Introduction

Decorative skin tattoos represent colored foreign –body implantation into various depths of the dermis. As the desire for tattoo removal increases, researchers continue to explore safe, innovative and efficacious methods of tattoo removal (₁,₂,₃). A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of Layered Dermabrasion. A simple controlled method for the treatment of Tattoos scarring, is needed. Treatment options for tattoos are well described in the literature and must be individualized to each patient by the treating physician (₄,₅,₆,₇,₈,₉,₁₀,₁₁,₁₂,₁₃,₁₄,₁₅,₁₆).

Most popular therapeutic technique of tattoos removals is utilizing laser therapy (₁₇,₁₈,₁₉,₂₀,₂₁,₂₂,₂₃). Lasers continue to be a reliable and efficacious tool in treating amateur, professional, cosmetic and traumatic tattoos. However the financial cost of laser treatment prevents patients from undergoing such treatment (₂₁, ₂₃).

Another popular method of tattoo removal is dermabrasion, where the surgeon scrapes away the outermost layer of skin with a rough wire brush, or a burr containing diamond particles, attached to a motorized handle (₂₄, ₂₆). Dermabrasion surgical technique stimulates the production and growth of new collagen and skin tissue in which skin cells are more plentiful and better vascularized.

Layered dermabrasion is a method incorporates the use of equipment that is present in the usual plastic surgical office. The method is presented as a treatment of tattoos that are too large for simple excision. The surgeon can dermabrade deeply, if needed, and remove the skin pigments followed by more superficial dermabrasion of the surrounding normal skin. Once the skin heals, the residual skin scar will have a different shape from its previous tattoo. This method has produced excellent improvement in removal of skin tattoos, with acceptable obliteration of the original tattoo shape with high patient's satisfaction.

Methods

Patient's data were collected from the year 2002 till 2006. Twenty-six patients with a mean age of 26 years participated with 34 tattoos treated over a 4 years period (Fig-1).

Both types of amateur and professional tattoos were encountered. Local and general anesthesias were used depending on the size of the tattoo. A classical dermabrasion instruments with diamond head where used in this procedure. Layered dermabrasion of the tattoo first was performed till complete removal of all pigments. Pattern of dermal bleeding did help in assessing depth of skin layers removal. The skin was continuously moistened with wet gauze soaked with a mixture of saline and 1/200,000 epinephrine. Following complete removal of the tattoo, superficial dermabrasion of the normal skin was carried out in an irregular fashion to smoothen the skin edges around the tattoo (Fig-2).Topical broad-spectrum antibacterial ointment soaked gauze dressing is applied immediately to the wound following the procedure. All patients followed a post operative well established skin care regimen and supervised regularly by the author (₂₇,₂₈). All dressing was left intact for approximately a week and then the outer dressing was removed leaving the direct meshed gauze intact over the treated skin to separate spontaneously in 2-3 weeks. Once the gauze removed, the patient should apply moisturizing mixture of ointments, Alfacort (Julphar, UAE) containing 1% of hydrocortisone mixed with Contratubex gel (Merz pharma, Germany) twice daily for one more month. In the second month the patient were instructed to apply a silicone sheath over the skin. The treated areas were assessed on monthly basis for clinical evaluation of tattoos pigment removal and complications. All patients were asked to avoid direct exposure to the sun to the treated skin.

Results

Twenty one patients (81%) had one tattoo, whereas five (19%) possessed bilateral tattoos. Most tattoos were applied for the sake of fashion. In those patients attending for removal, most tattoos are applied impulsively and inexpensively in youth. The main reasons for removal were enhancement of self-esteem and social, domestic and family reasons.

Following the surgery heavy eschar forms which separates in approximately 2 to 3 weeks. The residual skin results were excellent with remarkable patient satisfaction. The tattoos did disappear and the tattoos features were obscured by the surrounding healed skin (Fig-3).

Figure 1

Figure 1: A young 23 year old adult male with large decorative tattoo of his right arm.

Figure 2

Figure 2: Layered dermabrasion is completed. Pattern of dermal bleeding can guide the deep and superficial dermabrasion procedure.

Figure 3

Figure 3: The patient 6 months following Layered dermabrasion. Excellent scar quality, with complete loss of definition of the previous patient tattoo.

Postoperative complications did occur in dark skin colored patients in which hypertrophic scarring rate were less than 8 % in two patients. Whereas, four patients (14%) experienced permanent hyper pigmented derma-braded skin. Incomplete removal of all tattoos pigments in the skin did occur in only one patient (4%) of which another session of layered dermabrasion was performed after 6 months from the initial procedure.

Discussion

There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic (₁,₂,₃,₄,₅). Poor decision making and subsequent personal regret seem to be frequent motivations for tattoo removal. Important factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient (₆,₇,₈,₉). We like also to add other important factors related to the tattoo such as: size, form and shape of the tattoo.

Many authors have published numerous articles on the use of different methods with one aim, complete removal of tattoos with less scarring (₁₆). Laser removal of tattoos is not

generally or readily available to the public and removal in privately run clinics is expensive. Limitations to laser treatment include the need for multiple treatment sessions, minimal to incomplete responses in some cases, and the possibility of pigment and textural changes with higher cost to the patient. Also, for those seeking removal of their tattoo this can create significant financial hardship. Chemical and surgical methods of tattoo removal usually associated with scars complications (₈,₉,₁₀,₁₁,₁₂,₁₃,₁₄,₁₅,₁₆).

Regular dermabrasion method usually gives satisfactory results. Once used in an appropriate clinical setting, dermabrasion provides relatively efficacious clearance of decorative tattoo pigment. However, we have noticed the shape of the tattoo following dermabrasion still persist despite lacking some pigments. With layered dermabrasion technique it was possible to remove tattoo pigments in one session. The deep scraping of the pigmented skin will eventually heal within a superficially derma-braded surrounding normal skin. Thus, final shape of the healed skin will be poorly defined.

We should emphasize for the role of adequate post operative skin care to the operated skin. Such adjunct method will allow normal skin layers to heal, preventing further hypertrohic scar s formation.

Conclusion

Layered dermabrasion is a method of controlled surgical removal of decorative skin tattoos. Once combined with adequate postoperative scar skin care treatment, it will results in a complete removal of the tattoo with minimal scaring of the skin. It is a promising method for treating of decorative skin tattoos.