1. Laser treatment can be used for face rejuvenation through either ablative or non-ablative procedures. Ablative procedures completely remove the epidermis and damage the dermis, resulting in more dramatic effects but longer recovery times. Non-ablative procedures heat the dermis without damaging the epidermis, providing more subtle effects with little to no downtime. 2. Proper patient evaluation and expectations are important to determine whether ablative or non-ablative treatment is appropriate. Non-ablative treatments require multiple sessions to achieve results gradually over time with minimal risks, making them better for some skin types and goals. Ablative treatments carry higher risks like scarring and pigmentation changes.

1. LASERs for Face Rejuvenation
Dr. Christofer Tzermias
Dermatologist
Director
Invasive Dermatology Dept
Athens Medical Center
Athens - Greece

2. • Laser use on the skin has become one of
the most popular methods for
achieving a younger and smoother
facial appearance
• Unfortunately, the increasingly
widespread availability of cosmetic
laser therapy coupled with attendant
publicity has created extraordinary,
often unrealistic expectations.
• Proper patient selection and
assessment of each individual’s skin is
crucial prior to determining whether an
ablative or a non-ablative procedure
is indicated.
Face Rejuvenation:
Ablative or Non-ablative?

3. Laser Skin Interaction
• Laser light is monochromatic,
coherent and collimated.
• Generates high fluence.
• Reflected, Scattered, Transmitted, Absorbed
• Absorbed energy – Thermal energy
Clinical effect & collateral damage
• Ultrashort pulses of high energy
Ablate or do not ablate the epidermis
Dermal wounding
Thermal effect: significant or minimal

4. • The Carbon Dioxide Laser has long been the
“gold standard” for ablative resurfacing.
• Results from traditional CO2 systems have
been dramatic for severe photo-damage, but
patients need to be aware of associated
downtime requirements and the risk of
pigmentation alteration in darker skin
types.
• Newer technologies, including Er: YAG
Laser systems and Fractional Lasers, can
offer shorter recovery times and improved
safety in a broader spectrum of skin types.
Ablative Laser

5. Remodelling Phase
Extinction of Inflammatory Infiltration
Matured Collagen fibres
Increase of Collagen Fibre Strain
New Elastic fibres
Ablative Laser:
Mechanism of action
Acute Thermal Damage Phase (48-72 hours)
Oedema
Release of chemical mediators
Collagen Shrinkage
Proliferation Phase (30 days)
Fibroblastic Recruiting
New dermal matrix
molecules
New collagen fibres

6. 2.2. Collagen StimulationCollagen Stimulation
11. Fibres. Fibres ShrinkageShrinkage
3.3. RemodellingRemodelling
Time1st d 30th day
ShrinkageShrinkage
New collagen formationNew collagen formation
Vaporization
Thermal Damage
Healing
HealingHealing
2nd d

7. Preoperative patient evaluation
for Ablative Laser use
Is the patient taking isotretinoin or
immunosuppressive medication?
What is the patient’s skin type?
Does the patient have a history of cold sores?
Is the patient prone to acne breakouts?
Does the patient have a tendency to form
hypertrophic scars or keloids?
Does the patient have realistic expectations of
the procedure?

8. Preoperative care for
Ablative Laser use
• Pretreatment regimen:
broad-spectrum sun-screens,
tretinoin and/or glycolic acid creams,
prophylactic oral antibiotics, and
antiviral medications.
• Topical lightening agents:
hydroquinone, kojic acid, azelaic acid,
can also be used to
reduce postinflammatory
hyperpigmentation.

9. Postoperative care for
Ablative Laser use
• Wound care:
dilute acetic acid or saline soaks
every 2-4 h followed by bland emollients
are essential for proper healing
• Medications :
continuation of oral antibiotics and
antiviral drugs;
short-term pain medications
should be given in necessary
• Follow-up:
post-laser follow-up in the office at 2-5 days is
valuable to note the quality of the patient’s
wound care and the progress of wound healing.

10. Side-effects and complications of
Ablative Laser skin resurfacing
• Side-effects
Transient erythema
Localized edema
Pruritus
• Mild complications
Prolonged erythema
Milia
Acne
Contact dermatitis

11. Side-effects and complications of
Ablative Laser skin resurfacing
• Moderate complications
Pigmentary change
Infections
(bacterial,fungal,viral)
• Severe complications
Hypertrophic scar
Ectropion

12. Ablative Laser:
Considerations in darker skin
• Fractional ablative lasers can be used in a
conservative fashion to treat advanced damage.
• Pre-and post-procedural sun protection and
bleaching creams can minimize the risk of
postinflammatory hyperpigmentation.
• In the post-laser period, short-them use of a
medium potency steroid cream may also
reduce the hyperpigmentation risk.
• If postinflammatory hyperpigmentation
develops, glycolic acid peels and
microdermabrasion can hasten resolution.
• Nonablative technologies are considered first-
line because of a lower risk of postoperative
complications.

14. Nonablative Laser Face Rejuvenation
• Nonablative lasers heat the
papillary and reticular dermis,
without damaging the epidermis,
to stimulate collagen synthesis.
• Compared with ablative
procedures, nonablative resurfacing
provides more modest
improvements, but with essentially
no downtime and an excellent
safety profile. Nonablative lasers
attempt to heat and stimulate the
wound healing process in the
dermis, but without removing
epidermis.
• This is often referred to as
subsurface resurfacing.

15. Nonablative Lasers:
Pretreatment considerations
• Nonablative technology is not a replacement
for ablative laser resurfacing
• Overall appearance of the skin will be
improved, because lines and textural
differences will be softened, but not
eradicated
• Skin changes are usually subtle and gradual
• A number of treatments is required, over a
period of months before the full benefits can
be appreciated
• A total of 3-6 sessions is usually required, at 3-
4 week intervals

16. • Proper patient selection and
assessment of each individual’s skin
type is crucial.
• It is imperative to identify the key
goals of the patient, such as an
improvement in color, texture, or
wrinkling, expected timeframe or
number of procedures, and patient
tolerance for recovery.
• The physician should explore whether
a patient may tolerate multiple
treatments in order to achieve the
primary goal
Nonablative Lasers:
Pretreatment considerations

17. Nonablative Laser Rejuvenation
• Initially, available lasers were used to
achieve nonablative resurfacing, such as
the PDL and Nd:YAG lasers.
• Longer wavelengths,
improved epidermal cooling devices,
and fractional technology
have expanded the armamentarium of
devices available.

18. Nonablative LASERs available
• 595-nm Pulsed-dye
• 1064-nm, 1320-nm Nd:YAG
• 1450-nm Diode
• 1500- 1540- 1550 nm Erbium:glass

19. • The exact mechanisms of non-ablative dermal
remodeling are still under investigation;
however, a subthreshold laser-induced injury
to the dermis and/or the dermal vasculature
theoretically results in a wound repair
response, fibroblast recruitment and
stimulation, and collagen reformation.
• Because thermal energy is the source of this
injury, most non ablative devices target water,
the major component of the dermis, which is
heated through the process of selective
photothermolysis.
Nonablative Mechanism of action

20. To reach these dermal targets, non-ablative devices
typically rely on wavelengths in the mid-infrared
regions of the electromagnetic spectrum.

21. Electromagnetic Spectrum.
Ultraviolet
X-Ray
AM Radio
Microwave
Nd:YAG
(1064)
Smoothbeam
(1450)
Pulse-Dye(595)
TV and FM RadioAlexandrite(755)
I2PL (530-950)
Visible Light
Nanometers
Invisible Light

23. • Non-ablative laser devices exert
their effects by inducing dermal
collagen remodeling while
sparing the epidermis.
• The remodeling process is
achieved by producing thermal
energy in a controlled and precise
fashion, which recruits fibroblasts
and stimulates collagen
production.
Dermal remodeling

24. • In theory, dermal heating should be aimed
at tissue 100-500 μm below the skin
surface.
• More superficial injury may be ineffective
and result in epidermal injury, whereas
deeper injury may result in scarring.
• Too much dermal injury, even within this
zone, may result in irreversible damage to
the microvasculature and dermis, resulting
in necrotic tissue that cannot be
regenerated.

25. Depth of penetration as a function of a
laser wavelength (Nelson et al 2002)
Laser Wavelength μwater Depth of
(nm) (per mm) penetration
(μm)
Diode 980 0.0448 32000
Nd:YAG 1064 0.0177 81100
Nd:YAG 1320 0.204 7000
Diode 1450 3.04 470
Er.glass 1540 1.18 1200
Er:YAG 2940 1220 1.20
CO2 10600 84.40 17
μwater :absorption coefficient
Each type of laser is associated with a
different depth of penetration.

27. Patients should be reminded
• The maximum collagen
remodeling occurs 30-90 days
after
• May like the immediate post
look (attributable mainly to
edema). But this end-result is
possible after multiple
treatments
• Maintenance therapy can be
performed 3-4 times per year

28. Adverse events associated with
Nonablative Lasers (1/3)
Adverse event Comments
Pain Depends on device,
more so with deep-
infrared devices that
target water
Erythema Usually clears in hours,
but can last several
days. This is expected
endpoint with Fraxel
re: store
Edema Usually clears within
24h. May last longer
with Fraxel re: store

29. Adverse events associated with
Nonablative Lasers (2/3)
Adverse event Comments
Purpura Most Commonly occurs with PDL.
Transient purpura may be obtained
when treating telangiestacia. For
photo-aging: lower fluence or
lengthen pulse duration
Crusting Indicates too much epidermal
heating
Blistering Indicates too much epidermal
heating: may result in scarring

30. Adverse event Comments
Infection Query patient as to history of
prior HSV infection.
Consider Staphylococcus
aureus infection if
epidermis is inadvertently
ablated
Dyspigmentation Most common in darker
skin types. Correct amount
of epidermal
cooling should be used.
Textural scarring Rare
Adverse events associated with
Nonablative Lasers (3/3)

31. Nonablative Lasers:
Considerations regarding ethnic skin
• The advent of nonablative lasers makes ethnic
skin , a candidate for laser treatment
• Although protective, the presence of melanin
makes it more difficult to treat photo-aging.
• Melanin absorption of laser energy can result
in epidermal damage and decrease the
amount of energy that reaches the intended
dermal chromophores.
• Because the absorption coefficient of melanin
decreases as wavelength increases, near-
infrared and infrared wavelengths can best
provide nonablative rejuvenation for darker
skin types.
• Epidermal cooling is the most important part
of treating ethnic skin; however, too much
cooling can result in postinflammatory
hyperpigmentation.

32. Nonablative Lasers:
Post-treatment care
• Virtually all patients can return to work the same
day. There are no activity restrictions
• Make-up may be applied immediately after
treatment.
• Cooling gels can be used to minimize erythema
and edema.
• All patients should be counseled to use
sunblock regularly to prevent repigmentation
and postinflammatory hyperpigmentaton.
• There is no increased photosensitivity related to
nonablative laser treatment.

33. Conclusion (1)
• With any ablative modality,
treatment must be pursued
cautiously and with specific
precautions against scarring and
pigmentary alteration.
• Nonablative lasers are the result of
technology meeting patient
demands for “lunchtime”
treatments.
• Nonablative resurfacing is relatively
new and, although results may be
mild and sometimes inconsistent,
new developments and protocols
will improve efficacy.

34. • Although these devices do not
produce the same degree of
improvement as traditional CO or₂
Er:YAG resurfacing techniques, they
are an excellent alternative for
people seeking gradual aesthetic
improvement with minimal
downtime.
• Non-ablative rejuvenation shows
great potential in the treatment of
darker skin types, who are prone to
pigmentary alterations from classic
resurfacing modalities, because of its
emphasis on epidermal sparing.
Conclusion (2)

35. Acknowledgments
• Sonia Batra, MD, USC, LA, CA
• Tina Bhutani, BSc, USC, LA,CA
• Joy Kunishige, MD, UTHSC, Houston,
TX
• Paul Friedman, MD, UTHSC,
Houston, TX
Adapted from Cosmetic Dermatology
(Elsevier 2009)
Murad Alam, MD, Chicago, IL
Hayes Gladstone, MD, Stanford, CA
Rebecca Tung, MD, Cleveland, OH