Med Lasers 2024; 13(2): 104-107  https://doi.org/10.25289/ML.24.012
Optimizing tattoo removal using the picosecond laser with topical perfluorodecalin and subsequent fractional CO2 laser: a case report
Jiwon Lee1, Hannah Lee2, Sang Ju Lee3, Han Kyoung Cho1
1Department of Dermatology, Myongji Hospital, Goyang, Republic of Korea
2Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
3Yonsei Star Skin & Laser Clinic, Seoul, Republic of Korea
Correspondence to: Han Kyoung Cho
E-mail: trpchk@hanmail.net
ORCID: https://orcid.org/0000-0001-6074-013X
Received: May 28, 2024; Accepted: June 18, 2024; Published online: June 27, 2024.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Picosecond lasers are considered the most effective treatment for tattoo removal, with the R0 method using perfluorodecalin to rapidly remove opaque cavitation bubbles after each pass, allowing multiple sequential passes during each treatment session. Previous research indicated that combining picosecond lasers with fractional lasers yielded superior results and reduced posttreatment blistering. This paper presents the case of a 25-year-old female seeking tattoo removal from her chest. Initially, the patient underwent treatment using the R0 method with a picosecond laser set to 532 nm (0.8-1.3 J/cm2) and 1,064 nm (2.0-3.0 J/cm2). Each session included four passes with the picosecond laser and a single pass with the fractional CO2 laser. The lesion was cleared after only four treatment sessions. This case highlights the safety, efficiency, and effectiveness of combining the R0 method with subsequent fractional laser treatment for tattoo removal.
Keywords: Laser therapy; Perfluorodecalin; Tattoo removal
INTRODUCTION

As the prevalence of tattoos has increased in recent years, an increasing number of patients have sought to remove unwanted tattoos [1]. Traditional tattoo removal methods include dermabrasion, electrocauterization, cryosurgery, and chemical peeling; however, these methods were discontinued because of unsatisfactory results, significant scarring, and long recovery times [2,3]. Since the 1960s, when a ruby laser was first documented for treating unwanted tattoos, lasers remain the standard modality for tattoo removal [1-3]. Multiple passes per session yielded improved tattoo clearance compared to a single pass treatment; however, cutaneous whitening that impeded light entry must be resolved to perform multiple passes in a single session. By using topical perfluorodecalin (PFD) after each pass, cutaneous whitening can be removed immediately because of its high gas solubility (R0 method) [4]. Previous studies have shown that the combination of a picosecond laser and fractional CO2 laser results in greater tattoo clearance and less blister formation [5,6]. Here, we report a case of tattoo removal with a picosecond laser using the R0 method and a subsequent fractional CO2 laser.

A written informed consent was obtained from the patient for the publication of this case report.

CASE REPORT

A 25-year-old female visited our clinic for the removal of a tattoo that she got one year prior on her chest (Fig. 1A). She had no relevant medical history or tattoo removal. The patient was treated with a picosecond laser using the R0 method and subsequently with a fractional CO2 laser. Before the treatment, topical lidocaine (SM Cream 9.6%; CellBion Co., Ltd.) was applied for 30 minutes with occlusion. A sterile PFD patch (DESCRIBE® PFD Patch; Merz North America) was placed on the tattoo (Fig. 1B). The patient was treated with a picosecond laser (PicoWay®; Candela®) at wavelength 532 nm and 1,064 nm and total four passes were done on each treatment session. The specific parameters used in each session are listed in Table 1. After the picosecond laser treatment, the PFD patch was removed. Then, the patient underwent a fractional CO2 laser treatment (Ultrapulse® Encore; Lumenis) in DeepFx mode with the parameters of the energy 10 mJ and the density 5%. An aseptic gauze dressing was applied to the treated areas after each session. Four sessions were performed at intervals of 1-2 months, and the tattoo almost cleared (Fig. 1C). Two years after the last session, the lesion completely resolved without any scarring, hyperpigmentation, or hypopigmentation (Fig. 1D).

Table 1 . Specific picosecond laser parameters used for each wavelength

Session532 nm (J/cm2)1,064 nm (J/cm2)
1st0.82.0
2nd (month 1)1.02.4
3rd (month 3)1.22.6
4th (month 6)1.33.0

The number of the month indicates the duration in months since the first session.



Figure 1. (A) Before the treatment. (B) The picture of the perfluorodecalin patch that was used for the R0 method. (C) After the four treatments, the tattoo was almost removed. (D) Two years after the last session, the lesion completely resolved without any scarring, hypopigmentation, or hyperpigmentation.
DISCUSSION

The basic principle of tattoo removal is selective photothermolysis: when a chromophore is heated for a duration less than its thermal relaxation time (TRT), chromophore destruction occurs without damage to the surrounding tissue. Most tattoo pigment size ranges from 30 to 300 nm, corresponding to a TRT of less than 10 nanosecond (10–9 second); thus, picosecond lasers, which have a pulse duration of picosecond (10–12 second), have emerged as a safe and effective modality of tattoo removal [1-3]. In 1988, Ross et al. [7] proved that 35-picosecond pulses were more efficient than 10-nanosecond pulses in clearing black tattoos. Currently, picosecond lasers are available at 532, 730, 755, 785, and 1,064 nm and are effective for almost every color of tattoo ink [8].

The clinical endpoint of tattoo removal is immediate cutaneous whitening [9]. The ink particles in the tattoo absorb the energy of the laser and transfer it to the surrounding tissue, leading to the formation of microscopic cavitation bubbles, which appear as whitening over the tattoo. This opaque white layer is optically scattering and prevents the laser from effectively penetrating and interacting with the pigment, making multiple passes per session impossible [4,10]. The R20 method enables multiple passes in a single treatment session by waiting for 20 minutes for the whitening to spontaneously fade. However, this method can be clinically impractical and causes more epidermal damage and purpura than the single-pass treatment [10].

PFD is a fluorocarbon liquid with high gas solubility that has been approved as an artificial vitreous body substitute in ophthalmology [4]. When the laser induces microcavitation bubbles, a pressure gradient occurs between the treated surface and the PFD, followed by diffusion of gas from the treated side to the PFD. The R0 method is a method that applies topical PFD directly after each laser pass to eliminate whitening immediately. This method allowed the practitioner to proceed to the next pass without having to wait for the whitening to disappear, which resulted in a much shorter treatment time than the R20 method, making the treatment more efficient [4,10]. A PFD patch not only secures optical clarity but also prevents evaporation of liquid PFD, enhances epidermal protection, and acts as a heat sink by transferring heat away from the skin [10]. Previous studies have demonstrated the safety and effectiveness of combining picosecond lasers and PFD patches for tattoo removal [10,11]. Our previous study also used a picosecond laser with a PFD patch to treat 20 tattooed individuals, all of whom had more than 70% clearance after the fourth treatment session without any complications [12].

The combination of ablative fractional laser resurfacing (AFR) with Q-switched lasers has been proved to enhance tattoo lightening and reduce the number of required treatment sessions [5,6,13,14]. The AFR may facilitate tattoo removal via several mechanisms. First, it enhances transepidermal elimination of tattoo pigments and necrotic debris through epidermal ablation. Second, AFR increases inflammation and phagocytosis, accelerating pigment removal through lymphatics [6,13,14]. Finally, microscopic channels created by AFR release inflammatory exudates, prevent subepidermal blisters, and reduce healing time [5]. Au et al. [5] compared the incidence of bulla formation between patients treated with a picosecond 755 nm Alexandrite laser alone or in combination with a fractional CO2 laser. Among patients treated with the picosecond Alexandrite laser alone, 32% experienced blistering, while none of the patients treated with the combination lasers experienced blistering [5].

In this case report, we treated a tattoo with a multi-pass picosecond laser using the R0 method, followed by fractional CO2 laser. The patient experienced no complications during treatment, and no long-term side effects were observed during the 2 year observation. This case highlights the effectiveness and safety of combining the R0 method and fractional lasers, suggesting that larger prospective randomized controlled trials are needed to evaluate the efficacy and safety of this protocol.

SUPPLEMENTARY MATERIALS

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: SJL. Data curation: SJL. Formal analysis: SJL, JL. Investigation: JL, HL, SJL. Supervision: SJL, HKC. Project administration: SJL, HKC. Validation: SJL, HKC. Visualization: JL, HL, SJL. Writing–original draft: JL. Writing–review & editing: all authors.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

DATA AVAILABILITY

Contact the corresponding author for data availability.

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