Erbium YAG Laser Skin Resurfacing

Updated: Aug 12, 2019
Author: Meir Cohen, MD, MPS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS 


Practice Essentials

One method of improving the condition of the skin is by "resurfacing" it, by removing the outer layers to the level of the papillary dermis. Resurfacing can be used as an adjunct to facial surgery, or it can replace facial surgery when surgery is inappropriate or not desired by the patient. The goal of erbium:yttrium-aluminum-garnet (Er:YAG) laser resurfacing is the controlled, layer-by-layer ablation of skin while avoiding the creation of thermal injury so deep that scarring or other complications result.[1]

The abundance of facial skin care regimens and their enthusiastic promotion in the popular media is the modern expression of an ancient desire to attain beauty and recapture a youthful appearance. Facial rejuvenation has been practiced for thousands of years, as can be seen in documents from previous millennia that describe the topical application of substances such as soured milk, vegetable extracts, and mud packs.[2]

Modern agents include preparations of retinoic acid, ascorbic acid alpha-hydroxy acids, and antioxidants used in conjunction with sunscreens. These treatments are useful for restoring and maintaining the health of the epidermis, but they generally are not effective for deeper, long-lasting rejuvenation. A more penetrating removal of the outer layers of aged and sun-damaged skin, such as with chemical peels, is required to induce reepithelialization and new collagen formation. Laser resurfacing was developed as an alternative to chemical peels to operate in these upper layers of the dermis, and its popularity increased quickly and enormously (see the image below). Most recently, however, the popularity of laser resurfacing has declined, probably because of a desire to avoid its complications.[3]

Before (Left) and after (right) upper and lower li Before (Left) and after (right) upper and lower lip resurfacing with Erbium 2.94 laser. Courtesy of Meir Cohen, MD.


Testing in an inconspicuous area may be warranted if resurfacing is planned for locations that are at high risk for complications, such as the skin of the neck, the chest, and the dorsum of the hands. In elderly persons, these areas may be atrophic and have even fewer adnexal structures to serve as islands for reepithelialization.[4]


The epidermis can be completely ablated after two or three passes using a standard laser, although severely damaged skin, deep rhytides or scars, and deep dermal growths may require as many as 20 passes.[5]

A systematic approach is used, with the area to be lased separated into zones of approximately 6-10 cm2. The number of laser passes is counted sequentially. Alternating the direction of passes and overlapping the previous pass by 50% avoids striping and pattern marks on the skin and produces a more homogenous result.[6, 5]


As the face ages, skin quality deteriorates. Intrinsic aging from the genetically determined, natural, chronological degradation of metabolic processes leads to epidermal thinning, dermal hypocellularity, decreased numbers of dermal blood vessels, and decreased amounts of collagen and elastic tissue. These changes manifest as skin atrophy, pallor, and loss of elasticity.[7, 8, 9, 10]

Extrinsic aging from years of sun exposure and other external factors leads to the deposition of abnormal elastic fibers, the degeneration of collagen, and the twisting and dilation of microvasculature. These are compounded with the intrinsic changes and result in a rough surface texture with wrinkling, scaling, dyspigmentation, telangiectasias, and skin laxity.[11, 1, 2, 6] The accumulation of free radical damage probably plays a major role in both intrinsic and extrinsic processes.

Underlying anatomic structures sag as deep layers loosen and subcutaneous fat accumulates or atrophies. Furrows develop in the skin that overlies facial muscles. Surgically lifting the skin and subcutaneous tissue, rearranging the distribution of facial fat deposits, and paralyzing facial muscles with botulinum toxin are effective methods of addressing the underlying structural changes associated with aging, but they do not directly address the degradation in the quality of skin. One method of improving the condition of the skin is by "resurfacing" it, by removing the outer layers to the level of the papillary dermis. Resurfacing can be used as an adjunct to facial surgery, or it can replace facial surgery when surgery is inappropriate or not desired by the patient.

Removing the outer layers of skin to the level of the papillary dermis induces reepithelialization and new collagen formation, which can create a smoother, pinker, and more youthful appearance. Chemical removal of skin layers with peels (eg, trichloroacetic acid, phenol) and mechanical removal (ie, dermabrasion) are effective modalities for facial rejuvenation.

In the late 1980s, laser technology applied to skin resurfacing was discovered to yield more predictable depths of injury when compared with chemical peels or dermabrasion. The first laser used for skin resurfacing was a pulsed carbon dioxide laser that Fitzpatrick et al modified from a device that had been developed for otolaryngological and gynecological use. Its cosmetic uses were initially limited to the periorbital and perioral regions, but dramatic clinical results quickly led to its use for full-face resurfacing.[2]

The carbon dioxide laser quickly became the workhorse of the cosmetic laser surgeon, and its advantages and limitations are well documented.[12, 13] Although long-term skin tightening and improvement of facial rhytides is unparalleled, marked erythema persists for several weeks or months and permanent hypopigmentation occurs at a rate that is unacceptable to many patients. Even without complications, the early period of recovery until full reepithelialization can leave the patient housebound for up to 2 weeks.

Other lasers were developed for resurfacing; with these, more precise light energy can be applied to the skin, resulting in less intense adverse effects from collateral damage. The Er:YAG laser was introduced as a bone-cutting tool in the United States in 1996. Its unusual name derives from the Swedish town of Ytterby, which is the site of a quarry where the silvery rare-earth elements erbium and yttrium were discovered. The cutaneous absorption of the Er:YAG laser energy by water is 10-fold more efficient than that of the carbon dioxide laser, allowing for more superficial tissue ablation and finer control. Other qualities of the Er:YAG laser are best appreciated in comparison to the carbon dioxide laser, as discussed below.



In 2016, 586,662 laser-resurfacing procedures were performed in the United States, according to the American Society of Plastic Surgeons.[14]


Pulsed laser energy causes controlled vaporization of the skin according to the principles of selective photothermolysis.[15] The target tissue contains a chromophore with an absorption peak that selectively absorbs the particular wavelength of the laser pulse, whereas the tissue surrounding the chromophore absorbs the energy to a much lesser degree.

The interaction of the target tissue with the energy of the carbon dioxide laser is transformed mostly into a thermomechanical reaction that destroys dermal vessels and denatures dermal proteins. In the case of the Er:YAG laser, the interaction involves a photomechanical reaction. Absorption of the energy causes immediate ejection of the desiccated tissue from its location at a supersonic speed, creating a characteristic and almost startling "popping" sound. This translation of Er:YAG laser energy into mechanical work is an important factor that protects the surrounding tissue; minimal thermal energy remains to dissipate and cause collateral damage.

Immediately after the target tissue reaches its peak temperature, it begins to cool. The thermal relaxation time is the amount of time required for it to cool to half its peak temperature. When the duration of the carbon dioxide laser pulse is greater than the thermal relaxation time, a stacking of the laser energy and rapid heat accumulation occur. This stacking effect is much less important with the Er:YAG laser, despite a thermal relaxation time of 1.9 microseconds and a pulse duration of 250-350 microseconds, because the laser energy dissipates so rapidly and penetrates so shallowly.[16]

Three important variables in laser technology are wavelength, pulse duration, and fluence. (Fluence, or energy density, is the amount of energy delivered.) They are optimized to achieve maximal ablation of the target tissue with minimal collateral damage. The newer pulsed carbon dioxide lasers ablate tissue to a depth of 20-30 µm with each pass and cause collateral damage to a surrounding area of 20-70 µm.

Collagen contracts by approximately 15-25% during carbon dioxide lasing, producing a shrunken form that serves as a template for tighter, more organized new collagen formation.[17] Char forms in the wound during the procedure. This char must be wiped away before subsequent passes, but it marks the depth of ablation. The characteristics that produce the immediate contraction of collagen also create an injury that often causes prolonged erythema, lasting up to 6 months, and can lead to permanent scarring and dyspigmentation.

The Er:YAG laser operates at a more superficial level and with greater precision. Similar to the carbon dioxide laser, its chromophore is water; however, the energy is absorbed by a different absorption peak at a different wavelength. The Er:YAG emits a wavelength of 2940 nm, which is absorbed by water because of its 3000-nm absorption peak. The passes of short-pulse lasers (250 µm) penetrate to a depth of only 10-15 µm, and several passes only cause collateral thermal necrosis to a distance as thin as 20-50 µm.

Collagen contraction is 1-2% during lasing, and it may only reach 14% in the long term.[18] No char forms, and only a transient white discoloration of the wound bed occurs. Dermal vessels treated with the laser dilate and cause transudation of fluid; this increases the water (chromophore) content in the treated area and allows for consistent ablation with each subsequent pass.[6]

The clinical manifestations of laser treatment depend on the ability of the skin to resurface itself. After lasing, the vaporized, atypical, disorganized epidermal cells are replaced with normal, well-organized keratinocytes from the follicular adnexa. The irregular, disorganized collagen and elastin of the upper papillary dermis are replaced with normal, compact collagen and elastin organized in parallel configurations.[1] This manifests as a more youthful appearance and improved skin texture. Patients in the most favorable preoperative categories generally show a 50% improvement in rhytides and skin lesions. Whereas collagen remodeling and further clinical improvement often continue for up to 18 months after carbon dioxide laser resurfacing, the reduced photothermal effect of the Er:YAG laser allows the resurfacing process to end before 12 months.[19]

A study by Medved et al of patients who underwent Er:YAG laser rejuvenation of the facial skin found that microcirculation values (with regard to flow, oxygen saturation, velocity, and relative hemoglobin content) increased to a depth of 2 mm; by 6-month follow-up, the firmness of the superficial skin layer had also increased.[20]

A disadvantage of the superficial and fleeting energy absorption of the Er:YAG laser is its poor ability to cause hemostasis. Although thermal necrosis does not significantly interfere with subsequent passes of the laser, blood in the wound bed makes controlling the wound depth difficult. Only several passes may be possible, which may not ablate the tissue to the desired depth. The carbon dioxide laser can generally produce the same effect in a third of the number of passes, with better hemostasis. The carbon dioxide laser is a more reliable modality for deeper tissue ablation than the short-pulsed Er:YAG laser.[6]

Newer Er:YAG lasers with longer (500 µm) and variable pulses have been developed. They have better tissue penetration, which makes deeper tissue ablation less difficult. They create larger zones of thermal necrosis, leading to more collagen contraction and better remodeling. Although the postoperative erythema is greater and lasts longer than with the short-pulsed Er:YAG lasers, it is still less severe than after the carbon dioxide laser.[21, 22, 5] Another improvement is in the shape of the energy distribution within the laser beam; some lasers distribute the energy in a uniform, or "top hat," pattern rather than in a gaussian pattern. The uniform pattern is thought to provide better hemostasis.


The selection of patients who are best suited for laser resurfacing and the education of those who are at higher risk for complications are the most important parts of the initial consultation. The best results are achieved in patients with a fair complexion and few wrinkles. Fitzpatrick and Glogau developed classification schemes that help predict the effectiveness of skin resurfacing.

Fitzpatrick classes of skin phototypes are as follows:

  • Type I

    • Always burn, never tan

    • Light-eyed, fair-skinned northern European persons

  • Type II

    • Always burn, sometimes tan

    • Fair-skinned European persons

  • Type III

    • Sometimes burn, always tan

    • Mediterranean origin (eg, Spanish, Italian, or Greek persons)

  • Type IV

    • Never burn, always tan

    • Hispanic and Asian persons

  • Type V

    • Darkly pigmented skin

    • Hispanic and Asian persons

  • Type IV

    • Black skin

    • Darkly pigmented African and southern Indian persons

Glogau classes of photodamage are as follows:

  • Type I

    • Few wrinkles, no keratosis, require little or no makeup

    • Usually aged 28-35 years

  • Type II

    • Early wrinkling, sallow complexion with early actinic keratosis, require little makeup

    • Usually aged 35-50 years

  • Type III

    • Persistent wrinkling, discoloration of the skin with telangiectasias and actinic keratosis, always wear makeup

    • Usually aged 50-60 years

  • Type IV

    • Severe wrinkling, photoaging, gravitational and dynamic forces affecting skin, actinic keratosis, wear makeup with poor coverage

    • Usually aged 65-70 years

Patients categorized in Fitzpatrick and Glogau types I and II obtain better results than those in higher types. After carbon dioxide laser resurfacing, patients with higher Fitzpatrick skin types are likely to experience scarring, hypopigmentation or hyperpigmentation, and a prolonged recovery period. Complications are generally less frequent, milder, and of shorter duration after Er:YAG laser resurfacing, and the Er:YAG laser has been advocated for use in patients with darker skin.[1]


Indications for use of the Er:YAG laser are expanding.[23] Early indications included mildly photodamaged skin lesions (eg, solar keratoses); mildly atrophic facial scars (eg, from acne or varicella); dyschromias (eg, melasma, lentigines); and mild-to-moderate facial wrinkles in the perioral, periocular, and cheek areas. Deeper facial wrinkles and abnormalities, as are seen in persons in the higher Glogau classes, have conventionally been treated with the carbon dioxide laser because of its greater and wider tissue ablation.

Recent combined use of carbon dioxide and Er:YAG lasers has taken advantage of the properties of each system to extend their indications for use. Full-face resurfacing is safe with the combined system, which also decreases the lines of demarcation and textural differences between treated and untreated areas and allows uneven areas of photodamage to be treated at the same time. Combined laser use on the eyelids causes less coagulative dermal damage and results in reepithelialization in almost half the time than after the carbon dioxide laser alone.[1, 24, 25, 26] Many other skin lesions have been successfully treated with the Er:YAG laser, including compound nevi, sebaceous hyperplasia, trichoepitheliomas, miliary osteomas, syringoma, telangiectasia, rhinophyma, adenoma sebaceum, hidradenoma, xanthelasma, and the cutaneous manifestations of Hailey-Hailey disease and Darier disease.[27, 1, 28, 6]

The Er:YAG laser can also be cautiously used on the neck, arms, and hands, where fewer pilosebaceous units are found compared with the face. These pilosebaceous units are the source of new keratinocytes in the reepithelialization process, and resurfacing modalities more damaging than the Er:YAG laser can lead to fibrosis, hypertrophic scar formation, and prolonged healing.[29, 30] Even with the Er:YAG laser, surface changes are unpredictable.

The newer Er:YAG lasers with longer and variable pulses even allow patients with deeper wrinkles and scars to be successfully treated. Rhytides in the glabellar region and nasolabial folds are difficult to treat with any laser; they are associated with movement and are probably best approached with botulinum toxin therapy or surgical skin and muscle adjustment.

Relevant Anatomy

Perioral rhytides reflect generalized atrophy. Restoration of a "level playing field" with subdermal grafts ("fresh," nonrefrigerated autologous fat,) and intradermal filling (hyaluronic acid, human collagen injections), as well as mild derma planning, reduce the resurfacing required, thus reducing the number and severity of complications.


Absolute contraindications to Er:YAG laser skin resurfacing include active bacterial or viral infections, an inflammatory condition in the area to be treated, the presence of ectropion (in the case of infraorbital resurfacing), unrealistic patient expectations, and patient unwillingness or inability to care for the wound. Isotretinoin use within the preceding 12-24 months, which diminishes the sebaceous unit source of keratinocytes for reepithelialization, is also a contraindication.

Relative contraindications include extreme or habitual ultraviolet light exposure, collagen-vascular disease, immune disorders, prior lower blepharoplasty (in the case of infraorbital resurfacing), prior radiation therapy or burns with loss of cutaneous adnexal structures, extensive fibrosis from previous cosmetic procedures, and a tendency to form hypertrophic scars or keloids. Koebnerizing diseases such as psoriasis, lichen planus, or pyoderma gangrenosum are also relative contraindications.



Laboratory Studies

No specific preoperative laboratory evaluation is required before laser resurfacing.

Imaging Studies

As before any cosmetic procedure, obtain preoperative photographs of the patient.

Diagnostic Procedures

Testing in an inconspicuous area may be warranted if resurfacing is planned for locations that are at high risk for complications, such as the skin of the neck, the chest, and the dorsum of the hands. In elderly persons, these areas may be atrophic and have even fewer adnexal structures to serve as islands for reepithelialization.[4]



Surgical Therapy

Lasers can be prohibitively expensive, and a laser surgeon should carefully calculate the return on the investment. Some of the Er:YAG systems currently available include the Contour dual-mode (ablation and coagulation) laser (Sciton; Palo Alto, Calif), the carbonate (CO3) variable-pulsed laser (Cynosure; Chelmsford, Mass), the CB Erbium/2.94 uniform beam laser (HOYA ConBio; Fremont, Calif), the Venus-i uniform beam laser (Laserscope; San Jose, Calif), and the NaturaLase Erbium laser (Focus Medical; Bethel, Conn).

Some Er:YAG laser systems are no longer available because their manufacturers have concentrated on carbon dioxide or nonablative lasers. The cost of the lasers ranges from $50,000-80,000. Many companies, including third-party vendors, lease the systems for $1,000-1,500/mo with a long-term lease or approximately $600 for 4 hours without a lease. Preowned systems are also available for purchase.

Preoperative Details

Antiviral prophylaxis against cutaneous herpesvirus infection is essential before any full-face or perioral resurfacing; the epidermal trauma and thermal effects often reactivate labial herpes simplex virus. Because of the high prevalence of latent virus, even in persons who have never been symptomatic, prophylaxis is administered to all patients, beginning 24 hours before the procedure and continuing for 7-10 days. Famciclovir (250 mg) or valacyclovir (500 mg) twice daily are effective regimens. Those with a history of herpesvirus infection may receive 500 mg twice daily.[31, 32]

Patients are instructed to avoid taking aspirin or other nonsteroidal anti-inflammatory medicines for at least 10 days in an effort to decrease bleeding during the procedure.

Pretreatment of the skin before laser resurfacing is controversial. No consensus has been reached regarding the usefulness of any particular agent or the usefulness of the practice at all. Most laser surgeons prescribe topical retinoic acids, hydroquinone bleaching agents, and alpha-hydroxy acids for several weeks preoperatively to reduce postoperative inflammation and hyperpigmentation. A typical 6-week preparation regimen before laser resurfacing is as follows:

  • Retinoic acid cream (0.05-0.1%): Apply 0.5-1 g in the evening.

  • Hydroquinone cream (2-4%): Apply 0.5-1 g twice daily.

  • Alpha-hydroxy acid cream (2-4%): Apply 0.5-1 g in the morning.

Studies have not shown these regimens to have a significant effect; hydroquinone is cytotoxic to melanocytes and inhibits tyrosinase, thereby decreasing melanosome formation, but it probably does not reach the deeper melanocytes responsible for hyperpigmentation. Postoperative treatment of hyperpigmentation is more successful.[1, 33] Some advocate the use of antihistamines such as loratadine 30 minutes before using a high-energy Er:YAG laser in an effort to prevent immediate urticarial edema.[34]

Intraoperative Details

If general anesthesia from a concomitant procedure is not used, anesthesia is normally performed by injecting lidocaine mixed with epinephrine. Intravenous sedation is generally required. Topical anesthesia can be used in those procedures in which the Er:YAG laser is only applied superficially to a small area, although the hemostatic effect of epinephrine is lost.

The goal of Er:YAG laser resurfacing is the controlled, layer-by-layer ablation of skin while avoiding the creation of thermal injury so deep that scarring or other complications result.[1] Three variables are adjusted on the laser to create the desired tissue effect: spot size, fluence, and pulse repetition rate. Many laser surgeons use a 3- to 5-mm spot size, a pulse energy of 1-2 J, and a pulse repetition rate of 1-10 Hz. A fluence of 5 J/cm2 per pass is usually used in delicate areas such as the periorbital and preauricular regions or for superficial lesions. Higher energies (12-15 J/cm2 per pass) are used in thicker, more heavily photodamaged or scarred areas such as the cheeks, chin, perioral areas, and forehead.

The epidermis can be completely ablated after 2 or 3 passes using a standard laser, although severely damaged skin, deep rhytides or scars, and deep dermal growths may require as many as 20 passes.[5] Using a fluence of less than 5 J/cm2 heats the target too slowly, permitting greater heat conduction and collateral damage to the surrounding tissues. Higher-energy Er:YAG devices with a fluence of 20 J/cm2 have been developed that can ablate most of the epidermis after only one pass and, with subsequent passes, produce some dermal ablation with minimal thermal injury.[34]

A systematic approach is used, with the area to be lased separated into zones of approximately 6-10 cm2. The number of laser passes is counted sequentially. Alternating the direction of passes and overlapping the previous pass by 50% avoids striping and pattern marks on the skin and produces a more homogenous result.[6, 5] Making fewer passes at the periphery of the treated area provides a natural blending and minimizes the demarcation with untreated skin. A computerized scanner simplifies the lasing process, making it more precise and homogenous.

As ablation is carried deeper into the papillary and upper reticular dermis, the tissue changes from white to yellowish and pinpoints of bleeding occur; this is a useful visual end point to avoid overpenetration.[1, 5] If epinephrine is included in the local anesthetic, this bleeding may not be apparent and should not be used as a marker for the depth of penetration. The whitish desiccated skin is removed with saline-soaked gauze between each pass, but the wound bed must be kept dry at all times to avoid diminution of the laser energy transmitted to the target. Blotting the area with sponges soaked in a vasoconstrictive agent can minimize oozing and allow further passes, if needed.

The technical details of using the newer laser systems, such as the combined Er:YAG/carbon dioxide lasers and the high-energy variable pulse Er:YAG lasers, vary. One published protocol uses a dual-mode Er:YAG laser calibrated at a fluence of 22.5 J/cm2, ablation depth of 90 µm, and coagulation depth of 50 µm. The passes are overlapped 50% to vaporize the epidermis in a single pass. An additional 1-2 passes are applied to residual rhytides and scars. The final layer of desiccated tissue is left in place to serve as a biological wound dressing.[35] Most laser surgeons determine by trial and error a personal, individual protocol and laser parameters, such as using subablative low-fluence pulses following each ablative pulse or sculpting the tissue with various spot sizes after performing the bulk of the resurfacing.

Many recent reports describe technique variations whose developers seek to minimize even the small morbidity of this treatment. A single-pass procedure for mild to moderate photodamage was reported with short-pulsed Er:YAG lasers. They were passed once over the face, with 2-3 passes over the perioral and periorbital areas. Pigment irregularity and skin texture were improved, but fine wrinkles were not. Adverse effects were generally limited to 3-5 days of erythema.[36] Another report used a low fluence (5-17.5 J/cm2) single-pass procedure to treat mild to moderate photoaging. The results in thin skin were excellent and the results in thick skin were good. Reepithelialization was complete in 3-4 days.[37] A new portable laser was used on small areas of the face, in 1-6 passes of 5-6 J/cm2 fluence. Recovery time was comparable to the other reports.[38]

Concomitant use of the Er:YAG laser directly after facelift can be performed safely.

The most common adverse effect was transient hyperpigmentation, which occurred in 20.6% of 34 patients in 1 report. None of the patients experienced delayed reepithelialization, skin necrosis, or prolonged healing times.[39]

Postoperative Details

Postoperative care of the wound is directed at maximizing the rate of reepithelialization by providing a clean, moist environment. Small, circumscribed ablation craters can simply be covered with an antiseptic ointment until reepithelialization occurs. After wider removal of only the epidermal layer, usually only mild erythema and 2-3 days of edema occur. Reepithelialization occurs within 5-7 days, and ointments or water-based moisturizers can be used on the wound.

The care of deeper wounds is more involved because of the intense erythema, significant edema, raw skin, and copious serous discharge. The open method of wound management involves the application of an ointment every few hours. Exudative buildup is cleansed with saline and/or a weak acidic solution until reepithelialization is complete. The closed method uses a semiocclusive dressing left on the wound for several days in order to simplify wound care and decrease pain associated with cleansing the wound. Concerns about the closed method include wound maceration, a higher incidence of infection, and the masking of early wound healing complications.[35, 6] Patients treated with closed dressings should probably be examined every 24-48 hours. Some surgeons use a combination of methods, with a transparent occlusive dressing for the first 1-2 days followed by the open technique.

Ice packs, anti-inflammatory medications, and pain medications are important adjuncts after the procedure. A short course of systemic steroids is sometimes used. Aqueous topical ascorbic acid can decrease inflammation but is avoided immediately after the procedure because it is irritating.[40] A 1% hydrocortisone emollient can be used for pruritic or irritated areas.

Reepithelialization occurs over an average of 5.5 days. Patients are instructed to avoid sun exposure and to apply sunscreen daily. Erythema usually resolves as soon as 2-4 weeks and is directly related to the depth of ablation.[6, 5] Camouflage makeup can be applied in 7-10 days.

The use of postoperative prophylactic antibiotics is also controversial. Concerns about the vulnerability of the moist, deepithelialized wound to bacterial overgrowth must be balanced by the risks of adverse effects and resistant strains. No difference in the postoperative infection rate was noted in one retrospective study.[41] A definitive randomized, prospective, controlled trial remains to be reported.


Expected adverse effects include erythema, edema, serous discharge, crusting, and discomfort. Focal areas of bleeding may occur. Milia formation may occur from the use of occlusive dressings. These should all resolve within a week of the procedure, after the skin reepithelializes. Acne lesions may be exacerbated under occlusion, and they can usually be treated with topical preparations or a short course of antibiotics.[42]

Contact irritation from topical medications is common in deepithelialized skin, occurring in up to 65% of patients after laser resurfacing. The most common irritants are topical antibiotics, sunscreens, fragrance-containing compounds, and the preservatives used in topical corticosteroid products. Most cases of irritation resolve after discontinuing the offending agent.[6]

Hyperpigmentation occurs in approximately one third of all patients and to some degree in all dark-skinned patients after laser resurfacing, although it is usually transient and responds to treatment. The area over the lateral eyebrow appears to be particularly susceptible. Topical retinoic, glycolic, and azelaic acid or a series of light glycolic acid peels are effective and may be used in conjunction with hydroquinone. Intense pulsed light systems also may be an effective treatment.[43] Regular sunscreen use is important to prevent further hyperpigmentation.[6, 5] The best sunscreen is clear zinc oxide.

Hypopigmentation, a particularly dismaying complication seen in up to 20% or more patients after carbon dioxide laser resurfacing, probably occurs in fewer patients after Er:YAG resurfacing. It usually develops 12-48 months after the procedure and, because it appears to be permanent, is caused by the destruction of melanocytes.[44, 45, 46]

Approximately 2-10% of patients experience a reactivation of labial herpes simplex virus infection postoperatively, usually 5-10 days after the procedure, even with appropriate prophylaxis. The outbreak may appear as a cluster of erosions rather than as vesicles or pustules in deepithelialized skin. The severity of the outbreak can be reduced by preoperative prophylaxis. Treatment with oral antivirals (eg, famciclovir 500 mg tid) is usually effective.[6]

Superficial bacterial and yeast infections may occur 2-10 days after the procedure. Staphylococcus, Pseudomonas, and Candida species are the most common pathogens and must be treated aggressively with systemic agents to avoid scarring or dissemination.[1] Although a rate of 4% is observed after carbon dioxide laser resurfacing, the rate after Er:YAG resurfacing remains unclear. The Er:YAG laser has actually been reported to have a bactericidal effect.[47, 48]

Hypertrophic scarring is rare, and it should be treated early with steroids, silicone gel, or the vascular-specific 585-nm pulsed dye laser. Areas prone to scarring are the chin, mandible, neck, and perioral regions.[1]

A relatively large 2003 study by Tanzi and Alster is the first comprehensive evaluation of the adverse effects after using a currently available Er:YAG laser.[43] Hyperpigmentation occurred in 20% of patients but resolved completely within 11 weeks. Limited superficial bacterial infections occurred in 18%, mild acne in 16%, milia in 10%, dermatitis in 6%, and posttreatment erythema lasting longer than 1 month in 6%. All complications were easily controlled.[43]

The hypopigmentation and hyperpigmentation seem to occur more frequently, be more intense, and last longer with longer pulse durations of the laser.[49]

Outcome and Prognosis

Improvement after Er:YAG resurfacing is related to the patient's skin type and the amount of photodamage. Patients categorized in Fitzpatrick and Glogau types I and II generally have 50% improvement in rhytides and atrophic scars.[1, 50, 51]

Patients with darker skin still have acceptable results, and the relatively lower risk of hyperpigmentation compared with more penetrating lasers makes the Er:YAG system the recommended modality.[52]

A study by Sanniec et al indicated that Er:YAG laser resurfacing is a safe and effective means of addressing perioral rhytides. As assessed using a gradation improvement scale running from 1-8, the investigators found, at average 13-month follow-up, that patient scores had improved by 2.2 gradations. No hypopigmentation was found in the cohort at 6-month follow-up.[53]

Before and after images are shown below.

Before resurfacing with CB Erbium 2.94 laser. Phil Before resurfacing with CB Erbium 2.94 laser. Phillip Hughes, MD, courtesy of HOYA ConBio.
Same patient as in image above. After resurfacing Same patient as in image above. After resurfacing with CB Erbium 2.94 laser. Phillip Hughes, MD, courtesy of HOYA ConBio.
Before resurfacing with CB Erbium 2.94 laser. Davi Before resurfacing with CB Erbium 2.94 laser. David Vasily, MD, courtesy of HOYA ConBio.
Same patient as in image above. After resurfacing Same patient as in image above. After resurfacing with CB Erbium 2.94 laser. David Vasily, MD, courtesy of HOYA ConBio.
Before (Left) and after (right) upper and lower li Before (Left) and after (right) upper and lower lip resurfacing with Erbium 2.94 laser. Courtesy of Meir Cohen, MD.

A study by Sayan et al of 547 patients who underwent field- or lesion-directed Er:YAG laser resurfacing for seborrheic or actinic keratosis found that over a 12-month review period, keratosis did not recur in any of the individuals treated with field-directed therapy, compared with six patients managed with lesion-directed resurfacing. The investigators also found the incidence of actinic keratosis recurrence with malignant transformation to be about 2.5%.[54]

Future and Controversies

The versatility of the Er:YAG lasers suggests several potential modifications of the original operative technique.[55] The laser can be used to ablate the epidermis, and then it can be reset to coagulate within the dermis at various levels to stimulate more collagen formation. (A study by El-Domyati et al found that fractional Er:YAG laser therapy for upper facial rejuvenation stimulated new collagen formation [types I, III, and VII] up to 6 months posttreatment.[56] ) The optimal depth within the dermis remains to be determined.

Another use under investigation is to ablate residual thermal damage after carbon dioxide laser resurfacing or even after deep Er:YAG lasing; removal of the proinflammatory coagulated tissue could result in less erythema and faster healing, but the tissue removed could be needed to stimulate new collagen formation. Preliminary work suggests that no significant difference is noted in the amount of collagen injury, inflammation, and new collagen formation between various combinations of the Er:YAG and carbon dioxide lasers soon after treatment.[1, 5, 57]

New Er:YAG lasers are being tested that produce high fluence values and smaller pulse durations, which, when used with a cryogen to cool the epidermis, allow the laser energy to spare the epidermis and only ablate and coagulate the dermis. Subepidermal laser resurfacing is attractive to patients who do not have a significant amount of photodamage because it reduces the erythema and edema associated with laser resurfacing. These nonablative techniques were introduced with Nd:YAG lasers and intense pulsed light systems, which are currently challenging the market share of the Er:YAG lasers.[58]

The latest innovation is the aforementioned fractional photothermolysis with Er:YAG laser (eg, PROfractional [Sciton Inc., Palo Alto, Calif], Pixel [Alma Lasers Ltd, Caesarea, Israel], Fraxel [Reliant Technologies, Mountain View, Calif]). This technique is based on creating spatially precise microscopic thermal wounds. The wounds created by the laser are narrow, sharply defined columns of skin known as microscopic thermal zones. According to preliminary reports, this resurfacing technique has been shown to be both safe and effective for improving facial and nonfacial photodamage, atrophic acne scars, hypopigmented scars, and dyspigmentation.[59, 60] Healing time is 3-6 days. Because only a fraction of the skin is treated during a single session, a series (typically, 4 treatments) of fractional resurfacing at 4-wk intervals is required for the best clinical improvement.[59, 60, 61]

A study by Cohen and Ross indicated that in patients undergoing facial rejuvenation, treatment combining fractional ablative 2940-nm and nonablative 1440-nm lasers has similar effectiveness as, but fewer immediate side effects than, treatment with only ablative lasers. Combined treatments in the study used a fractional nonablative 1440-nm neodynium YAG laser and a fractional ablative 2940-nm Er:YAG laser, while purely ablative treatments employed a combined confluent/fractional ablative Er:YAG laser or a fractional ablative CO2 laser.[62]

The new laser resurfacing techniques, while becoming more popular because of easier recovery, may fall into disfavor if the results are not long-lasting and if the complications of scarring increase. The results of ongoing and future clinical trials will establish the relative effectiveness and indications of the Er:YAG and other types of lasers.

Outward beauty is not enough, and the woman who would appear fair must not be content with any common manner. Words, wit, play, sweet talk and laughter, surpass the work of too simple nature. —Pliny the Elder