Erbium laser resurfacing

What it is

• The erbium laser's light is absorbed strongly by water in the skin, so each pulse vaporizes a thin layer with little heat spread (PMID 8923427).
• Depth builds pass by pass: the first passes remove the outer skin, and pinpoint bleeding shows when the surgeon has reached the dermis (PMID 9648573, PMID 8923427).
• Short-pulse erbium removes tissue with little heat. Newer variable-pulse and dual-mode lasers add heat to control bleeding and tighten the skin more like a CO2 laser (PMID 10685096).
• It can treat the whole surface (full-field) or narrow columns with untreated skin between them (fractional) (PMID 32110799, PMID 18306165).

Where it came from

• In 1996 Kaufmann described the erbium:YAG laser for skin resurfacing, with very little heat injury below the treated layer (PMID 8923427).
• Early series showed improvement of lines around the eyes and mouth with healing in days and redness lasting about two weeks (PMID 9256915, PMID 10100644).
• In 1999 Weinstein published settings by area of the face and complication rates from a large practice (PMID 9950553). Side-by-side studies that year found CO2 better for wrinkles and erbium far less likely to leave skin permanently lighter (PMID 10206045).
• When the two lasers were set to cause the same depth of injury, they gave the same healing and the same improvement (PMID 11493293).
• Fractional erbium followed in 2008, with a return to routine in about four days (PMID 18306165).
• Many surgeons avoided resurfacing at the same operation as a facelift because CO2 heat risked skin loss on the lifted flap. In 2001 Weinstein and colleagues reported combining facelifts with erbium, which spreads little heat, with good results in nearly all patients (PMID 11214079).

Who it suits

• Fine to moderate lines around the eyes and mouth, and sun-damaged skin (PMID 9256915, PMID 10100644).
• People who want a shorter recovery and accept somewhat less wrinkle improvement than CO2 (PMID 28166434, PMID 10685094).
• Deeper lines need more passes, or erbium combined with CO2 (PMID 9950553, PMID 10206045).
• Darker skin types (III and above) have more temporary darkening and lightening, and the risk rises with longer pulses (PMID 15662626).
• Lower eyelid skin, often with a skin-pinch blepharoplasty at the same operation (PMID 42108678).
• Fractional erbium results are weaker with older age and smoking (PMID 33550718).

How it is done

• The surgeon chooses the energy and number of passes for each area: lower energy around the eyes, higher around the mouth, in between on the cheeks and forehead (PMID 9950553).
• A light full-field peel removes 50 micrometres or less; deep resurfacing goes further into the dermis (PMID 32110799).
• Fractional erbium makes deep narrow columns; several passes around the eyes reduced wrinkles in nearly all patients (PMID 18306165).
• Full-field and fractional erbium can be combined in one session (PMID 32319157).

Results and how long they last

• Around the eyes, the skin surface healed in about three days, redness lasted about two weeks and most patients reached about 75% improvement (PMID 10100644). Across six erbium lasers, improvement averaged about half, with no difference between devices (PMID 10100645).
• Around the mouth, improvement held at about a year, with no lasting lightening at six months (PMID 30589777).
• Compared with CO2, erbium gave less wrinkle improvement and much less lasting lightening: about 1 in 20 erbium-treated sides against about 2 in 5 CO2 sides (PMID 10206045). On the upper lip, crusts lasted about half as long with erbium (PMID 10685094).
• Fractional erbium and fractional CO2 reduced wrinkle depth by a similar amount around the eyes in a randomized trial (PMID 20166156). Fractional erbium worked better than radiofrequency microneedling around the eyes, and radiofrequency better on the lower face (PMID 31381220).
• For acne scars, fractional CO2 was more effective, with more pain (PMID 38733085, PMID 42720808).
• Short-term results are good; long-term data for fractional erbium are limited (PMID 32472427).

Risks and how surgeons lower them

• In a large full-field series: scarring about 1 in 125, temporary darkening about 1 in 30, lasting lightening about 1 in 25 (appearing after six months and linked to depth), and small skin bridges under the lower lid about 1 in 75, with no permanent outward turning of the lid (PMID 9950553).
• Temporary darkening is common with variable-pulse erbium, about 2 in 5, fading over about ten weeks (PMID 12618614).
• In darker skin, darkening affected about 2 in 5 and most faded within 16 weeks; lightening affected about 1 in 7 and most faded within a year (PMID 15662626). Shorter pulses lower this risk (PMID 15662626).
• Depth drives risk: complications followed about 1 in 10 light peels, about 1 in 4 deep treatments and about 2 in 5 deep treatments around the mouth (PMID 32110799).
• Ablative CO2 and erbium lasers carry the highest risks of scarring and infection among facial lasers (PMID 41968192).
• A moisturizer allergy delayed healing in one case, which healed without scarring (PMID 41146783).

Recovery

• The skin surface heals in about 2 to 8 days, depending on depth and pulse type (PMID 10100644, PMID 9648573, PMID 12618614).
• Redness lasted one to two weeks after short-pulse treatment (PMID 10100645) and about three to four weeks after long-pulse treatment (PMID 12534517).
• Combined full-field and fractional treatment healed in about six days, with redness for about two weeks; nearly all patients were satisfied (PMID 32319157).
• Tightness, swelling, tenderness and burning are common in the first days after fractional treatment and fade (PMID 39808078).
• Repeated erbium sessions did not change skin sensitivity a year later (PMID 31032742).

With a facelift

• Erbium with endoscopic, deep-plane or skin facelifts succeeded in nearly all patients; small areas of skin loss occurred only in heavy smokers, about 1 in 100 (PMID 11214079).
• In another series, complications followed about 1 in 26 facelifts with erbium, none after treatment around the mouth, with no flap skin loss or lasting lightening from the laser (PMID 25839172).
• Pooled studies found full-thickness skin loss in about 1 in 10,000 combined laser and facelift patients; full energy over lifted skin went with more slough (PMID 41063540).
• Erbium on the lower lids is combined with eyelid surgery (PMID 39921282, PMID 42108678).

Questions to ask a surgeon

• Erbium or CO2 for my lines, and why? (PMID 28166434)
• How deep will you go around my mouth and eyes? (PMID 32110799)
• What is my risk of darkening or lightening for my skin type? (PMID 15662626)
• How many days until I can be seen in public? (PMID 10100644)
• If I am having a facelift, how will you treat the lifted skin? (PMID 41063540)

Open questions

• Full-field erbium for heavy lines around the mouth is advocated in case reports (PMID 26580890), while complications rise with depth and are highest there (PMID 32110799).
• Erbium and CO2 are equal when matched for tissue injury (PMID 11493293); CO2 was more effective in a systematic review (PMID 28166434).
• Downtime comparisons for acne scars conflict (PMID 38733085, PMID 42720808).
• Long-term data for fractional erbium are limited (PMID 32472427).

Terms

• Er:YAG: erbium-doped yttrium aluminum garnet laser, 2,940 nm (PMID 8923427).
• Er:YSGG: erbium-doped yttrium scandium gallium garnet laser, 2,790 nm (PMID 21605237).
• Short-pulse and modulated erbium: short pulses remove tissue with little heat; variable-pulse and dual-mode lasers add coagulation (PMID 10685096).
• Full-field (confluent): laser covers the whole surface (PMID 32110799).
• Fractional: columns of injury with untreated skin between them (PMID 18306165).
• MicroLaserPeel: full-field erbium removal of 50 micrometres or less (PMID 32110799).
• Fluence: laser energy per area, in J/cm2 (PMID 9950553).
• Residual thermal damage: heat-injured tissue left below the removed layer (PMID 10206045).
• Pinpoint bleeding: the sign that the dermis has been reached (PMID 8923427).
• Synechiae: small skin bridges after healing, reported under the lower eyelid (PMID 9950553).

Papers