The Case for Doing the Hard Thing

The field has fallen in love with convenience. Fractional patterns, nonablative passes, and clever acronyms promise glow with little interruption. Those tools have a place, yet they do not equal what fully ablative, nonfractionated resurfacing can accomplish when executed well. Eyelid tightening that you can measure, real improvement in etched lines and perioral rhytids, durable change in texture and contour—these are surgical outcomes delivered with light, not the cosmetic sleight of hand that fills social feeds.

Fully ablative resurfacing works because it resets the surface and the substructure in one choreography. The ablation removes photodamaged epidermis and superficial dermis. Controlled thermal injury recruits fibroblasts and reorganizes collagen and elastin with force and direction. CO2 classically supplies robust coagulation, which extends the thermal footprint and tightens more aggressively. Modern erbium platforms allow tunable coagulation that mimics this effect while preserving erbium’s precision and a safer pigment profile. In experienced hands, erbium with added coagulation has become the favored instrument for periocular and perioral work where hypopigmentation risk must be kept low and precision matters.

If the goal is to erase perioral lines, to shorten a crepey lower lid without a scalpel, or to smooth severely photodamaged cheeks, fractional approaches are often insufficient. They deliver microcolumns of injury that leave bridges of untouched tissue. Healing is faster, but the biological push is smaller, and the lattice can miss deeply etched pathology. When patients sense that nothing meaningful happened, they are not wrong. The input was modest, so the output was modest.

A return to fully ablative therapy does not mean nostalgia. It means clarity. We should frame the conversation honestly. This is laser surgery. Real surgery has preparation, protected healing, and precise aftercare. In exchange, it delivers real change. That bargain is attractive to the right patient. Show calibrated before-and-after photos with a consistent camera, lighting, and expressions. Explain what nonablative or fractional treatments can and cannot do for their particular pathology. Then offer a choice that respects their priorities. Many will choose the path that gives them the face they remember rather than the glow that fades.

Edges and boundaries protect the craft. Patient selection is the first safeguard. Treat actinic elastosis, static perioral rhytids, cross-hatched forehead lines, and true lid laxity. Be more conservative when background melanin is high or when a patient cannot commit to aftercare. Pretreat high-risk patients for herpes simplex virus (HSV). Consider pigment suppression for those with a history of postinflammatory hyperpigmentation (PIH). Use corneal shields for lids. Respect vascular anatomy and feather across cosmetic subunits to avoid lines of demarcation. Define intraoperative endpoints by zone. For lids, chase tissue contraction while avoiding pooling blood. For perioral skin, pursue uniform ablation to the target depth with a clean, hydrated field. Smoke evacuates; irrigate char when present, and let biology, not bravado, set the pace.

Postoperative stewardship is the second safeguard. Choose occlusive or semiocclusive dressings you can support with high-touch follow-up. Control inflammation without starving remodeling. Watch for malar edema and treat early. Differentiate infection from exuberant inflammation. Set a surveillance schedule that catches problems before they matter. The surgery is only as good as the week that follows it.

None of this diminishes the value of fractional or nonablative tools. They are excellent for maintenance, pigment patterning, and bridging busy seasons, as well as for combination plans in which a fractional device prepares the field and a fully ablative session, timed well, performs the heavy lift. The point is not to disparage convenience. The point is to remember what is possible when we choose the hard thing and execute it expertly.

There is a professional identity embedded here. Dermatologists and plastic surgeons are not selling light. We are delivering surgical judgment with a laser handpiece. When we embrace that identity, we separate ourselves from commodity care. The industry may keep marching toward minimal downtime. Our patients still want meaningful change. Fully ablative, nonfractionated resurfacing is the tool that can deliver it. Let us lead.