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.

LaserOffers.com comment

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.

J Cosmet Laser Ther. 2008 Jun;10(2):67-71

Authors: Carniol PJ, Dzopa N, Fernandes N, Carniol ET, Renzi AS

BACKGROUND/OBJECTIVES: To determine the efficacy of the 1100-1800 nm infrared device for facial and cervical skin tightening.

METHODS: Ten female patients, with a mean age of 56.5 years, received two treatments 1 month apart with a chilled tip infrared device (Titan; Cutera, Brisbane, CA, USA). Individuals were examined and photographed prior to treatment and at 1 and 3 months post-treatment. Three treatment-independent evaluators compared the photographs and graded them on a standardized scale applied to seven regions subdividing the face and neck. After evaluating the photographs, the difference in pretreatment and post-treatment scores was expressed as a percentage. The patients also rated their results.

RESULTS/CONCLUSION: The greatest tightening was achieved over the malar region, the upper neck and the body of the mandible. In these areas the average tightening was 10%, 10%, and 12% respectively. The patients reported a 32% improvement in the appearance of their cheeks and a 20% visible improvement in their necks. Overall, they were pleased with the result of this non-surgical skin tightening.

PMID: 18569258 [PubMed - indexed for MEDLINE]

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.

LaserOffers.com comment

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.