Fractional Laser Resurfacing

Fractional laser resurfacing represents one of the most significant advances in cosmetic dermatology over the past two decades. By treating only a fraction of the skin surface at a time — leaving microscopic columns of untreated skin between treated zones — fractional technology delivers meaningful collagen stimulation and skin renewal while dramatically reducing downtime, risk, and recovery compared to traditional fully ablative resurfacing. For the periocular region, where skin is thin, healing is rapid, and patients want results without prolonged social downtime, fractional lasers occupy an essential niche in the oculoplastic surgeon’s toolkit.

Understanding where fractional resurfacing fits within the broader laser treatment landscape — and how it compares to fully ablative CO2 laser resurfacing — helps patients choose the right approach for their specific concerns, skin type, and lifestyle.

Fractional vs Ablative vs Non-Ablative

To appreciate fractional lasers, it helps to understand the three fundamental axes that describe any resurfacing device: ablative versus non-ablative, fractional versus fully resurfacing, and wavelength.

Ablative lasers vaporize tissue. They remove the epidermis and a controlled depth of dermis, allowing the skin to heal with new collagen and tighter architecture. CO2 (10,600 nm) and erbium:YAG (2940 nm) are the classic ablative wavelengths, both strongly absorbed by water in skin. Non-ablative lasers heat the dermis without removing the epidermis, relying on a controlled wound response below an intact skin surface.

Fractional simply means the laser beam is divided into a pattern of microscopic treatment zones (MTZs) separated by intact, untreated skin. The untreated bridges between zones act as reservoirs of healthy cells that migrate inward to heal the treated columns. Because only 15–40% of the surface is treated at any one session, recovery is faster and the risk of pigmentary problems, scarring, and prolonged erythema is markedly lower than with fully ablative resurfacing.

Combining these axes yields three practical categories used in periocular practice:

• Fully ablative resurfacing — traditional CO2 or erbium that vaporizes 100% of the surface. Maximum results, maximum downtime.
• Fractional ablative — fractional CO2 or fractional erbium. Strong results with intermediate downtime.
• Non-ablative fractional — devices like Fraxel Restore (1550 nm) or Clear + Brilliant (1440/1927 nm) that create microscopic dermal coagulation columns without breaking the surface. Mild-to-moderate results, minimal downtime.

Fractional Laser Devices

The fractional laser market is crowded, but most devices fall into three families based on wavelength and tissue effect.

Fractional CO2 (10,600 nm)

Fractional CO2 is the most powerful fractional option. The 10,600 nm wavelength is strongly absorbed by water, producing both vaporization and a surrounding zone of thermal coagulation that drives long-term collagen remodeling. Common platforms include:

• Fraxel Re:pair — a focused fractional CO2 originally designed for moderate-to-severe rhytids.
• Lumenis ActiveFX and DeepFX — ActiveFX delivers a broader, more superficial pattern for pigment and tone, while DeepFX uses a narrow, deeper microbeam for wrinkle and scar remodeling. The combination, often called TotalFX, is a workhorse for periocular skin.
• SmartXide DOT, Mixto, and similar platforms — alternative fractional CO2 systems with adjustable density and depth.

Fractional Erbium (2940 nm)

Erbium:YAG is even more water-avid than CO2, which makes it more purely ablative with less surrounding thermal coagulation. Fractional erbium devices such as the Sciton Halo (a hybrid fractional that delivers both a 2940 nm ablative wavelength and a 1470 nm non-ablative wavelength to the same microscopic treatment zones) and traditional fractional erbiums offer slightly faster healing than fractional CO2 with somewhat less dramatic tightening.

Non-Ablative Fractional

Non-ablative fractional devices leave the epidermis intact and rely on dermal microthermal zones to stimulate remodeling:

• Fraxel Restore (1550 nm) — the original non-ablative fractional, useful for fine lines and mild texture; it may be used cautiously for melasma, though melasma is best managed primarily with topical agents and photoprotection because laser can trigger recurrence.
• Fraxel Dual (1550/1927 nm) — adds a thulium 1927 nm wavelength tuned for pigment, sun damage, and actinic keratoses.
• Clear + Brilliant — a lower-energy, lunchtime version of non-ablative fractional, ideal for early prevention and skin maintenance.

Periocular Applications

Few areas of the face benefit more from fractional resurfacing than the periocular region. The eyelid skin is the thinnest on the body, which means it responds beautifully to controlled thermal injury — but also that aggressive ablative treatment carries risk. Fractional technology offers a calibrated middle path.

Common Periocular Indications

• Crow’s feet and fine periorbital rhytids — static lines that remain when the face is at rest.
• Lower eyelid crepiness — the fine, paper-thin texture that develops with sun exposure and aging, often unaddressed by surgery alone.
• Upper eyelid skin texture — subtle improvement when full blepharoplasty is not desired.
• Dyschromia and sun damage — mottled brown discoloration, lentigines, and solar elastosis around the eyes and temples.
• Post-blepharoplasty scar refinement — faint linear scars or transition lines along the lower lid crease can be softened with fractional treatment 6–12 weeks postoperatively.
• Residual lower lid wrinkles after blepharoplasty — surgery removes excess skin and fat, but fine wrinkles often persist and respond to fractional resurfacing.

Fractional resurfacing pairs naturally with broader skin rejuvenation strategies and is often combined with neuromodulators, fillers, and topical regimens for layered results.

Recovery vs Full CO2

The single most important reason patients choose fractional resurfacing over fully ablative CO2 is recovery. Full-field CO2 typically requires 10–14 days of open-wound healing followed by weeks-to-months of erythema. Fractional CO2 compresses that timeline dramatically.

The trade-off is straightforward: fractional treatment requires multiple sessions to approach what a single fully ablative session achieves, but each session is comparatively gentle. Most patients having fractional CO2 can return to work in under a week wearing makeup, while fully ablative CO2 typically requires two to three weeks of careful concealment and ointment-based wound care.

Skin Type Safety

The Fitzpatrick scale classifies skin from Type I (very fair, always burns) through Type VI (deeply pigmented, never burns). Ablative laser energy can trigger post-inflammatory hyperpigmentation (PIH) in darker skin types, and fractional technology has expanded the safe treatment envelope considerably — but not infinitely.

For Fitzpatrick IV–VI patients, non-ablative fractional and RF microneedling are generally preferred over ablative options. When fractional CO2 is used in darker skin, lower densities, longer treatment intervals, and rigorous pre- and post-treatment topical regimens (hydroquinone, retinoids, sun protection) are essential. A thorough consultation with an experienced provider is critical to set realistic expectations and minimize risk.

Combination with Blepharoplasty

One of the most common questions patients ask is whether laser resurfacing can be performed at the same time as eyelid surgery. The short answer is yes — with important caveats.

Same-Day Combinations

Fractional CO2 resurfacing of the lower eyelid skin is frequently performed in conjunction with transconjunctival lower blepharoplasty. Because the transconjunctival approach makes its incision inside the eyelid rather than through the external skin, the skin envelope retains its blood supply and tolerates resurfacing well. This combination is powerful: surgery addresses fat pseudoherniation and structural laxity, while the laser addresses skin texture and fine wrinkles that surgery cannot improve.

Combinations to Approach Carefully

Combining ablative laser resurfacing with a transcutaneous (skin-incision) lower blepharoplasty raises concerns about wound healing along the subciliary incision, where both the skin flap and the laser-treated tissue depend on the same vascular supply. Many surgeons stage these procedures — performing surgery first and resurfacing 8–12 weeks later — to minimize the risk of lower lid malposition from contracture.

Similarly, simultaneous ablative resurfacing of upper lid skin combined with upper blepharoplasty is usually avoided to protect the incision line. Non-ablative fractional treatment, by contrast, can often be performed sooner because the epidermis remains intact.

Realistic Outcomes

Patient satisfaction with fractional resurfacing depends heavily on expectations. The honest comparison with fully ablative CO2 is critical.

What Fractional Resurfacing Does Well

• Improves fine lines and crepey texture by 40–70% over a series of treatments.
• Refines pigmentation, evens skin tone, and softens sun damage.
• Stimulates measurable new collagen production with progressive improvement over 3–6 months.
• Smooths scars, including post-surgical and acne scars.
• Provides a meaningful refresh with manageable downtime.

What It Will Not Do

• It does not match the dramatic wrinkle effacement of fully ablative CO2 in deeply etched lines.
• It does not lift loose, redundant skin — surgery remains the treatment for true dermatochalasis.
• It does not eliminate deep static rhytids in a single session; multiple treatments are typically required.
• It does not replace neuromodulators for dynamic expression lines.

Patients with severe periocular wrinkling, heavy sun damage, and a willingness to tolerate two to three weeks of downtime generally achieve the best results from fully ablative CO2. Patients with moderate fine lines, busy schedules, or darker skin types are usually better candidates for a series of fractional treatments. Many patients ultimately benefit from a tailored combination — a single fractional CO2 treatment alongside blepharoplasty, followed by maintenance non-ablative sessions every 6–12 months.

The Bigger Picture

Fractional laser resurfacing is not a standalone solution to facial aging — it is one tool within a comprehensive rejuvenation strategy that includes surgery, injectables, energy-based devices, and medical skincare. Used thoughtfully, it bridges the gap between non-invasive maintenance and surgical intervention, offering patients a path to better skin quality without the commitment of fully ablative resurfacing.

If you are considering laser treatment around the eyes, the most important step is consultation with a surgeon who understands both the anatomy of the eyelid and the full range of resurfacing technologies. An ASOPRS fellowship-trained oculoplastic surgeon can evaluate your skin, your goals, and your tolerance for downtime, and recommend the device, density, and timing that best fit your situation. To start that conversation, find a doctor in your area for a personalized assessment.