A Guide to Lasers—and What’s Right for Your Skin

Updated on: June 15, 2023

How do you pick the right laser for your skin? There have never been more choices, says Robert Anolik, MD, a clinical assistant professor of dermatology at NYU School of Medicine and top board-certified dermatologist who practices at the Laser and Skin Surgery Center of New York. Anolik has an enormous knowledge about and experience with the newest skin-improving technologies in multiple areas of dermatology—including lasers, radiofrequency, Botox, and fillers—and beyond, to emerging technologies like Micro-Coring. He toggles between research and established facial laser therapies every day, combining new and existing technologies for his patients.

It turns out not everything we think of as a face laser actually is one. “Not all these technologies are lasers,” says Anolik. “Lasers are beams of light that are simply one wavelength. In cosmetic dermatology, we use devices that harness other forms of energy to stimulate a collagen-growth reaction, including radiofrequency, as in Thermage; ultrasound, like Sofwave or Ulthera; and microsurgery, like the Micro-Coring of ellacor. Notably, since these radiofrequency and ultrasound technologies are not lasers, they’re less risky for darker skin—if you treat a darker skin tone with an aggressive CO2 laser, for example, there’s a typically greater risk of hyperpigmentation.”

Lasers versus Botox and Fillers

Pulling back even further, patients are often unclear about what these devices can do for skin, as opposed to fillers, neuromodulators like Botox, or even plastic surgery, Anolik says. “Botox and other neuromodulators smooth wrinkles, fillers shape and add volume to the face, and lasers are about improving collagen quality, as well as discoloration,” he says. “If you’ve got redness, pigment, sun spots, melasma, superficial fine lines and wrinkles, or texture you don’t like, those are issues that lasers help with. A face-lift is not going to change texture, pigment—any of those kinds of things.”

Plastic surgery and devices do both offer certain types of benefits, like firming sagging tissue; they just work in different ways, require different amounts of downtime, and deliver different results from patient to patient. “Devices that work at the deeper planes of the skin, whether that’s radiofrequency, ultrasound, aggressive resurfacing, or fractional microneedling, aid collagen production, subtly firming the skin, which can help treat sagging,” Anolik says. “Plastic surgery doesn’t stimulate collagen production at all, but instead excises extra skin in a more dramatic surgery and therefore clearly treats sagging.”

At-Home Devices

Anolik sees potential in the new at-home devices—most of them are based in technologies used in dermatologists’ offices. Used consistently, they can support the results of in-office treatments, “just the way sunscreen and at-home treatments with retinol or AHAs can support what we’re doing in the office,” he says.

That said, he notes that in order to be safe enough to get FDA approval for consumer use, at-home lasers and devices are necessarily less powerful than in-office treatments. “They usually require real dedication—using the device every day for a certain amount of time, for example—which some patients have the bandwidth for and others don’t. But I think as a support, there’s potential,” he says.

No matter what technologies he’s using, Anolik customizes his treatment plans by patient. “You’re always going to find certain people who are the best responders to certain technologies,” he says. “I’m fortunate that I get to work with all the different strategies, so we can try different approaches to suit each patient: We might try ultrasonic energy, like Ultherapy, first; then six months later, we’d do some radiofrequency, like Thermage; six months after that, we might try a different ultrasound delivery method with Sofwave. We’d note any differences in response we could detect, and we’d ask them, ‘Did you notice differences?’ Lasers don’t always produce the same result in different people. That said, no matter which technology a patient ends up preferring, all will likely help delay the inevitable laxity that’s coming as we age.”

Beyond being a goop favorite, Anolik is a recipient of ELLE magazine’s Genius Award (they dubbed him the Techie), he’s featured on New York Magazine’s list of best doctors, and he’s the author of numerous academic articles, and lectures frequently on the subject of laser surgery, cosmetic dermatology, and skin surgery. Here, he answers our questions on which laser does what, along with how best to address common skin issues, from aging to rosacea.

5 Big Questions for Robert Anolik, MD

Q

What’s the best way to lift sagging skin—what really tightens skin?

A

The science that allows cosmetic dermatologists to tighten skin is one of the fastest growing areas in our field. I am involved in a number of clinical trials using these technologies, and there are several very interesting strategies that seem to be improving daily.

Radiofrequency

Radiofrequency was one of the first technologies to help tighten skin. A popular system is Thermage. With this science, we can safely deliver radiofrequency energy into the skin to produce heat throughout the underlying collagen fibers. This can stimulate remodeling of existing collagen and the production of new collagen. The result is a tightening and firming of the skin. This used to be a painful treatment, but innovations in delivery make it very comfortable. These strategies include vibration in the handpiece that touches the skin as well as cooling methods to comfort the surface skin.

Ultrasound

Ultrasound is one of the newer technologies used in skin tightening and lifting. One of the popular systems is Ulthera. This kind of technology allows me to safely deliver sound waves under the skin that focus on points at very specific depths. Think of the way a magnifying lens can take sunlight, focus that light onto a leaf, and leave a burn. Ultrasound can pass right through the skin’s surface painlessly but be focused to deliver the energy at a specific point at a specific depth under the skin. When the energy reaches the target area, the temperature goes up, stimulating collagen remodeling and collagen production. A newer version of ultrasound technology is Sofwave, which delivers a more diffuse plane of ultrasound waves instead of focusing on specific points. These procedures tend to be uncomfortable, but like the Thermage science, it has become more comfortable with strategies that include lower energy delivery with more passes of the sound waves.

Microneedling with Radiofrequency

Microneedling alone doesn’t do as much, as far as I’ve observed, but integrating it with radiofrequency can be powerful for skin. We can put these very fine insulated needles exactly at the depth that’s ideal, and the tips of those needles deliver the intense radiofrequency pulses or heat precisely where we need them. This means we can get to deeper planes of the skin in a nonwounding way—there’s less downtime because we’re bypassing the surface. For instance, what Fraxel can do at the top layers of skin is remarkably helpful, but these needles can dive into deeper planes, where they can help treat deeper acne scars, deeper wrinkles, and even burns.

Micro-Coring

This is a technology that’s been in the works for years, from Cytrellis, for tightening—it’s FDA-cleared for the lower face, and that may evolve as doctors work with it off-label. Unlike ultrasound or radiofrequency technologies, it’s not heat-based: Instead, it involves very fine needles—each a fraction of a millimeter—and as they come out of the skin, they withdraw a small amount of skin tissue, so you’re removing thousands of fragments of skin diffusely, and the skin heals around the gaps, which tightens it scarlessly. Normally, if you cut into the dermis, you disrupt its natural organization and there will be a mark if you look closely. But an excision that is precise and less than half a millimeter is imperceptible: You’re removing skin, which heals around the gaps, generating collagen, and it’s extremely helpful for tightening. It just came out this year, but we’ve studied Micro-Coring extensively, treating patients over many years. We use numbing cream and inject lidocaine so there’s zero sensation, and the downtime—you look pink and blotchy and treated for about a week—is much less than that with a CO2 laser such as a Fraxel re:pair. At this point, we recommend doing it two or three times, with a month in between each treatment, for the best results. It’s a whole new category for resurfacing and tightening.

Neuromodulators and Fillers

Finally, it’s important to note that cosmetic injections of Botox and filler also allow me to lift skin. With Botox, I am able to strategically place it into muscles that have a downward pull. These muscles include those immediately below the forehead and above the eye. Ideal placement here gives people a noticeable brow lift. (Don’t worry about Spock eyebrows—these are prevented by delicate placement of Botox in the forehead.) Botox can also be used in the chin to lift the corners of the mouth. And it can be injected into the neck to deliver a lift to the jowls and neck bands. Some of these methods are off-label but are routinely used by experienced board-certified dermatologists.

Filler injections also give the face a lift. In the hands of someone other than an expert doctor, filler results in a full face—which is not the goal. Skillful placement of filler results in contour and lift. Injections underneath facial muscles and in areas where the young face once had more-significant, supportive bone and fat pads give a natural-looking lift. No one will know you were treated, but the face is recontoured and lifted to prevent the appearance of sagging skin and jowls.

PRP

Platelet-rich plasma (PRP) injections were developed for orthopedic use in joints, but the science is used off-label in dermatology. Many colleagues whom I respect have published reports showing the likely benefits of PRP’s anti-inflammatory molecules and growth factors for both skin and hair. I incorporate those modalities in my office. Sometimes I’ll inject PRP directly into the skin, and at other times I’ll apply it after resurfacing laser treatments. Lasers often have their own benefits but also allow permeation of the applied PRP into the skin itself.

While all these lifting techniques are exciting and becoming more popular, I cannot say that we can achieve the lifting outcomes of surgery. But these procedures don’t carry the more substantial risks, scars, or permanency of surgery. And I theorize that remodeling and production of new collagen in the skin will slow the rate at which your skin sags over time, since the architecture of the skin is newer and healthier with these treatments. Please note that some of what I’ve described above is off-label by the FDA but used routinely.

Q

Are there antiwrinkle lasers? Which are best for surface skin texture issues? Do you believe that lasers are the best approach for crepiness?

A

In general, lasers that remodel collagen and stimulate collagen production throughout the dermis improve the appearance of wrinkles, texture, and crepiness. This is because the first two relate to the weakening or irregular conformations of the dermal collagen, while the latter is a result of the thinning of the dermal collagen. Remodeled and new collagen normalizes this layer so that it is more organized, more even in distribution, and deeper.

There is a surprising misconception that lasers take off the top layers of skin, leaving it white, shiny, or thinned. This is not the case. I suspect this mistaken patient belief relates to older methods of rejuvenation, like dermabrasion, deep chemical peels, and old-fashioned lasers, all of which did remove surface layers of skin and carried a risk of removing all normal pigment cells called melanocytes. (Today, I still see patients in the office who were treated in the ’80s, ’90s, and early 2000s with these older methods, and some do have these unusual signs of treatment.)

Fortunately, rejuvenating lasers today generally penetrate the surface skin, stimulating the collagen from within and below and triggering its production, rather than simply shearing off the surface. This is because resurfacing lasers today are fractional—meaning that the laser beam is delivered in a pixelated manner, touching the skin in tiny dots, separated by areas of untreated skin. This leaves behind healthy pigment-producing cells (melanocytes) and other normal skin cells unaffected by the treatment that rapidly heal the skin and markedly diminish the risk of abnormal pigmentation.

Fractional Resurfacing

The most commonly used lasers for these strategies are fractional resurfacing lasers. The most popular ones are those with limited downtime (generally from a few hours of pink and dryness to four or five days of pink and dryness). My current strategies include the nonablative (nonwounding) Clear + Brilliant laser and the Fraxel re:store dual laser. Not only do these lasers stimulate collagen, they also allow for a surface exfoliation of the skin, which sheds abnormal browning and dullness. Consequently, the skin looks brighter.

The stronger lasers are ablative (meaning they superficially wound the skin), leaving the skin with redness and scabs for about a week, followed by three to four weeks of pink skin. In the later part of that three to four weeks, the pink can generally be masked with makeup, since the skin has healed. These stronger versions are usually reserved for more-substantial signs of aging, uneven texture, deep wrinkling, or scars—often acne scars.

More good news about these therapies: I was part of a clinical trial published in 2012 that demonstrated the likelihood that these newer fractional laser treatments promote not just more beautiful skin but healthier skin as well, by supporting the elimination of precancerous skin changes known as actinic keratoses. These precancers have the potential to turn into squamous cell carcinomas.

Pico Lasers

Another method of collagen stimulation that benefits wrinkles, texture, and crepiness: picosecond laser technology. It first appeared after the FDA approval for picosecond laser treatment of pigment, most notably tattoos. (The one I use in my office is called the Cynosure PicoSure laser.) When I say picosecond technology, what I’m referring to is the rate at which laser energy is delivered to the skin. In this case, a beam of light at a certain energy is delivered within a picosecond, an extraordinarily rapid rate. I participated in clinical trials that studied the effects of these picosecond lasers when passing through a specialized diffractive lens. The lens ultimately delivered areas of peak energy and low energy, almost like a fractional laser, but there was always some low level of energy touching the surface of the skin. There are a number of theories as to why this laser technology helps remodel and produce collagen. One of the most interesting to me is that the rapid delivery of laser light might stimulate a vibration throughout the surface of the skin, triggering the collagen response. I have since been a part of publications and lectures describing the clinical trials we performed. What makes this science all the more interesting—and desirable for our patients—is the limited downtime. Usually the skin is just a bit pink for a few hours after treatment.

Rapid Acoustic Pulse

This is a technology that’s so far best used as complementary therapy—it can mechanically disrupt fragments of pigment for tattoo removal. Laser is still superior, but the two technologies can be used in tandem.

Q

Which lasers fight redness and promote skin evenness?

A

Redness on the skin is caused by a number of things, including sun damage, genetics, hormones, and rosacea. Topical treatments include prescription drugs that are able to limit some underlying inflammation, like metronidazole creams and azelaic acid gels and sulfacetamide lotions. But the most effective method of reducing facial redness is laser therapy. The underlying concept is that specific laser wavelengths can be delivered to the skin in order to heat and eliminate blood vessels while leaving the surrounding skin structures (hair, collagen, pigment, etc.) untouched. These blood vessels are simply cosmetic nuisances—we are not eliminating medically important structures.

The gold standard of redness reduction for years has been the pulsed dye laser (example: Vbeam laser). It’s so effective that we can use it to eliminate port-wine stain birthmarks (like the one that was on Gorbachev’s forehead). I most often use it for redness reduction stemming from the common causes mentioned earlier but also port-wine stains and the redness of scars (sometimes acne-related or surgical or traumatic). Each condition should be treated differently; an expert cosmetic dermatologist will know which parameters and strategies are best used to treat different targets.

Newer lasers have emerged that complement these treatments—and can sometimes be the primary laser choice. These include KTP lasers (like the excel V laser). These lasers give us two different wavelengths of light that are distinct from pulsed dye lasers. These newer wavelengths can often better target the larger blood vessels that look like red lines or squiggles or blue paths on the face (google “telangiectasia” and “periorbital vein” to see examples of what I mean).

When I treat a patient’s redness, I look for both diffuse redness and more pronounced red or blue capillaries. Patients with redness usually have both. For these patients, I use both a pulsed dye laser and a KTP laser on the same day to achieve optimal redness reduction. It’s a very tolerable treatment and feels like rubber band snaps over the face. Unpleasant but not painful. It usually lasts only a few seconds, and the downtime is usually just a few hours of looking blotchy and pink. Many of my patients don’t bother with makeup to hide the appearance, but patients can put makeup on afterward if they feel it’s very obvious.

Q

What’s the best treatment for dark spots?

A

The best treatment for dark spots is, without question, laser treatment once the spots appear. Topical products are helpful, but they’re most helpful in eliminating the development of brown spots. Consistent use of sunscreen and retinoids helps maintain even, bright tone.

The best facial laser treatments for dark spots fall into two major categories: pigment-specific lasers and fractional resurfacing lasers. Pigment-specific lasers are spot treatment therapies. They are used on one spot at a time and work by selectively heating the extra pigment particles in the target area. These lasers include ruby lasers, YAG lasers, and alexandrite lasers. Typically, the treated areas on the face appear as tiny surface scabs for several days to a week. So planning the right time for these treatments is important, since you may have several days of looking treated, even with makeup.

The other category, fractional resurfacing lasers, primarily builds collagen in the skin but also exfoliates the surface. There are many intensities of these lasers, from ones that leave the skin pink and dry for a few hours to one that leaves it looking superficially wounded for a week and pink for another three to four weeks. The stronger lasers are usually used only for patients with dramatically spotty or wrinkled skin; most patients do great with options that leave them pink and dry for a few hours or pink and dry for a few days.

The best treatment overall is combination therapy. To achieve the optimal outcomes, I encourage all my patients to protect their skin daily with sunscreen—even in winter and on rainy days—and, if their skin can tolerate it, to use retinol or prescription retinoids on a nightly basis. I say if they can tolerate it because the use of retinoids can make the skin irritated, but usually the skin becomes used to it, especially if the patient is moisturizing well. I use it nightly without any trouble. I then bring in the use of ruby, YAG, or alexandrite lasers for concentrated sun spots and fractional resurfacing lasers to diffusely exfoliate and brighten skin tone.

When my patients do this combination routinely, they are the ones people look at and say, “Wow, your skin is beautiful.”

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Q

What are the best options to treat acne?

A

We can use blue and red light to assist with inflammatory processes of acne. But what I find more effective is integrating light and vacuum benefits in a process called photopneumatic therapy. The system I use is called Isolaz. The procedure involves steaming the skin, then applying a handpiece to the skin that can pull excess oils out of the pores. Then the system delivers an intense pulsed light that can kill acne-causing bacteria and assist in normalizing the pink and brown acne discoloration on the skin. We are in the process of developing techniques with a variety of new laser technologies that target oil glands in the skin. These approaches could markedly reduce acne, even in the long term. There’s a recently cleared technology called Accure, which is one of these exciting options.