Facial Resurfacing With CO2/Erbium:YAG Laser, Fractional Lasers, and Other Devices

Richard H. Tholen, MD, FACS
Article by
Minneapolis Plastic Surgeon

Creating a smoother, less-wrinkled skin surface with a CO2 laser has been performed for nearly two decades; however, advances in laser instrumentation in the early 1990’s, along with media focus on "laser resurfacing" at that time, sparked significant interest in this “new” procedure.  The first-generation CO2 lasers used for facial skin resurfacing represented such a dramatic paradigm shift from previous wrinkle-removal procedures (predominantly dermabrasion and chemical peeling), that patients, doctors, and the media rapidly pounced on laser resurfacing as “the next new thing,” and everyone had to have it.  That is, any physician with a spare weekend for a laser course and willingness to buy or lease a $100,000+ laser, and any patient ready to spend $5,000 to $10,000 and a couple of weeks’ time healing to have the operation. 

And it worked! 

Sun-damaged, wrinkled, facial skin was being replaced with fresher, tighter, and more youthful-looking features.  Patients and doctors were excited, and the relatively few complications (scarring, beet-red healing skin, too-deep laser burns, etc.) were passed off as being caused by lack of experience, poor choice of patient, or incorrect laser settings.  As the hype and reputation grew, so did rumors about a second-generation Erbium:YAG laser that would give even more rapid healing and less redness.  Some physicians felt comfortable purchasing the successful first-generation CO2 technology; others waited for the second-generation Erbium:YAG laser, hoping for “new and improved.”

Erbium:YAG laser resurfacing represented an entirely different laser wavelength used for a similar purpose—removal of the upper layers of skin so that after healing, wrinkles were gone or diminished—but with more precision (less thermal damage and more superficial tissue removal) than the previous CO2 laser.  Some physician marketers even wanted to give laser resurfacing with this machine a new name; this added even more hype and misinformation about this “latest” type of laser skin resurfacing or "high-precision facial refreshing." 

Yet, despite all this, plastic surgeons and physicians in other specialties, as well as patients themselves, were seeing that first-generation CO2 laser resurfacing allowed such dramatic, safe, and long-lasting results that dermabrasion and some chemical peels were increasingly being replaced by this technique.  Early reports about the second-generation erbium:YAG laser resurfacing seemed to validate the claims of more rapid healing and less redness, though the degree of wrinkle removal was certainly less dramatic.  Advertising and media interest in laser resurfacing fueled both patient and physician demand for accurate information about this procedure.  Sometime around late 1997 or early 1998, media focus switched from “what’s new” to “disasters from laser.”  Scarring remained quite rare, even in relatively inexperienced hands, but a few widely-publicized cases began to scare patients as well as their doctors.  Then a few patients with initially-good results from their first-generation CO2 laser resurfacing operation began to notice lightening (hypopigmentation) of the laser-treated skin a year or two after their surgery, and happiness was replaced with another problem—the visible line of demarcation between treated lighter-colored skin and non-lasered normal darker skin.  Other patients treated with the second-generation  Erbium:YAG laser indeed had rapid healing with little redness, but with less-dramatic wrinkle removal that in some cases bordered on “no improvement at all!” 

By the time the third-generation resurfacing lasers were being developed and marketed to physicians in 1998 and 1999, the “bloom was off the rose” and laser resurfacing was no longer a jump-on-the-bandwagon procedure every physician who did cosmetic surgery had to have.  Too many potential user-physicians knew of a friend or colleague who invested in either the first- or second-generation lasers and now no longer used their lasers because of problems or lawsuits from dissatisfied patients.  Very few third-generation resurfacing lasers were sold; the public’s fascination had waned, and the number of resurfacing procedures performed dropped dramatically in national statistics as well as physician interest.   The tales of long-healing, redness, scarring, skin-color whitening problems with fully-ablative laser resurfacing now fueled interest in wrinkle-reduction without the need for surface skin healing: the so-called “subsurface collagen remodeling” or “nonablative wrinkle reduction” became the next big thing.

These “new and safer” techniques for wrinkle reduction were talked about in fashion, style, and self-improvement magazines, and involve several methods that use lasers, intense pulsed light (IPL), or radiofrequency (RF) energy to stimulate collagen and elastic fiber production below the skin surface (reducing wrinkles) with little or no damage to the surface of the skin (which also meant little or no healing).  Plasma (Rhytec-Portrait) treatment utilizes a plasma-generating technology to thermally heat skin and thereby stimulate collagen formation.  Thermage and Accent are two RF treatments marketed for the non-invasive skin-tightening marketplace.  Smoothbeam—Candela Corporation, Titan, Polaris, Aluma, ReFirme, LuxIR, GentleYAG, and others represent multiple manufacturers’ own type of laser, RF, or combination technology.  Each machine’s marketer, of course, promises some variation of  “no healing or downtime, no pain, and wonderful results,”  and both physicians and patients were eager to believe these claims. The problem, as is always the case, is to actually show results that support physicians’ and their gullible patients’ hope that  no pain and no healing can actually give visible improvements!  (If you truly believe this is possible, then I have a couple of cases of the Emperor’s clothes to sell you.)  There were and still are some reality-check or “fine print” items with regards to non-ablative wrinkle reduction: some patients may have redness or blistering of treated areas, some of these treatments are actually quite uncomfortable, multiple treatments are almost always required, and final results cannot be seen until months after treatment (so you “forget” what you looked like when you started?).  Comparison of pre- and post-treatment photographs (if they’re taken) rarely look like those in the brochures! 

The best way to summarize this (non-ablative) technology is that indeed all of these machines will cause some minimal degree of improvement with some discomfort and usually little downtime; each individual patient needs to decide if this slight benefit warrants the time and money spent.  I’m not saying they don’t work at all, but a carefully-performed TCA facial peel will give you similar or better results and only a few days of actual down-time, so why invest in an expensive technology that offers nothing more than (tech-hype) and higher cost?  Unfortunately, for some, the answer is that the technology becomes the marketing tool that only serves to “prove” the physician-user is “with-it” on the latest trends! 

In the past several years, both erbium:YAG and CO2 lasers have been re-engineered into “fractional laser resurfacing” machines which are promoted as offering “results as good as ablative resurfacing without the healing downtime or redness.”  Fraxel™—Solta Medical was the first and has become one of the most publicized fractional laser systems in use today.  Other fractional lasers are available by other laser manufacturers, including Pixel™ by Alma Laser, and ActivFX™, DeepFX™, and TotalFX™ Ultrapulse™ by Lumenis.  Basically, all of these fractional machines use either erbium:YAG or CO2 wavelength lasers focused into extremely narrow, high-energy, short pulse-duration beams that vaporize tiny holes in the skin separated by undamaged skin in a type of “polka-dot” pattern.  The type (wavelength) of laser and the intensity of the laser beam determines the size and depth of the tiny laser holes in the skin, and the resultant healing time. 

An additional “requirement” of fractional laser treatments is that you must undergo several treatments (since each procedure lasers no more than 15-25% of the skin—a "fraction" of the entire skin surface) to achieve the final result.  Three to six sessions, each one requiring the laser operation and each one requiring the discomfort of the procedure and the week or so of healing, are “recommended” for best results.  Unfortunately, many fractional laser surgeons overstate the degree of improvement as being equivalent to, or superior to, fully ablative procedures, while costing less and requiring less downtime.  By the time you add the time of each session, the cumulative time of healing and doctor’s office visits, and the cost of each treatment, fractional laser giving fractional results should by rights cost only a “fraction" of a fully-ablative laser resurfacing surgery.  Many former Fraxel patients have come to our office for full-face third-generation laser resurfacing, having been disappointed with the minimal (15% or so) improvement despite multiple Fraxel sessions elsewhere, and having often spent near the cost of our full-face (not fractional) procedure.

Regardless of the laser technology-du-jour, one thing has remained constant: physicians with little or no prior cosmetic surgery experience or laser training have sought to capitalize on the public's fascination with surgical lasers, and have started doing procedures on every patient they can aim their laser at—often for $6,000 - $8,000 or even more per procedure, or a series of less-costly ($500-$1500 per session) procedures that can approach or exceed these amounts in cost!  Unfortunately, the supposed "ease" of performing laser resurfacing or collagen remodeling procedures has fostered the bandwagon mentality that has led to performance of these precise surgical procedures by practitioners with large variations in surgical training and laser expertise.

Research your facial resurfacing doctor thoroughly—ask about laser training, specialty training, board certification (by what board?), and ask to see before and after photographs of patients who have utilized the proposed technological marvel! Beware practitioners who have no training or experience in plastic surgery, much less laser training and biophysics of laser-tissue interaction. See more than one laser surgeon before you decide.