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.
Since the advent of fractional resurfacing in 2004, the popularity of laser resurfacing has increased dramatically. Classical laser resurfacing, used in the past, involved removing the top layers of the skin (the epidermis and parts of the dermis) in the same treatment. These lasers included the Carbon dioxide (CO2) and erbium yag (Er:Yag) devices. The entire surface area of the skin was treated with each session of classical resurfacing, requiring weeks to heal and sometimes even longer. Many patients had residual redness of the skin that could persist for months. Late complications of these classical procedures also included discoloration of the treated skin, including lightening or darkening from the normal skin color. The results of these classical laser resurfacing procedures could be incredibly positive, with tightening of the skin and a major improvement in wrinkles, but the procedure was often fraught with complications. Because of these side effects, many physicians opted not to perform these procedures in their office and the search for a safer way to treat wrinkles began.
New lasers were then introduced to the market (non- fractional, non- ablative) that did not remove any skin but instead heated the deeper layer (dermis) of the skin while maintaining normal temperatures in the superficial layer (epidermis). By heating the dermis, these lasers stimulated your skin to produce new collagen and therefore improve the appearance of the treated area. The treatments were safe, but were painful and results were modest at best. These soon feel out of favor by most.
In 2004 the concept of fractional resurfacing was introduced to the literature by a team of dermatologists at Harvard University. The idea was to apply tiny microscopic injuries to the skin with laser to induce collagen production, resurface the skin, while decreasing the chance for side effects. These lasers apply microscopic spots of heat onto the skin that are separated from each other. Surrounding each spot is healthy intact skin. As a result, one is only treating a “fraction” of the total skin in a single session, hence the term fractional. The healthy untreated portions of skin help heal the adjacent treated spots allowing for effective resurfacing without many of the complications of classical resurfacing. Today, most cosmetic laser surgeons use fractional resurfacing devices to treat numerous skin conditions, including wrinkles, abnormal pigmentation and scars.
There are 2 types of fractional resurfacing lasers- ablative and non-ablative. Ablative lasers include the CO2, Er:Yag and yttrium scandium gallium garnet (YSGG) devices. Because these lasers have wavelengths that are absorbed well by the water in skin cells, they vaporize the tissue, they leave a microscopic open wound for a few days. Fractional Ablative lasers are therefore more "aggressive" in most cases, when compared to non-ablative fractional devices. Non-ablative lasers, including the original Fraxel re:store™ device, emit wavelengths that are only moderately well absorbed by water and result in a different type of skin injury. These microscopic spots cause coagulation of tissue, leaving a closed wound. Healing with the non-ablative fractional resurfacing devices is quick- sometimes in the order of hours to days. The following section will focus on non-ablative fractional resurfacing lasers.
Fractional non-ablative resurfacing (NAFR) devices are versatile laser systems cleared by the FDA for several indications. NAFR is achieved by using laser light of a wavelength that is only modestly absorbed by the water in the skin. The light heats the water in the skin, resulting in a micro-wound. This micro-wound is termed a microthermal treatment zone (MTZ). The microwound undergoes the normal healing process resulting in turnover of old tissue and regeneration of new collagen and elastic tissue. The depth and width of each MTZ can be controlled by adjusting the laser energy. The number of MTZs per area can also be adjusted depending on the desired treatment. For example, for the treatment of deep wrinkles or scars, deeper MTZs would be used. For the treatment of more superficial conditions, such as sun freckling, more superficial settings can be used. The microwounds heal quickly with the aid of the normal, untreated skin that is surrounding each MTZ. Healing time depends on the size and even more importantly, the number of MTZs per area of skin. With light treatments, patients heal within hours. With more aggressive treatments, patients may be swollen and red for a few days. After the redness resolves, most patients experience ‘bronzing’. This bronzing occurs as the treated zones have yet to be shed from the skin, which occurs typically somewhere between days 4-7. In most cases of NAFR, patients can go back to normal activity in one to three days. Off face areas, such as the hands, neck and chest, typically take longer to completely heal.
There are several NAFR devices on the market. All emit wavelengths absorbed by water. The skin has many structures that contain water, and hence the versatility of the lasers with water as their target. The NAFR devices as a group have been cleared by the FDA for treatment of wrinkles, acne scars, surgical scars, actinic keratoses (precancers of the skin), melasma (patches of abnormal dark pigmentation), and pigmented lesions (sunspots). Success with scars and fine lines and abnormal pigmentation with NAFR is real and impressive. Deeper wrinkles do not respond as well to NAFR, even with repeated treatments. The treatment of melasma with any laser or light device is controversial, and in most cases only used as a laser resort. Melasma can worsen with any laser treatment, so consult with an experienced physician before opting for this treatment. Case reports of using NAFR on other conditions, including residual hemangiomas, nevus of Ota, poikiloderma of Civatte, enlarged pores, and even hypopigmentation have been published. These treatments are considered ‘off label’, but can be performed at the physicians discretion.
NAFR procedures are performed in the office setting using little more than topical anesthesia. There typically is some discomfort during the procedure, but little more than a feeling of heat. Some describe it as hot and prickly. Some devices are more painful than others, but all are tolerable. Depending on the size of the area being treated, treatments can take anywhere from 5-30 minutes time. After the procedure, the skin feels warm, like a sunburn, with this sensation resolving within the hour. I have never had to administer narcotics post-operatively for any NAFR patient. Applying cool compresses or ice to the area, relieves the feeling immediately, and can be used to control pain as well as swelling.
Multiple sessions with NAFR are needed for optimal results. The exact number of sessions necessary will depend on the aggressiveness of the treatments and on the condition being treated. Typically 3-5 sessions are recommended for the best outcome. The interval between sessions will also depend on the condition being treated and your skin type. Longer times between sessions (4-6 weeks) are used for darker skin patients, those at risk for pigmentation, and sensitive areas such as the chest or neck. Short intervals, of as short as 2 weeks can be used in fair skin patients.
NAFR is typically a very safe resurfacing procedure with minimal side effects. Despite this, there are some complications that can occur.
Expected side effects include a few days of redness and possible swelling. Bronzing and peeling several days post-procedure are also common, especially with the first treatment. An acne-like eruption has also been reported after NAFR and is temporary. NAFR can also activate a dormant Herpes infection, especially in those who are prone to ‘cold sores’. Be sure to advise your physician if you have a history of cold sores. Post-inflammatory hyperpigmentation- darkening of the skin as a result of the treatment itself- is the most severe of the side effects of NAFR. Those with a history of abnormal pigmentation, melasma, or darker skin types may be especially prone to this complication. In some cases, this pigmentation can be long lasting. Though all skin types can be treated with NAFR, care must be taken to those at risk for pigmentation, including adjustment of the laser settings and intervals. Severe side effects such as permanent scarring have not been reported with the NAFR devices.
Laser resurfacing took the cosmetic world by storm in the mid 90’s with the invention of carbon dioxide (CO2) laser resurfacing. This treatment involved removing the entire superficial skin layer all at once and is commonly referred to as an ablative (taking away or removing) skin treatment. It significantly improved wrinkles and tightened skin. In 2000 the Erbium laser was introduced as an alternative ablative laser treatment. Both standard CO2 and Erbium laser resurfacing remain the most effective treatment for significant wrinkles caused by sun damage.
Classic CO2 and standard Erbium laser resurfacing treat the common manifestations of sun damage: mild to severe wrinkles as well as uneven brown pigmentation. Good candidates are those who have sun damaged facial skin. Patients who are not good candidates include those with poor general health and autoimmune diseases such as scleroderma, lupus, and rheumatoid arthritis that would adversely affect healing. Patients cannot be taking Accutane and must have been off of that medication for one year before the laser treatment can be performed as it will delay healing and potentially result in scarring. Patients who have had prolonged and intensive laser hair removal or electrolysis are also not good candidates because hair follicles are necessary for reformation of skin and wound healing.
Smokers can be treated though we strongly encourage patients to stop smoking with any surgery, and particularly laser resurfacing, to enhance the effectiveness of the treatment.
Classis CO2 and Erbium laser resurfacing remove the upper layers of the skin (epidermis and superficial dermis) by vaporizing the skin cells. Underneath, the dermis is heated to resulting in collagen formation and further skin tightening. The amount of ablation and residual heat injury to the skin are the main differences between the Erbium and the CO2 laser. The newer, healthier collagen coupled with the removal of wrinkles, gives an overall improvement to texture and decreased irregularity in the skin.
Expertise is required to determine the endpoint of treatment. The endpoint during the treatment is either the obliteration of the wrinkle or reaching a safe depth, beyond which abnormal lightening of the skin and/or scarring can result. It is important for the patient to realize that if the safety endpoint is reached before the wrinkles are totally removed, then the treatment must be stopped to ensure proper healing. Therefore, the patient must realize that obliteration of every wrinkle should not be an expectation. Significant improvement should be expected and is usually the rule, but even this varies from patient to patient. The patient must realize that his or her immune response and reaction to the treatment itself varies and that the patient or the doctor cannot control this.
Many physicians still prefer CO2 laser resurfacing because it causes greater collagen deposition from increased heating of the dermis. Others disagree because the Erbium laser can reach deeper levels with its vaporization than the CO2 laser resurfacing. Most would agree that the CO2 creates much more heat in the dermis, and therefore has a much higher rate of lightening of the skin as compared to Erbium. The residual heat also results in a longer healing time and prolonged redness.
When one obliterates wrinkles and new collagen is added, these results are permanent. However, if the sun damage involves the full thickness of the skin (both epidermis and dermis), then the entire extent of sun damage cannot be corrected with any single treatment. Therefore, the results of life long sun damage will eventually manifest themselves. Also, aging continues and wrinkles continue to be formed by the dynamic movement of muscles underneath them. However, the results of any single treatment are beneficial and life long.
Recovery is dependant almost entirely on the depth of treatment. The depth of any given treatment is dependent on the goals. If the goal of the treatment is to clear pigment primarily, then treatment to a shallower depth is all that is needed. Healing after such treatment will involve an open wound for approximately 3 days and 2-3 weeks of redness on average. For more significant sun damage, which is usually seen on upper lip lines (i.e. smokers lines) a deeper treatment into the mid dermis or deeper (with the Erbium only) are needed. Such treatment results in 5-10 days of open wounds followed by 8-16 weeks of redness. With each week the redness and pinkness declines. With Erbium laser there is approximately a 25-30% faster healing rate at any given depth of treatment with as compared to CO2.
The worse side effect of any laser treatment, or any treatment that applies heat to the skin, is scarring. Though the risk of scarring is small, it can occur, as there is always patient variability with regard to healing. Other potential complications include blistering and brownish pigmentation of the skin, also known as post inflammatory hyperpigmentation (PIH). Such hyperpigmentation is more common with patients of darker skin types. The pigmentation is typically temporary and treatable with mild steroids and a bleaching agent (hydroquinone). With more aggressive treatment, particularly with the CO2 laser, there is a higher incidence of abnormal and permanent lightening of the skin, also known as hypopigmentation. This can happen with Erbium laser, but it is less severe and less likely. Bacterial infections are rare. Viral (herpes zoster) breakouts can be triggered by laser treatment and as such every patient should be treated prophylactically with antiviral medication.
The chief alternative to laser resurfacing would include chemical peels and dermabrasion. Both of these techniques can achieve excellent results. Chemical peels are inherently less precise than laser treatments and dermabrasion is largely outdated.