Ablative Fractionated CO₂ Resurfacing Yields Excellent Result for Severely Atrophic Traumatic Scar on the Face

The development of ablative fractional resurfacing (AFR) has brought about an effective, well-tolerated method for skin resurfacing. AFR produces results similar to that of traditional ablative laser treatments while reducing the risks, discomfort, and recovery time for the patient. AFR continues to gain traction as an effective treatment for scars through increased collagen expression and modification of the existing collagen architecture.¹ We present a case in which an ablative fractional CO₂ laser was employed for the treatment of a severely atrophic scar on the face.

An otherwise healthy 53-year-old Caucasian female presented to the cosmetic dermatology unit with a history of an atrophic scar on the right cheek. This was the result of a spider bite further complicated by secondary infection. At presentation, the patient’s scar was atrophic, erythematous and depressed. Due to its size and location, it presented a significant psychological burden on the patient. On examination, the scar was 3.0 x 2.5 cm in size with marked atrophy and central depression reaching 2-3 mm (Figure 1a).

The patient was treated with the Fraxel re:pair 10,600 nm fractionated CO₂ laser. After administration of local anesthesia (1% lidocaine with epinephrine), a 7 mm tip was used with a 60 mJ, level 7 setting (25% coverage, 1.4 mm depth). A total of 1.5 kJ was delivered during the initial procedure. One month later, the patient was reevaluated with noticeable improvement in the texture and contour of the scar. The scar was less noticeable, less depressed and less atrophic. The patient was treated a second time with the same treatment settings, again delivering a total of 1.5 kJ. The patient received two more treatments, each at one-month intervals, using identical settings. Continued interval improvement was noted at subsequent treatments, and there was marked overall improvement in scar size, skin contour and texture one month following the fourth treatment. The area was smooth, no longer depressed, and blended well with the surrounding tissue (Figure 1b). Post-procedure care included vinegar water soaks for 10 minutes every two hours for the first 48 hours, along with regular application of petrolatum to the treated area for 5 days. A ceramide-based cream was recommended for use starting on post-operative day three.

One month following the final AFR treatment, the lesion was treated with a 595 nm V-beam pulsed dye laser (PDL) for residual erythema. Treatment settings for this procedure were 10 J/cm², 10 ms pulse duration, and a 7 mm spot size. The patient followed up in clinic 2 weeks after the procedure with marked improvement in erythema, resulting in overall excellent cosmetic improvement for the original scar.

In this case report, we present excellent cosmetic improvement following the treatment of a severely atrophic scar on the face with a series of four AFR treatments using the Fraxel re:pair CO₂ laser. This case highlights the effectiveness and utility of AFR in treating large, disfiguring atrophic scars. Our patient experienced marked improvement in scar texture, contour, and overall appearance. Combined treatment with PDL resulted in further blending of skin coloration and overall improved cosmesis.

Fractionated CO₂ resurfacing has been shown to be effective in many clinical scenarios, including the treatment of acne, burn, traumatic and surgical scars, chronic wounds, severe photodamage, and deep rhytides.^1-4 AFR devices, such as the CO₂ laser used in this case report, emit energy in a pixilated manner which produces fractional thermolysis, or ablative (destructive) damage. This creates small columns of thermal injury called microthermal zones (MTZs). Vaporization of these MTZs within the designated treatment area results in standing reservoirs of unaffected columns of skin that allow for rapid healing. This is partially accomplished through the