Clinics in Dermatology (2013) 31, 737–740

Facial skin rejuvenation: Ablative laser resurfacing,

chemical peels, or photodynamic therapy? Facts
and controversies☆
Khaled M. Hassan, MD ⁎, Anthony V. Benedetto, DO
Dermatologic SurgiCenter, Philadelphia, PA, USA

Abstract Patients and cosmetic surgeons continue to develop innovative devices and techniques in
search of the elusive fountain of youth. Our efforts in the past decade can be distilled to three primary
approaches: refinement of existing technologies (ablative lasers); refinement of tried-and-true
techniques (chemical peeling); and innovative use of new technologies (photorejuvenation). In this
contribution, the authors discuss how these three approaches are used to achieve facial skin
rejuvenation. Specifically, the authors compare and contrast the clinical benefits and disadvantages of
the ablative fractionated and unfractionated carbon dioxide resurfacing lasers, medium-depth and deep
chemical peeling, and the combination of photodynamic therapy with intense-pulsed light.
© 2013 Published by Elsevier Inc.

Introduction ablative laser.4,5 The traditional CO2 ablative laser, widely

As the practice of medicine is involved with the
recognition and correction of pathology, the (he)art of
cosmetic surgery is to rejuvenate—to restore youth and
vitality—and thereby address age-related pathology.
The controversy highlighted in this contribution is which
treatment modality is best for facial rejuvenation. Ablative
lasers, especially the fractionated carbon dioxide (CO2)
resurfacing laser, are quite popular due to their ease of use,
relatively low-risk profile, and predictable postoperative
course1–3; however, treatment sessions can be quite costly,
and the postoperative outcomes approach, but are not
equivalent to those of the traditional unfractionated CO2
☆
Disclosures: Dr. Hassan reported no relevant conflicts of interest. Dr.
Benedetto reported he is a speaker and has received honoraria from
Allergan, Merz, Lumenis, Dusa, Ortho (Johnson and Johnson), and
Stratpharma; is a stockholder in Allergan, BioDelivery, and Elan; and is a
consultant and has received honoraria from Johnson and Johnson, Allergan,
Shire, Galderma, Liposonix, Merz, and Stratpharma.
⁎ Corresponding author.
E-mail address: khaled314@gmail.com (K.M. Hassan).
considered the gold standard in facial rejuvenation, has
significant morbidity associated with treatment, increased
risk for scarring, hypopigmentation, and extended postoper-
ative healing and downtime.4,5
Chemical peeling provides an alternative method of skin
resurfacing. Whereas ablative lasers physically and thermal-
ly eliminate (ablate) the targeted epidermis and superficial
dermis, the application of a chemical peeling agent results in
a caustic liquefaction of the exposed tissue.6,7 Medium- and
deep-depth chemical peeling can be especially effective for
facial rejuvenation, removing the physical changes of
photodamage and stimulating neocollagenesis of the under-
lying dermis.6,7
Finally, photodynamic therapy (PDT) has emerged as a
procedure of choice for field therapy to treat superficial
neoplasms such as actinic keratosis (AK), superficial basal
cell carcinoma (BCC), and squamous cell carcinoma (SCC)
in situ.8–10 Other applications of PDT include the treatment
of acne and, in conjunction with intense-pulsed light (IPL)
activation, photorejuvenation.11,12 Patients typically report
that treatment results in improvement in the texture and tone

0738-081X/$ – see front matter © 2013 Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.clindermatol.2013.05.011
738
of their skin, visibly improving some of the telltale signs of
photoaging such as lentigines and fine rhytides.11,12
In discussing the facts and controversies of facial
rejuvenation with these three modalities, the clinical efficacy
of and perceived satisfaction with each technique and the
ease of treatment for both the dermatologist and the patient
are discussed.
Ablative laser resurfacing
As the resurfacing gold standard, the traditional
unfractionated, fully ablative CO2 laser delivers on all
fronts. Superficial rhytides can be nearly eliminated, and
deep static and dynamic rhytides can be significantly
effaced. 5,13,14 Most acne and varicella scars can be
effectively treated, and other textural irregularities such as
premalignant skin changes and benign neoplasms such as
syringomata, sebaceous hyperplasia, and seborrheic kerato-
ses can be successfully removed.4,15–17 Although vascular
lesions are not effectively targeted by the CO2 laser system,
facial dyschromia due to superficially deposited pigment—
eg, lentigines and macular seborrheic keratosis and
epidermal melisma—respond to treatment with the fully
ablative CO2.5
The biggest drawbacks to unfractionated laser resurfacing
involve the postoperative treatment period. Prolonged
healing times, compounded by patient anxieties, plague the
immediate postoperative period, whereas slight hypopig-
mentation often is noted in the long-term, not to mention the
sometimes unpredictable healing responses of certain
patients, which can result in keloids and the other
complications of scarring, such as ectropion and eclabion.5,18,19
Fractionated laser resurfacing successfully addresses
these concerns. Healing marches according to a very
predictable schedule, with most patients resuming normal
social activities within 7 to 10 days of the procedure.2,20 Due
to the fractionated nature of the device, patients are fully
reepithelialized, and often only slight erythema is visible at
this point.1,2,5,21 Permanent hypopigmentation does not
commonly occur, although temporary pigmentary alterations
can be seen, particularly with darker skin tones. Although
scarring is a potential complication of the fractionated lasers,
in general the incidence is much reduced compared with
fully ablative lasers and is thought to be a consequence of
bulk heat due to insufficient cooling, multiple passes, or
excessive energies—user-driven parameters that can be
minimized.22 All in all, the safety of fractionated devices
has been repeatedly demonstrated.1,2,4,21
In addition to their stellar safety profile, a significant
advantage of the laser systems over chemical peeling or
PDT is the precision with which treatments can be
delivered. Users can set the density of laser pulses within
a given spot size; control the depth of laser penetration by
adjusting the energy delivered per microthermal zone
K.M. Hassan, A.V. Benedetto
(MTZ) or pulse duration; and even control the width of
each MTZ. The computerized software of these sophisti-
cated devices allows for the randomized placement of MTZs
and real-time scanning of the skin to match pulse delivery
with handpiece movement.
Patient satisfaction and post-treatment clinical evaluations
after laser resurfacing are routinely rated near the top of the
scale.2,21,23,24 Fractionated devices, although not achieving
the same degree of ablation as unfractionated resurfacing
lasers, can still yield excellent results with respect to
superficial and deep rhytides, acne and varicella scarring,
epidermal dyschromia, and textural abnormalities of the skin.
Moreover, these lasers can induce long-lasting neocollagen-
esis, reversing some of the solar elastosis that contributes to
photoaging.25,26
Chemical peeling
Chemical peeling involves the use of various agents that
can result in epidermolysis, protein precipitation, or tissue
denaturation when applied to the skin.6,27 Research in this
field of aesthetic surgery has been ongoing for more than a
century, with many described combinations and uses.7,27
The basic types of chemical peels correlate with the extent or
depth of biologic effect on exposed tissues. Superficial peels,
in general, affect mainly the epidermis, with occasional
involvement of the papillary dermis. Medium-depth chem-
ical peels affect the skin through the papillary dermis and
into the upper reticular dermis. Deep chemical peels result in
tissue denaturation down to the mid-reticular dermis.6,7,27
These versatile agents have many uses in facial
rejuvenation. For epidermal lesions such as solar lentigines,
some forms of melasma, and other epidermal dyschromias,
superficial chemical peels such as the α-hydroxy acids, β-
hydroxy acids, and 10% to 20% trichloroacetic acid (TCA)
can even the skin tone and color, although regular repeat
treatments may be needed. For textural irregularities in the
skin including superficial neoplasms and fine rhytides,
medium-depth chemical peeling regimens such as the
Jessner’s–TCA combination are quite effective, even after
a single treatment session; however, deep rhytides may
require treatment with a deep peeling regimen to achieve
satisfactory results.6,7,27
In general, chemical peels compare favorably to laser
resurfacing. Medium-depth and deep chemical peeling can
improve the texture, tone, and color of treated skin. The
Jessner’s–TCA peel can treat AKs with greater than 90%
efficacy, induce neocollagenesis that persists at least 4
months after a single treatment, and reduces dyschromias due
to superficial melanin retention or deposition (refs). These
desired effects are enhanced with the use of deeper peeling
agents, such as the Baker-Gordon formula phenol peel.6,7,27
Although chemical peeling agents give the dermatologist
some level of control over the depth of treatment, they lack
Facial skin rejuvenation
the laser-like precision offered by computerized laser
devices. Chemical peels must be carefully titrated and (in
some cases neutralized) according to the in vivo observed
skin response to treatment. Chemical peels do manage to
achieve laser-like clinical results and patient satisfaction
while maintaining an advantage in cost, widespread
availability, and treatment times compared with ablative
resurfacing lasers.6,7 Postoperative healing also is very
predictable, especially for superficial peels, with increasing
risk for postoperative adverse events (AEs) with increasing
depth of tissue injury created.6,7,27
Photodynamic therapy
Photodynamic therapy is not typically considered a
primary cosmetic procedure, although it can be modified
for the purposes of photorejuvenation. When combined with
IPL as the photoactivating system, PDT can effectively treat
superficial signs of photodamage such as epidermal
dyschromias, vascular erythema, and some thin textural
irregularities such as AKs and fine rhytides.28
An advantage of the IPL–PDT treatment protocol is that it
combines the strengths of both modalities. It adds treatment
of the premalignant lesions that accompany photoaging in
lighter skin tones to the already versatile arsenal of the IPL. It
is the only one of the mentioned options that successfully can
address facial erythema.28 As with nonablative treatments,
the healing times are remarkably reduced, although the
period of photosensitivity from application of aminolevulinic
acid (ALA) can vary from individual to individual. The
results also can depend on a patient’s individual response to
the photosensitizing agent.
As a procedure that many people already receive for field
therapy of AKs, the addition of the IPL to the PDT regimen
makes this a treatment option that readily can be adopted in
many dermatologic practices today; however, the main
limitations of this procedure stems from its basis in a
nonablative light source. It is nonablative; hence, it cannot
resurface. Its treatment effects are due to targeting of blood
vessels, dispersal of pigment, and heating of dermal collagen
with resultant mild-modest neocollagenesis.29 Despite all of
the IPL’s versatility, multiple treatments may be required to
achieve what a simple medium-depth peel can achieve, and it
cannot provide the significant improvement in deep rhytides
and solar elastosis that the ablative lasers and medium and
deep chemical peeling provide.
Conclusions
For global facial rejuvenation, numerous noninvasive
treatment options and combinations are available, and
ultimately the best approach will take into consideration
739
the patient’s cosmetic needs and desires, the realistic
results that can be achieved with a particular approach, and
the treating dermatologist’s own comfort and facility with
the modality.
The fact remains that the fully ablative CO2 laser is the
standard by which other noninvasive physical rejuvenating
treatment modalities are measured. It provides the most
dramatic results, matched with very high patient satisfaction
levels, and with the advent of “fractionated” technology, we
can deliver near-equivalent results with a greatly reduced
postoperative recovery time and a significantly more
favorable safety profile. Although a Baker-Gordon formula
phenol peel can deliver similar clinical results as fully
ablative resurfacing lasers, there is no equivalent to
“fractionated” technology for chemical peels for either the
reduction of postoperative healing and erythema or the
reduction of AEs. Photorejuvenation using combined IPL–
PDT may benefit the patient whose primary rejuvenation
concerns stem from premalignant lesions and facial erythema
and/or dyschromia, but it is not effective in matching the
textural changes wrought by either chemical peeling or the
ablative lasers.
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