By Sean E. Mazloom, MD, FAAD, Double Board-Certified Dermatologist and Mohs Surgeon
Medically reviewed by Golta Rasouli, MD · Last updated October 2026
Table of Contents
Quick Answer
The best treatment depends on whether your main concern is wrinkles, loose skin or both. For deep wrinkles and heavy sun damage, fractional CO2 and erbium (Er:YAG) laser resurfacing give the biggest improvement, and erbium works about as well as CO2 for many wrinkles with only a few days of recovery. For sagging along the jawline and neck, HIFU and RF microneedling tighten skin without surgery and with little downtime. Dual Frax, a newer generation of the Fraxel Dual laser, smooths fine lines and sun damage with only a few days of recovery. Most adults over 60 have both wrinkles and laxity, so a combination usually works best. No device replaces a surgical facelift for heavy sagging.
Key Takeaways
- Wrinkles and sagging are different problems that sit at different depths in the skin, so they respond to different treatments.
- In a randomized split-face trial of 40 patients, fractional CO2 and fractional erbium lasers improved wrinkles about equally (roughly 40% each). The erbium side healed faster with fewer side effects.
- CO2 remains the strongest single treatment for deep, etched wrinkles and heavily sun-damaged skin, but it has the longest recovery and the highest risk of pigment changes.
- HIFU reaches the deepest layer of any nonsurgical device. A review of 45 studies found about 18 to 30% improvement in skin laxity, with minimal downtime.
- RF microneedling works especially well on the thicker skin of the lower face, jawline and neck, and it is safe for all skin tones.
- Dual Frax treats fine lines, sun spots and crepey texture with the least downtime of the lasers, usually as a short series.
- These treatments give meaningful improvement, but none matches a surgical facelift for significant sagging.
Wrinkles or Sagging: Start with the Right Question
As we age, collagen and elastin break down, facial fat pads shrink and shift, and facial bone slowly thins. These changes show up in two different ways. Wrinkles, crepiness and sun damage form at or near the surface. Laxity, or loose skin, comes from deeper layers and shows up as jowls, a softer jawline and sagging neck skin.
All five treatments in this article use controlled heat to make your skin build new collagen, but each one delivers that heat to a different depth. That depth decides what each treatment does best. Here is a quick guide.
| Your main concern | Treatments that usually fit best |
|---|---|
| Deep wrinkles and heavy sun damage, and you can take 1 to 2 weeks off | Fractional CO2 laser |
| Fine to moderate wrinkles, crow’s feet or lines around the mouth, with only a few days of downtime | Erbium (Er:YAG) laser, usually as a series of 3 combined with RF microneedling |
| Jowls, a softening jawline or loose neck skin, with little downtime | HIFU, RF microneedling or both |
| Fine lines, brown spots, uneven tone or crepey texture | Dual Frax laser series |
| Sagging and wrinkles together | A combination, such as our HIFU + RF microneedling + Dual Frax approach, adding CO2 or erbium for deeper lines |
| Lines that appear when you frown, squint or smile | A neuromodulator (Botox, Daxxify, Jeuveau or Xeomin), often paired with resurfacing |
| Heavy jowls or a lot of loose neck skin | A surgical consultation; devices can help but cannot replace a lift |
How Each Treatment Works
Fractional CO2 Laser
The CO2 laser targets water in the skin. It removes microscopic columns of skin and heats the layer underneath. Because its heat spreads more widely, it reaches deeper than erbium and tightens as well as resurfaces. Fractional CO2 leaves bridges of untouched skin between the treated columns, which heals faster and is safer than older fully ablative CO2 while keeping much of its power. It is the gold standard for deep wrinkles and heavily sun-damaged skin.
Erbium (Er:YAG) Laser
The erbium laser is absorbed by water even more strongly than CO2. It removes a very precise, thin layer of skin and leaves very little leftover heat behind. Less heat means faster healing and less redness, but also less deep collagen tightening than CO2. That precision makes erbium a good fit for delicate areas around the eyes and mouth. Recovery usually takes only a few days, and we typically recommend a series of 3 sessions.
HIFU (High-Intensity Focused Ultrasound)
HIFU focuses ultrasound energy into tiny points several millimeters below the surface. It reaches the deep skin and the SMAS, the supportive layer a surgeon tightens during a facelift. As that tissue heals, it contracts and lifts, while the surface of the skin is left untouched.
RF Microneedling
RF microneedling uses fine needles to deliver radiofrequency energy directly into the deeper skin at a depth we choose, while largely sparing the surface. Because it does not depend on skin pigment, it is safe for all skin tones. It is especially relevant for mature skin. In a split-face study of women 60 and older, RF microneedling improved wrinkles, firmness and hydration sooner and more than microneedling alone. Skin samples showed more new collagen and elastin and fewer aged, worn-out skin cells.
Dual Frax (Next-Generation Fraxel-Type Laser)
Many people know this type of laser by the brand names Fraxel Dual or Fraxel Duo. Dual Frax is a newer, more advanced version of that two-wavelength technology. The 1550 nm wavelength reaches deeper to rebuild collagen, and the 1927 nm wavelength works near the surface on sun damage, brown spots and uneven tone. It heats tiny columns of skin while leaving the outer layer intact, so recovery takes only a few days. Its effect is gentler than CO2 or erbium, so it is usually done as a series.
Best Treatments for Wrinkles
CO2 vs. Erbium Laser: Which Is Better for Wrinkles?
For most wrinkles, the two lasers perform about the same. In a randomized, double-blind split-face trial, 40 patients had 3 sessions of fractional CO2 on one side of the face and fractional erbium on the other. Wrinkles improved by 39.6% on the CO2 side and 40.4% on the erbium side, with no significant difference. The authors favored erbium because of its shorter downtime and fewer complications. A review of randomized trials reached a similar conclusion: erbium offers similar results and safety to CO2, with higher patient satisfaction and shorter downtime.
CO2 still has an edge for the deepest lines. In older studies of fully ablative lasers, CO2 achieved in fewer passes what erbium needed more passes to match, though with more redness and more pigment changes. In practice, we usually choose erbium for fine to moderate wrinkles and the eye area, typically combined with RF microneedling so the same plan both resurfaces and tightens. We reserve CO2 for deep, etched lines and heavily sun-damaged skin.
RF Microneedling
A systematic review of 41 studies found that RF microneedling consistently improves wrinkles and skin density, with new collagen and elastin confirmed under the microscope. Improvement builds gradually over a series of sessions.
HIFU
HIFU is mainly a tightening treatment, but it softens wrinkles too. A meta-analysis of 17 studies found moderate overall improvement. In a trial of 102 patients, wrinkles around the eyes, around the mouth and on the neck improved significantly, and the results held at 16 weeks.
Dual Frax
Non-ablative fractional lasers such as Dual Frax improve fine lines and texture, though usually less dramatically than CO2 or erbium. They need several sessions, and they have a good safety record, including in darker skin tones.
Best Treatments for Sagging Skin and Jowls
For tightening, depth matters most.
- HIFU reaches the deepest layer and is the most lift-focused nonsurgical option. Studies report about 18 to 30% improvement in laxity, most notably on the lower face, neck and around the eyes, and patients in real-world studies report high satisfaction.
- RF microneedling works especially well on the thicker skin of the lower face, jawline and neck. In one comparison, erbium laser worked better for lines around the eyes, where skin is thin, while RF microneedling worked better for smile lines, lines around the mouth, the jawline and the neck. An international study also found that RF microneedling reduced wrinkles and lifted the lower face.
- CO2 laser tightens through resurfacing and collagen contraction, and it tightens more than erbium.
- Dual Frax gives the mildest tightening and is best for texture and fine lines rather than true sagging.
We will be honest with you about limits. A surgical facelift remains the gold standard for significant sagging. These treatments give real improvement without surgical recovery or risk, and RF microneedling can also complement a facelift. If you have a significant amount of loose, redundant skin, a surgical lift is likely the better option. That decision requires an in-person assessment and examination, so we can recommend what is truly best for you.
Safety, Downtime and Skin Tone
CO2 has the longest recovery and the highest risk of pigment changes. In older studies of fully ablative lasers, lightening of the skin (hypopigmentation) was much more common after CO2 than after erbium, and erbium skin healed faster, with crusting that cleared in about half the time. Fractional CO2 is far safer than those older lasers, but this is still why we adjust settings carefully and may choose erbium or Dual Frax for some patients.
RF microneedling largely spares the surface of the skin. Side effects are usually limited to redness, swelling and brief discomfort, and dark spots are uncommon and temporary. HIFU is also very safe: fewer than 5% of patients report temporary redness, swelling or mild discomfort, and studies report no dark spots, although the treatment itself can be uncomfortable.
Before any laser treatment, tell us if you get cold sores, so we can prescribe a preventive medicine. Also tell us about blood thinners and any acne medicines you have taken, such as isotretinoin, so we can time treatment safely. Daily sunscreen before and after treatment protects your results.
Comparison Table: CO2 vs. Erbium vs. HIFU vs. RF Microneedling vs. Dual Frax
| Treatment | Best for | Typical downtime | Risk of pigment changes | Typical sessions |
|---|---|---|---|---|
| Fractional CO2 laser | Deep wrinkles, heavy sun damage, some tightening | About 1 to 2 weeks | Highest | Often 1 |
| Erbium (Er:YAG) laser | Fine to moderate wrinkles, eyes and mouth, texture | A few days | Moderate; lower than CO2 | Usually 3, often combined with RF microneedling |
| HIFU | Deep tightening and lift: jawline, neck, brow | Minimal | Very low | 1, then maintenance |
| RF microneedling | Lower-face, jawline and neck laxity; texture; all skin tones | A few days | Low | Series of 3 to 6 |
| Dual Frax | Fine lines, sun damage, uneven tone, crepey texture | Several days of redness and flaking | Low | Series of 3 or more |
Individual results vary. Your plan is based on an in-person evaluation.
Why We Combine Treatments at REJUVA
Most faces over 50 show some sagging, some wrinkling and some sun damage at the same time. Because each treatment works at a different depth, combining them treats the whole picture. RF and focused ultrasound work at complementary depths, and in a split-face trial, combining them improved skin rejuvenation. RF microneedling also pairs well with laser resurfacing. For lower-face and jawline tightening, our signature approach combines three treatments:
- HIFU to tighten the deep support layer and lift loose skin along the jaw and neck.
- RF microneedling to rebuild collagen in the deeper skin and firm the lower face.
- Dual Frax laser to smooth fine lines, crepey texture and sun damage at the surface.
For fine to moderate wrinkles, we typically pair erbium laser with RF microneedling over a series of 3 sessions. For deep, etched wrinkles, we add or substitute CO2 resurfacing. For expression lines, we add a neuromodulator such as Botox, Daxxify, Jeuveau or Xeomin. Treatments are staged safely to fit your schedule and recovery.
Are You a Good Candidate?
You are likely a good candidate if you have wrinkles, sun damage or mild to moderate sagging and want natural-looking improvement without surgery. Many of our patients are in their 60s and 70s, and age alone rarely decides the plan. Skin quality, sun damage, overall health, medications and how much downtime you can accept matter more. For mature or thinner skin, we may choose gentler settings or stage treatments to keep recovery comfortable.
Devices are not right for everyone. If you have significant skin laxity and redundant, loose skin on the face or neck, a surgical lift is likely to give a stronger and longer-lasting result. We decide this together after an in-person assessment and examination, so the recommendation fits your face and your goals.
What to Expect: Results, Timeline and Downtime
- Consultation: we examine your wrinkles, skin quality, laxity, sun damage and skin tone, review your medications and build a plan with you.
- Treatment day: we use numbing cream and cooling for comfort. Most sessions take under an hour; full CO2 resurfacing can take longer.
- Downtime: minimal for HIFU, a few days for RF microneedling, Dual Frax and erbium, and about 1 to 2 weeks for CO2.
- When you see results: laser resurfacing shows smoother skin once you heal. Tightening appears gradually, because collagen keeps building for about 3 to 6 months.
- How long results last: collagen-based improvement can last for years, though aging and sun exposure continue. Daily sunscreen and periodic maintenance help protect your results.
An honest note on the evidence: device studies vary in settings and how they measure results, many are small, and few compare all five treatments head to head. We base our recommendations on the best available research and on our own clinical experience with all five treatments.
Frequently Asked Questions
What Is the Best Nonsurgical Treatment for Wrinkles and Sagging Skin?
It depends on which is your main concern. CO2 and erbium lasers give the biggest improvement in wrinkles, while HIFU and RF microneedling are best for sagging along the jawline and neck. Because most people have both, a combination usually gives the best result.
Is Erbium Laser Better Than CO2 Laser?
For most wrinkles, they work about equally well. A randomized split-face trial found about 40% improvement with each, and erbium had shorter downtime and fewer complications. CO2 is still the stronger choice for deep, etched wrinkles and heavy sun damage.
How Long Is the Downtime After CO2 vs. Erbium Laser?
Recovery after fractional CO2 usually takes about 1 to 2 weeks. Erbium heals much faster, usually in just a few days, with less redness. We typically treat with a series of 3 erbium sessions, often combined with RF microneedling.
Which Is Better for Jowls, HIFU or RF Microneedling?
HIFU reaches deeper and is the most lift-focused nonsurgical option. RF microneedling tightens the thicker skin of the lower face and neck and also improves texture. For many people, combining the two works better than either alone.
Is Dual Frax the Same as Fraxel?
Dual Frax uses the same two-wavelength approach (1550 nm and 1927 nm) that made Fraxel Dual, also called Fraxel Duo, well known. It is a newer, more advanced version of that technology, used for fine lines, sun damage and uneven tone with only a few days of downtime.
Can These Treatments Replace a Facelift?
No. They give meaningful tightening and smoothing without surgery, but a facelift remains the gold standard for significant sagging. For mild to moderate laxity, a combination of nonsurgical treatments can be an excellent alternative. If you have significant loose, redundant skin, surgery is likely the better choice, and an in-person exam helps us make that decision with you.
Am I Too Old for Laser Resurfacing or Skin Tightening?
No. Many of our patients are in their 60s and 70s, and research in women 60 and older shows RF microneedling still stimulates new collagen and elastin. We adjust the plan for skin thickness, health and recovery.
Are These Treatments Safe for Darker Skin Tones?
HIFU and RF microneedling carry very low risk of dark spots because they spare the skin’s surface. Dual Frax is also generally well tolerated. CO2 carries the highest risk of pigment changes, so we choose settings carefully and may start with a test spot.
Where Can I Get Laser Resurfacing and Skin Tightening Near Venice or Sarasota, FL?
REJUVA Dermatology in Venice, FL offers fractional CO2, erbium, HIFU, RF microneedling and Dual Frax under the direction of double board-certified dermatologists, serving patients from Sarasota, Nokomis, Osprey, North Port, Englewood and the Wellen Park area.
Schedule a Skin Rejuvenation Consultation in Venice, FL
Whether your main concern is wrinkles, sagging or both, the right plan starts with an expert evaluation. At REJUVA Dermatology, a double board-certified dermatologist will match the treatment to your skin, goals and schedule.
REJUVA Dermatology, Cosmetic & Weight Loss Center
395 Commercial Ct, Ste C, Venice, FL 34292 · (941) 529-0070 · Book an appointment
Serving Venice, Sarasota, Nokomis, Osprey, North Port, Englewood and Wellen Park.
About the Author
Sean E. Mazloom, MD, FAAD, Double Board-Certified Dermatologist and Mohs Surgeon, is co-founder of REJUVA Dermatology in Venice, Florida, and an expert in cosmetic dermatology and lasers. He performs a wide range of laser and energy-based treatments, including fractional CO2 laser, erbium (Er:YAG) laser, Dual Frax non-ablative fractional laser, RF microneedling, HIFU (high-intensity focused ultrasound), intense pulsed light (IPL), Q-switched Nd:YAG and KTP lasers, and diode laser fat reduction. He developed REJUVA’s signature combination approach to lower-face and jawline tightening.
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