Fractional skin resurfacing technologies like Fraxel, Lumenis ActiveFX, DeepFX, Palomar Starlux 1540 and Starlux 2940, and are quickly becoming familiar to many cosmetic, dermatology, plastic surgery and medical spa practices.

The history of laser skin resurfacing goes back to 1995, when the first full face CO2 laser resurfacing for wrinkle removal was performed. The procedure was a revolution in facial laser surgery. A flock of lasers were developed primarily for plastic surgeons. The procedure was done under general anesthesia and created a burn wound, which took 7-10 months to heal. The hypo pigmentation that followed for about another 10-12 months was normal and fairly well accepted for a few years due to lack of other options.

The next advance in laser skin resurfacing was the development of Erbium (Er:YAG) lasers. They became available to plastic and dermatology surgeons around the year 2000. These were, and continue to be very effective for the resurfacing. Erbium lasers are a lot safer and cause a significantly reduced downtime for the patient. At about the same time fewer patients wanted to have a full face resurfaced as a nicely done areas around the eyes and mouth created a very comparable overall aesthetic result with even faster healing and shorter downtime. A mild laser peel will give most patients an excellent result with about one week of “take it easy” time.

Fractional laserswere introduced to the aesthetic market in 2002-2003 with a big bang and glitzy and very effective promotions by Reliant, which pioneered the fractional photothermolysis. The idea was to bring about a laser that would be non-ablative,  but as effective as the ablative lasers (the CO2 and Erbium) before it.

Fraxel laser by Reliant was the first non-ablative fractional laser for the cosmetic medical market and it gave birth to the first generation of non-ablative fractional lasers. While there were a lot of hype about these non-ablative fractional lasers, the clinical fact is that they had categorically fallen short of the goal of ‘profound results with zero downtime.’ As we have seen with these devices, patients had to tolerate painful treatment in multiple sessions while still enduring disruption of the epidermis and thus multiple episodes of downtime, before the final outcome, which also failed to meet expectations. Fraxel has been upgraded and improved by a number of other competing fractional laser skin resurfacing technologies such as the Lumenis DeepFX and ActiveFX, Palomar Starlux 1540, and Starlux 2940. The newest fractional skin resurfacing technologies employ the use of erbium lasers and may be non-ablative (Fraxel re:fine, Fraxel re:store, Palomar Starlux 1540) or ablative (the newest generation of fractional lasers). The laser beam is ‘fractionated’ into tiny micro-lasers, treating only a small portion of the skin (MTZ – microthermal zone, or sometimes called microscopic treatment zones) and leaving surrounding skin tissue undamaged. The goal is to speed up the healing.   These MTZs cause enough injury to the dermis to trigger new collagen production and stimulate the replacement of collagen damaged by aging and sun exposure. This production of new collagen ‘fills in’ or ‘plumps’ the underlying dermal tissues and smoothes wrinkles. The surrounding, untreated skin speeds the healing process to a mere 3-4 days. Since most of the pigment cells remain intact, hypo pigmentation is effectively prevented. The Fraxel re:fine, Fraxel re:store and Palomar Starlux 1540 are non-ablative lasers that don’t actually vaporize or remove the skin. Instead, the laser instantly heats MTZs, causes the thermal damage, which stimulates new collagen growth during the healing process. Results for wrinkle removal and skin tightening are less dramatic than with any ablative lasers, but some patients may appreciate the benefit of reduced recovery time and fewer side effects.

Fractional Ablative Laser Resurfacing

The newest generation of fractional lasers (Starlux 2940, Lumenis ActiveFX and DeepFx systems and Fraxel re:pair) use the ablative skin resurfacing, i.e. CO2 10600 nm or Erbium 2940 nm. They are designed to offer the best of both worlds: fractional treatments with less downtime and reduced complications and ablative laser skin resurfacing for better wrinkle removal and facial rejuvenation. These lasers actually remove tissue in the micro treatment zones, providing much better cosmetic result for patients with heavily wrinkled and sun damaged skin. These lasers provide “rapid remodeling from the inside out”: the fractional treatment results in both rapid reepitheliazation of the epidermis as well as collagen remodeling to depths of 1.6 mm. The skin heals much faster than if the entire area were treated at once, because the treatment uses the body’s natural healing process to create new, healthy tissue that replaces skin imperfections – such as wrinkles, melasma, dyschromia, actinic ketatosis, pigmented lesions, acne scars and surgical scars.

Fractional treatment works on and off the face, including delicate areas like the neck, chest and hands. This is a huge advantage over previous generations of ablative lasers, which required a truly skilled hand to work on these areas.

There is some increase in recovery time:  clinical downtime of 2-3 days (reepitheliazation of epidermis) and 5-7 days of social downtime (time for patients to resume regular activities). Thus the overall downtime is comparable to the downtime after a traditional non-fractional erbium ablative laser treatment.

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Leaving the laser skin resurfacing by pulsed non-fractionated CO2 lasers in the past (where it belongs now), most experts agree that the newest generation of fractional lasers, which uses ablative technologies (Erbium or CO2), have approached the clinical efficacy achieved by traditional Erbium resurfacing. The pain for the patient, downtime and potential side effects are comparable. It is up to the physician to define what patient will benefit more from the subtle difference between these lasers. In time when value and ROI are particularly important, the cost of acquisition of either type of the ablative laser will be the best helpers to the physician.

This is a short review of a new study by a group of Indian reserchers:
Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar AJ, Khopkar U, Kohli M, Kuriyipe VP, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu KK, Sacchidanand S, Sharma VK, Thomas J. Acne in India: Guidelines for management – IAA Consensus Document: Acne scars. Indian J Dermatol Venereol Leprol 2009;75(Suppl 1):S52-S3. Available from: http://www.ijdvl.com/text.asp?2009/75/7/52/45487 .

LaserOffers.com reviewed the part of the study that directly pertains to our focus on the use of lasers.

Acne scars are classified as atrophic and hypertrophic. Atrophic acne scars are further classified as ice-pick, rolling, and boxcar. The European acne group (ECCA) has renamed the atrophic acne scars as V-shaped (ice-pick), U-shaped (boxcar), and W-shaped (rolling). Scar characteristics can be further assessed with specialized techniques such as silicon elastomer mold which is then examined under a light microscope. Proper classification of acne scars is essential to assess the severity of cosmetic disfigurement and to choose the appropriate therapeutic intervention.

Resurfacing techniques

These include TCA peeling, phenol peeling, microdermabrasion, laser abrasion, selective thermolysis with Fraxel laser, and resurfacing by radiofrequency and electrosurgery.

The objective of any of the skin/scar resurfacing treatments is to restore skin contour by inducing neocollagenosis (new collagen growth). Resurfacing is indicated in U and W scars. The main complication is erythema which persists for weeks. There is also risk of pigmentation.

Spot TCA peeling is a good technique for V and deep U scars. A sharp stick (toothpick) soaked in 62% or 100% TCA is brought in contact with the target and the contact is maintained till whitening appears. It is a painful procedure and multiple sessions are required.

Microdermabrasion involves planing of the skin by mechanized means utilizing the projection of micromarbles consisting of aluminum oxide on scars. Six to seven sessions, at two week intervals are needed. In one session, twenty passes are made on each area until superficial bleeding appears. Six to seven session microdermabrasion has low efficacy and may be useful in superficial U scars. Chemabrasion is when microdermabrasion is combined with a peeling agent.

Lasers are increasingly being used to treat acne scars. Intense Pulse Light (IPL) acts by heating the dermis and stimulating neocollagenosis. It has weak activity and may be helpful in red, hypertrophic scars. Light-Emitting Diode (LED) does not warm but acts by photomodulation. It is a safe and painless procedure but the efficacy is low. It is being used for superficial U scars, erythema (acne macules), and pigmentation. Ablative laser resurfacing, although effective, is associated with excessive tissue reaction as erythema and edema, and complications such as pigmentation and scarring. It is less suited for skin types V-VI. Fractional photothermolysis, a new concept, using 1,550-nm erbium-doped fiber laser (Fraxel® ) appears to be very promising. Fractional photothermolysis creates microscopic thermal wounds to achieve skin rejuvenation without significant side effects. In a study from USA, 53 patients (skin types I-V) with mild to moderate atrophic facial scars were treated with three treatment sessions at monthly intervals. Clinical improvement averaged 51-75% in nearly 90% of patients. Clinical response rates were independent of age, gender, or skin type. Side effects included transient erythema and edema in most patients, but no dyspigmentation, ulceration, or scarring. It was concluded that atrophic scars can be effectively and safely reduced with 1,550-nm erbium-doped fiber laser. Fractional thermolysis is an expensive treatment, and typically 4-8 sittings are required depending on the depth of scars. A single treatment with Fraxel® in the U.S. may cost $1,500.

Prolonged exposure to UV-radiation induces photo-aging and a variety of visible skin changes such as lentigines, actinic keratoses and solar elastosis. Laser skin resurfacing using ablative lasers (CO(2) or Erbium:YAG) is a popular procedure to reduce these marks and improve the aesthetic appearance of photoaged facial skin . Skin resurfacing is defined as an ablation of the epidermis (the upper layers of facial skin).

The use of pulsed or scanning Carbon Dioxide, and pulsed Erbium-YAG lasers allows the programmable and reproducible photocoagulation of thin layers of the epidermis and superficial dermis. Thermal damage depends on the type of laser and is greater with CO(2) lasers. The degree of neocollagenesis is proportional to the thermal damage and is better with CO(2) lasers. Their main indication is the correction of photoaged facial skin but they can also be used for corrective dermatology, e.g. for scars and genodermatosis.

Ablative laser resurfacing is the most effective treatment for many conditions of the photoaged skin. Results are highly satisfactory but the technique is invasive, edema and prolonged erythema are commonand, and the patient experiences a social hindrance of about 7 to 10 days (“downtime”). Possible side effects are hyperpigmentation, hypopigmentation and, at worst, scarring.

A new concept of laser called fractional photothermolysis has been designed to create microscopic thermal wounds to achieve skin rejuvenation without significant side-effects. The fractional techniques such as the 1,550 nm erbium fiber laser (Fraxel Laser , Reliant Technologies) are used to treat non-adjacent microzones without ablation of the epidermis. Around 25 p. 100 of the affected region is treated per session without ablation of the epidermis. Each fraction is only mini-invasive and is performed under local anesthesia. Social hindrance is reduced. Fractional laser was an attempt to bridge the gap between the ablative and nonablative laser modalities to treat the epidermal and dermal signs of skin aging. By targeting water as its chromophore, the laser induces a dense array of microscopic, columnar thermal zones of tissue injury that do not perforate or impair the function of the epidermis. The significant skin remodeling that ensues can be used to treat, with limited downtime, epidermal pigmentation, melasma, and rhytides, as well as textural abnormalities that include acne-related and surgical scars.

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Nonetheless, the results are inferior to those obtained with ablative lasers, especially regarding deep wrinkles. The treatment is costly and four sessions are usually required to treat the whole affected area. 

Ablative treatments smooth roughened skin, periorbital rhytids, remove pigmented lesions and minimise acne scarring. Dr Peter Crouch discusses the latest advances and the tried-and-tested methods

Until the development of laser skin resurfacing in the 1980s, mechanical abrasion and chemical peeling agents were the mainstay of treatments targeting acne scarring, wrinkles and tired, aged skin. Controlled ablation promised the prospect of restoring a more youthful, radiant appearance. Non-ablative remodelling of existing tissue is only one method of stimulating positive change and is the key strategy with IPL and radiofrequency treatments and has been outlined in previous articles in this series. The approach with most non-ablative treatments is to provide a controlled thermal stimulus sufficient to denature and contract collagen while avoiding surrounding tissue damage. Most non-ablative procedures utilise thermal (heat) energy for immediate tissue contraction (short-lasting), followed over the next few months by collagen remodelling and regeneration (longer-lasting).

Ablation literally means destruction, and there are several approaches for removing unwanted tissue and to promote increased tissue turnover as part of healing. Depending on the depth of ablation, skin resurfacing, smoothing of periorbital rhytids, removal of pigmented lesions and minimisation of acne scarring are all possible outcomes of expertly delivered skin ablation. In the months following ablative treatment, the body’s natural healing processes produce new replacement tissue, resulting in healthier, more even, smoother skin and a more youthful appearance.

The ideal tissue-ablation device would cause little pain and discomfort, have little or no downtime, be affordable, show demonstrable results after each session and cause no unwanted side-effects. As tissue ablation can effectively remove unwanted targets and the ablation is more related to tissue water content and is relatively more indiscriminate, ablative techniques rely more on targeting precisely where the treatment beam ablates rather than using the wavelength of the treatment beam to discern one target from another based on pigmentation—that is, a specific chromophore, or the presence of, for example, haemoglobin. Because the wavelengths often used for ablation specifically target tissue water, the fluence often determines, fairly precisely, the exact depth of ablation.

What Is Blepharoplasty?

Blepharoplasty refers to eyelid surgery and is designed to remove the excess fat, along with skin and muscle, from the upper and lower eyelids. It is the second most common aesthetic procedure performed by plastic surgeons.

What Are the Goals of Blepharoplasty?

A properly performed blepharoplasty procedure will brighten the face and restore a more youthful appearance. In some patients the procedure will improve vision by removing the excessive skin of the upper eyelids, which can hang down and interfere with peripheral vision.

How Is the Procedure Performed?

Eyelid surgery is usually performed using local anesthesia and light intravenous sedation. It is commonly done in a doctor’s office, outpatient surgical center or, in some cases, in a hospital. The procedure is most often performed on an outpatient basis.

Are There Scars From the Blepharoplasty Procedure?

Scars are a result of any surgical procedure. The incisions made to accomplish the goals of the procedure are barely visible after several months as they are placed within the normal creases and folds of the upper and lower eyelids. In patients who only need removal of fat from the lower eyelids, the incision can be made on the inside of the eyelid, and will therefore result in an invisible scar.

Will the Fine Wrinkles Around My Eyes Go Away After Blepharoplasty? What About My Sagging Eyebrows and Dark Circles Under My Eyes?

The blepharoplasty procedure will not eradicate the wrinkles around the eyes (crow s feet) nor will it elevate droopy eyebrow. There are other procedures designed for these purposes. Dark circles under the eyes may improve a bit if this is related to large bags, but most often the dark appearance of the lower eyelid skin remains.

Can Anyone Have a Blepharoplasty?

The best patients are those who are healthy, psychologically stable and well motivated. Some medical conditions may increase the risk of blepharoplasty surgery such as thyroid disease, high blood pressure and patients who do not make sufficient tears to keep their eyes well lubricated.

What Are the Risks Involved With This Procedure?

Fortunately, when performed by a competent plastic surgeon, complications are infrequent and minor. All patients will experience some bruising and swelling for a few days after the surgery. In addition, a temporary problem with closure of the eyelids is usually seen. Some may have temporary blurring of their vision, usually due to the ointments applied to the incisions post operatively. In rare instances, the lower eyelid may be pulled down causing an ectropion. If this does not resolve on its own, further surgery may be necessary. The theoretical complications of any surgical procedure, such as bleeding, infection, wound disruption and heavy scarring are also possible, but rare.

Other Opportunity to Consider

Some of the surgeons may offer skin resurfacing around you eyes and mouth with an Erbium (Er:YAG) laser. You should seriously consider this option as your overal looks will benefit dramatically from this treatment. You may shed several years and improve (tighten) the texture of your facial skin.  Laser skin resurfacing (LSR) typically require 5-7 days of downtime, when your skin will be red and peeling. However, since Blepharoplasty requires the same, you will not even notice it.

Laser skin resurfacing

In laser resurfacing, sometimes called “laser peel,” a carbon dioxide (CO2) or and Erbium (Er:YAG) laser is used to remove areas of damaged or wrinkled skin, layer by layer. The procedure is most commonly used to minimize the appearance of fine lines, especially around the mouth and the eyes. However, it is also effective in treating facial scars or areas of uneven pigmentation. Laser resurfacing may be performed on the whole face or in specific regions. Often, the procedure is done in conjunction with another cosmetic operation, such as a facelift or eyelid surgery.

Laser resurfacing is still a very new procedure. However, it has been shown that in some cases, this surgical method produces less bleeding, bruising and post-operative discomfort than is typically seen with other resurfacing methods.

About the laser

Laser resurfacing is performed using a beam of laser energy which vaporizes the upper layers of damaged skin at specific and controlled levels of penetration.

It’s clear that laser resurfacing may offer a number of advantages over other resurfacing methods: precision, little (if any) bleeding and less post-operative discomfort. However, laser resurfacing isn’t for everyone. In some cases, an alternative skin resurfacing treatment, such as dermabrasion or chemical peel, may still be a better choice.

All resurfacing treatments work essentially the same way. First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Laser resurfacing is a new method being used by plastic surgeons to remove damaged skin. Because it is new, there are no long-term data on this technique. However, a number of studies using microscopic examination have shown that the physical changes that occur to laser-treated skin are essentially identical to those that occur with either dermabrasion or chemical peel. Ask your plastic surgeon about the latest facts concerning long-term follow-up.

For superficial or medium resurfacing, the laser can be limited to the epidermis and papillary dermis. For deeper resurfacing, the upper levels of the reticulas dermis can also be removed. Varied penetration allows treatment of specific spots or wrinkles.

It’s also important to consider the length of recovery when choosing among the skin-resurfacing alternatives. In general, the more aggressive the resurfacing procedure is, the more prolonged the recovery is likely to be. “Light” resurfacing procedures, such as superficial chemical peels or superficial laser resurfacing, offer shorter recovery times. However, these lighter procedures may need to be repeated multiple times to achieve results comparable to those achieved with more aggressive techniques.

The best candidates for laser resurfacing

Men and women of all ages can benefit from laser resurfacing. The ideal patient for laser resurfacing has fair, healthy, non-oily skin.
In many cases, facial wrinkles form in localized areas, such as near the eyes or around the mouth. The laser can be precisely controlled so that only these specific areas are targeted.

Patients with olive skin, brown skin or black skin may be at increased risk for pigmentation changes no matter what type of resurfacing method is recommended. Your plastic surgeon will evaluate your skin characteristics and make recommendations accordingly.

Also, individuals who have taken accutane in the past 12-18 months or are prone to abnormal (keloid-like) scarring or those with active skin infections on the treatment area may not be appropriate candidates for this procedure.

When healing is complete, the face has a more youthful appearance.

Remember, having laser resurfacing can help enhance your appearance and your self-confidence, but it won’t completely remove all facial flaws or prevent you from aging. Lines that occur as a result of natural movements of the face – smiling, squinting, blinking, talking, chewing – will inevitably recur. Your plastic surgeon can suggest ways to help you preserve your results by protecting yourself from sun exposure or using maintenance treatments, such as light chemical peels or medicated facial creams. Before you decide to have laser resurfacing, think carefully about your expectations and discuss them with your surgeon.

All surgery carries some uncertainty and risk

When laser resurfacing is performed by a qualified, experienced surgeon, complications are infrequent and usually minor. However, because individuals vary greatly in their anatomy, their physical reactions and their healing abilities, the outcome is never completely predictable.

Risks associated with laser resurfacing include: burns or other injuries from the heat of the laser energy, scarring, and obvious lightening or darkening of the treated skin. Also, laser resurfacing can activate herpes virus infections (“cold sores”) and, rarely, other types of infection.

Additional corrective measures and treatment may be required if healing seems abnormal or delayed or if there is any evidence of abnormal pigmentation or scarring.

You can reduce your risks by choosing a qualified plastic surgeon who has received special training in laser surgery.

Planning your surgery

Not every practitioner who offers laser surgery has the same level of experience and skill with laser use. That is why it is especially important that you find a plastic surgeon who is adequately trained in the procedure.

One safety measure is to find out whether your surgeon has privileges to perform laser resurfacing with a CO2 laser at an accredited hospital. Even if the operation is to be conducted in your doctor’s private facility, the fact that he or she has privileges to use that same laser in a hospital ensures that the doctor has been reviewed by the institution’s experts.

In your initial consultation, be frank in discussing your expectations with the surgeon and don’t hesitate to ask any questions you may have. Your surgeon should be equally frank with you, explaining the factors that could influence the procedure and the results – such as any abnormal skin condition which has been diagnosed or previously treated, medications you are taking or have taken in the past, previous skin injuries or previous operations.

Your surgeon will discuss your medical history, perform a routine examination and photograph the area to be treated. He or she should explain the procedure in detail, along with its risks and benefits, the recovery period and the costs.

Remember, cosmetic laser treatments can be expensive and are usually not covered by medical insurance. On rare occasions, the procedure can be used for modification of scars or the removal of pre-cancerous skin growths. These conditions could meet the criteria for “medical necessity,” usually required by insurance companies before coverage will be provided. Your plastic surgeon can advise you how to contact your insurance carrier to determine whether benefits will be allowed in such instances.

Preparing for the laser procedure

Fine, vertical creases or “lipstick lines” are commonly treated with laser resurfacing.
Depending on your individual needs, your surgeon may recommend that you begin a pre-treatment plan to prepare the skin for resurfacing.

At the time of the procedure, you will be given specific instructions on how to care for your skin immediately following your laser treatment. Your surgeon may also instruct you to follow a specific maintenance regimen for long-term care of the skin to maximize the benefits of the procedure.

Within about five weeks after treatment, the upper lip is noticeably smoother.
While you are making plans, be sure to make arrangements for someone to drive you home if you will be given tranquilizers or sedation for your laser treatment.

Types of anesthesia

Laser resurfacing is most commonly performed under local anesthesia with sedation, especially when it’s used to treat localized areas of the face. You’ll be awake but relaxed, and will feel minimal discomfort. For more extensive resurfacing, your surgeon may prefer to use general anesthesia, in which case you’ll sleep through the procedure.

The procedure

Laser resurfacing is a relatively quick procedure. It usually takes anywhere from a few minutes to 1 1/2 hours, depending on how large of an area is involved.

When the imperfections are especially deep, your surgeon may recommend that the resurfacing be performed in two or more stages.

During the procedure, the activated laser is carefully passed back and forth over the skin until the surgeon reaches the level that will make the wrinkle or scar less visible.

When the procedure is over, your surgeon may choose to treat the resurfaced skin with applications of protective creams or ointments until healing is complete. Some surgeons choose to apply a bandage over the treated areas which will cover and protect the healing skin for the first five to ten days.

After your treatment

You are likely to experience some mild swelling and discomfort after laser resurfacing. However, this can be controlled with ice packs and medications prescribed by your surgeon.

If a bandage was applied after your procedure, it may be replaced with a fresh one after a day or two. After about a week or so, your bandage will be removed and a thin layer of ointment may be applied to the skin. Once this stage is reached, your surgeon will provide instructions on how to gently wash and care for your healing skin.

During this phase of healing, it is very important that you not pick the crusts off the treated area or scarring may result. Most patients are free of crusts by about 10 days post-operatively. Redness may persist for several weeks.

Getting back to normal

Your new skin will usually remain bright pink to red in the weeks following the procedure. Your surgeon may prescribe medications to make this color subside more rapidly. After about two weeks or so, most patients can safely apply makeup to conceal this temporary color change. However, some pinkness may remain for up to six months.

It is rare, some patients may find that their healing skin is unusually sensitive to the makeup that was regularly used prior to treatment. In such instances, makeup should be avoided until a substitute can be found or until the healing progresses to a point at which the makeup no longer causes a reaction.

Above all, in the months following treatment, it’s important to protect the treated area from the sun until all the color has returned to normal. Using sun protection regularly will help to maintain your results and reduce the chance of any new sun damage to your skin.

If you must be in the sun, apply a strong sun block with an SPF of 15 or higher and shade your face with a hat or visor. If resurfacing was performed around the eyes, it’s best to also wear good quality sunglasses with UVA and UVB 100 percent filters.

Your new look

The final result from laser resurfacing may take several months to fully appear. However, once the pinkness fades, patients usually notice a significant improvement in the quality of their skin and a fresher, smoother appearance.

It’s important to understand that your results will be long-lasting, but not permanent. Remember, your new skin is not immune to the effects of aging. In the months and years following your laser treatment, your natural facial movements will eventually cause any “expression” lines to recur.

As with other methods of skin rejuvenation, laser treatments can usually be repeated. However, by protecting yourself from the sun and following a skin-care regimen recommended by your plastic surgeon, you can help maintain your rejuvenated look.

Fractional photothermolysis, based on creating spatially precise microscopic thermal wounds, is performed using a 1550-nm erbium fiber laser that targets water-containing tissue to effect the photocoagulation of narrow, sharply defined columns of skin known as microscopic thermal zones.

Fraxel resurfacing has been shown to be both safe and effective for facial and nonfacial photodamage, atrophic acne scars, hypopigmented scars, and dyspigmentation. Because only a fraction of the skin is treated during a single session, a series (typically 3 to 6 treatments) of fractional resurfacing at 2- to 4-week intervals is required for the best clinical improvement.

Many physicians have reported that a series of Fraxel treatments can achieve a similar clinical result for atrophic scars compared with traditional ablative laser skin resurfacing with either CO2 or Er:YAG 2940-nm lasers. However, the improvement seen after a series of Fraxel treatments for perioral laxity and rhytides often falls short of the impressive results that can be achieved with ablative laser skin resurfacing.