Ablative Fractional Resurfacing: The Best of Both Worlds?

Graeme M. Lipper, MD


October 31, 2008

Successful Treatment of Acneiform Scarring With CO2 Ablative Fractional Resurfacing

Chapas AM, Brightman L, Sukal S, et al
Lasers Surg Med. 2008;40:381-386


Cosmetically disfiguring acne scarring poses a therapeutic challenge. Ablative treatments such as CO2 laser resurfacing or dermabrasion are limited by side effects (eg, erythema, pigmentary changes, infections, scarring) and downtime, while nonablative treatments yield only modest scar improvement.[1] Recently, fractional photothermolysis (FP) was introduced as a superior treatment for acne scars, achieving dermal scar remodeling while limiting adverse effects.[2] The prototype fractional laser (Fraxel® SR; Reliant Technologies, Inc.; Mountain View, California) uses an erbium-doped fiber to deliver 3000 infrared (1550 nm) laser pulses per second, focused intradermally to create a pixelated array of microscopic treatment zones. In contrast to ablative lasers, fractional lasers spare islands of viable epidermis and untreated dermis, maintaining the skin's barrier function while speeding reepithelialization.[3,4,5] Ablative fractional resurfacing (AFR) represents an upgrade to FP technology, combining the thermal profile of traditional CO2 lasers with a pixelated treatment array that is the hallmark of nonablative FP lasers.

In a recent pilot study, Chapas and colleagues used a prototype AFR device (Fraxel® re:pair laser; Reliant Technologies) to treat 13 subjects (age range: 28-58 years; skin phototypes I-IV) with moderate-to-severe acne scarring. Volunteer subjects underwent a series of 2-3 treatments administered at 1- to 2-month intervals. Most patients received 2-3 laser passes per treatment, with higher fluences and treatment densities applied to areas of more severe acne scarring, such as the cheeks, forehead, and chin. Study outcome measures included clinical assessment of acne scar improvement (using a quartile grading scale), objective topographic analysis of acne scar depth (using the Primos topographic analysis software), and assessment of adverse effects such as erythema, petechiae, oozing, crusting, dyschromia, and scarring. All subjects were assessed at baseline, 3 days, 1 week, 1 month, and 3 months following each treatment.

The results of this protocol were impressive, with investigators reporting both objective and subjective improvement in facial acne scarring. Specifically, quartile grading scores showed 26% to 50% improvement in scar texture and atrophy, and objective topographic scar assessment showed a mean level of improvement of 66.8%. Patients tolerated the treatments well, with only a few cases of transient posttreatment hyperpigmentation noted. Longer-term complications such as chronic dyschromia, scarring, or infection were not reported.


Indications for FP have exploded over the past 5 years to include the treatment of facial rhytids, photodamage, poikiloderma, acne scarring, striae distensae, and dyschromias such as melasma.[3,4,5] As with all emerging technologies, new modifications of the original FP platform promise to offer an even broader set of powerful applications.

One such example is a new AFR device designed to deliver the best of both worlds by applying CO2 laser energy in the pixelated pattern characteristic of nonablative FP. Specifically, investigators in the above study used AFR to treat a small series of patients with moderate-to-severe facial acne scarring, delivering cosmetic improvement that compared favorably to traditional ablative lasers while minimizing downtime and avoiding significant adverse effects.

As a caveat, it should be noted that the results seen with AFR are likely to be highly operator-dependent because aggressive or overlapping treatments may be expected to produce full skin ablation without skipped areas of spared epithelium. This would, in turn, create results that are more comparable to those seen following traditional ablative CO2 laser resurfacing, including longer postoperative recovery times, oozing, crusting, prolonged erythema, and the potential for long-term adverse effects (eg, scarring, permanent dyschromia).



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