Laser Skin Rejuvenation: Surgery and Treatments

Lasers are used to help revitalize older, sun-damaged or aged skin and uncover fresher, younger looking skin. They can remove the dull-looking, wrinkled upper layers of skin so that, after you are fully healed, all that remains is a smoother and rejuvenated appearance.
Dermabrasion and chemical peels are other methods of rejuvenating skin by removing a top layer.

Lasers are also used in the treatment of birthmarks and vascular lesions, such as hemagiomas and port-wine stains, and are used to remove moles and warts, and tattoos. The can also be used to remove unwanted body hair and treat the skin diseases vitiligo and psoriasis.

What Is a Laser and How Does It Work?

Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. It is a device that creates an intense coherent beam of visible, infrared, or ultraviolet light.

With a laser device, electromagnetic energy (light is one type of electromagnetic energy) is changed into a tight, intense beam of monochromatic radiation capable of delivering enormous amounts of power or heat. The beam is called coherent because all the light waves line up with each other and are all the same wavelength, unlike regular light from a bulb or the sun. All lasers contain two mirrors placed parallel to each other. One of these mirrors is partially reflective and between these mirrors is a space with a medium, either a gas (carbon dioxide or a halide or other gas), a solid crystal (such as alexandrite or ruby), or a liquid.

An external power source is directed into this medium, energizing it and amplifying the light. If the medium is struck by a photon (a particle of light), it releases two photons of the same energy and wavelength in time with one another. Some photons strike other excited atoms and any photons that are not parallel to the long axis of the laser are then lost as heat. The small percentage of photons that are given off parallel to the long axis form an energy wave that strikes the mirrors and reflect back and forth rapidly between the mirrors. 

Unlike ordinary light, laser light is collimated, monochromatic (uniform wavelength, which would mean it is a single color), coherent (in tune with each other), and unidirectional. This means that the light waves (light is both a wave and a particle) are all parallel to each other, all in the same wavelength or color, and all going in the same direction. It carries very large amounts of energy and can be focused onto a very small spot, if needed. When it strikes an object, such as the skin, it be reflected, transmitted to deeper layers, scattered, or absorbed.

If laser light is absorbed, it is converted to heat, which can result in the burning or coagulation of the targeted tissue. The color (or wavelength if in the infrared or ultraviolet range) or a laser depends on the medium used and different colors of laser are absorbed by different colors of skin or tissue, which helps determine the effect of the laser. Different types of lasers are used on different colors because of the way they are absorbed. For example, alexandrite laser can be used to remove tattoos of black or blue ink, black spots, and darker hyperpigmented spots. Other lasers would be needed to removing tattoos of other colors. The most commonly used laser in laser resurfacing are carbon dioxide (CO2), erbium, and pulse dye.

Some lasers are pulsed, which means that the beam is turned on and off in short pulses, and others are continuous wave, which means they emit a continuous beam of laser light.

Laser Skin Resurfacing

First, let's do a quick primer on the anatomy of the skin. The skin has three basic layers: the epidermis, dermis, and subcutis. The epidermis—the outside-most layer of the skin—is in turn made up of the stratum corneum (mostly dead skin cells called keratinocytes), live keratinocytes, and the basal layer, which make the keratinocytes that live and die as they gradually move upward to the stratum corneum and get sloughed off. The epidermis also contains the melanocytes, the pigment-containing skin cells that give our skin its color. The dermis, the middle layer, is mostly made up skin cells, hair follicles, sweat glands, and is mostly held together by collagen, which is made by skin cells called fibroblasts. 

Laser resurfacing (also called laser peel, laser rejuvenation, laser skin tightening, and laser surgery), is the act of using a laser to remove wrinkles, discolorations, age spots, and sun damaged skin. The laser stimulates your fibroblasts to create more collagen thus treating the wrinkle from within. It can be used to eradicate wrinkles around the eyes and mouth or other unsightly lines, and remove hyperpigmentation, age spots, and other blemishes. Lasers are an effective way to remove those superficial lines that can make you appear aged. Laser resurfacing is considered a safer, less invasive rejuvenation procedure than deep chemical peels or dermabrasion. However, laser resurfacing is not for everyone, nor it is it the best choice for some types of skin or skin problems.

Facial resurfacing is usually done with what is called an ablative laser, such as CO2. Ablative means that the laser is removing a portion of the skin tissue. There are also nonablative lasers used in cosmetic surgery that do not remove any portion of the skin. Nonablative lasers do not resurface the skin per se, but rather heat up fibroblasts and stimulate them to thicken the underlying collagen structure. With ablative lasers, the top layer or layers of the skin are being removed, just as in a chemical peel or dermabrasion. Ablative lasers are more damaging and invasive. They remove a layer of your skin to resurface it; actually removing the wrinkle along with it's surrounding skin. The skin surface will appear red and moist afterward and you will need to allow for some time out of the public eye while you heal. With nonablative lasers, there is little downtime, although there may be a little swelling or pinkness.

Types of Lasers

There are many types of lasers that are used for various types of skin conditions or problems. As we said, there are different lasers that emit different colors and wavelengths, including ultraviolet and infrared. Here is a very short list of the types being used most commonly for cosmetic dermatology.

Carbon Dioxide Laser (CO2): This is the most common. We will use the CO2 to demonstrate the explanation of the surgery itself. They can be used to eradicate excessive or irregular scarring from a prior procedure although care must be taken when determining a candidate. Hyperpigmentation and hypertrophic scarring may occur in persons who are prone to that or in people with darker skin, including Hispanic, Mediterranean, and African skin types. Unfortunately, because of this, CO2 lasers aren't for everyone.

Neodymium-YAG (yttrium/aluminum garnet): This nonablative laser supposedly can be used on any skin color, any skin type, and on any part of the body with less risk of hypopigmentation or hyperpigmentation or shorter healing times that with other lasers. It is usually abbreviated as Nd:YAG, and is used to treat pigmented lesions (such as moles) and tattoos. It works by  stimulating fibroblasts to produce collagen. As the collagen layer thickens, skin tone and elasticity improve. Usually, for skin rejuvenation, you must have several treatments,

Q-switched Nd:YAG laser: This system can remove pigmentation lesions and professional tattoos that are blue or black. Tattoo removal usually takes between 8 and 12 sessions.

High Power Long Pulse Nd:YAG: This system was designed to remove both vascular lesions and can remove hair. The unique factor of this laser is that it can be used on dark skin, whereas most other lasers are contraindicated in dark skin types.

Long-Pulsed Nd:YAG laser: This laser system is good for vascular lesions and has proved very effective in treating facial flushing, redness, broken capillaries, telangiectasia (purple or blue veins on the face), hemangiomas (strawberry birthmarks) and more.

Erbium-YAG (yttrium/aluminum garnet) or Er:YAG: This laser is absorbed by superficial layers of the epidermis. This pulsed laser removed damaged or unwanted tissue. The pulsing actually lessens the heat on the skin emitted by the laser so there is less damage. It can greatly improve sun-damaged skin.

Are You a Candidate for Laser Resurfacing?

Laser resurfacing and skin rejuvenation is not for everyone. If you are prone to keloids, hyperpigmentation or hypopigmentation or do not react well to burns or if you scar excessively from minor cuts and abrasions, laser resurfacing is not a good idea for your. An ablative laser burns the skin. It literally evaporates the top layers of skin to reveal fresh skin beneath. If you scar badly when you are burned, the results of laser resurfacing could be disastrous. Also, if you have darker skin (i.e., a Hispanic, Mediterranean, or African-American background), you may be prone to pigmentation problems from laser resurfacing.

For some ethnic patients, the Erbium, pulsed dye, or NLite laser may be a safer choice although every case is individual and only a qualified surgeon who is very experienced with a laser can make this decision.

Communication is crucial in reaching your goals. You must be able tell your laser surgeon what you want if he or she is to understand what your desired results are. Talk with your surgeon so that you can reach an understanding with what can realistically be achieved.

You must be mentally and emotionally stable for any type of facial resurfacing.  This is a procedure that requires patience and stability as you heal. There is sometimes a period of depression after surgery and you already have a pre-existing emotional problem, this low period can develop into a more serious issue.  Please consider this before committing to laser facial resurfacing.

What to Expect at Your Consultation

Make sure you choose a surgeon who has been specifically trained in laser resurfacing and who is well-educated and experienced on the subject. Not all cosmetic surgeons know how to perform laser surgery. Levels of experience differ from surgeon to surgeon.

Check out your surgeon's background and credentials before you make an appointment for a consultation. Lasers resurfacing and laser treatments for other skin problems can be done by either dermatologists or plastic surgeons. The best choice is someone who is board certified in their field of medicine, but go with whoever has the most experience in laser skin treatments. You may want to have a consultation with two or more candidates.

At the consultation, you will discuss your goals and your health history. Your skin will be examined. You must discuss what you hope to get out of laser skin resurfacing. The surgeon should discuss the various techniques and lasers that are appropriate for your needs. 

Make sure the surgeon has your complete medical history and a list of any medications, supplements, or herbal products that you take. If you have a history of cold sores, fever blisters, herpes, chicken pox, shingles, or other viral infections, tell your surgeon. These viruses lie dormant in your body between outbreaks and can flare up after skin resurfacing. Also tell him or her if you have a poor immune system. After laser treatments, chemical peels, or dermabrasion, viruses like herpes and chicken pox can spread into the treatment area.

You will discuss your realistic expectations. The surgeon should discuss in detail the procedure and its risks and complications and what to expect in terms of discomfort and recovery. You will also discuss the choices in anesthesia. Most laser resurfacing procedures are performed under Light Sleep Sedation or general sedation, but some small procedures may need topical anesthetics.

You will discuss what areas should be treated. You may need treatment only around the eyes, or the lips, or perhaps the forehead will be resurfaced.

You must discuss fees and other costs during the consultation. Ask if any touch up treatment will be covered by the initial fee.

It is possible that the surgeon may recommend that you not get laser skin resurfacing. Dermabrasion or a light to medium chemical peel may be better for you than laser resurfacing. The surgeon may even recommend that you have 2 or 3 sessions instead of one very deep peel.  Discuss with your doctor the amount of time you may need to stay out of the public eye. Even though you may wish to have a lighter peel for shorter recovery, it may not give you the results that you desire.

For more information on consultations or a list of questions to ask your surgeon, visit our Consultation Page.

Your Preoperative Appointment

Depending on how extensive your laser treatment is expected to be, you may not need a preoperative appointment. This appointment will give you a chance to ask more questions and your surgeon a chance to give you full instructions for preparing for laser resurfacing and recovery. Do not hesitate to address any concerns that you may have. If you remember something when you get home or the next day or even the day of surgery, don't be afraid to ask.

You will probably get a packet of preoperative instructions and recovery period instructions. You should also discuss what to expect in the months ahead.

 Risks and Complications Associated with Laser Resurfacing

Make sure your surgeon discusses all of the risks and complications with you at your consultation. No surgery, even laser resurfacing, is risk free. There could be allergic reactions to the anesthetic. Just make sure that you disclose your medical history. If you are susceptible to keloid scarring or have active skin infections or a herpes outbreak, you may not be a good candidate for laser resurfacing.

If your skin is olive, black, brown or even yellow-toned, you may need to be careful about any  resurfacing. Even dermabrasion and chemical peels can cause noticeable damage to ethnic skins. You should request a "spot test" if you or your doctor are uncertain. You can never be too careful.

There is also the risk of bullae (blisters), infection, thicker scar tissue of the treatment area, hypopigmentation, and hyperpigmentation. You must also be very careful if you have taken Accutane (isotretinoin) within the past year and a half (12-18 months). Accutane causes dermal thickening and can cause increased scarring.

Preparing for Laser Skin Resurfacing

You should be given an information packet that explains everything you should do and know before your surgery date. The packet should include a list any medications you should avoid taking for 7 to 14 days before your surgery.

You will be given a prescription for antiviral medications before your procedure hand and will continue taking these drugs during healing phase. This is to help prevent any recurrence of herpes infection, cold sores, or other viral infections that are lying dormant in your system.

You may need to have blood tests done before your procedure. Some surgeons ask that you have physical, especially if you have an underlying condition such as asthma or diabetes. These will be out-of-pocket expenses for you.

How Laser Resurfacing Is Performed

Laser resurfacing can take from 30 minutes to more than an hour, depending on the size of the area being treated.

Before the procedure starts, you may be hooked up to monitoring equipment to keep track of your heart rate and blood pressure. You may have an intravenous (IV) line inserted with a bad of saline attached to keep you hydrated and so that medications can be administered.

Anesthesia will be administered. The type of anesthesia used should be discussed with the surgeon at your consultation or preoperative appointment.

Your face will then scrubbed with an antibacterial solution to remove surface bacteria.

The laser is a big machine, but the light beam is passed down fiber optics to a hand held wand or paddle. The surgeon passes the wand over the area to be treated. This will be done once or several times, depending on the type of laser, on your skin, and on how much resurfacing your skin needs. The laser literally evaporates the targeted areas of skin. The targeted, damaged skin disappears leaving only a faint trace of "smoke and steam" and revealing undamaged, pink skin.

Some surgeons may limit the laser's penetration to the epidermis (the uppermost areas of your skin) for the very lightest to medium peels. If the age damage is deeper, the laser can be set to penetrate the upper layers of the dermis.

After the skin resurfacing is complete, your surgeon may cover your face with either a thin film of antibiotic cream. Some surgeons use a layer of synthetic skin to protect the newly surfaced tissue during its healing process. There are several experimental coverings that are being evaluated. This is an area where different surgeons have different opinions on what is better and where there is a lot of rapid advancement.

After the laser procedure is completed, if you were asleep or sedated, you will be gently awakened and brought into the recovery room. Generally, you will be ready to be release in about 2 hours. Your face may feel tight and quite tender as the anesthesia wears off. You may even feel emotional or upset or shivering as you come out of anesthesia.

You will not be allowed to drive yourself home. You must be driven home by a responsible adult because you will still be groggy.

The Long Road to Recovery

You may be groggy from the anesthetic and or oral medications and probably won't remember much of the first day or two if you were sedated. You will have to take it easy and sleep on two pillows to keep your head elevated for 1 to 2 weeks or however long your surgeon suggests.

For the first 2 or 3 days, your face will look very swollen. But, as the days go on the swelling will dissipate. There may be bruising, but this will go away as well.

There will be redness and slight discomfort postoperatively. Your surgeon will have instructed you on the proper care of your treatment area and given you prescriptions for antibiotics and pain medications.

Take your temperature on time and regularly. An elevated temperature could mean an infection. Take your antibiotics and antiviral medications on time and don't skip any doses or stop taking the prescription early.

Swelling can be alleviated with ice packs. You may be instructed to apply ice, gel masks, or vinegar soaks on your treatment area for the first 48 hours.

The length of your healing time totally depends on the depth of your treatment. You can expect to be out of the public eye for at least 1 to 2 weeks. Your skin will feel as if you have a major sunburn. The treated area may weep and need dressing changes and additional antiseptic or antibiotic ointments. You will possibly need to wear bandages for from 5 to 7 days.

After your bandages are removed your doctor will go over with you the proper care for your treatment area, including how to keep the area clean and how to apply ointment. You will have crusts and scabs. DO NOT PICK AT THEM OR PULL THEM OFF! If you pick at the crusts and scabs, you will scar! Scabs and crusts usually resolve by day 10 after your procedure.

When your doctor gives you the go-ahead, you can start to wear cosmetics to cover the redness. This will be after any crustiness or scabbing is done. There are special cosmetics one can buy to offset the redness or you can experiment on your own with what you have. 

After your laser skin resurfacing, you will have to use sun block faithfully to protect your new skin. Your skin is very susceptible to sun damage. This includes artificial sunlight like tanning beds as well as simply driving to the store or around town all day in your car. You should avoid using alpha hydroxy acids, vitamin A (Retin A), or exfoliant products. Your skin is very fragile in its healing stage, and complete healing will take months.

Your skin will heal and become very smooth and young looking. The pinkness will subside as will the tenderness. You may be pink for up to 5 months or more, depending on your skin's ability to heal. You must take care of your skin to keep it looking vibrant and fresh. Although, no procedure can keep your skin from aging, laser skin resurfacing can give you a young, relaxed appearance and buy you some time.

The Average Prices Laser Resurfacing

The approximate prices for laser resurfacing vary significantly between geographical regions and surgeons.  Average prices range between $1,500 and $6,000.  This does not include medications, blood tests, or postoperative supplies.