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Surgery and Cosmetics

David J. Goldberg, MD

Fractional Resurfacing

David Goldberg

Monday, February 07, 2005

The laser treatment of photoageing skin has traditionally involved the use of ablative lasers and/or nonablative lasers or light-based therapy. Each technique has advantages and disadvantages:

  • Ablative laser technology regenerates ageing and sun-damaged skin with superior cosmetic results but is associated with significant potential side effects, risks, and prolonged healing and recovery times. Popular ablative lasers include either carbon dioxide or long-pulsed erbium:YAG lasers. Because of the high power levels and macroscopic spot sizes associated with ablative techniques, healthy tissue is often thermally damaged, in addition to the skin that is being treated. In addition, there is no computerized technological mechanism that can control the amount of thermal injury that is laser-delivered to the skin.
  • Nonablative techniques generally carry fewer risks but require numerous treatments over several months, producing only limited clinical cosmetic improvement.

It seems logical that treating the skin fractionally with patterns of microscopic laser hits, each of which is 30-50 µ in diameter, would result in a unique wound healing process. This approach would give both patient and physician the benefits of an ablative approach with the elegance of nonablative techniques.

With a new technique called fractional resurfacing, each laser-induced skin hit (known as a microthermal zone, or MTZ) is surrounded by healthy tissue. With such a selective approach, many of the stem cells and melanocytes in the papillary dermis are spared from damage. This "fractional" treatment and associated "fractional" wound healing result in both rapid re-epithelization of the epidermis, as well as collagen remodeling to depths of 400-700 µ.

Figure 1

Figure 1

The FraxelTM SR laser, used for fractional resurfacing, delivers 2000 microthermal zones per square centimeter. The technology provides for optimal spacing between MTZs, a distance of 200-300 µ. These MTZs are not visible to the naked eye (Figure 1).

Figure 2

Figure 2

Figure 3

Figure 3

Fractional resurfacing, a novel approach to laser skin treatment, represents a new science and category of cosmetic skin treatments that offer patients the positive results of ablative resurfacing with the lunchtime convenience of nonablative therapies. This innovative approach is specially designed to alter only fractional volumes of the target tissue. Similar to digital alteration of photographs and paintings, the clinical effect of this treatment technique is to alter the appearance of ageing and sun-damaged skin (Figures 2 and 3). The creation of tiny microwounds results in a microscopic wound healing process and the formation of new collagen fibers.

Side effects from fractional resurfacing are minimal and typically involve some swelling and redness. Mild post-treatment swelling generally subsides within a day or so; laser-induced redness usually fades over several days. Patients can apply makeup immediately after treatment and return to routine activities. There is limited, if any, risk of infection or scarring. No oozing or crusting has been observed.

Clinical studies suggest that 4-6 treatments, spaced about 5-7 days apart, produce a gradual remodeling of dermal matrix components as complete healing occurs. New collagen and elastic tissue can be expected to replace photodamaged epidermal and dermal tissue. Over a period of 1-3 months, clinical improvement in photoaged skin correlates with these epidermal and dermal changes.

Fractional resurfacing is preceded by mild cleansing of the skin followed by the application of a blue skin tint. Then a topical anesthetic is applied 45 minutes prior to treatment. The blue tint darkens the tiny folds of the skin surface to increase contrast and to allow the laser's robotic hand piece to precisely read the discrete contours of the treatment area. Similar to the optical mouse for a computer, the robotic hand piece glides across the skin, which, in essence, has been turned into a mouse pad via the blue tint. The blue tint and anesthetic are washed off immediately after treatment. A treatment typically takes approximately 30 minutes.

Fractional resurfacing combines the best of both ablative resurfacing, in terms of efficacy, and nonablative laser/light source treatments, in terms of elegance. This technique represents a dramatic new approach to the resurfacing of photodamaged skin.


  1. Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Laser Surg Med. 2004;34:426-438.