For those already in the tattoo removal field, you may have heard of the R20 method. Occasionally, you may have a patient ask if you offer R20 or "accelerated tattoo removal" at your practice. For those looking to enter the field, it's worth familiarizing yourself with the concept and its pros and cons.
Many patients have the misconception that R20 tattoo removal is a different type of technology for treating tattoos – a type of laser that is more efficient at removing ink. Actually, the R20 method is simply a protocol – a unique treatment style – for using a Q-switched laser for tattoo removal. Instead of one treatment pass over the tattoo during the patient's visit, multiple passes are performed with the goal of shattering more ink for more substantial ink clearance between sessions.
There are conflicting opinions in the tattoo removal space about the safety of the R20 method. Some practices happily offer it; others refuse to do so out of concern for side effects and permanent skin damage.
In this article, we'll explore the R20 method, where it originated, its challenges, and how to responsibly implement it at your practice.
What is the R20 Method?
With traditional tattoo removal treatments, a single pass is performed over the tattoo with the laser. After the pass is completed, the patient is bandaged and sent home. Then, at least six weeks later, the patient returns for their following treatment.
The R20 method differs from traditional tattoo removal not because of the type of laser used but because of how it is used. It is often referred to as "multi-pass tattoo removal" because the laser treats the entire tattoo multiple times during a single appointment.
Here's the standard protocol for R20:
- 1st pass with laser
- Wait 20 minutes
- 2nd pass with laser
- Wait 20 minutes
- 3rd pass with laser
- Wait 20 minutes
- 4th pass with laser
- Provide Aftercare
Four laser passes with 20 minute waiting intervals is the standard for the R20 method, but some physicians may perform fewer passes, adjust the waiting periods, decrease the fluence, or somehow otherwise alter the R20 protocols. It's not uncommon for experienced physicians to experiment with settings and find the method that gives the most effective clearance for their patients.
The waiting period between passes is necessary due to the temporary "laser frosting" that appears as a part of the tattoo removal process. Laser frosting is a result of the rapid temperature changes in skin tissue from the laser energy, causing plasma and gas to bubble within the skin. This frosting typically appears white or grayish in appearance and usually takes at least ten minutes to resolve.
Once the laser frosting appears, you must wait until it dissipates to perform an additional pass with the laser. Otherwise, too much of the laser energy would be reflected by the frosting and not penetrate down into the tattoo, treating the ink.
The goal with multi-pass tattoo removal is to have more ink destroyed with each individual session so that fewer sessions are needed to see complete results. People that are in a hurry to remove their tattoos – brides before their wedding, those looking to enlist in the military – will often seek out R20 tattoo removal to help them see faster results.
About the Clinical Research
The R20 method of laser tattoo removal came into view in early 2012 following a clinical study "Optimal tattoo removal in a single laser session based on the method of repeated exposures" published in the American Academy of Dermatology. The paper made waves within the tattoo removal industry, and quickly "R20" was the buzzword du jour. You can see below when searches for R20 tattoo removal peaked in popularity.
The study, performed by dermatologist Dr. Kossida and colleagues, was conducted in Greece on 18 unique tattoos across 12 patients. Each tattoo was divided in half, with one side receiving a traditional one-pass treatment and the other half receiving the R20 method (4 passes at 20 minute intervals).
For both homemade and professional tattoos, significantly greater ink clearance was achieved from multi-pass relative to single-pass. Here are some of the impressive findings from the study:
- 61% of areas treated with R20 showed complete ink clearance, compared to 0% from traditional protocols
- For all 18 tattoos, the ink clearance was better when treated with R20 protocols rather than traditional protocols
- Professional tattoos had a 70% improved fading response and homemade tattoos had a 59% improved fading response on average compared to traditional protocols
There are a few important things to note about this study:
- Extremely small sample size (12 patients)
- Alexandrite laser used (Nd:YAG is far more popular)
- 100 ns pulse width (unusually long pulse width for a Q-switched laser)
- 5.5 J/cm2 fluence and 3 mm spot size (this is a very aggressive starting point for treatments)
Challenges for the R20 Method
With such improved results for eliminating ink as shown in the study, why doesn't everyone use the R20 method all the time? There's a few reasons...
Greater Epidermal Injury
With its multiple passes, the R20 method is undeniably a more aggressive treatment modality than traditional laser tattoo removal. The Kossida study acknowledged this. The areas treated with the R20 method revealed "more pronounced and deeper skin injury."
In the study, none of the 12 patients scarred from the R20 method, but there's still an increased risk for texture changes with more injury to the skin tissue.
Also, please note that the laser used in the Kossida study was an older laser with less peak power than modern systems produced today. Imitating their protocols with a more powerful laser is untested and could cause extensive damage if performed irresponsibly.
Limited for Treating Ink Colors
The Kossida study used an alexandrite Q-switched laser, which produces a 755 nm wavelength, on black and blue tattoo inks.
Based on the absorption spectrum of key chromophores, 755 nm and 1064 nm (Nd:YAG) are similarly absorbed by hemoglobin (blood) and 755 nm is more absorbed by melanin (skin pigment) than 1064 nm. Because they are similar, many physicians have expanded to using the R20 method with the more common Q-switched Nd:YAG lasers as well.
However, neither 755 nm or 1064 nm wavelengths are effective at treating red, orange, or other warm-toned colors. The 532 nm wavelength (KTP frequency-doubled Nd:YAG) is the preferred wavelength for treating these warm hues. However, because 532 nm is highly absorbed by hemoglobin and melanin, it is a dangerous wavelength to use with the R20 method due to increased risk for negative side effects.
For this reason, there isn't a safe and effective way to perform the R20 method on tattoos with red, orange, pink, or other warm colors.
Too Aggressive for Sensitive Skin
In the Kossida study, no dark skin tones (types V or VI) were treated.
Darker skin tones often have temporary hypopigmentation or hyperpigmentation from traditional tattoo removal. A more aggressive treatment method puts patients with darker skin at a greater risk for more pronounced side effects or permanent damage to their skin tone.
One of the major concerns about the R20 protocol is the logistics of offering the treatment. If each pass with the laser takes five minutes, the entire duration of an R20 laser session will take 80 minutes (20 minutes of treatments + 60 minutes of waiting between treatments).
This is a logistical nightmare for practices. The typical tattoo removal appointment for a patient is 15 minutes, which is a hassle for patients and practices alike. For patients being treated with the R20 method, the practice must accommodate the treatment room being occupied for much longer.
New Horizons for Multi-Pass Tattoo Removal
One of the major issues with R20 tattoo removal is the time commitment offering it. Patients are bored during the waiting periods, and it's inefficient for practitioners. However, there is constant demand for laser tattoo removal to yield faster results, so many practices deal with the inconveniences of offering R20 for the sake of satisfying patient demands.
Since most of the need to have waiting intervals between R20 passes is born out of waiting for the laser frosting to resolve, one goal has been to accelerate the speed at which laser frosting dissipates. There recently has been progress in this area; PFD (perfluorodecalin) patches were brought to market in 2015 with the express purpose of facilitating multi-pass tattoo removal by minimizing laser frosting.
We'll be writing another blog post soon that analyzes and explains PFD patches in-depth, but we wanted to share that progress is being made in this area to make multi-pass tattoo removal safer and more convenient.
Ultimately, the question is – should your practice offer R20 tattoo removal?
Since R20 is an aggressive protocol that bears greater risks, it's probably best that experienced physicians and medical professionals are the ones that offer the procedure. There might be greater reward for the patient with accelerated fading, but there's also a greater liability for damage that the physician assumes.
If you do decide to offer it, you don't have to do it on the first session with the patient. You can provide a standard laser treatment at their first appointment and assess if they are a good candidate for R20 after you see how they've healed from a single-pass laser session.
It's also advisable to never do multi-pass treatments on high-risk patients (such as those with darker skin tones) or with the 532 nm wavelength.
If your practice decides to offer R20 laser tattoo removal, there are many precedents set by other practices that already offer it. Because it takes more time to provide R20 than traditional tattoo removal and it effectively is "four treatments in one," it's appropriate to charge extra for R20 laser tattoo sessions. Those that offer it often charge 4x as much for R20 sessions as they do for traditional tattoo removal.
Generally, at Astanza, we suggest that practices maintain high patient satisfaction by focusing on what is best for patients in the long run instead of trying to speed up the tattoo removal process too much and risk permanent damage.
If you ever have any questions and want to discuss R20, PFD patches, or anything else about laser tattoo removal, reach out to us!