Combined Fractional Ablative and Nonablative Laser Resurfacing Treatment:A Split-Face Comparative Study

February 2013 | Volume 12 | Issue 2 | Original Article | 175 | Copyright © February 2013

Joel L. Cohen MDa and E. Victor Ross MDb

aAbout-Skin Dermatology and DermSurgery, Englewood, CO bScripps Clinic Carmel Valley, San Diego, CA

Background: Fractional ablative and nonablative lasers are useful tools for facial rejuvenation; however, ablative lasers require a period of downtime during reepthelialization. A procedure that combines both ablative and nonablative lasers may deliver good cosmetic results and reduce downtime or other side effects of treatment.
Objective: The purpose of this study was to compare a combined fractional ablative and nonablative laser procedure to ablative-only procedures for facial rejuvenation. Methods: A total of 8 subjects in 2 study groups received a single, split-face, facial rejuvenation procedure in this study. In group A, we compared a combined procedure using a fractional nonablative 1,440-nm neodymium-doped yttrium aluminum garnet (YAG) laser and a fractional ablative 2,940-nm erbium (Er)-doped YAG laser on one side of the face, and a combined confluent/fractional ablative Er:YAG laser on the other. In group B, we compared the same 1,440/2,940 treatment as group A on one side of the face, and a fractional ablative CO2 laser on the other. Subjects were followed for 3 months to assess side effects and improvement in Fitzpatrick Wrinkle Score and pigmentation.
Results: Improvement in wrinkles and pigment were seen with all techniques in both groups, and results were equivalent. Areas treated with combined fractional nonablative and ablative technique demonstrated fewer immediate side effects.
Conclusion: Facial rejuvenation using a combination treatment of fractional ablative 2,940 and nonablative 1,440 lasers provides improvement in wrinkles and pigment similar to conservative purely ablative approaches. These purely ablative approaches include the Er:YAG laser used in a sequential confluent fractional manner, or fractional CO2 laser alone. Reduced side effects make the combined procedure an attractive option for facial rejuvenation.

J Drugs Dermatol. 2013;12(2):175-178.


Skin resurfacing to rejuvenate photoaged skin and improve the appearance of facial wrinkles was first reported by Fitzpatrick et al1 using an ablative, pulsed carbon dioxide (CO2) laser. The erbium (Er)-doped yttrium aluminum garnet (YAG) laser was introduced later and was associated with less thermal damage.2 Both modalities produced cosmetic improvement for wrinkles, but postoperative downtime remained an unavoidable consequence of the procedure. Fractional ablative and nonablative lasers were later introduced with the goal of producing good cosmetic results with less postoperative downtime.3-5 It was postulated that a procedure that combines both ablative and nonablative treatment modalities may deliver similar cosmetic benefits while reducing the severity of some of the undesired side effects associated with confluent ablative remodeling. This study was conducted to compare a facial rejuvenation technique that combines both fractional ablative and fractional nonablative treatments to procedures utilizing ablative CO2 and Er:YAG lasers alone. Treatment settings were chosen based on previous experience with the respective devices and their associated downtime, ie, settings that historically have shown equivalent times for reepithelialization.


This study was conducted with institutional review board (IRB) approvals from the Allendale IRB (Old Lyme, CT) and the IRB of the Scripps Clinical Research Center (La Jolla, CA). A total of 8 subjects were enrolled in this study, and all subjects provided written informed consent. The study population was divided into 2 treatment arms. Group A (n=6) was conducted at About-Skin Dermatology, Englewood, CO. Group B (n=2) was conducted at the Scripps Clinic Carmel Valley, San Diego, CA. All subjects presented with signs of photodamage in the form of facial wrinkles and/or pigmented lesions. Subjects were randomized via coin flip to which treatment they would receive on which side of the face. Cooling and analgesic options varied and included continuous cold air, topical analgesic cream, local injections of lidocaine, oral benzodiazepines, and facial nerve blocks, which were employed as needed to ease treatment discomfort.

Study Treatments

The 6 subjects in group A received treatment with a fractional nonablative 1,440-nm neodymium (Nd)-doped YAG laser using 2 passes with 50% overlap in the vertical and horizontal directions, a 10-mm diameter “macro” spot size, a treatment energy of 70 millijoules/microbeam (mJ/mb), microspot diameter of 400 ?m, and pulse width of 10 milliseconds (ms). This was followed immediately by 2 passes without overlap of the fractional ablative 2,940-nm Er:YAG laser using a 10 mm × 10 mm spot size at an energy of 5.5 mJ/0.1 mm of each groove, and pulse width 0.25 ms (Palomar ArtisanTM, 1;440 nm, 2940 Groove OpticTM; Palomar Medical Technologies, Inc, Burlington, MA). The width of the groove