The Idea That Made Resurfacing Survivable
Full-field laser resurfacing worked extremely well and almost nobody could face it. Removing the entire surface of the skin gave excellent results and two weeks of open wound, with a real risk of infection, permanent lightening and scarring. In 2004 a paper proposed treating only a fraction of the surface and leaving the rest intact as a reservoir for healing. That single idea is why resurfacing is now something people have on a Thursday.
The old way of laser resurfacing worked extremely well, and almost nobody could face it. Taking off the entire surface of the skin gave excellent results, and left you with two weeks of what was effectively an open wound, plus a real risk of infection, permanent pale patches and scarring. In 2004 someone suggested treating only a fraction of the surface and leaving the rest untouched, so the untouched skin could do the healing. That single idea is why resurfacing is now something people have done on a Thursday.
The Idea That Made Resurfacing Survivable: the essentials
The short version
Ablative resurfacing removed the entire treated surface at once
The laser took off the whole treated surface in one go.
Excellent, and accompanied by two weeks of open wound and significant risk
Excellent results, along with two weeks of open wound and real risk.
Fractional photothermolysis: treat columns, leave the skin between them intact
Treat the skin in thousands of tiny separate dots, and leave the skin between them untouched.
Untreated skin between the columns supplies the cells that resurface them
The untouched skin between the dots supplies the cells that cover them over.
Less downtime per session, and more sessions for the same total effect
Much less recovery time each session, and more sessions to get the same total effect.
Fractional devices exist in both forms; the choice changes depth, result and recovery
Some remove tissue, some only heat it. The choice changes how deep it goes, the result, and the recovery.
What was wrong with the old way
What was wrong with the old way
Traditional carbon dioxide resurfacing removes the epidermis across the whole treated area and heats the dermis beneath it. The skin then has to re-epithelialise from the edges of the treated zone and from the hair follicles and glands within it, which takes one to two weeks of genuine wound care.
Old style carbon dioxide laser resurfacing stripped the top layer of skin off the whole treated area and heated the layer underneath. Your skin then had to grow a new surface inwards from the edges, and outwards from the hair roots and glands inside the area. That takes one to two weeks of genuine wound care.
The results were and remain excellent for deep lines and sun damage. The problems were the fortnight of downtime, the risk of infection while the skin is open, prolonged redness lasting months, and delayed permanent hypopigmentation, a loss of pigment that can appear a year later and does not resolve. That last one is why a whole generation of dermatologists became cautious about full-field ablative resurfacing on anything but carefully selected patients.
The results were, and still are, excellent for deep lines and sun damage. The problems were the fortnight out of action, the risk of infection while the skin was open, redness that lasted months, and a late loss of colour: pale patches that can turn up a year afterwards and never go away. That last one is why a whole generation of skin doctors became cautious about the old method, and used it only on carefully chosen patients.
The insight
The idea that changed it
Dieter Manstein and Rox Anderson proposed treating the skin in thousands of microscopic columns, each perhaps a tenth of a millimetre across, separated by untreated tissue. Each column is a microthermal zone; the skin between them is entirely undamaged.
Two doctors, Dieter Manstein and Rox Anderson, suggested treating the skin in thousands of microscopic dots, each perhaps a tenth of a millimetre across, with untouched skin in between. Each dot is treated all the way down. The skin between the dots is not touched at all.
The consequence is that the wound is never open. Every treated column is surrounded on all sides by healthy tissue only fractions of a millimetre away, and that tissue resurfaces it within a day or two. The skin barrier is restored almost immediately even though a substantial volume of dermis has been treated.
The result is that you never have an open wound. Every treated dot is surrounded on all sides by healthy skin only a fraction of a millimetre away, and that skin covers it over within a day or two. Your skin’s protective barrier is back almost immediately, even though a good amount of the deeper layer has been treated.
The trade is arithmetic. If you treat twenty per cent of the surface in one pass, you need several passes to have treated the same total area that a full-field treatment covers once. Fractional resurfacing did not make resurfacing easier so much as it broke it into instalments the skin can pay.
The trade off is simple arithmetic. If you treat a fifth of the surface in one go, you need several goes to cover the same total ground the old method covered once. This did not make resurfacing easier so much as break it into instalments your skin can afford.
Two kinds, and the difference matters
Two kinds, and the difference matters
Fractional devices come as non-ablative and ablative. Non-ablative fractional lasers heat columns of dermis while leaving the epidermis over them intact; recovery is a few days of redness and roughness. Ablative fractional lasers remove a column of tissue outright; recovery is longer and the effect per session is greater.
These machines come in two kinds. One heats little columns of the deeper layer while leaving the surface above them intact, and recovery is a few days of redness and roughness. The other actually removes a tiny column of tissue, and recovery takes longer while the effect per session is bigger.
Neither is better in the abstract. Non-ablative treatment suits fine texture, early pigment change and people who cannot take downtime, and it is usually delivered as a series. Ablative fractional treatment suits deeper lines, significant sun damage and some scars, and it asks more of the patient in exchange for more per session.
Neither is simply better. The gentler kind suits fine texture, early brown patches, and people who cannot take time off, and it is usually done as a course. The stronger kind suits deeper lines, heavier sun damage and some scars, and it asks more of you in return for more per session.
Two variables are adjusted independently: how deep the columns go, and how much of the surface is treated. Depth drives how much remodelling occurs; density drives how much downtime results. A skilful operator can treat deeply at low density, or superficially at high density, and those are quite different treatments.
Two settings are dialled in separately: how deep the dots go, and how many of them are placed. Depth decides how much rebuilding happens underneath. Number decides how long you look red. A skilled operator can go deep with few dots, or shallow with many, and those are genuinely different treatments.
What it did not solve
What it did not fix
Fractional delivery reduced downtime and risk substantially. It did not abolish them, and it did not remove the need to match the treatment to the skin.
Treating in dots cut the recovery time and the risk a great deal. It did not get rid of either, and it did not remove the need to match the treatment to your particular skin.
Pigment change remains the main risk in skin that has more melanin to begin with, because heat is an inflammatory stimulus and inflammation drives pigment. Conservative settings, appropriate intervals, pre-treatment where indicated and rigorous sun protection afterwards are not optional extras in that context.
Patchy colour afterwards is still the main risk in skin that has more natural colour in it to begin with, because heat causes inflammation and inflammation sets off pigment. Careful settings, enough time between sessions, preparing the skin beforehand where that helps, and strict sun protection afterwards are not optional extras for those patients.
Infection is less likely than with open wounds but not impossible, and anyone with a history of cold sores is usually given antiviral cover before facial resurfacing, because the treatment can reactivate the virus across a wide area.
Infection is much less likely than with an open wound, but it is not impossible. And anyone who gets cold sores is usually given antiviral medicine beforehand for facial resurfacing, because the treatment can wake the virus up across a wide area at once.
Questions patients ask
How much downtime does fractional resurfacing need?
How much time off does this need?
Non-ablative fractional treatment typically means several days of redness, swelling and a bronzed, sandpapery texture. Ablative fractional treatment usually means a week or more of visible recovery. Both vary considerably with the settings chosen.
The gentler kind usually means several days of redness, swelling and a bronzed, sandpapery feel. The stronger kind usually means a week or more where you look like you have had something done. Both vary a lot depending on the settings chosen.
How many sessions will I need?
Because each pass treats a fraction of the surface, non-ablative courses are commonly three to five sessions spaced several weeks apart. Ablative fractional treatment achieves more per session and may be done once or twice.
Because each pass only treats a fraction of the surface, a course of the gentler kind is commonly three to five sessions, several weeks apart. The stronger kind does more in one go and may only be done once or twice.
When will I see the result?
Surface texture improves within weeks, but the collagen remodelling that produces the fuller result continues for three to six months. The result at three months is usually better than the result at three weeks.
The surface feels smoother within weeks, but the rebuilding underneath carries on for three to six months. The result at three months is usually better than the result at three weeks.
Is it safe for darker skin?
It can be, with conservative settings, appropriate device selection and careful aftercare, but the risk of pigment change is higher and the margin narrower. This is a conversation to have with a clinician who treats a range of skin types routinely.
It can be, with careful settings, the right machine and careful aftercare. But the risk of patchy colour is higher and there is less room for error. This is a conversation to have with a clinician who treats a wide range of skin tones every week.
Is microneedling the same thing?
It shares the principle of creating separated columns of injury with intact skin between them, but it does so mechanically rather than with light, and it does not remove tissue. The healing logic is similar; the depth, precision and heat are not.
It works on the same principle: make lots of separate little injuries and leave healthy skin in between to do the repairing. But microneedling does it with fine needles rather than light, and it does not take any tissue away. The healing logic is similar. The depth, the precision and the heat are not.
Talk it through with a physician first.
Every plan starts with an assessment of your skin, your anatomy and what you actually want to change.
This page is general health information, not medical advice. It cannot tell you whether a treatment is right for you. Approved uses, risks and results differ from person to person, and product labelling changes. Ask us at Dermatology and Laser Centre about your own situation, or make an appointment, and seek urgent care for any serious symptom.
