Comparison Study of Fractional Carbon Dioxide Laser

Resurfacing Using Different Fluences and Densities for Acne

Scars in Asians: A Randomized Split-Face Trial
XING-HUA YUAN, MD,*

SHU-XIA ZHONG, MD,* AND SHAN-SHAN LI, MD, PHD*

BACKGROUND Ablative 10,600-nm carbon dioxide (CO
2
) fractional laser treatments have shown favorable
outcomes for atrophic acne scars.
OBJECTIVE To compare the efcacy and complications of fractional CO
2
laser treatments with different
uences and densities for acne scars.
METHODS Twenty patients were treated using a single session of fractional CO
2
laser in Deep FX mode. In
Group A (n = 10), half of the face was treated with 20 mJ, density 10% and the other half with 20 mJ,
density 20%. In Group B (n = 10), half of the face was treated with 10 mJ, density 10% and the other half
with 20 mJ, density 10%. Patients were evaluated at baseline and 3 days, 1 week, 1 month, and 3 months
after the procedure.
RESULTS There was no signicant difference in efcacy between different laser settings within the groups,
although adverse effects were more evident in patients treated with higher densities or uences.
CONCLUSION Factional CO
2
laser treatment using the Deep FX mode may provide a signicant efcacy with
lower uence and density with fewer complications than with higher energies for acne scars.
The authors have indicated no signicant interest with commercial supporters.
A
trophic scars are dermal depressions com-
monly caused by the destruction of collagen
after inammatory acne. Conventional ablative laser
therapy with carbon dioxide (CO
2
) or erbium-doped
yttrium aluminum garnet laser is the criterion
standard for treatment of atrophic scars,
1,2
although
its usage is frequently limited in Asian patients
because of the lengthy recovery time and high risk of
adverse effects, including infection, edema, and
postinammatory hyperpigmentation (PIH).
2,3
To
address these limitations, newer modalities employ-
ing the principle of fractional photothermolysis (FP)
have been developed.
4,5
These laser treatments
create microscopic treatment zones (MTZs) sur-
rounded by undamaged tissues and hence result in
shorter recovery time and fewer adverse effects than
traditional ablative laser resurfacing. Recent studies
have shown favorable outcomes for atrophic acne
scars with an ablative 10,600-nm CO
2
fractional
laser system (CO
2
FS).
6,7
A CO
2
FS with two
treatment modes (Active FX and Deep FX) is one of
the more popular fractional CO
2
lasers available
today, combining supercial and deep fractional
CO
2
laser treatments. Cho and colleagues
8
used this
laser to treat atrophic acne scars in 20 Korean
patients. The treatment combined the Deep FX
mode, which focused on the scars only, whereas the
Active FX mode was used over the entire face. After
one session, 50% of patients achieved marked
improvement (>50%). The Deep FX mode with a
smaller (120 lm) spot size has the potential to
extend treatment from the epidermis to as deep as 3
*Department of Dermatology and Venereology, First Hospital of Jilin University, Changchun, China;

Department of
Dermatology and Venereology, Yanbian University Hospital, Yanji, China
2014 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
ISSN: 1076-0512 Dermatol Surg 2014;40:545552 DOI: 10.1111/dsu.12467
545
4 mm into the reticular dermis, but data on the
efcacy and adverse effects of this novel resurfacing
technique in dark-skinned patients are limited.
In this study, we compared the efcacy and com-
plications of fractional CO
2
laser treatment with the
Deep FX mode using different uences and densities
for acne scars in Asian patients in a randomized,
split-face, evaluator-blinded study.
Methods
Patients
This study followed the principles of the 1975
Declaration of Helsinki. Twenty Chinese subjects,
10 female and 10 male, aged 2231, with Fitzpatrick
skin types IIIIV and moderate to severe atrophic
acne scars were enrolled. Informed consent was
obtained from each patient. Patients with a history
of keloid scarring, isotretinoin use, pregnancy,
lactation, immunosuppression, history of ller
injection within the past year, or ablative or
nonablative laser resurfacing within 1 year of study
initiation were excluded from the study.
Laser Treatment
Patients were treated with a single session of the
Deep FX microscanner handpiece of the fractional
ultrapulse CO
2
laser (Ultrapulse Encore; Lumenis
Inc., Santa Clara, CA). The treatment areas were
cleansed with a mild cleanser and 70% alcohol.
Local anesthesia, comprising a topical eutectic
mixture of 2.5% lidocaine hydrochloric acid and
2.5% prilocaine cream (Compound Lidocaine
Cream; Ziguang, Beijing, China), was applied to the
entire face under occlusion before laser therapy.
After an hour of application, the anesthetic cream
was gently removed, and then, to obtain a com-
pletely dry skin surface, alcohol was used to
degrease the skin.
Twenty patients were randomly divided into two
groups. In Group A (n = 10), half of the face was
treated with 20 mJ, density 10% and the other half
with 20 mJ, density 20%. In Group B (n = 10), half
of the face was treated with 10 mJ, density 10% and
the other half with 20 mJ, density 10%. Facial
treatment halves were also randomized. A single
operator then administered a full-face, single-pass
treatment without overlapping pulse.
Immediately after each procedure, a thin layer of
uticasone propionate cream (Ketinv; Glaxo Oper-
ations UK Limited, Durham, UK) and a recombinant
human epidermal growth factor hydrogel (Yifu;
Huanuowei, Guilin, China) was applied to prevent
an inammatory reaction and reduce facial dryness.
Ice packing (4C) was applied to the treated surface
for 30 minutes or more until the pain or burning
sensation decreased. Subjects were instructed to
clean the treated sites gently with a mild cleanser
24 hours after the treatment. The uticasone pro-
pionate cream was applied twice daily for the rst
3 days and the recombinant human epidermal
growth factor hydrogel 4 times daily for 1 week.
After complete decrustation, all patients
were instructed to wear a broad-spectrum sunscreen
with a sun protection factor of 30 and to avoid
sun exposure.
Objective and Subjective Evaluations
Photographs were taken using identical camera
settings, lighting, and patient positioning at baseline
and 3 days, 1 week, 1 month, and 3 months after
treatment. Two blinded dermatologists compared
before and after photographs in nonchronological
order and provided objective clinical assessments of
the acne scars. Acne scars were graded using the
echelle devaluation clinique des cicatrices dacne
grading scale at baseline and 1 and 3 months after
the treatment.
9
The degree of improvement was
further assessed on a 4-point scale (0, no improve-
ment; 1, 025% [minimal improvement]; 2,
2650% [moderate] improvement; 3, 5175%
[marked] improvement; 4, >75% [near total]
improvement). Subjects also performed a
self-assessment of their results (range 010) 1 and
3 months after the treatment.
COMPARI SON STUDY OF CO
2
AFR
DERMATOLOGI C SURGERY 546
Immediately after each procedure, subjects were
asked to rate the pain associated with the treatment
using a 10-point pain scale (0 = no pain to
10 = severe pain). The investigators evaluated the
presence of bleeding, oozing, and edema during the
treatment was on a 3-point scale (0 = absent,
1 = mild, 2 = moderate, 3 = severe). Erythema was
also assessed on a 3-point scale at the 3-day follow-
up. Recovery times and other potential adverse
effects, including hyper- and hypopigmentation,
crusting, scarring, infection, and acneiform eruption,
were recorded at each follow-up visit.
Statistical Analysis
We compared clinical assessment scores of acne
scars using the nonparametric Wilcoxon signed rank
test with SPSS version 17.0 (SPSS, Inc., Chicago, IL).
Overall patient satisfaction levels and the grading
scores of adverse effects associated with the treat-
ments were analyzed using the Student t-test (paired
samples), while the data which did not follow a
normal distribution was analyzed using a
nonparametric test. Differences were considered
statistically signicant at p < .05.
Results
Follow-up results 3 months after a single laser
treatment with the same uence and different
densities (Group A) indicated that three of 10
patients treated using the lower density showed
marked improvement (5175%), ve showed mod-
erate improvement (2650%), and two showed
minimal improvement (<25%). Five of 10 patients
treated using the higher density showed marked
improvement (5175%), three showed moderate
improvement of (2650%), and two showed min-
imal improvement (<25%) (Table 1). Three months
after the laser procedure with the same density and
different uences (Group B), two of 10 patients
treated using the lower uence showed marked
improvement (5175%) (Figure 1AB), six showed
moderate improvement (2650%), and two showed
minimal improvement (<25%). Four patients trea-
ted using the higher uence showed marked
improvement (5175%) (Figure 1CD), four
showed moderate improvement of (2650%), and
two showed minimal improvement (<25%)
(Table 1). Overall patient satisfaction levels at the
3-month follow-up are shown in Tables 2 and 3.
There was no statistically signicant difference
between different densities (Group A) or uences
(Group B) in clinical efcacy or patient satisfaction
(p > .05). It was also observed that scar
improvements and patient satisfaction were
signicantly higher at the 3-month follow-up than
at 1 month (p < .05).
The results of adverse effects are shown in Tables 2
and 3. Pain, bleeding, oozing, edema, crusting,
erythema, and PIH were found to be more evident or
persisted for longer periods of time in patients treated
with higher densities (Group A, p < .05) or higher
uences (Group B, p < .05). Both sides of the faces in
all 20 subjects showed PIH that resolved within
3 months except for a patient treated with the higher-
density setting in Group A. There was no intervention
for the PIHother than daily sunscreen use. Acneiform
eruption (10%, n = 1), cutaneous pruritus (30%,
n = 3), and skin dryness (60%, n = 6) were observed
in patients in Group A. Four patients in Group B
experienced cutaneous pruritus, and ve experienced
skin dryness. All subjects with skin dryness were
successfully treated within 2 weeks using a moistur-
TABLE 1. Clinical Comparison of Different Energies
in Group A and Group B
Cases
Improvement Grade
Group A
Improvement
Grade Group
B
Density 10% Density 20% 10 mJ 20 mJ
1 1 1 2 2
2 2 3 2 3
3 2 2 1 1
4 2 2 2 3
5 3 3 3 3
6 3 3 2 2
7 2 3 2 2
8 1 1 1 1
9 2 2 2 2
10 3 3 3 3
YUAN ET AL
40: 5: MAY 2014 547
izing cream (Lauzome; Canada Highview & Ever-
bright Medical Technology Co., Ltd., Changchun,
China) three times daily. Acneiform eruptions in one
subject were successfullytreatedwithin2 weeks using
clindamycin phosphate gel and adapalene gel applied
day and night, respectively. Some subjects also expe-
riencedcutaneous pruritus inirradiationareas 25 days
after treatment. The sensation was sustainable
and automatically resolved within 1 week. Severe
complications such as hypopigmentation, scarring,
and infection were not observed in any of the 20
subjects.
Discussion
Ablative fractional resurfacing (AFR) with 10,600-
nm CO
2
lasers uses fractionated laser beams to
produce an array of microscopic columns of con-
trolled deep dermal tissue volumetric ablation and
vaporization surrounded by thermally induced
TABLE 2. Overall Comparative Data Between Different Densities in Group A
Density 10% Density 20% p-Value
Pain, mean SD (range 010) 4.36 1.10 6.12 1.24 <.001
Edema, days, mean SD 3.10 0.57 4.50 0.53 .004
Crusting, days, mean SD 4.80 0.79 6.60 0.52 .003
Postinammatory hyperpigmentation duration, days, mean SD 50.50 8.64 62.50 11.06 .005
Infection, n 0/10 0/10
Scarring, n 0/10 0/10
Acneiform eruption, n 1/10 1/10
Cutaneous pruritus, n 3/10 3/10
Skin dryness, n 6/10 6/10
Hypopigmentation, n 0/10 0/10
Patient satisfaction, mean SD (range 010) 5.90 1.37 5.95 1.40 .85
SD, standard deviation.
(A) (B)
(C) (D)
Figure 1. Twenty-seven-year-old male patient before (A) and 3 months after (B) treatment with 10 mJ, density 10% and
before (C) and 3 months after (D) treatment with 20 mJ, density 10%.
COMPARI SON STUDY OF CO
2
AFR
DERMATOLOGI C SURGERY 548
annular coagulation zones of denatured collagen
with interspersed regions of untreated tissue.
7,10
An
ex vivo histologic study demonstrated that the depth
of ablation in AFR depends on the pulse energy
used, with higher energies resulting in greater
penetration depth.
10
In turn, the depth of ablation
and coagulation correlated directly with treatment
efcacy in laser resurfacing.
1012
Various types of
fractional ablative CO
2
lasers have been used for
acne scar treatments with different penetration
depths at variable energy levels. Manuskiatti and
colleagues
12
treated 13 patients using a fractional
CO
2
laser for three sessions. Patients with mild to
moderate scars were irradiated with lower energy
levels (7590 mJ/MTZ), whereas deeper scars were
treated using a high-pulse energy level (105 mJ/
MTZ). A fractionated CO
2
laser system used in their
study creates 150- to 200-lm-deep MTZs. At the
3-month follow-up, 69% of subjects had at least 25
50% improvement. Likewise, in a controlled split--
face trial, Jung and colleagues
13
treated mild to
severe acne scars with a fractional CO
2
laser.
Lower-uence, higher-density settings (30 mJ/pulse,
250 MTZs/cm
2
) were compared with higher-uence,
lower-density settings (70 mJ/pulse, 150 MTZs/
cm
2
). More-pronounced effects were demonstrated
on the sides treated with higher uence and lower
density. Energy levels of 30 and 70 mJ corresponded
to a depth of the necrotic columns approximately up
to 282 and 486 lm, respectively, with the CO
2
FS
used in their study, as assessed through histologic
evaluation. Chapas and colleagues
6
treated 13
patients with moderate to severe acne scars using the
novel ablative 30W CO
2
Fraxel re:pair device at
pulse energies of 20100 mJ for two to three
full-face treatments. Patients treated with higher
energy levels (70100 mJ) on deeper scars on the
cheeks for the second and third treatments received
the highest improvement scores, with average over-
all improvement of 5175% 3 months after the nal
treatment. A previous study with this device showed
tissue ablation and thermal effects as deep as 1
1.6 mm into the skin at the higher energies of 70
100 mJ.
14
Thus, based on previous studies, it was
estimated that higher energy producing deeper tissue
injury into the dermis correlated with more-pro-
nounced clinical efcacy in laser resurfacing,
15,16
although it is unknown how deep the tissue injury
depth would tend to balance the biologic effects of
modulating and suppressing in wound healing
responses, which presents in similar clinical efcacy
with different energies. In our comparison study, we
treated patients with moderate to severe acne scars
using the Deep FX mode at energy levels of 10 and
20 mJ (Group B). Farkas and colleagues
17
reported
that, with a single pulse, the Deep FX mode
demonstrated tissue injury up to 1 mm from the
tissue surface at 10 mJ and up to 2 mm at 20 mJ as
assessed through histopathologic evaluation. At the
3-month follow-up, 80% of subjects had at least
2550% improvement, and 30% had 5175%
improvement in their scar conditions. There was no
TABLE 3. Overall Comparative Data Between Different Fluences in Group B
10 mJ 20 mJ p-Value
Pain, mean SD (range 010) 4.39 1.19 4.98 1.13 .02
Edema, days, mean SD 2.50 0.52 3.50 0.53 .001
Crusting, days, mean SD 4.00 0.67 4.80 0.79 .003
Postinammatory hyperpigmentation duration, days, mean SD 46.80 11.51 56.80 11.46 .004
Infection, n 0/10 0/10
Scarring, n 0/10 0/10
Acneiform eruption, n 0/10 0/10
Cutaneous pruritus, n 4/10 4/10
Skin dryness, n 5/10 5/10
Hypopigmentation, n 0/10 0/10
Patient satisfaction, mean SD (range 010) 5.30 1.25 5.42 1.30 .83
SD, standard deviation.
YUAN ET AL
40: 5: MAY 2014 549
signicant difference in clinical efcacy between 10
and 20 mJ laser irradiation. Tissue injury after
treatment with the Deep FX mode was similar to the
super-short-pulse Fraxel re:pair system, with the
ablation microcolumns penetrating from the epi-
dermis into the underlying papillary and reticular
dermis. The penetration depth with the lower-energy
level of this specic device may be in accordance
with the depth using higher energy with other
fractional ablative CO
2
lasers. In this study, with the
lower-uence 10 mJ of the Deep FX mode corre-
sponding to a depth of 1 mm, it was possible to
achieve signicant clinical efcacy, as previously
reported. It was hypothesized that penetration as
deep as 2 mm into the deep reticular dermis with
CO
2
FS treatment at higher energy may not result in
greater efcacy for treating acne scars.
We also compared the efcacy of CO
2
FS treatment
with different densities and found that there was no
statistically signicant difference between the lower-
density 10% and higher-density 20%. The results of
our study were compatible withthe previous report by
Kono and colleagues
18
indicating therapeutic effects
of 1,550-nm nonablative FP laser treatment in skin
rejuvenation. It was considered fromtheir study that,
when the fractional laser beamcreates a dense pattern
of epidermal and dermal MTZs, the untreated tissues
that surround the MTZs serve as a reservoir for
thermal healing. Using higher density, the quantity of
the undamaged tissues decreased, which was likely to
result in no greater efcacy in scar improvement.
Adverse effects such as pain, edema, crusting, and
PIH were found to be more evident or persisted for
longer periods in patients treated with higher den-
sities or higher uences, as found in a previous
study.
18
PIH is one of the most troubling adverse
effects of laser irradiation when treating Asian
patients. We observed that both sides of the faces in
all 20 subjects had PIH that had almost resolved
within 3 months. The majority of patients received
laser irradiation in the summer and early autumn,
when the sun is most intense, which may be
responsible for the high rate of PIH observed. The
pathogenesis of PIH is unknown. Some studies have
found high density to be a causative factor of
PIH.
6,18
In fractional resurfacing, too high a density
can cause overlapping thermal injury zones and, if
dense enough, act like traditional ablative laser
resurfacing, which has a high risk of PIH.
18
It is
estimated that the risk of PIH may be correlated
with the extent of overlapping thermal injury zones.
The extent of the overlapping thermal injury zones
seems to be related to the density and uence setting
of a fractional laser. Hantash and colleagues
10
found
that higher uence achieved greater thermal lesion
depth and width and resulted in greater lesion
dimensions, which is likely to enhance the degree of
overlapping thermal injury zones. When we applied
the higher density or uence, the severity and
duration of the PIH was more signicant. However,
we could not compare the effect of higher density
and uence on the characteristics of PIH. Because in
our study, there was lack of a same control group.
To avoid PIH, the use of lower densities and uences
is of particular importance. Delayed hypopigmen-
tation, which has been reported with traditional
ablative CO
2
resurfacing, was not observed in our
patients after CO
2
AFR treatments, but an extended
follow-up period is essential, because the delayed
pigment abnormality usually develops as late as
6 months to 1 year postoperatively.
19
Improvement in acne scars was signicantly greater
at the 3-month follow-up than at 1 month, which
was in accordance with previous reports.
6,12
Several
studies have indicated that FP-induced heat shock
protein (HSP) expression and new formation of
collagen and elastic bers lasted for 36 months or
even longer, which was in accordance with clinical
observation of long-term biologic effects.
20,21
Expression of HSPs such as HSP70 and HSP47 plays
an important role in wound healing responses, which
lead to collagen remodeling and formation. It was
estimated that 3 months or longer may be an
appropriate treatment interval. If the interval is
short, such as 12 months, the wound healing
responses of the last treatment session may not
produce the extreme effect, and several postoperative
COMPARI SON STUDY OF CO
2
AFR
DERMATOLOGI C SURGERY 550
safety indexes such as sebum excretion rate, trans-
epidermal water loss, and the melaninerythema
index may not completely recover.
22
Acne scars were graded using the ECCAgrading scale
at baseline and at follow-up visits.
9
The ECCA
grading scale is a tool designed to help dermatologists
assess the severity of acne scars and in standardizing
discussions about the treatment of scars.
9
The
advantage of the ECCAgrading systemis that it could
reect the overall facial atrophic acne scar conditions
with both qualitative and quantitative grading scale,
but it cannot reect the efcacy of each independent
scar improvement without the true pre-/post-scar
depth measured, which is a limitation of our study.
Other limitations of this study were the small sample
size and that there was only one treatment session
using a single laser modality. To maximize the
efcacy of scar treatment, various modalities should
be combined due to a diverse range of scar condi-
tions. Moreover, no treatment option available can
offer near-total improvement of moderate to severe
acne scars with only one treatment session.
In conclusion, we demonstrated the efcacy and
safety of a single-session treatment of acne scars
with fractional CO
2
laser depending on different
energy settings in Asian patients in a randomized,
split-face, evaluator-blinded study design. Frac-
tional CO
2
laser treatment using the Deep FX mode
may provide a signicant efcacy for acne scars
with lower uence and density and fewer compli-
cations. Future work would be benecial, including
longer follow-up for the assessment of scar
improvement and possible late-emerging
pigmentary changes.
References
1. Alster TS, West TB. Resurfacing of atrophic facial acne scars with
a high-energy, pulsed carbon dioxide laser. Dermatol Surg
1996;22:1515.
2. Tay YK, Kwok C. Minimally ablative erbium: YAG laser
resurfacing of facial atrophic acne scars in Asian skin: a pilot
study. Dermatol Surg 2008;34:6815.
3. Nanni CA, Alster TS. Complications of carbon dioxide laser
resurfacing. an evaluation of 500 patients. Dermatol Surg
1998;24:31520.
4. Manstein D, Herron GS, Sink RK, Tanner H, et al. Fractional
photothermolysis: a new concept for cutaneous remodelling using
microscopic patterns of thermal injury. Lasers Surg Med
2004;34:42638.
5. Laubach HJ, Tannous Z, Anderson RR, Manstein D. Skin
responses to fractional photothermolysis. Lasers Surg Med
2006;38:1429.
6. Chapas AM, Brightman L, Sukal S, Hale E, et al. Successful
treatment of acneiform scarring with CO
2
ablative fractional
resurfacing. Lasers Surg Med 2008;40:3816.
7. Walgrave SE, Ortiz AE, MacFalls HT, Elkeeb L, et al. Evaluation
of a novel fractional resurfacing device for treatment of acne
scarring. Lasers Surg Med 2009;41:1227.
8. Cho SB, Lee SJ, Kang JM, Kim YK, et al. The efcacy and safety
of 10,600-nm carbon dioxide fractional laser for acne scars in
Asian patients. Dermatol Surg 2009;35:195561.
9. Dreno B, Khammari A, Orain N, Noray C, et al. ECCA grading
scale: an original validated acne scar grading scale for clinical
practice in dermatology. Dermatology 2007;214:4651.
10. Hantash BM, Bedi VP, Chan KF, Zachary CB. Ex vivo
histological characterization of a novel ablative fractional
resurfacing device. Lasers Surg Med 2007;39:8795.
11. Hedelund L, Haak CS, Togsverd-Bo K, Bogh MK, et al.
Fractional CO
2
laser resurfacing for atrophic acne scars: a
randomized controlled trial with blinded response evaluation.
Lasers Surg Med 2012;44:44752.
12. Manuskiatti W, Triwongwaranat D, Varothai S, Eimpunth S,
et al. Efcacy and safety of a carbon dioxide ablative fractional
resurfacing device for treatment of atrophic acne scars in Asians. J
Am Acad Dermatol 2010;63:27483.
13. Jung JY, Lee JH, Ryu DJ, Lee SJ, et al. Lower-uence,
higher-density versus higher-uence, lower-density Treatment
with a 10,600-nm carbon dioxide fractional laser system: a
split-face, evaluator-blinded study. Dermatol Surg
2010;36:20229.
14. Farkas JP, Richardson JA, Burrus CF, Hoopman JE, et al. In vivo
histopathologic comparison of the acute injury following
treatment with ve fractional ablative laser devices. Aesthet Surg J
2010;30:45764.
15. Chan NP, Ho SG, Yeung CK, Shek SY, et al. Fractional ablative
carbon dioxide laser resurfacing for skin rejuvenation and acne
scars in Asians. Lasers Surg Med 2010;42:61523.
16. Alster TS, Tanzi EL, Lazarus M. The use of fractional
photothermolysis in the treatment of atrophic acne scars.
Dermatol Surg 2007;33:2959.
17. Farkas JP, Richardson JA, Brown SA, Ticker B, et al. TUNEL
assay to characterize acute histopathological injury following
treatment with the active and deep FX fractional short-pulse CO
2
devices. Aesthet Surg J 2010;30:60313.
18. Kono T, Chan HH, Groff WF, Sakurai H, et al. Prospective direct
comparison study of fractional resurfacing using different uences
and densities for skin rejuvenation in Asians. Lasers Surg Med
2007;39:31114.
YUAN ET AL
40: 5: MAY 2014 551
19. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing
treatment complications: a review. Dermatol Surg 2010;36:299
306.
20. Walia S, Alster TS. Prolonged clinical and histologic effects from
CO
2
laser resurfacing of atrophic acne scars. Dermatol Surg
1999;25:92630.
21. Xu XG, Luo YJ, Wu Y, Chen JZ, et al. Immunohistological
evaluation of skin responses after treatment using a fractional
ultrapulse carbon dioxide laser on back skin. Dermatol Surg
2011;37:11419.
22. Oh BH, Hwang YJ, Lee YW, Choe YB, et al. Skin characteristics
after fractional photothermolysis. Ann Dermatol 2011;23:448
54.
Address correspondence and reprint requests to: Shan-
Shan Li, MD, PhD, Department of Dermatology and
Venereology, First Hospital of Jilin University, 130000
Changchun, Jilin, China, or e-mail: shansalee@gmail.com
COMPARI SON STUDY OF CO
2
AFR
DERMATOLOGI C SURGERY 552