There is perhaps no better embodiment of the feeling of regret than a bad tattoo. ‘Bad’ in this instance can mean a lot of things. Maybe the artist failed miserably; what was supposed to be a majestic lion turned out to be a mutant kitty cat looking cross-eyed from your shoulder. Or perhaps your supposed soulmate’s name etched on your forearm is no longer relevant since you parted ways. There are, in fact, many reasons why people may have a change of heart and would like to reverse a decision they thought was permanent.

Luckily, that’s where tattoo removal procedures come in. However, it will cost you a lot of money, time, and a great deal of pain. In some instances, the procedure can leave scars.

Why tattoos are ‘permanent’

The same biology that allows tattoos to stay on your skin indefinitely also explains why they’re so cumbersome to remove, even with modern laser technology.

When a tattoo needle punctures the skin, it rips through the epidermis (the outer layer of skin), and spills ink into the dermis (the inner layer of skin) which is flooded with blood vessels and nerves. As a tattoo gun pushes a needle into the skin up to 150 times per second, it activates pain receptors while delivering a tiny amount of ink into the dermis. The immune system, sensing a wound that lets in foreign invaders, is instantly primed, which sends immune cells called macrophages to clean up the mess.

True to their name, which means ‘big eater’ in Greek, the macrophages flock to the site of injury, devour the ink and remain suspended in the dermis. After they die, the macrophages pass the ink to their replacements. It is this successive cycle of capture-release-capture that keeps tattoos from vanishing rather than stains to skin cells, wrote French researchers in a study published in the Journal of Experimental Medicine. You wouldn’t be wrong in saying that a tattoo is a permanent infection. Just don’t use this line on a first date.

How tattoos are removed

Since ink-noshing macrophages are what make tattoos, scientists have proposed removing unwanted tattoos by activating some other immune cells to grab the ink and take it off to lymph nodes, to be carried off in lymph fluid. But this is just an idea for now.

Momentarily, the most widely used tattoo removal procedures involve firing ultra-short laser pulses onto ink particles to break them up. The lasers fire a pulse every trillionth of a second, delivering a lot of energy to the particles in a very short amount of time. This procedure is known as photothermolysis, and is exactly the same process used in laser hair removal.

Once the ink particles — which may be made of titanium dioxide, lead, chromium, nickel, iron oxides, ash, carbon black, and other ingredients — are broken apart by the laser, the remnants are transported by white blood cells to the liver. Even without the laser breaking apart the ink, armadas of white blood cells are always moving small quantities of ink particles away from the tattoo site. However, they’re much too small to gobble up ink particles whole, so their impact is minimal. They nevertheless cause the tattoo to fade over time and lose its luster.

Black-colored tattoos are the easiest to remove since the dark ink absorbs virtually all laser wavelengths. Color pigments need to be treated by lasers firing at certain frequencies, typically requiring more lengthy sessions to remove.

Depending on the size and pigments used in the ink, a tattoo can take anywhere between two to a dozen sessions to fully remove from the skin. The laser removes some particles, then the skin needs to heal before the laser can break down new particles of skin. Between each session, the skin needs to heal for a couple of weeks, so this can take a lot of time. In fact, a complete tattoo removal can require up to two years.

Laser tattoo removal is not the only option on the table, but it sure beats the alternatives. Alternatively, you can try dermabrasion, which involves sanding off the epidermis, or surgically removing the tattooed skin and stitching the remaining skin back together.

How painful is tattoo removal

While laser tattoo removal is a painful experience, chances are it won’t hurt nearly as much as getting the tattoo. The laser pulses feel like a rubber band snapping against the skin, and the aftermath feels like a bad sunburn. All deeply annoying, but tolerable.

People don’t experience pain the same way though, so the experience may vary wildly. It pays to work with a trained dermatologist who can adjust the treatment to your comfort level or apply a local anesthetic to numb the pain.

And just like getting the tattoo in the first place, placement matters when it comes to pain tolerance because the sensitive pain receptors are not evenly distributed throughout the skin. The ribcage area, forehead, ankles, wrists, and armpits are some of the most painful places both to have a tattoo placed and have it removed.

In order to remove as much pain as possible from the experience, topical numbing creams or even applying ice to the tattoo before the appointment can help. After the procedure, sunscreen is needed to prevent damage to the treated site on the skin, which will be vulnerable for the next four weeks. On this note, you should use sunscreen often regardless of whether or not you’re considering a tattoo removed. Some clinics will refuse to remove tattoos that have been very exposed to the sun.

Bleeding may occur during laser removal, however, it’s only small pinpricks that clear up within a few days. This is nothing to worry about as long as you take precautions and keep the area protected from infection.

The skin left behind after tattoo laser removal is not exactly flawless. When laser tattoo removal is performed using top-of-the-line equipment by a trained dermatologist (as opposed to going to a spa), the likelihood of scarring is relatively low — but it can happen. However, bear in mind that the tattooing process itself is extremely traumatic to the skin and can leave scars if the tattoo artist is not very experienced and punctures too deep into the skin. You should see no scarring if both the laser removal and the initial tattooing were done flawlessly.

In the week or so following laser removal of ink pigments, it’s common to see a little whitening that professionals in the tattoo industry call ‘frosting’. Once the skin heals, the skin returns to its normal color.

Until not too long ago, tattoos were truly permanent. However, this doesn’t mean the decision should be taken lightly. Tattoo removal can cost from a few hundred dollars to thousands and the process is a lengthy and painful one. So better be sure before you get that dragon inked on your back.