229

FACIAL PLASTIC
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 15 (2007) 229–237

Fractionated Photothermolysis:
The Fraxel 1550-nm Glass Fiber
Laser Treatment
a b,c,
Robert J. Chiu, MD , Russell W.H. Kridel, MD, FACS *

- Fraxel laser treatment - Postoperative care

- Fraxel laser applications - Results
- Preoperative evaluation - Complications
- Preoperative considerations - Summary
- Fraxel laser treatment protocol - References
- Fraxel SR 1500 laser

The aging skin process results from intrinsic fac- and the subsequent development of ultrapulse
tors, namely genetic factors, and extrinsic factors, technology, which could achieve skin resurfacing
such as sun damage and other environmental fac- with greater control of treatment depth [1–4].
tors (eg, smoking and pollution). Over time, these This technology led to more predictable results,
factors cause formation of various skin dyschro- and the CO2 laser became the recognized gold stan-
mias, appearance of fine wrinkles, loss and rear- dard for skin resurfacing. The ablative skin resurfac-
rangement of collagen in the dermis with ing lasers, including the CO2 and erbium lasers,
thinning, and textural changes and drying of the remove superficial sun damage, pigmentation, and
skin. Deeper wrinkles in the face are also created wrinkles by vaporizing the epidermis. The laser
by repetitive motion of the underlying facial mus- then enters the upper dermis, where thermal con-
culature. To combat the changes to the quality duction denatures deeper collagen and causes tissue
and texture of aging skin, numerous treatment mo- contraction [5]. Collagen contraction leads to tissue
dalities have been devised. Traditional methods of tightening and elimination of wrinkles. Because the
skin resurfacing, including dermabrasion and ablative lasers remove the entire upper protective
chemical peels, sought to remove damaged skin epidermis, however, a minimum of 2 weeks is nec-
while stimulating the formation of newer, healthier essary for re-epithelialization with fresh, new skin.
skin. These methods often led to unpredictable re- As new skin is formed and thickens secondary to
sults and the attendant risk of scarring and pigmen- collagen remodeling, the resulting erythema can
tation problems. A significant advance came with take up to several months to resolve, which often
the introduction of the carbon dioxide (CO2) laser leads to unacceptably long recovery time for

a
Spartan Medical Facility, 100 Stoops Drive, Suite #240, Monongahela, PA 15063, USA
b
Division of Facial Plastic Surgery, Department of Otolaryngology – Head and Neck Surgery, University of
Texas Health Science Center, 6431 Fannin Street, Houston, TX 77030, USA
c
Facial Plastic Surgery Associates, 6655 Travis; Suite 900, Houston, TX 77030, USA
* Corresponding author. Facial Plastic Surgery Associates, 6655 Travis; Suite 900, Houston, TX 77030.
E-mail address: [email protected] (R.W.H. Kridel).

1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2007.02.005
facialplastic.theclinics.com
230 Chiu & Kridel

patients. Consequently, nonablative lasers, such as the dermis at day 16 (Fig. 1). At the cellular level,
the Cool Touch and Smooth Beam, and other de- the heat shock zones that surround each coagulated
vices, such as radiofrequency technologies (Ther- MTZ release key response mediators that create a sig-
mage), were developed to achieve deeper collagen naling cascade in the spared epidermal and dermal
remodeling without the loss of the epithelium zones. This process leads to the rapid re-epithelial-
that led to the protracted recovery. Although pa- ization seen histologically through direct repopula-
tients appreciate the decreased downtime, the re- tion of the epidermal basal layer via epidermal stem
sults of nonablative technologies are variable and cell migration. Regenerative signaling also con-
not completely predictable, and they do not treat tinues in the dermis to provide long-term dermal
superficial sun damage, lesions, and pigmentation. collagen remodeling [10].
In an effort to overcome the limitations of the abla- To patients, the skin appears entirely intact dur-
tive and nonablative lasers, a new class of fractional ing the healing phase because the MTZs and result-
resurfacing lasers has been developed. ing microscopic epidermal and dermal necrotic
debris are microscopic and undetectable to the hu-
man eye. Posttreatment erythema lasts for only
Fraxel laser treatment
a few days, and swelling for only 1 or 2 days. The
The new Fraxel laser treatment represents a new re- skin has a suntanned appearance for approximately
surfacing modality called fractional photother- 1 week after treatment and then exfoliates lightly
molysis [6–8]. The Fraxel laser is a 1550-nm for approximately 1 week. The Fraxel laser can be
erbium-doped glass fiber laser that uses water as used at various energy levels to treat a wide range
the chromophore and produces fractional photo- of skin tissue depths depending on the lesion that
thermolysis by coagulating multiple columns of tis- is being treated. The Fraxel laser reaches a depth
sue that are separated by surrounding uncoagulated greater than even the CO2 laser, possibly making
tissue. These columns of coagulated tissue create it a modality for refractory conditions such as
units, called microthermal zones (MTZs), penetrate deep acne scarring [11]. It can be used safely in areas
through the epidermis down to and into the deep off the face, including the neck, which represents
dermis. The overall pattern of MTZs laid down by a significant difference and advantage versus the ab-
the laser handpiece is akin to the pixels on a com- lative lasers [12]. The Fraxel laser treatment can be
puter screen. In this process, the epidermis is performed under local anesthesia, with topical
coagulated, but the stratum corneum remains struc- lipid-based agents, cooling device, and nerve blocks
turally intact and continuous [6]. Because there is with great patient acceptance. The effectiveness ver-
no need to create an entire layer of new skin, the sus safety profile of the Fraxel laser treatment com-
protracted downtime associated with the CO2 abla- pares favorably to the ablative and nonablative
tive laser is eliminated. Healing is also faster because resurfacing lasers (Fig. 2), although it is not as
the fractionated nature of the treatment means that
approximately 15% to 30% of the skin surface area
is treated in any given treatment session. The coag-
ulated MTZs are surrounded by a heat shock zone
and surrounding untreated tissue, which results in
rapid healing and remodeling of the treated areas.
The faster healing translates into less downtime
and greater patient tolerance. The consistency of
the MTZs created and the ability to control the exact
depth and treatment level creates more predictable
results and less risk of complications.
Histologically, each MTZ wound healing is char-
acterized by movement of keratinocytes within
1 hour to the deep and lateral wound margins of
the epidermal defect [9]. By 12 hours, viable cells
at the wound margins have encircled necrotic de-
bris and epidermal pigment to begin formation of
Fig. 1. This image shows the zones of denatured col-
the plug of microscopic epidermal and dermal ne-
lagen in the dermis after fractionated laser beam and
crotic debris. At 24 hours, the debris is found within the microscopic epidermal necrotic debris being
the stratum corneum while epidermal and dermal expelled at day 16. Healing occurs from surrounding
repair continue. The debris naturally exfoliates in viable tissue and there is complete re-epithelization
the epidermis and can be seen in combination in 24 hours. (Courtesy of Reliant Technologies, Inc.,
with controlled zones of denatured collagen in Mountain View, CA; with permission.)
 Fractionated Photothermolysis 231

SKIN REJUVENATION Fitzpatrick type III and darker skin, in contrast to

CO2 laser resurfacing, which cannot be used in
High darker skinned individuals because of the well-
known incidence of long-term hypopigmentation
CO2
EFFECTIVENESS

FRAXEL [17]. The Fraxel laser also can be used off the face
and can be offered to patients who present for eval-
ERBIUM uation of neck wrinkles, dyschromias and sun
damage of the décolleté, brown spots in the periph-
CHEMICAL eral extremities, and surgical scars in any part of the
PEELS
body [11–16]. The preoperative evaluation should
NON-
RF ABLATIVE include a detailed history of any previous use of
laser resurfacing, chemical peels, dermabrasion,
Low High
SAFETY and surgery. Patients are asked to provide any
Fig. 2. Effectiveness versus safety profile for Fraxel SR history of using Accutane or Retin-A products and
1500 laser as compared to other resurfacing modali- their current skin care regimen. Patients who have
ties. (Courtesy of Reliant Technologies, Inc., Mountain acne are asked to detail their history of active acne
View, CA; with permission.) and acne scarring and provide a list of previous
attempted medical and surgical treatments. Patients
with melasma are also asked to detail their history
effective for tissue shrinkage and deep rhytides as of previous treatments and current use of oral
the CO2 laser. contraceptives, hormones, and history of preg-
nancy, all of which have been associated with this
Fraxel laser applications condition. History of sun exposure degree is ob-
tained, as is the routine use of sunblock and level
Currently, the Fraxel laser has US Food and Drug
of sun protection factor.
Administration approval for the following condi-
Examination of patients should include docu-
tions: treatment of periorbital wrinkles, photocoag-
mentation of the skin type, dyschromias, skin tex-
ulation of pigmented lesions, including lentigos
ture and type, any scars, the presence of acne scars
(age spots), solar lentigos (sun spots), and dyschro-
or active acne, and melasma. Equally important is
mia, treatment of melasma, skin resurfacing proce-
the careful examination of relative contributions
dures, actinic keratoses, and treatment of acne scars
of skin quality versus skin laxity. Patients are
and surgical scars (Fig. 3) [11–16]. Currently, the
counseled that Fraxel laser treatment, as with
Fraxel laser is the only device cleared by the US
CO2 laser treatment, effectively targets problems
Food and Drug Administration to treat epidermal
and concerns regarding skin quality and texture.
‘‘mask of pregnancy’’ and dermal melasma and per-
Although the Fraxel laser does remodel collagen
form nonablative skin resurfacing.
and tighten the skin, neither the Fraxel laser nor
CO2 laser effectively treats moderate to severe
Preoperative evaluation skin laxity, which should be addressed with surgi-
Preoperative evaluation and patient selection, as cal options.
with other ablative resurfacing therapies or surgery,
is paramount with the Fraxel laser treatment. One Preoperative considerations
of the advantages of the Fraxel laser treatment is
the ability to resurface and treat patients with The Fraxel laser treatment is well tolerated, with rel-
atively low risk for treatment-related complications
compared to ablative resurfacing modalities. Sev-
eral considerations are given before treatment,
however. For patients who have acne and who
have used Accutane in the past, Accutane should
be stopped 6 to 12 months before Fraxel laser treat-
ment. Some practitioners also stop the use of ben-
Fig. 3. Schematic illustrating percentage of skin zyl peroxide products, such as Proactive, 1 week
treated per session and corresponding amount of
before treatment to lessen any risk of increased
redness a patient would experience. If the patient is
amenable to prolonged redness and swelling, the skin irritation after Fraxel laser treatment. Any Ret-
settings may be adjusted accordingly for a greater in-A products and glycolic acid products are
result. We prefer treating at level 9 for near-total cov- stopped 2 weeks before treatment. Hydroquinone
erage in five treatments. (Courtesy of Reliant Tech- and other bleaching agents can be used up to the
nologies, Inc., Mountain View, CA; with permission.) day before treatment. Patients are advised to stay
232 Chiu & Kridel

out of direct sunlight for 1 to 2 months after treat- adequate placement of the MTZs. Energy levels are
ment. Patients with a history of cold sores or blisters typically adjusted upward with consecutive treat-
are given prophylactic doses of an antiviral medica- ment sessions to accommodate and account for pa-
tion, such as Valtrex, before treatment. tient tolerance to pain and discomfort. Increasing
pulse energy levels are correlated with increasing
depth. Typically, treatment energies range from
Fraxel laser treatment protocol
6 mJ to 12 mJ for superficial lesions, including dys-
The Fraxel laser treatment protocol can be tailored chromias, pigmentation, and melasma. Energy
to each patient before and during treatment. Typi- levels of 10 mJ to 20 mJ are used for general resur-
cally, a lipid-based topical anesthetic agent—a 20/ facing, periorbital wrinkles, and actinic keratosis;
8/4% benzocaine/lidocaine/tetracaine mixture, and energy levels of 25 mJ to 40 mJ are used for re-
a 23/7% lidocaine/tetracaine ointment (which we surfacing deeper skin lesions and conditions, in-
prefer), or a 30% lidocaine gel—is applied to the cluding moderate to deep rhytides, surgical scars,
area of planned treatment 60 minutes before treat- and acne scars. At the time of this writing, the Fraxel
ment. Patients who are more sensitive to pain are laser treatment received additional US Food and
given a preoperative dose of narcotic pain pill, Drug Administration approval for use of pulse en-
such as Vicodin, with (Valium) for relaxation and ergy levels up to 70 mJ. Typically, eight to ten passes
an aid in prophylaxis for local anesthetic toxicity. are administered per treatment, corresponding with
Just before the actual treatment, consideration is 2000 to 2500 MTZ/cm2. After treatment, the Opti-
given to regional blocks, including the branches guide blue dye is removed with detergent or an
of the trigeminal nerve for treatment of the face, Opti-guide dye remover manufactured by the com-
and the cervical plexus for treatment of the neck. pany. Patients are asked to gently wash their face
The topical anesthesia then is removed, with careful with tap water, and a light moisturizing cream is
attention paid to avoiding contact of the topical applied.
anesthetic with the eye.
Fraxel laser treatment is typically administered
with the aid of a Zimmer cooling device, which Fraxel SR 1500 laser
has been shown to decrease discomfort when Recently, the Fraxel SR 1500 laser, the second-gener-
used concurrently with fractional photothermolysis ation Fraxel laser, was developed to afford surgeons
[18]. The cooling device decreases any residual dis- the capability of increasing the treatment energy
comfort not addressed by the previously mentioned and depth while decreasing bulk heating and dis-
strategies for pain reduction. Depending on the comfort of the procedure. The Fraxel SR 1500 laser
plan of treatment, several strategies can be used has several features that differentiate it from the
for eye protection, including protective goggles, tap- Fraxel SR 750 laser (first-generation Fraxel laser).
ing of the eye, placement of a wet eyepad, and inser- The handpiece has an auto-zoom feature that opti-
tion of an intraocular shield. The latter two mizes the spot size for each energy level, which
techniques are widely used in CO2 and erbium- translates into deeper penetration at higher energies
based ablative resurfacing. Currently, Opti-guide for increased dermal remodeling. The handpiece,
blue dye (FD&C No.1) is placed in a thin layer which weighs half of the first-generation handpiece,
over the area of planned treatment and serves as also has a detachable, upgradeable software plat-
guide ‘‘marker’’ for the optical tracking system in- form design (Box 1).
stalled in the Fraxel laser handpiece. A new treat- The Fraxel SR 1500 laser is also more user
ment tip has been developed with improved friendly, with an improved general user interface
tracking that obviates the need for the dye, however. that automatically controls coverage through
A lubricating substance, typically Aquaphor or Lip-
othene 133, is applied to enable smooth gliding
and continuous contact of the handpiece on the
skin. Box 1: US Food and Drug Administration–
The treatment technique itself is also variable, al- approved indications for Fraxel SR 1500 laser
though certain considerations are adhered to. The  Acne scars and surgical scars
laser handpiece is kept in contact with the skin at  Treatment of periorbital wrinkles
all times at an angle of 90 to the skin surface to  Photocoagulation of pigmented lesions,
achieve the best contact position. Several passes including lentigos (age spots), solar
are needed depending on the treatment level cho- lentigos (sun spots), and dyschromia
sen, with a 100% overlap technique for more con-  Melasma
 Skin resurfacing procedures
sistent results. The treatment passes are laid down
 Actinic keratoses
in horizontal and vertical patterns to achieve
 Fractionated Photothermolysis 233

treatment levels and automatically calculates the proves this reported advantage, however. The CO2
depth of treatment. This menu-driven feature en- laser depth of penetration is comparatively shallow
ables surgeons to use different treatment levels to and yet the results are impressive.
tailor a treatment strategy for each patient. Treat-
ment levels of 5-6 correspond to total treatment
Postoperative care
of approximately 20% of the coverage area, whereas
treatment levels of 9-10 approximate treatment of Postoperative care is straightforward versus the in-
30% of the skin (Fig. 4). In the Fraxel SR 1500 laser, tensive postoperative care and prolonged recovery
the number of passes is automatically calculated and follow-up involved with ablative resurfacing.
with a given treatment depth (energy) and treat- Patients who are being treated for deeper lesions
ment level. Thus far, preliminary experience with and treatment around the periorbital areas typi-
the Fraxel SR 1500 laser suggests that treatment cally experience more swelling after treatment
levels and depths can be increased while at the and can use ice packs and elevation on the night
same time decreasing any pain and discomfort as- of the treatment. Swelling and redness typically
sociated with the procedure, which reduces the last 2 to 3 days [19]. After the more intense redness
need for adjunctive techniques, such as regional subsides by day 2 or 3, patients have a bronzed or
nerve blocks. Theoretically, the increased depth of suntanned appearance for the next 3 to 5 days, ac-
penetration for the Fraxel SR 1500 laser may trans- companied by variable flaking of the skin. Patients
late into more effective treatment of deeper rhytides can apply makeup 24 hours after treatment, be-
and scars (Fig. 5). No clinical evidence to date cause the Fraxel laser treatment does not disrupt

Fig. 4. Human skin and depth of penetration of the Fraxel laser with corresponding energy settings. (Courtesy of
Reliant Technologies, Inc., Mountain View, CA; with permission.)
234 Chiu & Kridel

Fig. 5. (A) Pretreatment appearance of a patient with skin dyschromia and skin texture complaints. (B) Posttreat-
ment appearance of the same patient after six Fraxel treatments.

the stratum corneum. Patients are advised to apply develop transient postinflammatory hyperpigmen-
a light, nonirritating moisturizer and are counseled tation, which manifests in the first week after treat-
to avoid direct sunlight and apply sunblock of at ment. Individuals are placed on a hydroquinone
least 30 SPF. Subsequent Fraxel laser treatments 4% bleaching agent and told to continue its use
are spaced 2 weeks apart for lighter skinned pa- until the next treatment. Patients are typically
tients and approximately 4 weeks apart for darker taken off the bleaching agent for a few days after
skinned individuals. A certain proportion of pa- treatment and told to restart once the acute redness
tients—typically darker skinned individuals—may and swelling subsides. For darker skinned

Fig. 6. (A) Pretreatment appearance of a patient with skin dyschromia, wrinkles, and the desire for general skin
resurfacing. (B) Posttreatment appearance of the same patient after three Fraxel treatments.
 Fractionated Photothermolysis 235

individuals (Fitzpatrick skin type IV or more),

practitioners often start hydroquinone before the
first treatment as prophylaxis for postinflammatory
hyperpigmentation. The incidence of permanent
pigmentation changes, hypopigmentation, and
scarring is rare and lower than for ablative thera-
pies, such as CO2 laser [17]. In the rare case of
scarring, which is often associated with concurrent
use of retinoids or other skin irritants, the litera-
ture suggests that patients be counseled to con-
tinue with Fraxel laser treatment because it is
effective for the treatment of scars [13,14].

Results
The Fraxel laser has been shown to be effective
in the treatment of wrinkles, pigmented lesions,
including age spots and sun spots, treatment of mel-
asma, generalized skin resurfacing, and treatment of
acne scars and surgical scars [11–16]. In the senior
author’s experience, the Fraxel laser has achieved
consistent results in the treatment of skin dyschro-
mias and fine wrinkles and generalized resurfacing
(Figs. 6 and 7). Some of the most impressive results
have been with the most difficult-to-treat condi-
tions, including deep acne scars, unsightly surgical Fig. 8. (A) Pretreatment appearance of a patient with
scars, and melasma (Figs. 8–9) [20]. The results an unsightly scar in her left neck. (B) Posttreatment
appearance of the left neck scar in the same patient
after three Fraxel treatments.

for deep rhytides and tissue shrinkage are not as

dramatic as those with CO2 laser resurfacing.

Complications
One of the most advantageous features of the Fraxel
laser treatment is the comparatively low rate of
posttreatment complications and long-term adverse
sequela associated with the treatment compared to
traditional CO2 ablative resurfacing [17]. The rate
of postinflammatory hyperpigmentation is lower
than CO2 laser resurfacing and does not persist as
is the case with ablative resurfacing. Patient down-
time is decreased significantly, and healing is accel-
erated because of the fractionated nature of the
Fraxel laser treatment with preservation of an intact
stratum corneum layer [6]. Patients are counseled
regarding the possibility of pigmentation changes
and scarring, as with the ablative resurfacing tech-
Fig. 7. (A) Pretreatment appearance of a patient with niques. Care is taken to avoid complications associ-
deep acne scarring in the cheek area. (B) Posttreat-
ated with the numbing cream coming in contact
ment appearance of the same patient after eight
Fraxel treatments at a setting of 12 to 25 mJ, with with the eye, because there have been anecdotal re-
an average treatment density of 125 tz/cm2. The pa- ports, albeit rare, of corneal abrasions associated
tient had so many sessions because the early treat- with the treatment (Reliant Technologies, personal
ments were at low settings in our early experience communication, 2006). Patients with history of
with the Fraxel laser. herpetic cold sores may experience reactivation of
236 Chiu & Kridel

useful modality for difficult-to-treat conditions,

such as melasma and acne scarring.

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