Non-ablative Laser Rejuvenation

What is non-ablative laser rejuvenation?

Non-ablative skin rejuvenation uses a laser to improve the appearance of wrinkles, brown spots and minor scars by creating heat in the skin without injuring the surface of the skin. The heat generated by the laser promotes collagen production which causes the skin to tighten and look young and healthy. Nonablative lasers often are fractionated so they deliver heat into the skin through thousands of tiny, deep columns known as microthermal treatment zones with intervening normal untreated skin. The fractional approach allows the skin to heal much faster than if the entire area was treated. This approach lessens the recovery period and reduces the number of complications that can occur. Multiple sessions are needed in most cases.

What should first be done before considering non-ablative laser rejuvenation?

Before the procedure, an ASDS dermatologist will usually review the patient’s medical history and conduct a physical exam. Let your doctor know if you have a history of cold sores or similar disorders. This is also the time for the doctor and patient to discuss appropriate treatment expectations, potential risks and benefits of the procedure. Prior to treatment, the patient should:

• Avoid tanning or excessive sun exposure.
• Avoid perfumes, deodorants and other potential irritants in treatment area.
• Avoid taking aspirin and other blood thinners prior to treatment.

When is non-ablative laser rejuvenation appropriate?

The procedure is used to improve the appearance of skin conditions such as:

• Age spots 
• Scars 
• Sun-damaged skin 
• Wrinkles

Who is not a candidate for non-ablative laser rejuvenation?

The procedure may not be appropriate for people with certain chronic health conditions or unrealistic expectations of the procedure’s outcome.

Is non-ablative laser rejuvenation painful?

A topical anesthetic is usually applied to the treatment area to minimize discomfort. Pain is usually minimal.

What are the potential complications of non-ablative laser rejuvenation?

• Temporary lightening or darkening of the skin
• Scarring
• Swelling
• Redness
• Infection

What can I expect after having had non-ablative laser rejuvenation?

Recovery time following the procedure is minimal. Improvement is gradual and can take several months to take full effect. In some cases, a series of treatments may be necessary.

• Most patients can return to work immediately after the procedure.
• Redness caused by the treatment can be camouflaged by makeup without any negative effects.
• The treatment area should be kept well moisturized.
• Patients should avoid sleeping on the treated area to prevent prolonged swelling.
• Cold compresses can be applied to alleviate pain.
• Sun exposure should be avoided after the treatment. Broad spectrum sunscreens of at least SPF 30 should be applied daily.

For more information and referrals

For more information on skin conditions and treatments, along with a list of ASDS members in your state, please visit the find a dermatologic surgeon section of our website.

Fractional photothermolysis uses an array of small laser beams to create many microscopic areas of thermal necrosis within the skin. These areas of necrosis are deemed microscopic treatment zones (MTZs). Fractional photothermolysis performed within these MTZs completely destroys the epidermis and dermis, but the necrotic injury heals rapidly and adverse effects are few.[1, 2] A large number of new devices have come onto the market, and their individual use must be assessed by the dermatologist individually. Nonablative laser resurfacing has been evolving away from scanning technology to fractional technology.[3]

With nonablative laser, it is difficult to cause a robust fibroplasia on a histologic basis and its ability to induce skin tightening yeilds clinically inconsistent results.[4]

Fractional resurfacing is an effective treatment for hypopigmented scarring on the face.[5] Collawn[6] treated 70 patients with abnormal pigmentation, wrinkles, or scars on their faces and/or extremities for with 2-6 treatments 1-3 weeks apart using the Fraxel laser (Reliant Technologies, Inc). Patients experienced erythema and edema for a few days, followed by light skin exfoliation for a few days, and noted a more even skin color and texture and a decrease in the unwanted melanocytic pigmentation and rhytides. Others have noted that fractional laser reportedly is a useful treatment for pigmentation and texture improvement.[7]

Fractional resurfacing has also been reported to be successful in the treatment of third-degree burn scarring.[8]

Pulsed char-free carbon dioxide laser skin resurfacing has provided a method of removing thin layers of skin with minimal thermal damage. These lasers improve mild, moderate, and severe rhytides, as well as photoaged skin. Laser energy is delivered at the ablation threshold of the skin, without the adverse effects seen with older, nonpulsed, continuous-wave carbon dioxide lasers. The presumed mechanisms of char-free pulsed carbon dioxide laser rhytid improvement are epidermal ablation, dermal damage with collagen remodeling, and thermal contraction.

Carbon dioxide laser resurfacing has been used successfully on nodular and hypertrophic components of port wine stains.[9]

Despite the clinical improvement seen after carbon dioxide laser treatment, the enthusiasm for this system has been tempered by the prolonged healing and significant erythema that commonly occurs following laser treatment. Although this erythema may resolve in 1 month, it commonly lasts up to 6 months. When experienced laser physicians perform carbon dioxide laser surgery, the results are excellent; however, the novice laser physician has not found carbon dioxide systems to be as user friendly. With this significant learning curve, some physicians have shied away from laser resurfacing.

The erbium:yttrium-aluminum-garnet (Er:YAG) laser, with its 2940-nm wavelength, emits laser energy in the mid-infrared invisible light spectrum. This wavelength has 10-15 times the affinity for water absorption compared with the carbon dioxide wavelength (10,600 nm). It is this fact that leads to the difference in clinical response observed after treatment with these 2 lasers. The Er:YAG laser wavelength is at the peak of water absorption. Er:YAG laser treatment leads to epidermal ablation and dermal remodeling. Unlike carbon dioxide lasers, these systems produce little thermal effect.

The Er:YAG laser is a true ablation laser. This laser is unlike carbon dioxide lasers, which cause both vaporization and desiccation. Both the Er:YAG laser and the pulsed char-free laser have water as the absorbing chromophore. The Er:YAG laser produces only about 5-20 µm of thermal damage per impact as opposed to the 50-125 µm of additional thermal damage observed with each pass of the carbon dioxide laser. Carbon dioxide lasers produce a significant thermal effect; this residual thermal damage becomes a heat sink for the next pass of the carbon dioxide laser. This damage leads to desiccated collagen with a resultant increase in new collagen production. Such an effect would not be expected after Er:YAG laser treatment.

The duration of erythema after Er:YAG resurfacing is usually less than with carbon dioxide laser treatment because Er:YAG laser treatment often involves more superficial ablation and leaves minimal thermal damage. Wound healing and recovery time following Er:YAG laser treatment is generally shorter, making it ideal for resurfacing relatively young people who lack deep wrinkles or extensive photodamage. However, a draining wound is still created with Er:YAG laser technology.

Both carbon dioxide laser and Er:YAG laser technology, although promising in their benefits, sometimes are accompanied by untoward adverse effects and complications. The most common of these, as mentioned above, is postoperative erythema, an adverse effect experienced by virtually all patients treated with these modalities. Other potential risks induced by ablative, dermal wounding modalities include delayed healing, postoperative pigmentary changes, and scarring.

If a dermal wound and new collagen formation is the primary mechanism behind the improvement seen after laser resurfacing, techniques that induce a dermal wound without epidermal ablation theoretically should lead to cosmetic improvement of dermal photodamage. This arena of nonablative dermal remodeling is a new area of laser technology.

Handley et al[10] noted that adverse events can occur with nonablative cutaneous visible and infrared laser treatment.

Recent studies have shows that Fitzpatrick skin types IV to VI lasered with a 1,550-nm erbium-doped fractional type nonablative laser had a low incidence of treatment-related pigmentary alteration.[11]

It seems clear that nonablative laser has a place in the treatment of patients who are younger than 50 years and have nonsagging skin; it can yield results similar to ablative procedures in such patients.[12]

Finally, nonablative lasers have a place in improving the appearance of scars and grafts in patients after Mohs micrographic surgery.[13]

The dual-spot-size carbon dioxide ablative fractionated laser has been used effectively to treat acne, with few of the adverse effects of a truly ablative laser.[14]

Weiss et al[15] noted that based on a prospective clinical evaluation, 1440-nm laser treatment delivered by microarray is effective for treating photoaging and scars, specifically inducing neocollagenesis in the remodeling of scars and rhytides.

Trellas et al[16] noted that no single nonablative laser can achieve all the specific effects needed for effective skin rejuvenation, and they suggest that combinations of treatments are the most useful modes of treatment. Fractional resurfacing has largely replaced other ablative technologies, and nonablative techniques have become more widespread.

Although nonablative treatments are useful, they are still not as effective as ablative treatments. This was highlighted in a study by Ong and Bashir; ablative fractionated laser induced an improvement range between 26-83% whereas nonablative fractionated laser had an improvement range between 26-50%.[17]

Also see the Medscape Reference article Nonablative Facial Skin Tightening.

The techniques, because of their nonablative nature, appear to be safe. However, the risk of scarring is always present, which is true for any cosmetic procedure.

The most commonly used modalities for nonablative resurfacing are the 585-595-nm pulsed-dye lasers, the 1320-nm Nd:YAG laser, the 1450-nm diode laser, the 1064-nm Q-switched Nd:YAG laser, and the intense pulsed light source. This field is rapidly evolving, and newer modalities are expected over the next few years. A novel 1,550-nm erbium-doped laser (Fraxel, Reliant Technologies Inc.) has been shown to be effective in the treatment of photodamaged skin and scars with minimal postoperative recovery.[6] Combinations of treatments with nonabaltive resurfacing can yield improved cosmetic effects.[26] Nonablative lasers can be combined with topical bimatoprost to enhance repigmentation, but this effect requires further investigation.