Tattoo and permanent makeup removal specialist Lorena Öberg describes her method for removing permanent makeup tattoos
Ever since I started performing permanent makeup tattoo treatments, I have noticed its growth in popularity.1,2 Google Trends exemplifies this growth, where interest in the term ‘eyebrow tattoo’ has steadily increased over the past five years.3
However, in my experience, coinciding with this growth is the number of patients requiring removal. Traditionally, patients have requested removal because they feel the makeup no longer suits their more mature look. However, I am increasingly seeing people who have received bad permanent makeup treatment and have been disfigured by untrained technicians.
Currently, Level 5 training is recommended by Health Education England (HEE) for tattoo removal using lasers,4 although an individual does not need any qualifications to perform the actual permanent makeup treatment.
However, permanent makeup is a difficult skill to learn, so even if one has training, it does not mean that they can do the treatment well.
For medical aesthetic clinics currently performing tattoo removal, or if they are interested in doing so, they should also consider incorporating permanent makeup removal.
There are three ways to reduce or ‘lighten’ pigment molecules from the skin: topical, non-laser solutions applied with a tattoo gun, and laser. All three of these methods have a place in your practice and can be considered for different circumstances, as discussed below.
There are many lotions that are being sold as ‘tattoo removal creams’, but I have not come across any clinical studies showing their effectiveness without combining laser. I have personally found them ineffective because they cannot penetrate into the dermis to reach the tattoo ink.5-7
One guinea pig model study demonstrated a reduction in tattoo pigment using imiquimod and tretinoin after 28 days, however application started six hours after tattooing, which is not very reflective of real-life scenarios.8
There is also data that suggests that the use of imiquimod with laser is more effective than laser alone.9
Prior to laser treatments, I have found that there are alternative topical methods that can help to assist with the removal of pigment. If a permanent makeup tattoo is under six months old, I use a simple technique of applying fine sea salt to the area and gently exfoliating twice-per-day for two months, which draws out the ink. I have found this can cut the number of required laser treatments in half, but it’s only effective with new tattoos as after around six months the ink settles.
These procedures are performed by a trained permanent makeup artist and there are many variations of this same treatment. Removal can be achieved by opening the skin – in a way much like the original procedure – using a tattoo or a permanent makeup machine.
A bonding agent is then applied to the open skin, which then draws the ink to the skin’s surface.7 Bonding agents can be anything from salt or glycolic acid, to any number of branded products readily available to permanent makeup and tattoo artists.10,11
In my experience, one session will be equivalent to two months of topical exfoliation. I have found that this method is popular with artists who do not have access to lasers and it is especially useful when removing the skin-coloured pigment due to its large molecular size, which is discussed below. However, the limitation of this approach is that, generally, the rate of scarring is far higher than a laser as it causes damage to the epidermis.
Lasers are widely accepted as the most common treatment for removing pigment from the skin, so, like regular tattoos, they are widely used to remove permanent makeup. I do not recommend treating a tattoo that has been done in under six months.12 This is because there is a higher ink concentration, which will mean that the patient will require more laser sessions and the laser itself will react more violently, even on lower power settings, as it is more attracted to the ink molecules.13
This translates into a more aggressive treatment, therefore increasing the chances of scarring. Permanent makeup pigments are different in composition to tattoo inks as they are made from different ingredients.14
It’s therefore important to understand how makeup inks will react under the laser.
The two main things to consider when removing permanent makeup pigments is whether the pigment contains titanium dioxide (the colour white) and the molecule size.
Titanium dioxide in the form of ‘white’ is used in most pigments for those with a lighter Fitzpatrick skin type as those with darker skin require a tattoo with darker pigment, hence unlikely to contain titanium. It is also used in most lip pigments because it gives the tattoo a brighter base to sit on, making the colour stand out more.
Titanium is a metal that has been rusted into a white powder. When the laser hits this oxidised metal, a chemical reaction occurs that turns the titanium to its original state, which is a dark grey colour.15 This is why practitioners were previously told by laser manufacturers that they could not laser permanent makeup pigments as it turns black.15
Although this does occur, practitioners should have no problems removing it with further treatments – ranging from two to eight – and they should make their patients aware that this may happen. However, this is not recommended for the lip area as patients may find having black or grey lips distressing if this contrasts with their skin colour. For this area, I instead try to remove most of the pigment molecules with the non-laser method and then clean up residual particles that may linger in the deeper layers of the skin with a laser.
Molecule size for micropigmentation pigments can vary from one to 20 microns. These measurements mostly take into consideration the agglomerates of smaller molecules that happen in pigments and inks. The molecule size will also vary from organic to inorganic or synthetic organic pigments.
All pigment components come in powder form, they are then mixed with agents such as glycerin. Most molecules used in permanent makeup, such as titanium molecules, are big; unlike carbon black molecules more commonly used in black body tattoo ink. This is especially the case with skin coloured pigments that are designed to cover up mistakes, which are deliberately manufactured to have titanium molecules that are large enough to be used as a cover up.16
When using lasers, the molecule size they target at their optimum level and the wavelengths need to be considered.
In my experience, when used correctly, a Q-switched Nd:YAG is the most effective and is a gentle removal method. Research has shown that picosecond lasers can be more effective than nanosecond lasers for black ink tattoo removal.17 However, I have found that when dealing with larger sized molecules, these cannot be targeted effectively with picosecond technology and therefore I believe that a nanosecond laser is far more effective when dealing with permanent makeup.18,19
Up to 10 treatments for the face and 12 for the body may be required when using lasers to break the titanium molecules up enough. In my experience, when treating skin-coloured pigment, you can get more superior results by using two to three non-laser solution sessions in combination with a laser protocol.
I currently perform around five eyeliner removal procedures a week and I only use laser because the non-laser bonding agents and salt exfoliation is too harsh for this area. Removing eyeliner has its own set of challenges and I currently only know a handful of practitioners competent in this procedure. The skin around the periorbital area is extremely sensitive so we need to be very careful.
You must protect the cornea using the correct sized corneal protective shields that need to be inserted under the eyelid. The laser must be used on the lowest possible setting, with the least amount of power output, using the largest spot size possible. These levels will vary from laser to laser, but most users know their machine intimately by the time they attempt this delicate procedure. Treatments should also be spaced by a minimum of eight weeks, allowing for the epidermis to complete its full shedding cycle and so the lymphatic system has more time to dispose of the molecules, leading to fewer treatments.20
Scarring is a risk of the non-laser approach, as well as any laser procedure, including any form of tattoo removal. It is therefore important to remove the pigment safely using the fewest laser sessions possible to limit trauma to the skin.21
Allergy can also be an issue, as this can occur when attempting removal even if they have never shown previous signs of a problem. Test patching is crucial, but practitioners must bear in mind that test patching does not guarantee that an allergy is detected. An allergy may still manifest when more of the allergen is put through the body’s lymphatic system.22
Permanent makeup removal can be an incredibly rewarding treatment and when done correctly, it has a very low complication rate. There are still a relatively low number of laser technologies available that have ventured into this treatment and therefore there is room for future developments in this area.