Lasers Are Confusing—what Type of Laser Resurfacing is Best for the First Signs of Aging?

Attention all doctors who have experience using multiple laser-resurfacing modalities: between C02, erbium, fully ablative, fractionally ablative and non-ablative, which laser/combination of lasers is best for the first signs of aging? Specifically, I'm an early-30s, fair-skinned woman interested in smoothing fine lines (forehead, lip region) and preventing further facial deterioration overall. I don't mind a week (max) of downtime per year. Which specific equipment should I be seeking out? Thx!

Doctor Answers 8

Details about skin resurfacing with Lasers!

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Lauren, I've copied an entire article about the various forms of skin resurfacing lasers as you asked about. I would start as I end: do NOT seek out equipment; rather seek out expertise (understanding the biophysics of laser-tissue interaction is a good start--not just settings and trigger location!) and compare information and photographs. As with so many things, a hammer and a chisel do not make one Michelangelo, even if you make it a power hammer and laser chisel!

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 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 better results and only a few days of actual down-time, so why invest in an expensive technology that offers nothing more than 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, 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 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.
Best wishes and Happy New Year, Dr. Tholen

Minneapolis Plastic Surgeon
4.9 out of 5 stars 263 reviews

Laser for Early 30's

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Aesthetic light (lasers and IPL) can be helpful for facial aging, even for patients in their early 30's.  There are several factors to help determine which modality is best for you:

  • Skin type (Coloration)
  • Signs of aging (Brown spots, texture, fine lines, irregularities, etc)
  • Downtime

There are so many name brands of lasers but be more particular about the wavelength and modality of the laser.  In general, patients in their early 30's often seek quicker recovery procedures with less overall risk.

Anil R. Shah, MD
Chicago Facial Plastic Surgeon
4.8 out of 5 stars 179 reviews

Try Dermapen for skin resurfacing

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Lasers are great, but if you're in your early 30's, you probably don't have the severity of damage that requires a laser. Dermapen is a micro-needling procedure. Instead of using laser heat energy to stimulate a rejuvenation of collagen, it uses tiny needles to create a stimulus to the skin to rejuvenate collagen. It's very comfortable and the downtime can be controlled based on how the procedure is done. Remarkable results can be achieved with a series of no-downtime treatments. I've been very impressed with this technology.

Kimberly Finder, MD
San Antonio Dermatologic Surgeon
4.6 out of 5 stars 64 reviews

Laser resurfacing for early signs of aging

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Great question and i enjoyed reading the other answers which i agree with and also disagree with. I lecture about this very often and you can see a few webinars i have done on this topic on the sciton website. 

In short - choice of laser or other technology depends upon patients degree of damage (wrinkles etc), skin color, downtime and budget. in your case with fair skin, beginning signs of aging and a weeks downtime there are a number of devices that would give you the intended result. modern day lasers and devices are not like the on/off switch of mid 90's devices. the settings can be adjusted for depth, thermal damage and area of coverage. obviously we need to examine you first- but in our office with the conditions you gave i would do a medium depth tunable erbium (sciton) laser peel or a combination light full erbium peel with fractional as well (micropeel/fractional combo) or fractional co2 or ematrix  (syneron - fractional radiofrequency) or even a medium depth chemical peel. as you can see there are a number of options that work for u. seek out an experienced office with multiple devices

Jason Pozner, MD
Boca Raton Plastic Surgeon
4.7 out of 5 stars 46 reviews

Early aging - does this require lasers or would other options be better?

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There are certainly plenty of options for laser treatments. You "could" be a laser or eMatrix candidate (eMatrix is Radio Frequency and not laser so it reduces any risk of post treatment pigmentation); or you could be a candidate for simpler options like retinoid creams, antioxidants or simply a good skin care program.

Forehead lines can be smoothed with Botox or one of the other relaxers and the lines are more than likely caused by muscle contraction so laser wouldn't solve that problem.

Lip lines at your age are more often caused by the contraction of the muscles around your mouth. Watch your mouth action in a mirror when you are talking. If you tend to purse your lips strongly, the vertical wrinkles begin to get etched in. Laser may smooth them to some extent, but if the cause is dynamic (action-caused) then even with laser you will see them return.

Your best first option would be to visit a good cosmetic dermatologist and discuss both what you want to accomplish and the different levels of available corrective choices. Starting small is sometimes a better decision.


Rebecca Fitzgerald, MD
Los Angeles Dermatologic Surgeon
4.1 out of 5 stars 22 reviews

Laser Resurfacing Options for Aging Skin

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Thank you for your question. There are multiple laser resurfacing devices that work well in the right candidates and in the right hands. But these also have to be balanced with their side effect profile. At this time, the safest and most effective will be fractionated C02 or Erbium with about a week of downtime, depending on the settings and number of passes.  I would also recommend being treated under the supervision of a Board Certified Dermatologist or Plastic Surgeon for best results and safest treatments.  I hope this helps!

Yes, all the lasers are confusing.

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Not surprisingly, some doctors are confused too.  The primary goal of the laser companies is to sell lasers.  Every salesperson thinks he/she has the best laser, until they change jobs to another company.  In my humble opinion, the most effective laser for deep wrinkles is a carbon dioxide laser, fractionated or non-fractionated.  For somebody your age with fine lines and probably some uneven skin coloration I prefer nitrogen plasma resurfacing.  It is called Portrait.  I really like the quality of the skin you get.  It really can rejuvenate the skin.  Resurfacing takes about a week or so to heal.  Below is a link to some photos on my website and my Youtube video on the subject.

Stuart H. Bentkover, MD
Boston Facial Plastic Surgeon

Which Laser Resurfacing

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Hi Lauren.  We do not think you will accomplish your goals with the areas you want to treat and the downtime you are willing to accept.  Most lasers that have 5-7 days of downtime are used in a series of at least 2- 3 treatments.  We are sure you will find a practitioner to offer 1 treatment (fractionated or even traditional Erbium) with expectations for improvement, but the problem is the less treatments you have, the more limited the results will be.  This would only be in relation to lip lines.

The forehead is not a great area to expect improvement for fine lines because the lines are cause by muscle contraction.  This area is better treated with Botox or Dysport.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
4.4 out of 5 stars 7 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.