I remember my first tattoo. Of course I remember my first tattoo. It’s a little paper plane on the side of my right wrist, marking the extra inch I take after my father. Besides his high forehead, piercing sense of humour and penchant for “bad things” in life (his poison is tobacco, my knees go weak for tequila) we will share this inanimate object through life. Mine is a lone flight, heading towards the direction my dominant hand dare takes it. A fleet travels along my dad’s arm, each bird representing the members of his brood — and beyond. “As the family expands, the convoy grows in size and strength,” he explained to our tattoo artist between buzzes. 

Several of my other ink aren’t quite nearly as sentimental. A Tweety winks on my ankle (hehe), the number 13 rests above my elbow (my birthday, and I love the fact that it’s both good and bad luck in the Chinese and Western culture, respectively) and I have a pizza dripping off my right bicep, just ‘cus.

The likelihood of me regretting any of my body art is zero to none, even though I never have, and will never be able to get into an onsen. C’est la vie. But not everyone shares my stable surety. Whether you feel contrite about that tatt because you and your bae Ben aren’t made for forever after all, or you finally understand the stereotype of a Chinese person with a supersized dragon on his chest, we’re not here to judge. We are here to help. 

At least, Dr Kevin Chua, aesthetician and laser tattoo removal specialist in Singapore, is. Under his wing, we discover everything there is to know about the tattoo removal process — such as the possibilities of scarring (it’s not as common as you think), the pain (it’s probably as bad as you think) and the one tattoo people want to part with most (it’s as ironic as you think). 

First thing’s first. How many tattoo removal methods are there?
Laser removal remains the gold standard for tattoo removal. There are others including some extra ineffective ones where people use really strong soaps, because soaps are alkaline and burns as well as acids; they might just use salt to rub it in as well. In extreme cases, you can do skin grafts where you replace the skin entirely — you cut out the tattoo and you paste the skin. Obviously you leave yourself with two scars: one with the tattoo and one where you harvested the skin from. There is a method where you inject material into the skin and it breaks up the ink and peels off. For that particular method and using a machine to do the injections, the results aren’t as quick and there is a higher chance of scarring because you are introducing a foreign matter into the skin. Laser still remains the best option. 

Has the laser method been around for long?
The very first lasers used for tattoo removal were the carbon dioxide lasers — that was 15, nearly 20 years ago I imagine.

[Laughs] I assume it wasn’t very effective.
When you fire the laser into the skin, water will absorb the energy and effectively vapourize the tissue. The hope is that, the pigment will also be vapourised along with it — that method will leave you with pretty terrible scars.

The lasers of today are far more superior?
More recent invention then came by way of Q-switch lasers, the gold standard of lasers. Basically you pulse the laser into the skin in a nanosecond range and it stays for a short enough time to burn out some of the pigment and break up the others while still keeping the surrounding skin safe. This is the key — when you keep the surrounding skin safe, you have less damage. More recently, you have the picosecond lasers which is what I like to use. The lasers basically stay in the skin for 100 times less than the Q-switch lasers which means that I can send more energy into the skin while still keeping the surrounding skin safe. You end up with more pigment being burned, more pigment broken up in a more pace, producing much smaller pieces that allows your body to clear a lot easier. 

What do you need to know before you can start the process?
I get the history of the tattoo when the patient comes to me. I need to look at the tattoo, to feel the tattoo because I need to advice them on potentials of scarring or if there is already an existing scar. I need to know if there is a cover-up of the tattoo so it gives me a rough idea of how much ink I have to deal with. 100% removal is possible but not everybody will get this kind of a result. It depends on how deep the ink is in the skin. The colours of the tattoo makes a big difference as well. 

Some colours are more difficult to remove than others?
Yes. Black is the most straightforward. Sky blue and green used to be tricky, but not anymore using the pico light. Those two were traditionally the hardest inks to remove. Orange is still tricky, and so is brown. Those will take longer to clear. But dark blue remains the most stubborn of colours.

Does the size of the tattoo matter?
Size doesn’t matter in this aspect, it’s about how much ink there is, how deep the ink goes. In reality, it boils down to how enthutiastic the tattoo artist was. 

What do you mean?
I have treated more than one tattoo done by more than one tattoo artist and they clear up at different rates. The artist who was more heavy handed, their ink would stay in the skin for longer. There are instances where tattoo artists use more interesting inks which make it harder to remove as well.

I have a pizza of a tattoo on my arm, about an inch in width and length. How long is that going to take to remove?
How old is it?

I got it last February.
That’s a relatively young tattoo, something you need to consider. There is a lot more ink in there versus, say, one that’s been there for eight to 10 years. 

A young tattoo is harder to remove.
Because there is more ink that I have to deal with. Since the first time you got it, did you get touch-ups? Did you get any treatments done?

Nope.
No touch up means it’s straightforward, or ideally, straightforward. I will always show my patients pictures of scars because things can always go wrong.

What kind of scars are we talking about?
Scars can appear when the pigments absorb too much of the laser energy. Scar tissues may also form when patients pick and scratch at the healing skin, because it can get very itchy.

Does a tattoo fade out evenly?
In an ideal situation, the ink will fade out gradually in a way where there is very little skin change. Reds and yellows will fade out differently and we will get to a stage where we will pause for at least six months to allow your body to push the remaining ink closer together then we will start treating it again.

How long does the whole removal process take? How many sessions?
Anywhere from three to 12 sessions, or more. The gap between each session should be four weeks at least; the skin needs about 28 days to heal. I might even lengthen the gap between each session to allow more time for the body to heal in order to reduce chances of scarring. Basically, it could potentially take a very long time. Having said that, the pico light method is quicker than the Q-switch method. You need lesser sessions, it’s less painful, and recovery is also faster. There will come a point where I will be firing laser on the skin and I’ll get no reaction. My aim is to get rid of 90% to 95% of the ink, and your body will do the rest lymphatically. The ink will continue to fade as time passes.

Does it matter where the tattoo is?
Funny you ask, because it matters. The closer the tattoo is to the heart…

I’m assuming you’re referring to proximity, not emotional connection.
[Laughs] Yes. The closer a tattoo is to the heart, the faster it takes to clear. The further a tattoo is from the heart, the harder it is. The fingers are particularly difficult, the ankle where the skin is difficult, the back of the arm is really difficult. The chest is pretty straightforward. Arms and shoulders are pretty straightforward. Areas that are fleshy and easy to pinch with lots of blood circulation, are easier to treat.

Say I was drunk, I got a tattoo and I wake up regretting it it, do I have to wait for the tattoo to be completely healed…
Yes, you do. You need to wait for at least four weeks for your skin to heal before we can start lasering the ink off. If we start any sooner, the chances of scarring increases. It also gets quite bloody. 

What are common misconceptions about tattoo removal?
That it can leave a very bad scar. It’s not always the case. If you are prone to keloids then I would discourage treating certain areas. For instance, keloids tend to happen in the T-zone, shoulders, chest and back so we avoid those areas. I am also more conservative in delivering energy on dark skin because scarring can be more prevalent. I turn away pregnant women as well. The lasers can wait until after.

And pain?
Pain is subjective. We try our best to medicate the pain but tattoo removal is generally more painful than getting a tattoo so it all depends on the individual. Women generally have a higher tolerance than men — childbirth and all that. Where your tattoo is will also determine how much pain you’re going to have to deal with; fingers will hurt a lot; ankles will hurt, bony areas will hurt. 

Is tattoo removal expensive?
I charge per session; I have package plans too but it can cost anywhere from $50 for the removal of a very small tattoo using the older technology, to several thousand dollars using newer technology for very large tattoos or multiple tattoos. 

What is the most challenging tattoo removal process you have ever done?
Cover-ups. Say you have an existing tattoo you want to get rid of. Your tattoo artist promises you that they can cover it up with a bigger, more colourful piece and unfortunately, it doesn’t do anything to cover up the underlying tattoo, so you see both the old and the new. Unfortunately, this means that I am now treating not one but multiple layers of blacks, oranges, greens, purples… it will take a long time. They’re a lot harder to remove.

So if I hate my ink, I shan’t bother covering it up. 
Absolutely, get it removed by laser instead. Don’t get a cover-up tattoo because in order to camouflage the first layer of colour, you need even more ink to mask the one underneath. I do have patients who come to me because they want to replace a tattoo — they want to lighten up their existing one to a point that they can successfully cover it up with another. That’s definitely possible. 

All that tattoing and layering of colours… do they change the skin texture?
Not really, no. We can actually mitigate the change in skin texture due to other conditions. Skin texture change represents scarring, or potentally the early stages of scarring, which we can manage especially using the newer lasers. 

What would you say to people thinking of getting their tattoo removed?
Be prepared. Be really really patient. It does hurt but we do our best to mitigate the pain. You’re not going to be able to get it out in one round; it doesn’t matter what you read on the Internet, it doesn’t matter what you watched on YouTube.

The most common tattoo you’ve been asked to remove is…
‘Faith’.

As in the word ‘faith’?
Yeah. And ‘desire’.

That’s so sad! Do people lose their faith and desire?
I have no idea. F-A-I-T-H is about the most common phrase that I have removed.

Do you ever ask your patients why?
Of course! What was their motivation behind getting that tattoo in the first place? Why do they want to remove it now? I get various answers. I’m told most that it was a spur of the moment, or it had meant something at the time, or there’s been a change in religion. Some people have told me: “I can’t go swimming”, “I want to wear clothes that allow me to expose my arms”, “I found out that this tattoo was offensive when I went to the Japanese sauna”… Some tattoos are not cross-culturally friendly.

What about spouse’s name?
Yes, quite commonly removed, and significant dates too. Wedding anniversaries, birth dates, et cetera. 

Lesson learned!
If you want to tattoo ‘faith’, that’s entirely up to you. Choose your space wisely. Make sure that it’s not visible if you are not comfortable with other people looking. Unfortunately, Singaporeans are still a little too prejudiced. Any tattoos, anywhere, as long as it is visible, you risk getting prejudiced. 

Dr Kevin Chua operates a family clinic with wife Dr Iroshini Chua, which offers special services such as aesthetics and tattoo removal. Their clinic is located at 360 Orchard Road, International Building #03-05, Singapore 238869. For inquiries, call +65 6694 6700.