Article medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)
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.
Updated 4 July 2020
- 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.
- It can be used to treat wrinkles, improve sun-damaged skin, reduce skin pigmentation, and tighten skin.
- In fractional mode, it can be used to treat acne scarring and other types of scarring (including burns scars).
What is a carbon dioxide or CO2 laser?
The carbon dioxide (CO2) laser has a 10600nm wavelength that is attracted to water in the skin. Water is one of the main constituents of the skin. When the laser interacts with the skin, it vapourises a layer of skin as well as causes some heating of the skin. This laser has been used for many years to resurface the skin and to reverse the effects of ageing and sun exposure. It improves skin texture, reduces wrinkles, and reduces pigmentation caused by sun exposure.
What is the difference between fractional and non-fractional treatment with the CO2 laser?
In non-fractional or full-field mode, the laser treats 100% of the skin’s surface. This removes layers of the skin’s surface and with it removes wrinkles, pigmentation and sun-damaged skin. More than one pass of the laser can be performed for greater results. This treatment is the gold standard in skin resurfacing but requires a significant amount of recovery time. Click here to read a real patient account of her non-fractional carbon dioxide laser resurfacing.
In fractional mode, columns of laser energy are fired into the skin leaving untreated skin in between. This reduces the recovery period required at the expense of the results achieved.
It is also possible in fractional mode to fire laser columns deeply into the skin. This is useful in the treatment of scarring, where deeper collagen remodelling is required.
Finally, fractional CO2 can be used to create deep channels in the skin to deliver drugs such as cortisone. This is effective for hypertrophic or keloid scarring or burns scars. The cortisone reduces the excess collagen production in scar tissue and improves the appearance of the scarring.
Case Study - full face high-level non-fractional CO2 laser resurfacing
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 non-fractional high-level treatment with the Lumenis Ultrapulse CO2 laser. This was done under intravenous sedation and local anaesthetic. The recovering pictures show the patient’s face after 2 days and after 1 month. The social downtime was approximately 10 days in this case. The residual redness took several weeks to disappear.
What is Active Fx and Deep Fx?
Active Fx and Deep Fx are the names of the two handpieces that can be utilised with the Lumenis Ultrapulse laser.
The difference between the two handpieces is primarily in the size and depth of the columns of laser fired. The Active Fx handpiece 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 handpiece is used for the treatment of more superficial skin problems such as fine wrinkles, superficial sun damage, pigmentation, and skin sallowness.
The Deep Fx handpiece 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 handpiece is therefore used for the treatment of deeper problems within the skin such as atrophic (indented) acne scarring.
What is the difference between the modern CO2 laser technology and older CO2 lasers?
CO2 lasers have been used for resurfacing the skin for over 30 years. The treatments were previously more aggressive due to the machines being less adjustable than today’s CO2 lasers.
The introduction of fractional technology has improved both the flexibility and uses of the CO2 laser. Fractional lasers fire small columns of laser into the skin, leaving intact skin in between to help with healing and reduce the risk and recovery from the laser. The Lumenis Ultrapulse carbon dioxide laser can be used in fractional and non-fractional modes. This provides a significant advantage to the traditional carbon dioxide lasers.
In fractional mode, 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. For non-fractional treatments, the Active Fx handpiece can be used to cover 100% of the skin.
In summary, the main differences are;
|Traditional carbon dioxide laser
||Lumenis Ultrapulse carbon dioxide laser
|Fully ablates skin in the treatment area||Can be used in fractional or non-fractional modes|
|Shallow penetration into the skin||Depth of penetration into the skin is adjustable
|Prolonged recovery periods||Potentially shorter recovery periods
|May cause a waxy unnatural appearance to the skin||More natural-looking results|
|Higher risk of scarring||Lower risk of scarring
|Progressive hypopigmentation (over-whitening of skin)||Significantly reduced risk of hypopigmentation
Video Case Study
Am I a candidate for treatment? What can be treated with this laser?
Laser resurfacing with the CO2 laser 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.
The non-fractional, high-level CO2 treatments with the Active Fx handpiece are generally restricted to the face only and for those with fairer skin types. This gold standard treatment for improving facial wrinkles, sun damage, and tightening the skin.
Fractional CO2 with the Active Fx handpiece is most commonly used as a lower-intensity treatment for the same concerns but has less downtime and risk.
Fractional CO2 with the Deep Fx handpiece (the deeper penetrating fractional handpiece) is used for scarring and can be used on fair to darker skin types. Using the Deep Fx, we have achieved a significant improvement in scar texture, colour, and skin flexibility. Laser helps to remodel the scar tissue. Also, topical cortisone (Kenacort) may be applied to the skin post-laser for hypertrophic or keloid scars, 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.
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).
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.
Who cannot have treatment with this 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 non-fractional settings as the fairer skin types due to the increased chance of darker skin types to have pigmentary disturbances post-laser.
What does treatment involve?
The first step of treatment involves preparing the skin for laser treatment. A good skincare regime with medical-grade ingredients can help to prepare the skin. Topical retinoids used on the skin prior to laser resurfacing can help to improve skin turnover and have been shown to reduce the time of re-epithelialisation (regeneration and reformation of skin) post-laser.
Especially for non-fractional high-level treatments, anti-viral medications or antibiotics may need to be taken prior to and after the procedure to prevent infections.
The anaesthesia for the treatment will depend on the level of treatment required. For lighter treatments, a topical anaesthetic agent may be used without any other forms of anaesthesia. This will need to be applied at least 60 minutes prior to the onset of the procedure. Non-fractional high-level treatments are mostly performed under general anaesthetic.
During the treatment, your eyes will be covered, and for treatments around the eye area, 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 the 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.
What happens after treatment?
Full recovery takes from 4 to 14 days approximately depending on the level of energy used in the treatment and whether the laser is used in fractional or non-fractional mode. Off-face areas usually take longer to heal than the face, and only fractional treatments at lower settings 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.
For high-level non-fractional treatments, the skin’s barrier is significantly compromised. Vaseline needs to be applied consistently post-treatment until the skin re-epithelialises. Usually, for these treatments, we advise face washing and re-application of Vaseline 3 times a day. Anti-viral medications or antibiotics are required for this treatment, and we closely monitor you for any signs of infection. On average 7-10 days at home are required to recover from the high-level non-fractional treatments.
Fractional CO2 laser treatments typically take a lot shorter time to recover. The recovery time will depend on the percentage of skin coverage as well as the intensity at which the laser is set.
What is the difference between the Fraxel, Pearl fractional other fractional lasers, and the Lumenis Ultrapulse laser?
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.