SURGERY 


Surgical excision of tattoos can be carried out. This process removes all the layers of the skin in the area where the tattoo is. Surgical methods of removing tattoos will, however, always leave a permanent scar. The type of scar depends on the technique that is used to close the skin again after the tattoo itself has been removed.

Simple Excision
If the tattoo is small it may be possible to simply cut away the pigmented skin and suture the skin edges together. A linear scar will remain, that looks very similar to a surgical scar. If there is a lot of tension when the tattoo has been removed, then this scar will stretch over time. Normally up to about 25% of the size of the piece of tissue that was removed. 

Serial Excision

If the tattoo is larger and/or there is not much slack in the area, then it is possible to remove the tattoo a piece at a time, waiting between surgical episodes for the skin to heal. This allows the tension to reduce, and another area of slack tissue develops. Then a further piece of tattoo can be removed and the wound closed from side to side again. This process is very dependent on the location of the tattoo on the body. Some areas of the body, such as the trunk, are very amenable to this technique, and the sessions of tattoo excision can be quite close together, at approximately 6months. In areas where the skin is tighter, such as on the forearms, wrists and ankles, then the amount of slack present, and the speed that further slack can be regenerated, is far more limited. Therefore the amount of tattoo that can be removed at a single session, and the frequency of those sessions is different in different areas of the body.

Resurfacing

If the tattoo is too large to realistically plan a series of small excisions, or if the patient is very keen to remove the tattoo all at once, then the hole generated by the excision of the tattoo is not amenable to being closed primarily (ie the edges sewn together). This area of skin loss will therefore need to be resurfaced. To do this Miss Cubison uses a number of the techniques that she uses to manage patients who have significant burn injuries, and the scarring that results is very similar to the scar that you might have if you had a full thickness burn. 
The most straight forward technique is to resurface the area with a split skin graft.
This technique takes a slice of the top layers of the skin from somewhere else on the body, usually the thigh, and this skin is then placed over the hole after the tattoo has been cut away. The wound on the thigh from where the skin has been removed, called the donor site, then heals by itself, over a period of 2-3weeks, in the same way as a bad graze would heal if you scrap off the top layers of the skin.
The hairs remain on the thigh, and are not transferred to the new location, where the tattoo was.
The donor site, from where the skin was taken, will initially appear quite bright red, and then will gradually settle over a period of 6-24months, and eventually be only just visible as a slight change of colour on the thigh. The place where the tattoo used to be heals leaving a most definite scar, which appears as a patch. These scars shrink over time, and can produce quite a lot of tension in that area.
This means that although even large tattoos can be removed and resurfaced with a skin grafting technique, the quality of the result is unpredictable, and the scars can become tight and limiting. In areas such as the neck, it is not without consequence to remove what is in fact perfectly good quality skin, be it with tattoo pigment in, and replace it with lower quality skin from a split skin graft.

Other more modern techniques of burn management can also be used for tattoo resurfacing, and one of this is a dermal substitute called Integra.

Integra is a product that is derived from beef collagen and shark glycosaminoglycans. It is made into a two layer structure with a silicone overlayer, and this produces a scaffold for your body to use to regenerate the underlayer of the skin known as the dermis. This is the layer that is not put back using a standard split skin graft and is one of the reasons why there is a considerable amount of contraction after grafting is carried out. By using Integra, the Dermal Substitute, a layer of dermis is grown first and then the split skin graft placed over the top, to result in an improved cosmetic result, rather than just the standard split skin graft. This is an expensive technique. The Integra itself is an expensive product and the additional processes that are necessary are, in themselves, costly and time consuming.

The operation is undertaken in two parts: the first part being the removal of the tattoo and the insertion of the Integra with its silicone overlayer.
A pump is used to hold the Integra tightly onto the underlying tissue, so that new blood vessels can grow into the Integra.
It is important that you do not smoke, as the nicotine will slow down the ingrowth of blood vessels into the Integra. After approximately 2-3weeks, the Integra should have enough new blood vessels. At a second operation, the silicone layer of the Integra is removed and a very thin split skin graft is placed onto the new neo-dermis. The pump is then replaced for a further week – to ensure that the skin graft has the best possible chance of taking onto the Integra. The cosmetic results of resurfacing using Integra are much better if the Integra takes well.
The contraction is less and the new skin produced is less likely to be red and lumpy than a sim
ple kin graft.

It is also possible to resurface, particularly smaller areas, using full thickness skin. This involves taking the skin from another area of the body, normally the groin, where a piece of full thickness skin can be cut out and the skin sewn together again. This obtains the full thickness of the skin, rather than just the top layers. It results in a linear scar where the skin was removed,
rather than the flat rectangular pigmented scar from a split skin graft.

The full thickness skin graft produces a very nice cosmetic result, and is the best outcome, but the amount of full thickness skin available on the body to use for this technique is fairly limited, without leaving very considerable scars elsewhere. This technique is therefore something that is very dependent of the location of your tattoo, and is not always appropriate, although if the full thickness skin graft takes well it does produce an excellent cosmetic result both in texture and in appearance.