A Beam in Search of a Purpose
On May 16, 1960, the first functional laser was constructed by Theodore Maiman. In essence, he aimed a synthetic ruby crystal at the world and changed it. The laser beam lasted microseconds. The implications lasted longer. Medicine had its laser, and it did not know what to do with it — yet. It was studied and seemed to destroy pigment in the skin such as black hair and tattoo ink.
In 1964 another scientist figured out how to ablate skin. This opened the door for facial rejuvenation — eventually. This was done with the invention of the carbon dioxide (or “CO2”) laser. Its wavelength targets water. Since skin and soft tissue are 70-90% water, the clinical implication was immediate and obvious. What was not yet obvious was how to control it.
The Years of Getting It Wrong
For two decades, doctors initially used the CO2 laser the way early engineers used electricity — with enthusiasm and imprecision. In continuous-wave mode, the laser turned on and stayed on. It cut. It burned. It went too deep. The thermal energy conducted far past the intended target, deep into the dermis, and the body responded accordingly. The side effects were serious: permanent pigmentation changes, bad scarring, redness that persisted sometimes for six months or more.
The field needed a theory. In 1983, Rox Anderson and John Parrish gave it one. Selective photothermolysis. The idea was clean and hard: every target tissue has a thermal relaxation time (TRT), or the time it takes to cool by 50%. Hit the tissue faster and give it enough time to cool — the heat stays where you aimed it. It doesn’t keep building up as the laser keeps going. The surrounding area is spared. The damage is controlled.
This was the insight that made modern resurfacing possible. Not the machines. The idea behind the machines.
By the mid-1990s, high-energy pulsed CO2 systems were delivering results that practitioners called a gold standard. They removed a meaningful amount of skin with each pass of the laser. They limited the extra heat damage. They worked. The wrinkles responded. The collagen remodeled. There was still downtime — 7 to 14 days, sometimes more — but the outcomes justified it for the right patients.
The Cooler Alternative
Then came erbium.
The erbium, aka Er:YAG, laser was FDA-approved in 1996. It zaps at a different wavelength precisely at the peak absorption of water. Erbium lasers are ten times more efficient at hitting water than CO2 lasers. The difference is definitely not subtle. This means that erbium lasers can hit shallower or deeper, heat less, and spare more.
Recovery from an erbium laser compared to a CO2 laser is about 3 times faster. If a CO2 laser leaves you red for 10 days, then a similar erbium laser’s redness drops to about 3 days. The risk of post-inflammatory hyperpigmentation (“PIH”) — a serious concern especially for patients with darker skin tones — fell substantially. Treating with an erbium laser is quieter and less scary. It is also more precise.
The Fractional Turn
In 2004, Manstein and Anderson described fractional photothermolysis. Instead of resurfacing the entire face, you fire a grid of microscopic columns into the skin. You leave healthy tissue between each column. The healthy tissue heals the damaged zones fast. Downtime collapsed. The technology was quickly adopted by CO2 laser (made famous by the “Fraxel”) but it has now been applied to both wavelengths — CO2 and erbium lasers.
Today the frontier is hybrid or stacked lasers. Certain systems automatically combine lasers 2-in-1, like the Sciton Halo. Or you can “stack” multiple laser treatments together in a single session. For more on this, check out one of our prior posts (link: How Plastic Surgery Learned to Stop Worrying, and Started Stacking the Lasers).
No Single Answer
There is no best laser. There is only the right tool for the right face on the right day. The field learned this slowly, through the kind of failures that leave marks. Because no single laser option is the “best,” consider a personalized evaluation with a plastic surgeon who has all the different tools, knowledge, and experience.
Be an Individual. SoCal OncoPlastic Surgery.