Facial laser complications (A Five Year Review).

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Learn more: PMC Disclaimer | PMC Copyright Notice Lasers Med Sci . 2026 Apr 13;41(1):69. doi: 10.1007/s10103-026-04862-z Search in PMC Search in PubMed View in NLM Catalog Add to search Facial laser complications (A Five Year Review) Iris Zhorov Iris Zhorov 1 Carniol Plastic Surgery, Summit, USA Find articles by Iris Zhorov 1, ✉ , Melissa Goldstein Melissa Goldstein 1 Carniol Plastic Surgery, Summit, USA Find articles by Melissa Goldstein 1, ✉ , Armela Hasa Armela Hasa 1 Carniol Plastic Surgery, Summit, USA Find articles by Armela Hasa 1 , Paul Carniol Paul Carniol 1 Carniol Plastic Surgery, Summit, USA Find articles by Paul Carniol 1 Author information Article notes Copyright and License information 1 Carniol Plastic Surgery, Summit, USA ✉ Corresponding author. Received 2025 Sep 1; Accepted 2026 Mar 17; Issue date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13070971  PMID: 41968192 Abstract Lasers have become integral to dermatology and plastic surgery, with expanding applications for skin rejuvenation, scar revision, and pigmentary disorders. Despite technological advances, complications remain a significant concern, particularly in patients with darker skin types. A systematic review was performed following PRISMA 2020 guidelines. PubMed, Embase, and Scopus were searched for English-language studies published between January 2019 and September 2025 reporting complications of facial laser treatments. Search terms combined controlled vocabulary (MeSH/Emtree) and keywords across three domains: device/energy (e.g., lasers, IPL, RF, microneedle RF, HIFU/MFUS, CO₂, Er:YAG, PDL, Nd:YAG, 532/755/1064 nm), anatomic site (face, periocular, eyelid), and complications (adverse events, erythema, purpura, PIH, hypopigmentation, scarring, infection, ocular injury), with Boolean operators applied. Peer-reviewed clinical studies, systematic reviews, and meta-analyses were included; animal, in vitro, editorial, conference abstracts, and duplicate publications were excluded. Two reviewers independently screened titles and abstracts and performed full-text review, with disagreements resolved by consensus. Extracted data included laser type, patient demographics, Fitzpatrick skin type, and reported adverse events. Adverse events were summarized using pooled descriptive analysis stratified by laser modality and skin phototype; formal meta-analysis was not performed due to heterogeneity. The search identified 2,435 records; after duplicate removal (n = 180) and screening, 13 studies met inclusion criteria (n = 2,010 cases). Exclusions were due to non laser-based treatments (n = 25), incomplete data (n = 18), or irrelevant outcomes (n = 122). A PRISMA flow diagram illustrating this process is provided (Fig. 1). Extracted data included device type, treatment indication, patient age, sex, Fitzpatrick type, complications, management, and outcomes. Data were tabulated and analyzed descriptively, and findings were cross-referenced with FDA MAUDE adverse-event reports to contextualize real-world complications. Across 2,010 cases reviewed, post-inflammatory hyperpigmentation (PIH) emerged as the most frequently reported complication, particularly in Fitzpatrick IV–VI skin types. Ablative lasers (CO₂, Er:YAG) carried the highest risks of scarring and infection, while non-ablative (FDA [26]), (MAUDE, 2024 [27]) fractional lasers were associated with erythema and textural changes. Ocular complications, though less common, were among the most severe, emphasizing the importance of rigorous eye protection. Fractional and hybrid laser technologies demonstrated improved recovery profiles but still carried risks of PIH and persistent erythema. Analysis of MAUDE data reinforced these findings, highlighting recurring safety issues with ablative devices and periocular applications. Despite improvements in laser technology, complications such as PIH, scarring, and ocular injuries remain clinically significant. Patient-specific protocols—including careful screening, device selection, pre-treatment preparation, intra-procedural safety measures, and structured aftercare—are essential to minimize risks. The absence of standardized guidelines underscores the need for consensus-driven best practices to optimize outcomes and reduce complications in facial laser therapy. Keywords: Facial lasers, Facial laser complications, Dermatology, Plastic surgery Introduction Lasers have become integral tools in modern dermatology and plastic surgery, with diverse applications including skin rejuvenation, pigment correction, and scar revision. Over the past three decades, device evolution—from fully ablative CO₂ systems to fractional, non-ablative, and hybrid laser–radiofrequency platforms—has substantially improved safety and recovery profiles. Nonetheless, complications remain clinically significant, particularly in patients with darker skin phototypes, where melanin density influences both efficacy and adverse event risk. Reported complications such as post-inflammatory hyperpigmentation (PIH), scarring, infection, and ocular injury reflect complex interactions among device type, treatment parameters, operator experience, and patient-specific biology [ 1 – 3 ]. Recent international guidelines and consensus statements have advanced standardized approaches to laser safety and complication management. For instance, Salameh et al. [ 4 ] outlined expert recommendations for acne scar management using lasers, while Sowash and Alster [ 5 , 6 ] synthesized randomized controlled trial data highlighting persistent disparities in outcomes across skin phototypes. Despite these advances, there remains no unified clinical framework to guide complication prevention, reporting, and treatment across all facial laser modalities. What remains unclear, however, is the true scope and comparative frequency of complications across different lasers especially when accounting for patient skin type and procedural context. Existing studies often vary in design, terminology, and inclusion criteria, limiting meaningful meta-analysis. Moreover, real-world surveillance data, such as from the U.S. FDA Manufacturer and User Facility Device Experience (MAUDE) database, are rarely integrated with peer-reviewed literature, despite offering unique insight into device-related injuries under actual clinical conditions. The present systematic review therefore synthesizes published evidence from 2019–2025 alongside MAUDE data to characterize complication patterns, identify high-risk modalities, and propose evidence-based strategies to enhance patient safety and standardize future reporting. Methods Search strategy A comprehensive literature search was conducted in PubMed, Embase, and Scopus to identify peer-reviewed studies published between January 2019 and September 2025 that reported complications associated with facial cutaneous laser treatments. To ensure completeness and reproducibility, the search combined controlled vocabulary (MeSH/Emtree) and free-text keywords with Boolean operators across three domains: Device/energy: lasers (CO₂, Er:YAG, pulsed dye laser (PDL), Nd:YAG, 532/755/1064 nm), intense pulsed light (IPL), radiofrequency (RF), microneedle RF, high-intensity focused ultrasound (HIFU/MFUS) Anatomic site: face, periocular, periorbital, eyelid Complications/adverse events: laser complications, skin of color AND laser, post-inflammatory hyperpigmentation (PIH) AND laser, adverse events AND nonablative lasers, CO₂ laser complications, fractional lasers AND side effects, ocular complications AND laser treatments, laser resurfacing complications, Nd:YAG laser AND adverse effects Eligibility criteria Inclusion criteria comprised original clinical studies, case series, and case reports that documented adverse events following facial laser procedures. Exclusion criteria were non-human studies, review articles, conference abstracts without full data, and reports unrelated to dermatologic or aesthetic laser use. Screening and selection were based on titles and abstracts, followed by full-text review of eligible articles. Radiofrequency-based platforms were included when reported in conjunction with or integrated into laser systems. Ultrasound based energy devices, including high-intensity focused ultrasound (HIFU) and microfocused ultrasound (MFUS), were considered but excluded as non-laser energy modalities and therefore outside the predefined scope of this review. Long-pulse lasers were grouped as a single category, with subtypes defined by wavelength (532, 585–595, 755, 1064 nm) to improve clarity. Data extraction Extracted data included laser type, treated condition, patient demographics, comorbidities, medications, and Fitzpatrick skin type. Data analysis Adverse events were summarized using pooled descriptive analysis; reported complication percentages represent aggregated patient-level proportions across included studies and should be interpreted as descriptive summaries rather than meta-analytic estimates. Outcomes included post-inflammatory hyperpigmentation, erythema, scarring, infection, purpura, and ocular complications. Results were stratified by laser modality and skin phototype to address clinical heterogeneity. Formal meta-analysis was not feasible due to heterogeneity in study design, outcome definitions, follow-up duration, and incomplete reporting of variance measures. Study quality and reporting standards The review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Given the heterogeneity of study designs, inclusion of case reports and small case series, and integration of FDA MAUDE surveillance data, a formal risk-of-bias assessment (e.g., Newcastle–Ottawa Scale or ROBINS-I) was not performed. Instead, study quality was assessed qualitatively based on study design, sample size, and completeness of adverse event reporting. Across included studies, considerable variability was observed in study design (ranging from randomized controlled trials to retrospective case series and single-center case reports), sample size, follow-up duration, and granularity of adverse event reporting; this heterogeneity limits cross-study comparisons and the generalizability of reported complication rates. The protocol was not registered with PROSPERO, as the inclusion of MAUDE data placed the review outside the scope of conventional systematic reviews. FDA MAUDE database analysis To complement the literature analysis, data were also extracted from the U.S. Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database. Reports submitted between January 2019 and September 2025 were reviewed to identify adverse events associated with facial laser devices. Events were categorized by laser modality, treatment indication, and type of complication to identify patterns and trends across device types (Table 1 ). Table 1. Summary of laser-related complications reported between 2019–2024 across device categories ( n = 2,010). Complications include post-inflammatory hyperpigmentation (PIH), erythema, scarring, infection, and ocular injury. Data derived from 13 studies meeting inclusion criteria following systematic review screening (see PRISMA 2020 flow diagram, Fig. 1 ) Complication / Adverse event Ablative lasers (CO₂, Er:YAG) n = 730 Fractional lasers (Ablative & Non-Ablative) n = 460 Q-Switched Nd:YAG n = 220 Long-pulse Nd:YAG n = 170 Pulsed dye laser (PDL) n = 90 IPL n = 150 Hybrid / RF devices n = 190 Periocular procedures n = 70 Post-inflammatory hyperpigmentation (PIH) 32% 19% 21% – 10% 18% – – Erythema – 24% – 26% – 24% 22% – Scarring / texture changes 18% 8% – – – – 6% – Infection 11% – – – – – – – Blistering – – – 9% – 7% 9% – Purpura – – – – 29% – – – Rebound pigmentation – – 10% – – – – – Paradoxical hair growth – – – 5% – – – – Ocular injury – – – – – – – 2.10% Dryness / irritation – – – – – – – 5% Key References Bin Dakhil 2023; Baletic 2022; Zhang 2021 Aggarwal 2024; Chen 2022; Graber 2008 Lee 2022; Kalashnikova 2021 Hu 2022; Ezra 2016 Adotama 2021 Alam 2011; Alster 2009 Salameh 2022; Sturm 2023 Lee 2024; Blanco 2007 Open in a new tab PIH Post-inflammatory hyperpigmentation; RF Radiofrequency † “–” indicates absence of reported data in included studies; it does not imply that the complication did not occur ‡ Hybrid/RF devices represent combined laser–radiofrequency platforms (e.g., fractional RF-assisted laser systems); they are included for clinical completeness but are not purely laser-based modalities Sources: Bin Dakhil [ 3 ]; Baletic [ 7 ]; Zhang [ 8 ]; Aggarwal [ 2 ]; Chen [ 9 ]; Graber [ 10 ]; Lee [ 11 ]; Kalashnikova [ 12 ]; Hu [ 13 ]; Ezra [ 14 ]; Adotama [ 1 ]; Alam [ 15 ]; Alster [ 6 ]; Salameh [ 4 ]; Sturm [ 16 ]; Lee [ 17 ]; Blanco [ 18 ] Results The search identified 2,435 records; after duplicate removal ( n = 180) and screening, 13 studies met inclusion criteria ( n = 2,010 cases). Exclusions were due to non laser -based treatments ( n = 25), incomplete data ( n = 18), or irrelevant outcomes ( n = 122). A PRISMA flow diagram illustrating this process is provided (Fig. 1 ). Fig. 1. Open in a new tab PRISMA 2020 flow diagram illustrating the systematic review selection process. Of 2,435 records initially identified across PubMed, Embase, and Scopus, 180 duplicates were removed prior to screening. Following title and abstract review, studies were excluded for non-laser-based treatments (n = 25), incomplete data (n = 18), or irrelevant outcomes (n = 122), yielding 13 studies meeting full inclusion criteria (n = 2,010 cases) for final analysis Complications were more frequent in darker skin types (Fitzpatrick IV–VI), accounting for 62% of PIH cases and 41% of erythema cases. Among ablative lasers, CO₂ resurfacing yielded the highest cumulative adverse event rate (45%), largely due to post-inflammatory hyperpigmentation and scarring. Fractional technologies reduced scarring incidence by ~ 40% compared to full-field ablative devices but still presented pigmentary complications. Ocular complications, though rare, were among the most severe and primarily associated with periocular laser resurfacing and IPL applications without appropriate shielding. A PRISMA 2020 flow diagram (Fig. 1 ) summarizes the study selection process. We conducted a systematic review of facial laser treatments using pooled descriptive and subgroup analyses stratified by laser modality and Fitzpatrick skin type. Across the included studies ( n = 2,010), these analyses demonstrated clear variation in complication rates varied by laser modality and skin phototype. Post-inflammatory hyperpigmentation (PIH) was the most frequently reported adverse event across all device categories. When stratified by modality, ablative laser systems (CO₂ and Er:YAG) demonstrated the highest cumulative complication burden, with an overall adverse event rate of approximately 45%, driven primarily by PIH (32%), scarring (18%), and infection (11%). Fractional laser technologies were associated with reduced scarring compared with full-field ablative devices; however, pigmentary complications and prolonged erythema remained common, with PIH reported in approximately 19% of cases and erythema in 24%. Among non-ablative lasers, Q-switched Nd:YAG lasers exhibited complication profiles dominated by pigmentary disturbances, including PIH (21%) and rebound pigmentation (10%), while long-pulsed 1064 nm Nd:YAG devices were more frequently associated with erythema (26%) and blistering (9%). Long-pulse lasers are reported as a single category with subtypes by wavelength (532, 585–595, 755, 1064 nm) for clarity. Pulsed dye lasers caused purpura (29%) and transient hyperpigmentation (10%). Intense pulsed light devices showed mixed profiles, with erythema (24%), PIH (18%), and blistering (7%) reported across studies. Hybrid and radiofrequency-based platforms demonstrated intermediate complication rates, most commonly erythema (22%) and thermal injury or burns (9%). Subgroup analysis by skin phototype revealed a consistent overrepresentation of darker skin types among pigmentary complications. Patients with Fitzpatrick skin types IV–VI accounted for approximately 62% of PIH cases and 41% of erythema cases, a pattern observed across ablative, fractional, and Q-switched modalities. In contrast, Fitzpatrick skin types I–III more commonly experienced transient erythema or edema, with lower rates of persistent dyschromia. Although scarring and infectious outcomes were not uniformly stratified, available data suggest greater severity and persistence of complications in darker skin types following ablative resurfacing. Periocular laser procedures comprised a small subset of cases ( n = 70) but were associated with the most severe adverse events. Ocular complications occurred in approximately 2.1% of periocular treatments, with ocular dryness or irritation reported in 5%, often in the setting of inadequate eye protection. Specific ocular adverse events documented across included studies and MAUDE reports encompassed corneal burns, retinal burns, eyelid malposition, and vision loss. Corneal and retinal burns were most frequently associated with ablative CO₂ laser resurfacing of the periocular region performed without appropriate metal corneal or scleral shields. Eyelid malposition, including ectropion and ptosis, was reported following fractional ablative laser treatments at high fluences in the periorbital area. Vision loss, though rare, was documented in cases involving intraocular laser scatter during Nd:YAG and long-pulsed 1064 nm procedures conducted without adequate eye protection. IPL treatments applied near the orbital rim without ocular shields were similarly implicated in cases of retinal injury. Where device parameters were reported, high fluences, small spot sizes directed toward the orbital rim, and absence of certified ocular shields were the primary contributing factors identified. Although formal meta-analysis was not feasible due to heterogeneity in study design and reporting, pooled descriptive and subgroup analysis demonstrated clear modality- and phototype-dependent complication patterns. Ablative devices carried the highest overall risk, pigmentary adverse events predominated across modalities, and darker skin phototypes consistently exhibited increased susceptibility to PIH and prolonged dyschromia. Discussion Complications associated with facial laser treatments have evolved alongside advances in device technology and procedural technique. The most frequently reported adverse events include erythema, infection, scarring, and pigmentation changes, particularly post-inflammatory hyperpigmentation (PIH). Although early reports linked PIH primarily to ablative CO₂ lasers [ 19 , 20 ], more recent data demonstrate that it can occur after non-ablative and fractional modalities as well [ 2 , 3 ]. Our pooled descriptive and subgroup analyses suggest that complication rates vary by laser modality and skin phototype, with pigmentary adverse events remaining the most frequent complication across modalities. Notably, Jafarzadeh et al. [ 21 ] also report transient erythema and dyschromia as common findings in vascular laser treatments for acne, particularly in darker skin types, underscoring the persistence of pigmentation-related adverse events even in non-ablative, vascular-specific platforms. Importantly, transient pigmentary alterations are expected post-procedure,only persistent or exacerbated PIH qualifies as an adverse event requiring intervention. PIH arises from inflammatory cytokine release and melanocyte stimulation following epidermal or dermal injury. The depth of laser penetration, degree of thermal damage, and duration of inflammation determine whether pigment changes are transient or long-standing. Scarring similarly reflects the interplay between excessive dermal coagulation, delayed re-epithelialization, and secondary infection. These processes are modulated by laser fluence, pulse duration, skin phototype, and post-procedural wound care. Device parameters, operator technique, and aftercare are therefore major confounding factors. Ghassemi et al. [ 22 ] further supports this, showing significantly lower scarring and pigmentation risks with PDL compared to ablative CO₂ lasers. Our findings and MAUDE data collectively underscore the overrepresentation of darker phototypes (Fitzpatrick IV–VI) among patients with persistent PIH. Patients with skin types IV-VI accounted for most PIH cases, consistent with the pooled descriptive analysis and prior evidence that darker phototypes carry higher risk due to increased melanocyte activity and inflammatory response. This emphasizes the need for conservative settings, test spots, and strict photoprotection in these groups. Future studies should report outcomes stratified by Fitzpatrick skin type to enable phototype–specific risk assessment and guide evidence-based, tailored laser treatment recommendations. The use of hydroquinone (2–4%) or other topical agents before resurfacing remains controversial: while some trials suggest modest reductions in PIH severity [ 5 , 11 ], others find no significant benefit over sunscreen alone [ 13 ]. Consensus guidelines [ 5 ], Salameh et al. [ 4 ] now recommend selective, short-course prophylaxis only for high-risk patients, rather than universal pretreatment. Technological refinement—particularly the advent of fractional and hybrid laser systems—has reduced downtime and the incidence of scarring compared with earlier full-field ablative techniques Ghassemi et al. [ 22 ]. Yet erythema and dyschromia remain prevalent complications, especially in darker skin types, underscoring the need for individualized fluence titration, adequate epidermal cooling, and proper wound care. Operator experience plays a pivotal role as outcomes and complication rates vary significantly with practitioner training and familiarity with device-specific parameters. A recent randomized controlled comparison of rejuvenation modalities demonstrated that operator-dependent parameter adjustments substantially influenced both treatment efficacy and the incidence of adverse events across laser systems Sodagar et al. [ 23 ]. Although ocular injuries represent a small fraction of total adverse events, they remain among the most severe. Corneal and retinal burns, eyelid malposition, and vision loss have been reported [ 18 , 24 ]. These highlight the necessity of nonreflective ocular shields and documentation of protection measures during periorbital procedures. Underreporting—both in literature and FDA MAUDE submissions—likely leads to an underestimation of true incidence. It is important to emphasize that MAUDE data cannot be used to estimate incidence or calculate true complication rates; as a voluntary, passive surveillance system without denominator data, MAUDE reports reflect only submitted adverse events and are subject to both underreporting and reporting bias [ 25 ]. These data are therefore presented solely to identify qualitative patterns and recurring safety signals, not to quantify risk. Future efforts should prioritize standardized reporting frameworks and the development of prospective complication registries to improve safety monitoring across laser platforms. Emerging technologies hold the potential to further reduce complication rates. Artificial intelligence (AI) and machine learning algorithms could soon assist clinicians in selecting optimal treatment parameters based on patient phototype, lesion characteristics, and historical outcome data. Hybrid laser–radiofrequency systems and multimodal platforms may also improve outcomes, though they introduce new variables that require standardized protocols and longitudinal safety evaluation (Salameh et al. [ 4 ]; [ 16 ], Sodagar et al. [ 23 ]). In summary, while advances in laser technologies have markedly improved safety profiles, complications persist due to biological, procedural, and operator-dependent factors. The integration of real-world surveillance data with pooled descriptive and subgroup analyses provides a comprehensive understanding of laser-related risks. Going forward, adherence to consensus guidelines, continued emphasis on operator training, and establishment of multi-institutional registries will be essential to refine safety standards and advance the field toward predictive, data-driven laser medicine. Conclusion Laser therapy and emerging technologies are becoming an increasingly integral component of dermatologic and plastic surgery practice, offering versatile treatment options for a wide range of conditions. However, the risk of complications, most notably post-inflammatory hyperpigmentation (PIH), erythema, dyschromia, and scarring, remains a central concern, especially in patients with darker skin tones (Fitzpatrick types IV–VI). While ablative lasers (e.g., CO2, Er:YAG) carry the highest risk due to deeper tissue injury and greater inflammatory response, non-ablative fractional lasers and Q-switched lasers also carry risks even when used with careful technique and precautions. Despite the extensive body of literature on laser therapies, standardized clinical guidelines for complication prevention and management are limited. Minimizing laser-related complications requires a comprehensive approach that includes careful patient screening, appropriate pre-treatment skin preparation, precise intra-procedural parameters, and structured post-treatment care. Various strategies have been proposed to mitigate adverse outcomes; however, complications can still occur despite best practices. Ultimately, the details of patient preparation, laser selection, and other devices and their settings will depend on physician clinical judgment, patient preference, and overall treatment goals. The implementation of standard pre-, intra-, and post-treatment protocols, tailored to individual patient biology, could significantly enhance safety and improve patient outcomes across laser-based therapies. Author contribution I.Z and M.G drafted the first version of the paper and created the charts. Second revisions were made by I.Z, M.G, A.H as well as finalizing the figures. P.C oversaw research efforts and provided guidelines for writing the paper. All authors reviewed the manuscript. Final edits based on reviewers comments were made by I.Z and M.G. Funding No funding declaration/no funding was used. Data availability No datasets were generated or analysed during the current study. Declarations Conflict of interest The authors declare no competing interests. Clinical trial number Not applicable. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 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Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement No datasets were generated or analysed during the current study. 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