Laser skin resurfacing refers to the removal of the superficial layers of the skin through the application of a high energy light source. Like a chemical peel, this is an effective way to improve the appearance of the skin, but this treatment carries a higher risk of post-operative infection because the surface integrity of the skin (its primary defence) is removed (vs merely denatured as with a peel). In this article, we expand on the types of resurfacing treatments available and explain how to minimise your risk of complications.
What is a laser?
The word LASER is an acronym for Light Amplification through Stimulated Emission of Radiation and describes a concentrated light source with a narrow beam of application. Think of a flashlight beam as a crowd of commuters, pushing and shoving, jostling their way down the platform of a railroad station; by comparison, a laser beam is like a parade of soldiers all marching precisely in-step.
Lasers are monochromatic (they emit one colour of the light spectrum only). Each colour in the light spectrum has a different property, therefore distinct lasers are used for varying applications. This is because assorted colour lesions and different tissues will absorb dissimilar spectrums of light.
Lasers direct short, pulsating, concentrated beams of light at irregular skin, precisely removing it layer by layer. This popular procedure is also called lasabrasion, laser peel, or laser vaporization. The benefit of using a laser versus having a chemical peel is that a far more precise layer of skin removal is possible.
Who is a good candidate for laser resurfacing?
If you have fine lines or wrinkles around your eyes, mouth or on your forehead, shallow scars from acne, or non-responsive skin after a facelift, then you may be a good candidate for laser skin resurfacing. A laser resurfacing does not lift sagging muscles or tissue and therefore cannot replace a face-lift or threading. Think of it this way: a face-lift is like panel beating a car and a laser is the spray-painting to complete the picture.
If you have acne or if you have very dark skin, you may not be a candidate. This technique is also not recommended for stretch marks. You should discuss whether laser resurfacing is right for you by consulting with the doctor before having the procedure done.
How Does Laser Skin Resurfacing Work?
The two types of lasers most commonly used in laser resurfacing are carbon dioxide (CO2) and erbium. Each laser vaporizes damaged skin cells at the surface-level.
CO2 Laser Resurfacing
This method has been used for years to treat various skin issues including wrinkles, scars, warts, enlarged oil glands on the nose, and other conditions.
The newest version of CO2 laser resurfacing (called fractionated CO2) uses very short pulsed light energy (known as ultrapulse) or continuous light beams that are delivered in a scanning pattern to remove thin layers of skin with minimal heat damage. Recovery takes up to two weeks.
Erbium Laser Resurfacing
Erbium laser resurfacing is designed to remove surface-level and moderately deep lines and wrinkles on the face, hands, neck, or chest. One of the benefits of erbium laser resurfacing is the minimal burning of surrounding tissue. This laser causes fewer side effects -- such as swelling, bruising, and redness -- so your recovery time should be faster than with CO2 laser resurfacing. In some cases, recovery may only take one week. Ask your doctor how long recovery is likely to take for you.
If you have a darker skin tone, erbium laser resurfacing may work better for you.
Preparing for Laser Resurfacing
Start by consulting an aesthetic doctor to find out if you're a good candidate. Be sure to choose a doctor who has documented training and experience in laser skin resurfacing. The doctor will determine which laser therapy is best for you after considering your medical history, current health, and desired results.
Make sure to inform the doctor if you suffer from cold sores or get fever blisters around your mouth. Laser skin resurfacing can trigger breakouts in people who are at risk.
If you decide to go ahead with laser skin resurfacing, your doctor will ask you to avoid taking any medications or supplements that can affect clotting – such as aspirin, ibuprofen, or vitamin E -- for 10 days before your treatment.
If you smoke, you should stop for two weeks before and after the procedure. Smoking can prolong your healing time.
Previously, it was popular to prescribe antibiotics and antiviral medicine to prevent skin infections or herpes outbreak after the procedure. With the development of Hypochlorous solution (HOCl), as found in our GF1 Aftercare product, it is advisable to spray the skin before the laser procedure and to continue to do so afterwards to prevent infection, control inflammation and to stimulate healing23.
What to Expect
Generally, laser resurfacing is an outpatient procedure, meaning there is no overnight stay.
The doctor may treat individual wrinkles around your eyes, mouth, or forehead or treat your entire face. For small areas, the doctor will numb the areas to be treated with a local anaesthetic. You may also need sedation, which should be administered by an anaesthetist. You may even be given general anaesthesia if your whole face is being treated.
If the doctor is just treating parts of your face, the procedure will take about 30 to 45 minutes. A full-face treatment takes up to two hours. Following the laser procedure, the doctor will bandage the treated area. It is advisable to start Thoclor GF1 Aftercare spray as soon as the bandages are removed. In the beginning, spray the treated area hourly and reduce the frequency of application to three times per day from day two. Continue to spray GF1 until the bottle is used up as it is important to control inflammation long-term.
It's normal to have swelling after laser skin resurfacing. Sleeping on an extra pillow at night to elevate your head can help ease swelling. Putting an ice pack on the treated area also helps to reduce swelling in the first 24 to 48 hours after laser resurfacing. The most effective control of swelling will be from using our GF1 spray.
You may feel itching or stinging for 12 to 72 hours after the procedure. Two to three days after laser resurfacing, your skin will become dry and peel. If, however, you are not using our miracle mist then it may take up to 7 days before peeling will happen.
You will probably notice that your skin is lighter for a while after surgery. It is particularly important that you use a "broad-spectrum" sunscreen, which screens ultraviolet B and ultraviolet A rays, to protect your skin during that time. When selecting a sunscreen, look for one specially formulated for use on the face. It should have a physical blocker, such as zinc oxide. and a sun protection factor (SPF) of 15. Also limit your time in the sun, especially between the hours of 10 a.m. and 2 p.m. Wearing a broad-brimmed hat can help protect your skin from the sun's harmful rays.
People with darker skin tones are more likely to get darker pigmentation. These skin types will benefit hugely from using our GF1 HOCl spray as this will control inflammation, which is the biggest contributing factor in the development of hyperpigmentation23.
Complications of Laser Skin Resurfacing
An intact skin barrier is the best layer of defence against infection. By definition, fractionated ablative CO2 laser resurfacing perforates the skin barrier allowing for a potential infection post procedure. The disease-forming organisms that may infect the skin include bacteria, fungi, and viruses.
Laser treatment poses a higher risk of post-operative infection than chemical peels because the primary defence of the skin (its surface integrity) has been removed. With chemical peels, a biological dressing (a layer of denatured protein or “dead” skin) covers the wound. The most common cause of scarring is a postoperative infection, which usually presents several days after the procedure as a localized area of delayed healing.
The most common causes of infection include Staphylococcus, Pseudomonas, Klebsiella, and Enterobacter. Candidiasis may be quite subtle and present as prolonged erythema and itching1 - 6.
It is therefore of utmost importance to use an antiseptic solution like Thoclor GF1 in the post-operative phase of healing due to this loss of integrity of the skin. HOCl solution not only reduces the risk of infection dramatically but will also assist in healing and in the control of inflammation and pain in the treated area23.
Scarring and Ectropion
The most dreaded side effect, of course, is scarring.7,8. Manuskiatti documented a 3.8% incidence of scarring9. In this series, every case was caused by infection, highlighting the need for surveillance, and proper skin care including antibacterial and antiviral prophylaxis23, as is found in Thoclor GF1 Aftercare. Another cause of scarring represents operator error in the form of excessive laser energy or density, too many passes, or pulse stacking10. If the skin is heated beyond its ability to heal promptly and without excessive fibrosis, scarring will occur. The neck and chest are more susceptible to scarring than the face and must be treated with caution11,12,13.
Ectropion (the outward turning of an eyelid due to scarring) usually results from excessive laser energy on the thin skin of the lower eyelids8.
Hyperpigmentation, so common following previous generation CO2 lasers in darker skin types, is less likely with fractional resurfacing provided that excessive energy is not applied14. Fortunately, delayed-onset permanent skin lightening (as seen in up to 19% of cases with older generation CO2 lasers) is less common now15–19. Nevertheless, fractional lasers are certainly capable of damaging the skin enough to cause scarring and the disruption of pigment formation.
It can be particularly challenging to distinguish contact dermatitis from infection while the patient’s skin is red and swollen due to laser healing. It is generally recognised that a wide variety of creams, ointments, cleansers, and other skin care products may cause contact dermatitis after laser resurfacing20. If a product is suspected to be a culprit, it should be discontinued immediately.
Of special note, as previously mentioned, the use of topical antibiotics like neomycin, bacitracin, and polymyxin have been discouraged due to the heightened risk of allergic contact dermatitis. Bacitracin has been reported to cause not only contact dermatitis post resurfacing, but also foreign body granulomas due to its mineral oil content5,21. It should be mentioned that “natural” or “botanical” products could cause contact dermatitis despite the gentle nature implied. The use of Hypochlorous solution is recommended23.
Prolonged erythema, so common with earlier types of lasers, is uncommon. It can be caused by inappropriate laser settings, infection, aggressive debridement between laser passes, and contact dermatitis. Over time, post-resurfacing erythema fades gradually. It is important to use Thoclor GF1 Aftercare to reduce the redness, which results from inflammation.
Acne and milia are common minor side effects16,19,22. Spontaneous resolution can be expected. If bothersome to the patient, milia may be removed via extraction.
With advancements in technology laser skin resurfacing is a great way to even out skin tone, smooth wrinkles, treat acne scars or tackle sun damage. However, it is essential that you visit a registered and qualified practitioner who will ensure that the correct laser for your skin type and desired outcome is chosen. Manage your post-treatment healing and reduce your risk of infection by applying our HOCl aftercare product regularly and often. This will help you to achieve the results you are looking for.
- Alam M, Pantanowitz L, Harton AM, Arndt KA, Dover JS. A prospective trial of fungal colonization after laser resurfacing of the face: correlation between culture positivity and symptoms of pruritus. Dermatol Surg 2003;29(3):255–260
- Conn H, Nanda VS. Prophylactic fluconazole promotes reepithelialisation in full-face carbon dioxide laser skin resurfacing. Lasers Surg Med 2000;26(2):201–207
- Rao J, Golden TA, Fitzpatrick RE. Atypical mycobacterial infection following blepharoplasty and full-face skin resurfacing with CO2 laser. Dermatol Surg 2002;28(8):768–771, discussion 771
- Palm MD, Butterwick KJ, Goldman MP. Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as an atypical acneiform eruption): case report and literature review. Dermatol Surg 2010;36(9):1473–1481
- Fisher AA. Lasers and allergic contact dermatitis to topical antibiotics, with particular reference to bacitracin. Cutis 1996;58(4):252–254
- Ortiz AE, Tingey C, Yu YE, Ross EV. Topical steroids implicated in postoperative infection following ablative laser resurfacing. Lasers Surg Med 2012;44(1):1–3
- Ross RB, Spencer J. Scarring and persistent erythema after fractionated ablative CO2 laser resurfacing. J Drugs Dermatol 2008;7(11):1072–1073
- Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional CO2 laser resurfacing: four cases. Lasers SurgMed 2009;41(3):179–184
- Manuskiatti W, Fitzpatrick RE, Goldman MP. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am Acad Dermatol 1999;40(3):401–411
- Choi B, Barton J, Chan E, et al. Infrared imaging of CO2 laser ablation: implications for laser skin resurfacing. Proc SPIE 1998;3245:344–351
- Avram MM, Tope WD, Yu T, Szachowicz E, Nelson JS. Hypertrophic scarring of the neck following ablative fractional carbon dioxide laser resurfacing. Lasers Surg Med 2009;41(3):185–188
- Gewirtzman A, Meirson DH, Rabinovitz H. Eruptive keratoacanthomas following carbon dioxide laser resurfacing. Dermatol Surg 1999;25(8):666–668
- Mamelak AJ, Goldberg LH, Marquez D, Hosler GA, Hinckley MR, Friedman PM. Eruptive keratoacanthomas on the legs after fractional photothermolysis: report of two cases. Dermatol Surg 2009;35(3):513–518
- Tan KL, Kurniawati C, Gold MH. Low risk of postinflammatory hyperpigmentation in skin types 4 and 5 after treatment with fractional CO2 laser device. J Drugs Dermatol 2008;7(8):774–777
- Ward PD, Baker SR. Long-term results of carbon dioxide laser resurfacing of the face. Arch Facial Plast Surg 2008;10(4):238–243, discussion 244–245
- Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997;23(7):519–525
- Bisson MA, Grover R, Grobbelaar AO. Long-term results of facial rejuvenation by carbon dioxide laser resurfacing using a quantitative method of assessment. Br J Plast Surg 2002;55(8):652–656
- Laws RA, Finley EM, McCollough ML, Grabski WJ. Alabaster skin after carbon dioxide laser resurfacing with histologic correlation. Dermatol Surg 1998;24(6):633–636
- Shamsaldeen O, Peterson JD, Goldman MP. The adverse events of deep fractional CO(2): a retrospective study of 490 treatments in 374 patients. Lasers Surg Med 2011;43(6):453–456
- Lowe NJ, Lask G, Griffin ME. Laser skin resurfacing. Pre- and post-treatment guidelines. Dermatol Surg 1995;21(12):1017–1019
- Lee S. New and unresolved complications after upper lid blepharoplasty and full face CO2 laser resurfacing. Paper presented at: the 20th Annual Scientific Meeting of the American Academy of Cosmetic Surgery; January 29–Feburary 2, 2004; Hollywood, FL
- Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998;24(3):315–320
- Ashish Bhatia et al. Optimizing Wound Healing for Cosmetic and Medical Dermatologic Procedures. Practical Dermatology March 2018, p 42-45