Tattoo Removal Using the R0 Technique

Immediate Repetitive Laser Irradiation Using PFD

For tattoo removal, the method of breaking down pigments using nanosecond devices such as Q-switched Nd:YAG (1064nm) lasers has long been the standard approach.

However, the traditional method required waiting 6-8 weeks for skin recovery after one session before the next treatment could be performed. As a result, the total number of sessions often exceeded an average of 10, requiring a significant amount of time.

One of the new approaches attempted to overcome these difficulties is the R0 technique.

About the R0 Technique

The R0 technique refers to a tattoo removal method that involves irradiating the same area with a laser up to four times consecutively in a single visit.

A crucial element of this technique is the use of a special liquid substance called ‘PFD (Perfluorodecalin)’.

When a laser is applied to the skin, white, frost-like bubbles form on the surface, which are called ‘frosting’.

These frosting bubbles scatter laser light, becoming the main reason for significantly reducing the efficiency of subsequent laser irradiation. 

In the past, one would wait tens of minutes for these bubbles to disappear on their own, but they never completely vanished. Alternatively, it was common to wait until the next session.

However, applying PFD causes the frosting to disappear rapidly within seconds, which in turn makes it possible to shorten the laser irradiation interval to 1-2 minutes and perform multiple repetitive irradiations.

This allows for the significant reduction of tattoo pigment with a much shorter total treatment period compared to traditional methods.

Results Confirmed by Research

• Biesman et al., 2013 Study
• In the patient group using the R0 technique, the total number of sessions was reduced by approximately 30-50% compared to traditional methods, and
• the ability to immediately repeat laser irradiation was confirmed.
• Kauvar et al., 2020 Study
• For patients who underwent the R0 technique approximately 3 times, the total number of laser irradiations was equivalent to approximately 10 sessions (around 3 sessions with the R0 method),
• more than 70-90% of tattoo pigment could be removed was demonstrated.
• Furthermore, the incidence of side effects such as post-inflammatory hyperpigmentation (PIH) was reported at a low level.

If so, even though it's technically possible for up to 4 sessions, why is it often limited to 3 repetitive irradiations in practice?

Although the R0 technique is theoretically known to allow repetitive irradiation up to 4 times,

in actual practice, repetitive irradiation is often performed only 2-3 times.

There are several reasons for this:

1. Characteristics of Asian Skin

Asian skin has a relatively high chance of developing post-inflammatory hyperpigmentation (PIH) due to the sensitive reaction of melanin cells.

Especially for individuals with Fitzpatrick skin types III-IV,

Excessive repetitive irradiation, beyond just breaking down tattoo pigment, can overstimulate the skin, carrying the risk of worsening hyperpigmentation.

2. Balance between Number of Sessions and Patient Safety

While repetitive irradiation can be performed up to 3 times with close observation of skin reactions,

if treatment exceeds 4 sessions, the risk of damage to normal skin tissue, along with pain, erythema, and minor burn reactions increases.

3. Limitations of Laser Irradiation Efficiency

Even with PFD, there is a physical limit to the amount of tattoo pigment particles that laser light can reach and break down.

After approximately 3 repetitive irradiations in a single session, the efficiency of laser irradiation begins to decrease,

At this point, even if the laser intensity is increased, the expected therapeutic effect is minimal, while the risk of side effects tends to increase.

Thus, the ‘theoretical possibility of ‘up to 4 sessions’ and the ‘actual optimal number of irradiations that are safe and effective for the patient’ are different.

Therefore, prioritizing your skin safety and treatment effectiveness, we recommend 3 repetitive irradiations as a fundamental principle.

So, why isn't the R0 technique adopted by all medical institutions?

This treatment method does not only have advantages from the perspective of medical institutions.

• PFD drugs can be financially burdensome, and their supply may not always be smooth.
• The appropriate application timing and design of repeated treatments with this drug require the professional judgment of medical staff with extensive experience.
• The time required for the procedure itself can be 2-3 times longer than typical tattoo removal procedures.

Therefore, places that prioritize procedural efficiency may not prefer this method.

However, at our clinic, we prioritize the completeness of the procedure and reducing the burden on our patients,

Therefore, we cannot overlook the effectiveness and efficiency that PFD procedures offer.

We avoid unnecessary over-treatment and meticulously perform repeated treatments only as needed.

We always prioritize the safety of the patient's skin and approach treatments carefully to achieve the best possible tattoo removal results.

We strive for improved procedure speed, reduced number of sessions, enhanced safety, and increased satisfaction with treatment outcomes.