Special Topic

EVOLUTION OF ABLATIVE AND NONABLATIVESYSTEMSAblative laser skin resurfacing with either carbon diox-ide (CO2) or erbium:yttrium-aluminum-garnet (Er:YAG)laser systems is a well accepted treatment for facial reju-venation, predictably improving the appearance of pho-toinduced rhytides and dyschromia.1 However, completeepidermal ablation induced by these systems results inloss of cutaneous barrier function and an extended post-operative recovery period. Untoward side effects includeprolonged erythema, pigmentatry alteration, infection,and, in rare cases, fibrosis and scarring.2-4 Furthermore,because of the high risk of scarring in nonfacial areasbecause of a relative paucity of pilosebaceous units innonfacial skin, the use of ablative laser skin resurfacingis limited to facial areas.

Nonablative SystemsTo address the risks associated with ablative laser skinresurfacing, nonablative laser systems were developed.Nonablative laser or light-based systems (including1064- and 1320-nm Nd:YAG, 1450-nm diode, 1540-nmerbium glass lasers, and intense pulsed light systems)combine epidermal surface cooling with infrared ornear-infrared wavelengths that create a controlled ther-mal injury. In studies using various nonablative devices,neocollagenesis was evident on histologic evaluationwith minimal side effects, but clinical improvement was

modest and often inconsistent.5-9 Moreover, photoin-duced dyschromia, which is often seen in conjunctionwith wrinkles, is not adequately addressed with com-pletely nonablative laser systems.

FRACTIONAL PHOTOTHERMOLYSISIntroduced by Manstein et al10 in 2003, fractional pho-tothermolysis was developed to overcome the aforemen-tioned shortcomings associated with cutaneous laserresurfacing and is based on the creation of spatially pre-cise microscopic thermal wounds with sparing of the sur-rounding tissue. Fractional resurfacing is performed usinga 1550-nm erbium fiber laser (Fraxel; ReliantTechnologies, Mountain View, CA) that targets water-containing tissue to effect photocoagulation of narrow,sharply defined columns of skin known as microscopicthermal zones (MTZs), at depths of 200 µm to 500 µmand spaced at 200- to 300-µm intervals. Histologic evalu-ation of the MTZ demonstrates homogenization of der-mal matrix and the formation of microscopic epidermalnecrotic debris (MEND) that corresponds to the extrusionof damaged epidermal components by viable ker-atinocytes at the lateral margins of the MTZ. The depthof penetration of each MTZ is energy dependent and canbe tailored to the characteristics of the treatment area (ie,facial vs nonfacial skin). Increases in pulse energy lead toincreases in MTZ depth and width without compromisingthe structure or viability of interlesional tissue.11

The MEND exfoliates several days after treatment,lending the skin a bronzed appearance.12 The woundhealing response differs from ablative techniques becausethe epidermal tissue that is spared between thermalzones contains viable transient amplifying cells, capable

Volume 28 • Number 6 • November/December 2008 • 1Aesthetic Surgery Journal

Fractional photothermolysis, based on creating spatially precise microscopic thermal wounds, is performedusing a 1550-nm erbium fiber laser that targets water-containing tissue to effect the photocoagulation of nar-row, sharply defined columns of skin known as microscopic thermal zones. According to the authors, Fraxelresurfacing has been shown to be both safe and effective for facial and nonfacial photodamage, atrophic acnescars, hypopigmented scars, and dyspigmentation. Because only a fraction of the skin is treated during a sin-gle session, a series (typically 3 to 6 treatments) of fractional resurfacing at 2- to 4-week intervals is requiredfor the best clinical improvement. It is the authors’ experience that a series of Fraxel treatments can achieve asimilar clinical result for atrophic scars compared with traditional ablative laser skin resurfacing. However, theimprovement seen after a series of Fraxel treatments for perioral laxity and rhytides often falls short of theimpressive results that can be achieved with ablative laser skin resurfacing. (Aesthetic Surg J 2008;28:***.)

Drs. Tanzi and Alster are in private practice in Washington, DC.Dr. Wanitphakdeedecha is from the Department of Dermatology,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok,Thailand.

Fraxel Laser Indications and Long-Term Follow-Up

Elizabeth L. Tanzi, MD; Rungsima Wanitphakdeedecha, MD, MA, MSc; and Tina S. Alster, MD

AQ1

xxx-xxxc_YMAJ587_Tanzi_1P 10/20/08 1:39 PM Page 1

2 • Volume 28 • Number 6 • November/December 2008 Aesthetic Surgery Journal

of rapid reepithelialization. Furthermore, because thestratum corneum has a low water content, it remainsintact immediately after treatment, thereby maintainingepidermal barrier function and reducing the risk of infec-tion. In addition, fractional resurfacing can provide anadvantage over purely nonablative laser treatmentsbecause of the gradual exfoliation of the epidermis withresultant improvement in superficial dyspigmentation.

Investigators have shown Fraxel laser resurfacing to beboth safe and effective for a variety of indications,including facial and nonfacial photodamage, atrophicacne scars, hypopigmented scars, and dyspigmentation(Figures 1 through 3).13-21 Because only a fraction of theskin is treated during a single session, a series (typically3 to 6 treatments) of fractional resurfacing at 2- to 4-weekintervals is required for the best clinical improvement.

Side Effects and Complications Side effects of fractional resurfacing are typically mildand transient, including erythema and periocular edema,

and a slight darkening of the skin (bronzing) as theMEND desquamate. The overall complication rate is sig-nificantly lower with fractional skin resurfacing thanthat reported after ablative laser skin resurfacing.1-4

A retrospective evaluation of 961 successive 1550-nmFraxel laser treatments in patients with various skin pho-totypes (Fitzpatrick types I through V) was conducted in asingle clinical center.22 There were 73 reported complica-tions in 961 treatments (7.6%). The most frequent com-plications were acneiform eruptions (n = 18; 1.87%),herpes simplex virus (HSV) outbreaks (n = 17; 1.77%),and erosions (n = 13; 1.35%). Less frequent side effectsincluded postinflammatory hyperpigmentation (n = 7;0.73%), prolonged erythema (n = 8; 0.83%), prolongededema (n = 6; 0.62%), and dermatitis (n = 2; 0.21%).To reduce the risk of HSV outbreak, oral HSV prophylaxisis recommended for those patients with a strong historyof herpes labialis. Acne-prone patients were more likely toexperience posttreatment acne, presumably because of thedisruption of follicular units during treatment and reep-

AQ2

AQ3

AQ5

A B

Figure 1. A, Pretreatment view of a ***-year-old female with periocular rhytides. B, Posttreatment view 3 months after a series of three Fraxellaser treatments.

A B

Figure 2. A, Pretreatment view of a ***-year-old male with periocular rhytides. B, Posttreatment view 3 months after a series of five Fraxel lasertreatments.

xxx-xxxc_YMAJ587_Tanzi_1P 10/20/08 1:39 PM Page 2

Volume 28 • Number 6 • November/December 2008 • 3Fraxel Laser Indications and Long-Term Follow-Up

ithelialization. The use of oral antibiotics (eg, doxycycline,20 mg daily) during subsequent treatments preventedfuture outbreaks in these patients.

To date, permanent pigmentary alteration and scar-ring have not been reported. However, when an aggres-sive treatment protocol is used, placing a high density ofMTZ, the risk of visible epidermal ablation is increasedalong with the side effects and complications associatedwith ablative laser procedures.

CONCLUSIONSAs demand grows for minimally invasive treatments toaddress the signs of aging and photodamage, clinicianswill be challenged to develop procedures that combinereliable clinical results with minimal posttreatmentrecovery. Based on its demonstrated clinical efficacy andexcellent side effect profile in a wide range of skin types,fractional photothermolysis is considered a first-linetreatment for cutaneous resurfacing. To date, there areno published reports evaluating the clinical efficacy oftraditional ablative laser skin resurfacing compared withnonablative fractional resurfacing. It is the authors’experience that a series of Fraxel treatments can achievea similar clinical result for atrophic scars compared withtraditional ablative laser skin resurfacing. However, theimprovement seen after a series of Fraxel treatments forperioral laxity and rhytides often falls short of theimpressive results that can be achieved with ablativelaser skin resurfacing.

Over the next several years, variations on the themeof fractional photothermolysis, including ablative frac-tional photothermolysis with highly advanced CO2 andEr:YAG laser systems, will continue to advance cuta-neous laser resurfacing toward the ultimate goal of max-imum clinical improvement coupled with minimalrecovery and side effects. ◗

DISCLOSURES

The authors have no financial interest in and receive no compensa-tion from the manufacturers of products mentioned in this article.

REFERENCES1. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers: pre-

operative, intraoperative, and postoperative considerations. PlastReconstr Surg 1999;103:619–632.

2. Alster TS, Tanzi EL. Laser and light source treatment of clinical mani-festations of photodamage. In: Goldberg DB, ed. Photodamaged Skin.New York: Marcel Dekker; 2004:115–143.

3. Tanzi EL, Alster TS. Side effects and complications of variable-pulsederbium:yttrium-aluminum-garnet laser skin resurfacing: extended expe-rience with 50 patients. Plast Reconstr Surg 2003;111:1524–1529.

4. Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-passEr:YAG laser skin resurfacing: a comparison of postoperative woundhealing and side-effect rates. Dermatol Surg 2003;29:80–84.

5. Alster TS, Tanzi EL. Laser skin resurfacing: ablative and nonablative.In: Robinson J, Sengelman R, Siegel DM, Hanke CM, eds. Surgery ofthe Skin. Philadelphia: Elsevier; 2005:611–624.

6. Goldberg DJ, Samady J. Intense pulsed light and Nd:YAG laser non-ablative treatment of facial rhytides. Lasers Surg Med 2001;28:141–144.

7. Lupton JR, Williams CM, Alster TS. Nonablative laser skin resurfacingusing a 1540 nm erbium:glass laser: a clinical and histologic analysis.Dermatol Surg 2002;28:833–835.

8. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with anonablative 1450 nm diode laser: a controlled clinical and histologicstudy. Dermatol Surg 2003;29:124–128.

9. Tanzi EL, Alster TS. Comparison of a 1450-nm diode laser and a 1320-nm Nd:YAG laser in the treatment of atrophic facial scars: a prospectiveclinical and histologic study. Dermatol Surg 2004;30:152–157.

10. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractionalphotothermolysis: a new concept for cutaneous remodeling usingmicroscopic patterns of thermal injury. Lasers Surg Med2004;34:426–438.

11. Bedi VP, Chan KF, Sink RK, Hantash BM, Herron GS, Rahman Z, et al.The effects of pulse energy variations on the dimensions of microscopicthermal treatment zones in nonablative fractional resurfacing. LasersSurg Med 2007;39:145–155.

12. Fisher GH, Geronemus RG. Short-term side effects of fractional pho-tothermolysis. Dermatol Surg 2005;31:1245–1249.

13. Geronemus RG. Fractional photothermolysis: current and future appli-cations. Lasers Surg Med 2006;38:169–176.

14. Tannous ZS, Astner S. Utilizing fractional resurfacing in the treatmentof therapy-resistant melasma. J Cosmet Laser Ther 2005;7:39–43.

15. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractionalphotothermolysis: a pilot study. Dermatol Surg 2005;31:1645–1650.

16. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatmentof facial and nonfacial cutaneous photodamage with a 1550-nmerbium-doped fiber laser. Dermatol Surg 2007;33:23–28.

AQ4

A B

Figure 3. A, Pretreatment view of a ***-year-old male with atrophic scars. B, Posttreatment view 3 months after a series of four Fraxel laser treat-ments.

xxx-xxxc_YMAJ587_Tanzi_1P 10/20/08 1:39 PM Page 3

4 • Volume 28 • Number 6 • November/December 2008 Aesthetic Surgery Journal

17. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photother-molysis for the treatment of atrophic scars. Dermatol Surg2007;33:295–299.

18. Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, et al. Fractionalphotothermolysis for the treatment of acne scars: a report of 27 Koreanpatients. J Dermatolog Treat 2008;19:45–49.

19. Jih MH, Goldberg LH, Kimyai-Asadi A. Fractional photothermolysis forphotoaging of hands. Dermatol Surg 2008;34:73–78.

20. Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Fractional resurfac-ing for the treatment of hypopigmented scars: a pilot study. DermatolSurg 2007;33:293–294.

21. Waibel J, Beer K. Fractional laser resurfacing for thermal burns. JDrugs Dermatol 2008;7:59–61.

22. Graber EM, Tanzi EL, Alster TS. Side effects and complications of frac-tional laser photothermolysis: experience with 961 treatments.Dermatol Surg 2008;34:1–7.

Accepted for publication September 16, 2008.

Reprint requests: Elizabeth L. Tanzi, MD, 1430 K St. NW, Ste. 200,Washington, DC 20005. E-mail: etanzi@skinlaser.com.

Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/$34.00

doi:10.1016/j.asj.2008.09.006

xxx-xxxc_YMAJ587_Tanzi_1P 10/20/08 1:39 PM Page 4

Volume 28 • Number 6 • November/December 2008 • 5Fraxel Laser Indications and Long-Term Follow-Up

AQ1: Please provide Dr. Wanitphakdeedecha’s appoint-ment within the department (Associate Professor,Clinical Professor, et cetera).

AQ2: Is it okay to cite all 3 figures here?

AQ3: Is the addition of “Fitzpatrick types” okay?

AQ4: Please verify that no authors have any financialinterest in Reliant Technologies. Thank you.

AQ5: For Figures 1, 2, and 3, please provide the ages ofthe patients. Thank you.

xxx-xxxc_YMAJ587_Tanzi_1P 10/20/08 1:39 PM Page 5