Lumenis Ultrapulse fractional CO2 Laser Treatments

The carbon dioxide laser is the gold standard in improving skin texture and wrinkles

Article Medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)

Dr. Gavin Chan

Templestowe Lower and Berwick Clinics

Dr. Gavin Chan has a background in intensive care, anaesthesia, and emergency medicine. Since 2004, Dr. Chan has provided cosmetic procedures, including anti-wrinkle injections, dermal fillers, liposuction, fat transfer, skin needling, and laser treatments. He is a doctor trainer for various dermal fillers and anti-wrinkle injections.
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Quick Facts

  • The Lumenis Ultrapulse carbon dioxide laser uses tiny columns of laser energy to resurface skin.
  • It can be used to treat wrinkles, acne scarring, other types of scarring (including burns scars), skin pigmentation and skin sallowness and helps to tighten skin. It can also be used to treat off-face areas such as the hands, neck and decolletage.
  • The laser can be used in fractional mode, which reduces downtime and risk by treating a ‘fraction’ of the skin through the use of special handpieces that fire small columns of laser into the skin, leaving spaces in between.
  • Treatments with this laser can be done with the Active Fx hand piece, Deep Fx hand piece, or both hand pieces (Total Fx) depending on the type of problem that needs to be treated
  • Treatments can be done at various energy levels to tailor the results and downtime accordingly
  • The Lumenis Ultrapulse carbon dioxide laser is a highly effective laser for skin resurfacing,  and can be used in fractional mode or non-fractional mode.

What is a carbon dioxide laser?

Carbon dioxide (CO2) lasers have been used for many years to resurface skin. Typically, they are used to improve skin texture and tone, reduce wrinkles, remove sun damage and pigmentation, and to tighten skin on the face. They work by removing a fine layer of skin as well as heating the skin. This remodels the skin’s collagen, and this leads to significantly smoother, firmer, and more even-toned skin.

Despite the dramatic results, there are many downsides to treatment with traditional carbon dioxide lasers. The risk of traditional carbon dioxide laser treatment includes prolonged recovery periods, gradual loss of skin pigmentation, and a relatively high risk of scarring in comparison to non-ablative lasers.

The Lumenis Ultrapulse laser, however, is a carbon dioxide laser that uses fractional laser technology to effectively resurface skin with fewer risks and less downtime than with traditional carbon dioxide lasers.

Click here to read a real patient diary when she has carbon dioxide laser resurfacing.

Case Study 1

This 57 year old female presented to The Victorian Cosmetic Institute with concerns about her skin texture, wrinkles, skin pigmentation, and a naevi (mole) on her lower right cheek/jowl area. She had a high energy Total Fx treatment (see below) with the Lumenis Ultrapulse CO2 laser. This was done under light intravenous sedation and local anaesthetic. The recovering picture shows the patient’s face after 2 days. The total downtime was approximately 10 days in this case.

She also had dermal fillers and anti-wrinkle injections in addition to the laser.


fractional CO2 Laser Treatment before

fractional CO2 Laser Treatment after

fractional CO2 Laser Treatment post procedure


Traditional CO2 lasers were introduced just over 20 years ago. These machines were commonly used at very high levels, and with significant risk and downtime, could achieve some dramatic results.

The relatively recent introduction of fractional laser technology has revolutionised laser treatments. Fractional lasers fire small columns of laser into the skin, leaving intact skin in between to help healing and reduce risk and recovery periods. The Lumenis Ultrapulse is a fractional carbon dioxide laser, and has some significant advantages over traditional carbon dioxide lasers.

The advantages of the Lumenis Ultrapulse laser are that treatments can be more accurately tailored to suit the skin type, skin problem, and total downtime allowed.

Being fractional in nature, the percentage of skin treated can be varied by from 5 to 100%. The percentage coverage determines recovery time to a large extent. Secondly, the depth of penetration can also be varied to treat various skin conditions.  The smaller the ‘spot size’ (diameter of the laser columns fired) the deeper the penetration of the laser. The spot size on the Lumenis Ultrapulse is either 0.15mm (Deep Fx handpiece) or 1.3mm (Active Fx handpiece) in diameter. If deeper skin conditions such as acne scarring are to be treated, the Deep Fx handpiece is chosen, and the laser penetrates deeper into the skin to reach the area of concern. Conversely, if skin conditions such as skin texture are to be treated, then the Active Fx handpiece, which penetrates only superficially, is used.

In summary, the main differences are;

Traditional carbon dioxide laser
Lumenis Ultrapulse fractional carbon dioxide laser
Fully ablates skin in the treatment area Fires columns of laser energy into the skin, leaving intact healthy skin adjacent to these columns
Shallow penetration into the skin Deeper penetration into the skin
Prolonged recovery periods Shorter recovery periods
May require dressings to be applied No dressings required
Higher risk of scarring Low risk of scarring
Progressive hypopigmentation (over-whitening of skin) Significantly reduced risk of hypopigmentation

In summary, fractional laser technology is a balance to achieve the best results possible whilst reducing potential complications and recovery time. For those who have severe/deep wrinkling or skin problems, the laser can also be set to treat 100% of the skin surface (non-fractional treatment).

This laser treatment is for those people wanting skin resurfacing for the face, neck or body. Most commonly, the face, neck, decolletage, and hands are treated.

Most people who present for carbon dioxide laser treatment have a degree of concern about the effects of ageing and accumulated UV exposure on their skin.

Laser resurfacing with fractional carbon dioxide lasers can treat a number of skin concerns. It can be used to improve skin texture, reduce wrinkles, improve acne scars and other scars, reduce sun-induced skin pigmentation, and to reduce skin sallowness. It can also help to tighten skin.

Because the carbon dioxide laser is able to ablate (vapourise) skin tissue, certain skin lumps and bumps can be treated with this laser, including benign naevi (moles). See case study 1 for an example of this.

Rhinophyma, an enlargement of the sebaceous glands on the nose that leads to a bulbous nose, can also be treated with the carbon dioxide laser. Rhinophyma is usually caused by an underlying skin condition called rosacea. The carbon dioxide laser can ablate the excessive sebaceous tissue and return the nose to its normal size and shape.

Finally, we have also been using this laser to treat burn scars and other scars such as surgical scars or traumatic scars. Using the Deep Fx (deeper penetrating fractional handpiece), we have achieved a significant improvement in scar texture, colour, and skin flexibility. Laser helps to remodel the scar tissue. Also, topical cortisone (Kenacort) is applied to the skin post-laser, and this infuses into the channels created by the laser. The cortisone helps to reduce scar tissue activity and improve the appearance and flexibility of the scar. The laser therefore also not only remodels the scar, but provides a conduit for the delivery of medication through to the scar tissue. This may be a preferred alternative to injecting cortisone, which can, when delivered this way, cause atrophy of the scar or fat resulting in an indentation in the area. Recovery from this treatment for scars is significantly less than the recovery from skin resurfacing for wrinkles using the same laser.

We recommend those who are pregnant, breast-feeding, are prone to keloid scars, and those who have taken isotretinoin (Accutane, Roaccutane) in the past 6 months to avoid treatment.

The laser can also be used on most skin types from fair to dark, however, darker skin types may not be able to be treated with as aggressive settings as the fairer skin types due to the increased chance of darker skin types to have pigmentary disturbances post-laser.

Active Fx and Deep Fx are the names of the two hand pieces that can be utilised with the Lumenis Ultrapulse laser.

The difference between the two hand pieces is primarily in the size and depth of the columns of laser fired. The Active Fx hand piece emits laser columns with a diameter of 1.3mm and a depth of up to 0.2mm. The density or percentage of area covered by the laser ranges from 50 to 100%. Therefore, the Active Fx hand piece is used for the treatment of more superficial skin problems such as fine wrinkles, superficial sun damage, pigmentation, and skin sallowness.

The Deep Fx hand piece emits laser columns with a diameter of 0.15mm but these penetrate to a depth of up to 2mm. The density or percentage of area covered by this laser is much less, and ranges from 5 to 25%. This hand piece is therefore used for the treatment of deeper problems within the skin such as deep wrinkles, and acne (indented) scarring. The depth of penetration also induces significant skin tightening which is good for the treatment of the skin around the mouth and eyes.

Total Fx is simply the sequential use of the Active and Deep Fx hand pieces on the same areas of skin in one session. By utilising both hand pieces on one area, you can combine the benefits of both hand pieces and achieve results better than treating with one hand piece alone. The recovery period however is prolonged in comparison to treatment with a single hand piece.

The first step of treatment involves preparing the skin for laser treatment. A good skin care regime with medical grade ingredients, especially topical retinoids, before laser can help improve the results achieved from laser as well as reduce the potential side effects. Topical retinoids can help to improve skin turnover and have been shown, if used for at least two weeks prior to laser resurfacing, to reduce the time of re-epithelialisation (regeneration and reformation of skin). For those with darker or olive skin types, preparation with a topical lightening agent such as hydroquinone may help to reduce complications such as post-inflammatory hyperpigmentation (darkening of the skin in the treated areas as a result of treatment).

In some cases, a test patch may be done to help determine the level of energy to be used as well as the possible skin response to the laser. This is usually done in more olive or darker skin types to help predict the possible outcomes. It is also performed in an inconspicuous area if possible.

Especially for heavier treatments, anti-viral medications or antibiotics may need to be taken prior to the procedure to prevent infections.

The anaesthesia for the treatment will depend on the level of treatment and the hand pieces used. For lighter treatments, a topical anaesthetic agent may be used without any other forms of anaesthesia. This will need to be applied at least 30 minutes prior to the onset of the procedure. For stronger treatments, it may be necessary to use topical anaesthetic agents in conjunction with nerve blocks/injectable anaesthesia. Deep Fx treatments tend to require more anaesthesia or stronger forms of anaesthesia in comparison to the Active Fx treatments. Intravenous sedation is also a good option for stronger treatments, and this can help to reduce any discomfort of the procedure. It is also possible to use sedation with lighter treatments for those who would prefer the least possible discomfort.

The treatment with the laser takes approximately 30 minutes (not including anaesthetic) for a full face or neck/decolletage . The area is systematically covered  by the laser. Both or either of the Active Fx or Deep Fx hand pieces can be used. During the treatment your eyes will be covered with gauze, and for treatments within the orbital rim (within the bone surrounding the eyes), corneal shields may need to be inserted under the eyelids to protect the eyes.

The treated areas appear red and swollen after the treatment, and the small columns of laser can be seen on the face in a grid-like pattern of dots. The treated areas also feel quite hot after the procedure. To reduce this, we offer you a Zimmer cooler, a machine which blows cold air through a hose that can be directed at the areas to be treated.

Click here to read a real patient diary when she has carbon dioxide laser resurfacing.

Full recovery takes from 4 to 14 days approximately depending on the level of energy used in the treatment (this can be tailored to your requirements). Off-face areas usually take longer to heal, and usually only lower energy levels can be used for these areas.

There is a period where the skin appears quite red. Usually this subsides within 1 week in lower energy level treatments, but may take up to one month to fade for more aggressive treatments. Swelling of the face/eyes may occur for a few days, and sleeping on a 45 degree angle or greater can help to reduce this. There may be a mild acne-like break out (small white pustules) on the face after 3 days as the skin regenerates. The skin may scab, peel and flake and this occurs over one week.

Vaseline or Rescue Balm (Cosmedix) needs to be applied post treatment until the skin peels, and then a normal moisturiser can be used. Sun avoidance is important post procedure to help reduce the chance of pigmentation changes post treatment, or more specifically, darkening of the treated areas.

Anti-viral medications or antibiotics may need to be taken post-treatment, depending on the depth of your treatment, and we closely monitor you for any signs of infection.

Generally the post-treatment recovery period will depend purely on the level of the treatment, and therefore we are able to tailor the recovery time to match the time you can afford to take off your normal activities.

Click here to read a real patient diary when she has carbon dioxide laser resurfacing.

There are other fractional carbon dioxide lasers from other manufacturers, however, at 60 watts, the Lumenis Ultrapulse is the most powerful. The other fractional carbon dioxide lasers including the Deka Smartxide, the Medart 610 laser, Ellipse Juvia, and the Fraxel re:pair laser. However, we have chosen the Lumenis Ultrapulse because of its superior flexibility and power to the other fractional carbon dioxide lasers.

The Fraxel re:store laser is also a fractional laser, but not a carbon dioxide laser. Instead this laser emits laser energy at 1550 nanometres. At this wavelength, no tissue is actually ablated (vapourised) and only tissue heating occurs. This can help with problems such as acne scarring, but tends to be a less effective treatment than fractional carbon dioxide laser which both ablate and heat tissue to maximise the results.

Pearl fractional (2790 nanometres) and Pixel (2940nm) are also both fractional lasers, but again are not carbon dioxide lasers. The laser wavelengths of these two machines tend to ablate columns of skin, but unlike fractional carbon dioxide lasers, do not heat the skin to any large extent. As it is the heating which causes collagen contraction/skin tightening, these two lasers are limited as they do not cause much skin heating.

Dr. Gavin Chan
Dr. Gavin Chan

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