Lasers, Peels, and Resurfacing

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.

Patients willing to comply with pre-treatment and post-treatment protocols, including sun avoidance and proper skincare during recovery.

Patients not currently using strong actives that compromise the barrier or who can stop them in advance of treatment.

Lasers and Peels for Specific Concerns

Let me get practical about what works for what.

Sun damage and brown spots.

For lighter skin tones, IPL is often the workhorse treatment. Several sessions spaced a month apart can dramatically improve sun spots, redness, and overall skin tone. Cost is typically $300 to $600 per session, with three to five sessions for full effect.

For darker skin tones, IPL can be risky and is often inappropriate. Pico lasers can be safer choices, or careful chemical peels designed for pigment in darker skin.

For deep, etched sun damage with significant texture issues, fractional ablative laser resurfacing (like fractional CO2) can be transformative. Downtime is significant (typically a week to ten days of visible recovery), but the results can be remarkable.

Acne scarring.

This is one of the harder things to treat well. Different types of acne scars respond to different treatments.

Atrophic (depressed) scars, particularly boxcar and rolling types, often respond best to fractional laser resurfacing, sometimes combined with subcision (a needle technique that releases the fibrous tethers under the scar) and filler placement.

Ice pick scars (deep narrow scars) are notoriously difficult. TCA CROSS (chemical reconstruction of skin scars) is one technique that can help, where a high concentration of TCA is applied with a toothpick to individual scars to stimulate remodeling.

Hypertrophic and keloid scars (raised scars) need a different approach entirely, often involving steroid injections, silicone treatment, or specific lasers.

Realistic expectations: significant improvement is usually possible. Complete elimination of acne scars is generally not. Multiple sessions are usually required. Plan on a treatment series, not a single appointment.

Melasma.

I want to be careful here because lasers can both help and worsen melasma depending on choice and execution.

Pico lasers can sometimes help when used at gentle settings, often in combination with topical treatments.

Aggressive lasers, especially fractional ablative or non-ablative lasers, can trigger melasma flares, particularly in darker skin tones.

The mainstay of melasma treatment remains topicals, sun protection, and gentle peels designed for pigmentation. Lasers play a supporting role at most.

If a provider's first recommendation for your melasma is laser treatment, especially aggressive laser treatment, get a second opinion.

Rosacea and visible vessels.

Vascular lasers (V-beam, KTP) and IPL are genuinely effective here. Visible facial blood vessels, persistent redness from rosacea, and the broken capillaries that develop with age can all be dramatically improved.

This is one of the procedure categories where I see the most patient emotion. Patients who've struggled with their face flushing or with visible vessels they've been self-conscious about for decades can have life-changing results from a series of treatments.

Texture, fine lines, and skin quality.

Fractional non-ablative lasers (Fraxel, Clear+Brilliant) are workhorses here. They provide meaningful improvement with manageable downtime. Multiple sessions spaced weeks to a month apart.

Fractional ablative lasers provide more dramatic results in fewer sessions but with more downtime.

Chemical peels of various depths can be used for similar concerns, often as a more affordable alternative to laser, though typically with somewhat less dramatic results.

Loose skin.

This is where lasers and peels reach their limits. They can improve skin quality, tone, and texture, but they don't really tighten significantly sagging skin. For loose skin, you're typically looking at radiofrequency, ultrasound (Ultherapy), microneedling RF, or surgery.

What to Expect for Different Procedures

Realistic recovery for common treatments:

IPL. Most patients have some redness for a day. Brown spots typically darken before they slough off over five to seven days. Light makeup can usually be worn the next day. Sun protection is critical.

Light chemical peels. A few days of mild flaking, mostly tolerable. Can resume normal activity quickly.

Medium peels. Visible peeling for a week or so. Skin looks pink and tender during recovery. Most patients take a few days off social activities.

Non-ablative fractional lasers. Redness for a few days, sometimes mild swelling. Skin feels rough or sandpapery for several days as the treated areas resolve. Can return to work after a day or two depending on tolerance.

Ablative fractional lasers. Significant redness and oozing for the first few days. Crusting and peeling for a week to ten days. Pink, tender new skin for weeks afterward. Plan for substantial downtime.

Vascular lasers. Mild bruising or red marks for a few days to a week. Manageable downtime.

Pico lasers for pigment. Treated spots may darken before lightening over a week or two. Minimal downtime otherwise.

Provider-specific instructions matter enormously here. Following the protocol your specific clinic gives you, including any preparation in the weeks before treatment, is part of getting a good result.

Risks and Complications

The serious risks vary by procedure:

Post-inflammatory hyperpigmentation. Darkening of treated areas, particularly in darker skin tones. Sometimes resolves over months, sometimes persistent. Higher risk with more aggressive treatments and inappropriate device selection for skin type.

Hypopigmentation. Loss of pigment in treated areas. More common with deeper or more aggressive treatments. Can be permanent.

Scarring. Rare with appropriate treatment but can occur with overly aggressive settings, infection, or poor wound care during healing.

Infection. Risk with any procedure that disrupts the skin barrier. Most common after ablative treatments. Antiviral prophylaxis is standard for ablative laser treatment in patients with history of herpes simplex.

Allergic or chemical burns from peels. Rare with appropriate peel selection and provider experience.

Eye injury. Risk with all laser procedures. Proper eye protection is non-negotiable.

In experienced hands, with appropriate patient and procedure selection, these risks are low. They become significant when patients are treated with the wrong device for their skin type, when settings are inappropriately aggressive, or when post-care is inadequate.

Skin Type Considerations

I want to spend a moment specifically on darker skin tones and laser treatment because this is an area where I see real harm from inexperienced providers.

The Fitzpatrick scale classifies skin from I (very light, always burns) to VI (deeply pigmented, never burns). Most lasers and devices were originally developed and tested on lighter skin types. Many require modifications, different settings, or sometimes complete avoidance for darker skin.

Common issues:

Some IPL platforms are not safe for darker skin. The light energy can be absorbed by the melanin in the skin itself, causing burns and pigment changes.

Some ablative lasers can trigger significant post-inflammatory hyperpigmentation in darker skin.

Some pigment-targeting lasers can paradoxically darken pigmentation in darker skin if not selected and used correctly.

If you have a Fitzpatrick IV, V, or VI skin tone, you need a provider with specific experience treating skin like yours. Don't go to a clinic that primarily treats lighter skin and is using their default settings on you. Don't accept a treatment plan that doesn't specifically address skin type considerations.

This is an area where I encourage second opinions, especially for treatments like laser resurfacing or IPL. The provider who insists "I treat all skin types the same" is often the provider who's about to cause a problem.

A Deeper Look at Specific Laser Platforms

I want to spend some time on specific laser platforms because the device matters more than people realize. Two lasers in the same general category can produce different results, have different recovery profiles, and be better matched to different patients. Understanding the landscape helps you have informed conversations with providers.

Fraxel. Made by Solta Medical. The original fractional laser platform. Comes in several versions including Fraxel Dual (which combines two wavelengths, 1550nm and 1927nm) and Fraxel re:store and re:pair. The 1550nm wavelength addresses deeper concerns like texture and scarring. The 1927nm addresses surface concerns like pigmentation and tone. Fraxel Dual is workhorse for general skin rejuvenation with relatively manageable downtime. Patients typically need three to five treatments spaced about a month apart for optimal results.

Clear and Brilliant. Also made by Solta. Often called "baby Fraxel." A gentler fractional laser used for early signs of aging and skin quality maintenance. Less aggressive, less downtime, and good for patients who want gradual improvement without significant recovery. Common as a maintenance treatment for younger patients or as an entry point to laser therapy.

Halo (Sciton). A hybrid laser that combines ablative and non-ablative wavelengths in a single device. Allows providers to customize treatment depth and address multiple concerns in one session. Often considered a step up from non-ablative fractional lasers in terms of results, with moderate downtime (three to seven days of significant recovery).

CO2 fractional lasers (Lumenis UltraPulse, Lutronic eCO2, others). The most aggressive widely-used resurfacing platforms. Genuinely transformative for significant sun damage, deeper wrinkles, and severe acne scarring. The tradeoff is significant downtime, typically seven to ten days of visible recovery and pink skin for weeks afterward. Usually done as a single treatment or with significant intervals between sessions.

Erbium lasers (Sciton ProFractional, others). Also ablative but with different tissue interaction than CO2. Generally produces less heat damage to surrounding tissue, which can mean faster healing. Effective for moderate to significant aging concerns. Often paired with other treatments in combination protocols.

MOXI (Sciton). A relatively newer fractional laser at the 1927nm wavelength specifically. Lighter touch than Halo, easier on the patient, growing popularity for patients who want quality improvement without significant downtime. Particularly useful for patients with pigmentation concerns.

LaseMD (Lutronic). Another 1927nm fractional laser. Often used in combination with topical products applied immediately after treatment to enhance penetration. Lighter, more frequent treatments approach.

BBL HERO (Sciton). A broadband light platform (similar to IPL but more advanced). The HERO version is faster and more comfortable than older IPL platforms. Used for sun damage, redness, vascular concerns, and overall tone improvement. Many providers consider this their go-to "tone and texture" treatment.

Lumenis Stellar M22. A multi-application platform that includes IPL, ResurFX (a non-ablative fractional laser), and Nd:YAG (for vascular and pigment work). The advantage is multiple capabilities in one device, allowing combination treatments in single sessions.

Cutera Excel V+. A vascular laser platform that includes both KTP (532nm) and Nd:YAG (1064nm) wavelengths. Excellent for redness, vascular lesions, and rosacea. Also has settings for tone and pigmentation.

Pulsed-dye lasers (Candela V-Beam, others). Specifically designed for vascular targets. The gold standard for treating port-wine stains, hemangiomas, and severe rosacea with prominent vessels. The treatment can cause temporary purpura (purple bruising-like appearance) that resolves over a week or so.

Pico lasers (Cynosure PicoSure, Quanta Discovery Pico, Cutera Enlighten, others). Use very short pulse durations measured in picoseconds rather than nanoseconds. Originally developed for tattoo removal, now widely used for pigmentation, including some cases of melasma where traditional lasers might worsen the condition. Different platforms have different wavelength options and indications.

Q-switched Nd:YAG lasers. Used for pigment concerns and tattoo removal at 1064nm wavelength. The 532nm setting addresses red and orange tones, while 1064nm penetrates deeper for darker pigments.

Aerolase Neo. A specialized 1064nm Nd:YAG with a unique pulse structure marketed as safe for darker skin tones. Has gained popularity for melasma and acne treatment in patients where other platforms carry higher risks.

Pearl Fusion (Cutera). A combination of ablative and non-ablative wavelengths similar in concept to Halo. Less commonly available but produces good results in skilled hands.

The point of listing these isn't for you to memorize the platforms. It's to give you a sense of how varied this category is. When you go to a clinic for laser treatment, you should know what specific device they're using and why they're recommending it for your specific concern.

A clinic with one laser tends to recommend that laser for everyone. A clinic with multiple platforms can match the right tool to your situation, which usually produces better outcomes.

A Deeper Look at Specific Chemical Peels

Similarly, the peel category has nuances worth understanding.

Glycolic acid peels. The most common AHA peel. Concentrations range from 20% to 70% for professional use. The lower concentrations are gentle enough for regular use, often as part of facial protocols. Higher concentrations are more aggressive. Glycolic is one of the smaller AHA molecules, which means it penetrates more deeply than larger AHAs at similar concentrations.

Lactic acid peels. Gentler than glycolic at equivalent concentrations because of the larger molecule size. Also hydrating in addition to exfoliating. Good for patients with drier or more sensitive skin who still want some exfoliation benefit.

Mandelic acid peels. The largest molecule among common AHAs. Gentlest in terms of penetration. Particularly useful in darker skin tones because the gentler action reduces risk of post-inflammatory hyperpigmentation. Also has some antibacterial activity, making it useful for acne-prone skin.

Salicylic acid peels. BHA peels are oil-soluble and penetrate into pores, making them the peel of choice for acne and oily skin. Concentrations of 20% to 30% are common in professional treatments.

Jessner's peel. A classic combination peel containing resorcinol, salicylic acid, and lactic acid. Provides moderate exfoliation with multiple mechanisms. Used in many medical aesthetic practices, often as preparation before stronger treatments.

TCA (Trichloroacetic Acid) peels. Ranges from very mild (10-15%) to medium-depth (20-35%) to deep (over 35%). The most versatile peel category, used for everything from maintenance to significant resurfacing. Higher concentrations require careful application and have more significant recovery.

TCA CROSS (Chemical Reconstruction of Skin Scars). A technique where high-concentration TCA (often 70% to 100%) is applied to individual ice-pick acne scars with a toothpick or fine applicator. The local injury stimulates collagen remodeling and can improve scars that don't respond well to laser treatment. Requires expertise to perform safely.

Phenol peels (croton oil peels, Hetter peels). Deep peels reaching into the reticular dermis. Provide dramatic resurfacing results for significant sun damage and wrinkles. Recovery is significant (weeks). Less commonly performed now that laser options have improved. Has cardiac and renal considerations that require monitoring during the procedure.

Vi Peel (and other branded combination peels). Proprietary combinations of TCA, salicylic acid, retinoic acid, and other ingredients. Marketed heavily and widely available. Results are generally moderate, similar to other medium-depth peels at similar prices. Convenience and consistency of branded protocols is the main appeal.

Cosmelan and Dermamelan peels. Specifically designed for melasma and stubborn pigmentation. Combine multiple pigment-inhibiting ingredients in a take-home protocol after in-office application. Generally well-tolerated and can produce dramatic results for melasma when properly executed and followed up with maintenance.

Perfect Derma peel. Another branded medium-depth peel that's commonly available. Contains TCA, salicylic acid, kojic acid, retinoic acid, and other ingredients. Decent results in skilled hands.

Matching Treatment to Concern in More Detail

Let me get more specific about matching treatments to common concerns, because the general advice in this category often isn't specific enough.

For someone in their thirties with early aging signs and good skin quality:

Light maintenance peels (glycolic or lactic at moderate concentrations) every few months. Possibly a Clear and Brilliant or MOXI series once a year. IPL or BBL if sun damage is becoming visible. Continued strong home care with retinoid and sunscreen. This is mostly maintenance.

For someone in their forties with moderate sun damage:

A series of three to five IPL or BBL treatments to address the pigmentation. Possibly fractional non-ablative laser like Halo or Fraxel Dual for skin quality improvement. Continued strong home routine. Vitamin C for ongoing antioxidant support.

For someone in their fifties with significant accumulated photoaging:

Consider more aggressive intervention. Fractional ablative laser (eCO2, Halo at higher settings) for transformative resurfacing. Recognize the downtime tradeoff. Excellent home care to support results. Sun protection becomes even more critical post-procedure.

For acne scarring:

Treatment depends on scar type. Atrophic boxcar and rolling scars: fractional CO2 or non-ablative fractional laser, often combined with subcision and filler. Ice pick scars: TCA CROSS. Boxcar scars: ablative resurfacing. Rolling scars: filler often helps. Multiple modalities combined usually produce better results than single approaches.

For melasma:

Conservative approach. Topical treatments are foundational. Gentle peels (Cosmelan, Dermamelan, light salicylic, gentle TCA) can help. Pico lasers at gentle settings under expert hands. Avoid aggressive ablative laser. Sun protection is non-negotiable.

For rosacea and persistent redness:

Vascular lasers (Excel V+, V-Beam) and IPL/BBL are the mainstays. Often produces dramatic improvement after a series of treatments. Combine with appropriate topical management and trigger avoidance.

For deep static wrinkles:

Botox alone won't fully erase deep static lines. Consider fractional laser resurfacing, sometimes combined with subtle filler in specific lines (very small amounts of HA filler placed carefully). For the most significant lines, ablative resurfacing produces better results than non-ablative.

For loose skin:

Energy-based treatments help mild to moderate cases (RF microneedling, Ultherapy, Thermage). Skin laxity beyond moderate often requires surgical intervention for satisfying results. Lasers and peels alone don't address significant laxity.

Combining Treatments

The most effective aesthetic care often involves combining modalities. Botox plus filler. Filler plus lasers. Lasers plus microneedling. Skincare plus all of the above.

A few common and useful combinations:

IPL for pigment and redness, plus retinoids and vitamin C topically, for overall skin tone improvement.

Fractional laser plus PRP, where the PRP supports healing and may enhance results.

Microneedling RF plus topical biostimulators or polynucleotides, used during the immediate post-procedure window when penetration is enhanced.

A series of light peels alternating with home retinoid use for sustained improvement.

The right combination depends on the patient. What I caution against is the maximalist approach where every visit involves three different procedures stacked together. Sometimes that's appropriate. Often it's overkill, expensive, and disrespectful of the skin's need to recover between interventions.

A skilled provider builds a treatment plan over time, sequencing procedures in a way that gives each one time to work and adjusting based on results. A less thoughtful approach is to do everything at once and hope for the best.

A Final Note on Lasers and Peels

These are some of the most powerful tools in aesthetics for actually changing skin. They can also be some of the most regret-inducing when used inappropriately.

A few principles I'd encourage:

Start with the least aggressive treatment that can address your concern. You can always step up. It's much harder to step back from a more aggressive treatment that caused a complication.

Choose providers with deep experience in the specific device being used on your specific skin type. Generalist familiarity isn't enough for this category.

Take pre-treatment and post-treatment protocols seriously. The work you do before and after a procedure significantly affects the outcome.

Be patient with results. Many of these treatments require a series of sessions and weeks to months for full effect. The improvement you see at six weeks isn't the final result.

Set realistic expectations. Some skin issues will improve dramatically with laser or peel treatment. Some will improve modestly. A few are not really addressable with these tools, and a good provider will tell you that rather than selling you treatment.

The next chapter focuses specifically on microneedling and radiofrequency treatments, which have become so popular they deserve their own deep dive.