The Ultimate Guide to Fractional Lasers by an Aesthetic Doctor in Singapore (2020)

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Having smooth skin that is free of acne scars and wrinkles is the dream of many. There is little we will not do to achieve skin that becomes the envy of others.

As an aesthetic doctor who specialises in customised laser treatments, I have written this article about fractional lasers to help guide you in choosing which fractional laser treatment works best for you. 

What is a laser?

The term “laser” stands for Light Amplification by Stimulated Emission of Radiation.

Medical lasers are medical devices that use precisely focused light sources to treat or remove tissues [1].  Lasers are used in many types of surgical procedures. Some example includes:

  • Cosmetic surgery
  • Refractive eye surgery
  • Dental procedures
  • General surgery

What is a fractional laser?

Fractional laser therapy is a non-invasive treatment that uses a device to generate thousands of microscopic treatment zones by scanning the target area, radiating a fraction of the skin at a time. This is similar to a photographic image being enhanced or altered pixel by pixel. The tissues surrounding the microscopic treatment zones remain healthy and untreated and thus supporting the wound healing process [2], [3], [4]. 

The well known fractional laser marketed was the Fraxel® device, which emits a non-ablative 1550-nm wavelength. There are now some machines available that use fractional technology, based on erbium: YAG lasers for superficial treatments and CO2 lasers for deeper ablative treatments.  for example:

  • Fraxel Repair [Solta Medical]
  • Active and Deep FX [Lumenis]
  • Quadralase [Candela]
  • Pearl Fractional [Cutera]). [5]

What can fractional lasers treat?

Fractional laser treatment is used for the treatment of [6]:

  • Wrinkles
  • Rhytids
  • Fine lines and texture irregularities (furrows)
  • Reduction/ removal of uneven pigmentation
  • Acne scars

Although doctors advocate fractional laser to treat pigmentation disorders such as melasma, the treatment itself can lead to post-inflammatory pigmentation.

Fractional laser treatment can be used on any part of the body but is particularly useful on the neck, chest and hands when compared to traditional ablative modalities. Fractional laser treatment may also be useful in the treatment of sun-aged skin (poikiloderma of Civatte) and stretch marks.

Fractional laser treatment can be used on all skin types and patients, but techniques can vary depending on your age, skin type, sun exposure and body location. Fractional laser treatment can be safely combined with surgery and other skin treatments. 

What can I expect during a fractional laser treatment?

Pre-treatment skin preparation

Your aesthetic doctor may start you on a series of skin treatments to prepare your skin. These treatments often begin 2 weeks or more before your scheduled procedure. These skin treatments are customised to go well with your particular skin type to minimise complications and obtain the best result from your laser resurfacing.

Cosmetic laser resurfacing is usually done on an outpatient basis and should take between 30 minutes and 1 hour to complete.

Managing your discomfort

Laser skin resurfacing can be painful. This is why your doctor will numb the skin with local anaesthetics. You may also receive a sedative to help you relax. If you opt for extensive resurfacing, or if you have other cosmetic procedures at the same time, your surgeon may prescribe general anaesthetic instead. Afterwards, the doctor will prescribe painkillers to keep you comfortable. During the preparation, your face will be thoroughly cleaned and you might be given eye protection.

After the procedure

After laser resurfacing is completed, your doctor will proceed with cooling treatment and/or special topical treatments to optimise healing.

What are the different types of fractional lasers?

Various kinds of lasers are available; they are differentiated by the medium that produces the laser beam. Each of the different types of lasers has a specific range of utility, depending on its wavelength and penetration.

Ablative Fractionated Lasers

  • CO2

Used to treat deep textural scars like hypertrophic scars, the CO2 laser has carbon dioxide gas as its medium and emits energy at 10,600 nm [7]. It has the longest wavelength of all the lasers on the market and is used to target water in abnormal collagen several millimetres below the surface of the skin.

  • Erbium Yag

Erbium: YAG lasers are used to reduce mild to moderate wrinkles (rhytides) and depressed marks on the skin (textural scars). YAG lasers cause minimal residual thermal injury to underlying skin tissue, which leads to less chances of persistent post-treatment redness and changes in pigmentation compared to the CO2 laser. Ablative laser resurfacing typically takes between 30 minutes and two hours, depending on the technique used and the size of the area [8]. 

YAG lasers typically emit light with a wavelength of 2940nm, which is strongly absorbed by water compared to another laser wavelength. 

 

Non-ablative Fractionated Lasers

  • Erbium: Glass 

When compared with the CO2 laser, the erbium laser is gentler because the operator can treat layers of skin far thinner than with the CO2 laser. Erbium: Glass has a wavelength of 1540nm. 

  • Thulium lasers

The thulium fibre laser (Tm: Fiber) is commonly used to treat melasma and mild to moderate photodamaged skin.  It is good for superficial epidermal indications such as pigmentations as it has a low absorption coefficient with a wavelength of 1927nm. 

  • Diode lasers

The 1450nm diode laser is effective for the treatment of facial acne as well as for improving the appearance of scarring. This non-ablative laser has been shown to dramatically and safely improve inflammatory facial acne by partially damaging sebaceous glands to reduce sebum secretions. 

Non-ablative fractionated laser treatment takes 20 minutes - 2 hours depending on the technique used and the size of the area.

Radiofrequency Systems

Fractional Radiofrequency with micro-needling

RF systems are great treatments to treat atrophic acne scars, improve skin texture/rhytides and reduce pore size. The treatment time ranges from 5 - 10 minutes per unit area [9]. Much like laser systems, the RF systems achieves results by denaturing existing collagen, stimulating the production of newer and shorter collagen for tissue tightening, fibrous band destruction, and subcutaneous fat reduction. Fractional RF with micro-needling is a technology that uses insulates sharp microneedles to heat the depth of the dermis, which promotes dermal collagen remodelling. 

Combination platforms

There are laser machines or energy devices which combine technologies or mediums to generate different laser wavelengths to target specific skin chromophores. These procedures take 15 - 30 minutes. For example:

  • Fraxel Dual (a combination of 1927nm and 1540nm)
  • Fotona Dynamis Pro (a combination of 1064nm and 2940nm) 
  • and many more

What are the downtimes for fractional lasers?

Non-ablative lasers often require no downtime at all, while ablative lasers can require a 2 to 3 weeks healing process, depending on depth, before the new skin has healed completely and final results are obvious. 

What are the costs of fractional resurfacing laser treatments in Singapore?

These are the cost of fractional resurfacing laser treatments in Singapore [10]:

 

Types

Treatment Names

Cost

Ablative Fractionated Lasers

1. CO2:

- Ecoxel

- EDGE

- MiXTO

- SmartXide

- Fraxel re:pair

- Lumenis

2. Erbium:

- YAG: Lotus 3

- Alma PIXEL

- SP Dynamis

$300 - $1200 

Non-ablative Fractionated Lasers

1. Erb-Glass lasers:

- Sellas Evo

- Mosaic

- Fraxel re:store

2. Thulium lasers:

- Lavieen BB Laser

- LaseMD

3. Diode lasers:

- Clear and Brilliant

$300 - $1500 

Radiofrequency systems

Microneedling RF:

- Infini

- Intracel

$850 - $2500 

Combinations platforms

Combination platforms:

- De Oro Dual

- Fraxel Dual

$300 - $1000

 

Am I suitable for fractional laser treatment?

You are a suitable candidate for fractional laser treatment if:

Your skin tone is light enough (for CO2 laser)

Traditional CO2 lasers can create problems for people with darker skin tones as the increased risk of post-inflammatory hyperpigmentation. Patients with darker skin tone should go for alternative options of non-ablative fractionated resurfacing lasers/radiofrequency systems/combination platforms.

Your problem spots are identified and expectations discussed prior to the procedure

Remember, fractional lasers work only on the upper layers of the skin. Some deep scars or discolouration may be beyond the reach of the laser and often combination treatments needed. 

You have specific kinds of skin issues

Lasers can make a big difference in shallow wrinkles, acne scarring and brown spots. For example, diode lasers can make a lot of improvement in skins with active acne or have abnormal blood vessel formation due to your skin’s response to UV damage. But some skin problems, such as stretch marks or deep wrinkles, do not do as well with other resurfacing lasers

You have problem areas on other body parts besides your face

Fractional lasers can be used to treat problems not only on one’s face but also on other body parts. Fractional resurfacing lasers are commonly used for neck rejuvenation, stretch marks and loose skin reduction post-pregnancy.

Your skin sagginess is not your main concern

Laser resurfacing is capable of tightening skin to some extent, but it will do little to minimise loose, sagging skin in the jowls. For the kind of tightening to remove jowls, your doctor will likely recommend a facelift instead.

You don’t have a severe active acne flare-up 

While laser resurfacing can be very effective in smoothening scars from past acne breakouts, it has been known to exacerbate acne flare-ups after treatment. So people who are prone to frequent acne breakouts may need to reconsider having an intensive laser resurfacing treatment or combine with treatments for active acne breakout. 

You don’t frequently get cold sores

The laser skin resurfacing can make you more prone to cold sores immediately after the procedure. If you are prone to getting cold sores, then your doctor may prescribe antiviral medications to take leading up to your procedure. This will help to minimise the chances of cold sore-related complications.

Are fractional lasers painful?

Often, there will be some discomfort during a fractional laser treatment. Different people will have different experiences of the treatment. Some of my patients say it is merely little more than a ‘pins and needles’ sensation while others say it is a lot more painful than that. To ease the pain, prior to the procedure, numbing cream will be applied. 

It is best for you to avoid caffeine and follow your doctor advice before and after your fractional laser treatment to reduce any related discomfort.

How safe are fractional lasers?

Fractional laser treatment appears to be well-tolerated by most patients. You can apply tinted sunscreen or mineral make-up soon after treatment. Usually, you can return to work directly after treatments or on the following day, depending on your skin condition and treatment intensity.

How long does the effect of fractional lasers last?

Most atrophic scars improve permanently. For photoaging skin, how long the result will last depends on how well you protect your skin from the sun and your genetic ageing process. If you apply sunscreen and wear sun-protective clothing, your skin will look good longer than if you are tanning, including tanning booths, or spend a lot of time outdoors. If you are careful with your skin, your skin should continue to look good with regular maintenance treatments.

What are the risks and side effects of fractional laser treatments?

Fractional laser skin resurfacing possible side effects:

  • Redness, swelling and itching: Treated skin may become itchy, swollen and red. The degree of redness depends on the depth of the treatment and can be intense and lasting for several months. The aggravation of a previously existing skin condition, such as rosacea, can contribute to redness.
  • Acne: Applying thick creams and bandages to your face after treatment can worsen acne or cause you to temporarily develop tiny white bumps (milia) on the treated skin.
  • Infection: Laser resurfacing can lead to bacterial, viral or fungal infections. The most common infection is a flare-up of the herpes virus, causing cold sores to appear. In most cases, the herpes virus is already present but dormant in the skin.
  • Changes in skin colour: Treated skin may become darker or lighter than normal (hyper/hypopigmentation). Post-inflammatory hyperpigmentation is more common in people who have darker skin. Topical retinoic acid or glycolic acid can help treat hyperpigmentation after the treated area has healed. Using sunscreen during the healing process is also important. Non-ablative fractional photothermolysis may help improve hypopigmentation.
  • Scarring: Laser resurfacing poses a slight risk of scarring.

What should I take note of during the recovery period?

  • Avoid direct sunlight and keep skin moist and cool to aid healing.
  • Avoid environmental irritants during the healing process (e.g. dust, dirt, aerosols, cleaning agents).
  • Avoid dryness and excessive heat (e.g. high heat on blow dryer; medium heat is ok).
  • Avoid vigorous exercise for 2 weeks.
  • Stay hydrated, eat healthy foods and avoid alcohol.
  • Redness and a sunburn-type sensation will normally last several hours.
  • Neck redness is more persistent and will usually last several days longer than face redness.
  • The face will normally bronze and peel within 3-5 days (note: skin below the neck normally requires up to 2 weeks to bronze and peel).

Right after the treatment:

  • Keep treated areas covered with topical ointment/cream as instructed by your doctor.
  • Apply cooling compresses (note: do not apply ice directly to the skin and do not use towels as detergents may irritate the skin).
  • If you want, you may spray distilled or spring water mist on your skin.
  • You can take painkillers.

On the night post-treatment:

  • Sleep with your head slightly elevated.
  • Place paper towels over the pillow to keep the ointment/cream from getting on the pillow.
  • If you are experiencing irritation to the eye, you may use an eye lubricant.

Day 1 (first day after treatment):

  • Avoid direct sunlight and excessive heat.
  • Begin washing face 2-3 times a day with room temperature water and gentle cleanser.
  • You may take a shower and wash your hair. However, try to avoid using hot water.
  • Re-apply hydration and moisturizers to the treated area. Ensure skin remains constantly moist.
  • Use non-irritating sunblock SPF 30+ with zinc oxide (7-9%) and/or titanium dioxide when going outside.
  • You may apply mineral makeup (powder).

Day 2:

  • Swelling should subside and skin may bronze and feel gritty.
  • Itching, particularly along the jawline, tends to begin on this day.
  • Continue applying ointment/cream and cool compresses if needed.
  • Continue washing face with a gentle cleanser and room temperature water.
  • For extreme itching, hydrocortisone cream (OTC 1%) may be applied. DO NOT pick and/or scratch.
  • Use non-irritating sunblock SPF 30+ with zinc oxide (7-9%) and/or titanium dioxide when going outside.
  • You may apply mineral makeup (powder).

Day 4 - 7:

  • Itching usually subsides during this period.
  • You may start more aggressive washing with fingertips to promote further exfoliation (do not pick).
  • Use non-irritating sunblock SPF 30+ with zinc oxide (7-9%) and/or titanium dioxide when going outside.
  • You may apply mineral makeup (powder).

Day 7 - 28:

  • Continue to use moisturiser until the skin is hydrated to its usual level (3-4 weeks).
  • You may resume your regular skincare regime as long as you do not exfoliate.
  • Continue applying non-irritating sunblock (SPF 30+) and use mineral makeup (powder) to protect treated areas.
  • Avoid exposure to excessive sunlight for up to 4 weeks. Headwear or clothing must be used to protect the treated areas.
  • You may resume exercising.

Why do lasers cause PIH and acne flares after sessions?

Post-inflammatory hyperpigmentation (PIH) is a frequently encountered problem and represents the sequelae of various cutaneous disorders and therapeutic interventions. The pathogenesis of PIH includes an increase in melanin production and an abnormal distribution of this pigment. After trauma or cutaneous inflammation, melanocytes can react with increased or decreased production of melanin, reflected clinically as hyperpigmentation or hypopigmentation. Post-inflammatory hyperpigmentation is probably the most common adverse effect of laser treatments in dark-skinned individuals

Acne-prone patients will be informed that a flare-up may occur after treatment. Some acne-prone patients will be pretreated for 4-6 weeks pre-procedural with topical retinoic acid to minimize the likelihood and severity of a flare-up. If a flare-up does occur, it is most likely due to treatment itself inducing heat and inflammatory response or post-procedural treatment ointment that can clog pores (petrolatum-based) or a combination of two. Topical retinoic acid will be prescribed or restarted as soon as epithelialization is complete if a flare-up does occur.

To summarise

There are many types of fractional laser treatments in Singapore that you can choose from. However, you should be fully informed of treatment expectations, the treatment process, possible risks as well as the things you need to take note of during your recovery period.

I hope this article is helpful to you in choosing the best treatment to achieve the glow that you desire. That being said, if you have more questions regarding fractional laser, you should consult your trusted doctor.

References: 

1. Center for Devices and Radiological Health. Medical Lasers. U.S. Food and Drug Administration. Published 2019. Accessed February 25, 2020.

2. Ahrari F, Heravi F, Hosseini M. CO2 laser conditioning of porcelain surfaces for bonding metal orthodontic brackets. Lasers in Medical Science. 2012;28(4):1091-1097. doi:10.1007/s10103-012-1152-x

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All content posted is for general informational purposes only and is not a substitute for professional medical advice. This Q&A is not a patient consultation and any information provided herein is not intended to replace consultation with a qualified medical professional. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.

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