Interest in plastic surgery is at an all-time high, but stigma and misinformation still surround the industry and patients. Welcome to Life in Plastic, a series by Allure that aims to explain cosmetic procedures and provide all the information you'll need to make the decision that is right for your body — no judgment, just the facts. Here, we're covering everything you need to know about laser resurfacing treatments.
Some acronyms are used so frequently, so colloquially, we overlook the meaning in their very letters. A prime example in beauty is "laser," which stands for light amplification by stimulated emission of radiation. Such gadgets operate in a very specific way, "emitting a narrow beam of a single wavelength, or color, of light," says Shereene Idriss, a clinical instructor in dermatology at the Icahn School of Medicine at Mount Sinai in New York City. However, she adds, the term has become a generic catchall for an entire class of plug-in dermatologic devices — wrongly so, of course, as many of these machines rely on different kinds of energy (ultrasound, or, say, radiofrequency) to achieve separate and distinct effects.
True lasers are characterized by key features — among them, "their wavelength, which is absorbed by select targets in the skin, and their pulse width, or the rate at which that beam of light is delivered," says Robert Anolik, a clinical assistant professor of dermatology at the NYU School of Medicine. Generally speaking, the longer a wavelength, the deeper it penetrates. The swifter a pulse width, the better optimized it is for small targets. (Minuscule pigment fragments, for instance, call for a faster pulse width than slightly larger blood vessels.) Once a bullseye is hit, it "becomes so focally hot, it breaks down or vaporizes," Anolik adds.
In the case of resurfacing lasers, the target isn't melanin or capillaries, but water molecules within the collagen layer of the dermis. "We're not trying to affect the water's appearance, obviously, but heating it creates a grid of what we call microthermal zones, which trigger extensive repair and collagen production by tricking the skin into a healing phase," Anolik says.
Semantics and physics aside, lasers are now being used to zap everything, including sun damage, skin cancers, acne scars, and regrettable tattoos — and often with little to no downtime. Which ones are best for your particular skin type and issue? Here, the country's top laser gurus spell it out for us.
What They Treat: The redness of rosacea, sun damage, spider veins, cherry angiomas (aka red moles), fresh stretch marks, some types of scars, port wine stains, and superficial bruises.
How They Work: By taking aim at hemoglobin, a protein in red blood cells, vascular lasers — namely the pulsed dye laser (PDL), and the KTP laser — heat and destroy blood vessels. Powered by actual dye (who knew?), a PDL, like the Vbeam Perfecta, "produces pulses at the 595 nanometer (nm) wavelength, which travels through the epidermis and dermis to reach its target while sparing the surrounding tissue," explains Idriss. A KTP laser uses a potassium-titanyl-phosphate crystal to shoot a wavelength of 532 nm. ("K," you might recall, is the symbol for potassium on the periodic table.)
"The PDL's wavelength and more rapid pulse width make it helpful for diffuse background pinkness, which arises from millions of extremely tiny individual blood vessels," Anolik says. The PDL can also eviscerate the microscopic red blood cells comprising bruises (at certain stages, anyway). Bigger, deeper red squiggles and spots (like cherry angiomas) tend to respond better to KTP lasers, sometimes clearing immediately after treatment. (Fading scars, stretch marks, birthmarks, and resistant capillaries commonly require repeat appointments.)
Vascular lasers, despite being around for decades, are now being explored for their integral role in scarless skin cancer treatments — more specifically, as part of emerging combination therapies for basal and squamous cell cancers. "Eighty percent of non-melanoma skin cancers are on the head and neck — highly visible areas — which is why noninvasive diagnosis and management have become real game-changers for many patients," says Orit Markowitz, an associate professor of dermatology at the Icahn School of Medicine at Mount Sinai. While the laser's mechanism of action in this realm is still being investigated, Markowitz says, "cutting off blood supply to tumors is likely only one piece of the puzzle."
What They Feel Like: You can skip the numbing cream: "Treatment with a pulsed dye laser is more startling than painful, as patients can see the reflection of the laser's flash through their opaque goggles," says Heidi Waldorf, an associate clinical professor of dermatology at the Mount Sinai School of Medicine. With the KTP, you'll feel a cool blast on the skin and then a quick pinch.
Downtime: Vascular lasers can leave skin pink, puffy, and blotchy for a few hours.
Risks: While bruising can happen, it's unlikely "unless someone has a particularly large dilated vessel, or is very pink due to the sheer number of vessels in the area," Anolik says. As with any laser, pigmentary abnormalities (unwanted darkening or lightening), burns, and scarring are possible though rare when devices are used appropriately. (Trust only board-certified dermatologists and plastic surgeons to wield lasers near your flesh.)
Price: $300 to $1000 per session depending on the area being treated
What They Treat: Individual brown spots and tattoo ink of all colors
How They Work: Pigment-seeking lasers fall into two main camps: Q-switched (à la the Ruby, Alexandrite, and Nd: YAG) and picosecond (PicoSure, Pico Genesis, PicoWay). Q-switched lasers are best known for squelching discrete sunspots, sometimes in a single shot. They release energy in short nanosecond bursts (that's one-billionth of a second), and without cooling the skin's surface, so pigment clusters up high and down low can take in heat.
With a span of wavelengths, they offer safe options for every skin tone: The forgiving Nd:YAG suits deeper (more heat-sensitive) complexions, including Hispanic, Indian, Asian, and African American; the more aggressive Ruby caters to Irish through Mediterranean types. With a more dizzying pulse duration, picosecond lasers fire 1,000 times faster than nano — so fast that the skin doesn't even register their heat, says Anne Chapas, a clinical instructor of dermatology at the Mount Sinai Medical Center.
They generate a strong acoustic wave that shatters pigment particles (safely, in all skin types). While they can help with sunspots, they shine as tattoo erasers: "They've made the removal process more effective than it was even one year ago," Anolik says. "Ink colors, like blue, green, and purple, which were extremely difficult to get with traditional Q-switched lasers, respond just beautifully to the picosecond pulse." Patients can expect to clear 90 percent of a tattoo over the course of several monthly sessions (six to 12 on average).
What They Feel Like: The Q-switched sensation is akin to a rubber-band snap. Discomfort during tattoo removal with a picosecond laser is more palpable. "I strongly recommend having a dermatologist apply numbing cream and inject lidocaine [an anesthetic] before treatment," Anolik says. "Otherwise, it can be extremely painful."
Downtime: Brown spots zapped with a Q-switched laser immediately turn pinkish-white, then darken to a flat, red-purple scab that lingers for a week before flaking off to reveal unsullied skin below. Tattoos will also white up post-pico before forming a broad scab that needs to be kept covered for about a week. "As pigment fades over time, the treatments create less intense wounds," Anolik says.
Risks: "The more baseline pigment a patient has — whether natural or from a suntan — the greater the chance of developing hypopigmentation [skin lightening] or hyperpigmentation [darkening]," says Waldorf. What’s more, she adds, those with medium skin tones, like some Hispanics and Asians, have a higher risk of post-inflammatory hyperpigmentation — dark marks born of inflammation — and recurrent pigment, meaning spots that clear but then return weeks later.
Price: $300 to $1000 per session depending on the area being treated
What They Treat: Moderate sun damage, melasma, minor scars
How They Work: Here we're talking surface-sparing fractional lasers, and picosecond lasers outfitted with something called a diffractive lens, which essentially fractionates, or breaks up, the beam. (These tools cover widespread areas, not lone spots, and are appropriate for most skin types.) "Their main role is to refresh and rejuvenate by building new collagen, helping to smooth the skin, and eliminating some of the pigment that comes from sun damage," says Chapas.
Engineered to curtail downtime, fractional lasers hit the skin in a pixelated pattern, with some columns receiving a dose of light, and others going untouched. Picosecond devices deliver varying intensities of energy across the skin, "creating a vibration [rather than heat], which triggers cell signaling and the production of new collagen," Anolik explains.
One's tool of choice depends largely on what’s being treated. Baby fractional lasers, such as the Fraxel Clear + Brilliant, transmit minimal energy for a striking radiance boost, but only subtle textural improvements. (This gentle treatment is Anolik's go-to for melasma.) Picosecond lasers are a step up, as "they go a little deeper, and have more of an effect on fine lines, wrinkles, and scarring," notes Chapas. A stronger fractional laser, like the Fraxel Dual, is made for "someone who got too much sun in her youth, but started wearing sunscreen in her 30s or 40s, as its wavelengths can correct significant, not deep, UV damage on the face, neck, chest, arms, and hands," says Waldorf.
The Dual's more superficial 1927 wavelength tackles pigment, pores, fine lines, and even precancerous lesions; its 1550 wavelength attacks deep wrinkles and scars. (Why, yes, close readers, we did say that longer wavelengths go deeper. And 1927 > 1550. But according to Anolik, “penetration depth increases with wavelength only up to about 1300 nm, at which point, it decreases due to the intense absorption of longer wavelengths by water.”)
What They Feel Like: Derms may offer numbing cream before baby fractional and picosecond procedures, but you can probably tolerate the prickly zaps without it. More potent fractional devices demand a full hour of topical numbing, plus acetaminophen or ibuprofen beforehand, and even then, you may need to breathe your way through the treatment’s hot static-like shocks. Vibrating massage cushions and nitrous oxide can further distract from the discomfort, notes Waldorf.
Downtime: Maybe an hour of flushing and one day of sandpapery dryness follow the mild resurfacers. With the dialed-up Dual (or equivalent laser), skin typically looks red right after, then bronze, flaky, and dirty for up to a week as tarnished cells are shed.
Risks: All of the aforementioned risks apply here. Additionally, fractional lasers can trigger herpes outbreaks in those who are prone, which is why doctors give a precautionary dose of an antiviral drug, like Valtrex, before the procedure. Acne and eczema flares can occur, too. “Those with a history of eczema are also at risk for a bacterial colonization of the nose, which can, in turn, increase the odds of infection on all treated skin post-Fraxel,” Waldorf warns. Inform your dermatologist of any preexisting skin-specific or general medical conditions before getting lasered.
Price: $500 to $2500 depending on the laser used
What They Treat: Deep wrinkles, severe sun aging, prominent scars
How They Work: These lasers act on water as well, but their higher energies, and the way in which they're absorbed, generate greater heat, "creating purposeful wounds on the skin's surface that we don't see with nonablative resurfacing, when that topmost layer remains intact," Anolik says. Ultimately, the ablation, and its resultant injuries, translate to more generous collagen renewal in the weeks ahead.
While undeniably fierce and heavy on downtime, the latest generation of fractional ablative lasers (like the deep-acting Fraxel Re:pair, a carbon dioxide laser, and the Sciton Profractional, an erbium laser with a slightly shallower reach) are safer and more predictable than the non-fractionated ablative lasers of old, from which "up to 25 percent of patients were at risk for depigmentation — a shiny white appearance — or scarring," says Anolik. The chance of either happening with fractional ablative lasers is almost nil if used properly. (That said, they're not recommended for dark complexions.)
What They Feel Like: Nothing, once you're thoroughly prepped with numbing cream, nerve-blocking lidocaine injections, and Percocet and/or Valium.
Downtime: Plan on taking at least one week off from life after an ablative procedure: "You'll basically look like a burn victim — swollen and scabby all over — and patients have to be psychologically ready for that," says Anolik. On the upside, he adds, "the healing phase is remarkably painless." With the erbium, crusting lasts three or four days, and subsequent pinkness about two weeks. Following a round of CO2, expect four to eight days of scabbing, and about a month of ruddiness.
Risks: Bacterial infections and herpes outbreaks (doctors start patients on oral antibiotics and antivirals days in advance to minimize these risks); acne breakouts; prolonged redness and swelling; and very rarely, depigmentation and scarring. Doctors like to monitor healing closely, so be ready to book a couple follow-ups for the week after your ablative treatment.
Price: Starting at $500 for around the mouth
More on plastic surgery:
- The 7 Biggest Plastic Surgery Trends for 2019, According to Experts
- Everything You've Ever Wanted to Know About Fillers
- How Breast Augmentation and Liposuction Procedures Are Evolving in 2019
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