The pursuit of beauty and a youthful appearance has a history dating back thousands of years, including the practices of ancient Egyptians. However, advancements in technology have provided an unprecedented array of options for achieving these goals. Non-surgical skin rejuvenation, laser skin resurfacing, wrinkle treatment, fillers, facelifts, and skin tightening are among the common approaches to enhance one’s skin. Among these choices, laser skin resurfacing stands out as the most effective non-invasive or semi-invasive surgical approach to achieve dramatic results.

It’s essential to note that every new resurfacing laser or device is compared to the industry’s most powerful machine over the past four decades: the carbon dioxide (CO2) laser. Invented in 1964, the CO2 laser has been widely used in medicine, particularly in dermatology for facial resurfacing. It often delivers desired results in a single treatment, effectively addressing fine lines, intermediate lines, acne scars, and achieving maximal skin tightening, with results lasting for several years. However, its drawback is the relatively long social downtime of 10-14 days, making it less appealing to individuals with work commitments. To address this issue and minimize healing time, the aesthetics industry has recently developed devices that avoid injuring the uppermost skin layers through non-ablative techniques. The most significant advancement in this regard has been fractional technology, which leaves small islands of normal skin intact, allowing for faster skin regeneration compared to traditional full skin ablation methods.

This review will provide insights into industry-recognized ablative and non-ablative strategies for skin rejuvenation, highlighting the advantages and disadvantages of each technique.

The CO2 laser, as an ablative laser, vaporizes tissue and effectively eliminates fine and intermediate lines, improves overall skin texture, treats acne scars, and tightens the skin. It can make you appear up to ten years younger and often eliminates the need for a facelift unless there is severe skin sagging. While the preparation and postoperative care for CO2 laser resurfacing closely resemble those of a full surgical procedure, it can be performed under local anesthesia. The trade-off for the remarkable results is a social downtime of one to two weeks as the skin reepithelializes. Additionally, the resurfaced skin may appear pinkish for several months afterward.

Since the beginning of 2007, advanced systems with partial degrees of ablation that preserve small islands of normal skin, allowing for faster skin regeneration, have revolutionized skin resurfacing. Among these systems, the combination of DeepFx and ActiveFx, manufactured by the leading CO2 technology provider Lumenis, delivers results that closely compare to traditional laser resurfacing. This new technology offers quicker healing times while maintaining excellent results. Several laser companies have now introduced their own versions of fractional CO2 lasers, including Fraxel re:Pair, Slim Mixto/SX, Exelo 2, and Mosaic.

The traditional erbium laser once delivered results comparable to the CO2 laser but fell out of favor due to significant postoperative bleeding. Today, erbium laser treatments are primarily fractionated or pixelated to minimize downtime. You may come across brand names like Pearl, Pixel, ProFractional, and Starlux 2940. However, except for Pearl, these do not achieve results that match the original erbium laser. While downtime typically ranges from 1 to 4 days, most fractionated erbium technologies primarily target sun damage and skin texture improvement, with excellent results in these areas but limited impact on fine lines. They are often considered as aggressive peels, and several treatments are usually required to achieve desired results. These fractionated lasers are not particularly effective for skin tightening, wrinkle removal, or addressing acne scars.

Non-ablative lasers protect the epidermis, the outermost layer of the skin, minimizing social downtime. They deliver energy into the deeper layers of the skin, causing swelling rather than oozing, which is more socially tolerable. Among non-ablative lasers, FRAXEL is the most widely marketed, with other brands including Affirm, StarLux-Lux, and Mosaic.

These lasers use a wavelength lower than that of a CO2 laser, stimulating collagen production and tightening the skin. Results after a single treatment are minimal, and it can take 4-8 treatments to observe a noticeable effect. While the effects on wrinkles and lines after 4-8 treatments are somewhat similar to the results of a single CO2 laser treatment, they do not appear to be as effective for addressing scars. Additionally, Fraxel has received FDA approval for treating melasma, a condition characterized by symmetric facial pigmentation resulting from sun exposure and increased estrogen levels.

Plasma and radiofrequency devices fall into this category, with a focus here on plasma technology due to its more convincing results. Plasma technology does not rely on laser principles but instead introduces plasma into the skin to induce partial epidermal ablation and stimulate collagen renewal beneath the skin’s surface. Aggressive treatments can be completed in 1-2 sessions, yielding results similar to fractionated CO2 laser resurfacing. When energy levels are minimized to minimize redness lasting just a few hours, multiple treatments are needed for noticeable effects. However, with this latter technique, results tend to be less dramatic. This technology gained FDA approval in the second half of 2007, and its long-term results are still being studied.

In summary, there is a wide array of exciting technologies available today for skin resurfacing. The general principle that less downtime often corresponds to less significant results still holds. Non-ablative technology typically does not produce noticeable results in a single treatment, and even after multiple treatments, the overall outcome may fall below expectations. Ablative devices tend to provide better results, often requiring fewer treatments, and fractional technology can effectively reduce social downtime. Ultimately, your goals, your tolerance for social downtime, and your budget will guide you and your treating physician toward a customized skin resurfacing plan.