Thanks to Star Wars, many people think of lasers as magical, and when it comes to facial rejuvenation, lasers are frequently touted as truly magic wands. I wish it was that easy! Helping patients understand their options when it comes to facial skin rejuvenation treatments is difficult because the number of options continues to increase and the science behind these treatments can be difficult to understand. This article is my effort to simplify the information available regarding lasers and other non-invasive skin-tightening treatments.

I should state at the outset that I do not use lasers in my practice. This may come as a surprise, as I perform a very large number of facial rejuvenation surgeries and treatments every year. Most patients who come to see me in consultation for facial rejuvenation request that their saggy skin be lifted or their loose skin be tightened. I do not feel that lasers do either well at all. If the currently most popular laser on the market tightens skin 1–3 mm (less than 1/8 inch) I don’t have much use for it and neither do my patients. So what do lasers do well? Some improve pigmentation problems, some lighten and flatten scars, and a few help with fine lines, but none do it all. Most require recurrent treatments and at least local anesthesia. That can get expensive in a hurry. In comparison, I like the predictably excellent results I achieve with a combination of skin care, peels, and surgery.

A laser is nothing more complicated than energy in the form of light. Energy comes in different wavelengths. Some wavelengths result in visible light, and other wavelengths do not, such as infrared, radio waves, or microwaves. When laser energy or infrared energy is applied to skin, the resistance of flow through the tissue of this energy generates heat. Heating the surface and/or the deeper layers of the skin stimulates new collagen production and better-looking skin. It all sounds simple enough.

Unfortunately, the lasers that were used early on for rejuvenation (such as CO2 and Erbium) heated all layers of the skin, resulting in lengthy recovery times, lots of redness, pigment loss, and even scarring. While the wrinkles were generally corrected, the side effects were a high price to pay. Consequently, a new generation of lasers were designed that cooled and protected the surface of the skin, only generating heat in the deeper layers. The good news is the recovery times are shorter, and problems with scarring and pigment loss are diminished dramatically. The bad news is many patients required multiple treatments and found the sessions painful. Commonly, satisfaction ratings with wrinkle reduction and skin tightening were very low.

In came the happy medium, or so I thought. Newer lasers were developed that damaged both the surface and deeper layers in columns, leaving uninjured skin in between. The most commonly known laser in this group is called Fraxel. Multiple treatments are frequently still required, and wrinkle reduction isn’t quite as good as ablative treatments, but recovery times are short and satisfaction ratings are higher than with non-ablative treatments.

The newest generation of lasers is trying to combine the best of both worlds by ablating larger areas of the surface and the depths of the skin while improving wrinkle reduction and keeping recovery times short. The problem is this technology is still developing. Even the leaders in the field state they don’t yet know the exact depth of injury that is perfect or whether more or less heat is better. That is one of the reasons there seems to be a new laser treatment being advertised every week.

Non-light based forms of energy are also being explored. Thermage has become a very popular skin-tightening treatment that uses alternating electrical current via radio frequency instead of light energy. The electrical current causes heat in the deeper layers of the skin that leads to collagen remodeling and less wrinkling. Most users feel multiple treatments are required, and local anesthesia is necessary due to the discomfort the procedure causes. It is said that 80% of patients see improvements and skin tightening improves 5–20%.

If it is not clear as to why I don’t use lasers at this point, I will state it very clearly here: My patients want guaranteed improvements 100 percent of the time. Almost none of them would accept an 80% chance of 5–20% skin tightening. If they are coming to see me, they want saggy skin tightened. I find the predictable and excellent results obtained with the combination of skin care, peels, and surgery to be the right treatment for most of my patients. If someone wants limited-to-no downtime and is willing to re-invest in recurrent treatments at short intervals, laser and other energy-based treatments may be something for them to explore. I am going to wait for the science to improve the predictability and the completeness of the results obtainable with energy-based treatments before I jump on that bandwagon. It could be a long wait.

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