Why Some People Have Worse Skin After Laser Threatment? (photo)

Question

I wish to improve my skin texture and lift it a little bit. I'm looking for a fraxel laser (Pixel, Total FX, Deep FX) However, according to realself replies about fractional lasers, some people says: "no effect at all" and some people says their skin is worse than before laser (they mention "orange peel" skin effect after laser). Therefore, I'm confused what to do/try to improve my skin texture. I can't tolerate if it will be worse. Why its happening and what is a solution? Skin pic added.

Richard H. Tholen, MD, FACS · Answer

I risk the disagreement of many of my colleagues who have and use fractional lasers in their practices, but I would be able to submit evidence that this is indeed a correct statement. First, I will state that there is nothing WRONG with fractional lasers or resurfacing--they do make nice changes in wrinkled or scarred skin and are generally appreciated by patients who have these procedures. BUT. . .laser surgeons who charge a lot, and promise even more, can risk the wrath of patients who feel their fractional laser results are not a good value for what they paid, or who required more healing time than "advertised."
	
		This is particularly true for patient such as you who have relatively "mild" textural changes (often described as "big pores") and want smoothing, when fractional lasers, by their design, treats the target skin in tiny polka dots that can actually lead to little improvement and sometimes even more textural irregularities!
	
		I have taught laser surgery, including resurfacing, for over twenty years, nationally and internationally (Korea, Canada, Caribbean), and have performed thousands of laser cases in my practice. (I am in private practice,  do not have academic affiliation, publish sparingly, but have taught nearly a hundred laser courses and thousands of physicians of various specialties over these years). Now, just the facts, Ma'am.
	
		Ablative CO2 laser resurfacing came first, gave great (dramatic) results, but fell somewhat out of favor as hypopigmentation (skin color lightening) occurred a year or so after treatment. Wrinkles, spots, and sun damage still gone, but line of demarcation where treatment stopped, and lighter skin color where treatment was done. Bummer!
	
		Ablative Erbium-YAG laser resurfacing came next, but treated much more superficial layers, so skin healed faster, with less redness, but with less dramatic changes. If the doctor promoted this as "better than CO2" and charged as much, patients were unhappy, but not because the laser had a "problem" other than milder results. Bad doctor "marketing!"
	
		By the time that third-generation combination CO2/erbium-YAG lasers came along about ten years ago, the herd of dermatologists, plastic surgeons, and other laser doctors had moved on to the "non-ablative" lasers or therapies such as Thermage, N-lite, Cool-touch, Smoothbeam, and many others. These all "worked" to varying degrees, but usually with very minimal results. Prices dropped, and so did most of the hype, and "the herd" of doctors that need the "latest and the greatest" moved on to Fractional lasers.
	
		Fractional lasers started with Erbium wavelengths, and treated the skin in tiny polka-dots. Bridges of intact skin were left untreated, which is said to promote faster healing and less down-time (partially true). Actually, less skin treated = less result, which required multiple treatments, which = more procedures, more healing and MORE cumulative downtime. Oh, and the total cost adds up to a tidy sum usually! The results are real, but with superficial layer and polka-dot treatment came mild results (and sometimes textural changes). More, give us more!
	
		The next fractional lasers returned to CO2 wavelengths, which penetrate deeper, and still treated skin in tiny polka-dots. Fortunately, unless the energy was turned up too much, or the polka-dot density too tight, hypopigmentation changes were limited, and the results were indeed better. Still only in the fraction of the skin treated, still requiring more than one treatment for results that could approach that of well-performed third-generation combination CO2/Erbium-YAG fully-ablative (read "smooth") resurfacing (which very few doctors even had then, or have today), and still adding up to a tidy sum for only "fractional" results. BTW, it still takes a week to heal fractional laser treatments, and if you add up the time for multiple procedures, doctor's visits, and cost, HOW can this be "LESS DOWNTIME"?
	
		So at the risk of being contrarian, I would submit that a properly-performed ablative CO2/Erbium-YAG full-face laser resurfacing remains the BEST one-time laser resurfacing procedure available. For textural issues such as yours, it is preferential! With proper skin care, I routinely have patients healed in 7-10 days, and with minimal (truly) redness easily covered with standard make-up. I even purchased a second CO2/Erbium-YAG laser for parts--they are no longer available. But the marketplace delivers what the public (and their doctors) demand. I know from all the courses I have taught over the years, that many, if not most, of the doctors that use lasers don't even understand the basic laser biophysics of how laser energy interacts with tissues--they just want to know "what is the basic setting, where is the trigger, and how much can I charge?"
	
		So instead of searching for a fractional laser surgeon to treat your skin, I would suggest a fully ablative Erbium-YAG (superficial) laser resurfacing to improve your skin texture, or if you really want more aggressive improvement (your skin does not look as if it needs it), then combination CO2/Erbium-YAG ablative resurfacing would be my recommendation (if you can find someone who still has that kind of laser). Otherwise, you may be just as pleased with a full face chemical peel (TCA). Please see several laser experts before you decide. Best wishes!
	
		But beware of asking for what you "think" you need--you may well end up with more textural irregularities than you started with! Enough said, my soapbox is sagging! Caveat emptor!

Steven Hacker, MD · Answer

There are certainly risks with Laser Resurfacing and thus a properly trained physician should be consulted . These risks typically include infection or hypo or hyperpigmentation. Not everyone is a candidate.

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