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laser tattoo removal session in surrey showing patient and laser hand piece

What is the R20 laser tattoo removal protocol, and how does it speed up treatments?

Editorial note: an earlier version of this article was first published on November 21, 2012. It was updated on September 4, 2020.

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In February of 2012, the American Academy of Dermatology published the results of a tattoo removal study based in Greece. In this experiment, Dr. Theodora Kossida and her colleagues found that performing four passes over a tattoo with a Q-switched laser, each spaced 20 minutes apart, was far more effective than the traditional method. Traditional method calls for one pass in each session. In fact, the multi-pass approach was 50-85% more effective in removing a black tattoo, which was discovered at the three-month follow-up. Twelve patients took part in the study. It was small, but very promising.

The Greek doctors named this procedure the R20 method of laser tattoo removal. It quickly became a popular option for getting rid of unwanted tattoos, fast. It was adopted by laser tattoo removal clinics around the world.

However, it remains true today that this procedure can only be used in certain cases, and by employing certain safety precautions.

Since 2012, advances in laser technology for removing tattoos has also made the process even faster, and more effective. What we’re left with today are much more powerful machines, with a rather quick, but cautious approach, to getting ‘de-inked.’

If you’re looking for R20 tattoo removal in the Vancouver area, we can help. We have several years’ experience performing the procedure safely on multiple tattoo colours, skin tones and with various lasers. We’ve also got other ‘tricks of the trade’ to help your tattoo removal process go faster, in case the R20 method is not suitable for your case.

Below are some pointers you will want to know when seeking the R20 procedure at any tattoo removal clinic, whether in Vancouver, Canada or elsewhere.

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The R20 protocol must always start with a test treatment

The R20 method involves passing over a tattoo with a high energy pulse not once, but four times, all in a single session (lasting about 1 – 1.5 hours). That’s a lot of energy (and thus, heat) to impart into the lower layers of the dermis.

Laser tattoo removal diagram showing coloured ink tattoo removal and immune system reaction

In between each pass, an effect known as ‘frosting’ occurs. This is your skin’s reaction to the light breaking up the ink particles by ‘bulldozing’ them at a molecular level. As the laser does this, it no-doubt heats up your skin cells very, very quickly. Plasma and gas bubble within the skin, as a result.

We know that sounds scary; but it’s not, don’t worry. You will see your skin turn white or gray for about 10 minutes. If you’ve had a wart frozen off before, you’ll know what we mean. It’s a similar effect.

Eventually your skin cools back to its ‘normal’ temperature. After 20 minutes, depending on how quickly your skin ‘bounces back,’ another pass can be done.

Now, no practitioner (treating any skin tone) should perform the R20 procedure during the first treatment session. It is critical to perform a ‘regular’ single pass, and then wait about 6 weeks. In that time, skin reactions should be monitored. Only if the skin has not reacted, can the R20 method be used during the next session. Tattoo removal can accelerate from there.

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The R20 laser tattoo removal protocol can’t be done on very dark skin tones

When it comes to laser treatments of any kind, a practitioner should always be careful with dark skin. Dark skin can develop hyperpigmentation or hypopigmentation easily – and that goes especially if the treatments are not done with precision and care. Often, skin colour and texture changes are temporary. But if the skin is severely damaged, it can be permanent.

This doesn’t make laser tattoo removal impossible on dark skin tones. It just means that, if you fall into this boat, you’ll want to seek a very experienced provider. They should be aware of how dark skin reacts to lasers. They’ll need to use special techniques to achieve desired results for your skin type. Milder pulses and more time in between sessions might be required. This can, inevitably, take longer.

As described above, the R20 method involves passing the laser over a tattoo four times, and waiting a period of time after each pass. This is to allow the whitening effect to dissipate after heating.

In dark skin, this first ‘heating up’ should not be repeated. Dark skin contains more melanin. This means it will absorb more light energy than lighter skin would. Plus, the starting wavelength for the R20 procedure is already high to begin with, and is generally not advisable for dark skin. Essentially, dark skin will be at higher risk for permanent damage with this method.

That said, there are always exceptions to the ‘rule.’ Some doctors may be able to perform R20 tattoo removal on certain types of coloured skin. Or, some people who possess seemingly light skin, but who have a certain genetic heritage, may not be eligible for R20. That’s because melanin can be ‘hidden’ in some groups of people. So, seeking an experienced laser professional is best, in any case.

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What about patches that reduce frosting during tattoo removal?

In some countries, a PFD patch is available for use during laser tattoo removal. It is essentially a clear sheet made of special silicone material. It sticks on top of the tattoo before the laser passes over it. It is said to reduce frosting time, so that R20 treatments can move along faster, and result in fewer side effects.

However, this type of patch is not available in Canada. Nonetheless, some practitioners in the U.S. claim it doesn’t add much benefit, and that it only increases the cost of treatments.

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R20 is only ideal for smaller tattoos

Surrey laser tattoo removal on finger with picosecond technology

Because of the potential for skin damage with the R20 method, it can be dangerous to perform on very large tattoos. For example, if one has a sleeve tattoo from the elbow to the wrist, it should generally not be done. Too much of the skin will be heated up at once.

While a clinic should always start with a spot test, even on small tattoos, there is no guarantee that the R20 method will not cause any unpredictable side-effects, during any treatment session, with any setting used. It is an intense treatment in itself, due to the multi-pass requirement.

Not only that, 2012 was a different era for cosmetic lasers (when the above-mentioned study was completed). The equipment available today is much, much more powerful. So, even though those in the study were not scarred, that doesn’t mean the chances for scarring are totally eliminated. Plus, it was only 12 patients. So, even when using older equipment, prudence is still the wiser choice.

Those who undergo this procedure should be aware of the risks, regardless of the size of their tattoo. But, when the treatment area is considerably large, a practitioner may just say ‘no’ to using this method altogether – even if you are ok with it. That’s because the potential for noticeable scarring or post-inflammatory hyperpigmentation will be too high.

In other words: it’s one thing to have a one-inch mark on the back of your shoulder. It’s another thing to be scarred on your entire forearm. It’s also a bigger undertaking to try to reverse, if it happens.

See related on our blog:

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R20 laser tattoo removal is more expensive, and requires longer treatment sessions

The cost of laser tattoo removal treatments can go hand-in-hand with the amount of time each session takes. The R20 protocol is a lot of work; it requires that a patient be in the clinic about 8 times as long as a traditional session. The laser technician must be with the patient (or in the clinic), and a doctor must be nearby the entire time. Sometimes, frosting takes up to an hour to dissipate in between each pass.

Being that each session is not as quick as when doing a single pass (which can take about 15 – 30 minutes), R20 is more expensive to perform.

However, some people don’t mind this. For example, those with an upcoming wedding, or who need their tattoo removed for a career, may find it well-worth the added expense. That’s because the tattoo fades more quickly afterwards. In the long-run it can be faster, even if the time in session is tedious.

And, let’s not forget: laser tattoo removal can be painful! It’s mentally and physically harder to be in session for that long.

Due to the above reasons, many patients are perfectly happy with traditional, one-pass treatments, spaced 6 to 8 weeks apart. With the latest picosecond lasers, some people see results in as little as 4 sessions (each case is different). So it’s not too bad of a wait. This is a major reason why the R20 method is not always used, even if it has the potential to be more effective on some tattoos.

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R20 laser tattoo removal can be done with newer, picosecond lasers

While the original study that popularized the R20 method was done using a Q-switched laser, these days, we can perform the same procedure using more modern, picosecond lasers. These include:

And others.

The great thing about these more modern lasers is that they work on many colours. Plus, even when using the traditional, single-pass method, they still work much faster to fade tattoos than ever before.

Our clinic was the first in B.C. to acquire the above branded picosecond lasers. You can learn more about how they work at their aforementioned links.

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Should you get R20 laser tattoo removal? Ask a doctor!

While we realize that reading this article can get someone excited, or discouraged, about R20 laser tattoo removal, we’d say that it’s best not to jump to conclusions too quickly.

Every tattoo is different; some are located at different depths in the skin, some use unusual inks, some are infected, some are old and some are new. All these factors – in addition to your skin tone and health history – can affect the methodology used to remove an unwanted tattoo.

If you are interested in R20 tattoo removal, or are otherwise weary of it, we’d encourage you to discuss your case with a doctor first. It may be that R20 is right for you, but it may also not be.

Practitioners can also use their own protocols, which are not standardized across the industry. This is because as they gain experience working on unique cases, they learn a few ‘secrets’ of their own. As mentioned at the beginning of this article, at our clinic, we can use methods other than the R20 protocol to speed up tattoo removal.

If you live in the Metro Vancouver area and want your tattoo removed, we’d love to have you come in for a consultation.

If you live elsewhere and are researching your options for tattoo removal, we’d encourage you to not only do your Internet reading, but also speak to a provider. Ask for their before and afters, and learn more about their experience (especially if you have a dark skin tone). Look for recommendations, too.

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