The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
In this article, we report our experience detailing permanent damage incurred to an iPhone 7 camera lens positioned 60 cm away from the skin, while video recording an Nd:YAG laser tattoo removal treatment. Our findings can serve as a starting point for future studies.
Case Report
A 23-year-old brown-skinned Filipino woman presented for removal of black- and red-colored professionally rendered tattoos on both her wrists of 2 years’ duration. She had no previous attempts or past procedures done for tattoo removal. The tattoo on the right wrist measured 5 × 4 cm (Figure 1), and the tattoo on the left wrist measured 5.5 × 3.5 cm (Figure 2). After signing informed consent, wavelength-specific protective glasses (Model YGN, Oculo-Plastik, Inc, Canada) were worn by the treating physician and the clinic assistant assigned to do the video recording, while protective metal goggles (I-SHIELD, Oculo-Plastik, Inc, Canada) were worn by the patient. Both the treating physician and the assistant conducting the video recording were positioned on the left side of the patient who was seated on a dental chair.
Figure 1. The tattoo on the right wrist measured 5 × 4 cm.
Topical anesthesia cream consisting of tetracaine 5%, lidocaine 2.5%, and prilocaine 2.5% (Triocaine-10, Time Machine Cosmetiques, Philippines) was applied over the treatment sites and occluded with clear plastic film (Kitchen Magic Cling Wrap, RKMI Pilipinas Inc) for 1 hour prior to laser treatment. Q-switched Nd:YAG laser (Mermaid-C, RUIKD Co, Ltd, South Korea) tattoo removal treatment was performed by the physician, while the clinic assistant video recorded the treatment using the back camera of an iPhone 7.
First, the 1064-nm F50 laser tip attached to the laser handpiece was used to treat the black portions of the tattoo. The parameters were set at 1000 mJ and 5-Hz repetition rate with 2-mm spot size. No untoward incident was noted.
Then the laser tip was changed to 532-nm F50 to treat the red tattoos, with 800 mJ and 5-Hz repetition rate with 2-mm spot size.
The iPhone 7 camera used for video recording was held at a distance of about 60 cm and at a 50°- to 60°-angle from the tattoo on the patient’s left wrist (Figure 2); and about 90 cm distance and at a 65°- to 70°-angle from the tattoo on the right wrist. The tattoo on the left wrist was treated first, followed by the tattoo on the right wrist.
Figure 2. The tattoo on the left wrist measured 5.5× 3.5 cm.
Article continues on page 2
Specks of green were noted on the screen of the iPhone immediately after treatment of the left wrist with the 532-nm F50 tip and just before treatment of the right wrist. (Figure 3). The specks were dots the same size as the spot size of the laser. During the tattoo removal treatment of the right wrist, no additional new specks of green appeared.
Figure 3. Green specks were noted on the screen of the iPhone immediately after treatment of
the left wrist with the 532-nm F50 tip and just before treatment of the right wrist.
Upon review of the video recording, it was noted that a new green speck appeared with each flash of 532-nm laser pulse while treating the left wrist but none appeared while treating the right wrist. The back camera lens of the iPhone is permanently damaged and all pictures and videos subsequently taken using the back camera, such as the picture of the right wrist taken before laser treatment was started, are viewed with green dots (specks) on the image screen (Figure 4).
Figure 4. The back camera lens of the iPhone is permanently damaged and all pictures and videos
subsequently taken using the back camera are viewed with green specks on the image screen.
The patient was sent home with routine post-laser wound care instructions and advised to follow-up for 7 more tattoo removal sessions at 8-week intervals.
Discussion
Q-Switched Nd:YAG lasers used for tattoo removal, along with other lasers used in dermatology, are classified by the American National Standards Institute as Class 4, which carries the highest warning vs hazards3 from fire or burning due to conversion of light energy to heat; potential respiratory disease from inhalation of laser plume; and ocular injuries, including blindness, mostly from reflection of incident laser light. Documented reports of accidental injuries due to reflected or scattered Nd:YAG laser beam usually involve the skin (burns) and the eye, specifically the retina.4,5 Lens and corneal damage have been reported but only in cases where the Nd:YAG laser was used in intraocular surgeries; this is due to the proximity of the damaged structure to the targeted tissue.6
A person with knowledge about laser properties and laser-tissue interactions would assume that the 1064-nm beam would result in greater damage compared with the 532-nm beam. This is due to a number of factors: (1) 532 nm belongs to the visible light spectrum and persons who are exposed while a beam was being fired shut their eyes as a response to the flash of bright green light5; (2) 1064 nm is near infrared and is invisible to the human eye so eye protection could sometimes be taken for granted5; and (3) 532 nm is double the frequency of the fundamental wavelength (1064 nm) of the machine, which means the penetrability of the beam is decreased.7
As a general rule, shorter wavelengths of light when reflected are expected to bounce back at a shorter distance, whereas longer wavelengths when reflected are expected to bounce back at a longer distance. However, in this case, no adverse incident was noted while treating the black tattoos using the longer wavelength (1064 nm) of the Nd:YAG laser. Yet, the shorter 532-nm wavelength used to treat red tattoos caused immediate permanent damage to the camera lens of the iPhone 7 during video recording from a distance of 60 cm from the skin but not from a distance of 90 cm, presumably by reflection.
We surmise that the 1064-nm wavelength, which is known to deeply penetrate and reach up to the dermis, was better absorbed and so had insignificant reflection. In comparison, the 532-nm wavelength, which is known to penetrate more superficially, up to the level of the epidermis1,3,7 was presumably not as well absorbed and that much of the light was reflected, causing damage to the camera lens of the iPhone 7 during video recording of the procedure.
More studies are needed to determine the minimum and maximum distance of reflected light during laser treatment to determine definitive recommendations for safety.
Dr Piansay-Soriano is founder-president of the Philippine Academy of Dermatologic Surgery Foundation Inc (PADSFI) in Manila, Philippines. She is an associate professor and chief of the section of dermatology at the Davao Medical School Foundation. She is a mentor of the American Society for Dermatologic Surgery International Traveling Mentorship Program (ASDS-ITMP) and awarded the Gold Medal of Excellence in 2014.
Dr Coronica-Soroan is a graduate of the Integrated Arts and Medicine Program of the University of the Philippines College of Medicine and has been a mentee of Dr Soriano under the ASDS-ITMP Program. She is an associate dermatologist at Medi-Skin Clinic in Davao City, Philippines.
Disclosure: The authors report no relevant financial relationships.
References
1. Marini L. Tattoo removal using a multilayer Q-switched laser. PRIME J. 2016;6(4):14-23.
2. Ansari MA, Mohajerani E. Mechanism of laser-tissue interaction: I optical properties of tissue. J Lasers Med Sci. 2011;2(3):119-25.
3. Laser safety manual. University of Florida, Environmental Health and Safety. August 24, 2005. University of Florida Environmental Health and Safety. Laser manual. https://webfiles.ehs.ufl.edu/lasersafeman.pdf. Published April 24, 2015. Accessed July 20, 2017.
4. University of Pittsburgh Department of Environmental Health and Safety. Laser safety training. https://www.ehs.pitt.edu/assets/docs/LaserSafety.pdf. Published July 2014. Accessed July 20, 2017.
5. Environment Health Safety Division Radiation Protection Group, Berkeley Lab. Laser bio-effects. https://www2.lbl.gov/ehs/safety/lasers/bioeffects.shtml. Published September 10, 2015. Accessed July 20, 2017.
6. Steinert RF. Nd:YAG laser posterior capsulotomy. https://www.aao.org/munnerlyn-laser-surgery-center/ndyag-laser-posterior-capsulotomy-3. Published November 4, 2013. Accessed July 20, 2017
7. Cencic B, Lukac M, Marincek M, Vizintin Z. High fluence, high beam quality Q-Switched Nd:YAG laser with Optoflex delivery system for treating benign pigmented lesions and tattoos. J Laser Health Acad. 2010;1:9-18.
The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
In this article, we report our experience detailing permanent damage incurred to an iPhone 7 camera lens positioned 60 cm away from the skin, while video recording an Nd:YAG laser tattoo removal treatment. Our findings can serve as a starting point for future studies.
Case Report
A 23-year-old brown-skinned Filipino woman presented for removal of black- and red-colored professionally rendered tattoos on both her wrists of 2 years’ duration. She had no previous attempts or past procedures done for tattoo removal. The tattoo on the right wrist measured 5 × 4 cm (Figure 1), and the tattoo on the left wrist measured 5.5 × 3.5 cm (Figure 2). After signing informed consent, wavelength-specific protective glasses (Model YGN, Oculo-Plastik, Inc, Canada) were worn by the treating physician and the clinic assistant assigned to do the video recording, while protective metal goggles (I-SHIELD, Oculo-Plastik, Inc, Canada) were worn by the patient. Both the treating physician and the assistant conducting the video recording were positioned on the left side of the patient who was seated on a dental chair.
Figure 1. The tattoo on the right wrist measured 5 × 4 cm.
Topical anesthesia cream consisting of tetracaine 5%, lidocaine 2.5%, and prilocaine 2.5% (Triocaine-10, Time Machine Cosmetiques, Philippines) was applied over the treatment sites and occluded with clear plastic film (Kitchen Magic Cling Wrap, RKMI Pilipinas Inc) for 1 hour prior to laser treatment. Q-switched Nd:YAG laser (Mermaid-C, RUIKD Co, Ltd, South Korea) tattoo removal treatment was performed by the physician, while the clinic assistant video recorded the treatment using the back camera of an iPhone 7.
First, the 1064-nm F50 laser tip attached to the laser handpiece was used to treat the black portions of the tattoo. The parameters were set at 1000 mJ and 5-Hz repetition rate with 2-mm spot size. No untoward incident was noted.
Then the laser tip was changed to 532-nm F50 to treat the red tattoos, with 800 mJ and 5-Hz repetition rate with 2-mm spot size.
The iPhone 7 camera used for video recording was held at a distance of about 60 cm and at a 50°- to 60°-angle from the tattoo on the patient’s left wrist (Figure 2); and about 90 cm distance and at a 65°- to 70°-angle from the tattoo on the right wrist. The tattoo on the left wrist was treated first, followed by the tattoo on the right wrist.
Figure 2. The tattoo on the left wrist measured 5.5× 3.5 cm.
Specks of green were noted on the screen of the iPhone immediately after treatment of the left wrist with the 532-nm F50 tip and just before treatment of the right wrist. (Figure 3). The specks were dots the same size as the spot size of the laser. During the tattoo removal treatment of the right wrist, no additional new specks of green appeared.
Figure 3. Green specks were noted on the screen of the iPhone immediately after treatment of
the left wrist with the 532-nm F50 tip and just before treatment of the right wrist.
Upon review of the video recording, it was noted that a new green speck appeared with each flash of 532-nm laser pulse while treating the left wrist but none appeared while treating the right wrist. The back camera lens of the iPhone is permanently damaged and all pictures and videos subsequently taken using the back camera, such as the picture of the right wrist taken before laser treatment was started, are viewed with green dots (specks) on the image screen (Figure 4).
Figure 4. The back camera lens of the iPhone is permanently damaged and all pictures and videos
subsequently taken using the back camera are viewed with green specks on the image screen.
The patient was sent home with routine post-laser wound care instructions and advised to follow-up for 7 more tattoo removal sessions at 8-week intervals.
Discussion
Q-Switched Nd:YAG lasers used for tattoo removal, along with other lasers used in dermatology, are classified by the American National Standards Institute as Class 4, which carries the highest warning vs hazards3 from fire or burning due to conversion of light energy to heat; potential respiratory disease from inhalation of laser plume; and ocular injuries, including blindness, mostly from reflection of incident laser light. Documented reports of accidental injuries due to reflected or scattered Nd:YAG laser beam usually involve the skin (burns) and the eye, specifically the retina.4,5 Lens and corneal damage have been reported but only in cases where the Nd:YAG laser was used in intraocular surgeries; this is due to the proximity of the damaged structure to the targeted tissue.6
A person with knowledge about laser properties and laser-tissue interactions would assume that the 1064-nm beam would result in greater damage compared with the 532-nm beam. This is due to a number of factors: (1) 532 nm belongs to the visible light spectrum and persons who are exposed while a beam was being fired shut their eyes as a response to the flash of bright green light5; (2) 1064 nm is near infrared and is invisible to the human eye so eye protection could sometimes be taken for granted5; and (3) 532 nm is double the frequency of the fundamental wavelength (1064 nm) of the machine, which means the penetrability of the beam is decreased.7
As a general rule, shorter wavelengths of light when reflected are expected to bounce back at a shorter distance, whereas longer wavelengths when reflected are expected to bounce back at a longer distance. However, in this case, no adverse incident was noted while treating the black tattoos using the longer wavelength (1064 nm) of the Nd:YAG laser. Yet, the shorter 532-nm wavelength used to treat red tattoos caused immediate permanent damage to the camera lens of the iPhone 7 during video recording from a distance of 60 cm from the skin but not from a distance of 90 cm, presumably by reflection.
We surmise that the 1064-nm wavelength, which is known to deeply penetrate and reach up to the dermis, was better absorbed and so had insignificant reflection. In comparison, the 532-nm wavelength, which is known to penetrate more superficially, up to the level of the epidermis1,3,7 was presumably not as well absorbed and that much of the light was reflected, causing damage to the camera lens of the iPhone 7 during video recording of the procedure.
More studies are needed to determine the minimum and maximum distance of reflected light during laser treatment to determine definitive recommendations for safety.
Dr Piansay-Soriano is founder-president of the Philippine Academy of Dermatologic Surgery Foundation Inc (PADSFI) in Manila, Philippines. She is an associate professor and chief of the section of dermatology at the Davao Medical School Foundation. She is a mentor of the American Society for Dermatologic Surgery International Traveling Mentorship Program (ASDS-ITMP) and awarded the Gold Medal of Excellence in 2014.
Dr Coronica-Soroan is a graduate of the Integrated Arts and Medicine Program of the University of the Philippines College of Medicine and has been a mentee of Dr Soriano under the ASDS-ITMP Program. She is an associate dermatologist at Medi-Skin Clinic in Davao City, Philippines.
Disclosure: The authors report no relevant financial relationships.
References
1. Marini L. Tattoo removal using a multilayer Q-switched laser. PRIME J. 2016;6(4):14-23.
2. Ansari MA, Mohajerani E. Mechanism of laser-tissue interaction: I optical properties of tissue. J Lasers Med Sci. 2011;2(3):119-25.
3. Laser safety manual. University of Florida, Environmental Health and Safety. August 24, 2005. University of Florida Environmental Health and Safety. Laser manual. https://webfiles.ehs.ufl.edu/lasersafeman.pdf. Published April 24, 2015. Accessed July 20, 2017.
4. University of Pittsburgh Department of Environmental Health and Safety. Laser safety training. https://www.ehs.pitt.edu/assets/docs/LaserSafety.pdf. Published July 2014. Accessed July 20, 2017.
5. Environment Health Safety Division Radiation Protection Group, Berkeley Lab. Laser bio-effects. https://www2.lbl.gov/ehs/safety/lasers/bioeffects.shtml. Published September 10, 2015. Accessed July 20, 2017.
6. Steinert RF. Nd:YAG laser posterior capsulotomy. https://www.aao.org/munnerlyn-laser-surgery-center/ndyag-laser-posterior-capsulotomy-3. Published November 4, 2013. Accessed July 20, 2017
7. Cencic B, Lukac M, Marincek M, Vizintin Z. High fluence, high beam quality Q-Switched Nd:YAG laser with Optoflex delivery system for treating benign pigmented lesions and tattoos. J Laser Health Acad. 2010;1:9-18.
The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
In this article, we report our experience detailing permanent damage incurred to an iPhone 7 camera lens positioned 60 cm away from the skin, while video recording an Nd:YAG laser tattoo removal treatment. Our findings can serve as a starting point for future studies.
Case Report
A 23-year-old brown-skinned Filipino woman presented for removal of black- and red-colored professionally rendered tattoos on both her wrists of 2 years’ duration. She had no previous attempts or past procedures done for tattoo removal. The tattoo on the right wrist measured 5 × 4 cm (Figure 1), and the tattoo on the left wrist measured 5.5 × 3.5 cm (Figure 2). After signing informed consent, wavelength-specific protective glasses (Model YGN, Oculo-Plastik, Inc, Canada) were worn by the treating physician and the clinic assistant assigned to do the video recording, while protective metal goggles (I-SHIELD, Oculo-Plastik, Inc, Canada) were worn by the patient. Both the treating physician and the assistant conducting the video recording were positioned on the left side of the patient who was seated on a dental chair.
Figure 1. The tattoo on the right wrist measured 5 × 4 cm.
Topical anesthesia cream consisting of tetracaine 5%, lidocaine 2.5%, and prilocaine 2.5% (Triocaine-10, Time Machine Cosmetiques, Philippines) was applied over the treatment sites and occluded with clear plastic film (Kitchen Magic Cling Wrap, RKMI Pilipinas Inc) for 1 hour prior to laser treatment. Q-switched Nd:YAG laser (Mermaid-C, RUIKD Co, Ltd, South Korea) tattoo removal treatment was performed by the physician, while the clinic assistant video recorded the treatment using the back camera of an iPhone 7.
First, the 1064-nm F50 laser tip attached to the laser handpiece was used to treat the black portions of the tattoo. The parameters were set at 1000 mJ and 5-Hz repetition rate with 2-mm spot size. No untoward incident was noted.
Then the laser tip was changed to 532-nm F50 to treat the red tattoos, with 800 mJ and 5-Hz repetition rate with 2-mm spot size.
The iPhone 7 camera used for video recording was held at a distance of about 60 cm and at a 50°- to 60°-angle from the tattoo on the patient’s left wrist (Figure 2); and about 90 cm distance and at a 65°- to 70°-angle from the tattoo on the right wrist. The tattoo on the left wrist was treated first, followed by the tattoo on the right wrist.
Figure 2. The tattoo on the left wrist measured 5.5× 3.5 cm.
,
The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
In this article, we report our experience detailing permanent damage incurred to an iPhone 7 camera lens positioned 60 cm away from the skin, while video recording an Nd:YAG laser tattoo removal treatment. Our findings can serve as a starting point for future studies.
Case Report
A 23-year-old brown-skinned Filipino woman presented for removal of black- and red-colored professionally rendered tattoos on both her wrists of 2 years’ duration. She had no previous attempts or past procedures done for tattoo removal. The tattoo on the right wrist measured 5 × 4 cm (Figure 1), and the tattoo on the left wrist measured 5.5 × 3.5 cm (Figure 2). After signing informed consent, wavelength-specific protective glasses (Model YGN, Oculo-Plastik, Inc, Canada) were worn by the treating physician and the clinic assistant assigned to do the video recording, while protective metal goggles (I-SHIELD, Oculo-Plastik, Inc, Canada) were worn by the patient. Both the treating physician and the assistant conducting the video recording were positioned on the left side of the patient who was seated on a dental chair.
Figure 1. The tattoo on the right wrist measured 5 × 4 cm.
Topical anesthesia cream consisting of tetracaine 5%, lidocaine 2.5%, and prilocaine 2.5% (Triocaine-10, Time Machine Cosmetiques, Philippines) was applied over the treatment sites and occluded with clear plastic film (Kitchen Magic Cling Wrap, RKMI Pilipinas Inc) for 1 hour prior to laser treatment. Q-switched Nd:YAG laser (Mermaid-C, RUIKD Co, Ltd, South Korea) tattoo removal treatment was performed by the physician, while the clinic assistant video recorded the treatment using the back camera of an iPhone 7.
First, the 1064-nm F50 laser tip attached to the laser handpiece was used to treat the black portions of the tattoo. The parameters were set at 1000 mJ and 5-Hz repetition rate with 2-mm spot size. No untoward incident was noted.
Then the laser tip was changed to 532-nm F50 to treat the red tattoos, with 800 mJ and 5-Hz repetition rate with 2-mm spot size.
The iPhone 7 camera used for video recording was held at a distance of about 60 cm and at a 50°- to 60°-angle from the tattoo on the patient’s left wrist (Figure 2); and about 90 cm distance and at a 65°- to 70°-angle from the tattoo on the right wrist. The tattoo on the left wrist was treated first, followed by the tattoo on the right wrist.
Figure 2. The tattoo on the left wrist measured 5.5× 3.5 cm.
Article continues on page 2
Specks of green were noted on the screen of the iPhone immediately after treatment of the left wrist with the 532-nm F50 tip and just before treatment of the right wrist. (Figure 3). The specks were dots the same size as the spot size of the laser. During the tattoo removal treatment of the right wrist, no additional new specks of green appeared.
Figure 3. Green specks were noted on the screen of the iPhone immediately after treatment of
the left wrist with the 532-nm F50 tip and just before treatment of the right wrist.
Upon review of the video recording, it was noted that a new green speck appeared with each flash of 532-nm laser pulse while treating the left wrist but none appeared while treating the right wrist. The back camera lens of the iPhone is permanently damaged and all pictures and videos subsequently taken using the back camera, such as the picture of the right wrist taken before laser treatment was started, are viewed with green dots (specks) on the image screen (Figure 4).
Figure 4. The back camera lens of the iPhone is permanently damaged and all pictures and videos
subsequently taken using the back camera are viewed with green specks on the image screen.
The patient was sent home with routine post-laser wound care instructions and advised to follow-up for 7 more tattoo removal sessions at 8-week intervals.
Discussion
Q-Switched Nd:YAG lasers used for tattoo removal, along with other lasers used in dermatology, are classified by the American National Standards Institute as Class 4, which carries the highest warning vs hazards3 from fire or burning due to conversion of light energy to heat; potential respiratory disease from inhalation of laser plume; and ocular injuries, including blindness, mostly from reflection of incident laser light. Documented reports of accidental injuries due to reflected or scattered Nd:YAG laser beam usually involve the skin (burns) and the eye, specifically the retina.4,5 Lens and corneal damage have been reported but only in cases where the Nd:YAG laser was used in intraocular surgeries; this is due to the proximity of the damaged structure to the targeted tissue.6
A person with knowledge about laser properties and laser-tissue interactions would assume that the 1064-nm beam would result in greater damage compared with the 532-nm beam. This is due to a number of factors: (1) 532 nm belongs to the visible light spectrum and persons who are exposed while a beam was being fired shut their eyes as a response to the flash of bright green light5; (2) 1064 nm is near infrared and is invisible to the human eye so eye protection could sometimes be taken for granted5; and (3) 532 nm is double the frequency of the fundamental wavelength (1064 nm) of the machine, which means the penetrability of the beam is decreased.7
As a general rule, shorter wavelengths of light when reflected are expected to bounce back at a shorter distance, whereas longer wavelengths when reflected are expected to bounce back at a longer distance. However, in this case, no adverse incident was noted while treating the black tattoos using the longer wavelength (1064 nm) of the Nd:YAG laser. Yet, the shorter 532-nm wavelength used to treat red tattoos caused immediate permanent damage to the camera lens of the iPhone 7 during video recording from a distance of 60 cm from the skin but not from a distance of 90 cm, presumably by reflection.
We surmise that the 1064-nm wavelength, which is known to deeply penetrate and reach up to the dermis, was better absorbed and so had insignificant reflection. In comparison, the 532-nm wavelength, which is known to penetrate more superficially, up to the level of the epidermis1,3,7 was presumably not as well absorbed and that much of the light was reflected, causing damage to the camera lens of the iPhone 7 during video recording of the procedure.
More studies are needed to determine the minimum and maximum distance of reflected light during laser treatment to determine definitive recommendations for safety.
Dr Piansay-Soriano is founder-president of the Philippine Academy of Dermatologic Surgery Foundation Inc (PADSFI) in Manila, Philippines. She is an associate professor and chief of the section of dermatology at the Davao Medical School Foundation. She is a mentor of the American Society for Dermatologic Surgery International Traveling Mentorship Program (ASDS-ITMP) and awarded the Gold Medal of Excellence in 2014.
Dr Coronica-Soroan is a graduate of the Integrated Arts and Medicine Program of the University of the Philippines College of Medicine and has been a mentee of Dr Soriano under the ASDS-ITMP Program. She is an associate dermatologist at Medi-Skin Clinic in Davao City, Philippines.
Disclosure: The authors report no relevant financial relationships.
References
1. Marini L. Tattoo removal using a multilayer Q-switched laser. PRIME J. 2016;6(4):14-23.
2. Ansari MA, Mohajerani E. Mechanism of laser-tissue interaction: I optical properties of tissue. J Lasers Med Sci. 2011;2(3):119-25.
3. Laser safety manual. University of Florida, Environmental Health and Safety. August 24, 2005. University of Florida Environmental Health and Safety. Laser manual. https://webfiles.ehs.ufl.edu/lasersafeman.pdf. Published April 24, 2015. Accessed July 20, 2017.
4. University of Pittsburgh Department of Environmental Health and Safety. Laser safety training. https://www.ehs.pitt.edu/assets/docs/LaserSafety.pdf. Published July 2014. Accessed July 20, 2017.
5. Environment Health Safety Division Radiation Protection Group, Berkeley Lab. Laser bio-effects. https://www2.lbl.gov/ehs/safety/lasers/bioeffects.shtml. Published September 10, 2015. Accessed July 20, 2017.
6. Steinert RF. Nd:YAG laser posterior capsulotomy. https://www.aao.org/munnerlyn-laser-surgery-center/ndyag-laser-posterior-capsulotomy-3. Published November 4, 2013. Accessed July 20, 2017
7. Cencic B, Lukac M, Marincek M, Vizintin Z. High fluence, high beam quality Q-Switched Nd:YAG laser with Optoflex delivery system for treating benign pigmented lesions and tattoos. J Laser Health Acad. 2010;1:9-18.
The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
In this article, we report our experience detailing permanent damage incurred to an iPhone 7 camera lens positioned 60 cm away from the skin, while video recording an Nd:YAG laser tattoo removal treatment. Our findings can serve as a starting point for future studies.
Case Report
A 23-year-old brown-skinned Filipino woman presented for removal of black- and red-colored professionally rendered tattoos on both her wrists of 2 years’ duration. She had no previous attempts or past procedures done for tattoo removal. The tattoo on the right wrist measured 5 × 4 cm (Figure 1), and the tattoo on the left wrist measured 5.5 × 3.5 cm (Figure 2). After signing informed consent, wavelength-specific protective glasses (Model YGN, Oculo-Plastik, Inc, Canada) were worn by the treating physician and the clinic assistant assigned to do the video recording, while protective metal goggles (I-SHIELD, Oculo-Plastik, Inc, Canada) were worn by the patient. Both the treating physician and the assistant conducting the video recording were positioned on the left side of the patient who was seated on a dental chair.
Figure 1. The tattoo on the right wrist measured 5 × 4 cm.
Topical anesthesia cream consisting of tetracaine 5%, lidocaine 2.5%, and prilocaine 2.5% (Triocaine-10, Time Machine Cosmetiques, Philippines) was applied over the treatment sites and occluded with clear plastic film (Kitchen Magic Cling Wrap, RKMI Pilipinas Inc) for 1 hour prior to laser treatment. Q-switched Nd:YAG laser (Mermaid-C, RUIKD Co, Ltd, South Korea) tattoo removal treatment was performed by the physician, while the clinic assistant video recorded the treatment using the back camera of an iPhone 7.
First, the 1064-nm F50 laser tip attached to the laser handpiece was used to treat the black portions of the tattoo. The parameters were set at 1000 mJ and 5-Hz repetition rate with 2-mm spot size. No untoward incident was noted.
Then the laser tip was changed to 532-nm F50 to treat the red tattoos, with 800 mJ and 5-Hz repetition rate with 2-mm spot size.
The iPhone 7 camera used for video recording was held at a distance of about 60 cm and at a 50°- to 60°-angle from the tattoo on the patient’s left wrist (Figure 2); and about 90 cm distance and at a 65°- to 70°-angle from the tattoo on the right wrist. The tattoo on the left wrist was treated first, followed by the tattoo on the right wrist.
Figure 2. The tattoo on the left wrist measured 5.5× 3.5 cm.
Specks of green were noted on the screen of the iPhone immediately after treatment of the left wrist with the 532-nm F50 tip and just before treatment of the right wrist. (Figure 3). The specks were dots the same size as the spot size of the laser. During the tattoo removal treatment of the right wrist, no additional new specks of green appeared.
Figure 3. Green specks were noted on the screen of the iPhone immediately after treatment of
the left wrist with the 532-nm F50 tip and just before treatment of the right wrist.
Upon review of the video recording, it was noted that a new green speck appeared with each flash of 532-nm laser pulse while treating the left wrist but none appeared while treating the right wrist. The back camera lens of the iPhone is permanently damaged and all pictures and videos subsequently taken using the back camera, such as the picture of the right wrist taken before laser treatment was started, are viewed with green dots (specks) on the image screen (Figure 4).
Figure 4. The back camera lens of the iPhone is permanently damaged and all pictures and videos
subsequently taken using the back camera are viewed with green specks on the image screen.
The patient was sent home with routine post-laser wound care instructions and advised to follow-up for 7 more tattoo removal sessions at 8-week intervals.
Discussion
Q-Switched Nd:YAG lasers used for tattoo removal, along with other lasers used in dermatology, are classified by the American National Standards Institute as Class 4, which carries the highest warning vs hazards3 from fire or burning due to conversion of light energy to heat; potential respiratory disease from inhalation of laser plume; and ocular injuries, including blindness, mostly from reflection of incident laser light. Documented reports of accidental injuries due to reflected or scattered Nd:YAG laser beam usually involve the skin (burns) and the eye, specifically the retina.4,5 Lens and corneal damage have been reported but only in cases where the Nd:YAG laser was used in intraocular surgeries; this is due to the proximity of the damaged structure to the targeted tissue.6
A person with knowledge about laser properties and laser-tissue interactions would assume that the 1064-nm beam would result in greater damage compared with the 532-nm beam. This is due to a number of factors: (1) 532 nm belongs to the visible light spectrum and persons who are exposed while a beam was being fired shut their eyes as a response to the flash of bright green light5; (2) 1064 nm is near infrared and is invisible to the human eye so eye protection could sometimes be taken for granted5; and (3) 532 nm is double the frequency of the fundamental wavelength (1064 nm) of the machine, which means the penetrability of the beam is decreased.7
As a general rule, shorter wavelengths of light when reflected are expected to bounce back at a shorter distance, whereas longer wavelengths when reflected are expected to bounce back at a longer distance. However, in this case, no adverse incident was noted while treating the black tattoos using the longer wavelength (1064 nm) of the Nd:YAG laser. Yet, the shorter 532-nm wavelength used to treat red tattoos caused immediate permanent damage to the camera lens of the iPhone 7 during video recording from a distance of 60 cm from the skin but not from a distance of 90 cm, presumably by reflection.
We surmise that the 1064-nm wavelength, which is known to deeply penetrate and reach up to the dermis, was better absorbed and so had insignificant reflection. In comparison, the 532-nm wavelength, which is known to penetrate more superficially, up to the level of the epidermis1,3,7 was presumably not as well absorbed and that much of the light was reflected, causing damage to the camera lens of the iPhone 7 during video recording of the procedure.
More studies are needed to determine the minimum and maximum distance of reflected light during laser treatment to determine definitive recommendations for safety.
Dr Piansay-Soriano is founder-president of the Philippine Academy of Dermatologic Surgery Foundation Inc (PADSFI) in Manila, Philippines. She is an associate professor and chief of the section of dermatology at the Davao Medical School Foundation. She is a mentor of the American Society for Dermatologic Surgery International Traveling Mentorship Program (ASDS-ITMP) and awarded the Gold Medal of Excellence in 2014.
Dr Coronica-Soroan is a graduate of the Integrated Arts and Medicine Program of the University of the Philippines College of Medicine and has been a mentee of Dr Soriano under the ASDS-ITMP Program. She is an associate dermatologist at Medi-Skin Clinic in Davao City, Philippines.
Disclosure: The authors report no relevant financial relationships.
References
1. Marini L. Tattoo removal using a multilayer Q-switched laser. PRIME J. 2016;6(4):14-23.
2. Ansari MA, Mohajerani E. Mechanism of laser-tissue interaction: I optical properties of tissue. J Lasers Med Sci. 2011;2(3):119-25.
3. Laser safety manual. University of Florida, Environmental Health and Safety. August 24, 2005. University of Florida Environmental Health and Safety. Laser manual. https://webfiles.ehs.ufl.edu/lasersafeman.pdf. Published April 24, 2015. Accessed July 20, 2017.
4. University of Pittsburgh Department of Environmental Health and Safety. Laser safety training. https://www.ehs.pitt.edu/assets/docs/LaserSafety.pdf. Published July 2014. Accessed July 20, 2017.
5. Environment Health Safety Division Radiation Protection Group, Berkeley Lab. Laser bio-effects. https://www2.lbl.gov/ehs/safety/lasers/bioeffects.shtml. Published September 10, 2015. Accessed July 20, 2017.
6. Steinert RF. Nd:YAG laser posterior capsulotomy. https://www.aao.org/munnerlyn-laser-surgery-center/ndyag-laser-posterior-capsulotomy-3. Published November 4, 2013. Accessed July 20, 2017
7. Cencic B, Lukac M, Marincek M, Vizintin Z. High fluence, high beam quality Q-Switched Nd:YAG laser with Optoflex delivery system for treating benign pigmented lesions and tattoos. J Laser Health Acad. 2010;1:9-18.
Specks of green were noted on the screen of the iPhone immediately after treatment of the left wrist with the 532-nm F50 tip and just before treatment of the right wrist. (Figure 3). The specks were dots the same size as the spot size of the laser. During the tattoo removal treatment of the right wrist, no additional new specks of green appeared.
Figure 3. Green specks were noted on the screen of the iPhone immediately after treatment of
the left wrist with the 532-nm F50 tip and just before treatment of the right wrist.
Upon review of the video recording, it was noted that a new green speck appeared with each flash of 532-nm laser pulse while treating the left wrist but none appeared while treating the right wrist. The back camera lens of the iPhone is permanently damaged and all pictures and videos subsequently taken using the back camera, such as the picture of the right wrist taken before laser treatment was started, are viewed with green dots (specks) on the image screen (Figure 4).
Figure 4. The back camera lens of the iPhone is permanently damaged and all pictures and videos
subsequently taken using the back camera are viewed with green specks on the image screen.
The patient was sent home with routine post-laser wound care instructions and advised to follow-up for 7 more tattoo removal sessions at 8-week intervals.
Discussion
Q-Switched Nd:YAG lasers used for tattoo removal, along with other lasers used in dermatology, are classified by the American National Standards Institute as Class 4, which carries the highest warning vs hazards3 from fire or burning due to conversion of light energy to heat; potential respiratory disease from inhalation of laser plume; and ocular injuries, including blindness, mostly from reflection of incident laser light. Documented reports of accidental injuries due to reflected or scattered Nd:YAG laser beam usually involve the skin (burns) and the eye, specifically the retina.4,5 Lens and corneal damage have been reported but only in cases where the Nd:YAG laser was used in intraocular surgeries; this is due to the proximity of the damaged structure to the targeted tissue.6
A person with knowledge about laser properties and laser-tissue interactions would assume that the 1064-nm beam would result in greater damage compared with the 532-nm beam. This is due to a number of factors: (1) 532 nm belongs to the visible light spectrum and persons who are exposed while a beam was being fired shut their eyes as a response to the flash of bright green light5; (2) 1064 nm is near infrared and is invisible to the human eye so eye protection could sometimes be taken for granted5; and (3) 532 nm is double the frequency of the fundamental wavelength (1064 nm) of the machine, which means the penetrability of the beam is decreased.7
As a general rule, shorter wavelengths of light when reflected are expected to bounce back at a shorter distance, whereas longer wavelengths when reflected are expected to bounce back at a longer distance. However, in this case, no adverse incident was noted while treating the black tattoos using the longer wavelength (1064 nm) of the Nd:YAG laser. Yet, the shorter 532-nm wavelength used to treat red tattoos caused immediate permanent damage to the camera lens of the iPhone 7 during video recording from a distance of 60 cm from the skin but not from a distance of 90 cm, presumably by reflection.
We surmise that the 1064-nm wavelength, which is known to deeply penetrate and reach up to the dermis, was better absorbed and so had insignificant reflection. In comparison, the 532-nm wavelength, which is known to penetrate more superficially, up to the level of the epidermis1,3,7 was presumably not as well absorbed and that much of the light was reflected, causing damage to the camera lens of the iPhone 7 during video recording of the procedure.
More studies are needed to determine the minimum and maximum distance of reflected light during laser treatment to determine definitive recommendations for safety.
Dr Piansay-Soriano is founder-president of the Philippine Academy of Dermatologic Surgery Foundation Inc (PADSFI) in Manila, Philippines. She is an associate professor and chief of the section of dermatology at the Davao Medical School Foundation. She is a mentor of the American Society for Dermatologic Surgery International Traveling Mentorship Program (ASDS-ITMP) and awarded the Gold Medal of Excellence in 2014.
Dr Coronica-Soroan is a graduate of the Integrated Arts and Medicine Program of the University of the Philippines College of Medicine and has been a mentee of Dr Soriano under the ASDS-ITMP Program. She is an associate dermatologist at Medi-Skin Clinic in Davao City, Philippines.
Disclosure: The authors report no relevant financial relationships.
References
1. Marini L. Tattoo removal using a multilayer Q-switched laser. PRIME J. 2016;6(4):14-23.
2. Ansari MA, Mohajerani E. Mechanism of laser-tissue interaction: I optical properties of tissue. J Lasers Med Sci. 2011;2(3):119-25.
3. Laser safety manual. University of Florida, Environmental Health and Safety. August 24, 2005. University of Florida Environmental Health and Safety. Laser manual. https://webfiles.ehs.ufl.edu/lasersafeman.pdf. Published April 24, 2015. Accessed July 20, 2017.
4. University of Pittsburgh Department of Environmental Health and Safety. Laser safety training. https://www.ehs.pitt.edu/assets/docs/LaserSafety.pdf. Published July 2014. Accessed July 20, 2017.
5. Environment Health Safety Division Radiation Protection Group, Berkeley Lab. Laser bio-effects. https://www2.lbl.gov/ehs/safety/lasers/bioeffects.shtml. Published September 10, 2015. Accessed July 20, 2017.
6. Steinert RF. Nd:YAG laser posterior capsulotomy. https://www.aao.org/munnerlyn-laser-surgery-center/ndyag-laser-posterior-capsulotomy-3. Published November 4, 2013. Accessed July 20, 2017
7. Cencic B, Lukac M, Marincek M, Vizintin Z. High fluence, high beam quality Q-Switched Nd:YAG laser with Optoflex delivery system for treating benign pigmented lesions and tattoos. J Laser Health Acad. 2010;1:9-18.
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The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
The Q-switched Nd:YAG laser is considered one of the gold standards for tattoo removal alongside picosecond lasers. The shorter 532-nm wavelength is used to remove red tattoos, while the longer 1064-nm wavelength is used to remove black or dark blue tattoos. When tissue is irradiated with laser light, most of the energy of the laser light is absorbed by target chromophores, in this case, the tattoo pigments, resulting in photoacoustic fragmentation and eventual clearing by phagocytic dermal cells—the fibroblasts, macrophages, and mast cells.1 The remaining light rays are either scattered, transmitted, or reflected. Absorption, scattering, and transmission of laser light occurs in the direction pointing toward the tissues being treated; whereas with reflection, the light bounces back toward the direction of its source,2 which could be toward the treating physician and other personnel in the laser room, potentially causing injury. How far reflected laser light can reach during treatment has not been studied.
