For my patients who have really bad upper lip wrinkles, I sometimes pull out the old CO2 laser, but in general I use the Fraxel.
We use a combination of the new NeoStrata Skin Active program with the Alma Celebrity Peel program, which is an intense photofacial and a light pixel ablative laser peel. We combine this with mild alpha hydroxy acid peels and special Skin Active skin-care products that contain retinols, sunscreens, anti-inflammatories and antioxidants. The overall program we put together works very well to reverse the signs of sun damage.
The best laser is based on how much sun damage your skin has had. For very mild sun damage such as irregular pigmentation, the photofacial may be highly effective. This modality has little risk, virtually no downtime, and is generally inexpensive. For individuals with some discoloration, and early superficial wrinkles, options would include the photodynamic therapy approach, the erbium laser, or superficial fractionated lasers. Within that group of choices, we try to pick the method that best accommodates your needs, your budget, and how you feel about downtime. For more severe sun damage, the fractionated CO2 laser is our overwhelming choice. This laser can actually be used for any type of sun damage from mild to severe, and is the gold standard for treatment of moderate sun damaged skin. I prefer the fractionated CO2 laser for those individuals having more sun damage and deeper wrinkles. The fractionated CO2 laser does have a few days of downtime, which must be considered when you are choosing a laser treatment. Also for more severe sun-damaged skin, the laser is used at higher settings, and there are always potential problems associated with any laser used at higher settings. Keep in mind that laser treatments are safe, but not risk free.
For those with the worst sun damage including loose skin, the fully ablative CO2 lasers that first were used 10 years ago are still the gold standard for the most severely sun damaged. No one approach works for every skin type on every individual. People with ethnically darker skin may not be the best candidates for stronger CO2 Fractionated lasers. A consultation with a specialist is the best way to decide on an approach for you.