Risks from Ablative CO2 Laser Resurfacing?

After having done some research, it seems that one of the largest risks/complications of ablative CO2 Laser resurfacing is permanent hypopigmentation. Are certain skin types more prone to this, or is this a complication that is mostly related to aggressiveness of treatment?

Also, does the hypopigmentation extend uniformly to the entire treated area (i.e., in the case of full face treatment, the whole face takes on a mask-like appearance), or does it usually manifest itself in a more spotted manner across the treatment site? I would think permanent lightening would be desirable for somebody with severe sun damage.

Doctor Answers 10

Hypopigmentation is rare but can occur

Probably the most publicized side effect of heavy CO2 resurfacing is hypopigmentation. This occurred more frequently years ago when CO2 lasers first came out. The lasers back then were slower and hotter making all types of side effects more common.

Today, CO2 lasers are faster, better controlled through computer scanners and are very safe. With more aggressive treatments, however, there are small chances of delayed healing, or theoretically hypopigmentation.

More common issues to be considered are prolonged redness lasting anywhere from weeks to months. In patients with more natural pigment, there is also the risk of increased or hyperpigmentation after treatment. Avoiding sun exposure and the use of bleaching creams can help decrease this risk.

Something else to consider, today there are now Fractionated CO2 lasers. These lasers, such as the Total FX by Lumenis, are delivered in a pixelated manner using a computer scanner. The laser still penetrates deeply and creates some nice skin tightening, but is not as aggressive as the fully ablative CO2 laser. Healing is shortened and the safety profile is better. For many patients, this is a better option and definitely something to look into.

Hope that this helps

Beverly Hills Dermatologic Surgeon
5.0 out of 5 stars 1 review

CO2 laser resurfacing and side effects

One of the biggest advantages of the new, more sophisticated CO2 lasers is the significant decrease in side effects when compared to older lasers and older techniques. CO2 resurfacing has been around for a long time, but initially the lasers or much more limited with respect to the control that you had over them, and the treatment area was continuous without any islands of normal skin left in between to expedite healing.

The most publicized side effect of CO2 resurfacing was hypopigmentation, which did tend to happen in a continuous fashion, not being broken up, and giving the entire treated area a lighter appearance. This was sometimes desirable, but often left A line of delineation between treated and untreated areas.

New her CO2 lasers are significantly more sophisticated and allow your laser surgeon to carefully choose parameters and control them very closely. This allows your treatment to be tailored exactly to your needs, maximizing your benefits and minimizing your side effects. This is where all laser surgeons are not created equal.

In addition to increased control, most of the new CO2 lasers have the capacity to fractionate your treatment. What that means is instead of treating the entire surface of the skin, small zones of skin are ablated, leaving normal islands of skin and between intact. This allows you to heal quickly and significantly decreases the side effects while still providing the overall capacity for your desired results to be obtained.

In addition to hypopigmentation, scarring was always a theoretical risk, as well as prolonged redness. Even with fractionated lasers this redness can last 2 to 4 weeks in a normal situation, but when persisting longer is considered to be prolonged redness.

CO2 resurfacing can get beautiful, dramatic results at a very reasonable price. As I said though, not all laser surgeons are created equal. To guarantee you're receiving the highest level of care, seek out a dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these "core four" cosmetic specialties.

Cameron Chesnut, MD, FAAD, FACMS, FASDS
Spokane Dermatologic Surgeon
5.0 out of 5 stars 40 reviews

CO2 and hypopigmentation

With the traditional fully ablative CO2 lasers, there was a risk of hypopigmentation or waxy white discoloration to the skin. The hypopigmentation risk is significantly less with the fractional co2 laser. The fractional CO2 drills tiny column in the skin, thus treating only a certain portion of the skin as opposed to the fully ablative one. Overall, its a lot safer with less risk of side effects. Dr. Behnam, Santa Monica 

Ben Behnam, MD
Santa Monica Dermatologic Surgeon
5.0 out of 5 stars 2 reviews

Hypopigmentation, demarkation and scarring are the highest risks....

Yes, I agree with Dr Fincher, in this day and age hypo pigmentation or lightening of your skin is the biggest risk. Demarkation lines are also common, and good laser operators will ensure a blend. The other risk is that of scarring, and infection. Providing you consult a Dermatologist or Plastics trained in this procedure, your risks are small. 

As a guide, my preferred option is a fusion of lasers- namely the use of CO2 Fractional at full power and depth coupled with Erbium laser. This technique, in my hands gives the safest outcomes with excellent results. 
Hope this helps

Dr Davin S. Lim

Davin Lim, MBBS, FACD
Brisbane Dermatologist
5.0 out of 5 stars 43 reviews

Ablative CO2 Laser

Fractional CO2 Laser resurfacing produces wonderful and dramatic results. The Fractional CO2 Laser can be performed in an more aggressive ablative mode for acne scars, lines and wrinkles and for more aggressive skin tightening, or it can be used in a microablative mode for complexion, quality, pores, and sundamage with pigmentations. Different areas of the face are treated with varying levels as well. Much, of course, will depend on the pigmentation skin types. Using more aggressive ablative mode on darker pigmented skin can cause hypopigmentation and ever hyperpigmentation. When fractional CO2 laser is performed properly on the right candidates, hypopigmentation is rare. For more aggressive ablative procedures it is recommended to prepare the skin for at least a couple weeks with hydroquinone ( a skin lightener which stabilizes the pigment producing cells ) and a retin A type product, which sheds the outer dermis of dry and dead skin cells, increases the production of new skin cells and collagen. And to further answer your question, complications can arise when being too aggressive, especially on darker pigmented skin, or when patients are on certain medications. Permanent lightening is hypopigmentation and not desirable. What's desireable is resurfacing the skin to create tighter, smoother, clearer, healthy and glowing looking younger skin. A post laser skin regimen, preferably simple, is important to keep the new quality of the skin looking great. 

Loss of pigmentation

The issue with hypopigmentation was particularly related to the traditional, fully ablative resurfacing machines, like the Coherent ultra pulse.  Despite our attempts to "feather" the edge of the treatment zone, we'd see a step off in color between the treated area (lighter) and the untreated area (tanned / darker) in the occasional patient.

Fortunately, this is dramatically better with the use of fractional resurfacing.  Unless you increase the treatment densities and energies to levels approaching the old ablative machines, you really don't see that problem much anymore.

Decreased pigmentation following CO2 laser resurfacing

I am in Florida where people don't like to wear a lot of makeup due to the heat.  One of the nice advantages of newer fractional CO2 laser resurfacing techniques is that I really don't see any pigment change (other than desired removal of solar lentigos (brown spots)).  There is no need to cover up the interface between where the laser was used and where it was not with the fractional CO2 laser because there is no persistent alteration of baseline skin pigmentation. 

Use of completely ablative CO2 laser resurfacing can result in some lightening of pigmentation although the best lasers have high energies applied for very short dwell times - this yielded much less of a problem than the early lasers had.  I used the Coherent Ultrapulse laser and had very nice results with a minimal effect on pigmentation. 

At this time I use fractional CO2 laser almost exclusively as it retains most of the fully ablative CO2 laser power with a shorter recovery time and less effect on pigmentation (the concern you describe). 

Douglas M. Stevens, MD
Fort Myers Facial Plastic Surgeon
5.0 out of 5 stars 7 reviews

Less Risks associated to C02 nowadays than years ago

The beauty of C02 technology is that it has evolved and the risks have been reduced. Years ago, hyperpigmentation was a big concern. Currently, the gold standard C02 lasers are fractionated- some of the benefits are increased control and parameters for the provider and faster healing for the patient, as well as a reduction in side effects like hypopigmentation. The results are unparalleled and are absolutely worth it, but to reduce the risks and ensure your safety, it is extremely important to choose an expert with a reputable practice.

Cory Torgerson, MD, PhD, FRCSC
Toronto Facial Plastic Surgeon
4.5 out of 5 stars 69 reviews

How to Avoid Hypopigmentation with CO2 lasers

The newest advancements in CO2 laser treatment of the skin is Fractionated CO2 Lasers which do not result in abnormal loss of skin pigmentation (hypopigmentation) and has a faster healing time.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 107 reviews

Resurfacing Risks

 CO2 laser resurfacing is very safe in experienced hands. Perhaps you might find it useful to read an article published by me on this very topic.
Ramsdell WM. Fractional CO2 laser resurfacing complications. Semin Plast Surg 2012;26:137-140.

William M. Ramsdell, MD
Austin Dermatologic Surgeon
4.5 out of 5 stars 2 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.