The term ‘laser’ — short for light amplification by stimulated emission of radiation — includes a host of technologies aimed at everything from correcting complexion concerns to zapping warts and cancerous lesions. There are lasers for tattoo removal, lasers for getting your glow on, and lasers that remove unwanted hair (to name just a few).
We’ve touched on the different types of lasers before, so here’s a recap:
- Ablative: These lasers removed some or all of the epidermis.
- Non-Ablative: Lasers that leave the skin intact, while heating the dermis to stimulate collagen and elastin production.
- Fractional: These lasers have a pixelated energy beam that dissipates some of the heat.
- Non-Fractional: The laser beam remains focused and concentrated to treat smaller areas.
Different combinations of the above (think: ablative fractional, ablative non-fractional, non-ablative fractional, non-ablative non-fractional) make a laser better suited for different concerns. Non-ablative pulsed dye lasers like the Vbeam®, for example, are great for treating vascular lesions (i.e. broken capillaries and stretch marks). A non-ablative fractional laser like Clear + Brilliant is commonly called a ‘lunchtime laser’ because it produces only very slight inflammation (the ‘glow’) with minimal downtime. The tradeoff, of course, is less dramatic results.
When it comes to the big guns (so to speak) — those lasers capable of actually resurfacing the skin in the most technical sense — we’re talking about ablative carbon dioxide (CO2) and ablative erbium lasers. Treatments with these technologies are also known as a laser peel, laser vaporization, and lasabrasion. The trend has been toward using the fractional varieties, like Fraxel® Re:pair (CO2) and erbium YAG (a.k.a. Er:YAG, which stands for yttrium aluminium garnet, for you science-y types).
Ablative Laser Skin Resurfacing 101
Let’s back it up for a minute: what do these ‘amplification radiation’ tools really do to your skin? “Lasers are light waves that attack certain targets,” explains Jason Roostaeian, MD, board certified plastic surgeon in Los Angeles. “There are certain lasers that attack redness and certain lasers that attack any dark pigmentation. Those are generally for tattoo removal, red spots, or taking redness out of scars.”
So, where do the skin resurfacing lasers come into play? “Then there’s skin resurfacing lasers, which attack water,” he continues. “A carbon dioxide laser is more like a general nuke bomb that causes more heat in the area and has more thermal injury.” There is an increased risk of hyperpigmentation after treatment because that thermal injury can also destroy melanocytes (the skin's pigment cells), he adds. Erbium lasers, meanwhile, have a “higher affinity for water,” which means they cause “less thermal damage,” Dr. Jason says. Typically, this results in a quicker recovery time compared to carbon dioxide lasabrasion.
The net net? With ablative laser resurfacing, we’re talking about creating a controlled burn to the skin to stimulate the healing process, generate elastin and collagen production, and, ultimately, produce brand spanking new skin cells.
What Concerns Does Ablative Laser Resurfacing Treat?
Erbium and CO2 lasers address a myriad of aesthetic skin concerns, including:
- Fine lines and wrinkles (especially on the forehead, around the mouth, and under the eyes)
- Chickenpox and acne scars
- Sun damage
- Age spots (a.k.a. liver or sun spots)
- Certain birthmarks
- Sebaceous hyperplasia (tiny bumps — often on the nose — as a result of inflamed oil glands)
“Ablative resurfacing is a good option for people who have surface changes to the skin such as extensive sun damage, dark spots, large pore size, fine lines and wrinkles,” says Adriana Lombardi, MD, a board certified dermatologist and founder of the Skin Cancer & Cosmetic Surgery Center of New Jersey.
How Ablative Laser Skin Resurfacing Works
Laser skin resurfacing machines vary, but they’re essentially vertical, box-like contraptions on wheels with some type of wand or handheld attachment that offer customizable treatment options. “You can control the depth based on the settings of the laser,” Dr. Jason says. “You can up the energy and it’s going to go a little bit deeper.”
In addition to the machine’s settings, the degree of resurfacing is also dependent on the technique of the practitioner. “If you keep doing passes, it’s going to go deeper and deeper and deeper,” he explains. The trick is to create as little overlap as possible with each pass to ensure an even result.
We went down the rabbit hole for a second and wondered: how deep is too deep? “You don’t want to go so deep to the point where you’re causing true scarring,” he says. To explain that sweet spot, let’s revisit skin anatomy 101…
How Deep Ablative Laser Skin Resurfacing Goes
Human skin is composed of two layers: the epidermal (outer) layer and the dermal (inner) layer. The former contains mostly keratin and dead skin cells and the latter is made mostly of collagen and elastin. We’ve covered the five layers making up the epidermis already, so now let’s delve — ahem — deeper into the two layers that make up the dermis:
- Papillary: The superficial of the two dermal layers, it’s composed of highly vascular connective tissue.
- Reticular: A thicker and denser layer of connective tissue that makes up the majority of the dermis.
The dermis contains blood vessels, nerve endings, hair follicles, and glands. This layer supports the epidermis, helps regulate body temperature, and serves as an important physical and immunological barrier. It’s important that you don’t do too much damage to this layer or your skin won’t be able to regenerate. But certain skin concerns call for maximum penetration. “For deep wrinkles around the mouth, you need to go deep into the dermis,” Dr. Jason explains. “We tend to go down to the reticular and papillary juncture at the most.” In case you were wondering, this is precisely why you need to visit a highly trained, board certified plastic surgeon or dermatologist for any laser treatment.
If you paid attention during our primer on the five epidermal layers, you might be wondering how the epidermis ‘magically’ reappears after it's burned off. According to Dr. Jason, there are still enough skin cells left in the dermis after treatment (in the recesses of the hair follicles, for example) for your epidermis to gradually rebuild itself.
Preparing for Ablative Laser Skin Resurfacing
With any type of laser skin treatment, it’s best to consult with a board certified provider. Ablative laser resurfacing absolutely requires the expertise of a board certified plastic surgeon or dermatologist, however, the rules governing exactly who can perform laser treatments vary from state to state. In California, for example, it has to be a medical professional (read: not an aesthetician). Regardless of the regulations, do your research and find someone with extensive experience.
During your consultation, talk to your provider about your medical history. Treatment can trigger outbreaks like herpes and eczema. Your skin type, as well as any skin conditions like rosacea and melasma will certainly affect your treatment plan. You’ll also need to stop certain medications, including drugs and supplements that inhibit blood clotting (think: aspirin, ibuprofen, vitamin E, turmeric).
What It’s Like to Get Ablative Laser Skin Resurfacing
In a nutshell, you’ll be asleep for the entire procedure. Due to the pain involved, general anesthesia — though not absolutely required — is the standard of care for ablative CO2 and erbium YAG laser skin resurfacing. Dr. Jason says that it’s too difficult to numb the face with topical anesthetic to the degree necessary to keep the patient comfortable.
Depending upon the area(s) being treated, laser skin resurfacing can take anywhere from 30 minutes to two hours, and it will set you back somewhere in the neighborhood of $2,000 to $3,000. Unless you’re undergoing more extensive plastic surgery at the same time, it’s an outpatient procedure.
Recovering From Ablative Laser Skin Resurfacing
“We have many different types of lasers, so what to expect afterwards and how much downtime there is depends on the type of laser you are receiving,” explains Julie Russak, MD, a board certified dermatologist and founder of Russak Dermatology Clinic in New York City. Intensive laser skin resurfacing isn’t exactly a ‘set it and forget it’ cosmetic procedure. After treatment, your face will be bandaged. Beginning 24 hours post-op, you’ll clean the area and apply ointment (like petroleum jelly) several times a day to prevent scabbing. Healing takes anywhere from 10 to 21 days, depending on the treatment area.
Swelling after resurfacing is common. Your doctor may prescribe steroids to keep it in check, especially if you’ve had treatment around the eyes. Elevating the head (including while sleeping) and icing for the first 48 hours can minimize swelling. Burning or itching in the first few days is common. Expect the skin to peel about a week post-treatment.
Avoid your usual skincare and makeup until the wounds heal completely. Instead, look for products specially formulated for sensitive, post-procedure skin, and use only as directed by your doctor. Redness can linger for a few months (maybe even longer, if you’re fair-skinned). Your provider will let you know when it’s safe to use a green-tinted concealer to hide residual redness. Sunscreen and moisturizer are critical to keeping your fresh skin hydrated and protected.
Combining Laser Peels with Other Procedures
Many surgical facial rejuvenation patients (think: facelifts and blepharoplasties) opt to add on ablative laser skin resurfacing while they’re at it. Experts say that cosmetic procedures like these can be safely combined in the right candidates. A resurfacing laser, he says, can be like the icing on the cake of any anti-aging facial surgery. Patients experience the added bonus of one recovery period.
“Right now, in the time of COVID-19, it’s perfect for treatments that require more downtime because most people are staying home and wearing masks when they are out and don’t need their faces to be seen,” Dr. Russak notes. “ Chemical peels and strong ablative lasers are very popular at the moment.“
Non-Ablative Lasers & IPL
We promise we’re not purposely trying to confuse you, but there are also erbium YAG lasers (and a whole host of other types) that are non-ablative, meaning they don’t remove the epidermis. Don’t be surprised if a ‘simple’ Google search for laser resurfacing leaves your head spinning. That’s why it’s best to consult with your trusted provider and rely on their expertise to address your particular concerns.
Technically speaking, it’s more accurate to describe non-ablative lasers and intense pulsed light (IPL) as skin refining rather than skin resurfacing, since they don’t remove the epidermis. Instead, these treatments use light to heat the underlying dermal layer, stimulating collagen and elastin production. Non-ablative lasers treat skin with a single wavelength of light, whereas IPL utilizes multiple wavelengths. The result? A gentler (but also less dramatic) procedure.
Dr. Lombardi’s go-to non-ablative regimen includes non-ablative erbium YAG (M22 ResurFX) and IPL. She uses them alone or in combination, depending on the patient. “Combining a non-ablative laser plus the IPL targets both surface changes as well as wrinkles and scarring and has minimal downtime,” she notes.
What It’s Like to Get Non-Ablative Laser & IPL Skin Resurfacing
As Dr. Lombardi explains, IPL does not require any topical numbing medication. While the flash of light can be startling, the pain is described as similar to a snapping rubber band. Most patients find it tolerable. Non-ablative erbium YAG treatments do require topical anesthetic because the laser is going deeper into the skin and can be more painful. “We typically use a topical numbing product for 30 minutes prior to the procedure and use ice packs during it,” she shares.
Unlike the one-and-done nature of ablative resurfacing, non-ablative and IPL treatments are usually done in series. Dr. Lombardi often recommends three sessions spaced one month apart for best results. Another tip? Consider booking now. “The winter time is ideal as a patient cannot be tan prior to laser treatment,” she adds.
Recovering From Non-Ablative Laser & IPL Skin Resurfacing
Compared to ablative laser procedures, non-ablative lasers and IPL have a far more truncated recovery process. “Clear + Brilliant really doesn’t have any downtime besides the few hours of redness post laser, whereas IPL will make brown spots appear darker post-treatment and flake off after a few days and you will have swelling for a few days following,” Dr. Russak explains. “With an erbium laser you can have redness and skin peeling for up to one week.”
Risks of Laser Skin Resurfacing
Removing layers of skin — your body’s first line of defense — is a delicate business. Risks of both ablative and non-ablative laser treatments include infection, burns, scarring, and unwanted pigmentation changes (either hyper- or hypopigmentation). Darker skin carries a higher risk of hyperpigmentation. Burning, itching, redness, skin peeling, and milia (tiny white bumps on treated areas) are typical and temporary post-ablative procedure side effects.
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