1. Ablative & Nonablative
Lasers
for Face Rejuvenation
Dr. Christofer Tzermias
Dermatologist
Director
Laser Dermatology Dept
Athens Medical Center
Greece

2. Introduction
• 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 procedure is indicated.

3. Laser Rejuvenation
• Laser light is monochromatic, coherent and
collimated. Generates high fluence.
• Reflected, Scattered, Transmitted, Absorbed
• Absorbed energy – Thermal energy
Clinical effect & collateral damage
• 1956 – Maiman – Continuous output
• 1985 – Selective Photothermolysis
• Ultrashort pulses of high energy
Ablate or do not ablate the epidermis
Dermal wounding
Thermal effect: significant or minimal

4. 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

5. Ablative LASER
• Thecarbon dioxide laser has long been the
“gold standard” for ablative resurfacing.
•Results from traditional CO2 systems have been
dramatic for severe photo-damage and scarring, but
patients need to be aware of associated downtime
requirements and the risk of pigmentation alteration
in darker skin types.
• Newer technologies, including erbium : yttrium-
aluminum-garnet (Er: YAG) systems and fractional
lasers, can treat a variety of cutaneous disorders
while offering shorter recovery times and improved
safety in a broader spectrum of skin types.

6. Preoperative patient checklist
Perform complete patient medical history
and dermatologic examination
Patient education
• Video demonstration
• Review brochure
• Show representative photographs
• Provide information sheet
• Take preoperative patient photographs
Begin preoperative skin care regimen
Obtain informed consent for procedure

7. Preoperative patient evaluation (1/3)
Does the patient have lesions that are
amenable to laser resurfacing?
Has previous treatment been received for the
condition?
Is the patient taking isotretinoin or
immunosuppressive medication?
What is the patient’s skin type?
Does the patient have a history of cold sores?

8. Preoperative patient evaluation (2/3)
Is there a history of collagen vascular disease
or immunodeficiency?
Are other dermatologic conditions present that
could spread after treatment?
Is the patient prone to acne breakouts?
Does the patient have a tendency to form
hypertrophic scars or keloids

9. Preoperative patient evaluation (3/3)
Does the patient have realistic expectations of
the procedure?
Will the patient be compliant with all
preoperative and postoperative instructions?
Are there medical conditions that would
interfere with using intravenous anesthesia?

10. Fitzpatrick skin types
Skin type Color Skin characteristics
I. White Always burns, never tans
II. White Usually burns,
tans less than
average
III. White Sometimes mild burn,
tans about average
IV. White Rarely burns,
tans more than
average
V. Brown Rarely burns,
tans profusely
VI. Black Never burns,
deeply

11. Commonly used ablative modalities
for skin resurfacing:
spectrum from least to most aggressive
Least aggressive
Microdermabrasion
Superficial chemical peel
Medium-depth chemical peel
Deep chemical peel
Fractional lasers
Er: Yag laser
CO2 lasers
Most aggressive
(greatest depth of ablation)

12. Glogau classification
• The Glogau classification system
helps the physician determine the
deth of damage, and thus offers some
indication of what the depth of
resurfacing should be.
• Patients with minimal photo-damage
may require ablation of only the
upper part of the epidermis.
• Those with moderate photo-damage
may require more extensive
resurfacing to the level of the
papillary dermis, and so on.

13. Glogau classification
Damage I (mild)
Description Characteristics
No wrinkles Early photo-aging:
* Mild pigmentary changes
* No keratoses
* Minimal wrinkles
* Patient age: 20s to 30s
* Minimal or no make up
* Minimal acne scarring

14. Glogau classification
Damage II (moderate)
Description Characteristics
wrinkles in Early to moderate photo-
motion aging:
* Early senile lentigines
* Keratoses palpable but
not visible
* Parallel smile lines
beginning to appear
* Patient age : 30s to 40s
* Some foundation
make-up worn
* Mild acne scarring

15. Glogau classification
Damage III.(advanced)
Description Characteristics
wrinkles at Advanced photo-aging:
rest * Obvious dyschromias
and telangiectasia
* Visible keratoses
* Static wrinkles present
* Patient age : older than
50years
* Heavy foundation
usually worn
* Acne scarring : make-up
cannot cover

16. Glogau classification
Damage IV.(severe)
Description Characteristics
Only wrinkles Severe photo-aging:
* Yellow-gray skin color
* Prior skin malignancies
* Wrinkles throughout-
no normal skin
* Patient age :60s or 70s
* Make-up cannot be
worn – it cakes and
cracks
* Severe acne scarring

17. Glogau classification
• The patient’s goals and severity
of condition will quide the
therapeutic plan.
• The potential improvement in
texture afforded by this technique
must be weighed against the
greater potential for pigmentary
alteration and/or scarring.

18. Carbon dioxide lasers (1/2)
• CO2 laser resurfacing can be performed
in the office or under anesthesia.
• The wavelength 10,600nm.
• Depth of tissue ablated per pass is
approximately 20-30μm.
• Thermal damage produced is 30-100 μm.
• Time to re-epithelialization is 7-10days.
• Duration of post-laser erythema is 3-6
months.
• Significant collagen shrinkage and
remodeling requires at least two passes.
• A greater number of passes or excess energy
densities results in an increased risk of
scarring.
• CO2 systems in pulsed or scanning modes
deliver predictable ablation levels and
consistent results.

19. Carbon dioxide lasers (2/2)
• Advantages include excellent tissue
contractions and hemostasis.
• Valuable for treating entire cosmetic
subunits, focal lesions, or full-face
resurfacing.
• Indications include moderate to severe
rhytides and photo-damage, scarring,
actinic keratosis, and other superficial
lesions.
• In darker skin types, more conservative
settings and fewer passes can decrease the
risk of scarring and pigment alteration.
• Laser “test spots” in inconspicuous areas
can be performed in patients at high risk of
dyschromia.

20. Preoperative care for CO2 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, soy, azelaic acid,
and others can also be used to
reduce postinflammatory hyperpigmentation.
Anxious patients:
oral benzodiazepines such as diazepam
(5-10 mg) can be given half an hour
before the procedure.

21. Postoperative care for CO2 laser use
Wound care:
dilute acetic acid, saline, or tap water 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 including narcotics
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.

22. Erbium : yttrium-aluminum-garnet laser
• Can be performed in the office or under
anesthesia.
• Wavelength 2940 nm.
• Tissue ablated per pass approximately 2-3
μm.
• Thermal damage produced 5-30 μm.
• Time to re-epithelialization 4-5 days.
• Duration of post-laser erythema 3-4 weeks.
• Er: YAG produces less thermal damage than
the CO2 laser-multiple passes are needed to
ablate to an equivalent level.
• Indicatiοns are mild to moderate rhytides
and photo-damage, mild to moderate
scarring, and superficial lesions.
• Can be a good option in patients with darker
skin types.

23. Side –effects and complications of
ablative laser skin resurfacing
Side-effects Mild complications
Transient erythema Prolonged erythema
Localized edema Milia
Pruritus Acne
Contact dermatitis

24. Side –effects and complications
of ablative laser skin resurfacing
Moderate Severe
complications complications
Pigmentary change Hypertrophic scar
Infections Ectropion
(bacterial,fungal,viral)

25. Management of adverse events
Hyperpigmentation:
Continue broad-spectrum sun protection,
bleaching creams, and series or superficial
peels
Infection:
Be guided by culture and sensitivity
Scarring:
Aggressive treatment will lead to resolution.
Topical steroid creams with intralesional
steroids
if hypertrophic scars, series of pulsed dye laser
treatments, silicone sheeting, or topical gels.
Arrange frequent gratis follow-up visits
in your office

26. Fractional ablative lasers
• Fractional laser devices produce
rejuvenation and collagen remodeling
by creating thousands of
microscopic wounds called
microscopic treatment zones (MTZs)
with sparing of adjacent skin.
• Indications include mild to moderate
rhytides and photo-damage,
acne scars, pigmented lesions, and
actinic keratoses.

27. Fractional laser treatment allows to
obtain remarkable results with
minimal downtime.
The laser energy, applied in a fractional way,
creates very thin and spaced columns of thermal
damage which penetrate deep into the dermal
skin layer and stimulate a new collagen
production. The tissue
between the columns
of thermal damage is
spared, resulting in
a faster healing process.

28. Fractionated lasers
Fractional delivery may be superior to
traditional uniform delivery of heat for three
reasons:
• Higher irradiation within the columns results
in more damage and increased wound
healing response. This can be achieved
without increasing the power of the optical
source.
• Faster healing response due to increased
surface-to- volume ratio of the microwounds.
The interface between injured and normal
skin, where most neocollagen formation
occures, is maximized.
• Larger safety margin as fractional resurfacing
is less likely to result in infections and
scarring.

29. Healing Process
Shrinkage
Healing Fractional
Skin Resurfacing
Erythema
time
1dd 2dd 4-7dd
Shrinkage
Traditional
Skin Resurfacing
Healing
Erythema
time
1dd 2dd 8-10dd 40gg – 3 months

30. Various CO2 lasers with fractioned
emission are currently available on the
market.
Despite the fact that all these systems are
based on the same principles, they present
significant differences with regard to
output power, dwell-time, distance
between the dots, varying scanner shapes
and the laser beam profile. These
differences may produce clinical results
that differ greatly between one device and
another.

31. Considerations in darker skin
Nonablative technologies are considered first-line
because of a lower risk of postoperative
complications.
However, ablative therapies (combination treatment
with CO2 and erbium lasers, single-pass CO2
laser, or long-pulsed Er :YAG systems) can be
used in a conservative fashion to treat advanced
damage and scarring.
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.

32. Nonablative Lasers
• Nonablative lasers heat the
papillary and reticular dermis,
without damaging the epidermis,
to stimulate collagen synthesis.
• Synonyms include
nonablative remodeling.
• Applications include photo-aging,
acne, and acne scars.
• Compared with ablative procedures,
nonablative resurfacing provides
more modest improvements, but
with essentially no downtime and
an excellent safety profile.

33. Reported indications for nonablative
lasers
Photodamage
Rhytides
Pigmentary dyschromia
Lentigenes
Melasma
Telangiectasia
Erythema
Acne
Acne scarring
Atrophic scars
Hypertrophic scars
Surgical scars
Hair removal

34. Epidermical cooling devices
Ice
Aluminum roller
Cooled gels
Cooled pads
Sapphire plate
Precooled air
Cryogen spray

35. Index of nonablative devices available
• Pulsed-dye lasers (PDLs) were the first
modality to be used for nonablative
remodeling and show to improve acne
vulgaris.
• Neodymium: yttrium-aluminum-garnet
(Nd:YAG) lasers benefit rhytides and acne
scarring.
• 1450-nm diode is effective for rhytides,
acne, and acne scarring, but is associated
with some pain.
• 1540-nm erbium: glass may be used for
rhytides or acne.
• Fractionated erbium lasers are nonablative
with a growing list of applications.

36. Fractionated nonablative lasers
• Synonym: fractional photothermolysis
• Fractionated lasers deliver energy to
vertical columns of skin to create
microscopic treatment zones (MTZs)
• Inter-MTZ skin remains untreated and
serves as a reservoir of healthy skin to
speed healing
• Multiple passes and treatment sessions
are needed to treat a given area
completely
• Results are probably somewhere between
that of nonablative and ablative laser
therapy, although efficacy differs widely
from patient to patient

37. 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

38. Reported indications (1/2)
Photodamage
Poikiloderma of Civatte
Rhytides
Hyperpigmentation
Lentigenes
Becker’s nevus
Melasma
Telangiectasia
Erythema
Acne

39. Reported indications (2/2)
Acne scarring
Atrophic scars
Hypertrophic scars
Hypopigmented scars
Surgical scars
Striae distensae
Actinic keratosis
Disseminated superficial actinic
porokeratosis

40. Pretreatment checklist
Number of treatments that will be required
Amount of improvement to expect-
show realistic before and after pictures
Avoid certain medications for 1 week before
and after certain laser procedures:
• Aspirin
• Ibuprofen
• Vitamin E
• Anti-inflammatory medications
• Photosensitizing medications

41. Pretreatment checklist
Stop topical medications for 2 days
before and after:
• tretinoin topical
• a-hydroxy acids
• vitamin C derivatives
Confirm no contraindications
for laser treatment:
• pregnancy
• history of keloids
• current suntan
• isotretinoin therapy within 6 months
• lupus erythematosus or
other photosensitivity

42. Pretreatment checklist
If history of herpes simplex
virus,prescribe valaciclovir 500mg by
mouth twice daily for 3 days.
Start 1 day before procedure
If petreatment anesthesia needed,
prescribe topical anesthetic such as
EMLA cream to treatment area 1 h
before treatment under plastic wrap
occlusion.
Pretreatment photos in a reproducible
position and lighting
Eye protection for patient and physician
Teeth protection for patient

43. Selected nonablative light sources
and suggested parameters (1/8)
Laser Wavelength(nm) Indications Parameters
Long-pulsed 595 Photo-damage; 7-8.5 j/cm2,
PDL(V-beam, acne vulgaris 6-20 ms.
Candela) 10-mm spot
Nd: YAG 1064 Photo-damage 3.5 j/cm2,
(Gentle YAG; 6-mm spot
Candela) (28 ns pulse
duration is
standard)

44. Selected nonablative light sources
and suggested parameters (2/8)
Laser Wavelength(nm) Indications Parameters
Q-Switched 1064 Acne scars 3-4 j/cm2
Nd: YAG 4-6 ns puls du,
(Medlite rep. rate 10Hz,
IV; Continuum) 6-mm spot
Deliver
overlapping
pulses until
mild to
moderate
erythema
achieved

45. Selected nonablative light sources
and suggested parameters (3/8)
Laser Wavelength(nm) Indications Parameters
Nd:YAG 1064 photo-damage; Energy
(CoolTouch II; acne scarring 12-16 j/cm2,
ICN DCD
Pharmaceuticals) before
during and
after

46. Selected nonablative light sources
and suggested parameters (4/8)
Laser Wavelength(nm) Indications Parameters
Diode(Smooth 1450 Photo-damage 12-14 J/cm2
Beam, ICN acne and acne 6mm spot
Photonics) scarring
DCD
before,
during and
after

47. Selected nonablative light sources
and suggested parameters (5/8)
Laser Wavelength(nm) Indications Parameters
Er:glass 1,540 Photo-damage 3 pulses
(Aramis per shot,
-Quantel 10J per pulse
Laser; Quantel fluence
Medical, 30J/cm2,
4-mm spot,
slightly
France) ovelrapping
pulses, no
visible
changes occur

48. Selected nonablative light sources and
suggested parameters (6/8)
Laser Wavelenght(nm) Indications Parameters
Fractional 1500 Photo-damage Treatment
laser (Fraxel acne and acne level 8-11
re:store Reliant scarring to obtain23-32%
Technologies) coverage,
energy
level 50-70mJ,
approximately
8 passes to
deliver total
of 3-4kJ

49. Selected nonablative light sources and
suggested parameters (7/8)
Laser Wavelength(nm) Indications Parameters
Intense 500-1200 Photo-damage, 560nm
Pulsed light including filter,fluence
(Lumenis One, poikiloderma 16-18J/cm2
Lumenis of Civatte;acne with thin
Santa Clara,CA) layer of gel.
Double
pulse with3-
4ms pulse
duration and
delay of
10ms.
Parameters
may vary for
other systems

50. Selected nonablative light sources
and suggested parameters (8/8)
Laser Wavelenght(nm) Indications Parameters
LED Preodominantly Periorbital Total output
(Gentle 590 thytides of 0.1 j/cm2
Waves, per treatment
Virginia has been
Beach, reported
VA)

51. 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

52. 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

53. 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
acne and photo-aging lower
fluence or lengthen pulse
duration
Crusting Indicates too much epidermal
heating
Blistering Indicates too much epidermal
heating: may result in scarring

54. Adverse events associated with
nonablative lasers (3/3)
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

55. Conclusion
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 “Iunchtime”
treatments. Nonablative resurfacing is
relatively new and, although results may be
mild and sometimes inconsistent, new
developments and protocols will improve
efficacy, with an outstanding safety profile.

56. 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

57. 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
– Remodelling Phase
– Extinction of Inflammatory Infiltration
– Matured Collagen fibres
– Increase of Collagen Fibre Strain
– New Elastic fibres