Laser Resurfacing

Laser Skin Resurfacing: A Primer

Reviewed by Timothy R. Miller, MD

Lasers are all the rage when it comes to revitalizing and rejuvenating aging and sun-damaged skin. It seems as if there's a new anti-aging laser being touted as the best one yet each time you flip through a beauty magazine, doesn't it?

But what can lasers really do for your skin? Are any of the latest lasers really the greatest? We'll help you sort out the hope from the hype with our primer on laser skin resurfacing, also called laser rejuvenation, laser skin tightening or laser surgery.

Courtesy of AAFPRS

Lasers can treat aging and sun-damaged skin, but that's not all — not by a long shot (or zap, as the case may be). Other applications include:

  • Removal of birthmarks and vascular lesions (such as hemangiomas and port wine stains)
  • Deep-set wrinkles
  • Fine lines
  • Moles and warts
  • Tattoos
  • Unwanted body hair
  • Skin diseases such as vitiligo and psoriasis. Vitiligo is marked by white patches caused by the destruction of melanocytes, the cells that give skin its color. Psoriasis is a chronic skin problem that occurs when skin cells grow too quickly, resulting in thick patches of skin.
  • Acne
  • Scars
  • Acne scarring

The word "laser" is actually an acronym for Light Amplification by Stimulated Emission of Radiation. Lasers create intense beams of visible, infrared or ultraviolet light. When laser light is absorbed by your skin it's converted to heat, which can result in the burning, vaporization, or coagulation of the targeted tissue.

Different lasers emit different wavelengths or color. These colors of laser energy are absorbed by different components of the skin or tissue, which is why certain lasers are recommended to treat certain conditions or skin types over others.

Some lasers are pulsed, which means that the beam is turned on and off in short pulses. Others are continuous wave, which means they emit a continuous beam of laser light.

To understand how and where lasers affect your skin, you must understand the layers and structure of your skin. The skin has three basic layers: the epidermis, dermis, and subcutis. The epidermis is the outermost layer of the skin. It is comprised of the stratum corneum (mostly dead skin cells called keratinocytes), live keratinocytes and the basal layer (which makes the keratinocytes). The epidermis also contains the melanocytes, or pigment-containing skin cells that give our skin its color. The dermis, or middle layer, is mostly made up of skin cells, hair follicles and sweat glands that are held together by collagen. Collagen is one of the main structural proteins found in our skin and is produced by skin cells called fibroblasts.

Ablative vs. Non-Ablative Lasers

Facial resurfacing for wrinkles and sun damaged skin is usually done with an ablative laser (e.g., CO2 laser). Ablative means that the laser is removing some of your skin. Ablative lasers can be divided into fully ablative (traditional CO2 and Erbium lasers) or partially ablative (fractional CO2 and fractional erbium lasers).

Non-ablative lasers do not remove skin. Instead, they heat up fibroblasts and stimulate them to thicken the underlying collagen — in essence treating skin laxity and, less so, wrinkles from the inside out. Ablative lasers are more damaging and invasive than non-ablative lasers. Another difference is that non-ablative lasers require multiple treatments, while ablative lasers usually require just one.

Laser Types

There are many types of lasers that are used for various types of skin conditions or problems, and new ones seem to be introduced on a regular basis. Among those used most commonly are:

  • Carbon Dioxide Laser (CO2): The oldest type of ablative laser and still considered the gold standard, the CO2 laser can improve skin texture, skin tone, acne scarring, and wrinkles. The main drawback is that it's invasive, which means that there is a significant recovery period and you will have some residual pinkness in the treated area for about a month. Hyperpigmentation may occur in people with darker skin and should be discussed with your surgeon prior to your laser treatment.
  • Erbium-YAG (yttrium/aluminum garnet) or Er:YAG: The energy from this laser is absorbed by the superficial layers of the epidermis, dissolving damaged or unwanted tissue. The pulsing actually lessens the heat on the skin, so there is less damage. It can greatly improve sun-damaged skin. This is a less invasive alternative to CO2 lasers. It is not as effective for deeper wrinkles, but the recovery period and downtime are shorter, so it's a trade-off.
  • Q-switched Nd:YAG laser: This system can remove pigmentation lesions and blue or black tattoos. Tattoo removal usually takes between eight and 12 sessions.
  • High-Power Long-PulsedNd:YAG: This system was designed to remove both vascular lesions and hair. This laser can be used on dark skin.
  • Long-Pulsed Nd:YAG laser: This laser is good for vascular lesions, facial flushing, redness, broken capillaries, and telangiectasia (purple or blue spider veins on the face).
  • Fractionated lasers: These lasers are a form of ablative laser technology. They were developed to give patients an alternative to more intense treatments. Fractional lasers are excellent for sun damaged skin, wrinkles, acne scarring, and improving the overall texture of your skin. These are among the most popular treatments because they involve significantly less downtime and recovery than traditional lasers do.. The Fraxel laser and other fractionated lasers (Active Fx, Matrix, etc.) may be among the best treatment options for wrinkles around the eye.

Are You a Candidate for Laser Resurfacing?

As good as it may sound, laser resurfacing is not for everyone. If you are prone to raised, red keloid scars, hyper-pigmentation or hypopigmentation, or if you scar excessively from minor cuts and abrasions, laser resurfacing is probably not an option.

A consultation with a qualified physician can help determine if you are an appropriate candidate for laser skin resurfacing, and which laser is best suited to your skin type and/or condition. There is no one-size-fits-all laser, and the latest laser is not necessarily the best for you.

Make sure the physician you choose has your complete medical history and a list of any medications, supplements or herbal products that you take. If you have a history of cold sores, fever blisters, herpes, chicken pox, shingles or other viral infections, tell your surgeon. These viruses lie dormant in your body between outbreaks and can flare up after laser skin resurfacing.

Laser Resurfacing Risks

Laser resurfacing isn't risk-free. Risks may include:

  • Allergic reactions to the anesthesia
  • Scarring
  • Burns or blisters
  • Abnormal pigmentation
  • Infection

In addition, infections, as well as dormant viruses such as herpes, may be awakened by laser treatment. However, most surgeons will place you on medications to prevent these complications.

These risks are further minimized when you choose a qualified physician with extensive experience in laser skin resurfacing who is able to best match a specific laser to your skin type or concern.

Your Laser Resurfacing Procedure

Laser resurfacing can take from 30 minutes to more than an hour, depending on the size of the area being treated. Exactly how many treatments will be needed depends on the type of laser as well as the specific skin condition being treated.

At the beginning of the procedure, your face is cleansed with an antibacterial solution to remove surface bacteria. Most laser resurfacing procedures are performed with only topical anesthesia or under light sleep sedation, where you are awake but not fully aware. General anesthesia may be recommended if a large area is being treated.

The laser's light beam is passed down through a hand-held wand or paddle. Your surgeon passes the wand over the area to be treated. This may be done once or several times, depending on the type of laser, your skin type and treatment goals. Some lasers literally vaporize the targeted areas of skin, leaving only a faint trace of "smoke and steam" and revealing undamaged, pink skin.

After the laser skin resurfacing is completed, your surgeon may cover your face with a thin layer of ointment, cream or synthetic sheeting to aid in healing. Recovery varies based on the type of laser used and the size and scope of the treated area. For example, the recovery from a traditional, fully ablative CO2 laser is about seven to 10 days. By contrast, recovery after the partially ablative fractional CO2 treatment is three to four days. Expect redness, puffiness and some pain after laser skin resurfacing. You may see blood spots on the treated skin during the first night after your treatment. Don't panic. This is not just normal, it is also a sign that the treatment worked and hit the skin at the correct depth. It can take a few days or months for all the redness to fade depending on which laser treatment you had performed. You can usually use makeup to camouflage the redness within a week. Follow your doctor's instructions carefully to avoid any complications.

Keeping your skin moisturized is crucial. You may be told to wash your face several times a day to help get rid of dead skin cells and the build-up of ointments. Avoiding sun exposure is also important. Most physicians recommend wearing a wide-brimmed hat and applying sunscreen with a sun protection factor (SPF) of 15 or higher to your skin because it is very susceptible to sun damage after laser resurfacing treatment.

Laser Resurfacing Cost

The approximate prices for laser resurfacing range between $1,500 and $6,000. The cost varies based on the type of laser, the area treated and the number of sessions required. Find out the cost of the laser resurfacing before booking your treatment(s). If the cost is prohibitive, inquire about payment plans or financing options.

About the Reviewer of this Article

Timothy R. Miller, MD, is double board-certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head and Neck Surgery. His practice, Facial Aesthetic Concepts, is devoted exclusively to aesthetic surgery of the face and neck. Dr. Miller has offices throughout Orange County, Calif., and has operating privileges at many area hospitals, including the Mission Regional Medical Center in Mission Viejo, Calif., Saddleback Memorial Hospital San Clemente Campus in San Clemente, Calif., and the Pacific Coast Ambulatory Surgicenter in San Clemente, Calif.

Dr. Miller received his medical degree from the University of California, Davis School of Medicine, and completed a five-year surgical residency in Otolaryngology-Head and Neck Surgery at the University of Utah School of Medicine, followed by a facial plastic and reconstructive surgery fellowship accredited by the American Academy of Facial Plastic and Reconstructive Surgery. Dr. Miller is a Fellow of the American Academy of Facial Plastic and Reconstructive Surgery and the California Society of Facial Plastic Surgery.