Procedure guide
How laser resurfacing works, which laser fits which goal, and what to expect.
Written by Orr Shauly, MD, plastic surgery resident. Updated .
For information and education only, not medical advice.
The short answer.
Laser resurfacing uses light energy absorbed by water in the skin to remove or heat layers of skin, which heal with new collagen and smoother, more even skin.1,2 Fully ablative CO2 resurfacing remains the most effective laser for deep wrinkles but heals slowly, with redness that can last 6 months or more, while fractional lasers heal at the surface within about a week and usually need several sessions.1,2 In a systematic review of 1,093 patients treated with resurfacing lasers, adverse events occurred in 9.7%, and most were temporary.3
- 9.7%
- adverse events
- Patients with an adverse event across 34 studies of 1,093 patients treated with resurfacing lasers.3
- About 1 Week
- surface healing, fractional
- Typical time for the skin surface to heal after ablative fractional treatment.1,2
- 6 Months
- or more of redness after CO2
- Redness after fully ablative CO2 resurfacing can last this long, which has reduced its popularity.1
- 5.0%
- nonablative fractional events
- Adverse events across 856 nonablative fractional treatments, all temporary.4
What laser resurfacing is.
Resurfacing lasers deliver light that is absorbed by a target in the skin, which for wrinkles and texture is water. The heat removes or injures a controlled layer of skin, and healing replaces it with new collagen and healthier tissue.1,2 Lasers that target pigment or blood vessels are used for brown spots and redness.1,5
Ablative lasers remove the outer skin, while nonablative lasers heat the dermis and leave the surface intact. Fractional lasers of either kind treat thousands of microscopic columns and leave bridges of untreated skin that speed healing.1,2 Benefit, recovery time and risk all rise with the depth of injury.1
Types of resurfacing lasers.
| Laser Type | How It Works | Typical Downtime | Best Suited For |
|---|---|---|---|
| Fully Ablative CO21,2 | Vaporizes the surface and heats deeper skin, which tightens collagen | Weeks of healing, redness for months | Deep wrinkles around the mouth and eyes |
| Fully Ablative Erbium1,2 | Removes skin with less heat spread to surrounding tissue | Faster healing than CO2 at a similar depth | Wrinkles and texture, with less risk of lightening |
| Ablative Fractional1,2 | Removes microscopic columns of skin between untreated bridges | Surface heals in about a week, redness for 2 - 8 weeks after aggressive settings | Wrinkles, acne scars, the lower eyelids, neck and chest |
| Nonablative Fractional5 | Heats columns of dermis without breaking the surface | Redness and swelling for 24 - 48 hours | Pigment, fine lines and acne scars, over 3 - 6 sessions |
In a split-face comparison, fully ablative CO2 produced 63% improvement with 7.7 days of crusting, compared with 48% improvement and 3.4 days with erbium, although results depend heavily on depth and energy.1 In a randomized, double-blind split-face trial of 28 patients, a single session of fractional CO2 or fractional erbium reduced periorbital wrinkle depth by about 20%, with no meaningful difference between them.6
Who is a candidate.
Skin type matters most. Darker skin types carry a higher risk of dark spots after treatment, and a history of freckles, melasma or dark marks after injury signals that risk in any skin type.1,2 Nonablative fractional lasers are preferred in darker skin because of their lower risk of hyperpigmentation, and a review of 40 studies found strong evidence for their use in melasma and atrophic scars in skin types IV - VI.7
- Recent Sun: A tan or sun exposure in the 2 weeks before treatment increases the risk of burns and uneven pigment.1,5
- Cold Sores: All patients having ablative treatment receive antiviral medication, starting before treatment.1,2
- Isotretinoin: A review of 1,563 patients found insufficient evidence to delay fractional lasers after isotretinoin, but fully ablative lasers are not recommended during its use.8
- Fewer Skin Appendages: Prior extensive laser hair removal or electrolysis can slow healing after ablative treatment.2
What happens during treatment.
- Protection: Everyone in the room wears laser-specific eyewear, the patient's eyes are shielded, and fire precautions and smoke evacuation are used.2,5
- Anesthesia: Numbing cream is usually enough for nonablative treatment, while deeper ablative treatment may use nerve blocks, local injections, sedation or general anesthesia.2,5
- Treatment: The laser is passed over each facial region, and the endpoint, such as a color change in the skin, guides when to stop.1,2
- Blending: Edges are feathered between treated and untreated areas to avoid visible lines.1,2
Recovery.
Recovery depends on how deep the treatment goes. These milestones come from surgical textbooks and vary by device and settings.1,2,5
| Time | What Usually Happens |
|---|---|
| Days 1 - 31,2 | Oozing and crusting form, swelling peaks, and an occlusive dressing may be used |
| Up to 2 Weeks1 | Antiviral medication continues |
| Days 7 - 101,2 | New skin covers the surface, and most patients resume normal activities and makeup |
| Months 1 - 42 | Pink redness fades, although it can last longer after fully ablative CO2 |
| Up to 6 Months2 | Final results appear as collagen remodels |
After nonablative treatment there is no open wound, and redness and swelling usually resolve within 24 - 48 hours.1,5
Risks and complications.
| Complication | Reported Rate | Context |
|---|---|---|
| Prolonged Redness2 | 30% | Typically lasts 1 - 4 months |
| Delayed Hypopigmentation2 | 16% | Appears 6 - 12 months after treatment and is usually permanent |
| Hyperpigmentation2 | 5% - 83% | Risk rises with darker skin types |
| Herpes Outbreak2 | 2% - 7.4% | Antivirals are given to all patients |
| Ectropion2 | 2% | Pulling down of the lower eyelid, more likely after prior eyelid surgery |
| Scarring2 | 0.1% - 1% | Most often on the upper lip, jawline, cheeks, eyelids and neck |
Fractional treatments carry lower risks. After ablative fractional treatment, redness lasted more than 3 months in 7%, and hyperpigmentation occurred in 20% - 27%.2 Across 856 nonablative fractional treatments, adverse events occurred in 5.0%, most often prolonged redness (1.8%) and hyperpigmentation (1.1%), with no long-term problems.4
With nonablative lasers, hyperpigmentation was reported in 0.3% of the fairest skin type vs 33% of skin type V.5 In 107 Asian patients treated with fractional CO2 for acne scars, 15.0% had an adverse event, including hyperpigmentation in 6.4% and scarring in 0.6%.9 The neck and chest scar more easily than the face, so they are treated conservatively.1
What the evidence shows.
- Overall Safety: In 1,093 patients, adverse events occurred in 9.7%, and only 5 developed hypertrophic scars.3
- Acne Scars: In a meta-analysis of 5 comparative studies, fractional CO2 was more likely than erbium lasers to improve scars by more than 50%, at the cost of more pain and about 3.67 more days of downtime.10
- Repeat Sessions: Periorbital wrinkles improved noticeably in 30% of patients after one fractional treatment and 54% after four.1
- With a Facelift: In 86 patients who had fractional CO2 over lifted facelift skin at the same operation, all healed within a week with no flap loss.11
Melasma is hard to treat predictably with lasers. Early improvement can be followed by recurrence or hyperpigmentation, and topical treatment remains the mainstay.1
What we don't know yet.
Common questions.
How long is the downtime after laser resurfacing?
It depends on the laser. Nonablative treatment causes redness and swelling for a day or two. Fractional ablative treatment heals at the surface in about a week, and fully ablative CO2 takes 7 - 10 days to heal with redness that can last months.
What is the difference between ablative and nonablative lasers?
Ablative lasers remove the outer layer of skin and give stronger results with more downtime. Nonablative lasers heat the deeper skin without breaking the surface, so recovery is quick but more sessions are needed and results are milder.
Is laser resurfacing safe for darker skin?
It can be, with the right device and conservative settings. Darker skin has a higher risk of dark spots after treatment, so nonablative fractional lasers, careful skin preparation and sun protection are usually preferred.
How many laser treatments will I need?
Fractional lasers treat only part of the skin each session, so several sessions are typical, and nonablative fractional lasers often need 3 - 6 treatments spaced weeks apart. Deeper fully ablative treatments produce more change in a single session, with longer recovery.
Can laser resurfacing be done at the same time as a facelift?
In one series of 86 patients, fractional CO2 laser over the lifted facelift skin healed within a week with no flap loss. Whether combining is appropriate depends on the facelift technique and the individual patient.
Is laser resurfacing right for me?
Only an in-person evaluation can answer that. This guide is educational and cannot assess an individual case. A qualified plastic surgeon or dermatologist can review your skin type, goals and history with you.
Key terms.
- Ablative Laser
- A laser that removes the outer layers of skin, such as CO2 and erbium lasers.
- Nonablative Laser
- A laser that heats deeper skin without removing the surface.
- Fractional Laser
- A laser that treats microscopic columns of skin and leaves untreated skin between them to speed healing.
- CO2 Laser
- A 10,600 nm ablative laser that vaporizes skin and tightens collagen with heat.
- Erbium Laser
- A 2,940 nm ablative laser that removes skin with less heat spread than CO2.
- Selective Photothermolysis
- Using a wavelength absorbed by a specific target, such as water, pigment or blood, to heat it while sparing surrounding tissue.
- Hypopigmentation
- Lightening of the skin from loss of pigment cells, which can be permanent after deep resurfacing.
- Ectropion
- Outward pulling of the lower eyelid away from the eye.
References.
- 1.Basci D, Kenkel J. Nonsurgical facial rejuvenation and skin resurfacing. In: Chung KC, editor. Grabb and Smith's plastic surgery. 8th ed. Philadelphia: Wolters Kluwer; 2020. p. 459-71.
- 2.Freeman DW, Austin MB, Burns AJ. Ablative laser resurfacing. In: Janis JE, editor. Essentials of aesthetic surgery. New York: Thieme; 2018. p. 212-22.
- 3.Mirza HN, Mirza FN, Khatri KA. Outcomes and adverse effects of ablative vs nonablative lasers for skin resurfacing: A systematic review of 1093 patients. Dermatol Ther. 2021;34(1):e14432. PubMed
- 4.Lee SM, Kim MS, Kim YJ, Won CH, Lee MW, Choi JH, et al. Adverse events of non-ablative fractional laser photothermolysis: a retrospective study of 856 treatments in 362 patients. J Dermatolog Treat. 2014;25(4):304-7. PubMed
- 5.Khansa I, Austin MB, Burns AJ. Nonablative laser resurfacing. In: Janis JE, editor. Essentials of aesthetic surgery. New York: Thieme; 2018. p. 223-30.
- 6.Karsai S, Czarnecka A, Jünger M, Raulin C. Ablative fractional lasers (CO(2) and Er:YAG): a randomized controlled double-blind split-face trial of the treatment of peri-orbital rhytides. Lasers Surg Med. 2010;42(2):160-7. PubMed
- 7.Aggarwal I, Rossi M, Puyana C, Tsoukas M. Review of Fractional Nonablative Lasers for the Treatment of Dermatologic Conditions in Darker Skin Phototypes. Dermatol Surg. 2024;50(5):459-66. PubMed
- 8.Latifaltojar R, Pour Mohammad A, Goodarzi A. Keloid Formation and Any Skin Complications in Patients Treated With Isotretinoin and Undergone Any Skin-Related Procedures. J Cosmet Dermatol. 2025;24(2):e16680. PubMed
- 9.Ochi H, Tan L, Tan WP, Goh CL. Treatment of Facial Acne Scarring With Fractional Carbon Dioxide Laser in Asians, a Retrospective Analysis of Efficacy and Complications. Dermatol Surg. 2017;43(9):1137-43. PubMed
- 10.Song X, Zhi BW. Comparative efficacy and safety of fractional carbon dioxide and erbium-based fractional lasers for atrophic acne scars: A systematic review and meta-analysis. Lasers Med Sci. 2026;41(1):222. PubMed
- 11.Wright EJ, Struck SK. Facelift combined with simultaneous fractional laser resurfacing: Outcomes and complications. J Plast Reconstr Aesthet Surg. 2015;68(10):1332-7. PubMed