What is a fractionated CO2 (carbon dioxide) laser?

What is a Fractionated CO2 Laser?

A fractionated CO2 (carbon dioxide) laser is an ablative skin resurfacing device that delivers a 10,600 nm wavelength laser beam split into multiple microscopic treatment zones (microbeams), creating controlled columns of thermal injury while leaving surrounding tissue intact to accelerate healing and stimulate new collagen formation. 1, 2

Mechanism of Action

The technology operates on the principle of fractional photothermolysis, which fundamentally differs from traditional full-field CO2 laser resurfacing 2, 3:

• The laser beam is divided by a lens into several microbeams that create microscopic ablation zones rather than treating the entire surface area 1
• Each microbeam removes epidermis and variable portions of dermis while producing residual thermal coagulation in surrounding tissue 1
• The nonresurfaced epidermis between treatment zones enables rapid healing with significantly shorter recovery times compared to traditional CO2 resurfacing 1, 3
• Super-pulse mode operation limits pulse width and requires power adaptation to achieve the desired fluence per microbeam 1

Technical Parameters and Settings

The device allows customizable treatment intensity 1:

• Low, medium, and high settings are preprogrammed to control resurfacing strength
• Medium settings (2 Hz, 30 W, 60 mJ with two passes) are used for darker skin types and mild wrinkles 1
• High settings (2 Hz, 60 W, 120 mJ with three passes) are employed for severe wrinkles and scar tissue 1
• Laser pulsing can operate repeatedly on the same spot or move randomly over the skin using multiple passes to achieve desired thermal effects 1

Clinical Applications

Fractionated CO2 laser effectively treats multiple dermatologic conditions 1, 4, 5:

• Facial photoaging and wrinkle reduction across various severity grades 1, 2
• Acne scars and other scar tissue with documented improvement in texture and appearance 1, 4
• Skin tightening through new collagen formation confirmed by histologic evaluation 1, 2
• Treatment can be performed on full face, periocular areas, upper lip, and localized scar regions 1

Histologic Effects

The wound healing response produces measurable tissue changes 1, 2:

• Immediate vaporization with clear ablation and collateral heat coagulation occurs with stacked pulses 1
• At 2 months post-treatment, thicker multicellular epidermis and evident collagen increase are observed histologically 1
• Electron microscopy confirms new collagen deposition consistent with wound repair mechanisms 2

Combination Therapy Recommendations

The American Academy of Periodontology recommends combining fractionated CO2 laser with platelet-rich plasma (PRP) to reduce downtime and enhance outcomes 6, 7:

• PRP should be applied after laser treatment, not before, as ablative wavelengths can damage platelets if applied beforehand 8
• Combination therapy results in shorter duration of erythema, edema, and crusting compared to laser alone 8, 6, 7
• Studies demonstrate improved wound healing, better scar resolution, and higher patient satisfaction with combined treatment 8, 7
• PRP can be delivered topically, via microneedling, or as an injectable immediately following laser treatment 8

Safety Profile and Recovery

The fractional approach significantly improves the risk-benefit ratio compared to traditional CO2 resurfacing 2, 3:

• Short-term postoperative erythema is the primary expected side effect, with resolution typically within weeks 1, 3
• No serious or long-term complications were reported in clinical studies across various skin types 1, 2
• Treatment is safe for Fitzpatrick skin types I to IV when appropriate settings are used 1, 2
• Topical anesthesia is typically sufficient, though injectable anesthesia may be needed for scar tissue treatment 1

Common Pitfalls to Avoid

• Excessive laser passes on the same area can cause prolonged erythema plaques, though these typically resolve by 2-month follow-up 1
• Applying PRP before laser treatment can result in cell damage due to the ablative nature of the laser 8
• Inadequate post-treatment care increases risk of infection and post-inflammatory hyperpigmentation, particularly with repetitive treatments 4