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Refer to: Wheeler ES, Miller TA: Tattoo removal by split thick- ness tangential excision. West J Med 124:272-275, Apr 1976 Tattoo Removal by Split Thickness Tangential Excision ERVIN S. WHEELER, MD, and TIMOTHY A. MILLER, MD, Los Angeles Split thickness tangential excision is a simple means of tattoo removal with very acceptable cosmetic results. The technique has several advantages. (1) The depth of skin removal may accurately be controlled as the tattoo pigment is excised with a dermatome. The major portion, if not all of the remaining pigment, is extruded and sloughs with the crust. (2) Scar formation, if it occurs at all, is negligible. (3) No donor site is created. (4) The procedure may be carried out rapidly without admitting patients to hospital, is inexpensive for patients and conserves time for physicians. THE PROBLEM of tattoo removal is far from new. In the Book of Leviticus (XIX:28), Moses was commanded, "Ye shall not ... tattoo any marks upon you." Unfortunately for plastic surgeons, this advice has not been followed, and tattooing remains a relatively popular means of identifica- tion and a fashionable mode of social expression among certain groups. Bromberg suggested that tattooing is frequently a sign of emotional imma- turity.' All methods of tattoo removal involve some element of destruction of the skin to ablate pig- ment design. Pigment depth varies with the tech- nique used. The pigment in a professional tattoo is injected with an automatic reciprocating needle at a constant depth, usually in the superficial From the Surgical Service, Wadsworth Veterans Administration Hospital, Los Angeles, and the Department of Surgery, Division of Plastic Surgery, UCLA School of Medicine, Los Angeles. Submitted June 17, 1975. Reprint requests to: Timothy A. Miller, MD, Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA 90024. dermis. Various amateur techniques that employ sharpened needles, with or without thread and covered with india ink or shoe polish, offer little control over the depth of pigment deposition. The pigment frequently is deposited in the deep dermis or in the subcutaneous tissue. Obviously, greater success in removing the tattoo can be achieved when the pigment lies superficially. The approach to tattoo removal may be divided into two categories: nonsurgical methods utilizing locally applied chemical or physical agents and surgical techniques. Nonsurgical Methods Counter-tattooing with tannic acid in conjunc- tion with other topically applied agents has been used extensively by tattoo artists for many years as a means of altering unwanted tattoos. A recent modification of this procedure has been de- scribed.2 272 APRIL 1976 * 124 * 4

Tattoo Removal by Split Thickness Tangential Excision

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Page 1: Tattoo Removal by Split Thickness Tangential Excision

Refer to: Wheeler ES, Miller TA: Tattoo removal by split thick-ness tangential excision. West J Med 124:272-275, Apr1976

Tattoo Removal by Split ThicknessTangential ExcisionERVIN S. WHEELER, MD, and TIMOTHY A. MILLER, MD, Los Angeles

Split thickness tangential excision is a simple means of tattoo removal withvery acceptable cosmetic results. The technique has several advantages. (1)The depth of skin removal may accurately be controlled as the tattoo pigmentis excised with a dermatome. The major portion, if not all of the remainingpigment, is extruded and sloughs with the crust. (2) Scar formation, if it occursat all, is negligible. (3) No donor site is created. (4) The procedure may becarried out rapidly without admitting patients to hospital, is inexpensive forpatients and conserves time for physicians.

THE PROBLEM of tattoo removal is far from new.In the Book of Leviticus (XIX:28), Moses wascommanded, "Ye shall not ... tattoo any marksupon you." Unfortunately for plastic surgeons,this advice has not been followed, and tattooingremains a relatively popular means of identifica-tion and a fashionable mode of social expressionamong certain groups. Bromberg suggested thattattooing is frequently a sign of emotional imma-turity.'

All methods of tattoo removal involve someelement of destruction of the skin to ablate pig-ment design. Pigment depth varies with the tech-nique used. The pigment in a professional tattoois injected with an automatic reciprocating needleat a constant depth, usually in the superficial

From the Surgical Service, Wadsworth Veterans AdministrationHospital, Los Angeles, and the Department of Surgery, Divisionof Plastic Surgery, UCLA School of Medicine, Los Angeles.

Submitted June 17, 1975.Reprint requests to: Timothy A. Miller, MD, Department of

Surgery, UCLA Center for the Health Sciences, Los Angeles,CA 90024.

dermis. Various amateur techniques that employsharpened needles, with or without thread andcovered with india ink or shoe polish, offer littlecontrol over the depth of pigment deposition. Thepigment frequently is deposited in the deep dermisor in the subcutaneous tissue. Obviously, greatersuccess in removing the tattoo can be achievedwhen the pigment lies superficially.The approach to tattoo removal may be divided

into two categories: nonsurgical methods utilizinglocally applied chemical or physical agents andsurgical techniques.

Nonsurgical Methods

Counter-tattooing with tannic acid in conjunc-tion with other topically applied agents has beenused extensively by tattoo artists for many yearsas a means of altering unwanted tattoos. A recentmodification of this procedure has been de-scribed.2

272 APRIL 1976 * 124 * 4

Page 2: Tattoo Removal by Split Thickness Tangential Excision

TATTOO REMOVAL

Sodium chloride was first reported as an abra-sive for use in tattoo removal in 1935.3 In 1971,Crittenden5 coined the term "salabrasion" to de-scribe his refinement of the technique in whichcrystalline salt is rubbed over the tattooed areawith a moist sponge. When delivered to the der-mal tissues, the salt solution is thought to act notonly as an abrasive but also as a stimulant topigment phagocytosis by macrophages.0 The pig-ment-laden macrophages migrate to the woundsurface where they are removed with the dressingchanges.Numerous physical agents have been employed

in the ablation of tattoos. Use of boiling water,hot irons and electrocoagulation are effective bycausing thermal injury to superficial layers of skin.Finsen light reportedly speeds the normal fadingprocess.7 Lasers have been used to vaporize andto disburse the particles of pigment, although theirroutine clinical use has not been recommended.8

Both physical and chemical agents act by de-stroying varying depth of skin. With subsequentexfoliation or sloughing, tattooed pigment is re-moved. The principal difficulty with the use ofchemical and physical agents is depth control.Deep dermal injury or full-thickness loss with at-tendent scarring may result.

Surgical Methods

Surgical techniques for tattoo removal havegenerally been the most popular with physicians.Dermabrasion is widely used because of its sim-plicity and generally satisfactory results. In thefirst description of this technique, the tattooedarea was abraded until all pigment was removed,with deep dermal injury and frequent excessivescarring resulting. Recent refinements in thetechnique have led to advocacy of superficialabrasion and partial pigment removal, with re-liance upon the phagocytic response to extrudethe remainder of the pigment in the crust9 or tocarry away the pigment through the lymphaticsystem.10 However, pigment removal is often in-complete, and repeated dermabrasions are re-quired.

Excision of the tattoo with simple woundclosure has long been a popular and acceptablemethod for removing small tattoos. Indeed, indealing with small tattoos, it is probably themethod of choice. Staged excision has been usedfor removing those tattoos that cover large areas.However, after aggressive excision and closure

under tension, the scar often spreads and thereis an undesirable cosmetic result.A sure method of removing all pigment is full-

thickness excision of the tattoo and coverage ofthe defect with a split-thickness skin graft. How-ever, subsequent hyperpigmentation of the graftand scarring at the margins may compromise thecosmetic result.

Tattoo removal using the method and derma-tome of Reese was described by Bunke and Con-way." The pattern of the tattoo is painted withcement, and a thick split-thickness graft is taken.In this way most, if not all, of the pigment is re-moved. A graft of similar thickness from anothersite is then used to cover the bed. The remainingpigment can be partially obscured by the opales-cent nature of the thick graft. Bailey12 has alsorecommended tangential excision with a Watson-Braithwaite knife, followed by skin grafting.

With dermabrasion, pigment removal is oftenirregular and depth of abrasion difficult to con-trol. In techniques in which grafting is used, asecond wound is created and therefore the likeli-hood of scar formation is increased.We have had success with a simple method in

which the tattoo is excised tangentially with apower-driven oscillating dermatome. The woundis allowed to heal like a split graft donor site, pre-cluding the necessity of an additional graft pro-cedure.

MethodThe area is shaved and prepared with providone-

iodine. Next, a solution of 0.5 percent lidocainewith 1:200,000 epinephrine is infiltrated into theskin to elevate the exact area of pigment to beremoved. An intermediate split-thickness portionof the skin is then excised with the power-drivenoscillating dermatome. The thickness of the tan-gentially excised tattoo is determined by the lo-cation of the tattoo; that is, very thin sectionsare taken for sites such as the volar forearm, andthick grafts are removed in areas such as thetrunk. The wound is then covered with a singlelayer of fine mesh gauze and wrapped in a bulkygauze dressing. The following day the bulky dress-ing is removed, and the wound is allowed to forma crust with the fine mesh gauze in place. Withspontaneous separation of the crust and fine meshgauze, the wound is fully epithelialized similar toa donor site. Pigment that remains after excisionof the specimen with the dermatome is oftenfound adherent to the fine mesh gauze and crust.

THE WESTERN JOURNAL OF MEDICINE 273

Page 3: Tattoo Removal by Split Thickness Tangential Excision

TATTOO REMOVAL

ResultsThis method has been used in 24 patients. In

all, the pigment was sufficiently removed to pre-vent recognition of the original design, and theresults were considered to be cosmetically accept-able. In 14 tattoos, all pigment was removed, as

illustrated in Figure 1. In four patients, a secondprocedure was required to complete the tattoo re-moyal. The remaining six patients were satisfiedwith the ablation of the word or design of the tat-too although some pigment remained. There wereno wound infections or full-thickness losses.

* * v v* ;; * f .I,..x.,,,

..,

Figure 1.-Upper Left, preoperative viewsplit-thickness graft taken with the Brownmented area. Lower Left, wound treated6 weeks postoperatively.

!r .. _,I

of forearm tat as a donor site. Lower Right, tangentially excised areadermatome foltoo. Upper Right, tangentially excised moderate depthconventionallylowing injection of tattoo with lidocaine to elevate pig-

274 APRIL 1976 * 124 * 4

Page 4: Tattoo Removal by Split Thickness Tangential Excision

TATTOO REMOVAL

Discussion

Simple tangential partial-thickness excisionprovides an alternative means of rapidly remov-ing tattoos. Dermabrasion, in our experience, hasgenerally yielded satisfactory results. However,with dermabrasion considerable time is requiredand if the abrasion is too deep and done unevenly,dermal injury may result in conspicuous scarformation. We continue to use excision and pri-mary closure for removing small tattoos in pa-tients with sufficient skin mobility to permitclosure with minimal tension. Salabrasion hasbeen used with success by some authors.3-6 Whendone by a physician and the proper depth isachieved, results can be excellent although, again,the procedure is time-consuming. When a patientdoes the procedure himself, results are generallyless than optimal. A well-motivated patient seenin our clinic had been too vigorous in his attemptsat salabrasion, and the abraded site healed withsubstantial scar formation. Furthermore, pain isproduced with the abrasion because the salt mostoften does not provide sufficient anesthesia, as hasbeen reported. Although subsequent salabrasionsmay be done, patients usually request an alternatemethod.

It has been suggested that salt solution acts asa stimulus to pigment phagocytosis. Similarly,other authors have noted that active pigment isphagocytized by macrophages that migrate tothe wound surface.9 Boo-Chai'0 theorized thattrauma induces accelerated pigment removal bylymphatics. It seems reasonable that this phe-nomenon is a consequence of a general inflamma-tory response and occurs regardless of the initialtraumatic stimulus, whether it be salt, dermabra-sion or tangential excision.

Tangential excision, as described, removes allor a large portion of the pigments, as do othermethods. Tangential excision also appears to actas a stimulus to the inflammatory response. Theadvantages of this technique are that it is easier tocontrol the depth of skin removal with the derma-tome, and the procedure may be completed more

rapidly than with abrasive techniques. Othershave found unacceptable scarring with tangentialexcision without graft cowrage.12 It should bepointed out, however, that imnthe study with thisfinding, multiple excisions had been carried outuntil all pigment was removed. Such a deep der-mal wound frequently results in excessive scar-ring. Time was not allowed-for subsequent inflam-matory pigment removal postoperatively.

Excision of the tattoo with the oscillatingdermatome followed by coverage with a split-thickness graft was in the past a popularmethod."'12 With this overgrafting technique, asecond wound is created and this often necessi-tates admission of the patient to hospital. It shouldalso be noted that contraction and hyperpigmen-tation of the graft can result.

In the technique described, the superficiallyexcised area heals without an o\verlying graft, likea donor site. It is not necessary to take skin fromanother site to cover the defect. Because thetangential excision is superficial, there is seldomany apparent scarring, and the remaining pigmentis usually extruded in the crust. The depth of epi-dermal excision is more precisely controlled withthe dermatome than with abrasion techniques, andthe procedure is carried out far more rapidly. Inour experience, the results have proved superiorto other methods.

REFERENCES1. Bromberg W: Psychologic motives in tattooing. Arch Neurol

Psychiat 33:228-232, 19482. Scutt RWB: The chemical removal of tattoos. Br J Plast

Surg 25:189-194, 19723. Janson -P: Ein einfache Methode der Entfemung von Tato-

wierungen. Dermat Wchnschr 101:894, 19354. Kloevekorn GH: Ein einfache Methode der Entfernung von

Tatowierungen. Dermat Wchnschr 101:1271, 19355. Crittenden FM Jr: Salabrasion-Removal of tattoos by super-

ficial abrasion with table salt. Cutis 7:295-300, 19716. Manchester GH: Tattoo removal-A new simple technique.

Calif Med 118:10.12, Mar 19737. Shie MD: A study of tattooing and methods of its removal.

JAMA 90:94-99, 19288. Goldman L, Rockwell RJ, Meyer R: Laser treatment of

tattoos. JAMA 201:841-844, 19679. Clabaugh W: Removal of tattoos by superficial dermabrasion.

Arch Dermatol 98:515-521, 196810. Boo-Chai K: The decorative tattoo: Its removal by derma-

brasion. Plast Reconstr Surg 32:559-563, 196311. Bunke HJ Jr, Conway H: Surgery of decorative and trau-

matic tattoos. Plast Reconstr Surg 20:67-77, 195712. Bailey BN: Treatment of tattoos. Plast Reconstr Surg 40:

361-371, 1967

THE WESTERN JOURNAL OF MEDICINE 275