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Fractional Carbon Dioxide Lasers for Scar Reduction

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 CHAPTER 
Fractional Carbon Dioxide Lasers for
Scar Reduction
Koushik Lahiri, Ishad Aggarwal
„
INTRODUCTION
Injury to skin initiates a cascade of organized sequential
events of inflammation, granulation, and remodeling,
which lead to wound healing. Any deviation in this
process leads to formation of scars. In the world that
constantly becomes centered upon appearance, scars
could lead to significant psychological distress and loss of
self-esteem. Consequently, cutaneous surgeons all across
the globe, find themselves attending to an ever increasing
desire amongst people for scar reduction. The field of
laser scar reduction has seen a sea of change over the
past few decades. The purpose of this chapter is to review
the principles of fractional carbon dioxide (CO2) laser for
reduction of various kinds of scars, with special focus on
Indian skin.
„
CONCEPT OF SELECTIVE
PHOTOTHERMOLYSIS IN FRACTIONAL
CARBON DIOXIDE LASERS: A HISTORICAL
OVERVIEW AND BASIC PRINCIPLE
The earliest laser devices pioneered in 1970s were
continuous wave lasers which had the ability to coagulate,
cut, or ablate tissues nonspecifically, thereby leading
to larger number of complications, mostly due to bulk
tissue damage. Renaissance into the field of cutaneous
laser medicine was heralded by the landmark theory of
selective photothermolysis by Anderson and Parrish in the
year 1983.1 The theory describes localized photothermal
injury to a specific chromophore. The idea is to selectively
target the major chromophores such as water, melanin,
and hemoglobin and contain the thermal damage into
the target tissue without nonspecific destruction of the
surrounding tissue. This is achieved by emitting photons
of a specific wavelength which was specific to the target
chromophore and differed from that of surrounding
tissue, keeping the energy fluence sufficiently high to
damage the target tissue and pulse duration less than
or equal to thermal relaxation time (TRT) of the target
chromophore.
Carbon dioxide laser became available for treatment
in 1964 and since then it has been a popular ablative laser
in dermatological practice. Carbon dioxide laser emits
photons in the invisible infrared spectrum at 10,600 nm.
The chromophore for this laser is water presenting both
intracellularly and extracellularly. Water is abundantly
present in epidermis and dermis which absorbs
the incident light, causing vaporization of skin and
coagulative necrosis of the dermis. The earlier CO2 lasers
were continuous wave lasers, which leave behind a thick
zone of thermal necrosis measuring about 0.2–1  mm in
thickness. The consequent risk of complications is higher
and there runs a longer downtime of recovery.2
Laser resurfacing using CO2 lasers saw a paradigm
shift, when Manstein and colleagues came up with a
novel concept of fractional photothermolysis in 2004.3
198 Textbook of Lasers in Dermatology
Although an extension of the principle of selective
photothermolysis, fractional photothermolysis involved
creation of pixelated patterns of full thickness columns
of skin coagulation, which were termed as microthermal
zones (MTZ).3,4 By utilizing the principles of selective
photothermolysis and creating short pulses of energy,
the concept of fractional photothermolysis fosters
the remodeling of collagen in these MTZs with aid of
surrounding normal tissue. Fractional photothermolysis
has become the industry standard of lasers which are
involved in resurfacing and scar reduction, and, hence,
the genesis of fractional CO2 lasers.
„
HISTOGENESIS AND
LASER TISSUE INTERACTIONS
In an ideal scenario, MTZ are cylindrical microscopic
zones in dermis. The reparative capacity and resultant
collagen remodeling is dependent upon the surrounding
normal tissue. The diameter and depth of these zones
is dependent upon a host of factors like fluence,
wavelength, machine used, and number of stacking
applied. Ablative fractional CO2 lasers cause disruption
of both epidermal and dermal tissue. Studies have shown
that by 48 hours, invaginating epidermal keratinocytes
replace the MTZ and there is extrusion of necrotic debris
by 1 week also known as microscopic epidermal necrotic
debris (MEND),4 with complete replacement of stratum
corneum by 1 month. Remodeling of collagen takes place
by 3 months which is indicated by increased expression
of heat shock protein 47 (Hsp47)4 in this tissue, which is
a marker of collagen synthesis. The depths of these MTZ
vary between 100 and 160 Pm and constitute 15–25% skin
surface area under treatment per session. Carbon dioxide
lasers vaporizes both epidermis and dermis to a depth
of 20–60 μm while the thermal damage zone extends
to another 20–50 μm. Approximately, 90% of CO2 laser
energy is absorbed in the initial 20–30 μm of skin. Theory
of selective photothermolysis states that selective heating
of the target chromophore can be achieved when using
laser pulses shorter than the TRT of the chromophore
(time required for chromophore to lose 50% of its heat
to surrounding tissue). Thermal relaxation time for 20–
30 μm of skin tissue is approximately 1 millisecond. Using
the theory of selective photothermolysis, CO2 lasers with
pulse duration of less than 1  millisecond are capable of
selectively vaporizing tissue with only very thin zone
of residual thermal necrosis measuring approximately
100  μm. To have a clinical effect in the skin, laser
energy must be absorbed by the target chromophore.
Energy fluence (density) necessary to vaporize tissue
is approximately 5 J/cm2 (ablation threshold). Overall,
delivering 1 millisecond CO2 laser pulse with an energy
fluence of approximately 5 J/cm2, leads to tissue
vaporization measuring 20–30 μm and residual thermal
injury measuring 40–120 μm.5 This zone of thermal
necrosis is sufficient to seal small dermal blood vessels
and lymphatics, yet narrow enough to reduce incidence
of scarring.5
„
FRACTIONAL CARBON DIOXIDE
LASERS FOR SCAR REDUCTION
Although ablative CO2 lasers have been in use for skin
resurfacing and scar reduction since 1960s, however, they
came heavily upon the downtime and rate of complications.
Nonablative lasers which selectively destroyed dermis,
give lesser downtime and complications, but inferior
results. Fractional lasers bridge the gap between these
two modalities.
Two main types of fractional CO2 lasers are currently
being used by laser surgeons. They are:
x The scanning CO2 laser
x The pulsed CO2 laser.
The scanning CO2 lasers use an optomechanical flash
scanner connected to a continuous wave CO2 laser, which
efficiently distributes laser energy into train of pulses
with dwell time shorter than TRT of the tissue, hence,
mimicking a pulsed CO2 laser.
Most conventional continuous wave CO2 lasers can
be converted into pulsed lasers by a pulsing technique.
These pulsed lasers can produce a train of relatively high
power, short duration pulses which work on the principle
of selective photothermolysis. Some of these machines
have computerized pattern generators which place
individual laser beams into a specific pattern.
Pulsed Wave Carbon Dioxide Lasers
When the pulse length of the laser beam is shorter than
the TRT of target tissue, it results in quick ablation of
tissue with minimal thermal damage:
x Superpulsed lasers
x Ultrapulsed lasers.
Superpulsed CO2 lasers were lasers with pulse
duration of 10–100 milliseconds which have now been
replaced by the ultrapulsed lasers which have pulse
durations of submicroseconds.

„
INDICATIONS
Scars Amenable to
Fractional Carbon Dioxide Lasers6
Of the wide variety of clinical scars a dermatosurgeon is
confronted with, following types are the ones that shows
significant improvement with fractional CO2 lasers:
x Atrophic scars due to acne
x Atrophic scars due to nonacne etiologies such as
trauma, post-varicella infection, or surgical scars
x Burn scars
x Striae distensae.
Patient Selection
When considering a patient for scar reduction using
fractional CO2 lasers, the caveats hold true as for different
lasers otherwise and, especially, for ablative ones,
the following points can generally be helpful to avoid
complications and select patients for the procedure.
„
INDIAN SKIN TYPES
Color of Skin
The Indian skin type is predominantly Fitzpatrick types IV
to V, although rarely skin types III and VI may also be seen
in isolated cases. It is important to understand that the
Indian skin may be more predisposed to develop keloids
and hypertrophic scars after an ablative procedure, hence,
appropriate history should be sought before performing
the procedure. While discussing laser treatment outcomes
with the patient, it is important that the treating physician
be apprised with the possibility of developing transient
postinflammatory hyperpigmentation.7
Concurrent Infections8
It is important to see that any infections seen on the
cutaneous surface being treated, be free of any viral or
bacterial infection which may otherwise flare up after
treatment.
Coexistent Inflammatory Skin Conditions8
It is important that laser surgeon identify any inflam-
matory process, such as active acne, psoriasis, or contact
dermatitis, and then treat prior to performing the
procedure and treat them.
Fractional Carbon Dioxide Lasers for Scar Reduction 199
Medication8,9
Patients seeking treatment for atrophic scarring due
to acne may have concurrent or recent history of
isotretinoin intake. It has been shown that this could lead
to development of hypertrophic scars due to isotretinoin
effects on collagenase. There is much debate over the
isotretinoin drug free interval and contrary to prevalent
notion , many dermatologists treat patients on isotretinoin
with fractional CO2 lasers, the current consensus is to
have a 6-month drug free interval before performing scar
revision with these lasers.
Allergy to Systemic or Local Anesthetics
It is important to rule out history of developing any
reaction to local or systemic anesthetics which are used
during the procedure.8
Realistic Expectations
It is important to identify unrealistic expectations,
psychological instability, and patients who will neither
tolerate nor be compliant of postprocedure care.8
„
PRINCIPLES OF USING FRACTIONAL
CARBON DIOXIDE LASER
The settings depend upon the types of scars being used
and the machine that a treating laser surgeon has at his
disposal. However, a few basic principles must be kept in
mind before using a fractional CO2 lasers:10
x Depth of skin vaporization and degree of thermal
necrosis is directly proportional to pulse energy and
number of passes performed
x The relationship between number of passes and depth
of thermal damage is not linear. The first laser pass
significantly ablates more tissue than the second or
subsequent passes; an ablation plateau is reached in
3–4 passes, limiting ablation depth to approximately
250 μm. The effect of such passes is cumulative
x The goal of scar reduction using any CO2 lasers system
are to achieve a soft transition between atrophic
indentation and surrounding normal skin; to stimulate
collagen in the indented area. To get a desirable result,
entire cosmetic unit should be treated together. To
avoid sharp demarcation lines between treated and
untreated skin, it is important to perform a technique
called feathering, in which the surrounding normal
skin is treated with lower energy
200 Textbook of Lasers in Dermatology
x In case multiple passes are required, the partially
desiccated tissue should be removed with saline
soaked gauze to prevent charring
x Another important parameter in fractional CO2
devices is the density of the MTZ that are active in
the beam of light. The higher the density, higher is the
vaporisation of the tissue.
„
SCARS CHARACTERISTICS AND
PARAMETERS
Scar characteristics, such as size, color, morphology,
and history of previous treatments are essential to be
determined because such differences could require
modifications of treatment protocols.
Atrophic Scars
Atrophic scars are depressions seen on the surface of skin
which is the result of inflammatory processes such as
acne, varicella infection, or trauma.
Atrophic Acne Scars11,12
Atrophic acne scars are classified and have traditionally
been classified as ice picks, rolling, or boxcar scars. Ice
pick scars are typically narrow (<2 mm), sharp tracts that
extend into the dermis or may even go as deep as the
subcutis. These scars taper down and are wider at the
surface. Rolling scars are wide and produce undulations
over the surface of the skin. Boxcar scars are round to
oval depressions over the surface of skin and show no
tapering. It is, however, prudent to state, that due to
the complexity of the nature of acne scars, fractional
CO2 lasers although represents a major advancement in
treatment modality for acne scars, it does, however, come
with certain limitations and hence, a combination of scar
revision techniques are advocated for best results. Most
studies have reported good outcomes in superficial and
medium depth scars, thereby making it a good treatment
modality for superficial boxcar scars. In ice pick scars and
depressed boxcar scars, the aim is to soften the abrupt
transition between the scar edge and normal skin and
to stimulate collagen in the dermis. However, in rolling
scars, the treatment outcome depends upon the severity
to which the scar is tethered to underlying dermis and
subcutis. Such scars present an ideal opportunity for a
dermatosurgeon to perform subcision before attempting
ablation with fractional CO2 lasers.
Laser parameters for atrophic acne scars vary with
different machines with different settings.13 Many
manufacturers provide different handpieces which differ
in amount of energy released and depth of penetration.
With a CO2 laser, a fluence of 300 μJ with 60 watt power
is typically used in a single pass to achieve ablation of
epidermis with variable sized and shaped parameters.14
Depending upon the scar severity, 2–3 passes may be
required, with depth of ablation increasing at each
successive pass. It is advisable to avoid overlapping in
lasers with computer generated pattern and clean debris
with saline soaked gauze in between passes.15 The second
pass after the first pass may also be given in a direction
perpendicular to the initial pass. Cosmetic end point in a
session is ablation of the tissue, however, safety end point
is considered to be attained when the treated skin color
appears yellowish even after it is washed with saline.
Outcomes in Atrophic Acne Scar Reduction with
Fractional Carbon Dioxide Lasers
In a study conducted in India by Majid et al., 43.3% of
the patients showed excellent response to fractional CO2
lasers as monotherapy for atrophic acne scars.16 They used
fluence of 15–20 J/cm2 with a density of 100–150 MTZ/cm2
with single or double pass and repeated sessions every 6
weeks for 3–4 sessions. They found good results in rolling
scars and boxcar scars. Wang YS et al. conducted a study
on type IV Asian skin, and found similar results.17 Their
parameters were fluence of 28 J/cm2 and 20% coverage in
single pass.
Suffice to say that fractional CO2 lasers can bring good
outcomes in acne scars; however, the laser parameters
need to be picked carefully to prevent complications,
especially, in Asian skin types. Results shown by Yuan
XH et al. shows that lower fluence of 10 J/cm2 shows
comparable results and fewer complications in Asian
skin(Figs 1 to 3).18
„
COMBINATION OF FRACTIONAL CARBON
DIOXIDE LASER WITH OTHER TREATMENT
MODALITIES
Due to versatility of acne scars, most treating dermato-
logists find it more rewarding to combine different
therapeutic modalities to achieve the most optimum
results. The most commonly used modalities are non-
ablative lasers, microneedling techniques, and chemical
peels.13
 Fractional Carbon Dioxide Lasers for Scar Reduction 201

A B
FIG. 1: A, Box and ice pick types of post acne scars; B, improvement after four sessions of fractional carbon dioxide laser treatment

A B

C D
FIG. 2: A, Atrophic acne scars before treatment; B, improvement after three sessions of fractional carbon dioxide laser treatment;
C, improvement after four sessions of fractional carbon dioxide laser treatment; D, improvement after five sessions of fractional carbon
dioxide laser treatment
202 Textbook of Lasers in Dermatology
A B
FIG. 3: A, Post acne scars before therapy of fractional carbon dioxide laser; B, improvement seen after two sessions of fractional carbon
dioxide laser treatment
„
WHAT IS NEW FOR FRACTIONAL
CARBON DIOXIDE LASER
x Focal acne scar treatment technique, a recently
introduced concept, challenges the common know-
how and envisages the usage of higher fluence focused
beam of laser only over the scar area, thus, sparing the
normal skin. It has been used with comparable results
in ice pick scars which hitherto have been lesser
responsive to fractional CO2 lasers19
x Radiofrequency microplasma technique has been
introduced for scar correction. In combination with
fractional CO2 laser, it has been shown to reduce
complications and give better results20
x Fractional CO2 laser may also be used to inject
substances like poly L-lactic acid inside scars to give
better cosmetic outcome.21
„
FRACTIONAL CARBON DIOXIDE LASER
IN NONACNE SCARS
Nonacne Atrophic Scars
Fractional CO2 lasers are currently commonly used
in practice for treatment of scars caused by varicella,
although studies for this indication are largely lacking.
However, extrapolating from data obtained for acne
scars, it could be good treatment modality for correction
of post-varicella scars. Fractional CO2 laser has been
used to treat atrophic scars due to leishmaniasis in
11 subjects by Alghamadi and Khurram and they showed
more than 50% improvement in all patients at 3 months
follow-up.22
Scars due to Trauma and Surgery
Scar reconstruction after trauma and surgery could be
a challenge. Fractional CO2 lasers have been found to
reduce the scar size and volume in post-traumatic and
surgical scars and are more effective for atrophic scars
than hypertrophic scars. A study conducted by Wiess
et  al. demonstrates a 38.0% mean reduction of volume
and 35.6% mean reduction of maximum scar depth in
nonacne atrophic scars due to trauma and surgery. In
another Korean study on 23 post-thyroidectomy scars
treated with fractional CO2 laser, 12 out of 23 patients
showed more than 51% improvement at 3 weeks after
surgery.23 The parameters used were single session of
two passes of a CO2 fractional laser system with a pulse
energy setting of 50 μJ and a density of 100 spots/cm2,
2–3  weeks after surgery.24 Both fractional CO2 laser and
pulsed dye laser (PDL) have been used for scar revision,
but it has been seen that fractional CO2 laser give better
scar contour and PDL gives better color improvements.
Postburn Mature Scars25
Histological and biochemical analyses have been
performed over mature burn scars treated with fractional
CO2 laser and it was found that there is increase in
collagen remodeling and expression of growth factors
and ribonucleic acid with statistically significant clinical
improvement. However, given the nature of scars,
multiple sessions may be required and other lasers like
PDL may be used in combination to give better cosmetic
improvement, more so in the color of scars, especially, in
keloidal and hypertrophic burns scar (Fig. 4).

A B
FIG. 4: A, Postburn scar before treatment; B, improvement noted after treatment with fractional carbon dioxide laser
Striae Distensae
Traditional PDL has been used to treat striae distensae,
but there is growing evidence of fractional CO2 laser’s
efficacy in this condition. Combination of PDL with
fractional CO2 laser has been shown to be more
efficacious than either modality alone.26 In a Korean
study, energy of 10 μJ and area coverage of 10% were
used to treat striae in single session and good outcomes
were reported.27
„
COMPLICATIONS AFTER FRACTIONAL
CARBON DIOXIDE LASER TREATMENT28,29
AND MANAGEMENT
Since fractional CO2 laser ablates the skin and imparts
thermal energy to skin, some effects are expected,
therefore, these side effects must be differentiated from
complications.
Some of these immediate effects include post-
procedure pain, edema, pruritus, and scab formation.12
Application of ice, postprocedure analgesics, efficacious
sun protection, and emollients help to alleviate these
effects and must be given to all the patients.30
Mild complications sometimes occur and usually are
of minimal consequence. Minor complications include
milia formation, perioral dermatitis, acne and/or rosacea
exacerbation, contact dermatitis, and postinflammatory
hyperpigmentation. Transient postinflammatory hyper-
pigmentation is very commonly seen in the Indian skin
types and generally resolves within a few days.
The first postoperative week is critical. It is important
to closely monitor patients for appropriate healing
responses and complications such as dermatitis and
Fractional Carbon Dioxide Lasers for Scar Reduction 203
infection. Carbon dioxide laser reepithelialization
requires 7–10 days.
Moderate complications include localized viral,
bacterial, and candidal infection, delayed hypopig-
mentation, persistent erythema, and prolonged healing.
The most severe complications are hypertrophic scarring,
disseminated infection, and ectropion. Early detection
of complications and rapid institution of appropriate
therapy are extremely important. Delay in treatment
can have severe deleterious consequences, including
permanent scarring and dyspigmentation.
Erythema
Erythema may persist for 12 weeks or more. Mild
corticosteroids twice a day for 3–4 weeks can be used
for persistent focal areas of erythema. Diffuse erythema
may be secondary to contact dermatitis. This may occur
with excessive intraoperative use of wet gauze or early
postoperative use of topical tretinoin.
Dyspigmentation
A significant adverse effect that may occur with
fractional CO2 laser is transient hyperpigmentation.
Although hyperpigmentation is more common in
patients with darker skin tones, it may occur in any skin
type. Transient hyperpigmentation is observed early
in the postoperative course, occurring approximately
1–2 months after treatment.28,29 While the process is
usually self-limited, resolution may be hastened with
depigmenting creams (e.g., hydroquinone, arbutin) or
acid preparations (e.g., glycolic, retinoic, azelaic, kojic,
ascorbic).8 Hypopigmentation is a relatively late sequel of
204 Textbook of Lasers in Dermatology
treatment (typically observed ≥6 months postoperatively)
and appears to be permanent.
Infection8
Significant pain that occurs at day 2 after procedure may
indicate a bacterial, fungal, or viral infection. A high degree
of vigilance and suspicion is necessary because signs
may be subclinical, and the patient may be dismissed as
having a low pain threshold. They should be identified
early and treated accordingly. Incidence can be reduced
with appropriate use of prophylactic antibiotics and, more
importantly, aggressive postoperative wound care.
Scarring28
Postprocedure scarring may occur with excessive thermal
damage or infection. Treatment should be instituted
as early as signs of scarring are evident. Treatment with
potent topical steroids, intralesional steroids, and silicone
gel may be given.
„
CONCLUSION
In a world where technology has made us fickle and even
impatient, where everyone wants everything now, where
micro is becoming nano, fractional CO2 lasers find them-
selves comfortably placed. With ever increasing demand,
lesser downtime and better results, they have become a
reliable tool for the ambitious cosmetic surgeons. With
careful watch, thoughtful mind, and sound knowledge of
the principles, we could offer more with this technology.
„
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