Nonablative and Ablative Fractional Resurfacing

The risks of ablative resurfacing and the limitations of nonablative resurfacing and pho­torejuvenation led to the development of fractional resurfacing, which is now the preferred

mode of resurfacing. Fractional resurfacing can be divided into true nonablative fractional resurfacing and true ablative fractional resurfacing, with the former having the longest duration of clinical experience at the time of publication. True fractional nonablative resur­facing requires preservation of the stratum corneum, creation of microthermal zones of injury, and extrusion of epidermal contents. Mid – infra-red wavelengths such as 1550 nm were employed as they showed an excellent affinity for water, and little collateral competi­tions for chromophores. “Pseudo” nonablative fractional resurfacing employed existing ablative and nonablative wavelengths, and did not really address the issues of bulk heating, which was the predominating risk factor in both traditional ablative and nonablative modes. True nonablative laser resurfacing creates columns of microthermal injury, the depths and widths of which can be adjusted to reflect the clinical entity being treated. For example, deep scars and rhytids necessitate deeper dermal penetration, while superficial pigmentary anomalies require superficial dermal penetration.

True nonablative laser resurfacing is now the preferred modality of skin resurfacing, and can be utilized to treat both facial and nonfacial areas. Mild to moderate rhytids show con­sistent improvement, unlike near infra-red nonablative devices and visible laser and light photorejuvenation devices. Indications for true nonablative resurfacing include periorbital and perioral rhytids, facial and nonfacial rhytids, facial and nonfacial photodamage, melasma, acne scars, and surgical scars. Three to five treatments are usually necessary for optimal results (Fig. 13.3).

The most recent introduction to skin resurfacing is the concept of deep dermal ablative fractional resurfacing. While photorejuvenation and true nonablative fractional resurfac­ing yield very impressive results, there are subsets of patients with significantly more advanced photoaging where traditional ablative laser resurfacing remains the only viable option. In addition, several patients desire single treatment modalities with reduced recov­ery period. Ablative fractional resurfacing with deep dermal ablation employs traditional ablative wavelengths of light (2940 and 10,600 nm). Initial results show impressive

outcomes on rhytids and laxity. While published data is very limited at this point, early observations with true deep dermal ablative fractional resurfacing do not show risks of hypopigmentation, which was reported to be as high as 20% in traditional ablative resurfacing. Long-term follow-ups and studies are necessary to confirm these early observations.

As with traditional ablative resurfacing, for optimal correction of rhytids, adjuvant ther­apy with botulinum toxins and dermal fillers is indicated.