Part II · Smart aesthetics
Lasers, Peels, and Resurfacing
How light, heat, and chemical resurfacing target pigment, redness, texture, and scars.
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This page includes the opening section of the chapter. The complete chapter is available in the book.
This is where we get into the procedures that actually change your skin.
I want to draw a distinction. Botox and fillers change your appearance by relaxing muscles or adding volume. They don't change the skin itself. The skin is still doing whatever it was doing, just on a face that looks different.
Lasers, peels, and resurfacing change the skin. The texture, the tone, the pigmentation, the depth of lines. The underlying tissue is altered, often dramatically, by these treatments. This is the category that addresses everything Botox and filler can't touch.
It's also the category where the gap between what each treatment can do is widest, and where matching the right treatment to the right patient matters most. A laser appropriate for sun damage in one patient could cause real problems in another patient with darker skin. A peel that's gentle for one person can be aggressive for another. The expertise required isn't just technical skill with the device. It's judgment about who should get what, at what setting, with what preparation, with what recovery support.
Let me walk you through the landscape.
What Lasers Actually Do
A laser delivers focused light energy at specific wavelengths. Different wavelengths are absorbed by different targets in the skin: water, pigment (melanin), red blood cells (hemoglobin), or specific colors of tattoo ink. By choosing the wavelength, the energy, and the pulse duration, a laser can target a specific structure in the skin while leaving surrounding tissue relatively untouched.
The categories of laser most relevant to cosmetic dermatology:
Vascular lasers. Target blood vessels and redness. Used for rosacea, visible facial vessels, port-wine stains, and similar concerns. Common platforms: pulsed-dye laser (V-beam), KTP lasers.
Pigment lasers. Target melanin to break up unwanted pigmentation. Used for sun spots, age spots, certain types of melasma, and tattoo removal. Common platforms: Q-switched lasers, picosecond lasers (PicoSure, PicoWay, Discovery Pico).
Ablative lasers. Remove the surface of the skin in a controlled way to allow it to heal back smoother and more uniform. Used for significant sun damage, deeper wrinkles, and acne scarring. Common platforms: CO2 lasers, erbium lasers. The most aggressive category, with the longest downtime.
Non-ablative fractional lasers. Create columns of heated tissue beneath the skin without removing the surface. Used for moderate texture concerns, fine lines, and skin quality improvement with less downtime than ablative. Common platforms: Fraxel, Clear+Brilliant.
IPL (Intense Pulsed Light). Technically not a laser, but in the same category. Uses broad-spectrum light to target multiple chromophores. Excellent for sun damage, mild redness, and overall skin tone improvement. Lower energy and broader application than focused lasers.
Q-switched and picosecond lasers. High-energy, very short pulses primarily used for pigment and tattoo concerns.
Each of these has appropriate uses, optimal patient candidates, and specific risks. Treating them as interchangeable is a recipe for poor outcomes.
What Chemical Peels Do
Peels use acid solutions to remove the outer layers of skin in a controlled manner. The skin then heals, with the new surface being smoother, more uniform, and often more youthful in appearance.
Peels are categorized by depth:
Superficial peels. Penetrate only the outermost layer (epidermis). Glycolic acid, lactic acid, salicylic acid, low-strength TCA. Mild peeling, minimal downtime, used for surface concerns like dullness, mild texture, or maintenance.
Medium-depth peels. Penetrate deeper into the papillary dermis. Higher-strength TCA, often combined with other agents. Moderate downtime, visible peeling for a week, used for moderate sun damage, melasma, and fine wrinkles.
Deep peels. Reach into the reticular dermis. Phenol-based peels and high-strength TCA. Significant downtime (weeks), substantial recovery, used for severe sun damage, deep wrinkles, and significant aging concerns. Less commonly performed now that laser resurfacing has improved.
What good candidates for peels look like:
Lighter skin tones (Fitzpatrick types I-III) tolerate aggressive peeling better than darker skin tones, which carry higher risk of post-inflammatory pigmentation.
Concerns that are surface-level to mid-depth rather than deep.