Fractionalised laser skin resurfacing (FLSR) has become an important component of facial rejuvenation surgery as patients continue the trend of seeking less invasive procedures with low downtime and low risks. This behavioural change in attitude has also been prompted by a realisation of both doctors and patients that the recent much hyped non-ablative methods are not comparable with ablative skin resurfacing and were often subject to extravagant claims in terms of efficacy. * During the nineties, CO2 laser resurfacing was considered the ‘gold standard’ for the treatment of acne scarring, deep rhytids and photo-damaged facial skin. It was one of the earliest gas lasers to be developed (invented by Kumar Patel of Bell Labs in 1964).

1. T H E E V O L U T I O N O F F L S R
F R AC T I O N A L I S E D L A S E R S K I N R E S U R FAC I N G
Fractionalised laser skin resurfacing (FLSR)
has become an important component of facial
rejuvenation surgery as patients continue the
trend of seeking less invasive procedures with
low downtime and low risks. This behavioural
change in attitude has also been prompted by a
realisation of both doctors and patients that the
recent much hyped non-ablative methods are not
comparable with ablative skin resurfacing and
were often subject to extravagant claims in terms
of efficacy. *
During the nineties, CO2 laser resurfacing
was considered the ‘gold standard’ for the
treatment of acne scarring, deep rhytids and
photo-damaged facial skin. It was one of the
earliest gas lasers to be developed (invented
by Kumar Patel of Bell Labs in 1964). The CO2
laser produces a beam of infrared light with a
wavelength around 10, 600 nm. Because CO2
lasers operate in the infrared, special silvered
mirrors and windows
made of either germanium
or zinc selenide are
necessary for their
construction.
In 1995, some physicians,
including Prof Nick
Lowe went further and
stated the ultrapulsed
CO2 laser was the
most effective modality
for repairing photo-damaged
skin. Although it quickly became
FLSR
the best option for treatment of this type of
photo-aged facial skin, it also had considerable
post-procedural problems, including prolonged
postoperative recovery, pigmentary changes
and a high incidence of adverse side effects.
The infections included acne flares, fungus and
herpes simplex virus (HSV) infection. Many
patients also complained of oedema, burning,
and erythema that sometimes lasted for many
months. The delayed healing, the implied risks
and long downtime made many patients
reluctant to accept this method.
For a period during the early part of this century
some physicians, including Prof David Goldberg
favoured the use of Erbium YAG devices to
minimise these side effects. These new lasers
were solid-state lasers whose lasing medium
was erbium doped yttrium aluminium garnet
(Er:Y3Al5O12). Er:YAG lasers typically emit light
Fractionalised laser skin resurfacing
(FLSR) has become an important
component of facial rejuvenation surgery
as patients continue the trend of seeking
less invasive procedures with low
downtime and low risks
www.cosmeticnewsuk.com 23
Dr Patrick Treacy
Dr Patrick Treacy is Medical Director
of Ailesbury Clinics Ltd and Ailesbury
Hair Clinics Ltd. He is Chairman of the
Irish Association of Cosmetic Doctors
and is Irish Regional Representative
of the British Association of Cosmetic
Doctors. Dr Treacy is a renowned
international guest speaker and
features regularly on Irish breakfast
television (TV3), RTE and as an expert
panelist with the BBC World Service.
He had a series on Discovery Health
and the Discovery Channel (New York)
recently filmed a programme about
his work. He is an active member of
many international medical societies
and is a Fellow of The Royal Society
of Medicine.

2. FLSR
Fractionalised C02 lasers are extremely versatile,
in that they can be used for the treatment of facial
rhytides, acne scars, surgical scars, melasma and
photo-damaged skin
with a wavelength of 2940nm, which is infrared
light. Unlike similar Nd-YAG lasers, the output
of an Er:YAG laser is strongly absorbed by
water. This fact limits the use of this laser in
surgery, and in many other laser applications
where water is present. They were mostly used
for acne scarring, deep rythides and melasma.
In addition to being absorbed by water, the
output of Er:YAG lasers is also absorbed by
hydroxyapatite, makes it a good laser for cutting
bone as well as soft tissue.
Radio-frequency devices such as Polaris ® and
Thermage® arrived in 2004, promising non-invasive
treatments that delivered tighter skin,
renewed facial contours and healthier collagen
after a single treatment.
One year later, the Fraxel laser made by
Reliant Technologies arrived on the market. It
took its name from the fact that it worked
on only a fraction of the skin’s surface. The
device created a pattern of pinpoint burns
(microzones) of injury in the skin, surrounded
by normal intervening skin that rapidly healed
the injured tissue. Only about 15 to 20% of
the skin was affected and the relatively light
burn healed within a few days, eliminating the
prolonged downtime of the resurfacing lasers.
The technique was called fractional thermolysis.
Non-sequential fractionalised technology had
arrived with its benefits of faster recovery time,
more precise control of ablation depth, and
reduced risk of post procedural problems.
In 2006, Lumenis released the ActiveFx as an
upgrade of the Ultrapulse Encore with smaller
spot size and a new CPG giving a random pattern
reducing the possibility of having several adjacent
spots with resultant heat accumulation. This was
followed by the Deka 30W SmartXide DOT.
The newer SmartXide DOT adopts lightweight
titanium articulated arm in conjunction with a
user friendly colour Touch-screen control panel
to display the settings. The SmartXide DOT
requires an external plume device.
The obvious benefits of these lasers led to many
new fractional resurfacing lasers reaching the
market at the same time. These new fractionalised
CO2 lasers substantially reduced the high level
of non-responders seen with quite expensive
non-ablative RF type treatments that in reality
often required multiple painful sessions.
The adoption of the newer fractionalised C02
lasers by many physicians also reduced the
morbidity associated with this type of laser
treatment. Damage to the epithelium is less
apparent because unlike in conventional
ablation some of the stratum corneum remains
intact during treatment and acts as a natural
bandage. This allows the skin to heal much
faster than if the whole area was treated, as
the ‘healthy’ untreated tissue surrounding
the treated zones helps to fill in the damaged
area with new cells. Downtime is also reduced
and erythema is moderate, permitting patients to
apply cosmetics five days after treatment.
Fractionalised C02 lasers are extremely versatile,
in that they can be used for the treatment
of facial rhytides, acne scars, surgical scars,
melasma and photo-damaged skin. This photo-ageing
effect is demonstrated clinically as a
gradual deterioration of cutaneous structure and
function. It manifests itself in the epidermis
and upper papillary dermis by giving skin a
roughened surface texture as well as laxity,
telangectasias, wrinkles and variable degrees of
skin pigmentation.
There are presently several high-energy,
fractionalised carbon dioxide (CO2) lasers
currently available for cutaneous resurfacing.
Although each laser system adheres to the
same basic principles there are significant
differences between lasers with respect to
tissue dwell time, energy output, and laser beam
profile. These differences may result in variable
clinical and histological tissue effects.
24 www.cosmeticnewsuk.com