by a facility as it is usually only offered by clinics that are using the 755 nm Alexandrite as opposed to the more powerful and versatile devices that are more commonly used. Moreover, dermatologists offering the R20 method should inform patients that it is just one alternative to proven protocols and is not a gold standard treatment method to remove tattoos. Multiple pass treatment methods (R20, as mentioned above, and R0) have generally shown to carry a greater risk of side effects, due to the increased amount of energy used in treatment. One caveat to this, however, is incorporating a perfluorodecalin (PFD) patch into the protocol. A PFD patch utilizes a clear silicone gel patch, with a small amount of PFD liquid applied to the treatment area immediately before each pass of laser application, and conducting the passes in rapid succession. The combination of the patch and liquid reduce the epidermal scatter, which can limit the predicted side effects typically seen in aggressive laser tattoo removal treatments (hyper and hypopigmentation, blistering, etc.). Additionally, the liquid reduces the laser frosting very quickly, allowing for faster re-treatment, limiting the time of treatment while still improving efficacy. Early studies have been performed to indicate improved clearance with the use of this patch in 3-4 passes, in a single session, utilizing more energy than typically allowable with a traditional treatment methodology. All these physical properties of the patch work to substantially reduce the total number of laser treatments required for ink clearance. While the PFD patch is currently FDA cleared for use with all picot and nanosecond domain lasers and wavelengths, it is only cleared for Fitzpatrick Skin Types I-III. Early studies have shown anecdotally that there isn't necessarily increased risks with Fitzpatrick Skin Types IV-VI, though still not FDA cleared as an indication. Factors contributing to the success of laser tattoo removal There are a number of factors that determine how many treatments will be needed and the level of success one might experience. Age of tattoo, ink density, color and even where the tattoo is located on the body, and whether the tattoo was professional, or not, all play an important role in how many treatments will be needed for complete removal. However, a rarely recognized factor of tattoo removal is the role of the patient's immune response. The normal process of tattoo removal is fragmentation followed by phagocytosis, which is then