Laser ResurfacingFull Field and Fractional

Jason N. Pozner, MDa,b,*, Barry E. DiBernardo, MDc

KEYWORDS

� Laser resurfacing � Full field resurfacing � Fractional resurfacing � Hybrid fractional laser� Carbon dioxide laser � Erbium laser � Laser complications

KEY POINTS

� Full field means 100% of the treated area is removed to the selected depth.

� Fractional means discontinuous portions of the treated area are removed.

� Recovery time is linked to the amount of damage created.

� Fractional treatments usually have less downtime than full field treatments.

� Complications can arise with all of these laser treatments.

INTRODUCTION

Data from The American Society of AestheticPlastic Surgery1 collected yearly from core spe-cialists since 1997 through 2014 have shown theincrease, decrease, and increase again of laserresurfacing. In 2014 more than 583,000 full fieldand fractional laser resurfacings were performedin core offices making this the fourth most popularprocedure overall after botulinum toxins, hyal-uronic acid fillers, and laser hair removal.

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HISTORYFull Field Resurfacing

The introduction of carbon dioxide lasers for skinresurfacing in the mid 1990s started the era oflaser resurfacing. Lasers quickly replaced chemi-cal peels and dermabrasion in many offices. Thesedevices are used for full field resurfacing, whichmeans that 100% of the target area from theepidermis down is treated (Fig. 1A). Continuousmode carbon dioxide lasers (10,600 nm) wereinitially used, but complications due to excessivedepths of ablation and thermal damage led todiscontinuous or pulsed systems. The water chro-mophore of the carbon dioxide laser allowed

a Cleveland Clinic Florida, Weston, FL, USA; b Sanctuary Ptic Surgery, 29 Park Street, Montclair, NJ 07042, USA* Corresponding author. Sanctuary Plastic Surgery, BocaE-mail address: jpoznermd@gmail.com

Clin Plastic Surg 43 (2016) 515–525http://dx.doi.org/10.1016/j.cps.2016.03.0100094-1298/16/$ – see front matter � 2016 Elsevier Inc. All

tissue vaporization and left behind in the tissuessome resultant thermal injury. The initial discontin-uous systems delivered either short pulses (Ultra-pulse laser, Lumenis lasers, Yokneam, Israel) orscanned pulses (Silk-touch and Feather-touchlasers, Lumenis lasers, Yokneam, Israel). Bothmethods created a short exposure time to ablatetissue (approximately 75–100 mm) and limited thethermal damage (approximately 75–100 mm) thatwas created with the continuous systems. Spec-tacular results of eradicating wrinkles and tight-ening lax tissue were excellent in many patients,but as long-term experience was obtained therewas noted to be an unacceptably high hypopig-mentation rate. The pigmentary complications,scarring in some patients, and the considerablepatient healing period led to the demise of full fieldcarbon dioxide laser resurfacing around the turn ofthe century.1

Erbium:YAG lasers (2940 nm) have a higherwater absorption coefficient than carbon dioxidelasers (about 10 times more efficient) and ablatetissue with much less thermal damage (5–10mm).2 These lasers were introduced around theend of the carbon dioxide full field era and wereinitially marketed for superficial resurfacing as theinitial machines were low powered and it was

lastic Surgery, Boca Raton, FL, USA; c New Jersey Plas-

Raton, FL.

rights reserved. plasticsurgery.th

eclin

Laser

Dermis

Dermis

SubQ

SubQ

No zones of spared epidermal tissue remain.

Islands of new epithelium

Traditional Ablative Laser Resurfacing

Nonablative Fractional Laser TreatmentLaser

Zones of spared tissue contain clusters of epidermal stem cells and Transit Amplifying (TA) cells

Healing occurs from viable tissue

A

B

C

Dermis

SubQ

Zones of spared tissue contain clusters of epidermal stem cells and Transit Amplifying (TA) cells

Healing occurs from viable tissue

Ablative Fractional Laser Treatment

Fig. 1. (A–C) Full field versus nonablative and ablative fractional resurfacing. SubQ, subcutaneous.

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difficult to achieve deeper depths of ablation. Sub-sequent systems had more significant power andhad pattern generators similar to the moreadvanced carbon dioxide systems. Complicationsseemed to be less than with carbon dioxide sys-tems, although comparative studies showed re-covery time and results to be determined bydepth of injury rather then the laser used.3 Combi-nation systems of carbon dioxide and erbium la-sers were also used (Derma-K, Lumenis lasers,Yokneam, Israel).

The authors’ favorite full field laser is the Scitonvariable pulse width erbium laser (Sciton Inc, PaloAlto, CA). This device blends the best concepts ofthe carbon dioxide lasers with the best of theerbium lasers by having a very-high-power erbiumlaser and by allowing variation of the erbium pulsewidth, which controls the amount of residual ther-mal injury.4,5 This system creates very preciseablation and where needed/wanted controlledthermal damage (less then with carbon dioxidesystems). The clinical results are excellent with amuch shorter period of erythema and much lowerrisk of hypopigmentation (Figs. 2–4).

Other wavelengths for skin resurfacing havebeen introduced (2780 nm and 2790 nm) (CuteraLasers, Cutera, Brisbane, CA; Palomar Lasers,Cynosure Inc, Westford, MA) but have not had sig-nificant commercial success.

Fractional Resurfacing

Fractional lasers create an array of injury and treata fraction of the skin at any one time leaving intactskin bridges adjacent to the treated area (seeFig. 1B). This method differs from full field resur-facing in which 100% of the skin surface treatedis removed. Manstein and colleagues6 introducedthis concept in 2004. The first generation of thesedevices was nonablative and created a zone of

Fig. 2. Before and 8 years after full field eyelid resur-facing (Sciton erbium).

desiccated tissue called a microthermal zone(MTZ) (Fig. 5). The first of these devices was at1550 nm (Reliant technologies, Mountain View,CA, now Solta Medical part of Valeant Pharmaceu-ticals International). Currently other nonablativewavelengths are also used (1440 nm, 1470 nm,1540 nm). After an MTZ was created, healingoccurred from deeper structures as well as fromadjacent structures. This method differs from fullfield resurfacing in which healing occurred fromonly deeper structures, that is, hair follicles andsebaceous glands. Deeper treatments and bodytreatments can safely be performed with nonabla-tive fractional lasers. After the injury was created,the epidermal basal layer was restored within24 hours and the skin expelled the MTZ over thenext week. The expelled MTZ containing melaninwas called the microscopic epidermal necroticdebris. New collagen was created and the skinrejuvenated. Advantages of nonablative fractionalresurfacing were avoidance of an open woundand very low risk of complications, includingpigment disturbance or scarring.7–14 Disadvan-tages include the need for multiple treatmentsand somewhat less clinical response than withfull field ablative resurfacing.

The next advance in laser resurfacing was thedevelopment of fractional ablative resurfacing(Fig. 1C). These lasers in wavelengths of carbondioxide, erbium, and YSGG systems created a col-umn of tissue ablation in the skin instead of a col-umn of desiccated tissue like the fractionalnonablative systems15 (see Fig. 5). The varyingfractional ablative devices differ not only in wave-length but also in system power, spot size, andamount of thermal damage created adjacent toand deep to the ablated hole. Carbon dioxide abla-tive fractional lasers ablate tissue and leave a ringof adjacent thermal tissue. The erbium lasers leaveless thermal damage but with usually morebleeding. The Sciton ProFractional erbium frac-tional laser allows one to vary the amount of ther-mal damage similarly to their full field system(Fig. 6). Other newer carbon dioxide fractional la-sers allow variation of the thermal damage zones(Deka Medical, San Francisco, CA), whereasothers allow superficial and deeper penetrationwith a single scan (Syneron, Yokneam, Israel).These ablative fractional lasers are more effica-cious then the nonablative fractional lasers butcreate more patient healing time albeit much lessthen the full field ablative variants. Experimentswith both ablative and nonablative fractional lasersin same session treatment proved promising.16

The Thulium device (1927 nm) by Solta Medicalis a nonablative fractional device marketed asespecially effective in removing superficial

Fig. 3. Before and 6 years after full field perioral resurfacing (Sciton erbium).

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pigment. This device is generally used with theirnonablative 1550-nm laser.The newest fractional laser on the market is a

hybrid fractional laser made by Sciton (Palo Alto,

Fig. 4. Before and 3 years after full face full field erbium

CA) and called the Halo. This device is veryinteresting as it allows coincident delivery of firsttheir erbium fractional laser then a nonablative1440-nm pulse in the same hole. This device is

resurfacing (Sciton erbium).

Fig. 5. Comparison of fractional histology: nonablative versus ablative versus hybrid. (H&E stain, arrow showsbottom of the nonablative wound.)

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very efficacious and creates very minimal healingtimes. This laser is the authors’ laser choice forskin rejuvenation when recovery time is limited(Figs. 6 and 7).

Fig. 6. Before and after treatment with erbium MicroLase

PATIENT SELECTION

Patient selection is critical to successful out-comes. Indications for both full field and fractional

rPeel and erbium fractional laser.

Fig. 7. Before and after hybrid fractional resurfacing.

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laser resurfacing are superficial dyschromias,textural anomalies, superficial to deep rhytids,acne scars, and surgical scars. Other conditionsthat may respond favorably include sebaceoushyperplasia, xanthelasma, syringomas, actiniccheilitis, and diffuse actinic keratosis. Melasmahas been successfully treated with fractionalresurfacing, but results are not consistent. Theface is the usual area to be treated, but bodyand neck skin may be treated with variations oftechnique. Nonfacial areas lack the appendagesnecessary for skin rejuvenation, and treatmentmust be modified to avoid complications. Patientswith Fitzpatrick skin types I to IV are generallytreated, but the lasers can be used in skin typesV and VI with modifications of technique.The patient assessment includes Fitzpatrick

skin type, ethnicity, wrinkles versus pigment, etc,to be treated. Some problems, such as perioralrhytids, may be treated by one deep full field resur-facing; but other pathology, such as acne scarring,responds better to multiple fractional treatments.The patients’ healing period is a very criticalcomponent of the laser consultation, as some pa-tients may not be able to spend the week off toheal from a deep full field treatment but may beable to have a few fractional ablative laser treat-ments with a few periods of limited recoveryspaced monthly. Another consideration is laserresurfacing while patients are undergoing otherprocedures, such as facelift, abdominoplasty, or

aesthetic breast surgery. These patients oftenhave built-in downtime from other proceduresand have the recovery time available for deepresurfacing.

OVERVIEW OF TREATMENT STRATEGYLaser Safety

Laser safety is critical to both practitioners and pa-tients. There are excellent published guidelines onlaser safety. Specifically relevant to ablative andnonablative resurfacing is the risk of fire and thatof eye safety. Fire is an extremely rare occurrence;one must be cognizant not to fire an ablative laserin the presence of exposed oxygen sources, suchas nasal cannulas, or test on paper products orgauze. Some recommend the use of wet towelsaround the patients’ face to prevent a fire hazard.Eye protection is critical for all personnel

and patients. Laser-specific eyewear is used forthe treating practitioner and all people in the treat-ment room. External or internal contact lens–typelaser-specific eye shieldsmust be used onpatients.There are a few absolute contraindications for

laser treatment and some areas of caution.1

Absolute Contraindications

Active infectionThis is pretty much the rule for most of surgery andelective aesthetic procedures should not be per-formed in the face of active infection. This is true

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for bacterial, viral or fungal infections whetherlocalized to the treated are or not.

Appendageal abnormalityPatients with abnormalities of the hair follicles andsebaceous glands may have problems with woundhealing as laser wounds heal in full field resurfac-ing from the deep tissues towards the surfacefrom precursor cells in the hair follicles andsebaceous glands and in fractional resurfacingfrom those areas and adjacent normal tissue.Concurrent or recent oral retinoid use is generallyconsidered an absolute contraindication to laserresurfacing. The data are confusing as to whetherfractional resurfacing is safe with oral retinoid use.Most experts agree that it is safe to perform deepfull field resurfacing after cessation of oral retinoidswith return of sebaceous function a (usually6 months to 2 years after cessation).

Skin graftsDeep full field resurfacing is contraindicated in thepresence of skin grafts, as the appendagesmentioned earlier are not present in those areas.

Extensive electrolysisExtensive electrolysis may also be an absolutecontraindication for deep full field resurfacing,but fractional or superficial full field resurfacingshould be safe.

Relative Contraindications

Unrealistic expectationsUnrealistic expectations are a problem we dealwith regularly in plastic surgery and aestheticdermatology. Laser resurfacing in all its variationscan produce some remarkable results but shouldnot be overstated and oversold. Acne scarringespecially can be improved dramatically but mayrequire multiple treatments.

Keloid or scarring historyPatients with a history of abnormal scarring maycreate scars with laser resurfacing. They shouldbe approached with caution, and a test treatmentarea (test spot) may be helpful.

Regional resurfacing in darker-skinnedindividualsDeep full field resurfacing in darker-skinnedpatients may create color differences in adjacentareas. Superficial or fractional regional resurfacingis generally considered safe.

Previous deep chemical peelCaution needs to be taken in patients with previ-ous deep phenol peels as appendages may bedamaged and skin may not heal normally.

History of cold soresPatients with a strong history of cold sores need amodified prophylaxis regimen compared with pa-tients with no history of cold sores. This regimenshould start earlier, by 2 to 3 days, and extendlonger after healing. Even once fully epithelialized,recently resurfaced skin seems to have increasedsusceptibility to viral infection, unlike bacterialinfection risk, which seems largely eliminated byfull epithelialization.

Laser Treatment

The laser procedure is treated as any other officeor operating procedure. Following the initial con-sultation, a proper history and physical examina-tion is obtained. Informed consent specific to thelaser used is obtained. Patients usually start anti-viral medications before the procedure. The skinis cleaned of makeup; eye precautions, as outlinedearlier, are placed. Most fractional treatments orvery superficial full field treatments are usuallyperformed with topical anesthetics and a cold airchiller (Zimmer USA, Zimmer Medizin Systems,Irvine, CA) for added comfort. Deeper full field pro-cedures or aggressive fractional procedures areperformed under facial nerve blocks, intravenous(IV) sedation, or general anesthesia. It is very com-mon in the authors’ office to perform deep laser fullfield resurfacing with an oral benzodiazepine,intramuscular (IM) meperidine, facial blocks, anda Zimmer chiller. General anesthesia or IV sedation(monitored anesthesia care) is usually used whencombined with other more invasive procedures.Following the treatment postprocedure care asoutlined next is performed.

Pretreatment and Posttreatment Regimens

There are numerous pre- and post-treatment reg-imens.17 Pretreatment with topical retinoids andbleaching creams is another controversial subjectwith proponents on either side of this debate withdata from chemical peel and laser literature beingmixed. The authors’ think that in full field resurfac-ing greater than 100 mm, the treated melanocytesare ablated so no benefit to pretreatment is seen.In superficial full field and fractional resurfacing,pretreatment may be beneficial in preventing hy-perpigmentation. Most recommend cessation ofthese products a few days before treatment.

The use of antiviral prophylaxis is important withablative resurfacing. There is debate in the litera-ture as to when to start antiviral therapy, withsome proposing 3 days before treatment, whereasothers recommend starting on the day of treat-ment. Most agree that therapy should continueuntil complete re-epithelization occurs. This time

Fig. 8. Herpes infection after laser resurfacing.

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is laser, patient, and treatment parameter depen-dent. The use of antiviral therapy with fractionaltreatments is controversial. The authors recom-mend its use, as the risk of these medicationsis low.Prophylactic antibiotic use is often recommen-

ded, although the authors know of no controlledstudies of their use. Bacterial infection is extremelyrare and is covered in the next section.After laser treatment there are a myriad of ways

to care for the treated skin. For full field proce-dures most recommend an occlusive ointment ordressing until epithelialization is complete. Theauthors find that occlusive, work well for carbondioxide full field resurfacing but are difficult tokeep on erbium patients because of the transu-date that occurs following this procedure. The au-thors’ recommendation is to use Aquaphor orVaseline until epithelialization is complete andthen a nonocclusive moisturizer, such as Cetaphillotion. Deep ablative fractional treatments are usu-ally treated with a similar occlusive regimen for 24to 48 hours, although some may prefer a nonoc-clusive dressing because of the incompleteepidermal removal.Use of sunblock is mandatory for all laser-

resurfacing patients in the authors’ practices afterepithelialization is complete. The authors alsorecommend institution of a skin care regimen afterepithelialization is complete and the skin has had achance to calm down, which maymean a few daysfor fractional treatments to a few weeks for full fieldtreatments. There are many good skin careregimens appropriate after laser resurfacing. Thecombination of 4% hydroquinone and low-strength tretinoin (Retin-A) is still used, althoughnewer regimens with added growth factors arefavored by some. The key is to start theseregimens slowly to avoid irritation of the skin (seelater discussion: irritant dermatitis).

Complications and Treatment

InfectionInfection after laser resurfacing can be viral, bacte-rial, or fungal. The most well-known complicationis due to herpes simplex virus (Fig. 8). Manypatients have been infected previously or arecarriers. The current recommendation as outlinedearlier is for all patients to be protected againstherpes viral infections. Some patients may avoidtaking the antiviral medications, whereas othersmay experience breakthrough infection. The treat-ment is early recognition of the infection andtreatment with oral antiviral agents. For verysevere infections with herpes simplex or zoster,IV antiviral medication may be needed.

Bacterial infection after laser resurfacing usingopen treatment is uncommon, but with increasingmethicillin-resistant Staphylococcus aureus therehave been patients who have had infection afterlaser resurfacing. The treatment is administrationof broad-spectrum antibiotics with culture of theskin and targeted antibiotic treatment after cultureresults are obtained.True fungal infection is rare, but infection with

yeast (Candida albicans) is common. Patientsusually present with an extremely red face with ahistory of having improvement in the healing andsuddenly appearing much redder. Treatment istopical antifungal therapy with a rare need for anoral antifungal medication, such as fluconazole(Diflucan).

ErythemaErythema after laser resurfacing is a normal part ofthe inflammatory healing process. It is directlyrelated to depth of laser resurfacing and to theamount of thermal damage created. Some pa-tients will experience an amount of erythemadisproportionate to the treatment. They may beleft untreated for the erythema to resolve sponta-neously (which it will) or else they may be treatedwith mild topical steroids, light-emitting diodetreatments, intense pulsed light (IPL) treatments,or with a vascular laser.

Skin eruptionsSkin eruptions due to acne or milia are commonfollowing laser resurfacing. This response may bedue to overocclusion with topical products ordue to activation of gland function. Acne may betreated with discontinuation of occlusive agents.If this fails, oral antibiotics and/or acne laser treat-ment with mini-infrared lasers may be used. Miliaare treated with opening with a small-gaugeneedle.

TelangiectasiaIncreased appearance of telangiectasia afterlaser resurfacing is common. This appearance is

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due to eradication of overlying photodamage andunmasking of the vasculature. Treatment is witha vascular laser.

DermatitisTwo types of dermatitis are seen following laserresurfacing: irritant and allergic. Irritant derma-titis, as mentioned previously, may be due tostarting topical skin care treatments, such asretinoids, too early or too aggressively. Allergicdermatitis is due to true allergy usually to oneof the topical agents but may also be due toone of the oral antibiotics. Treatment ofboth conditions is discontinuation of theoffending agent and application of a mildtopical steroid.

HypopigmentationHypopigmentation is a dreaded complication ofdeep laser resurfacing and has been reportedwith both carbon dioxide and erbium treatmentand with both full field and fractional treatment. Itis not uncommon with deep carbon dioxide resur-facing, with some series reporting up to 70% ofpatients getting hypopigmentation. It is very rarewith deep erbium full field resurfacing and veryrare with all fractional treatments. There are notmany treatments, but some have reportedimprovement with excimer laser therapy.Blending, by treating the adjacent area may behelpful.

Fig. 9. Hyperpigmentation after laser resurfacing and cor

HyperpigmentationPostinflammatory pigmentation (PIH) is a verycommon problem following laser resurfacing(Fig. 9). It is more common in darker skin typesand in patients who have had early sun expo-sure. Prevention as outlined earlier is key. Treat-ment is with topical bleaching creams (theauthors like to combine with retinoids). Failuresof this regimen are usually treated with IPLtreatments.

ScarringScarring after laser resurfacing may occurbecause of overly aggressive full field or fractionaltreatment, infection, or even scratching bypatients (Fig. 10). Full field resurfacing is acontrolled first-degree or second-degree burnand anything, such as infection, may convertthat controlled second-degree burn into athird-degree burn with resultant scarring. Overag-gressive fractional resurfacing may be due totoo-deep treatment or too much density, creatinga full field defect when a fractional treatment wasintended. The authors prefer early treatment ofthickened areas that seem to be heading towardsscarring with topical potent steroids, such as apulsed regimen with clobetasol. Intralesional ste-roids, intralesional 5-fluorouracil, vascular laseror IPL treatment, and fractional lasers have allbeen used to improve hypertrophic scars afterlaser resurfacing.

rection with skin care.

Fig. 10. Hypertrophic scar after laser resurfacing and after correction with fractional erbium, IPL, and intrale-sional steroids.

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EctropionEctropion is caused by laser resurfacing bytightening of the lower eyelid skin in the faceof a weak lower eyelid canthal support. Asnap test or other measurement of lower eyelidlaxity is recommended before laser resurfacing.Patients with significant laxity are offeredeither canthal support surgery (rare) or canthaltemporary support (temporary tarsorrhaphy,common).

SynechiaSynechia is caused by healing of 2 epidermalsurfaces and appears as a line (usually in the lowereyelid). If untreated this may lead to cyst forma-tion. Treatment is to manually stretch the edgesof the synechia until the line opens.

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