The Ultimate Guide To Skin Resurfacing

Let’s face it: we tend to take our skin for granted. When we’re young, our skin seems impervious to daily abuse. Our sunburns heal, our pores survive bouts of pimple-picking, and creases instantly plump back up all thanks to a seemingly endless supply of fresh, new skin cells constantly regenerating. But, as we age, that process of cell turnover (technically known as desquamation) slows, leading to a buildup of dead skin cells on the surface. Even with the most diligent skincare routine, scars, sunspots, broken blood vessels, and fine lines (to name a few!) become more pronounced. The complexion takes on a dull, uneven, and crepey appearance.

The solution to this problem seems simple: Why not just slough it all off? And that’s the underlying premise of skin resurfacing, a category of cosmetic treatments that’s gaining popularity as technology advances. To make sense of all the procedure options, we talked to two cosmetic dermatologists about the ins and outs of skin resurfacing.

Skin Structure 101

Before undergoing or even considering a skin resurfacing treatment, it’s useful to know a little about the anatomy of the body’s largest organ. Human skin is made up of two layers: the dermis and the epidermis. The innermost layer is called the dermis and contains blood vessels, nerves, sweat and oil glands, hair follicles, and the coveted collagen and elastin that gives the skin its structure. The outermost layer, meanwhile, is known as the epidermis. It is comprised of five distinct levels, Below is a breakdown from the inside out:

1. Stratum Basale: Where skin cells (a.k.a. keratinocytes) are born. This layer also contains melanocytes (pigment cells) and merkel cells (receptors sensitive to touch).
2. Stratum Spinosum: Composed of eight to 10 cell layers, this ‘spiny’ layer contains irregularly shaped cells that fortify the skin.
3. Stratum Granulosum: This granular level, three to five cell layers deep, contains bundles of keratin (to give skin strength) and lipids (to provide a cohesive moisture barrier).
4. Stratum Lucidum: Present only in the thicker skin of the fingers, palms, and soles, this ‘clear’ layer (named for the absence of granular bodies) is two to three cell layers thick.
5. Stratum Corneum: Made up of about 20 to 30 layers of keratin and dead keratinocytes, it’s the uppermost layer of our skin and plays an important role in our immunity.

The body has a natural skin resurfacing mechanism known as desquamation. During this process, the entire stratum corneum is replaced by new cells that have worked their way up from the stratum basale. This regeneration happens every four weeks or so.

The desquamation process changes with age, which often results in a thicker layer of dead cells on the surface of the skin. “We build up skin cells that block the pores from receiving all the nutrient- and vitamin-rich serums we’re applying daily. Dead skin cell buildup also makes our skin appear dull and accentuates wrinkles,” explains Julie Russak, MD, a board certified dermatologist and founder of Russak Dermatology Clinic in New York City. “In order to get optimal product penetration and help slow down the aging process, we need to aid the process of regeneration quicker by resurfacing our skin.”

What Is Skin Resurfacing?

Skin resurfacing treatments are designed to remove the skin’s outermost layers to reveal brighter, smoother, and more even skin beneath. The term ‘skin resurfacing’ encompasses a variety of cosmetic treatments that address common complexion concerns, including:

• Fine lines and wrinkles
• Pigmentation (think: sunspots and broken capillaries)
• Acne and acne scarring
• Uneven skin tone and texture

Different treatments remove layers of skin to varying degrees, which allow them to address different aesthetic concerns. “Skin resurfacing creates wounds and stimulates the healing process which, in turn, stimulates collagen production,” says Adriana Lombardi, MD, and board certified dermatologist and co-director at Advanced Laser and Skin Cancer Center of New Jersey. Needless to say, collagen and elastin are the hallmarks of youthful, healthy skin.

What Are the Main Types of Skin Resurfacing?

Though there are several categories of skin resurfacing, the modalities share a common bond: they all use energy, in various forms, to remove layers of skin cells and/or stimulate the skin to rebuild itself. The most common types of skin resurfacing techniques include:

• Light-based therapy (think: lasers and IPL)
• Mechanical methods (like dermabrasion, dermaplaning, microneedling)
• Chemical treatments (i.e. peels)

If you feel like you've heard more talk of skin resurfacing in the past year, you’re not imagining it. “COVID-19 has given people an opportunity to have cosmetic procedures done without having to worry about ‘downtime,’” Dr. Lombardi says. “People have been working from home, major events have been placed on hold, and people are wearing masks.”

In the coming weeks, we’ll be diving deep into each of the categories mentioned above to bring you everything you need to know about these treatments. For now, we’re just, well, scratching the surface:

Laser Skin Resurfacing

The word ‘laser’ is actually an acronym for: Light Amplification by Stimulated Emission of Radiation. In other words, a laser device focuses light energy into a concentrated beam. There are four general classifications for skin resurfacing lasers:

1. Ablative Fractional Skin Resurfacing
2. Ablative Non-Fractional Skin Resurfacing
3. Non-Ablative Fractional Skin Resurfacing
4. Non-Ablative Non-Fractional Skin Resurfacing

Ablative (a.k.a. wounding) lasers completely remove the top layer of the skin, whereas non-ablative (or non-wounding) lasers heat up the skin’s underlying layers to stimulate collagen production. ‘Fractional’ means that the energy from the laser is dispersed, rather than concentrated in a beam. Breaking up — or fractionating — the energy makes the treatment gentler, with less downtime, but it also means that the laser treatment isn’t as powerful. Non-fractional lasers act on the entire surface area.

Due to the variety, laser skin resurfacing can address a myriad complexion concerns:

• Fine lines and wrinkles
• Hyperpigmentation (including both sun damage and rosacea)
• Scars
• Tattoo removal

In fact, it’s even being used to treat skin cancer. While milder laser skin treatments require only topical numbing cream, the more intense ablative lasers are best done with some form of anesthesia. It’s absolutely critical to visit a highly experienced professional for any type of laser procedure to avoid the possible risks ranging from infection and burns to unwanted pigment changes and scarring.

Unlike lasers, which use a single wavelength to target complexion concerns, intense pulsed light (IPL) therapy uses multiple wavelengths to treat skin. Compared to lasers, IPL tends to be less targeted and less intense (think: less downtime but also less dramatic results). Case in point? “IPL does not require any topical numbing medication,” Dr. Lombardi notes. It can treat more minor skin concerns and is also used for hair removal.

Dermabrasion, Microdermabrasion, & Dermaplaning

Dermabrasion, its gentler cousin microdermabrasion, and dermaplaning are all mechanical forms of skin resurfacing. These techniques involve physically scraping the outer layers of the skin’s surface to remove textural irregularities like fine lines and mild scarring. Like laser skin resurfacing, dermabrasion can address irregularities like fine lines, pigmentation, age spots, and scars.

So, what’s the difference between these techniques?

• Dermabrasion: This invasive, surgical procedure essentially sands the skin using a rotating abrasive brush or wheel to remove the upper layers. Depending upon the area being treated and the depth desired, some form of anesthesia is required. The skin is wounded and requires time to heal before revealing smoother skin beneath.
• Microdermabrasion: This minimally invasive treatment uses an abrasive crystalline material sprayed or rubbed onto the skin to remove only the outermost dead skin cells. Although there is no damage to the skin’s underlying layers, some inflammation and swelling occurs, resulting in a ‘glow’ effect.
• Dermaplaning: Also called microplaning, this non-invasive treatment exfoliates the skin’s dead outer cells (along with any peach fuzz) with a surgical scalpel. Bolstered by COVID-19 stay-at-home orders, DIY dermaplaning has been trending recently. It’s similar to shaving, but the blade is tailored specifically for exfoliation.

Because of the risks involved (and the anesthesia required), dermabrasion should only be performed by a plastic surgeon or experienced dermatologist. It’s safe to see a licensed aesthetician for microdermabrasion and dermaplaning, but it’s a good idea to run it by your dermatologist first — especially if you’re going the DIY route.

Chemical Peels

Resurfacing the skin using a chemical solution (usually an acid) is known as a chemical peel. Chemical peels are classified into three basic categories:

1. Superficial chemical peels
2. Medium chemical peels
3. Deep chemical peels

Superficial peels (a.k.a. ‘lunchtime’ peels) remove only the outermost, dead cells, while medium and deep peels reach — you guessed it — progressively deeper levels. Regardless of the potency, the chemical solution is applied, given time to work its magic, then neutralized. Afterwards, the skin literally peels or flakes off over time. The severity and duration is dependent upon the strength of the peel. Like their resurfacing counterparts, chemical peels address skin concerns ranging from dullness and sun damage to fine lines and wrinkles.

Medium and deep chemical peels require a doctor’s supervision, in spite of what you may have seen on the internet and social media. It’s safe, however, to have your licensed aesthetic practitioner perform a superficial peel, though you should consult your dermatologist before using any at-home peel treatments.

Microneedling

This trendy treatment (also known as collagen induction therapy) involves pricking the skin with tiny, sterile needles. Creating these micro-wounds stimulates the skin’s innate rebuilding process, while swelling and inflammation lend a temporary glow.

Proponents of microneedling cite measurable increases in new collagen and elastin production with repeated sessions, particularly with the addition of the patient’s platelet rich plasma (PRP). Other reported benefits include a reduction in fine lines, pore size, acne, acne scars, and hyperpigmentation.

Despite its ubiquity on social media, microneedling (and its at-home counterpart dermarolling) is not a one-size-fits-all, risk-free treatment. Possible complications include infection, bleeding, bruising, enlarged pores, and scarring, so make sure you do your homework and seek out a highly trained, licensed professional. Before dermarolling at home, consult with your dermatologist (and follow the directions to a T).

Preparing for Skin Resurfacing Treatment

Before trying any skin resurfacing treatment — whether it be in your doctor’s office, a medspa, or at home — do your research. Not all techniques are appropriate for all skin types or all skin conditions. We’ve covered many of the risks here, but it’s important to talk to a professional about your medical history and treatment options. Certain medications (like Accutane and retinoids) can cause healing complications, while some medical conditions (like herpes and eczema) can flare up post-op.

Although downtime and side effects vary based on the treatment, it's best to avoid sun exposure and follow your post-procedure plan as directed by your provider. Whereas more invasive resurfacing options may have been avoided in the past due to the recovery time involved, there has been renewed interest during the pandemic. “Chemical peels and strong ablative lasers are very popular at the moment,” Dr. Russak notes.

How to Choose a Provider for Skin Resurfacing

Skin resurfacing is typical of most other cosmetic procedures: the quality of your result depends on the skill of the practitioner you choose. But how do you determine whether it’s safe to see a licensed aesthetician for your treatment versus when you need to seek out a board certified plastic surgeon or dermatologist? Generally speaking, experts agree that less invasive treatments (think: microneedling, dermaplaning, and light peels) can be safely performed by aestheticians, whereas deeper resurfacing (like ablative lasers and TCA peels) are best left to plastic surgeons and dermatologists. And for those determined to do it yourself, be sure to talk to your doctor first.