Lasers, Intense Pulse Light Therapy,and Radio Frequency Resurfacing

Issues involving cosmetic corrective surgical procedures are complicated enough, but when the topic turns to lasers, intense pulse light (IPL), or radio frequency resurfacing, what you will find is a clutter of complex, technical information that is hard to decipher. All this is further complicated by enthusiastic physicians making unrealistic claims and promises. An article in the Archives of Facial Plastic Surgery (January-March 2002, pages 6-7), summed up the problem beautifully: "In facial plastic surgery, many articles written by physicians may read more like advertisements than science, overestimating the advantages of laser surgery, while underestimating the disadvantages and complications. Currently, it is unclear who is benefiting from laser madness in medicine. Is it the patient, the physician, or the laser company?"

Perhaps the best way to start making sense of cosmetic resurfacing procedures is to describe the kind of resurfacing methods being used, how they work, and then explain what machines are employed to perform those tasks.

When it comes to lasers, IPL, or radio frequency resurfacing machines, they function as either ablative or non-ablative modalities. Non-ablative treatments target the lower layers of skin (dermis), while leaving the skin's surface (epidermis) unharmed and intact. Ablative laser resurfacing targets both the surface and the lower layers of skin by injuring or "ablating" the surface of skin. Lasers can perform either ablative or non-ablative resurfacing, while IPL and radio frequency resurfacing are considered non-ablative methods. Which system you choose depends on the results you are looking for and how much risk you are willing to take.

Ablative resurfacing can make a significant difference in the appearance of deep wrinkles, surface wrinkles, and skin discolorations. But there are serious risks and complications that can occur with ablative resurfacing. These include swelling, scabbing, oozing, bleeding, flaking, redness, and irritation, and there is also a risk of longer-term skin discoloration and scarring.

Non-ablative resurfacing has none of the side effects associated with ablative resurfacing. However, non-ablative resurfacing doesn't produce the same dramatic or impressive results as ablative resurfacing does. Not only are the results subtle, but multiple treatments are required for any kind of noticeable outcome. The advantage for non-ablative resurfacing is its minimal downtime; women can reapply makeup before leaving the doctor's office and return to work the same day.

Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. In essence, lasers work by generating a concentrated and penetrating stream of pulsed bright light that can be controlled and strategically directed over the skin. Resurfacing the skin with lasers can work as ablative or non-ablative procedures depending on the type of laser utilized. An ablative laser literally vaporizes and removes deep wrinkling and scars from the surface of skin and penetrates deeper into skin tissue, reorganizing and stimulating production of collagen and elastin fibers in the process.

Non-ablative lasers can remove some skin discolorations, improve some wrinkling, and, with repeated treatments, help generate collagen and elastin. (Sources: American Academy of Dermatology, www.aad.org; and Cosmetic Dermatology, December 2002, pages 39-43.)

For ablative resurfacing with a laser peel, the quality of the postoperative techniques is as important as the skill of the physician during the procedure. After ablative laser treatment, the skin oozes, crusts, and needs to be cleaned and dressed for about two weeks before you look even vaguely normal. Because the top layer of skin has been stripped away, the raw, exposed skin needs to be cleaned and treated very carefully. Patients need to make sure they follow post-op care instructions precisely, because inconsistency or incomplete care can cause infection, delay healing, and increase irritation.

The following is a list of the more popular lasers and light-emitting machines in use for cosmetic resurfacing: (Note: The cost of the various procedures can vary so dramatically from doctor to doctor that there is no way for me to provide a cost estimate for these treatments.)

CO2 Pulse Laser (trade names Feather Touch or Ultra Pulse): This is one of the oldest types of ablative machines around. Although it can create more lasting and noticeable results than any other laser, it is also associated with the most risk and potential skin damage. The skin can take one to two weeks to heal and can be red for one to two months afterward. Risks of scarring, skin discoloration, and uneven texture must be weighed against the intended outcome, although these side effects are rare when the doctor is experienced with this kind of procedure (Sources: Dermatologic Surgery, April 2004, pages 483-487; Lasers in Surgery and Medicine, May 2003, pages 405-412; and International Journal of Dermatology, June 2003, pages 480-487).

Erbium:YAG Laser: This ablative laser is far less invasive than the CO2 Pulse laser and is considered effective for minor or superficial wrinkling. However, if the intensity of the machine is increased, deeper wrinkling can also be treated. Another option is the Variable Pulse YAG Laser which alternates frequency with pulses that heat the skin and cause ablation that resurfaces the skin almost as effectively as CO2, but with fewer side effects (Sources: Dermatologic Surgery, August 2004, pages 1073-1076; Archives of Dermatology, October 2003, pages 1295-1299; and Archives of Facial Plastic Surgery, October-December 2002, pages 262-266).

A combination of CO2 and Er:YAG laser treatments is now gaining popularity. In this treatment, the Er:YAG laser is first used to remove the epidermis, followed by use of the CO2 laser to achieve contraction of underlying collagen. This produces the collagen-tightening benefits of CO2 therapy but with minimal damage to surrounding tissues (Source: Department of Otolaryngology/Head and Neck Surgery at Columbia University and New York Presbyterian Hospital, http://www.entcolumbia.org/laserskinresurf.htm; and Dermatologic Surgery, February 2000, pages 102-104).

Long-Pulsed YAG Laser (tradenames CoolTouch and Lyra): This non-ablative laser is often used for wrinkles and reducing the appearance of acne scars. As is true with any non-ablative laser resurfacing, it takes several treatments to achieve very subtle results. The CoolTouch has a built-in cooling device that protects the top layer of skin but it can still feel like a rubber band snapping against the face as it is used. Types of the Long-Pulsed YAG Laser can be used for hair removal and removing surfaced capillaries (Sources: Lasers in Medicine and Science, April 2004, pages 219-222, Seminars in Cutaneous Medicine and Surgery, December 2002, pages 288-300; and Laser Abstracts from the 14th Annual Congress of the American College of Phlebology).

Several lasers are used for other cosmetic considerations aside from wrinkling. These include:

Q-Switched Ruby Laser: This laser is minimally ablative and is primarily used to selectively remove skin pigment, such as freckling, sun-damage spots, and actinic keratosis without damaging the surrounding tissue. It is also useful for removing birthmarks. It usually takes several treatments to see the desired results. One of the popular uses for the Q-Switched Ruby laser is cosmetic tattoo removal. Many physicians have noted that impulsive tattoo designs or the poor work from inexperienced or poorly trained aestheticians who tattoo lip liner, eyeliner, and eyebrows on women is so rampant that eliminating these constitutes a large portion of their laser work (Source: American Journal of Clinical Dermatology, February 2001, pages 21-25).

Pulsed Dye Laser, Short- and Long-Pulsed: This non-ablative laser gives impressive results in removing surfaced capillaries on the face, port wine marks, hypertrophic scarring (thick or raised scars), and hemangiomas (red dots on the surface of skin). It doesn't cause skin damage, but it almost always causes temporary bruising. Several treatments may be required (Source: Dermatologic Surgery, January 2004, pages 37-40).

Long-Pulsed Alexandrite Laser (trade names GentleLASE and Cool Pulse): This non-ablative laser is another option for hair removal and removing surfaced capillaries and leg veins. This machine quickly covers large areas of skin. (Sources: Lasers in Surgery and Medicine, May 2002, pages 359-362 and Dermatologic Surgery July 2001, pages 622-626.)

The following is a summary covering a range of laser machines and the skin conditions they address. Which one to use depends mostly on the physician you see, which laser machines they own (or lease), and their skill with those particular machines.

Skin Condition Laser or Light Emitting System
Wrinkles and lines CO2 (carbon dioxide)
Erbium:YAG
CoolTouch Long-Pulsed YAG
Brown spots CO2 (carbon dioxide)
Nd:YAG
Q-Switched Ruby
Deep pigmented lesions Q-Switched Ruby
Nd:YAG
Pulsed Dye
Scars and stretch marks CO2 (carbon dioxide)
Pulsed Dye
CoolTouch Long-Pulsed YAG
Tattoos CO2 (carbon dioxide)
Nd:YAG
Q-Switched Ruby
Hair removal Nd:YAG
Long-Pulsed Alexandrite
Intense Pulsed Light
Long-Pulsed YAG


Intense Pulse Light (IPL): A "light" modality that uses high intensity pulses of light that are not lasers and are considered to be exclusively non-ablative. Though similar to lasers in many ways, the IPL's beam of light is limited to the depth of resurfacing it can produce. This technique is not meant for those with extensive sun damage and skin discolorations but it can reduce surfaced capillaries or veins, port wine marks, hemangiomas, brown spots, as well as tighten the skin to some degree. The number of side effects is minor, but it can take several treatments (typically 4-6) to see desired results. There are a range of IPL machines including PhotoDerm VL, PhotoDerm PL, PhotoDerm HR, EpiLight, and Quantum (Sources: Plastic and Reconstructive Surgery, May 2004, pages 1789-1795; Lasers in Surgery and Medicine, February 2003, pages 78-87); and www.emedicine.com, "Non-ablative Resurfacing," June 30, 2003).

Several IPLs are used for other cosmetic considerations aside from wrinkling. These include:

PhotoDerm VL (for vascular lesions): Light pulses are directed at the spider and varicose veins as well as vascular birth marks. The tissue targeted is the red-pigment (hemoglobin) in the blood which is heated by the light pulses destroying it without affecting the skin or other tissue.

PhotoDerm PL (for pigmented lesions): Light pulses are directed at the "age spots," freckles, flat pigmented birthmarks and other types of discolorations. The tissue targeted is the melanin in the skin's surface. The melanin is then heated and the resulting damage or destruction removes skin discolorations.

PhotoDerm HR and EpiLight (hair removal): Light pulses are directed at the hair follicle causing the hair to fall out and prevent further growth, but this method is not permanent.

Radio frequency (RF) resurfacing is neither a laser nor IPL. Rather, it is a form of electromagnetic energy very similar to microwaves. It is considered a non-ablative resurfacing treatment. The RF treatment passes radio frequency electricity through the skin to heat up tissue. This is supposed to make the tissue contract and, as is true with any injury to skin, it begins making collagen. The most popular RF machine is known as Thermage. Another device, called the Aurora, uses IPL and RF together for a unified procedure, supposedly to give the patients the best of both modalities (Sources: Journal of Cosmetic Dermatology, January 2002, page 142; and Cosmetic Surgery Times, "New Trends Spur Doctor, Patient Education," July 1, 2004, www.cosmeticsurgerytimes.com/cosmeticsurgerytimes/article/articleDetail.jsp?id=106139).

You may have heard claims that RF treatments are painless, have no adverse effects, or complications, yet the research, though extremely limited, demonstrates otherwise. First, RF is considered by some as one of the most painful non-ablative procedures, requiring localized anesthesia because it intensely heats up the skin (Source: Cosmetic Dermatology, December 2003, pages 28-34).

A study published in Lasers in Surgery and Medicine (November 2003, pages 232-242) reported that "fifty percent (41/82) of subjects reported being satisfied or very satisfied." Keep in mind that means 50% of the subjects were less than satisfied or were unhappy with their results. Further, 2nd degree burns did occur and "Three patients had small areas of residual scarring at 6 months." Scabbing and edema (skin swelling) occurs in some patients and though it does resolve it can take six months to do so. Technically the improvement measured in this study saw an average lift of 0.5mm. Half of one-millimeter is 0.019 inch long. That may not be exciting for what can be a costly procedure.

Paula Begoun