Combination Ablative Approach to Laser Therapy in Advanced Aging of the Face

July 2018 | Volume 17 | Issue 7 | Case Reports | 796 | Copyright © July 2018

Brandon Worley MD MSc,a Joel L. Cohen MD FAAD FACMSa,c,d

aDepartment of Medicine, University of Ottawa, Ottawa, ON, Canada bAboutSkin Dermatology, Greenwood Village, Denver, CO cUniversity of California Irvine, Irvine, CA dUniversity of Colorado, Denver, CO

Background and Objective: Misperceptions have persisted regarding scanning full-field erbium laser that have caused it to be overshadowed by fractional ablative resurfacing. This can lead to sub-optimally treating the periocular and perioral skin. Our report describes the utility of a combined approach of fractional ablative CO2 with full-field erbium ablation for full face rejuvenation. Each laser has a role in creating the optimal outcomes for advanced photoaging in the fewest treatments. Methods: A patient with severe photodamage and etched-in lines underwent full face fractional ablative CO2 (CO2RE, Syneron Candela) and full-field ablative perioral and periocular erbium laser (Contour TRL, Sciton Inc.). The pre-procedure consultations included evaluation of the severity of the photodamage and etched-in lines, as well as discussion of patient goals and appropriate treatment options. Photos of similar patients and post-treatment recovery were reviewed. Fully ablative lasers are generally avoided in Fitzpatrick skin type IV-VI. Prior to treatment, full face nerve blocks and topical anesthesia was provided. Full facial fractional ablative CO2 laser was then applied in one orthoganol pass to the whole face. This was followed by treating the infraorbital and perioral skin with four passes of full field erbium laser. Visualized residual lines were focally treated. Marked improvement was seen in a single treatment session. Results: Standardized digital imaging revealed dramatic improvement in skin texture and etched lines. Conclusion: For appropriately selected patients, combination fractional ablative CO2 and full-field ablative erbium resurfacing for facial rejuvenation is safe, efficacious and merits consideration. J Drugs Dermatol. 2018;17(7):796-799.


Facial aging is multifactorial. Photodamage, loss of subcutaneous fat, reduced skin elasticity, periosteal remodeling, and the repetitive action of the facial muscles contribute to the visible signs of aging – dyschromia, etched fine lines, and uneven skin texture. The best approach to facial rejuvenation should target each of these different factors sequentially. One such strategy has been described previously.1 To specifically address the changes in texture and etched lines, a laser with sufficient dermal penetration, photothermolysis of collagen, and targeting of elastin is required to provide the most dramatic results.2-4 However, the subunits of the face are not equal. Fractional ablative CO2 (FACL) is established for facial rejuvenation, but in our opinion, is frequently limited by its ability to sufficiently treat periocular and perioral areas in a single session as it less effectively targets elastin. Full-field ablative Er:Yag (FFAE) is designed to address this without the delayed hypopigmentation seen with fully ablative CO2.1,4Here we describe a combination treatment of FACL and FFAE that addresses advanced changes in texture and etched lines. This safely creates marked improvement in one treatment session. We also discuss the evidence for preparing the skin for treatment as well as the post-procedural care that can help achieve the patient’s goals.


A 65-year-old woman presented with a primary concern of Grade 3 etched fine lines and decreased quality of the skin. The desire to appear her self-perceived age, but maintain a natural look was emphasized. She was shown photos of patients similar to herself. Treatment options were discussed and she was given a topical retinoid to begin applying regularly. Counselling regarding the expectations for peeling, crusting, and a downtime of 10 days with a combination strategy of FACL and FFAE was addressed to ensure they were aware of the healing process. Pre-operative botulinum toxin for the key facial muscles that cause etched lines was discussed as it has known synergistic effects on laser therapy,5 but she declined. After patient consent, full facial nerve blocks were placed along with 30% lidocaine as topical analgesia. FACL in fusion mode with 30% fractional coverage, ring 116, core 70 (CO2RE, Syneron Candela Inc) was applied in one orthogonal pass on the face along with a single-pass