Is Fraxel and Fractional CO2 Dangerous for Dry Ey Patients?

A couple of patients have asked if Fraxel laser will damage meibomian glands and make dry eye worse. I have not seen any paper or mention of this anywhere on Pubmed or google. I have contacted the company to ask how “deep” the laser penetrates.

For now, I would avoid the eye area.

Side effects of Fraxel published include, redness, discoloration of skin, discomfort.


More info below:

Fraxel Laser Resurfacing

Fractional CO2 Laser Resurfacing ALSO AVAILABLE

SPECIAL – Fraxel full face session $650.

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Frequently Asked Questions

WHAT IS Fraxel® SR Laser Resurfacing?
Fraxel® SR Laser is a revolutionary approach to all laser resurfacing procedures. It is used to treat wrinkles, age spots, and melasma from years of accumulated sun-damaged skin. It can treat areas on the face , including around the lips and eyes, and body parts including neck, arms , and hands. It can also be used for acne scars. (Fraxel is not for Active acne breakouts, which we can treat with our IPL/Acne Triple Package) There is no cutting of the skin, so patients can achieve the same positive effects of ablative laser procedures (CO2 and Erbium lasers) and deep chemical peels without the associated “downtime” or potential side effects. There is NO peeling or flaking of skin. We also offer lighter treatment options called mini fraxel, and fraxel facials. More info below*
WHAT is The Difference between Fraxel and Fractional CO2 (aka Mixto)?
The scientific answer is the Fraxel is an erbium laser, whereas the Fractional CO2 is a CO2 laser. They have different wavelengths. For layman’s terms it is best to think of the fractional CO2 as a more aggressive treatment , therefore 1-2 sessions are all that is required with 4-5 days downtime. The regular Fraxel usually requires 3-5 sessions with 1-2 days downtime. Darker skin types are best treated with the regular fraxel , whereas lighter skin can be more aggressively treated with Fractional CO2.*

Fraxel vs Fraxel CO2 chart
A microdermabrasion followed by a 5 minute light exfoliating with Fraxel laser. Treatment time is 30 minutes done for exfoliation, skin cell turnover , tone, texture and glowing complexion. Performed to enhance results of microdermabrasion. No downtime, no topical anesthesia required, very mild stinging sensation may occur during the active fraxel time. A good skin maintenance treatment. May feel like a mild sunburn for 30 minutes to 1 hour after the treatment. You can return to your daily routine immediately afterwards. Please note this is not a full fraxel treatment . Not recommended if your goal is for wrinkle improvement, discoloration or acne scaring. Pre treatment requirements : no recently tanned skin , avoid any other exfoliation treatments ( such as peels, laser) 1 week prior to treatment, post care use mild cleanser and sunscreen. $325/session.
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Fractional CO2 Laser Resurfacing Complications

William M. Ramsdell, M.D.


Fractionated CO2 laser technology has allowed physicians to resurface patients with a lower rate of complications than nonfractionated ablative laser treatment. Unfortunately, adverse effects can still occur even with the best technology and physician care. Complication prevention, detection, and treatment are an important part of a physician’s ability to provide the best result when treating a patient with fractionated CO2resurfacing.
Keywords: complication, infection, scar, dyschromia
The development of CO2 lasers was motivated by the desire to achieve excellent results while maintaining a favorable side-effect profile. Although significant side effects are relatively uncommon, they do occur and occasionally may be severe. Understandably, cosmetic surgery patients have less tolerance of side effects than patients undergoing medically indicated procedures. The astute surgeon will learn to prevent, promptly recognize, and treat these side effects.


Complication prevention should be kept in mind throughout the treatment process. During the initial consultation, the patient should be evaluated for factors that may predispose that patient to developing a side effect. A history of poor wound healing, keloids, or hypertrophic scarring may be an indication to avoid aggressive skin resurfacing. Patients who tan easily may be at risk for hyperpigmentation after their laser session. An individual with extensive sun-damaged skin may need full-face treatment (as opposed to partial treatment) to ensure cosmetic blending of skin color. In addition, patients with a compromised immune system are at greater risk of infection. A detailed history obtained during the consultation is vital to predicting these risks and selecting suitable candidates.
Proper skin care postprocedure is vital to achieving quick healing while minimizing the risk of infection. Although an in-depth exploration of skin care is beyond the scope of this article, specialized skin care involving the use of gentle cleansing along with protective ointments and/or dressings, antibiotics, and antivirals are typically the basis of postoperative ablative fractional resurfacing care.


An intact skin barrier is the best layer of defense against infection. By definition, fractionated ablative CO2 laser resurfacing perforates the skin barrier allowing for a potential infection postprocedure. The pathologic organisms that may infect the skin include bacteria, fungi, and viruses. The most common cause of scarring is postoperative infection, which usually presents several days postoperatively as a localized area of delayed healing (Fig. 1). Inexperienced or inattentive surgeons as well as patients may find it difficult to distinguish infection from the normal healing process. When an infection is suspected, it is advised to promptly perform microbiologic culture testing to identify the organism and determine its sensitivity to treatment.
Figure 1

(A) Culture-proven Pseudomonas infection. (B) Source of the infection—Pseudomonas paronychia.
The most common causes of infection include StaphylococcusPseudomonasKlebsiella, and EnterobacterCandidiasis may be quite subtle and present as prolonged erythema and pruritus.1,2 Herpes simplex virus may disseminate over the entire face without prophylaxis (Fig. 2). Atypical mycobacterial infection has also been reported and may present as papules or nodules.3,4
Figure 2

Culture-positive herpes simplex in a patient on valacyclovir. Further dissemination would have necessitated intravenous acyclovir.
Most patients are prescribed a course of both antibiotic and antiviral medications. The antibiotic is usually selected for Staphylococcus coverage and the antiviral for herpes simplex. Systemic antibiotics are preferable to most topical antibiotics due to the possibility of allergic contact dermatitis, especially to neomycin, polymyxin, and bacitracin.5
Postoperative steroid usage immediately after resurfacing is controversial due to increased infection risk. Of note, recently two cases of infection presumably caused by the substitution postoperatively of a potent topical steroid in place of petrolatum have been reported.6

Scarring and Ectropion

The most dreaded side effect, of course, is scarring.7,8Manuskiatti documented a 3.8% incidence of scarring.9In this series, every case was caused by infection, highlighting the need for surveillance, and proper skin care including possible antibiotic and antiviral prophylaxis. Another cause of scarring represents operator error in the form of excessive fluence or density, too many passes, or pulse stacking.10 If the skin is heated beyond its ability to heal promptly and without excessive fibrosis, scarring will occur (Fig. 3). The neck and chest are more susceptible to scarring than the face and must be treated with caution (Fig. 4).11
Figure 3

(A) Impending disaster caused by excessive fluence with secondary infection. (B) Resolution without scarring. The patient received optimal wound care including five intense pulsed light treatments delivered over 8 weeks.
Figure 4

Scarring on the neck and chest.
Ectropion may be the result of cicatrix, but usually results from excessive fluence or density on the thin and highly contractile skin of the lower eyelids.8 Patients with previous subciliary lower blepharoplasty, scleral show, large globes, and lax lower eyelids are particularly prone (Fig. 5).
Figure 5

(A,B) Ectropion following Active FX corrected immediately via canthopexy. A subciliary lower blepharoplasty had been performed previously.


Any dermatosis that Koebnerizes may be initiated by laser-induced trauma. This includes diseases such as vitiligo and psoriasis (Fig. 6). Eruptive keratoacanthomas have been reported, presumably secondary to Koebnerization.12,13
Figure 6

Persistent erythema 6 months following infraorbital Active FX resurfacing. The patient subsequently developed plaques on her elbows diagnostic of psoriasis. Although the patient did not have a prior personal history of psoriasis, there was a positive …


Temporary hyperpigmentation, so common following previous generation CO2 lasers in skin types IV and V, is less likely with fractional resurfacing assuming reasonable treatment parameters (Fig. 7).14 Fortunately, delayed-onset permanent hypopigmentation seen in up to 19% of cases with previous generation CO2 lasers is very uncommon.15,16,17,18,19 Nevertheless, fractional lasers are certainly capable of damaging the skin enough to cause excessive fibrosis and disruption of melanogenesis, the causes of hypopigmentation.
Figure 7

Hyperpigmentation in a patient with Fitzpatrick type 4 skin. Severe acne scarring was treated with double-pulsed Deep FX followed by Active FX.

Contact Dermatitis

Postoperative contact dermatitis may be either irritant or allergic in nature. Perforation of the skin barrier may promote this side effect. It can be particularly challenging to distinguish contact dermatitis from infection while the patient’s skin is red and edematous due to expected laser healing. Even in the prefractionated resurfacing era, it was recognized that a wide variety of creams, ointments, cleansers, and other skin care products may cause contact dermatitis after laser resurfacing.20 If a product is suspected to be a culprit, it should be discontinued immediately.
Of special note, as previously mentioned, topical antibiotics such as neomycin, bacitracin, and polymyxin have been discouraged due to the heightened risk of allergic contact dermatitis. Bacitracin has been reported to cause not only contact dermatitis postresurfacing, but also foreign body granulomas due to its mineral oil content.5,21 It should be mentioned that “natural” or “botanical” products can definitely cause contact dermatitis despite the gentle nature implied.

Prolonged Erythema

Prolonged erythema, so common with previous lasers, is uncommon. It can be caused by inappropriate laser settings, infection, aggressive debridement between laser passes, and contact dermatitis. Over time, postresurfacing erythema fades gradually. Optionally, the usage of a pulsed dye laser or intense pulsed light device may be helpful in reducing the redness more quickly.


Acne and milia are common minor side effects.16,19,22Spontaneous resolution can be expected. If bothersome to the patient, milia may be removed via extraction or pinpoint electrodessication. Acne treatment must be administered carefully as the recently reepitheliazed skin is temporarily more sensitive after resurfacing.


When used according to accepted parameters, fractional CO2 laser resurfacing is a very safe procedure. The laser surgeon must have a thorough knowledge of the structure and physiology of skin. Early recognition, close monitoring, and careful wound care will prevent long-term sequelae when complications do occur.

Article information

Semin Plast Surg. 2012 Aug; 26(3): 137–140.
PMCID: PMC3580977
PMID: 23904822
1Private practice, Austin, Texas
Address for correspondence and reprint requests William M. Ramsdell, M.D.102 Westlake Drive, Suite 100, Austin, Texas, 78746, moc.mredxetnec@rmw
Articles from Seminars in Plastic Surgery are provided here courtesy of Thieme Medical Publishers


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References 2:


5 Things You Must Know Before Getting a Fractional Laser Treatment

5 Things You Must Know Before Getting a Fractional Laser Treatment
Some things are better the second time around: a vintage Hermès bag, re-binging This Is Us, finding love again. So when I showed up at the dermatologist’s office for my second fractional laser treatment — a collagen-boosting technology that helps reduce wrinklesdark spots, and other signs of skin aging — I was giddy with anticipation of my soon-to-be glowing complexion. I had good reason: my initial experience took less than 10 minutes and gave me such radiant skin for weeks afterwards that I stopped wearing makeup for almost a month. Yeah, it worked that well.
But three months later when I did my second treatment, it was like the bad sequel to a hit movie. This time, the radiance never came. Instead, a few days later, my face appeared slightly darker and redder than the skin on my neck and around my eyes (the latter had been covered with protective patches during the treatment). There were even visible demarcation lines from where the eye pads had been, making me look like I was permanently wearing way-too-light undereye concealer.
As if this wasn’t enough to manage, my regular skincare products — which had never caused me problems before — suddenly began making my skin turn beet red for up to an hour after I applied them. And even after the flushing subsided, my face was still speckled with small red blotches. My once well-behaved complexion was now throwing daily tantrums, and even after I switched to all ultra-gentle, healing and calming skincare, it took a full year for my skin to finally return to normal.
So what went wrong? Well, it wasn’t the doctor’s fault — both treatments were administered safely, correctly, and spaced apart by three months (more than enough time in between for the type of treatment I had as suggested by the MD). While it’s possible I’m part of a small percentage of people whose skin simply doesn’t tolerate fractional lasers well, I went into the treatments knowing almost nothing about them. Therefore, I didn’t take certain precautions beforehand or afterwards that could have greatly reduced my chances of having a bad reaction.
Just because lasers don’t involve a needle or a scalpel doesn’t mean they should be taken lightly. Few people understand that — and the technology behind them —better than Dr. Macrene Alexiades, a New York City dermatologist who’s authored numerous clinical studies on skin lasers. If you’re considering a fractional laser treatment, follow her five rules for safe and effective beaming.

1. Understand what a fractional laser does to your skin.

Just as you wouldn’t swallow a pill without knowing what it is, you want to be certain of how lasers treat your complexion. These are not the intense resurfacing lasers of the ’90s that destroyed the outer layer of skin and required weeks of recovery time. “A fractional laser emits thousands of tiny micro-beams that treat a fraction of the skin’s surface,” says Dr. Alexiades. Basically, it punches teeny holes in the skin that are invisible to the naked eye, but are enough to activate the skin’s wound response. This signals your complexion to create collagen.
Fractional lasers are either ablative (meaning they create micro-wounds in the skin to trigger collagen) or non-ablative (they use heat to get your collagen cranking). Neither device causes much discomfort: though you may feel a mild, prickly stinging sensation, your dermatologist will numb your skin beforehand. “Ablative lasers tend to do better at reducing wrinkles and sun damage than non-ablative ones,” says Dr. Alexiades. “Plus, with some ablative lasers you need only one treatment, whereas the non-ablative ones may require up to five monthly treatments.”

iStock by Getty Images / utkamandarinka

2. Use these devices to treat a specific issue, not for an overall complexion boost.

Be warned: Fractional lasers aren’t facials with benefits. I got the treatment because I saw how great other people looked after trying it, and I wanted in. But that’s like going to physical therapy when you don’t have an injury. “Some doctors push these lasers as quick, easy rejuvenation treatments even when there’s nothing to rejuvenate,” says Dr. Alexiades. “Tell your dermatologist what your skin issues are that you’d like to address, then let him or her advise the best course of action. You shouldn’t just pick a service off the shelf, because it may not be ideal for your skin.”

3. Take precautions pre- and post-treatment.

Even the slightest change in your skin can increase your chance of having an adverse reaction to a fractional laser. Because of this, Dr. Alexiades advises her patients to follow this protocol: “During the four weeks both before and after each treatment, avoid significant sun exposure, and don’t start any new topical or oral medications or introduce any new skincare products into your routine,” she says.
In my case, I failed to mention to my dermatologist that I’d been on antibiotics less than a month before my second fractional laser appointment. As it turns out, antibiotics can make skin more vulnerable to light-induced damage and irritation for weeks after you finish the medication. Plus, I had my second session just two weeks before going on a beach vacation. (Not wise, I know.) Another smart safety measure recommended by dermatologists, especially if you’re a first timer: do a patch test of the laser on a small area of skin behind your ear. Wait a week to see if you have any redness or irritation there. If you do, don’t move forward with the treatment.
 [Editor’s Note: Please note that some laser treatments may include up to three months of avoiding sun exposure.] 

iStocky by Getty Images / utkamandarinka

4. Stick to the advised number of treatments.

I’ve heard of women getting fractional lasers done every two weeks, indefinitely, just to maintain their skin. “This is where people can really get into trouble,” says Dr. Alexiades. “When women — especially those under 40 — use these devices too often, their skin sometimes develops a shiny plastic appearance due to too much wound-healing response.” (Have you ever burned your skin on the stove and noticed that the area looks shiny during the healing process? A similar reaction takes place when you overdo fractional lasers.)
“For some patients, their skin is never quite the same — even after they stop the lasers,” adds Dr. Alexiades. While there are different courses of treatments for different devices, no skin issue should require more than three to five monthly fractional laser treatments — period.

5. If you have an adverse reaction to a laser, tell your licensed provider ASAP.

If you see something, say something. When my skin began reacting a few days after my second treatment, I figured it was temporary and would clear up in a week or two. When it didn’t, I waited until my next appointment with my dermatologist — which wasn’t for another three months — to tell her about it. Big mistake, says Dr. Alexiades.
“Inform your dermatologist right away of any unexpected changes in your skin post-laser,” she warns. “If you allow redness or irritation to persist for too long, it becomes a lot harder to treat and may not go away for up to a year.” (Sounds familiar!)
Despite my complicated experience, I still believe that fractional lasers do a lot more good than harm. As long as you know the basic rules — and, of course, know that this professional treatment is not to be treated as casually as a facial — lasers can light the way towards a balanced, beautiful complexion.
Dr. Macrene Alexiades is a paid Allergan consultant.
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