Author: Jay Burns, MD FACS
Fractional resurfacing was introduced in 2004 and has become widely popular in the last few years. The technology stands as a radically different approach from classic standard laser resurfacing which removes the entire upper layer of skin one layer at a time. Fractional resurfacing does not impact the entire surface of the skin, but rather punches micro-holes in the skin much like one would aerate your lawn. Because the holes are separated from each other, only a “fraction” of the skin is treated during the resurfacing. This also results in a decreased chance of complications less downtime than that of classic resurfacing. The trade-off is that the procedure has not proven to be as effective as classic or standard resurfacing for moderate to severe wrinkles. The treatment does give mild to moderate improvement on most wrinkles. As such, clear communication of expected extent of improvement is critical.
Anyone who has evidence of sun damage, including brown spots, flakiness, textural irregularities, large pores, premalignant skin changes, and wrinkles would benefit from fractional resurfacing. In addition, fractional resurfacing has proven to be very effective for certain conditions such as acne scarring, and has become the treatment of choice for this condition. Although it is not the treatment of choice for broken capillaries, it can produce mild improvement.
Fractional resurfacing can be used with any skin type and can be used on all skin surfaces of the body. This differs from classical resurfacing that can only be performed on the face for healing reasons.
Patients with autoimmune diseases, such as scleroderma, lupus, and rheumatoid arthritis are not ideal candidates, especially if their disease is active in any way. Such patients are usually not recommended for classic resurfacing, but with inactive disease, fractional resurfacing would remain a possibility. The greatest increased risk in this instance is poor wound healing and possible scarring. Patients taking Accutane should not undergo fractional resurfacing as the medication impairs wound healing. One needs to have been off Accutane for a year before laser resurfacing is considered.
It may be best to describe this procedure by comparing it to standard laser resurfacing. With standard laser resurfacing the top layers of skin are taken off in layers and 100% of the surface of the skin is removed. Fractional laser resurfacing is best compared to aerating the lawn. Microscopic holes are created with the laser through the epidermis and dermis of the skin. The depth of treatment can be altered by adjusting the energy settings. Because most of the skin has not been treated with the laser, a predictable improvement can be seen in most cases with fractional resurfacing. During the healing process, new collagen is deposited over the next 6 months. Any new collagen deposition is permanent, as it is deposited within the skin. However, the aging process continues and wrinkles can recur.
After the treatment, the skin is red, swollen and has mild crusting for 3-4 days. Both the intensity and longevity of redness is approximately 25-40% less with fractional vs. standard laser resurfacing. The skin is then red and shades of pink for s 2-3 weeks afterwards.
The side effects are essentially the same as for standard classic laser resurfacing, although much less common. Scarring can result with any laser treatment where heat is generated but is really not common even with aggressive classic resurfacing. Brownish pigmentation of the skin after treatment may occur and is called post inflammatory hyperpigmentation (PIH). This is usually temporary and can be treated more easily if detected early. PIH has a much higher incidence in patients with darker skin. Such skin types can be treated both prophylactically and post operatively with mild steroids and hydroquinone.
Alternatives to fractional laser resurfacing are classic laser resurfacing if one wants a more aggressive and more predictable result and is willing to accept the potentially higher complication rate and longer recovery. Other alternatives would be chemical peels and dermabrasion.
Fractionated CO2 laser resurfacing: our experience with more than 2000 treatments. Hunzeker CM, Weiss ET, Geronemus RG. Aesthet Surg J. 2009 Jul-Aug;29(4):317-22.