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Treatments for photoaging range from nonablative laser resurfacing to ablative laser resurfacing. Both of these techniques are described in detail in previous chapters.

Put simply, the most effective lasers, carbon dioxide and erbium ablative resurfacing lasers, provide the most dramatic benefit for photoaging and other skin conditions, but also carry the highest risk for adverse effects. They remain the gold standard treatment for photodamaged skin. Dramatic results, however, can be seen with one treatment. Side effects include prolonged erythema (for months), permanent hypopigmentation, temporary hyperpigmentation, infection, and scar. Additionally, downtime from work and social activities is significant. For this reason, the popularity of ablative lasers has decreased dramatically over the past several years among patients and physicians.

By contrast, nonablative lasers, with multiple treatment sessions, provide a safe method for providing mild improvement of mild-to-moderate photodamage with little risk of side effects. Unfortunately, the predictability of improvement is uncertain. Some patients do not experience any discernible benefit even after multiple treatments. In the past 5 years, nonablative fractional lasers have produced enhanced results from other forms of nonablative resurfacing with multiple treatments. These lasers have also proven to be safe in skilled hands. Still, their efficacy is limited, especially when compared to ablative laser resurfacing.

More recently, fractional ablative lasers, both carbon dioxide and erbium variants, have been developed to provide enhanced results with relatively good safety. The concept is to provide the more aggressive technology of ablation, but to confine potential downtime and side effects by employing a fractional pattern of tissue damage, which encourages more rapid healing times with fewer side effects. Only a fraction of the skin is ablated at each treatment, as opposed to traditional ablative resurfacing procedures. Further, the depth of ablation is deeper than with traditional ablative resurfacing procedures.

Advantages of fractional ablative lasers are as follows:

  • Better improvement of deeper rhytides than nonablative devices

  • Significant benefit with one treatment

  • Can provide some improvement for skin laxity, pigmented lesions, and vascular dyschromia as well

  • Significant reduction in postoperative downtime compared to traditional ablative devices

  • Can treat cosmetic units effectively without lines of demarcation often seen with traditional ablative procedures, that is, perioral/periorbital areas


  • Rhytides, especially moderate-to-severe perioral and periorbital rhytides

  • Photodamage, including skin texture and tone

  • Acne scars, including boxcar, atrophic, rolling scars

  • Surgical and burn scars

  • Mild improvement in skin laxity

  • Not effective for dynamic rhytides


  • Skin type (I–III are best candidates)

  • Sun exposure

  • History of keloids

  • Systemic infections

  • Prior plastic surgery, especially neck lifting procedures and face lifts

  • Isotretinoin use in past 6 months

  • Patients with unrealistic expectations

A consultation is required before this treatment to assess the patient as well as appropriately prepare the patient for the procedure. The patient should be fully educated as ...

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