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How do I choose the best CO2 laser treatment?

Editorial note: an earlier version of this article was first published on March 3, 2009. It was updated on October 15, 2020.

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If you’re in the market for laser skin resurfacing, you may be asking: is there a difference between the many brand names of CO2 and fractional lasers out there? Will a doctor try to sell me on whatever machine they have, without it necessarily being the best for me? How can I know I’m getting the best treatment?

No doubt, it’s important to be educated on the types of lasers there are to treat skin conditions. You should also know what will be used on you, and your provider’s qualifications.

In this article, we’ll attempt to give you some background information on how to choose the best CO2 laser treatment, or fractional laser treatment.

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A good laser machine does not guarantee a good outcome; practitioner experience matters!

While we can talk your ears off about cosmetic laser science and technology, know that none of it is useful if the person directing treatments on you is not trained and experienced.

Laser skin resurfacing with a CO2 laser can be a touchy procedure to perform. Some clinics may not offer it at all, due to the level of expertise it requires. It would not be uncommon to find only a handful of providers in your area that offer true CO2 laser resurfacing. Nonetheless, you should still look into their qualifications, even if they are one of a few.

Experience and training in the world of skin resurfacing can be compared to photographic technique.

Let’s say you give an amateur photographer a fancy camera. You then ask them to take an award-winning photograph on their first, second or even tenth try. Chances are, they won’t be able to do it.

That’s because the skill is not in the tool, it’s in the technique and knowledge that goes into using it. Getting the ‘perfect shot’ requires putting so many factors together.

On the other hand, professional photographers can take stunning photographs using an old iPhone (or any lower-tier camera). Really – you can google it. It’s amazing.

Can success happen by chance? Maybe. But when your skin is on the line, you don’t want to take that risk.

So, the principle is similar (and it can be applied to so many professions). Except, in this case, the results will be on your skin, not in a fleeting photo!

It’s important to pick the right laser clinic for a skin treatment of this nature. At the very least, a doctor should be leading the practice.

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There are three types of lasers that can achieve skin resurfacing and rejuvenation effects

Next, you should know that there are three main categories of lasers that medical-grade clinics use when it comes to skin resurfacing and rejuvenation. They are:

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Fully ablative lasers

Ablative lasers remove thin ‘sheets’ of skin off your face (or off of other treatment areas). They are semi-old-fashioned in that way (we’ll explain more on this below). However, they still have plenty of practical uses in modern clinics.

Laser skin resurfacing with an ablative laser - diagram

The tough thing about undergoing laser skin resurfacing on a large area with ablative lasers, is that they require at least three to four weeks of healing time (if not more). They are also painful, and can lead to several side effects. Side effects can include skin darkening or lightening, infection, and prolonged redness.

So, fully ablative lasers are best used for small procedures, such as getting rid of moles or warts. They can also be used on lower settings, for a very mild laser peel effect. This is similar to a photofacial.

At our clinic we use the ablative, Erbium YAG (Er:YAG) laser for the above purposes. Other Erbium lasers can be non-ablative, depending on the model.

CO2 lasers are the other common type of laser that fall into the ‘ablative’ category. However, not all CO2 lasers are fully ablative. We’ll explain more on this below.

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Fractional ablative lasers

Fractional lasers split their main laser beam into thousands of miniscule fractions. Thus, we get the term, “fractional.” They produce deep ‘columns’ in the skin, so that not all of it is removed, as would be the case with ablative lasers.

Fractional laser skin resurfacing diagram showing hole punctures made by laser to induce collagen and healing

The idea here is similar to plugging holes into a lawn to aerate it. A lawn with holes in it will recover much more quickly than if an entire layer of grass were removed from it.

In the same vein, with smaller injuries being made by the laser, the skin can heal faster. Fewer complications can occur, which is another benefit of a fractional treatment.

Common fractional ablative CO2 laser brands include:

  • MiXto Pro
  • Fraxel® Re:pair
  • Cynosure Smartskin®+
  • Lumenis® UltraPulse® and AcuPulse™
  • Alma Pixel CO2
  • Lutronic eCO2™ Plus
  • SmartXide DOT®

And others.

Plus, these brands often come out with newer, upgraded models on a regular basis. So, the model names we’ve listed above may have changed if you’re reading this in the future :) However, they generally remain ‘big ones’ in the industry.

There are also Erbium lasers that are made to be fractional ablative. Some notable ones include:

  • Cutera xeo® (with the Pearl® modules)
  • Sciton ProFractional-XC
  • Focus NaturaLase Er

However, like with CO2 brands, there are many more out there.

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Fractional non-ablative lasers

Fractional non-ablative lasers also make columns in the skin through one beam that is divided into many. However, these lasers don’t go as deep as fractional ablative lasers. They come with much less downtime, as a result.

Probably the most well-known fractional non-ablative laser would be the Fraxel® re:store. The upgraded version of this would be the Fraxel® DUAL. The Fraxel® DUAL allows a practitioner to work with two different wavelengths, to target varying depths in the skin.

Other brands and models in this category include:

  • Palomar Lux 1540
  • StarLux 1540
  • Lumenis® ResurFX™

And others.

Some picosecond lasers can use a special lens to fractionate their beams, too. That way, they can have a similar effect.

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How do CO2 and skin resurfacing lasers work?

At this point, we should probably back up a little bit.

Before you start looking for recommendations on the best CO2 laser, or the best fractional laser, or the best this-and-that laser, it’s important to understand how these lasers work. If you know the underlying concept behind their science, you can be better equipped to make decisions about their differences.

We wrote an article about this technology here. Go check that out, then come back to keep reading below!

Also see our pages on the lasers and services we provide, which explain even more:

On this note, it’s important to keep in mind that laser skin resurfacing is not the same as general skin rejuvenation, and it can’t do everything. If you are looking to treat redness or pigmented lesions, for instance, other solutions may be more appropriate for your case. This is further explained in the article linked to above. You may also want to read the following:

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What makes a good skin resurfacing laser?

Now the big question: what makes the best CO2 laser or skin resurfacing laser?

This can come down to the features on each machine, and whether or not they suit you the most. Some come with built-in cooling devices, to speed up treatment times. Some have larger spot sizes, which can mean fewer pulses per treatment. And, the list can go on.

Each brand and model will have its own perks that can make the procedure more comfortable. Though, note you will likely be given anaesthetic before skin resurfacing treatments. So, you won’t feel much during the session anyway.

With ‘perks’ aside, the main thing you’d want look for, in terms of effectiveness, are the following:

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The depth of the beam, and whether it can be adjusted

Generally, the longer the beam, the more it can penetrate into the skin, for better rejuvenation of skin cells. However, not every skin condition needs a very deep pulse. So, having the ability to change the settings on a laser machine is important. This allows flexibility for the practitioner to address different areas of the skin more precisely.

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The delivery pattern of the fractionated beams

With each pulse of light from a fractional ablative laser, microthermal zones (i.e. holes) are created in your skin, and of course, this must come in some sort of pattern.

Some practitioners appreciate the way older lasers create even, ‘stamped’ pixel patterns across the skin. These are usually shaped like a square of many ‘dots.’ Others prefer an uneven, semi-random pattern to these dots.

This is because, after the procedure, you will, of course, be left with marks on the skin. If these are not uniform, the treatment area will look less like a ‘checkerboard.’ An uneven pattern looks better during recovery. It can also smoothline the effects of the laser across your skin, for a more natural-looking result.

When you choose a provider for your skin resurfacing treatment, you’ll want one with a machine that can deliver both of the above options. The practitioner may need to switch between different pixel patterns for your case.

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The best CO2 laser treatment requires technique and technology

As we’ve seen above, CO2 laser treatments – whether ablative or fractional – come in many varieties. Sometimes, they don’t even use CO2 to power their energy. They can use other forms of light beams, at different wavelengths.

While it’s true that these types of cosmetic lasers come with many commonalities between them, they also compete on the market with special features that can make your treatment slightly more comfortable, or even more effective.

That said, your top priority when choosing the best CO2 laser treatment is, by far, going to be the quality of your provider.

A quality laser clinic will not only have the latest technology on hand, they’ll have multiple lasers to target your specific skin concerns.

More than that, the doctor and technicians doing treatments will be skilled at using this type of laser on various skin types. That goes regardless of the age of the laser. For example, they will be able to balance each pulse, on each area of your skin, with the right strength and speed, so as to avoid side effects. Of course, there’s more to it than that, since this is a highly specialized service, which requires dutiful training to perform.

If you live in the Vancouver area and are looking for a skin resurfacing or rejuvenation treatment, we encourage you to get in touch. We have been working with CO2 lasers since 2002. We’ve used a host of other cosmetic technologies since 2000.

Read more about our fractional CO2 skin resurfacing treatments, here.

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