What's the Best Laser for Skin Resurfacing?

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 the 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."

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, Fotofacial, 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 wavelength lasers (old lasers in new boxes) with scanner handpieces re-purposed to treat 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 (sometimes with a "pebbly" texture from improperly-spaced polka-dots). 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 ablative 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 dual-wavelength CO2/Erbium-YAG full-face laser resurfacing remains the BEST one-time laser resurfacing procedure available. With proper skin care, I routinely have patients healed in 7-10 days, and with minimal (truly) redness easily covered with standard make-up. The results are much more uniform than any fractional polka-dot treatment, multiple treatments are not necessary, and healing doesn't take any longer than most fractional treatments. Smoothness and outcomes are superior, and downtime is certainly less than any multiple-session protocols! 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?"

Enough said, my soapbox is sagging! Caveat emptor!

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are excellent options in our clinic. We also perform CO2 fractional and erbium depending on skin tone and tolerance for downtime. Patients do have to use a Melarase cream before and after treatment to help further reduce pigmentation after laser. Dark spots can improve with these treatments. I recommend fractional laser for incisional scars as well, especially after plastic surgery.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Fraxel and/or CO2 are best for resurfacing, but Erbium is a good alternative. I always combine lasers with microneedling/PRP for more robust outcomes. For skin tightening, I recommend a combination of Ultherapy with RF treatments and Sculptra for skin tightening. I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

The laser we recommend for optimal skin resurfacing is the Profractional laser by Sciton, which is an Erbium YAG laser device. This laser works by breaking down the beam to smaller “baby beams,” which allow healthy tissue to repopulate more quickly and therefore resurface your skin.  A short and long pulse width allows the settings to be adjusted to be more or less aggressive, depending on your skin type and what concerns we are addressing. Your skin texture can go from “burlap to silk,” and collagen can be stimulated as well.  

There is no one "best" laser for skin resurfacing. In my practice, I utilize several different lasers depending on the patient, skin type, area of concern, goals of treatment, and potential available down time. I most commonly utilize a fractional CO2 laser or an Erbium:Yag laser for skin resurfacing. I find that I am able to get very aggressive results with minimal down time using these devices. There are MANY different types and name brands of lasers out there. Be sure to find a doctor that you trust and can show you legitimate before and after results of patients who have been treated with the laser that they recommend so you can understand the types of changes that are possible and expected.Best,

I often get asked what the best laser is for skin resurfacing.  Not all lasers are the same.  There are different modalities that exist, such as CO2 lasers, erbium lasers, etc.  However, most lasers do work to achieve similar results.  For instance, some lasers may focus on pigment, some on redness, and some on improving texture and tone.  Some lasers are can be aggressive while others can be almost as mild as a peel.  Although your dermatologist and/or favorite Medspa may carry two different brands of lasers, each of the lasers may be appropriate for you, depending on the issues you desire to address.  Consult with knowledgeable provider who will tell you whether or not you are a good candidate for laser resurfacing. 

The best type of laser depends on your type of skin, and what condition your skin is in when you present to your physician. The advantage that we have today is that we have a wide array of different lasers available to us that can address various conditions of the skin. Therefore is certainly recommended that whenever you go in for your consultation you are not getting advice for one treatment that does everything. As you know, it is impossible for one type of treatment to treat everything. Usually a photo-therapy treatment will address some pigmentation issues or vascularity. My personal preference is the Erbium based laser for deeper lines and skin rejuvenation. However, you have to be conscious of the fact the deeper the laser goes, the longer the downtime will be, but it will have a better impact and longer lasting results. The advantage of laser treatment these days is that you can decrease your downtime by using fractional laser treatment which allows you to treat multiple components of the skin. In our practice we prefer the use of Halo by Sciton for this very purpose, and we have been very happy with what it can deliver along with a relatively short recovery period. 

Just as there are many different devices that can "resurface" skin, there are many considerations that need to be included in the choice(s) made. The "best laser" for you may be the worst one for someone else.First, no matter what device you choose, it has to be appropriate for your SKIN TYPE and COLOR. Since skin with abundant pigment will also tend to HYPER Pigment following laser, other non-laser options are typically a better choice., though none of those guarantee zero treatment-induced pigment response.The PURPOSE of your treatment also dictates which option is recommended. Simply refreshing the skin may only take light chemical peels; acne scarring may require a lengthy and carefully balanced mix of procedures to get the best response.Availability for "downtime" - if you can't or won't allow time for a healing process, that also limits the options, especially with scar treatments.Fractional lasers and fractional devices, in general, have become popular because healing is accelerated and downtime is usually quite minimal. Fully ablative lasers remove ALL the surface layer of the skin and the post operative care is very precise. Fractional CO2 lasers require longer healing periods than erbium. Depth and density of treatment energy affects both healing time and outcome. (So you see it is not so simple to pick one best device.)Your HEALTH is a factor. Do you heal easily? Scar easily? Are you recovering from illness or taking medications? The choice is not always "which" device, but what's best AND safest for you as an individual.All fractional devices have the ability to improve your skin. The path to a successful outcome requires many considerations and appropriate skill levels. Experience, training and expertise can make the difference between a good or poor end result. Stick with Board Certified physicians who have invested the time being educated about skin, and spend some time of your own researching the available treatment options for whatever you are wanting to correct or improve.

Likely the laser your dermatologist offers goes a bit deeper than the med spa. That will increase the downtime and the risks but it will also maximize the results. As far as knowing which one is right for you it depends on a few factors. # 1 what are your goals? Is it redness or vessels, is it wrinkles or lines? # 2 what is your baseline skin tone? For darker skin tones we are limited with the power and types of lasers we can use in order to be safe and prevent post treatment skin darkening or scarring. I recommend having this discussion with a surgeon after a careful consultation.Hope this helps,Best of luck.DrC

The most important factors to consider are not the specific laser to be used, but rather who is using the laser and why is it being used. There are a variety of resurfacing lasers available today and they are broadly categorized into ablative vs non-ablative. A further subdivision is into fractionated and non-fractionated lasers. Generally speaking, non-ablative and fractionated lasers have less healing time associated with them but also produce less prominent results. However, ablative lasers are not appropriate in many situations. Therefore, it is very important to have a face to face consultation with an experienced expert who can assess your exact needs and make the appropriate recommendations.

There are many lasers in the aesthetic industry today. The "best" laser is the one that can give you the result you desire with the least amount of risk and downtime. It therefore depends on what you want to improve as to what the best laser would be. If you are concerned about a vascular lesion, the preferred laser would be different than if you were trying to treat wrinkles. So, if you are just looking for an overall improvement in skin coloration, I would argue that Broad Band Light (a form of intense pulsed light) would be the best way to treat your concerns while eliminating any downtime. If you are looking to reduce wrinkles as well as improve the overall appearance of your skin, I'd recommend the new Halo laser. It is a hybrid fractional laser, firing two lasers simultaneously at the same spot. It can improve discolorations, textural imperfections, pore size and even wrinkles with little to no downtime and virtually no risk. If you have extremely deep wrinkles around the mouth, then I'd recommend a deep erbium laser resurfacing. The erbium laser has been shown to give equivalent wrinkle reduction to the CO2 laser but with far lower risks and complications.Ultimately, you want to see someone with extensive experience with lasers and make sure they understand what you expect from the treatment. They should be able to then tell you why their recommended treatment is the "best".Andrew Campbell, M.D.Facial Plastic SpecialistQuintessa Aesthetic Center