Guide to Fractionated Carbon Dioxide C02 Laser


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Fractionated or "pixilated" carbon dioxide (CO2) lasers are one of the latest advances in non-surgical skin rejuvenation treatments. The CO2 has the longest wavelength of all the lasers on the market and can be used safely on darker skin types with appropriate adjustments in the settings.

Fractionated CO2 lasers excel at treating deeper wrinkles, more severe textural changes from sun damage, wrinkles, blotchiness, acne scars, and surgical or traumatic scars. It can be used on the delicate eyelid skin and around the mouth. It is also a very effective treatment for sun damage and precancerous growths (actinic keratoses – note that insurance will not cover this).

Dr. Irwin performing a fractional CO2 laser resurfacing treatment

It can be used to improve texture, wrinkles, and blotchiness on the neck, chest, arms and legs but this should only be done by experts because the risk of complications, including scarring, is higher in these areas.

What does it NOT do? It does not take care of redness including- dilated blood vessels (telangectasias), or that reddish blotchy discoloration on the neck (poikiloderma). Temporarily, it can even make these problems look worse because the laser treatment itself causes some redness. For problems with red and veins, a medical (not salon) grade IPL or pulsed dye laser like a Candela is more effective.

So the question of which fractionated laser system to choose is important. How do you, as a consumer, figure it out? First, find a reputable cosmetic dermatologist or plastic surgeon (see the section on finding a good doctor). Good equipment in incompetent hands will not help you!

Here’s my "two cents" on the different systems. I think the clear leader is the Deka Smartxide "DOT" system because it easily facilitates customizing each treatment for individual patients and particular sites of the body. It has, in my opinion, the best "microdot" size which helps to optimize results. The treatments are the most comfortable for you, the patient. It also has the best medical studies to support its claims.

  1. DEKA Smartxide "DOT" - For the reasons above.
  2. Lumenis Ultrapulse Active/Deep Fx - A close second but it’s unnecessarily overpowered, the spot sizes aren’t as optimal, more painful, too sensitive to movement. The "deep" spot size causes more bleeding. Their "new" Accupulse system (40W) is a hasty remake of prior systems and not as well engineered as the DOT.
  3. Fraxel "Repair". Clearly differentiate this from the original "Restore" which is an erbium based system – not a fractionated CO2. Additional costs to the patient in the form of expensive, consumable tips, quite painful with higher potential for bleeding due to the 200 um spot on the hand piece, slightly longer healing times compared to the DOT.
  4. Cynosure Affirm CO2 – almost exactly the same as the DOT but without some of the "stacking" programs and CPG controls. Still - a great laser.
  5. Alma Pixel, the Mixto, Ecclipse Juvia, and Lutronic – avoid for many reasons. Generally underpowered, use "stamping" technology (not true fractional), uneven and inconsistent results.
  6. Cutera Pearl, Focus Naturalase, Sciton Profractional - these are NOT CO2 lasers – they are erbiums with very different results usually. Some of the marketing is misleading to consumers.

What’s the difference between the fractional CO2 laser and the fractional erbium laser like the Fraxel "Restore?"

The CO2 laser goes slights deeper and has a different way of shrinking collagen than the Fraxel laser. Therefore, it generally gives a better result for deeper wrinkles, acne scars, upper line lines, and crepeyness around the eyes. The CO2 is best for patients who are late 40s to 70s with moderate to deep wrinkles/sun damage or with moderate to severe acne scarring. It also works well on crepey eyelid and neck skin when performed by an expert with the proper settings. But because the CO2 can go deeper, there is more "downtime" than with the Fraxel. If you cannot take any time off from your normal activities, the CO2 laser on the face is not the right choice for you. Some off-face areas can be kept covered and may be fine.

Fraxel Restore is best for younger patients (approx 30-50ish) who have early wrinkles or mild to mod acne scarring or for those who truly can’t take any time off from work/children to have CO2 treatments.

Does Fractional CO2 resurfacing work for wrinkles?

Does Fractional CO2 resurfacing work for sagging skin?

How does the fractional CO2 laser work?

The fractional CO2 laser takes the CO2 laser beam and fractionates, or pixellates that beam into thousands of tiny little shafts of light. These tiny shafts of light penetrate into the deeper layers of the skin. The skin then repairs those tiny shafts by pushing out the old sun damaged skin and replacing it with new skin. The "collateral" heat damage also helps to shrink existing collagen.Can I do the fractional CO2 laser with other cosmetic treatments?

Not the same day generally. The CO2 laser is compatible long term with Botox, Juvederm, Restylane, Sculptra and other laser based technologies like hair removal, Fraxel Restore, IPL, pulsed dye, etc.

How long do the effects of a fractional CO2 resurfacing laser treatment last?

That depends on how well you protect your skin from the sun and other factors that cause aging like your general health, smoking, changes in weight, etc.  If you apply sunscreen and wear brimmed hats, you can maintain the good effects of your CO2 laser treatment for several years. How long does the fractional CO2 laser take to work? 

When will I see results?

Bear in mind that the fractional CO2 laser can be customized. Treatments can be deeper, with more healing and downtime, or shallower, with less healing time. The deeper the treatment, the better the results generally. But some patients prefer to have two treatments that aren’t as deep so they can avoid a lot of downtime.

You will see some immediate results but you won’t see the full results for 3-6 months. After your skin heals, which may take up to 3-14 days, there will be a period of 4 to 6 weeks after that when your skin might be slightly pink. During this period, your skin will feel smoother and looks less blotchy. As the color returns to normal, you will see fewer lines, less blotchiness, and more glow. 

How much do fractional CO2 laser treatments cost?

The cost varies by where you live (New York is more expensive than Seattle), the office you go to, and the size of the area being treated. Expect full face treatments between $1,500-3,000. You’ll get a specific quote from your dermatologist at your consultation. Generally, up to 2 areas at a time can be treated. For example, face and neck or neck and chest, would have different prices. More areas at the same visit are not advised due to the potential toxicity of the numbing cream used prior to the treatment.

How are fractional CO2 laser treatments performed?

This is a prototype treatment for our office. Other offices will be different so be sure to ask and not just assume it’s the same!You need to arrive 1 ½ hours before your treatment. You or a technician will cleanse the treatment area and then apply a numbing cream to the area to be treated. We also have our patients take the anti-inflammatory Toradal, which helps to reduce the discomfort. Then you just relax, read, and listen to music, while the numbing cream takes effect.

After you numb for about an hour, the numbing gel will be removed. The treatment takes about an hour for a full face and feels a little like a "pins and needles" sensation. A strong stream of cold air (a Zimmer cooler) is blown on the area during the treatment to make it comfortable. The discomfort ranges from mild to moderate (2-4/10). Plan on being in the office for 2 ½ hours total.

Most people drive to and from their own fractional CO2 laser appointments. Offices vary in this. Some offices will use mild narcotics or anti-anxiety drugs which do require some else to drive after the treatment.

How does this laser work for acne scars and other scars?

CO2 lasers have always been very effective for acne and other scars and the fractionated CO2 is no exception. It remains to be seen if it is as effective as the traditional CO2. However, as the settings for the "DOT" or "Deep Fx" for both acne, surgical and traumatic scars keep being improved, many of us think that results will be as good without many of the risks with the older forms of this laser. Go to an expert if scars are your issue.

Are treatments on the eyelids safe?

Yes, because special laser "contact lenses" are used to protect the eye. Don’t let anyone do treatments directly on the eyelids without these. Numbing eye drops are placed in the eye before insertion of a contact lens-like eye shield. A protective ointment on the side next the eye cushions the special shield. The shield fits comfortably within the eye and is easily removed at the end of the treatment. Even our patients who don’t wear contact lenses have been comfortable.

The eye treatment is then performed on the upper & lower eyelids. It is normal (as with all areas treated with the fractional CO2 laser) to have swelling and redness for 2-4 days after the treatment. You also have to avoid all sun exposure during the healing time. Plan on 2-3 weeks for being "camera ready."

What will I look like right after the treatment and what is the healing time?

During the first 24 hours after treatment, your skin may feel as though it is sunburned. Ice packs/frozen peas are used 5-10 minutes per hour for the first 5-6 hours after the treatment.

Your skin will peel for 2-7 days and will be pink for 3 to 6 weeks. This healing all depends on how deep your treatment is. After a week or so, you can wear make-up to cover the pink. Rarely, bruising may develop, which can take up to two weeks to resolve. Allow 2-4 weeks for weddings, reunions, family pictures, etc just to be safe. Allow longer for body sites like arms or legs. 

Can I go back to work and activities immediately?

No, you will need to take the rest of that day off to ice and care for the treated area. For the lighter fractional CO2 treatments, you will need 3-5 days of downtime. For the deeper treatments, plan on 7-10 days of healing before you can go out in public.

How many treatments will I need?

The number depends on the extent of your sun damage, scarring or wrinkles, and on how much downtime you can accept. If you can tolerate 7 days of downtime, you would generally need only 1 or 2 fractional CO2 treatment.

Are there any reasons not to be treated with these lasers?

Reasons not to do a fractional laser treatment may include use of medications that increase photosensitivity, use of anticoagulants (some are fine), use of Accutane in the last year (vs. 6 months), chemotherapy, history of difficulty healing or scarring, history of bleeding disorders, and pregnancy.

Are there any medical or cosmetic side effects?

A good dermatology office with experience in lasers is your best way to avoid any complications. And complications are rare. But here is a list of some of the possible complications of fractional CO2 laser treatments:

· Pain. Most people feel very little pain during treatment due to the measures discussed above. Rarely there is mild discomfort for the first day after surgery, but Tylenol is effective for it.

· Redness. A pink color may persist for two weeks to two months after the laser surgery. In rare instances, it may last three to six months. This is more common in patients who have a history of flushing and blushing easily or who already have dilated vessels on the surface of the skin.

· Wound Healing. The CO2 laser causes a superficial wound to the skin that takes approximately 2 to 10 days to heal. The superficial injury of the outer layers of the skin may result in mild to moderate swelling. Crusting is rare but peeling is common. Once the surface is treated, it may be sensitive to the sun for approximately 4-6 weeks.

· Pigment Changes. The treated area may heal with increased or decreased pigmentation. This is rare and occurs most often in darker skin and 2-6 weeks after treatment. Hyperpigmentation usually fades in three to six months, though rarely pigment changes can be permanent.

· Excessive Swelling. Immediately after laser surgery, there will be swelling of the skin. This is a temporary condition and will resolve over three to seven days.

· Scarring. There is a very small chance of scarring. This includes hypertrophic scars or, very rarely, keloid scars. Keloid scars are thick, raised scar formations. To minimize chances of scarring, it is important to follow post-operative instructions carefully. It is important that any prior history of unfavorable healing be reported. Do not pick!

· Eye Exposure. There is also a risk of harmful eye exposure to laser surgery. It is important to keep your eyes closed and have protective eyewear at all times during the laser treatment.

· Depression or emotional difficulties even if the procedure is successful.

· Since every patient is an individual, you may not respond exactly the way other patients do. You also may not be completely happy with the effects of treatment.

· Infection. Occasional infections can occur. If not treated promptly, these could result in scarring.

Next, learn about which skin care product Dr. Irwin uses in her personal regimen.

See Dr. Irwin's expert answers to other's reader's questions on eyelid Fractionated Carbon Dioxcide CO2 Lasers:

Would a fractionated CO2 Laser like the DEKA DOT be helpful for crepey arms?

Would the fractional CO2 or the "Mosaic" laser be better for treating acne scaring? 

From www.SkinTour.com and Dr. Brandith Irwin. Copyright 2008-2014 SkinTour LLC. All rights reserved. Journalists, bloggers, and media may reprint this without permission so long as they include this credit box with the article.
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