drained away via the lymphatics. Consequently, it is the inflammation resulting from the actual laser treatment and the natural stimulation of the hosts’ immune response that ultimately results in removal of tattoo ink. Because of this, the effectiveness of laser tattoo removal varies widely. Pain management during treatment Laser tattoo removal is painful; many patients say it is worse than getting the tattoo. The pain is often described to be similar to that of hot oil on the skin, or a "snap" from an elastic band. Depending on the patient's pain threshold, some patients may forgo anesthesia altogether, but most patients will require some form of local anesthesia. Pre-treatment might include the application of an anesthetic cream under occlusion for 45 to 90 minutes or cooling by ice or cold air prior to the laser treatment session. A better method is complete anesthesia which can be administered locally by injections of 1% to 2% lidocaine with epinephrine. A technique which helps to reduce the pain sensation felt by patients has been described by MJ Murphy. He used a standard microscope glass slide pressed against the tattooed skin and fired the laser through the glass. This technique may represent a simplest and effective method to reduce the pain sensation when treating small tattoos. Post-treatment considerations Immediately after laser treatment, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed. This white color change is thought to be the result of rapid, heat-formed steam or gas, causing dermal and epidermal vacuolization. Pinpoint bleeding represents vascular injury from photoacoustic waves created by the laser's interaction with tattoo pigment. Minimal edema and erythema of adjacent normal skin usually resolve within 24 hours. Subsequently, a crust appears over the entire tattoo, which sloughs off at approximately two weeks post-treatment. As noted above, some tattoo pigment may be found within this crust. Post-operative wound care consists of simple wound care and a non-occlusive dressing. Since the application of laser light is sterile there is no need for topical antibiotics. Moreover, topical antibiotic ointments can cause allergic reactions and should be avoided. Fading of the tattoo will be noted over the next eight weeks and re-treatment energy levels can be tailored depending on the clinical response observed. Side effects and complications About half of the patients treated with Q-switched lasers for tattoo removal will show some transient changes in the normal