Nonablative Resurfacing 

Updated: Jan 14, 2021
Author: Omobola Onikoyi, DO, MSc; Chief Editor: Dirk M Elston, MD 

Overview

Background

Nonablative resurfacing is a technique in which lasers are used to resurface the skin to improve pigment and texture without physical injury to the skin surface. Similar to ablative resurfacing lasers, nonablative lasers can be one of two types, fractionated (most common) or nonfractionated. Changes in patient preferences and improved laser technology have led clinicians to prefer nonablative laser resurfacing techniques over older and more destructive ablative techniques.

Nonablative nonfractionated lasers create uniform thermal damage to the dermis while sparing the epidermis. They are best for the treatment of mild-to-moderate photodamage and early signs of skin aging. Fractionated lasers deliver energy through a process called fractional photothermolysis, in which an array of small laser beams create many microscopic areas of thermal injury within the range of 100-400 um in width and 300-700 um in depth. These areas, referred to as microscopic treatment zones, are columns of thermal damage surrounded by areas of normal skin that serve as a source of healthy tissue and stem cells for remodeling and effective rejuvenation and allow for safe and rapid healing.[1] Nonablative fractionated lasers combine the best of the gentle and safe aspects of both fractionated and nonablative technologies and are ideal for patients seeking moderate improvement with minimal postrecovery time.[2]

The most common uses of nonablative resurfacing lasers include the treatment of photoaging, rhytides, scars, skin pigmentation, and overall skin rejuvenation. A report from 2017 looked at the use of these devices to assist in drug delivery.[3]

History of the Procedure

The desire for facial rejuvenation dates as far back as ancient Egypt. The Egyptians used sour milk and lactic acid to perform chemical peels. Since then, there has been significant experimentation and advancement in order to achieve the optimal balance between skin damage and skin improvement.

The use of fractional lasers in medicine was first introduced in 2004 by dermatologist Dieter Manstein and has since revolutionized the field of laser resurfacing and rejuvenation. These specific devices use varying wavelengths, with the goal of improving skin appearance with minimal downtime and adverse effects.

Problem

The key problem in assessing evaluations of nonablative resurfacing in the last 5 years has been understanding its ability to induce objective clinical improvement.

Investigators using nonablative lasers have noted that the induction of new collagen creations are not specific to a wavelength. That is, identical alterations of collagen can be histologically demonstrated using the Er:glass laser, Nd:YAG laser, and diode lasers. The primary effects appear to be thermal injury to the dermis, inducing collagen remodeling and formation instead of vascular injury. What may be occurring is dermal remodeling or toning in a parallel fashion to the healing response elicited by an injury that initiates collagen regeneration, turnover, and deposition.[4]

Histological alteration does not exactly mirror clinical enhancement of skin. Results vary, and studies even of the same lasers with similar (but almost always slightly different) settings and parameters report different results (ie, some with clinically significant change and some without objective alterations in the skin).

Studies have been performed on pulsed-dye, 585- to 595-nm lasers; Er:glass, 1540-nm lasers[5] ; Nd:YAG, 1320-nm lasers; diode, 1450-nm lasers; and intense pulsed-light, 560- to 640-nm lasers with a cutoff filter.[6]

It might be best understood that nonablative laser treatments are likely not the most effective treatments for rhytid reduction. However, they seem to be effective and useful modalities for amelioration of scars and superficial dyschromias. Obviously, for minimal facial damage, they allow patients to pursue their regular activities and thus are useful and important treatment options.[7]

Trellas et al noted that no single nonablative laser can achieve all the specific effects needed for effective skin rejuvenation,[8] and they suggest that combinations of treatments are the most useful modes of treatment. Fractional resurfacing has largely replaced other ablative technologies, and nonablative techniques have become more widespread.

Although nonablative treatments are useful, they are still not as effective as ablative treatments. This was highlighted in a study by Ong and Bashir[9] ; ablative fractionated laser induced an improvement range of 26-83%, whereas nonablative fractionated laser had an improvement range of 26-50%.

Indications

Nonablative lasers work by stimulating collagen synthesis, thereby promoting improved skin texture and tone. This type of laser may be used to improve the appearance of acne scars, fine lines, wrinkles, melasma, and much more. The fast postprocedural recovery time is what makes it a highly desired cosmetic technique. While nonablative nonfractionated lasers are best for treating mild-to-moderate photodamage and dyschromia, nonablative fractionated lasers are considered superior for rejuvenation and retexturizing.

A study from 2017 reports on the effective use of nonablative laser resurfacing for a wide array of dermatological conditions seen specifically in skin of color.[10]

Relevant Anatomy

Nonablative laser techniques have mainly been used to treat areas on the facial skin; however, interest is increasing in the role of these techniques on the neck, the hands, and other areas of the body.

The use of lower wavelengths in nonablative laser resurfacing techniques allows for the restoration of damaged collagen without causing disruption to the stratum corneum (epidermis), the outermost layer of the skin. The underlying dermis is disrupted via light energy, eliciting an inflammatory response and further initiating collagen repair. Fractionated nonablative lasers create microscopic columns of thermal injury interspersed with normal tissue, which allows for quicker and more efficient recovery.

Contraindications

Contraindications to skin resurfacing with lasers include active psoriasis and lichen planus, active bacterial or fungal infections, and active neoplastic disease. Individuals who are unable to give proper informed consent should not receive laser treatment, and those with unrealistic expectations should be cautioned.[11]

 

Treatment

Surgical Therapy

Currently used nonablative systems are based on the studies discussed below. New systems include the 1927-nm system of fractional thulium fiber that produces laser light.

In 2012, articles noted that nonablative lasers have been used to treat burn scars, striae, macular seborrheic keratosis, actinic keratosis, and a variety of neoplastic and scarring conditions, including treatment of post-Mohs surgical scarring and skin grafting. They can be used with ablative devices to enhance effect.[12] Blinded physician global assessment for hypertrophic scars was unable to prove the clinical effect of the 1540-nm nonablative fractional system laser.[13] Some claim that they can repigment hypopigmented scars, but the mechanism and consistency of this result must be further defined. They may play a role in hand rejuvenation.

Treatment of melasma using fractional photothermolysis (1550-nm Fraxel SR laser) achieved a greater than 50% improvement in 5 of 8 patients treated (3-8 times), with long-term follow-up.[14] However, anecdotal reports suggest that dermatologists with experience with this condition have indicated they have not been able to replicate this level of effect.

In 2001, Rostan et al[15] studied 15 patients using the long-pulse flashlamp-pumped pulsed-dye laser (LPDL) with and without cooling to ameliorate rhytides, to stimulate collagen synthesis, and to facilitate dermal remodeling. Eleven of 15 patients showed improvement of the laser-treated cheek, while only 3 of 15 patients showed a better appearance on the cryogen-treated side. Histologic specimens had more activated fibroblasts and demonstrated more positive procollagen staining on the LPDL-treated cheek. Thus, the LPDL can be a useful nonablative modality.

Bjerring et al[16] have shown increased levels of collagen precursors following treatment with a 350-μsec pulsed-dye laser. This laser is different from the usual pulsed-dye lasers currently used in cutaneous laser treatment because it emits shorter pulse width laser irradiation at low fluences.

In another study,[17] the use of intense pulsed light was also evaluated in the treatment of rhytides. Thirty female research subjects aged 35-65 years with Fitzpatrick type I-II and class I-II skin phenotypes were treated. Treatment areas included the periorbital, the perioral, and the forehead regions. Over a period of 10 weeks, one to four treatments were provided. Noncoherent intense pulsed light was delivered to the skin by using a 645-nm cutoff filter. This technique leads to an emission of light with wavelengths of 645-1100 nm. Light was delivered through a bracketed cooling device in triple 7-msec pulses with a 50-msec interpulse delay between the pulses. Delivered fluences were between 40-50 J/cm2. The author evaluated the degree of improvement 6 months after the last treatment. Complications were also evaluated at this time. Clinical improvement was divided into the following four quartiles: no improvement, some improvement, substantial improvement, and total improvement. Six months after the final treatment, five research subjects were noted to have no improvement. Similarly, no research subjects were noted to have total improvement. Sixteen research subjects showed some improvement, while nine showed substantial improvement. All research subjects were evaluated for pigmentary changes, posttreatment blistering, erythema, and scarring. Three of the 30 research subjects were noted to have blistering immediately after treatment. All 30 research subjects had posttreatment erythema. Six months after treatment, no pigmentary changes, erythema, or scarring was noted. The author concluded that intense pulsed light could improve some rhytides, as demonstrated in the images below.

Periorbital rhytides before treatment with an inte Periorbital rhytides before treatment with an intense pulsed light source.
Improvement in rhytides after treatment with an in Improvement in rhytides after treatment with an intense pulsed light source.

New collagen formation and improvement of age-related vascular and pigmented lesions can follow treatment with this nonlaser technology. However, the changes appear to be subtler than those seen with ablative techniques.

The first specifically nonablative laser to be solely marketed to the physician community is a 1320-nm Nd:YAG laser. The goal of this system, similar to that of the previously described systems, is improvement of rhytides without the creation of a wound. The 1320-nm wavelength is advantageous in its high scattering coefficient. Thus, the laser irradiation scatters throughout the treated dermis after nonspecific absorption by dermal water.

In 2001, Pham[18] reported that the CoolTouch (Roseville, Calif) laser that blends an Nd:YAG, 1320-nm wavelength beam and thermal-sensing cryogenic spray was an effective nonablative treatment modality.

In 2004, Fulchiero et al[19] reported tandem treatment with needle subcision of acne scars and 1320-nm Nd:YAG nonablative laser resurfacing. They deemed this double-pronged treatment modality to be a well-tolerated and highly effective regimen compared with either modality alone.

In 2005, Bellew et al[20] reported on 29 patients treated with nonablative laser skin resurfacing with a 1320-nm Nd:YAG laser. They demonstrated significant positive changes in the appearance of facial acne scars and reported no adverse effects.

In August 2004, Sadick and Schecter[21] reported on seven persons with photoaged hands. These patients underwent six monthly treatments with a 1320-nm Nd:YAG laser. They assessed skin smoothness improvement objectively, and patients also evaluated the results. The scale used was a 6-point improvement scale with 1 point for no improvement, 2 points for 20% improvement, 3 points for 40% improvement, 4 points for 60% improvement, 5 points for 80% improvement, and 6 points for 100% improvement. The mean improvement by objective assessment was 2.4 points. They noted objective improvement in four of seven patients. In these four patients, a mean improvement score of 3.5 points was recorded. The mean improvement reported by the patients was 3.1 points.

In July 2004, Sadick and Schecter[22] exposed eight persons with facial acne scars to six monthly treatments with a 1320-nm Nd:YAG laser with built-in cryogen cooling. They assessed acne scar improvement after treatment with the 1340-nm laser. They assessed the improvement objectively, and, again, the patients also evaluated the results. The 6-point improvement scale was also used again, with 1 point for no improvement, 2 points for 20% improvement, 3 points for 40% improvement, 4 points for 60% improvement, 5 points for 80% improvement, and 6 points for 100% improvement. They noted the mean improvement by objective assessment was 3.9 points (P = .002) at 5 months and 4.3 points (P = .011) at 1 year. The patient evaluations yielded similar scores of 3.6 points (P = .002) at 5 months. These researchers stated that acne scar improvement achieved statistical significance at the 5-month and 1-year milestone evaluation points.

In 2003, Rogachefsky et al[23] studied 12 patients with atrophic facial acne scars (N = 6) or a combination of atrophic and pitted, sclerotic, or boxcar scars (N = 6). These patients received three laser exposures with a 1320-nm laser. Both the researchers and the patients evaluated the scars before the initiation of treatment and at 6 months subsequent to the final laser exposure. A 10-point rating scale was used. Rogachefsky et al[23] found an average acne scar enhancement of 1.5 points (P = .002). The patient enhancement evaluations scored 2.2 points (P = .01). Patients rated the acne scars as worse compared with the ratings of Rogachefsky et al.[23] The researchers concluded that the 1320-nm was a useful and effective modality for ameliorating acne scars, and no adverse effects were reported at 6 months.

In 2002, Fatemi et al[24] used a 1320-nm laser on 10 patients and then performed biopsies. They stated that their data indicated that in addition to dermal collagen heating with subsequent collagen healing, nonablative resurfacing can engender subclinical epidermal injury that somehow improves appearance. They speculated that acute alterations of superficial blood vessel injury somehow linked to cytokine release are also important factors. They concluded based on histologic findings that three passes with fluence and cooling adjusted a maximum temperature of 45-48°C yields optimal clinical improvements.

In the study by Nelson et al,[25] one or more passes of a 1320-nm Nd:YAG laser were used on photoaged skin. The waveform consisted of 3200-µsec laser pulses at a 100-Hz repetition rate. Laser energy was delivered through a 5-mm spot size with fluences up to 10 J/cm2. A dynamic cryogen cooling technique was applied immediately prior to laser treatment to produce selective subsurface skin heating without epidermal damage. Immediately after treatment, mild edema and erythema appeared in the treated skin. These adverse effects resolved within 2 days. At 2 months after treatment, facial rhytides improved notably. No persistent erythema or pigmentary changes were observed.

The currently available model of this 1320-nm Nd:YAG laser is accompanied by a unique handpiece with three portals. One portal contains the cryogen spray that cools the epidermis prior to and during treatment, another portal emits the 1320-nm Nd:YAG laser irradiation, and the third portal contains a thermal sensor. Fluences that are used with the currently available models vary from 30-40 J/cm2. Such fluences lead to peak measured temperatures of 42-48°C. Patients are usually treated at 2- to 4-week intervals and can be expected to show the degree of improvement expected from a nonablative approach.

Consistent with the noted clinical improvement is the histologic replacement of the irregular collagen bands with organized new collagen fibrils, as demonstrated in the images below.

Histologic findings consistent with solar elastosi Histologic findings consistent with solar elastosis.
Histologic findings 6 months after 4 treatments wi Histologic findings 6 months after 4 treatments with a 1320-nm Nd:YAG laser. Note the upper papillary dermal fibrosis.

This laser has also been used as part of a full-face antiaging approach because it produces new collagen formation, as demonstrated in the images below. Eyelid tightening and improved aperture through nonablative fractional resurfacing has also been reported.

Patient with almost no rhytides seeking full-face Patient with almost no rhytides seeking full-face 1320-nm Nd:YAG laser antiaging treatment.
Nonablative resurfacing. Six months after 1320-nm Nonablative resurfacing. Six months after 1320-nm Nd:YAG laser treatment.

The newest version of this laser leads to extremely safe and fast nonablative treatment through the use of either pretreatment cryogen cooling or posttreatment cryogen cooling and delivery of laser energy through a 10-mm spot size.

A 1450-nm diode laser has also been shown to be effective for the nonablative treatment of photoaged skin. The 1450-nm wavelength is extremely well absorbed by water. The laser also uses cryogen cooling to protect the epidermis before, during, and after treatment, as demonstrated in the images below.

Periorbital rhytides before treatment with a 1450- Periorbital rhytides before treatment with a 1450-nm diode laser.
Improvement in rhytides after treatment with a 145 Improvement in rhytides after treatment with a 1450-nm diode laser.

In 2005, Hohenleutner et al[26] reported on treatment of 30 facial areas with a 1450-nm diode laser. The treating laser surgeon and two blinded observers reviewed prelaser and postlaser exposure photographs. While as much as 35% enhancement seemed to occur in some patients, little concordance was achieved between the three reviewers. Thus, objective data did not demonstrate the efficacy of nonablative treatment of rhytides with the 1450-nm diode laser.

In 2004, Tan et al[27] reported a series of patients treated with the 532-nm laser on one side of the face and with the 532- and 1064-nm lasers to the other side of the face, followed by three treatments with the 1064-nm laser to both the right and left cheeks. They assessed skin quality (ie, visual dryness, roughness, uneven pigmentation) before, during, and up to 4 months after laser exposure. They noted greater than 25% improvement in overall skin quality for more than 30% of patients at the 1-month follow-up and for more than 40% of subjects at 4-month follow-up. The skin qualities most enhanced were visual dryness, roughness, and uneven pigmentation. Tan et al did not report adverse effects, and they stated that persons who receive more treatments with the 1064-nm laser would have greater improvement, but this outcome did not achieve statistical significance.

Dayan et al[28] in 2003, in a study of 1064-nm laser treatment in 51 patients, found that it reduced coarse wrinkles and skin laxity and induced an overall improvement in the appearance of skin. Most patients received seven treatments. Adverse effects were minimal.

In 2004, Tanzi and Alster[29] reported their important study involving 20 people with Fitzpatrick skin types demonstrating mild-to-moderate atrophic facial acne scars. These 20 persons were randomly exposed to three successive monthly laser exposures with the nonablative long-pulsed 1320-nm Nd:YAG and 1450-nm diode lasers. Tanzi and Alster found that the 1320-nm and 1450-nm lasers provided enhancement with minimal untoward changes. However, the 1450-nm diode laser provided greater clinical scar amelioration when used by at the settings Tanzi and Alster used.

In 2002, Lupton et al[5] reported on a study of the 1540-nm Er-doped phosphate glass laser operated by one laser surgeon. They found that the 1540-nm Er-doped phosphate glass laser was effective. Interestingly, histologic dermal alteration did not appear immediately; instead, several months after exposure to the 1540-nm laser, a dermatopathologist was able to report that a greater quantity of dermal collagen was present. Lupton et al noted slow, progressive clinical and sustained improvement of rhytides in most patients.

In 2001, Fournier et al[30] reported on their study of 60 patients (mean age 47 y) who had skin phototypes ranging from I-IV and who were exposed for four treatments over 6-week periods to the 1540-nm Er:glass laser with contact cooling for nonablative skin remodeling. The focus was perioral and periorbital rhytides. All patients experienced subjective improvement. Ultrasound imaging data showed a 17% increase of dermis thickness (P< .005), and histologic data demonstrated new collagen formation. Thus, Fournier et al concluded that the 1540-nm laser was a useful nonablative modality.

Fractional resurfacing has been used to decrease the size and extent of atrophic facial acne scars in various skin types, including Asian skin.[31, 32] Fractional resurfacing has also been noted to improve and tighten eyelid skin.[33]

The low-density, low-energy, nonablative, 1440-nm fractional laser can produce a slight improvement after four treatments on certain aspects of photodamage, without long-term adverse effects.[34]

A 1927-nm wavelength laser can be used effectively for nonablative skin resurfacing.[35]

Postoperative Details

Graber et al[36] studied the use of the fractionated 1550-nm laser retrospectively from 961 treatments. Of these treatments, 7.6% of patients developed complications. The most common adverse effects were acneiform eruptions (1.87%) and herpes simplex virus eruptions (1.77%). Of note, darker-skinned patients experienced more pigmentary alteration.

After ablative fractional carbon dioxide laser resurfacing, reduced erythema and rapid healing was achieved with autologous platelet-rich plasma application.[37]

Postprocedural erythema after nonablative laser resurfacing usually resolves within a matter of a few days. Posttreatment care may include cleansing of the skin with a gentle cleansing agent and use of bland emollients to aid in wound healing and to decrease postprocedural erythema. Icing and topical steroids may be also used when needed during the first few days post procedure to help reduce swelling.

Complications

Nonablative lasers are generally used for individuals with moderate scarring. Although downtime may be decreased when compared with ablative laser use, efficacy with regard to overall clinical outcome may be compromised. Risks of postprocedural scarring, dyspigmentation, edema, and erythema are still present; however, the risk of these adverse effects is decreased when compared with ablative resurfacing procedures.[11]

Erythema and edema are common postprocedural complications that may be seen after nonablative laser treatment. Burns and scars, although rare, can be seen with any type of laser treatment. Very rare complications related to herpes simplex virus (HSV) activation have also been reported with use of lasers. It has been recommended that anyone with previous history of HSV-1 or HSV-2 be treated prophylactically with antivirals prior to laser treatment.[38]

Individuals with Fitzpatrick types IV and above may also have a greater risk of postinflammatory hyperpigmentation.

Outcome and Prognosis

Individuals treated with nonablative lasers should experience improvement in the quality, tone, and texture of their skin. Mild improvement of rhytides may occur, although, there are some limitations with regard to the effects of nonablative lasers on certain features of cutaneous aging. The overall outcome of nonablative laser treatment is positive, as there are minimal risks involved and there is a significant decrease in downtime. Adjunct agents such as fillers, botulinum toxin, and microdermabrasion may be used to enhance the cosmetic outcome.

Future and Controversies

Nonablative laser resurfacing has become widely used in dermatology over the past decade and has shown to be effective and safe in the treatment of individuals with darker skin tones. Recovery time and postprocedural complications such as erythema and postinflammatory hyperpigmentation are significantly decreased with the use of nonablative lasers when compared with other resurfacing procedures. Selecting the appropriate device and modest use of device settings becomes extremely important for individuals with darker skin. Additional studies should be performed including Fitzpatrick skin types V and VI in order to create optimal treatment modalities for these patients.[1]