Photomedicine and Laser Surgery

Volume 32, Number 1, 2014

ª Mary Ann Liebert, Inc.
Pp. 42–46
DOI: 10.1089/pho.2013.3608

Non-Ablative 1550 nm Erbium-Glass and Ablative

10,600 nm Carbon Dioxide Fractional Lasers
for Various Types of Scars in Asian People:
Evaluation of 100 Patients

Suhyun Cho, MD,1 Jin Young Jung, MD, PhD,2 Jung U. Shin, MD,1 and Ju Hee Lee, MD, PhD1

Abstract

Objective: We compared the efficacy and safety of treatments with photothermolysis systems (FPS) and carbon
dioxide fractional laser system (CO2 FS) for various types of scars in Asians. Background data: Concerns
regarding the cosmetic outcomes of scar treatment are increasing, and non-ablative 1550 nm erbium-glass FPS
and 10,600 nm CO2 FS have been effectively used to improve the appearance of various types of scars. Methods:
One hundred patients with various types of scars were enrolled. The laser devices were chosen individually,
based on the characteristics of the scars. We used a quintile grading scale for evaluations. Results: At 3 months
after treatment, the mean grade of improvement based on clinical assessment was 2.64 – 0.76 for FPS, 2.60 – 0.68
for CO2 FS, and 2.94 – 0.83 for combination therapy ( p = 0.249). The mean grade of improvement was higher in
patients who received treatment within 3 years of scar development (2.84 – 0.69) than in patients who received
treatment > 3 years after scar development (2.51 – 0.82; p = 0.042). Conclusions: FPS and CO2 FS were both
effective and safe for the treatment of scars, and can also be used together safely as a combination treatment. The
proper laser device and proper treatment time should be decided considering various factors.

Introduction that require a large treatment area and high pulse energy;
these lasers are well tolerated by patients, with fewer side

S car formation after trauma, surgical procedures, and

cutaneous diseases is quite common. In most cases, scars
cause functional and cosmetic deformities, discomfort, psy-
chological stress, and patient dissatisfaction. As attentiveness
to beauty has increased, together with concerns about the
cosmetic outcome of scarring in modern society, various
treatment modalities have been used to treat scars, consider-
ing the characteristics of the lesion. Intralesional steroids,
surgical scar revision, cryosurgery, radiotherapy, and con-
ventional laser therapies, including pulsed dye laser, carbon
dioxide laser, intense pulsed light, and erbium:YAG laser
have been used; these methods have resulted in variable pa-
tient satisfaction.1,2 Efforts to utilize different treatment mo-
dalities for different types of scars have been made. The
fractional photothermolysis (FP) system has been introduced,
and previous reports suggest its effectiveness in treating
various types of scars. It is now widely used singly or com-
bined with other treatment modalities for scar treatment.3–5
Fractional lasers, which induce small, focal zones of tissue
injury, are effective for treating various cutaneous diseases
effects than conventional laser therapies. In contrast to con-
ventional ablative laser modalities that create a confluent,
uniform patch of epidermal or dermal injury, fractional la-
sers induce a microscopic zone of tissue injury, stimulating
collagen remodeling and deposition.6 Currently, the non-
ablative 1,550-nm erbium-glass fractional photothermolysis
system (FPS) is one of the most popular fractional lasers in
use clinically, and because the stratum corneum remains
intact after FPS treatment and the epidermal barrier function
is preserved, the severity and duration of side effects as well
as the down time are significantly reduced.6–9 The ablative
10,600-nm carbon dioxide fractional laser system (CO2 FS) is
also a frequently used device that is coming to the forefront.
The action mechanism of the CO2 FS laser includes tissue
ablation, immediate collagen shrinkage, and dermal collagen
remodeling, which causes matrix metalloproteinases to
eliminate the fragmented collagenous matrix and promote
new collagen synthesis.6,10 CO2 FS is gaining popularity
because of its higher energy delivery and better outcomes
with fewer treatment sessions.

1
Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea.
2
Yeouido Oracle Cosmetic Dermatosurgery Clinic, Seoul, Korea.

42
FRACTIONAL LASERS FOR VARIOUS TYPES OF SCARS IN ASIANS
To the best of our knowledge, comparative studies eval-
uating clinical outcomes and adverse events of FPS and CO2
FS therapy for various types of scars in a large group of
Asian patients are rare, and our purpose was to compare the
clinical outcome of each laser device for scars in Asian skin.
Therefore, we evaluated the efficacy and safety of treatments
using FPS and CO2 FS to improve the cosmetic outcomes of
scars.
Materials and Methods
Patients
We conducted a retrospective study to compare the effi-
cacy and safety of treatments with FPS and CO2 FS for
various types of scars in East Asian people. One hundred
patients with various types of scars who visited the De-
partment of Dermatology at Yonsei University Health Sys-
tem from March 2010 to February 2011 were enrolled in the
present study (29 males, 71 females, mean age 27.4 years,
range 3–63 years, Fitzpatrick skin type III-IV). An informed
consent was obtained from every individual prior to initia-
tion, and the study was performed according to the ethical
guidelines of the 1975 Declaration of Helsinki. The duration
of scars varied widely among patients, from 3 weeks to 55
years (mean 73.7 months), and the number of treatments
performed ranged from 1 to 12 sessions (Table 1). The types
of scars included surgical scars, post-traumatic scars, burn
scars, acne scars, and scars after cutaneous diseases. Scars
were additionally classified as depressed or atrophic scars,
hypertrophic scars, combined scars, and acne scars. Exclu-
sion criteria were: history of keloid scarring, isotretinoin use,
pregnancy, use of immunosuppressants, and previous con-
comitant treatments, including skin resurfacing procedures
and chemical reconstruction of skin scars (CROSS) using
trichloroacetic acid. Patients who had FPS or CO2 FS treat-
ments within the previous 6 months were also excluded.
Laser treatment
The proper laser device and treatment parameters were
chosen individually, based on the characteristics of patient
scars. Patients were treated with either the non-ablative
1550 nm erbium-glass FPS using a MosaicTM laser (Lutronic
Corporation, Goyang, Korea), or the ablative 10,600-nm
CO2 FS using a Mosaic eCO2TM laser (Lutronic Corporation,
Goyang, Korea). If necessary, a combination therapy of FPS
and CO2 FS was also conducted. The treatment intervals
were 1.5–2 months, based on the scar characteristics, and
the end-point of treatment was decided individually, con-
sidering the clinical outcomes and degree of patient satis-
faction. For local anesthesia, the lesion was cleansed with a
Table 1. Characteristics of Patients and Scars
Total number of patients 100 (29 males, 71 females)
Total number of scars 106
Age 3–63 (mean 27.4 years)
Scar duration 3 weeks to 55 years
(mean 73.7 months)
Interval of treatment 1.5–2 months
Number of treatments 1–12 (mean 2.81)
43
mild cleanser and 70% alcohol, and topical EMLA cream
(eutectic mixture of 2.5% lidocaine HCl and 2.5% prilocaine;
AstraZeneca AB, Södertälje, Sweden) was applied under
occlusion 1 h prior to laser therapy.
For FPS, the laser was applied at a pulse energy setting of
25–32 mJ fluence, 200 spots/cm2 density, and static and/or
dynamic operating modes; for CO2 FS, the laser was applied
at 100–150 mJ fluence, 100–120 spots/cm2 density, and static
and/or dynamic operating modes. After treatment, the
treated areas were cooled with ice packs for 5–10 min for
protection. To promote post-laser therapy wound healing,
the patients were instructed to use a moisturizer several
times a day for 1 week after treatment.
Objective and subjective evaluations
Objective evaluation. Photographs were taken using
identical camera settings, lighting conditions, and patient
positioning at baseline, before every treatment, and 3 months
after the last treatment. Two blinded physicians evaluated
the scars by comparing the clinical photography in a non-
chronological order, taken before and after the treatment.
We used a quintile grading scale for evaluations: grade 0,
no improvement; grade 1, < 25% = minimal improvement;
grade 2, 26–50% = moderate improvement; grade 3, 51–
75% = marked improvement; and grade 4, > 75% = near-total
improvement.
Subjective evaluation. Patients were surveyed 3 months
after the last treatment to determine their overall levels of
satisfaction with the treatment results using the following
response choices: very satisfied, satisfied, moderately satis-
fied, slightly satisfied, and dissatisfied. The patients also re-
ported any side effects of treatments including erythema,
bleeding, oozing, edema, post-therapy dyschromias, scaling,
crusting, and scarring.
Statistical analysis
We compared and analyzed the clinical assessment scores
by dermatologists and the overall patient satisfaction levels
associated with FPS and CO2 FS treatment using one way
ANOVA, two sample t test, and correlations with Statistical
Package for the Social Sciences version 18.0 (SPSS Inc., Chi-
cago, IL). Differences were considered statistically significant
when the p value was < 0.05.
Results
Among the 100 patients, 42 patients had scars caused by
trauma, 36 had postoperative scars, 10 had burn scars, 5 had
acne scars, and 7 had scars induced by other cutaneous
diseases such as herpes zoster, chicken pox, or Stevens–
Johnson syndrome. Some patients had multiple scar lesions,
and, therefore, the total number of scars was 106. Classifi-
cation of the scars according to their characteristics was
performed, and the 106 scars were classified into depressed
or atrophic scars, hypertrophic scars, combined scars, and
acne scars. Fifty-one patients (48%) had combined scars, and
34 patients (32%) had depressed or atrophic scars (Fig. 1). For
improvement of scar lesions, 36 patients with 36 (34%) scars
were treated with FPS, 18 patients with 20 scars (18.8%) were
treated with CO2 FS, and 46 patients with 50 (47.2%) scars
44 CHO ET AL.

FIG. 1. Scar classifications.

(a) Causes of scars among
patients (n = 100) and (b)
characteristics and classifica-
tion of scars (n = 106).

were treated with a combination treatment of FPS plus CO2
FS. The proper laser device and treatment parameters were
chosen individually, based on the characteristics of the scars
of each patient (Table 2). The end-point of treatment was also
decided individually, according to the clinical outcomes and
degree of patient satisfaction.
Follow-up 3 months after the last laser treatment resulted
in 27 (25.5%) of the 100 patients showing moderate im-
provement, 61 (57.5%) patients showing marked improve-
ment, and 12 (11.3%) patients showing near-total
improvement (Figs. 2 and 3). The mean grades of clinical
improvement based on assessment of the clinical photogra-
phy were 2.64 – 0.76 for FPS, 2.60 – 0.68 for CO2 FS, and
2.94 – 0.83 for FPS + CO2 FS. The mean values did not show
significant differences among laser devices ( p = 0.249). The
mean grades of clinical improvement according to scar type
were 2.72 – 1.02 for depressed or atrophic scars, 2.25 – 0.91
for hypertrophic scars, 2.27 – 0.98 for combined scars, and
2.31 – 0.95 for acne scars. The results did not differ signifi-
cantly among scar types ( p = 0.344). The mean grade of im-
provement also did not differ between males and females
( p = 0.919) and did not show any correlations with patient
age ( p = 0.857). When patients were divided into two groups
based on time since scar development—patients who re-
ceived treatment within 3 years of scar development (n = 73)
and patients who received treatment after 3 years of scar
development (n = 27)—the mean grade of improvement dif-
fered significantly between these two groups, 2.84 – 0.69 for
the former group and 2.51 – 0.82 for the latter ( p = 0.042). The
number of treatments did not significantly influence the
grade of clinical improvement ( p = 0.251) (Table 3).
Surveys evaluating the degree of patient satisfaction re-
vealed that 37 (34.9%) patients were moderately satisfied
3 months after the last treatment, 37 (34.9%) were satisfied,
and 10 (9.5%) were very satisfied. Only one (0.9%) patient
was dissatisfied with the outcome, among the 100 patients.
Degree of patient satisfaction did not differ between males
and females ( p = 0.793), and also did not show any correla-
tion with age ( p = 0.874). Most participants reported that
post-treatment erythema, edema, crusting, and scaling re-
solved within 1 week. Eleven patients experienced post-
treatment hyperpigmentation, and six patients reported
post-treatment erythema that lasted for > 1 week, but
spontaneous resolution occurred within 3 weeks in all cases.
Other possible adverse events, including post-therapy blister
formation, scarring, and secondary bacterial or viral infec-
tion, were not observed.
Discussion
The concept of FP was introduced in 2004 by Manstein
and colleagues.6 FP produces arrays of microscopic thermal
wounds called microscopic treatment zones (MTZs) in the
skin at a depth of 300–400 lm into the dermis without giving
injury to the surrounding tissue. Therefore, in spite of the
depth of injury in the mid-dermis, the intact dermal tissue

Table 2. Laser Devices Used for Scar Treatment, and Scar Characteristics of Each Treatment Group

Laser device

FPS CO2 FS FPS + CO2 FS Total

No. of patients 36 18 46 100

No. of scars 36 (34%) 20 (18.8%) 50 (47.2%) 106 (100%)
Scar type
Depressed/atrophic 2 (5.9%) 8 (23.5%) 24 (70.6%) 34 (100%)
Hypertrophic 9 (56.3%) 0 7 (43.7%) 16 (100%)
Combined 4 (7.8%) 5 (9.8%) 42 (82.4%) 51 (100%)
Acne 0 0 5 (100%) 5 (100%)

FPS, photothermolysis systems; CO2 FS, carbon dioxide fractional laser system.
FRACTIONAL LASERS FOR VARIOUS TYPES OF SCARS IN ASIANS 45

Table 3. Mean Grade of Improvements Based

on Clinical Assessments By the Physician
Panel 3 Months After the Last Treatment

Mean grade
of improvement p Value

Laser device
FPS 2.64 – 0.76 0.249
CO2 FS 2.60 – 0.68
FPS + CO2 FS 2.94 – 0.83
Scar type
Depressed, atrophic 2.72 – 1.02 0.344
Hypertrophic 2.25 – 0.91
Combined 2.27 – 0.98
Acne scars 2.31 – 0.95
Time of treatment
Treatment within 3 years 2.84 – 0.69 0.042
of scar development
Treatment after 3 years 2.51 – 0.82
FIG. 2. (a) A patient (M/30) with a post-traumatic and of scar development
postoperative (skin graft) scar of 2 months’ duration on the Number of treatment
nose before laser treatment. (b) The same patient showed £ 2 times 2.62 – 0.71 0.251
near-total improvement after three sessions of photo- 3-5 times 2.74 – 0.81
thermolysis systems (FPS) + carbon dioxide fractional laser > 5 times 2.41 – 0.84
system (CO2 FS) treatment.
FPS, photothermolysis systems; CO2 FS, carbon dioxide fractional
laser system.
next to the MTZ rapidly heals around the columns of thermal
damage, and stimulates progressive collagen remodeling.6
The original concept of FP was non-ablative, using near- of FPS + CO2 FS resulted in highest improvements, the mean
infrared energy, sparing the epidermis, and, therefore, ide- grade of improvement did not show statistically significant
ally provided rapid healing time and fewer side effects such differences among FPS, CO2 FS, and FPS + CO2 FS. This re-
as erythema or edema. However, despite the advances of flects the fact that not only the laser device, but also the
reduced down time of nonablative FP, the requirement of duration of the scar or scar characteristics and number of
multiple treatment sessions to receive an acceptable outcome treatment sessions are also important factors that can affect
resulted in the development of the more aggressive ablative the clinical outcome of scar treatment. Furthermore, al-
FP, in which the MTZs included the epidermis. The greater though depressed or atrophic scars showed the greatest
degree of cutaneous injury induced by ablative FP was improvements, the mean grade of improvement did not
shown to provide a greater and prolonged effect on inducing differ significantly among scar characteristics. Therefore, it
new collagen generation and remodeling of dermal colla- can be suggested that various factors such as scar charac-
gen.11–13 Currently, nonablative and ablative FP devices have teristics, scar duration, number of treatment sessions, laser
been validated to be used in various cutaneous conditions, modalities, and technique complexly contribute to the im-
including wrinkles, photoaging, pigment abnormalities, provement of scars. Nevertheless, treating the scar with re-
scars, and others.14–17 petitive sessions did not correlate with better treatment
In this study, we reviewed 100 patients with various types outcomes, suggesting that scar characteristics, treatment re-
of scars who received FP laser treatments for the purpose of sponse, and patient satisfaction should be considered to-
clinically improving scars. Laser devices and number of gether to decide the end-point of treatment. These results
treatment sessions differed among individuals according to show that it is difficult to simply predict the outcome of scar
their scar characteristics. Although the combination therapy treatment, because the process is very complex with various
contributable factors.
Our results suggest that early treatment after scar formation
may lead to better improvement after laser therapy, as patients
who received treatment within 3 years of scar development
showed significantly greater improvements than did patients
who received treatment > 3 years after scar formation. It is
known that scar remodeling and clinical improvement con-
tinues to occur over 2–3 years after scar formation, and be-
cause of the ability of remodeling and regeneration of the
cutaneous tissue during this period, laser treatment can facil-
FIG. 3. (a) A patient (F/30) with a post-traumatic scar of 3 itate and help this process. Therefore, although the appropriate
years’ duration on the cheek, before laser treatment. (b) The window for laser treatment after scar formation is yet un-
same patient showed marked improvement after two ses- known, early initiation of treatment is now preferred.18,19
sions of carbon dioxide fractional laser system (CO2 FS) Scar treatment with FPS and CO2 FS was a safe and tol-
treatment. erable procedure with minimal side effects and acceptable
46
clinical improvements. However, our results do not constitute
a conclusive comparison of the two fractional laser systems,
because of the limited sample size, variations in scar charac-
teristics and scar durations, and the different number of
treatment sessions among patients. As our study includes
various different types of scars with different causes, it is dif-
ficult to objectively compare the treatment results, because
every scar may show a different healing course after laser
treatments due to the diverse nature of each scar. The different
parameters used for each device are another limitation in this
study, because to accurately compare treatment outcomes, the
penetration depth and width of the laser column should be
controlled. Selection bias is also a possibility, as the type of
laser device was chosen upon the initial physician’s
assessment, and less severe types of scars might have received
non-ablative procedures. However, we made efforts to objec-
tively select the laser device according to the characteristics of
the scar, such as depression, atrophy, and hypertrophy, and
not the severity of the scar. Additionally, we could not com-
pletely eliminate the possibility of subject bias, as the partici-
pants experienced different post-treatment responses with FPS
and CO2 FS. A prospective, randomized study with unified
conditions of scars and treatment sessions with controlled
parameters would be required to compare the efficacy and
safety of the two laser systems more accurately and objectively.
Conclusions
In conclusion, the present study demonstrated the efficacy
and safety of laser treatments on various types of scars using
FPS and CO2 FS in East Asian patients. As a result, FPS and
CO2 FS can both be safe and effective options to consider for
scar treatment, and the two devices can also be used together
safely. However, it can be suggested that the proper laser
device and proper initiation time for scar treatment should
be decided considering various factors such as type of scar,
duration of scar, anatomical site, and patient demand. We
also suggest that early treatment of scars is safe and effective,
and although the proper time to initiate laser treatment after
scar formation remains unknown, early treatment of scars
may result in better improvements.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ju Hee Lee
Department of Dermatology and Cutaneous
Biology Research Institute
Yonsei University College of Medicine
250 Seongsanno, Seodaemun-gu
Seoul, Korea
E-mail: juhee@yuhs.ac