Fractional laser resurfacing for scars, texture and fine lines

What it is

It is used for depressed acne scars, surgical and burn scars, stretch marks, fine lines around the eyes and mouth, and rough texture. The ablative CO2 form reaches deepest with the most downtime; the erbium form works more superficially with less residual heat.

What this page covers

• Fractional CO2 resurfacing for fine lines, texture and mild laxity
• Fractional CO2 for atrophic acne scars — rolling, boxcar and mixed
• Fractional CO2 for surgical, traumatic and burn scars, including cautery and cupping scars
• Fractional Er:YAG 2940 nm resurfacing where less residual heat is wanted
• Periorbital and perioral fractional resurfacing, with internal metal eye shields for eyelid work
• Fractional laser for striae, including post-pregnancy and post-bariatric stretch marks
• Vascular and fractional laser for the redness of hypertrophic and keloid scars, alongside intralesional treatment
• Antiviral and antibacterial cover before ablative or deep fractional sessions

Who it suits

• Someone whose complaint is in the surface of the skin itself: the depth of a scar, rough texture, or the fine lines around the eyes and mouth — once the examination has confirmed that the problem is texture rather than color
• Someone who can give the recovery its due: days with a swollen red face that weeps and then crusts, indoors and out of the sun, arranged around work, home and travel — not compressed in ahead of a wedding, Eid, exams or Umrah
• Someone with an established scar — surgical, cesarean, a burn, traditional cautery or cupping — who accepts that the aim is to soften it and bring its texture and color closer to the skin around it, rather than to remove it
• Someone able to commit to daily sun protection, before the session and after it. Here that is a requirement rather than advice
• And not you if your answer to "how many days can you be out of sight?" is none. There is no version of an ablative session without a recovery, and lowering the settings until the recovery disappears hands you the risk without the benefit. If that is where you are, say so; the quieter route — radiofrequency microneedling and its like — is a different conversation rather than a lesser one

When we advise delaying or not treating

• Oral isotretinoin, now or recently. Ablative resurfacing waits, and the interval is set by whoever prescribed it rather than by a rule read online: the decision is made case by case and recorded, and superficial procedures are judged on different terms from deep resurfacing. Do not stop the medicine yourself to bring a session forward. And if you are taking it for acne, the order is already settled: the acne is treated to stability, and its marks are looked at afterwards. The question is asked at every visit rather than only the first, and a course that ended months ago is still worth mentioning
• Cold sores on or around the lip — even once, even years ago. Say so before the session rather than after it. Antiviral cover is started before the procedure and continued afterwards, and it does not help if it is begun once the blisters have appeared. Nor is this confined to the mouth: resurfaced skin is one open connected surface, the virus on it does not stop at the lip, and a flare across it can end in a scar. An active cold sore postpones the session, and prophylaxis lowers the risk rather than removing it
• Pregnancy and breastfeeding. Elective device sessions are postponed in pregnancy, and while you are breastfeeding each case is decided on its own rather than assumed to be barred or assumed to be fine. Resurfacing has an added reason here: a wide area of numbing cream over an abdomen or a whole face is not a step to wave through in that period. And pregnancy-related pigment change can resemble or worsen melasma, so anything aimed at color is reassessed after delivery. Tell us before the session, not in it
• A known tendency to keloid or hypertrophic scarring, in you or in your family — meaning a scar that grew wider or thicker than the cut that made it, stayed raised rather than flattening, and often itched or stung for months. The history asks specifically about ear piercing, surgical and cesarean scars, cupping and traditional cautery. That tendency is more common in deeper skin, and any device can provoke the very scar it came to treat; so a small area is treated first, laser is combined with intralesional treatment, and laser is not left on its own to be enough
• Active melasma. Ablative fractional resurfacing is rarely appropriate for it and frequently makes it worse. It takes a different route: melasma is managed with photoprotection and topical treatment first, and managed as a chronic condition to be controlled rather than a problem finished in a session
• Active inflamed acne in the area, or any infection or open lesion in it. Skin with something flaring on it now is not resurfaced: every new lesion undoes what was done and leaves a mark of its own, and an infection on a surface that has just been broken behaves differently from one on intact skin
• Skin thinned by an unlabeled mixed cream used for months. It ablates deeper than the settings predict, heals unpredictably and can scar. The cream is withdrawn and the skin brought back to baseline first. It is not stopped all at once, and not on your own: many of these creams contain a steroid, and stopping one abruptly flares the skin, so it is tapered on a plan. That is a reason to delay, not a reason to lower the settings. Bring the container with you as it is
• An area threaded, waxed or sugared in the preceding days. All of them lift the surface layer, so the laser over it takes more than was intended, and numbing cream absorbs unpredictably and stings out of all proportion. The question is when it was done, not whether
• Diabetes that is not well controlled. The skin after a session is a wide open surface, and infection and slow healing here are a candidacy decision rather than a footnote at the end of the form. Deferring until control improves is care rather than refusal, and it comes with a clear appointment to come back to
• Recent sun exposure, or an active tan on the area. Skin fresh from the sun takes energy differently and burns and pigments more readily. We postpone until it has settled, and it is asked before every session rather than only at the first
• An allergy to a local anesthetic, a history of fainting during procedures, or G6PD deficiency in you or your family. Say so before the numbing cream is chosen rather than after it is on: some preparations are ruled out on that basis, and how you are positioned and watched while it works changes if fainting is a possibility
• A request for "fractional laser" without naming the device. We do not book it that way. The name covers machines whose recoveries differ enormously, and someone who agreed to "fractional" does not know which one she agreed to. Have the device named in the consent before anything is booked — and ask for it in any other clinic too
• A request to have it before an event, or compressed into a short window. We decline it. The session needs its recovery and the plan needs its intervals, and forcing that ahead of a fixed date is itself what causes harm. What can be done before the event is something else: settling whatever is inflamed, a simple routine, and sun protection
• A request for the strongest settings, one strong session instead of a staged plan, or full-field resurfacing instead of fractional. We decline it. Settings are chosen for your skin type rather than for the heaviest effect available. And full-field resurfacing — which is not the fractional procedure — carries the longest recovery of anything on this page, with a real risk of prolonged redness and of a loss of color that may never even out against the skin around it, and it is rarely appropriate for Fitzpatrick IV to VI
• A request for stretch marks to disappear, or to treat them while your weight is still changing. Striae improve in texture rather than going away, and older white ones respond less than newer red ones. After bariatric surgery, iron and ferritin, zinc, B12, vitamin D and protein status are looked at before any plan is started, because skin in deficit does not heal as it should — and because the hair shedding that goes with it usually weighs more heavily than the striae do
• A request to treat narrow deep scars with laser alone. They respond poorly to it, and they have other steps done point by point that come before the laser or alongside it — see acne scarring

Possible effects

Stated in full, because the decision is not sound without them:

• The expected course itself: redness, heat and swelling, weeping and then crusting, itch and a tight feeling in the skin. This is not a complication — it is what healing looks like after columns of skin have been removed — but it is heavier than many people picture before they go through it, which is why it is said before booking
• Post-inflammatory hyperpigmentation: the commonest of them on this skin, set out in the Honestly section at the top of this page, and completed by the note on darker skin below
• Infection on a wide open surface, bacterial or fungal, or a herpes flare across the resurfaced skin. Clustered painful blisters, pain that increases instead of easing, spreading redness, pus, or fever: a same-day appointment, not reassurance and not waiting for the next one — and out of hours, the nearest emergency department
• Prolonged redness that persists after the crusts have gone and lasts longer than you were told to expect. It usually settles, and it needs patience and review rather than being left unassessed
• Loss of color in places, meaning patches paler than the skin around them, which can appear late — after everything looked healed. It is slower to change than darkening, and the color may not even out. With pale stretch marks in particular: they can become more noticeable after treatment rather than less, and that is said before starting
• A new scar, or thickening of one that had settled — uncommon, and associated with energy or density that did not suit the skin type, with infection or a herpes flare across skin that is still healing, with crusts lifted before they were ready, and with steroid-thinned skin that ablates deeper than the settings predict
• The eyes: internal metal shields are mandatory for eyelid work, and wavelength-specific eyewear is worn by everyone in the room for every pulse. Any eye pain, blurring of vision or sensitivity to light after any session — wherever on the body the laser was aimed — needs assessment the same day, and out of hours the nearest emergency department
• The numbing cream itself: strong preparations over wide areas and under an occlusive cover carry a genuine risk of systemic toxicity, which is why it is applied and timed inside the clinic and is not dispensed for use at home. Do not buy numbing cream and apply it yourself before you come, and do not cover it with plastic wrap or a dressing — a strong cream, a wide area, and something sealed over the top is the combination that makes it dangerous. If that has happened and you feel numbness around the mouth, a metallic taste, ringing in the ears, dizziness, blurred vision, or unusual drowsiness or agitation: wipe it off at once, wash it away, and go to the nearest emergency department
• Some areas not responding as much as hoped even after what was agreed is complete. The assessment is then redone against the photographs and the plan adjusted, rather than the same session repeated in hope

A note on darker skin

Most of the skin treated here is Fitzpatrick III to VI, and skin type is judged for each individual in the clinic, never inferred from nationality. What the Honestly section above does not say is that the name "fractional" covers devices whose risk on darker skin differs enormously, and that alone changes the answer. Full-field resurfacing — which is not the fractional procedure — is the heaviest of them, and is rarely appropriate for Fitzpatrick IV to VI, because the loss of color after it may never even out against the skin around it. Then ablative fractional CO2: the deepest, the longest to recover from, and the one that leaves the most residual heat. Then fractional erbium: it removes tissue too, but more superficially and with less residual heat, so its recovery is usually shorter and its tightening less — and it is still fully ablative, with a real healing time. Then non-ablative fractional laser, which heats the columns without removing the surface, and whose recovery is lighter rather than absent — and even that is not free of cost: the superficial wavelength used for pigment — thulium 1927 nm — is recognized as a trigger for the very darkening it is aimed at on deeper skin. What is adjusted for this skin: lower density, wider spacing, longer intervals between sessions, cooling that is not optional here, and a small test area treated first and then waited on — bearing in mind that a test area lowers the risk without giving clearance, since a pigment reaction can appear late after the test looked fine. Three further things belong to these skin types: a tendency to keloid is more common in them and changes the plan on its own; loss of color, where it happens, shows more plainly and is slower to change, and pale stretch marks can become more noticeable afterwards; and small benign spots and growths — including the dark dots commonly seen across the cheeks and temples — are treated with very light settings and a test area, because each dot treated can leave a pale or dark mark in its place. Any mole or tattoo inside the treatment area is covered before the first pulse. And the line in the advertising that a device suits every skin tone is not a reason to raise the energy.

Afterwards

• Care for the skin exactly as you were told to: gentle washing, an ointment that keeps it moist, and do not let it dry out and crack. After a session the skin is a wide superficial wound and is treated as a wound rather than as skin
• Let the crusts come away on their own. No picking, no rubbing, no exfoliants, no loofah, and no threading or waxing of the area until you are told it is allowed. Whatever is lifted by hand leaves color or a scar in its place
• Sun protection daily on the area, indoors as well. Here it is part of the treatment itself: light is what fixes the darkening the skin may pass through after a session
• Put no lightening cream, no mixed cream and nothing you were not given on a face that is healing. If you notice darkening, message us before you apply anything — unlabeled mixed creams make it worse
• Tell us the same day about: clustered painful blisters, pain that increases instead of easing, spreading redness, pus, or fever. Do not wait for the next appointment, and out of hours go to the nearest emergency department
• Tell us the same day about any eye pain, blurring of vision or sensitivity to light after any session, wherever on the body the laser was aimed
• Report any darker patch as soon as you notice it, not at your next appointment. It is treatable, and it is more straightforward the earlier it is seen
• Report an area that has stayed red beyond the period you were given, or that is starting to rise, thicken and itch. A thickening scar is more manageable at its beginning
• Tell us before the next session about anything that changed: a new medicine, isotretinoin, pregnancy or breastfeeding, a cold sore, threading, waxing or sugaring of the area, or a change in your diabetes control. The screening is repeated before every session and is not taken once at the first visit
• Photograph the area in the same light and from the same angle before each session, and come to the review appointment even if you think nothing has changed. The interval between one session and the next is a decision made at that appointment, not a period that passes on its own

Honestly

The downtime is real: days of redness, crusting and swelling. Post-inflammatory hyperpigmentation after fractional CO2 is common rather than rare in Fitzpatrick IV–VI, the medium and deeper skin tones. It means patches darker than your own skin tone in the areas that were treated, and it usually appears weeks after the session rather than the next day. It normally fades gradually, though it can take time and may need treatment to help it along. What lowers the chance: preparing the skin beforehand when the examination calls for it, avoiding the sun and using sunscreen daily before and after, and settings chosen for your skin type rather than for the strongest effect. If you notice darkening after a session, message us before you reach for a lightening cream — unlabeled mixed creams make it worse. Skin threaded or waxed in the last few days, skin thinned by an unlabeled mixed cream, and uncontrolled diabetes each postpone the session rather than merely change the settings.

Common questions

See also

Nd:YAG laser, IPL photorejuvenation, Tattoo removal, Skin tightening