Apr 15, 2025

Where’s the beef?

Preparation and precision are key for fractionated resurfacing laser treatments.

Cosmetic dermatology has come a long way since the original meat slice and meat juice facial — a popular trend influenced by Elizabeth Amali Eugenie, better known as Queen Sisi (1837–1898), wife of Austrian Emperor and King of Hungary, Franz Joseph I.

For Gabriela Maloney, DO, FAAD, a dermatologist with Forefront Dermatology in Brookfield and Oconomowoc, Wisconsin, fractionated resurfacing laser is a much better alternative. Not only is it her “favorite device,” she said fractionated resurfacing laser remains the gold standard for treating wrinkles, scars, and other textural irregularities, if performed correctly and safely.

Gabriela Maloney, DO, FAAD“It can be life-changing for patients,” Dr. Maloney said. “The primary goal of fractionated resurfacing lasers is to rejuvenate the skin by creating controlled microthermal zones of injury, stimulating the body’s natural healing process. This approach promotes collagen remodeling and regeneration while leaving surrounding tissue intact, which accelerates healing and minimizes downtime.”

According to Dr. Maloney, the lasers are widely used for scar revision, including acne scars, surgical scars, and stretch marks, as well as for mild skin tightening to address early signs of laxity. It can correct pigmentation irregularities, such as sunspots, melasma, and post-inflammatory hyperpigmentation, while enhancing overall skin tone and radiance.

A look at the technology

Fractional laser resurfacing uses microbeams to create a pixilated pattern of small columns of thermal damage called microthermal treatment zones (MTZ). Dr. Maloney offers the following tips for fractionated resurfacing laser settings:

Higher energy (mJ): Deeper penetration; more collagen remodeling, better for scars.
Higher power (W): Faster treatment, but not necessarily deeper. Can increase thermal damage.
Density: A percentage of skin covered by the laser micro beams per pass.
Higher density (%): A more aggressive setting that covers more thermal zones per cm2. The entire treated area is regenerating at a more consistent rate, leading to a more uniform recovery. There are more regenerative cells available close to each injury site, which offers faster resurfacing. Downtime is longer and there is a more intense inflammatory response.
Lower density (%): A lighter treatment for larger, untreated areas between laser columns. It will likely require multiple sessions but is better for delicate areas. Healing relies on migration of cells from adjacent skin. Healing cells must travel further, prolonging epithelial closure and leading to longer “mosaic-like” healing.
High energy, low density: This deeper, more aggressive setting preserves surrounding skin and is better for scars.
Low energy, high density: This setting covers more surface and is better for wrinkles and mild tightening.

By offering a customizable balance between efficacy and recovery time, fractionated resurfacing lasers provide patients with noticeable, long-lasting improvements in skin health and appearance, Dr. Maloney said.

Do’s and don’ts

Fractional laser resurfacing isn’t for everyone. Dr. Maloney said it’s important to identify disease candidates and prevent potential complications. She underscores the importance of proper, post-treatment care and certain protocols to ensure optimal healing and minimize complications.

Do’s:

Do know your settings.
Do have the right protocol.
Do understand the many different applications.
Do consider post-treatment enhancements.

Don’ts:

Don’t do it on just anyone: Know the patient’s medical history, skin type, and lifestyle factors.
Don’t do it if you can’t manage complications.

Dr. Maloney reminds dermatologists to emphasize to their patients the importance of a gentle skin care routine. For example, cleansing with a mild, non-foaming solution and using sterile saline or diluted vinegar soaks to reduce inflammation, soothe the skin, and prevent infection.

Additionally, it’s important to apply a thick occlusive, such as petroleum jelly or a specialized post-procedure balm. This is critical for maintaining a moist wound-healing environment, which accelerates recovery and reduces scarring risks, she said. Likewise, sun protection is paramount.

“Advise patients to avoid direct sunlight, wear broad-spectrum sunscreen (SPF 30+), and use physical barriers like wide-brimmed hats once the skin barrier has healed,” said Dr. Maloney. “To reduce redness and swelling, recommend using cool compresses or an over-the-counter hydrocortisone cream sparingly. Oral antihistamines may also help alleviate itching during the recovery phase. Hydration and avoiding smoking will further support collagen remodeling and overall healing.”

Finally, follow-up appointments are necessary to monitor progress, address concerns, and guide the reintroduction of active skin care products like retinoids or acids, usually after four to six weeks, she said. For patients who have higher Fitzpatrick types or a history of post-inflammatory hyperpigmentation, Dr. Maloney said dermatologists should consider prophylactic topical agents, like hydroquinone or a mild steroid, during the recovery phase.

Setting realistic expectations and providing clear, detailed instructions can greatly enhance patient satisfaction and safety following CO₂ fractionated resurfacing.

Special considerations

Understanding the patient’s Fitzpatrick skin type is essential, Dr. Maloney said, as darker skin tones are more prone to post-inflammatory hyperpigmentation (PIH). Dermatologists should also consider previous treatments and procedures, as these may influence skin sensitivity and healing capacity. During the procedure, Dr. Maloney recommends using conservative settings, especially for higher-risk patients, and adhering to evidence-based protocols to prevent complications such as burns, scarring, or delayed healing.

For example, she said the key to safer treatments would be to follow this protocol:

Lower density
Lower energy
Longer pulse durations to minimize thermal damage
One to two lighter passes with little overlap
High energy and low density for deeper scars

A detailed pre-procedure consultation should screen for:

Contraindications, such as active infections
Autoimmune conditions
Recent use of isotretinoin, which can impair healing

Dr. Maloney said formulating effective prevention and treatment strategies requires proactive measures. This includes prescribing antiviral prophylaxis for laser resurfacing patients with a history of herpes simplex and recommending sunscreen and topical depigmenting agents (e.g., hydroquinone) for PIH-prone individuals. After a procedure, regular follow-up visits allow for early detection of complications such as infections, erythema, or hypertrophic scarring.

Changing course

In the event of reversal, Dr. Maloney said prompt interventions tailored to the complication are essential. For example, she recommends treating PIH with topical retinoids or chemical peels, addressing erythema with pulsed-dye lasers, or managing infections with appropriate antibiotics.

“Ultimately, clear communication and individualized care plans help dermatologists navigate complications effectively, ensuring both patient safety and satisfaction,” she said.

Last but not least

Finally, Dr. Maloney reminds dermatologists to always make patients comfortable. She recommends starting with a topical numbing for one hour with lidocaine 23% and tetracaine 7%. If doing the neck in addition to the face, keep topical numbing on the neck until ready to start. Proceed with: