Fractional or fully ablative CO2 laser for acne scars?
For the majority of patients with acne scarring, fractional resurfacing is the more appropriate choice. I do not currently offer fully ablative resurfacing for acne scarring, although I do perform it for rhinophyma, where the calculation is different.
Fully ablative laser resurfacing removes a continuous layer of skin and achieves more in a single session. It can be an effective treatment for severe acne scarring, however it has a prolonged recovery period and even in very experienced hands a proportion of patients can be left with severe complications.
Fractional CO2 treats the skin in thousands of microscopic columns, leaving untreated skin between them. These untreated islands are what allow the surface to heal quickly and are the reason the procedure can be repeated. Fully ablative treatment removes a continuous layer across the whole treated area, so there are no islands to heal from, healing is slower and the margin for error is considerably narrower.
In my view fully ablative resurfacing is advisable only in the most severe cases, and only in the hands of a practitioner performing a large number of these treatments regularly. Even then a proportion of patients can experience permanent complications, such as scarring, prolonged redness lasting months and permanent loss of pigment. In view of this I would not recommend it except for severe, disfiguring scarring.
For moderate to severe scarring the alternative is fractional CO2 resurfacing, once the contour of the scars has been addressed with subcision, TCA CROSS or punch excision as appropriate. Resurfacing performed before that work has been done is treating the wrong problem. I will always treat a small test area first to assess how the skin heals before treating the whole face, and where a lower risk of pigmentary change is required non-ablative laser is an alternative.
Where fully ablative resurfacing is being proposed for acne scarring, it is important to ask how many procedures the practitioner performs each year, what proportion of their patients have experienced a complication and whether they have had any complaints. It is a defensible procedure in the right hands for the right case, but it is not a routine treatment for acne scars and it is essential that other less invasive alternatives have been considered.
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