Ideas and Innovations: Complete Resolution of Surgical Marking Tattoo Postminimal Access Cranial Suspension Facelift Using a High-power Picosecond Laser

Summary:

Traumatic tattoos can occur when foreign pigment particles are embedded within the dermis, sometimes resulting as traumatic events. Traditional treatment modalities, including surgical excision, cryosurgery, electrosurgery, dermabrasion, CO₂ lasers, and argon lasers, have limitations such as nonselectivity for pigment and risks of scarring and discoloration. We present the case of a patient who developed a postoperative tattoo after a minimal access cranial suspension facelift procedure that subsequently completely resolved after treatment with the high-powered 1064-nm picosecond laser. The patient achieved complete resolution of the postoperative tattoo after five laser treatments without adverse events or recurrence of pigmentation on follow-up. High-powered 1064-nm picosecond laser can serve as a fast, safe, and effective modality that in our clinic has become the first-line treatment for traumatic tattoos, and in our patient led to high satisfaction.

CLINICAL CASE

A 49-year-old woman of Fitzpatrick skin type I presented to our laser and surgery center for evaluation of blue-black discoloration embedded within her facelift incision scar. She noticed this discoloration unilaterally within her left preauricular incision postoperatively after a minimal access cranial suspension (MACS) facelift. The patient was concerned with the appearance of this discoloration and presented to our clinic for the discussion of treatment options. She declined presently or previously taking any medications that could increase proclivity for pigmentation, including minocycline, amiodarone, chloroquine, cyclophosphamide, chlorpromazine, or imipramine. She also denied having dyed her hair for several weeks postoperatively, and denied any history of facial trauma or facial tattoos before MACS facelift. Physical examination was significant for a patterned distribution of blue to black lines and dots located along the left temporal hairline and preauricular skin, directly within her left MACS incision scar (Fig. 1A). The right preauricular incision scar had no embedded pigment. On evaluation, we discussed that treatment options included monitoring, surgical excision, and laser treatment. We recommended against surgical correction, which could lead to clinical asymmetry between her right and left facial profiles. Based on our center’s success using the high-powered 1064-nm picosecond laser (PicoPlus, Lutronic, South Korea) to effectively treat traumatic and cosmetic pigmentary tattoos, we recommended this treatment modality for our patient due to both the high safety and effectiveness profile.

Fig. 1.

Side-to-side comparison of clinical images of a patient with a black-blue surgical marking tattoo post-MACS facelift at initial visit before treatment (A) and after a total of five treatments (B) with high-powered picosecond laser. Resolution can be appreciated in Figure 1B.

Informed consent was obtained, and a local anesthetic was injected into the pigmented incision scar (3–4 mL 1% lidocaine with epinephrine). A single pass of the high-powered 1064-nm picosecond laser (PicoPlus, Lutronic, South Korea) was used to treat focal pigmentation within the left preauricular incision scar. The treatment endpoint was whitening, which is thought to represent water vaporization within the tissue. After injectable numbing, each laser treatment itself was complete within 30 seconds. Our patient received a total of five treatments at 2–3 week intervals over the course of 2 months (laser settings can be referenced in Table 1). By her final visit, she achieved complete resolution of the surgical tattoo ink (Fig. 1B), and she has not had recurrence of pigmentation at 6-month follow-up. Notably, our patient experienced no adverse events from treatment, including pigmentary alteration, cutaneous scarring, or infection.

Table 1.

Laser Settings Utilized at Each Treatment Visit

	Treatment 1	Treatment 2	Treatment 3	Treatment 4	Treatment 5
Color treated	Blue-black	Blue-black	Blue-black	Blue-black	Blue-black
Laser type	PicoPlus 1064-nm picosecond laser	PicoPlus 1064-nm picosecond laser	PicoPlus 1064-nm picosecond laser	PicoPlus 1064-nm picosecond laser	PicoPlus 1064-nm picosecond laser
Spot size	4 mm	4 mm	4 mm	4 mm	4 mm
Fluence	3 J/cm2	3 J/cm2	3.8 J/cm2	3.8 J/cm2	3.8 J/cm2
Wavelength	1064	1064	1064	1064	1064

DISCUSSION

Traumatic tattoos result from a foreign body of exogenous pigment being embedded within the dermis, sometimes but not always from an explosion or traumatic event. Such tattoos may or may not be associated with concomitant scarring depending on the circumstances of the inciting event. Common culprits include firework particles such as gunpowder and asphalt, sand metals, glass, dust, and petroleum products. Graphite from pencil point injury can also result in a traumatic tattoo. Traditional modalities for treatment have included surgical excision, cryosurgery, electrosurgery, and dermabrasion. Limitations of these treatment modalities include that they are nonselective for pigment, may be ineffective in reaching the depth of the tattoo particles, and can be associated with concomitant risks for scarring and/or dyspigmentation.

The development and application of selective photothermolysis to laser surgery has offered a more targeted approach for the fragmentation and destruction of pigment, which mechanistically and practically has served to be a more selective, effective, and safe modality for the treatment of both cosmetic and traumatic tattoos.¹ Notably for many years, quality-switched nanosecond lasers had replaced CO₂ and argon lasers as the first-line treatment modality for tattoo removal.² However, more recently, the development of picosecond lasers that deliver energy in shorter pulse durations can allow for photoacoustic and photomechanical destruction of pigment with less collateral thermal damage. To this effect, there is increasing evidence that picosecond lasers have improved effectiveness for the removal of tattoo pigment.^3,4 Another consideration in the treatment of traumatic when compared with cosmetic tattoos, is that they tend to be solely blue/black in color, and thus respond best to lasers that emit the 1064 nm wavelength. Though not relevant to our patient, clinicians should be aware that when treating tattoos in darker skin types, additional measures should be taken to reduce the risk of pigmentary alteration, including modification of settings and/or use of a perfluorodecalin patch as a physical barrier to protect the epidermis from thermal injury.^5,6

In summary, we present an unusual case of a “traumatic tattoo” in a patient who underwent a MACS facelift at an outside institution, after which she noticed blue-black pigmentation within her facelift scar. As aforementioned, the etiology of a traumatic tattoo is conventionally from an accident or otherwise, in which typically graphite, asphalt, or another foreign body is embedded into the skin. In this unique case, though the etiology of foreign body is neither classic nor clear because the pigmentation was embedded directly within her scar, and the patient temporally noticed this pigmentation postsurgically, authors question whether the tattoo resulted from a novel or improper marking pen used pre- or intraoperatively. We do not have an explanation for the asymmetric nature of the pigment within only her left-sided surgical scar and were unable to find other relevant cases in the literature. We welcome further discussion within the community as to possible contributing etiologies and how best to prevent such cases in the future. We also seek to draw attention to the high-powered picosecond laser, which serves as a fast, safe, and effective modality that in our clinic has become the first-line treatment for traumatic tattoos, and in our patient led to high satisfaction.

DISCLOSURES

Roy Geronemus is on the medical advisory board for Lutronic. All the other authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of her image.