrum of the pigment to provide an effective
treatment. Certain tattoo pigments, such as yellows, greens and
fluorescent inks are more challenging to treat than darker blacks and
blues, because they have absorption spectra that fall outside or on the
edge of the emission spectra available in the tattoo removal laser.
Widely considered the gold standard treatment modality to remove a
tattoo, laser tattoo removal requires repeat visits. The newer
Q-switched lasers are said by the
National Institutes of Health to result in scarring only rarely and
are usually used only after a
topical anesthetic has been applied. Areas with thin skin will be
more likely to scar than thicker-skinned areas. There are several types
of Q-switched lasers, and each is effective at removing a different
range of the
color spectrum. Lasers developed after 2006 provide multiple
wavelengths and can successfully treat a much broader range of tattoo
pigments than previous Q-switched lasers.
The amount of energy (flounce/joules/jcm2) is determined prior to
each treatment as well as the spot size and treatment speed (Hz/hertz).
To mitigate pain the preferred method is simply to cool the area during
treatment with a medical-grade chiller/cooler and to use a topical
anesthetic. During the treatment process the laser beam passes
harmlessly through the skin, targeting only the ink resting in a liquid
state within. While it is possible to see immediate results, in most
cases the fading occurs gradually over the 7–8 week healing period
between treatments.[4]
Mechanism
of laser action
Experimental observations of the effects of short-pulsed lasers on
tattoos were first reported in the late 1960s.[5]
In 1979 an argon laser was used for tattoo removal in 28 patients, with
limited success. In 1978 a carbon dioxide was also used, but generally
caused scarring after treatments[6]
It was not until the late 1980s that Q-switched lasers became
commercially practical. One of the first published articles describing
laser tattoo removal was authored by a group at
Massachusetts General Hospital in 1990.[7]
Tattoos consist of thousands of particles of tattoo pigment suspended
in the skin.[8]
While normal human growth and healing processes will remove small
foreign particles from the skin, tattoo pigment particles are permanent
because they are too big to be removed. Laser treatment causes tattoo
pigment particles to heat up and fragment into smaller pieces. These
smaller pieces are then removed by normal body processes.
Laser tattoo removal is a successful application of the theory of
selective photothermolysis (SPTL).[9]
For laser tattoo removal, SPTL for the selective destruction of tattoo
pigments depends on four factors:
- The color of the light must penetrate sufficiently deep into the
skin to reach the tattoo pigment.
- The color of the laser light must be more highly absorbed by the
tattoo pigment than the surrounding skin. Different tattoo pigments
therefore require different laser colors. For example, red light is
highly absorbed by green tattoo pigments.
- The time duration (pulse duration) of the laser energy must be
very short, so that the tattoo pigment is heated to fragmentation
temperature before its heat can dissipate to the surrounding skin.
Otherwise, heating of the surrounding tissue can cause burns or
scars. For laser tattoo removal, this duration should be on the
order of nanoseconds.
- Sufficient energy must be delivered during each laser pulse to
heat the pigment to fragmentation. If the energy is too low, pigment
will not fragment and no removal will take place.
Q-switched lasers are the only commercially available devices that
can meet these requirements.[10]
Although they occur infrequently, mucosal tattoos can be successfully
treated with Q-switched lasers as well.[11]
A novel method for laser tattoo removal using a fractionated CO2 or
Erbium:YAG laser, alone or in combination with Q-switched lasers, was
reported by Ibrahimi and coworkers from the Wellman Center of
Photomedicine at the Massachusetts General Hospital.[12]
This new approach to laser tattoo removal may afford the ability to
remove colors such as yellow and white, which have proven to be
resistant to traditional Q-switched laser therapy.
Laser parameters that affect results
Several colors of laser light (measured as wavelengths of laser
energy) are used for tattoo removal, from visible light to near-infrared
radiation. Different lasers are better for different tattoo colors.
Consequently, multi-color tattoo removal almost always requires the use
of two or more laser wavelengths. Tattoo removal lasers are usually
identified by the lasing medium used to create the wavelength (measured
in nanometers (nm)):
- Q-switched Frequency-doubled Nd:Yag: 532 nm. This laser creates
a green light which is highly absorbed by red and orange targets.
Useful primarily for red and orange tattoo pigments, this wavelength
is also highly absorbed by melanin (the chemical which gives skin
color or tan) which makes the laser wavelength effective for age
spot or sun spot removal.
- Q-switched Ruby: 694 nm. This laser creates a red light which is
highly absorbed by green and dark tattoo pigments. Because it is
more highly absorbed by melanin this laser may produce undesirable
side effects such as pigmentary changes for patients of all but
white skin.[13]
- Q-switched Alexandrite: 755 nm. The weakest of all the
q-switched devices and somewhat similar to the Ruby laser in that
the Alexandrite creates a red light which is highly absorbed by
green and dark tattoo pigments. However, the alexandrite laser color
is slightly less absorbed by melanin, so this laser has a slightly
lower incidence of unwanted pigmentary changes than a ruby laser.[14]
This laser works well on green tattoos but because of its weaker
peak power it works only moderately well on black and blue ink. It
does not work at all on red, orange, brown, etc.
- Q-switched Nd:YAG: 1064 nm. This laser creates a near-infrared
light (invisible to humans) which is poorly absorbed by
melanin, making this the only laser suitable for darker skin.
This laser wavelength is also absorbed by all dark tattoo pigments
and is the safest wavelength to use on the tissue due to the low
melanin absorption and low
hemoglobin absorption. This is the wavelength of choice for
tattoo removal in darker skin types.
- Dye modules are available for some lasers to convert 532 nm to
650 nm or 585 nm light which allows one laser system to safely and
effectively treat multi-color tattoo inks. The role of
dye lasers in tattoo removal is discussed in detail in the
literature.[15]
Pulsewidth or pulse duration is a critical laser parameter. All
Q-switched lasers have appropriate pulse durations for tattoo removal.
However, lasers with a shorter pulses have a safer and more efficient
removal method because the peak power of the pulse is greater.
Spot size, or the width of the laser beam, affects treatment. Light
is optically scattered in the skin, like automobile headlights in fog.
Larger spot sizes slightly increase the effective penetration depth of
the laser light, thus enabling more effective targeting of deeper tattoo
pigments. Larger spot sizes also help make treatments faster.
Fluence or energy level is another important consideration. Fluence
is measured in joules per square centimeter (J/cm²). It is important to
get treated at high enough settings to fragment tattoo particles.
Repetition rate helps make treatments faster but is not associated
with any treatment effect.
Number of laser tattoo removal treatment sessions needed
Complete laser tattoo removal requires numerous treatment sessions,
typically spaced at least seven weeks apart. Treating more frequently
than seven weeks increases the risk of adverse effects and does not
necessarily increase the rate of ink absorption. Anecdotal reports of
treatments sessions at four weeks leads to more scarring and dischromia
and can be a source of liability for clinicians. At each session, some
but not all of the tattoo pigment particles are effectively fragmented,
and the body removes the smallest fragments over the course of several
weeks. The result is that the tattoo is lightened over time. Remaining
large particles of tattoo pigment are then targeted at subsequent
treatment sessions, causing further lightening. The number of sessions
and spacing between treatments depends on various parameters, including
the area of the body treated and skin color. Tattoos located on the
extremities, such as the ankle, generally take longest. As tattoos fade
clinicians may recommend that patients wait many months between
treatments to facilitate ink resolution and minimize unwanted side
effects.
The amount of time required for the removal of a tattoo and the
success of the removal varies with each individual. Factors influencing
this include: skin type, location, color, amount of ink, scarring or
tissue change, and layering. In the past health care providers would
simply guess on the number of treatments a patient needed which was
rather frustrating to patients. A predictive scale, the "Kirby-Desai
Scale", was developed by Dr.
Will Kirby and Dr. Alpesh Desai, dermatologists with specialization
in tattoo removal techniques, to assess the potential success and number
of treatments necessary for laser tattoo removal, provided the medical
practitioner is using a quality-switched Nd:YAG (neodymium-doped yttrium
aluminum garnet) laser incorporating selective photothermolysis with six
weeks between treatments.
The Kirby-Desai Scale assigns numerical values to six parameters:
skin type, location, color, amount of ink, scarring or tissue change,
and layering. Parameter scores are then added to yield a combined score
that will show the estimated number of treatments needed for successful
tattoo removal. Experts recommend that the Kirby-Desai scale be used by
all laser practitioners prior to starting tattoo removal treatment to
help determine the number of treatments required for tattoo removal and
as a predictor of the success of the laser tattoo removal treatments.[16]
Prior to 2009, clinicians had no scientific basis by which to estimate
the number of treatments needed to remove a tattoo and the use of this
scale is now standard practice in laser tattoo removal.
A study referred to as the R20 method showed that four passes with
the laser, twenty minutes apart, caused more breaking up of the ink than
the conventional method. In this limited study performed in Greece it
was reported that this technique created no more scarring or adverse
effects than traditional methods and it removed more ink than a single
pass. However, this study was performed on a very small patient
population (12 patients total) using the weakest of the QS lasers, the
755 nm Alexandrite laser. One of the main problems with this study, in
addition to the limited number of patient participants, was the fact
that more than half of the 18 tattoos were not professional and amateur
tattoos are always easier to remove. Proof of concept studies are
underway but many laser experts advise against the R20 method using the
more modern and powerful tattoo removal lasers available at most offices
as an increase in adverse side effects including scarring and dischromia
are likely. Patients should inquire about the laser being used if the
R20 treatment method is offered by a facility as it is usually only
offered by clinics that are using the weak 755 nm Alexandrite as opposed
to the more powerful and versatile devices that are more commonly used.
Moreover, dermatologists offering the R20 method should inform patients
that it is not a gold standard treatment method.
Factors contributing to the success of laser tattoo removal
Multiple factors contribute to the success of laser tattoo removal,
one of which is a patient's own immune system. The Kirby-Desai scale
parameters qualify the factors that can dictate tattoo removal success.
Moreover, treatment on some patients with immune systems problems are
contraindicated.[17]
Pain
management during treatment
Laser tattoo removal can be uncomfortable but is very tolerable in
most cases. The pain is often described to be similar to that of hot oil
on the skin, or a "slap" from an elastic band. Depending on the
patient's
pain threshold, and while some patients may forgo anesthesia
altogether, most patients will require some form of local anesthesia.
Pre-treatment might include the application of an anesthetic cream under
occlusion for 45 to 90 minutes prior to the laser treatment session. In
very rare cases, if complete anesthesia is necessary, it can be
administered locally by injections of 1% to 2% lidocaine with
epinephrine. Anecdotal reports however have noted that patients
receiving anesthesia by local injection may require additional treatment
as the injection causes
mechanical edema, a spreading out of the tattoo ink, which in turn
makes it more difficult for the laser light to act on specific ink
particles and thus, experts in the laser tattoo removal field caution
against injecting anesthetic as these injections may also increase the
risk of scarring and/or additional treatment.[18]
Post-treatment considerations
Immediately after laser treatment, a slightly elevated, white
discoloration with or without the presence of punctuate bleeding is
often observed. This white color change is thought to be the result of
rapid, heat-formed steam or gas, causing dermal and epidermal
vacuolization. Pinpoint bleeding represents vascular injury from
photoacoustic waves created by the laser's interaction with tattoo
pigment. Minimal edema and
erythema of adjacent normal skin usually resolve within 24 hours.
Subsequently, a crust appears over the entire tattoo, which sloughs off
at approximately 14 days post-treatment. As noted above, some tattoo
pigment may be found within this crust. Post-operative wound care
consists of simple wound care and a non-occlusive dressing. Since the
application of laser light is sterile there is no need for topical
antibiotics. Moreover, topical antibiotic ointments can cause allergic
reactions and should be avoided. Fading of the tattoo will be noted over
the next eight weeks and re-treatment energy levels can be tailored
depending on the clinical response observed.[18]
Side
effects and complications
About half of the patients treated with Q-switched lasers for tattoo
removal will show some transient changes in the normal skin
pigmentation. These changes usually resolve in 6 to 12 months but may
rarely be permanent.[19]
Hyperpigmentation is related to the patient's
skin tone, with skin types IV, V and VI more prone regardless of the
wavelength used. Twice daily treatment with hydroquinones and
broad-spectrum sunscreens usually resolves the hyperpigmentation within
a few months, although, in some patients, resolution can be prolonged.[19]
Transient textural changes are occasionally noted but often resolve
within a few months; however, permanent textural changes and scarring
very rarely occur. If a patient is prone to pigmentary or textural
changes, longer treatment intervals are recommended. Additionally, if a
blister or crust forms following treatment, it is imperative that the
patient does not manipulate this secondary skin change. Early removal of
a blister of crust increases the chances of developing a scar.
Additionally, patients with a history of hypertrophic or keloidal
scarring need to be warned of their increased risk of scarring.
Local allergic responses to many tattoo pigments have been reported,
and allergic reactions to tattoo pigment after Q-switched laser
treatment are also possible. Rarely, when yellow cadmium sulfide is used
to "brighten" the red or yellow portion of a tattoo, a photoallergic
reaction may occur. The reaction is also common with red ink, which may
contain cinnabar (mercuric sulphide). Erythema, pruritus, and even
inflamed nodules, verrucose papules, or granulomas may present. The
reaction will be confined to the site of the red/yellow ink. Treatment
consists of strict sunlight avoidance, sunscreen, interlesional steroid
injections, or in some cases, surgical removal. Unlike the destructive
modalities described, Q-switched lasers mobilize the ink and may
generate a systemic allergic response. Oral antihistamines and
anti-inflammatory steroids have been used to treat allergic reactions to
tattoo ink.
Studies of various tattoo pigments have shown that a number of
pigments (most containing iron oxide or titanium dioxide) change color
when irradiated with Q-switched laser energy. Some tattoo colors
including flesh tones, light red, white, peach and light brown
containing pigments as well as some green and blue tattoo pigments,
changed to black when irradiated with Q-switched laser pulses. The
resulting gray-black color may require more treatments to remove. If
tattoo darkening does occur, after 8 weeks the newly darkened tattoo can
be treated as if it were black pigment.[20]
Very rarely, non Q-switched laser treatments, like CO2 or Argon
lasers, which are very rarely offered these days, can rupture blood
vessels and aerosolizes tissue requiring a plastic shield or a cone
device to protect the laser operator from tissue and blood contact.
Protective eye-wear may be worn if the laser operator choose to do so.
With the mechanical or salabrasion method of tattoo removal, the
incidence of scarring, pigmentary alteration (hyper- and
hypopigmentation),and ink retention are extremely high.[21]
The use of Q-switched lasers could very rarely produce the
development of large
bulla[disambiguation
needed]. However, if patients follow post care
directions to elevate, rest, and apply intermittent icing, it should
minimize the chances of bulla and other adverse effects. In addition,
health care practitioners should contemplate the use of a cooling device
during the tattoo removal procedure. While the infrequent bulla
development is a possible side effect of Q-switched laser tattoo
removal, if treated appropriately and quickly by the health care
practitioner, it is unlikely that long term consequences would ensue.[22]
Risks
Although laser treatment is well known and often used to remove
tattoos, unwanted side effects of laser tattoo removal include the
possibility of discoloration of the skin such as hypopigmentation (white
spots, more common in darker skin) and hyperpigmentation (dark spots) as
well as textural changes - these changes are usually not permanent when
the Nd:YAG is used but it is much more likely with the use of the 755 nm
Alexandrite and the R20 method.. Very rarely, burns may result in
scarring but this usually only occurs when patients don't care for the
treated area properly. Rarely, "paradoxical darkening" of a tattoo may
occur, when a treated tattoo becomes darker instead of lighter. This
seems to occur more often with flesh tones, pink, and cosmetic make-up
tattoos.[23][24]
Some tattoo pigments contain metals that could theoretically break
down into toxic chemicals in the body when exposed to light. This has
not yet been reported in vivo but has been shown in laboratory tests.
Laser removal of traumatic tattoos may similarly be complicated
depending on the substance of the pigmenting material. In one reported
instance, the use of a laser resulted in the ignition of embedded
particles of firework debris.[25]
References
-
^
Harris Interactive Europe Poll
-
^ Armstrong ML, et
al., Motivation for contemporary tattoo removal: a shift in
identity. Arch Dermatol. 2008 Jul;144(7):879–84.
-
^
Tierney, John (4 January 2013).
"You Won’t Stay the Same, Study Finds". The New York
Times. Retrieved 6
January 2013.
-
^ Kirby W, Holmes E,
Desai A, Desai T. Best Clinical Practices in Laser Tattoo
Removal: Tips for improving patient outcomes and managing
patient expectations. The Dermatologist, June 2012: 23-28.
-
^ Goldman L. et al.
Effect of the laser beam on skin. J Invest Dermatol. 1963;40:
pp. 121–122.
-
^ Kirby, William,
Desai, Alpesh, Desai, Tejas, Kartona, Francisa, Tattoo Removal
Techniques: Effective Tattoo Removal Treatments - Part 1,
Skin and Aging, September 2005.
-
^ Taylor C.R. et
al., Treatment of tattoos by Q-switched ruby laser. A
dose-response study. Arch Dermatol. 1990 Jul;126(7): pp. 893–9.
-
^ Kilmer SL, Garden
JM. Laser treatment of pigmented lesions and tattoos. Semin
Cutan Med Surg. 2000 Dec;19(4):239.
-
^ Anderson RR,
Parrish JA. Selective photothermolysis: precise microsurgery by
selective absorption of pulsed radiation. Science. 1983 Apr
29;220(4596):524–7.
-
^ Kilmer SL. Laser
treatment of tattoos. Dermatol Clin. 1997 Jul;15(3):409–17.
-
^ Kirby W, Chen C,
Desai A, Desai T. Successful Treatment of Cosmetic Mucosal
Tattoos Via Q-Switched Laser. Dermatologic Surgery, December
2011.
-
^
Ibrahimi OA, Syed Z, Sakamoto FH,
Avram MM, Anderson RR. (June 2011).
"Treatment of tattoo allergy with ablative fractional
resurfacing: a novel paradigm for tattoo removal". J Am
Acad Dermatol. 64 (6): 1111–1114.
doi:10.1016/j.jaad.2010.11.005.
PMID 21571169
PMID 21571169.
-
^ Kilmer SL,
Anderson RR. Clinical use of the Q-switched ruby and the
Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of
tattoos. J Dermatol Surg Oncol. 1993 Apr;19(4):330–8.
-
^ Alster TS.
Q-switched alexandrite laser treatment (755 nm) of professional
and amateur tattoos. J Am Acad Dermatol. 1995
Jul;33(1):69–73.
-
^
F. J. Duarte (ed.), Tunable Laser Applications (CRC,
New York, 2009) Chapter 8.
-
^ Kirby, William;
Desai, Alpesh; Desai, Tejas; Kartona, Francisa; Patel, Getta.
The Kirby-Desai Scale: A Proposed Scale to Assess Tattoo-removal
Treatments, Journal of Clinical and Aesthetic Dermatology, March
2009, Volume 2, No. 3
-
^ Kirby, William
http://www.rethinkyourink.blogspot.com/, Your Immune System
and laser Tattoo Removal, October, 2008
-
^
a
b
Kirby, William; Desai, Alpesh;
Desai, Tejas; Kartona, Francisa. Tattoo Removal Techniques:
Effective Tattoo Removal Treatments - Part 2, Skin and Aging,
October, 2005.
-
^
a
b
Kirby, William, Koriakos, Angie,
Desai, Alpesh, Desai, Tejas, Undesired Pigmentary Alterations
Associated with Q-Switched Laser Tattoo Removal, Skin and Aging,
August 2010
http://www.drtattoff.com/images/articles/Undesired-Pigmentary-Alterations-Associated-with-Q-Switched-Laser-Tattoo-Removal-Skin-and-Aging-Aug-2010.pdf
-
^ Kirby, William,
Kaur, Ravneet Ruby, Desai, Alpesh, Paradoxical darkening and
removal of pink tattoo ink.
Journal of Cosmetic Dermatology, June, 2010
http://www.drtattoff.com/images/articles/Paradoxical-darkening-and-removal-of-pink-tattoo-ink-JOCD-Jun-2010.pdf
-
^ Kirby, William,
Desai, Alpesh, Desai, Tejas, Kartona, Francisa, Tattoo Removal
Techniques: Effective Tattoo Removal Treatments - Part 1, Skin
and Aging, September, 2005
-
^ Kirby W, Kartono
F, Desai A, Kaur R, Desai T, "Treatment of Large Bulla Formation
after Tattoo Removal with a Q-Switched Laser",
Journal of Clinical and Aesthetic Dermatology, January,2010
http://www.jcadonline.com/2210/treatment-of-large-bulla-formation-after-tattoo-removal-with-a-q-switched-laser/#more-2210
-
^ S. Varma, et al.
Tattoo ink darkening of a yellow tattoo after Q-switched laser
treatment. Clinical and Experimental Dermatology. 2002:
Volume 27 Issue 6, pp. 461–463
-
^ Holzer A, et al.
Adverse Effects of Q-Switched Laser Treatment of Tattoos.
Dermatologic Surgery 2007: Volume 34 Issue 1, pp. 118–122
-
^ Taylor Charles R.,
"Laser ignition of traumatically embedded firework debris,"
Lasers in Surgery and Medicine, 1998/22:157–158
Further reading
- Kirby W. Lasers and Energy Devices for the Skin, Second Edition.
Chapter 4: Tattoo Removal. Ed. Goldman, Fizpatrick, Ross, Kilmer.
CRC Press. Pgs: 74-93. July 15, 2013. ASIN: 1841849332.
ISBN 978-1841849331
- Vartanian,Varci "Your Permanent Record? The Scoop on Tattoo
Removal - Discussion with Dr. Kirby" The Daily Muse, July 1, 2012
http://www.thedailymuse.com/health/your-permanent-record-the-scoop-on-tattoo-removal/
- Kirby W, Kartono F, Small R. (September 2011). "Chapter 30:
Tattoo Removal with Lasers. Dermatologic and Cosmetic Procedures in
Office Practice". Elsevier. pp: 367-376.
ISBN 978-1-4377-0580-5
- Wysong P, "Tattoo Removal Comes Of Age - An Expert Interview
With Dr. William Kirby and Dr. Rady Rahban" Medscape, August 16,
2011
http://www.medscape.com/viewarticle/747828
- Kirby W, Kartono F, Desai A, Kaur R, Desai T, Treatment of
Large Bulla Formation after Tattoo Removal with a Q-Switched Laser,Journal
of Clinical and Aesthetic Dermatology, January,2010
http://www.jcadonline.com/2210/treatment-of-large-bulla-formation-after-tattoo-removal-with-a-q-switched-laser/#more-2210
- Verhaeghe, Evelien (January 2010).
"Chapter 7: Techniques and Devices Used for Tattoo Removal". In De
Cuyper, Christa; Pérez-Cotapos S, Maria Luisa. Dermatologic
Complications with Body Art.
Heidelberg:
Springer-Verlag. pp. 91–105.
doi:10.1007/978-3-642-03292-9_7.
ISBN 978-3-642-03291-2.
- Goldberg, David J. (4 December
2007). "Chapter 3: Pigmented Lesions, Tattoos, and Disorders of
Hypopigmentation". Laser Dermatology: Pearls and Problems.
Malden, Massachusetts:
Blackwell. pp. 71–113.
doi:10.1002/9780470691991.ch3.
ISBN 978-1-4051-3420-0.
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Impostare INGLESE anziché italiano e
ripetere la procedura descritta.
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