As ablative laser produces the greatest non-surgical improvements in the skin, it is natural that this form of laser skin resurfacing is associated with more potential risks. However, more recent delivery systems such as the pulse wave or fractional forms of ablative laser have significantly reduced both the recovery periods and complication risks. Although the use of ablative laser for cosmetic purposes continues to evolve and improve, studies have already shown it to be an effective and safe modality for laser skin resurfacing. Before proceeding with an ablative laser treatment, it’s important to consult with a trusted medical professional to determine if an ablative laser can achieve the desired outcome for a laser treatment for face or body.

For some conditions such as moderate wrinkling and facial scarring, an ablative laser will produce the best results because, unlike a non-ablative laser, this type of laser resurfacing removes the top layer of skin. The level of discomfort may also vary depending upon the type of ablative laser, the source of active ions in the laser (such as erbium or carbon dioxide), and the administration of the laser treatment. For example, a non-fractional ablative laser using carbon dioxide (CO₂) will be more invasive with more potential for discomfort than an erbium-based fractional laser.⁴ Recent developments in laser technology include ablative fiber laser to decrease heat in the skin and increase patient comfort.^5,6

The sensations of laser skin resurfacing will also vary based on the location of the target tissue. For example, sensations may be more mild in the cheek area while regions with thinner skin or close proximity to bone, such as the forehead and around the eyes, may be more sensitive to laser resurfacing. However, methods to reduce discomfort during the procedure, such as a local anesthetic, are very effective and most patients rate the discomfort of an ablative laser skin resurfacing as mild to moderate.

The word “ablative” literally means “removing body tissue,” referring to the ablative laser’s ability to actually vaporize all or layers of the epidermis (top layer of skin). Non-ablative lasers do not remove the top layers of the skin, leaving the epidermis intact (known as selective photothermolysis). An ablative laser delivers an intense wavelength of light into the skin creating a thermal injury that removes the epidermal layer of the skin and may also include removal of superficial dermal layers.⁷ Ablative laser is associated with longer recovery times, but also more dramatic and long-lasting results. Ablative laser skin resurfacing describes the process of removing the epidermal and superficial dermal layers of the skin to reduce cutaneous signs of photoaging.

One thing that sets an ablative laser apart from nearly all other non-surgical esthetic procedures is that it removes the top layer of skin, producing entirely new skin after the healing process. The new skin then becomes subject to the biological conditions and lifestyle habits of the patient. A patient in good health who adheres to a healthy lifestyle may enjoy years of skin improvement after an ablative laser treatment. This promise of new skin may tempt some to seek out ablative laser treatments often, but it’s important to wait 6 months to judge the full results. An experienced and knowledgeable clinician can then recommend any subsequent laser resurfacing with an ablative laser that may be helpful.

Ablative lasers can be divided into two groups; ablative lasers using the metal erbium as the energy source and lasers that use the gas carbon dioxide, or CO₂ ablative lasers. Both types of ablative lasers are absorbed by water chromophores in the tissue. These water molecules are evenly distributed throughout the tissue and as the laser heats them the water molecules are converted to gas causing the skin cells to evaporate, or “ablate”. While both an erbium and CO₂ laser share this basic functionality, the CO₂ ablative laser can reach deeper depths of the skin (with an energy wavelength of up to 10,600 nm) resulting in greater neocollagenesis, but also more potential for injury. This greater depth and thermal injury potential of a CO₂ ablative laser makes it the “gold standard” for deeper skin flaws such as warts, acne scarring, wrinkles and advanced photoaging.² For example, many acne laser treatment options for deep scarring are CO₂ ablative laser. Erbium-based ablative laser tends to be used for more superficial conditions such as fine lines, wrinkles and skin laxity, but with shorter downtime and less risk for adverse side effects post laser skin resurfacing.

Ablative lasers can deliver the energy in a continuous wave, with a pulsed delivery, or in a wave divided into a grid of microscopic columns, otherwise known as a “fractional laser,” sometimes called “fraxel laser”. These microscopic columns destroy only a “fraction” of the skin without injuring the surrounding skin. This undamaged tissue speeds recovery and minimizes possible side effects. The microscopic thermal zones of a fractional laser can reach a depth of up to 1300 μm in the skin. Some popular brands of fractional laser include Fraxel®, Cutera®, Candela® and Lumenis®.