Erbium:YAG cutaneous laser resurfacing

The short-pulsed Er:YAG laser system is an excellent ablative tool for cutaneous resurfacing. This system is most efficacious for patients with milder cutaneous involvement, including mild photoinduced facial rhytides, mildly atrophic scars, and textural changes caused by fibrosis and dermatochalasis. The Er:YAG laser cannot achieve the same dramatic clinical and histologic improvements produced with the CO2 laser but does offer some distinct advantages that make it a valuable addition to the laser surgeon's armamentarium. The Er:YAG laser, because of its higher affinity for water-containing tissues, effects a much finer level of tissue ablation. Although erbium laser resurfacing results in decreased postoperative morbidity with a shorter recovery period, it cannot effect the same degree of improvement in photodamaged skin as can the CO2 laser. Excellent results, however, can be achieved with this laser, up to 50% or more overall clinical improvement, in patients with milder photodamage and scarring (Glogau classes I and II). In darker-skinned patients, the Er:YAG laser is often the preferred treatment modality. Continued research in the field has already led to the development of longer-pulsed Er:YAG lasers, which offer a compromise between the CO2 laser and the short-pulsed Er:YAG lasers in terms of clinical benefits while maintaining the safety profile of the traditional short-pulsed system. In addition, many surgeons now use a combination approach with the CO2 and Er:YAG lasers in an effort to maximize collagen contraction in certain areas and limit postoperative morbidity. As more research is conducted within the field of cutaneous resurfacing, newer systems will be developed in the continuing effort to create the ideal laser system--one which ameliorates the signs of photoaging without risk of major side effects or significant postoperative recovery.     

Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin

BACKGROUND: Laser resurfacing has been used for treatment of photoaged facial skin since late 1993. Very few long-term follow-up studies regarding the effectiveness and side effects of this procedure have been reported. METHOD: Patients who received carbon dioxide laser resurfacing for facial photoaging and wrinkling from Dec 17, 1993, to Nov 30, 1996, were followed up with clinical evaluation and patient questionnaires. Histologic study was also performed in 10 representative patients who had had preoperative biopsies. All treatments were performed by 2 experienced laser surgeons (R. E. F. and M. P. G.). RESULTS: One hundred four patients were examined and interviewed with an average 24-month postoperative follow-up (range 12 to 44 months). We observed high patient satisfaction ratings and significant persistence of wrinkle score improvement. Long-term histologic features confirmed the long-lasting nature of the clinical improvement and demonstrated continuing, progressive improvement in solar clastosis deep in the dermis for an average follow-up period of 2 years. Prolonged use of topical tretinoin (retinoic acid) postoperatively may contribute to continued improvement. The incidence of long-term side effects, including pigmentary changes and scarring, was generally very low and these side effects were usually not noticed by the patients. CONCLUSION: Improvement from cutaneous laser resurfacing has persisted for an average 24-month postoperative period with a low incidence of side effects. Hypopigmentation is the most common long-term side effect and appears to be related to the degree of pre-existing photodamage as it contrasts with the newly healed undamaged skin.     

Single‐pass CO2 laser skin resurfacing of light and dark skin: extended experience with 52 patients

BACKGROUND: Multiple‐pass carbon dioxide (CO₂) laser skin resurfacing has been a favored treatment modality for photodamaged and acne‐scarred skin over the past several years. Its association with numerous side effects and complications, particularly prolonged erythema and dyspigmentation, however, has dampened the initial enthusiasm reserved for its use. By reducing the laser‐associated tissue ablation depth and degree of thermal necrosis, it is possible that the incidence of these side effects can also be reduced.

PURPOSE: To evaluate the clinical efficacy and side effect profile of single‐pass CO₂ laser skin resurfacing in a large series of patients.

MATERIALS AND METHODS: A total of 52 consecutive patients (skin phototypes I–VI) with mild facial rhytides, atrophic scars, or infraorbital hyperpigmentation underwent single‐pass treatment with a high‐energy, pulsed CO₂ laser. Side effects to treatment were closely monitored and tabulated. Clinical improvement using a quartile grading scale was assessed independently by two masked medical evaluators at 1, 3, 6, and 12 months postoperatively.

RESULTS: Significant clinical improvement was seen in all patients, with peak improvement scores noted at 12 months. Greater clinical improvement was seen in patients with darker skin tones despite the near universal incidence of transient postoperative hyperpigmentation in these patients.

CONCLUSIONS: Single‐pass CO₂ laser skin resurfacing can improve the appearance of fine rhytides, mild atrophic scars, and infraorbital hyperpigmentation in all skin types. The severity and duration of side effects and complications are reduced with this technique (compared with multiple‐pass procedures) and may offer a possible solution to the problem of treating patients with darker complexions.     

Kaposi''s varicelliform eruption in an HIV-positive patient after laser resurfacing

Kaposi's varicelliform eruption (KVE) is an infection produced by the cutaneous dissemination of herpes virus type 1 or 2. Usually this disease has been described in atopic patients. In this report we present an HIV-positive woman with a Kaposi's varicelliform eruption that started after skin resurfacing with a laser. This is the first report, to the best of our knowledge, of Kaposi's varicelliform eruption after laser resurfacing. The immunodepressed status of the patient may have played a role in her infection.     

Fractionation: past, present, future

The development of fractional photothermolysis is a milestone in the history of laser technology and cutaneous resurfacing. Based on the concept that skin is treated in a fractional manner, where narrow cylinders of tissue are thermally heated and normal adjacent skin is left unaffected, the fractional devices have shown effectiveness in treating a variety of conditions. Since its development, we are becoming more adept at using optimal parameters to induce near carbon dioxide laser benefits with a much more comfortable postoperative period and fewer complications. The future remains bright for fractionated laser devices and with new devices and wavelengths, the applications of this technology continue to grow.     

Preoperative and postoperative considerations for carbon dioxide laser resurfacing

Cutaneous laser resurfacing is a tremendous advance in the treatment of photoaged skin. With the recent developments in laser technology, the procedure has become widely utilized among many physician subspecialists. The latest laser systems permit controlled vaporization of skin so that most novice operators feel comfortable with the technique in a short period of time. Nevertheless, there are many issues that need to be addressed before performing the procedure. First, not every person is an appropriate candidate for laser resurfacing. Second, both the physician and the patient must be aware of the preoperative preparation and prolonged postoperative care involved with the procedure. Finally, the physician must be able to identify and treat, and the patient must be educated about, the side effects and potential complications associated with the procedure. It is only by addressing these issues that the clinical results obtained by CO2 laser resurfacing can be maximized.     

Effect of a new infrared light device (1100-1800 nm) on facial lifting.

Laser skin resurfacing procedures can be classed into two categories - invasive and non-invasive. The last several decades have witnessed a host of advancements in ablative laser therapy and other ablative modalities for the rejuvenation of skin, including the CO(2) laser, the erbium : yttrium aluminum garnet laser, chemical peels, and dermabrasion. Despite the excellent results that can result from the practice of these techniques by experienced surgeons, the invasive nature of these devices is associated with inherent risks and patient discomfort. Therefore, much of the focus has been on non-ablative lasers and intense-pulsed light devices. We evaluated the efficacy and safety of treatment with the new infrared light device (1100-1800 nm), Titan, and assessed the degree of improvement associated with two-time laser treatments, as compared to one-time laser treatment.     

Hypoxic conditioned culture medium from fibroblasts grown under embryonic-like conditions supports healing following post-laser resurfacing

Objectives  Treatment of facial skin perturbed by laser resurfacing with a novel, topical hypoxic conditioned culture medium (HCCM) product results in apparent, accelerated wound recovery time. The HCCM product is conditioned by neonatal fibroblasts under hypoxic conditions and used as the active ingredient in a formulated topical lotion. The HCCM contains significant quantities of growth factors such as vascular endothelial growth factor, keratinocyte growth factor, and interleukin-8. As these molecules are known to play an important role in normal wound healing in vivo , we conducted a pilot clinical evaluation "Proof of Concept" in which individuals, after receiving laser resurfacing, were instructed to use either active or placebo lotion on their abraded skin.
Methods  The end points used were clinical assessment of the time to complete healing, clinical and bioinstrumental mexameter measurements of erythema, and the number of days of rescue petrolatum use by patients, post-laser.
Results  Day 7, post-laser treatment, resulted in a greater improvement in erythema, and re-epithelization of the peri-oral and peri-ocular regions in subjects using the active lotion vs. placebo control as determined by blinded, clinical evaluation of gross photographs and bioinstrumental mexameter measurements. A statistically significant reduction in rescue petrolatum use in active lotion-treated subjects was reported. Finally, no attendant cutaneous safety concerns (e.g., irritant/allergic dermatitis) were reported with either active or placebo lotion.
Conclusions  This HCCM product may have broad applications within the field of skin wound repair.     

Are all infrared lasers equally effective in skin rejuvenation

In an attempt to limit the prolonged postoperative healing associated with ablative laser skin resurfacing and in response to growing public interest in less invasive treatment modalities, nonablative laser and light source technology was developed. Over the past few years, several clinical and histologic research studies have been conducted to determine the relative efficacy of these nonablative systems. These systems stimulate dermal collagen remodeling using wavelengths and concomitant tissue cooling that limit injury to the epidermis, thereby minimizing or eliminating postoperative sequelae. While nonablative lasers do not supersede already established ablative laser technologies, they supplement the treatment armamentarium, making a wider range of treatment options available and enhancing the ability to correlate the needs of individual patients more closely with the specific advantages offered by a particular modality.     

The Asian Dermatologic Patient

The Asian patient with Fitzpatrick skin types III–V is rarely highlighted in publications on cutaneous disorders or cutaneous laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context. Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians, prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light (IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma. Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring. Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin. Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring. We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together with treatment strategies.     

Single-pass carbon dioxide laser skin resurfacing combined with cold-air cooling: efficacy and patient satisfaction of a prospective side-by-side study

BACKGROUND: Ablative skin resurfacing with carbon dioxide (CO(2)) and erbium:YAG lasers is still considered the gold standard for treating rhytides, photodamage, and acne scars. However, the prolonged downtime and undesired concomitant effects that are involved have sent dermatologists looking for less invasive nonablative laser techniques to rejuvenate skin. OBJECTIVE: To combine cold-air cooling with single-pass CO(2) laser skin resurfacing to generate as much benefit as possible while minimizing the spectrum of adverse effects. STUDY DESIGN: The efficacy of single-pass CO(2) laser skin resurfacing on perioral and periorbital wrinkles was examined prospectively during a 6-month follow-up period. In a side-by-side comparison, the influence of simultaneous cold-air cooling on concomitant effects, pain tolerance, therapeutic success, and patient satisfaction was also studied. Eight patients with perioral and/or periorbital wrinkles underwent the procedure. During laser treatment, only the right half of each face was cooled using a cold-air system. RESULTS: Six months after treatment, a mild improvement of the wrinkles was observed in all cases. The use of cold-air cooling did not have any impact on the long-term results, although in a direct comparison between sides, it was observed that cooling reduced the recovery period from 3.9 +/- 1.5 (mean +/- SD) days to 3.5 +/- 1.4 days (P = .09) and helped postoperative erythema fade more quickly, from an average of 21.3 +/- 17.9 days to 11.7 +/- 3.9 days (P = .17). The reduction of pain was significant, which led to a much higher level of patient acceptance: on a numerical analog scale of 1 to 10, the rate decreased from an average of 6.8 +/- 1.8 (mean +/- SD) to 3.6 +/- 1.7 (P = .006). CONCLUSIONS: Given the clear decline in demand for invasive laser technologies, single-pass CO(2) laser skin resurfacing in conjunction with cold-air cooling is a worthwhile alternative both to conventional resurfacing and to conventional subsurfacing. The use of cold-air cooling not only minimizes intraoperative and postoperative adverse effects, it also contributes strongly to patient satisfaction.     

Treatment of mild-to-moderate facial cutaneous aging using a combination peel containing 6% trichloroacetic acid and 12% lactic acid

Chemical peeling treats facial cutaneous aging and may avoid risks in patients with sensitive skin, darker skin types, limited finances, or concern for side effects of other resurfacing techniques. Tolerability and improvement of photoaging using a combination peel containing 6% trichloroacetic acid and 12% lactic acid for treatment of mild-to-moderate signs of facial photoaging were assessed. This is a prospective, single-center, single-arm, study of 32 female subjects with mild-to-moderate signs of facial aging and Fitzpatrick Skin Types I–V treated with three monthly treatments of a combination peel containing 6% trichloroacetic acid and 12% lactic acid. After 3 treatments, there were statistically significant improvements in clarity, brightness, redness, pigmentation, fine lines, tactile and visual roughness, and overall appearance scores. Subjective improvements in photoaging parameters varied from 53% (fine lines) to 91% (clarity/brightness). Three treatments with a combination peel containing 6% trichloroacetic acid and 12% lactic acid achieved improvements in signs of facial photoaging. This procedure is safe and effective at treating cutaneous aging for all skin types and a viable option for patients who wish to avoid other resurfacing techniques such as laser resurfacing, microneedling among others.     

Nonablative skin rejuvenation

Laser resurfacing of photodamaged or scarred skin has traditionally involved the use of ablative lasers with their associated limitations and side effects. Nonablative skin rejuvenation is a relatively new concept in facial rejuvenation, which aims to induce dermal remodeling without visible epidermal disruption. A number of laser devices and light sources, emitting at various wavelengths, have been shown to effectively enhance the appearance of facial skin through nonablative mechanisms. Among the conditions that can be treated with this novel modality are erythema, telangiectasia, pigmentation, lentigines, and textural imperfections ranging from fine and moderate rhytides to other surface irregularities such as acne scarring. A major attraction of nonablative laser therapy is the very limited downtime after each treatment, making it an ideal method for patients seeking a minimally invasive procedure with an excellent safety profile.     

Laser Treatment of Dark Skin

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements.Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults.Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.     

Ablative fractional resurfacing for the treatment of traumatic scars and contractures

After a decade of military conflict, thousands of wounded warriors have suffered debilitating and cosmetically disfiguring scars and scar contractures. Clearly, there is a need for effective scar treatment regimens to assist in the functional and cosmetic rehabilitation of these patients. Traditional treatments, including aggressive physical and occupational therapy and dedicated wound care, are essential. Adjunctive treatments with established laser technologies, such as vascular lasers and full-field ablative lasers, have had a somewhat limited role in scar contractures due to modest efficacy and/or an unacceptable side effect profile in compromised skin. Refractory scar contractures often require surgical revision, which can be effective, but is associated with additional surgical morbidity and a significant risk of recurrence. Furthermore, current scar treatment paradigms often dictate scar maturation for approximately a year to allow for spontaneous improvement before surgical intervention. Since 2009, the Dermatology Clinic at the Naval Medical Center San Diego has been treating scars and scar contractures in wounded warriors and others using ablative fractionated laser technology. Although traditionally associated with the rejuvenation of aged and photo-damaged skin, our clinical experience and a handful of early reports indicate that laser ablative fractional resurfacing demonstrates promising efficacy and an excellent side effect profile when applied to the functional and cosmetic enhancement of traumatic scars and contractures. This article discusses our clinical experience with ablative fractional resurfacing and its potential prominent role in rehabilitation from traumatic injuries, including a possible shift in scar treatment paradigms toward earlier procedural intervention. Potential benefits include the optimization of scar trajectory and higher levels of full or adapted function in a more favorable time course.     

Will nonablative rejuvenation replace ablative lasers? Facts and controversies

Since the early 1980s, the field of skin rejuvenation has evolved rapidly. Traditional ablative resurfacing with carbon dioxide and Er:YAG lasers offered dramatic improvement of the skin tone and texture, but prolonged postoperative period and an increased risk for side effects and complications were unacceptable for the majority of patients. It prompted the development of nonablative lasers and non-laser systems, which stimulate dermal neocollagenesis without epidermal disruption, and therefore, produce less adverse effects with little or no healing time. Recently, fractional nonablative and ablative lasers have been introduced, employing a completely new concept of fractional photothermolysis, which ensures high efficacy and fewer risks. Ablative laser resurfacing still remains the gold standard for treating advanced and severe photoaging providing excellent results in experienced hands. Alternatively, ablative fractional resurfacing can be used, with the results, which are comparable to fully ablative lasers with better standard of safety. Nonablative resurfacing is ideal for patients under the age of 50 years with minimal facial sagging, and for those who are unwilling to undergo expensive and demanding ablative procedures. It can be concluded that the key of therapeutic success is in proper patient selection, setting appropriate expectations and combining different rejuvenation technologies with other therapeutic modalities, such as botulinum toxin and fillers.     

Punch excision combined with erbium:YAG fractional laser: Its application on different types of scars in Asian patients (a pilot study)

Abstract

Scars cause significant impact on the quality of life of the affected patients and compel the search for more effective treatments. Ablative laser skin resurfacing, either alone or in combination with other modalities, is the gold standard for treating various scars but is associated with prolonged recovery and many side effects. To address these limitations, newer modalities employing the principle of fractional photothermolysis have emerged. Herein, we investigated the combined effect of punch excision and the erbium:YAG (Er:YAG) fractional laser on different types of scars in Asian individuals.     

Effect of carbon dioxide laser resurfacing on epidermal p53 immunostaining in photodamaged skin

OBJECTIVE: To quantitatively examine changes in p53 tumor suppressor gene immunostaining after carbon dioxide (CO(2)) laser resurfacing of photodamaged skin to assess the potential value of this treatment in reducing the risk of progression to cutaneous carcinoma. DESIGN: Serial in vivo immunohistochemical analyses after laser therapy. SETTING: Academic referral center, Department of Dermatology, University of Michigan, Ann Arbor.Other PARTICIPANTS: Volunteer sample of 11 adults, 51 to 76 years old, with clinically evident photodamage of the forearms. INTERVENTION: Focal CO(2) laser resurfacing of photodamaged forearms and serial biopsies at baseline, 3 weeks, and 6 months after treatment. MAIN OUTCOME MEASURES: Because keratinocytes with mutations in p53 or altered p53 expression stain via immunohistochemical techniques, image analysis of immunohistochemically stained sections was used to quantify p53 expression. RESULTS: Positive immunostaining for p53 in the interfollicular epidermis was noted in 8 of 11 subjects at baseline, with an average staining density of 250 cells/mm(2). Average staining decreased to 3 cells/mm(2) 3 weeks after treatment. This decrease was sustained at 5 cells/mm(2) 6 months after resurfacing. CONCLUSIONS: There was a consistent decrease in p53 immunostaining in the interfollicular epidermis lasting for at least 6 moths after CO(2) laser resurfacing of photodamaged skin. Since p53 mutation or overexpression is observed in a majority of cases of cutaneous carcinoma, the posttreatment repopulation of the epidermis with p53-negative keratinocytes should theoretically decrease the risk of malignant progression. Further study of laser resurfacing as a prophylactic procedure in patients at high risk for skin cancer development appears warranted.     

Laser resurfacing: a safe and predictable method of skin resurfacing

Skin resurfacing with lasers for skin restoration has been the most exciting advance in cosmetic surgery in the past 2 years. This method has effectively replaced chemical peel and dermabrasion as modes for skin rejuvenation, yet surprisingly, very little has been published on its effectiveness. Our aim is to delineate clear indications, methods and results of laser skin resurfacing. Laser resurfacing has evolved over the past 13 years and our current method has emerged from this experience. This method has been employed on 258 consecutive patients treated over the past 2 years. A total of 201 patients were treated for photodamaged skin, 53 for facial acne scarring and four for post-surgical scars. Each of these conditions has in common the pathological finding of contour irregularity of the involved abnormal skin. The CO2 Ultrapulse laser's advantage is the predictable ability to vaporize the upper layer of elevated skin, tighten collagen bundles and induce a local inflammatory reaction with epithelial proliferation. This paper presents a clear, concise, and conservatively oriented technique, including pre- and post-operative care of laser skin resurfacing. The technique presented is conceived to correct precisely the underlying pathological condition and can be used in conjunction with other cosmetic procedures. A total of 200 patients underwent full face resurfacing, 41 periorbital, 13 perioral and four for facial scars. Of the patients, 78% were female and 22% were male. The results of each patient were judged by an independent observer. Some 92% were found to have either an excellent or very good result; 2% were judged to be satisfactory; and 6% were from outside the region or were lost to follow-up. Minor complications included 12% transient post-inflammatory hyperpigmentation, 3% acute acne and 1% herpes type 1. There were no major complications, including hypertrophic scarring. A total of 15% required some type of secondary touch-up resurfacing. Our method of laser skin resurfacing offers a consistent method for dramatic improvement of facial skin quality for those patients with photodamage and acne scarring, while minimizing risk.     

Laser resurfacing today and the ‘cook book’ approach: a recipe for disaster?

Background Laser ablative skin resurfacing achieves skin rejuvenation by precise ablation of photoaged skin and subsequent re‐epithelialisation and dermal remodelling. Carbon dioxide (CO₂) and Erbium:YAG (Er:YAG) lasers are the established choice. A wide range and many sets of parameters have been proposed as the gold standard for each system but results have varied. Aims To show that this single system ‘cook book’ approach must be rejected in favour of a more comprehensive approach. Subjects and methods The author has experience of ablative skin resurfacing in over 1200 patients and has used both systems. A more flexible approach, using a combined wavelength system, is presented. It comprises precise ablation of the epidermal with the Er: YAG (to create an epidermal window), followed instantaneously with subablative heating of the exposed dermis with the CO₂ laser. Results Since adopting the dual wavelength/dual modality approach, more than 600 patients have been treated, with excellent results and a very high patient satisfaction index, currently around 90%, obtained from the sum of the very satisfied and satisfied patients using a five‐grade scale. Possible resurfacing‐related complications have included prolonged erythema, hyper or hypopigmentation, scarring and viral infections, which were more common with single system resurfacing. The author's complication rate remains under 1%, without any prophylactic use of antiviral agents. Conclusions The cook book approach, whereby a particular set of fixed laser resurfacing parameters for a specific single laser system are adopted and rigidly applied in all patients, will not achieve the best treatment effects and may even produce a bad result and dissatisfied patients. The dual modality approach allows a combination of the favourable elements of each of the two wavelengths with excellent and consistent results.