Laser (light amplification by stimulated emission of radiation) surgery is used to treat a variety of cosmetic and noncosmetic skin conditions. It involves the use of lasers that cut, seal or vaporize skin tissue and blood vessels in the affected area.

Improved laser technology and increased understanding of how lasers interact with tissue has made it possible to accurately target specific areas of the skin. Stronger lasers are typically used for lesions or markings that extend deep into the skin, whereas procedures involving only the outer layers of the skin are typically performed with lasers of lower intensity.

Prior to surgery, the operating physician determines the appropriate laser device to use, predicts the outcome of the treatment and instructs the patient about how to prepare (e.g., dietary restrictions). The patient’s medical history will be reviewed and a physical examination may also be performed.

Recovery time from laser surgery depends on which surgery is performed and the patient’s ability to heal. However, most pain or inflammation experienced by the patient following surgery is usually manageable with over-the-counter medications (e.g., ibuprofen).

Laser surgery has fewer of the risks associated with traditional skin surgery (e.g., reactions to general anesthetic). However, laser surgery may cause adverse affects such as skin discoloration or scarring.

Laser (light amplification by stimulated emission of radiation) surgery is used to treat a variety of skin conditions. It involves the use of lasers that cut, seal or vaporize skin tissue and blood vessels in the affected area.

Lasers have been used surgically for several decades. However, they were typically avoided in the past because they often caused adverse affects (e.g., scarring). Current laser technology and increased understanding of how lasers interact with skin tissue enables physicians to accurately target specific areas of the skin, without harming surrounding tissue, and lower the risk for these complications.

Certain parts of the skin called chromophores absorb the light from the laser when it is directed at the skin. When this occurs, physical, mechanical, chemical or temperature changes occur inside the tissue of the affected area. This often removes or diminishes the unwanted growth or marking with little or no lasting adverse affects.

In order for a laser to be produced, a large number of electrons must be “excited.” Most lasers use intense flashes of light or electrical discharges to initiate this process. The electron settles after being excited and releases energy in the form of photons (light energy). The photon that is emitted has a specific wavelength (color) that is determined by the energy level of the electron. The wavelength is measured in nanometers (one billionth of a meter) and describes a laser’s intensity. Higher measurements indicate stronger lasers and lower measurements indicate lasers that are less intense.

The light a laser produces is much different than ordinary “white” light, which is weak and travels in many different directions. Lasers produce strong, concentrated light that is organized (coherent), with each photon moving in unison with the others.

Currently, no single laser is available that can be used for all cosmetic and noncosmetic skin conditions. In addition, the patient's skin type and hair color, as well as the location of the area being treated, may affect the physician's choice of laser. Some of the more commonly used lasers include:

• Pulsed lasers. Each of these lasers falls into one of three subcategories:
  
  
• • Pulsed dye lasers (PDL). The treatment of choice for spider veins, rosacea, and various other skin conditions. Ultra-long or variable pulsed-dye lasers (e.g., V-Beam) are capable of treating larger areas of skin with fewer side effects.
    
    
  • Pulsed KTP lasers. Used to treat vascular (pertaining to blood vessels) skin conditions. Pulsed KTP lasers slowly heat the affected blood vessels for long durations allowing the vessels to cool without rupturing.
    
    
  • Long-pulsed infrared laser. Primarily used to treat leg vein disorders that affect the skin. Long-pulsed infrared lasers emit a longer wavelength, penetrating farther into the skin than other lasers.
    
    
• CO2 (carbon dioxide) lasers. These include the high-powered pulsed CO2 laser, which is used for procedures that require deep penetration of the skin.
  
  
• Er:YAG laser. Used for more superficial procedures (e.g., skin resurfacing).
  
  
• Red-light or IR-light systems. Commonly used for hair removal. There are numerous types of lasers that can be used to remove unwanted body hair. Different types may be better suited depending on patient skin and hair color.
  
  
• Continuous-wave lasers. Commonly used until the mid 1980s. They are less popular today because of an increased risk for scarring and skin discoloration as opposed to more modern lasers.
  
  
• Quasicontinuous-wave lasers. Also used frequently in the past to treat many different skin conditions. However, they are not as popular today because of an increased likelihood of scarring.
  
  
• Q-switched lasers. Used to treat or remove superficial and deep pigmented (colored) lesions, tattoo ink and pigment-related skin abnormalities.

In addition, a highly versatile laser–like device known as the intense pulsed light (IPL) source may be used to treat large areas of skin for cosmetic (e.g., hair removal) and noncosmetic procedures (e.g., removal of varicose veins). The IPL can be used extensively because it produces pulsed light at a variety of pulse durations and intervals. However, more treatments of longer durations, as well as a higher degree of expertise by the operator tend to be necessary with the IPL source compared to other lasers.

Many cosmetic procedures are performed using lasers. Some of the most common include:

• Laser resurfacing (“laser peel”). A carbon dioxide (CO2) or Er:YAG laser is used to remove layers of wrinkled or damaged skin. The laser evaporates the water present in the skin, resulting in removal of the skin's top layers and tightening of the lower levels. This is most commonly performed to minimize the appearance of fine lines around the mouth and eyes. It may also be used to treat facial scars or to correct areas where skin color (pigmentation) is uneven. Laser skin resurfacing can be performed on an isolated region or across the entire face. It is often done along with other cosmetic procedures (e.g., facelift).
  
  
• Hair removal. Lasers remove unwanted hair by targeting melanin, the pigment that is found in hair follicles and is responsible for hair color. The energy absorbed by the melanin is converted to heat. This rise in temperature destroys the follicle, causing it to stop or lessen hair growth. Multiple treatments may be required to permanently remove unwanted hair.
  
  
• Tattoo removal. Lasers remove or diminish the appearance of tattoos by delivering high-energy bursts of light in short pulses that is absorbed by the tattoo ink. The laser energy causes ink particles to break apart. Multiple lasers of different intensity may be used for tattoos that are large or have a wide array of colors (as each color absorbs a different wavelength).

Lasers are used surgically to treat a wide variety of noncosmetic skin conditions. Some of the more common skin conditions treated with lasers includes:

• Spider veins (telangiectasia). Permanently enlarged (dilated) small blood vessels that develop either toward the surface of the skin or internally. Lasers remove spider veins by sending strong bursts of light onto the vein, causing the vein to slowly fade and disappear.
  
  
• Rosacea. A vascular (blood vessel) condition leading to redness and pimples on the nose. Heat from the laser’s energy builds within the visible vessels and causes them to diminish or disintegrate.
  
  
• Common warts. Small growths typically found on the hands and feet. Laser surgery uses heat vaporization (change from solid to gas) to eliminate warts that do not respond to more traditional treatment (e.g., freezing).
  
  
• Removal of skin growths and birthmarks. Laser surgery may be appropriate to remove freckles, moles, port-wine stains, sunspots and other markings by vaporizing the growth or skin of the affected area. The treatment may also be used to remove precancerous lesions caused by sun exposure.
  
  
• Scars. Certain types of scars (e.g., keloids, hypertrophic scars) can be lessened with laser surgery. Several different types of lasers may be used. The advantage of a laser is precision that may minimize trauma and inflammation of the skin. Because scars tend to recur, laser therapy is sometimes combined with other types of therapy, such as corticosteroid injection.
  
  
• Granulomas. Small area of inflammatory tissue in the body caused by tissue injury (e.g., infection). Granulomas are effectively removed with pulsed–dye lasers. However, multiple treatments are usually necessary.
  
  
• Genital warts. Growths on or around the genitals or anus caused by particular varieties of the human papilloma virus (HPV). Laser surgery is often effective at vaporizing genital warts. However, this form of treatment may not cure the virus or prevent new warts from growing.
  
  
• Skin cancer. Laser therapy has recently been used to treat squamous cell carcinoma in situ, which involves only the epidermis (outer layer of the skin). It can also be used to treat superficial basal cell carcinomas, which are also located near the surface of the skin.

During an initial consultation, the physician determines the ideal laser device to use and provides a prediction of the outcome of the treatment. The patient’s medical history will be reviewed, including existing medical conditions and past medical or cosmetic procedures, and a list of current medications will be taken. A physical examination will also be performed to check for any underlying conditions that may complicate surgery. Patients may wish to consult a dermatologist, a specialist in skin conditions.

A spot test in a small site is generally done to assess the patient’s response to laser surgery and to determine the setting for laser treatment. The best sites for this test are in low-visibility areas with the same skin type as the area intended for treatment.

Patients who are scheduled to undergo laser surgery should follow any preparatory instruction given by their surgeon. As with any form of surgery, this may include dietary restrictions and taking certain medications for several hours or days prior to the procedure. For instance, those with a history of herpes simplex virus may be required to take antiviral medications to prevent a breakout following surgery. A patient should also make plans for postsurgical care and help, if needed.

Both cosmetic and noncosmetic laser surgery do not usually require anesthesia (medication used to eliminate pain). However, some patients may require a topical (applied directly to the skin) or intralesional (applied directly into the lesion) anesthetic for extensive procedures such as the removal of large pigmented lesions, extensive tattoos or the treatment of sensitive areas (e.g., fingers). In addition, laser surgery may be difficult for children and require the use of anesthesia in some form (e.g., local anesthetic).   

Before the procedure, the operation site may be cooled with cooling gel or active cooling systems that are integrated into the laser apparatus. This helps reduce pain and the risk of adverse effects (e.g., scarring). It also allows the laser to be used at higher settings for increased effectiveness. Neighboring areas of the skin may also be covered to prevent unnecessary tissue damage. Protective eyewear is also typically worn by everyone in the room (including the patient) to prevent any potential eye damage.

During laser resurfacing for wrinkles with a CO2 laser, the laser is first passed over the affected area to remove the top layer of skin with as little overlap as possible. This is followed by a gentle but thorough wiping of the dried out (desiccated) debris with saline-soaked sponges. Finally, the borders of the affected area are blended with the surrounding tissue by decreasing the energy and density of laser pulses.

The technique of laser resurfacing varies somewhat if an Er:YAG laser is used. Up to four passes may be required to remove the top layer of skin and as many as eight passes may be needed to complete the procedure. The treated area is typically covered with pulses that slightly overlap.

Acne scars are removed with a different approach than typical skin resurfacing because deeper penetration of the skin is necessary to achieve an acceptable result. The edges of the scar may be treated before the rest of the face because facial swelling during the procedure may obscure the acne scars.

Laser hair removal is usually performed by using heat from the laser to destroy the hair follicle. Most lasers do this by targeting melanin, the substance in the skin that absorb light and produces color.

Laser use for tattoo removal is largely dependent upon the type of tattoo and its pigment (color). Tattoos consisting of more than one color may require the use of more than one laser and more than one treatment session for complete removal. Professional tattoos tend to have a greater variety of inks and colors and therefore may be more resistant to laser treatment. In contrast, amateur, single-colored or older tattoos typically respond better to lasers and require fewer treatments.

Vascular lesions (e.g., rosacea) are most often removed with pulsed dye laser (PDL) pulses emitted through a hand piece held by the operating physician. The pulses of the laser are placed closely with a slight overlap to avoid missing areas between spots. Disappearance of the lesions and/or a slight redness often indicates the endpoint for treatment. 

The techniques and characteristics of laser surgery for removing pigmented lesions (e.g., moles) may vary depending on the type of laser being used, the type of lesion being treated and the color of the patient’s skin. Generally speaking, stronger lasers are used for lesions that extend deep into the skin, whereas more superficial growths or markings are removed with lasers of lower intensity. Patients with darker skin are typically treated with lower energy settings than patients with lighter skin. The number of treatments required may also vary depending on the type and anatomic location of the lesion being treated. Some lesions may require one treatment but others require multiple procedures.

Most cosmetic and noncosmetic laser surgeries are outpatient procedures. However, some cases may require a hospital stay. Patients who will be going home immediately after the surgery may be required to have someone drive them home afterward if they have been sedated.

The time it will take to recover from laser surgery depends largely on which surgery is performed and the healing tendencies of the patient. The operating physician can typically provide a fair estimate of the recovery time needed based on an evaluation of the patient’s medical history.  

Any pain or inflammation experienced by the patient following surgery is usually manageable with over-the-counter medications (e.g., ibuprofen) and ice packs. However, stronger medication may be necessary after laser surgeries in particularly sensitive areas. Topical corticosteroids may also be used for the first day or two following treatment to reduce swelling and topical emollients may be used to maintain skin moisture.

Additional factors that may need to be considered following laser surgery include:

• Exposure to the sun may need to be limited or avoided in the days or weeks following laser surgery to prevent rapid burning (photosensitivity) of newly exposed skin and hyperpigmentation. The physician will advise the patient on appropriate measures to protect the skin.
  
  
• Any bandages that may be applied following laser surgery can usually be removed in about one week.
  
  
• Picking or scratching of crusts that may develop on the treated area can cause scarring and should be avoided.
  
  
• The operating physician may prescribe medication to lessen any reddening or pinkness of the skin that normally develops.
  
  
• Makeup may irritate the skin following laser surgery in some patients and may need to be avoided temporarily.

Typically, lasers are more precise and cause less damage to normal tissues than traditional skin surgeries that use scalpels or other methods. Patients often experience less pain, bleeding, swelling and scarring than they would with traditional skin surgery. In addition, patients usually heal more quickly and are less likely to get infections following surgery. In most cases it can be performed on an outpatient basis without the need for a hospital stay.

Laser surgery is generally less risky than traditional skin surgery. However, certain skin conditions may recur more frequently after laser surgery (e.g., skin cancer) than with other methods that use a scalpel. As a result, repeat procedures may be necessary. Laser surgery is also costly and requires a physician who has specialized training to perform the procedure.

Some of the more common side effects and complications of laser surgery include:

• Reddening of the skin (erythema). Depending on the type of procedure, it may last between one and four months and is considered a normal part of the healing process. It is caused by increased blood flow and inflammation in the affected area.
  
  
• Skin discoloration. One of the most common adverse affect of laser resurfacing. In general, laser surgery of the outer layers may cause darkening of the skin (hyperpigmentation), whereas surgery performed on deeper skin layers may cause the skin to lighten (hypopigmentation). Patients with darker skin tend to be affected most frequently. Skin discoloration may be more severe during the summer months or in continually sunny areas. Skin discoloration usually goes away within a few months if treated early with bleaching creams.
  
  
• Bruising. The laser-treated skin may bruise afterwards. This is a temporary condition that normally lasts 7 to 14 days.
  
  
• Acne. Mild cases of acne may occur in the first few weeks following laser resurfacing in patients with a prior history of acne. It usually responds well to standard acne treatment (e.g., benzoyl peroxide).
  

• Dermatitis or eczema. May occur following laser surgery. However, these conditions are usually temporary and respond well to treatment with moisturizers or corticosteroids.
  
  
• Bacterial or viral skin infection. May occur following laser surgery where skin layers are removed over a larger area (e.g. laser resurfacing). However, bacterial and viral infections can be avoided by administering antibiotics or antivirals prior to surgery.
  
  
• Scarring or changes in skin texture. Typically caused by too many laser passes, a laser intensity that is too high or overlaps previously treated areas. Stubborn markings may be treated multiple times at a lower intensity to minimize this risk.
  
  
• Burns. The skin can retain too much heat and burn if the laser is set too high.

In addition, patients with sensitive skin may react to the medications and lubricants used on the skin during recovery.

There is uncertainty about the potential for some viruses to spread through laser smoke. Consequently, a mask may be worn by the medical staff because of growing concern about the spread of viruses from vaporized skin and tissue. Furthermore, the physician and staff also typically wear sterile gloves and gowns to prevent infected tissue fragments and blood that may become airborne during laser surgery.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about laser surgery:

1. Am I a candidate for laser surgery?
   
   
2. How long will my laser surgery session take?
   
   
3. How many sessions of laser surgery will I need?
   
   
4. Will I experience pain during the procedure? What about after?
   
   
5. How long will it take for me to heal? Will I need to miss work?
   
   
6. Will my surgery be covered by insurance?
   
   
7. What is the likelihood that growths/markings may recur after laser surgery?
   
   
8. How experienced are you in laser surgery?
   
   
9. Will I have any significant scarring or other unwanted effects from my laser surgery?
   
   
10. Will I have to avoid the sun following laser surgery? If so, for how long?