Laser Resurfacing for Skin Renewal

Chapter 1: Introduction:

1.1 Background, history and overview of laser techniques in facial rejuvenation:

1.1.1 History and background of fractional CO2 ablative laser and full-field ablative CO2 laser resurfacing:

Laser resurfacing is the process of improving the appearance by using the laser beam which removes the damaged and unwanted skin tissues thereby making the skin looks younger and beautiful (Ansari et al. 2018). In recent years two most common laser resurfacing techniques are the fractional ablative CO2 laser and the full field ablative CO2 laser resurfacing. The ablative CO2 resurfacing is the widely preferred technique in the modern medical field in which a CO2 laser beam is used to vaporise the water in the topmost layer (epidermis) of skin thereby removing damaged and dead tissues (Artzi et al. 2019).

Laser resurfacing was first mentioned in aesthetic science in 1951 (Arroyo, 2017). Then clinical intervention, evidence-based studies and experiments had been done over the decades on this laser resurfacing process to improve the expected outcomes of this technique. The first laser resurfacing had been performed in 1962 and the second was performed in 1970 (Ansari et al. 2018). Although at those times there was a lack of expertise, skill, technologies and device to aesthetic surgeons, these two-laser resurfacing surgery became highly successful. The concept of CO2 ablative laser resurfacing had been first introduced in the 1980s in the UK (Barrera et al. 2018). During that time ablative CO2 laser resurfacing was performed for removing the sun-damaged skin by using a slow and systematic process to generate the smooth, tight and glowing skin on the face. Evidence suggests that during the late 80s, mainly full field ablative CO2 laser resurfacing was performed by the dermatologists which were not a very organised and well-structured process like it is in recent days. As mentioned by Artzi et al. (2019), in the late 80s as well as in the early 90s, although the full field ablative CO2 laser techniques were proved to be highly useful for skin rejuvenation, the result and associated health outcomes of this technique was highly unpredictable. This is because of the lack of proper controlling measures and supportive technologies in the aesthetic field which made it difficult for dermatologists and aesthetic surgeons to predict and manage the risk that is associated with the post-surgical condition. As mentioned by Boehm et al. (2020), during past times such as 1980 to early 90s due to lack of controlling measure there were high risk of different types of adverse impacts of full-field CO2 laser resurfacing such as skin irritation, skin infection and inflammation scarring, harpix, eczema, dryness and redness on the skin Following the late 90s, dermatologists felt the necessity of well-structured and highly modernised laser resurfacing techniques in which only the target tissues of skin can be removed but not the normal surrounding tissues (Datz et al. 2018). Hence the fractional ablative CO2 laser technique had been introduced. Over the last 10 years, there has been tremendous development in the work process of fractional ablative CO2 laser resurfacing which enables aesthetic surgeons to use laser resurfacing with a high level of expertise in terms of meeting the client needs.

The main laser resurfacing process used today is the fractional ablative CO2 laser resurfacing that assists modern aesthetic surgeons and dermatologists to deal with wide ranges of critical skin issues such as fine lines, scars, stretch marks, wrinkles, burning marks and photodamaged skin (Filippini et al. 2017). As compared to the full field ablative CO2 laser techniques, the fractional laser is highly preferred in recent years which not only enables dermatologists to vaporise only that part of the target skin tissues that are needed to be removed thereby generating the natural healing properties of the underlying layer of skin by producing hyaluronic acids and collagen fibres

1.1.2 Brief overview of full-field and fractional ablative CO2 laser resurfacing:

In the modern era, people are more concerned about the appearance of their facial skin than in previous times. In recent years ageing of facial skin has become a matter of great concern for people as they want to look younger than their age shows (Hamilton et al. 2018). In this context, ablative CO2 laser technology is considered the best solution to all these facial skin issues such as ageing, wrinkle, acne, pigmentation and loosening of facial skin. Nowadays, two major CO2 ablative techniques are widely used by the majority of dermatologists in the UK. These two techniques are the Fractional CO2 ablative laser and full-field ablative CO2 laser technique (Hessler and Trujillo, 2021). The ablative C02 laser resurfacing is a modern and widely preferred technique that is associated with removing the damaged skin tissues by causing vaporisation of the underlying layers of the skin. Both the fractional and full-field ablative CO2 laser resurfacing are widely used in many developed countries such as the UK for carrying out different skin treatments such as facial acne, pigmentation of facial skin, wrinkle, burning spots, dark spots, loose skin and fine lines on face (Issler-Fisher et al 2017).

In both full field and fractional CO2 ablative laser resurfacing CO2 laser is used as it has a wavelength of 10,600 nm that is perfect to be absorbed by the water present in the topmost layer (epidermis) and the underlying layer of skin (dermis) (Kang et al. 2021). The ablative CO2 laser process targets the water of the skin thereby leading to vaporisation of the epidermis and dermis of the skin. Through causing this vaporisation, the ablative CO2 laser technique instigates the natural healing ability of skin thereby leading t the production of the college fibre and hyaluronic acid that are the two most essential elements for forming tight as well as young skin (Lueangarun and Tempark, 2018). Although the purpose and basic process of working are similar in both the fractional and full-field ablative CO2 laser techniques, the latter (fractional) is more preferred and widely used laser technology over the other.

1.1.3 Overview of comparison between full field and fractional ablative CO2 laser resurfacing:

As compared to the full field CO2 ablative laser resurfacing in which the full facial skin is placed under the CO2 laser beam, the fractional ablative CO2 laser technique only targets the skin tissues that are needed to be removed by applying the CO2 laser beam on the particular point of the skin. As mentioned by Mani et al. (2021), in developed countries such as the UK, there is a high demand for fractional ablative CO2 laser techniques over the full fielded CO2 ablative resurfacing, because the former has fewer side effects and a faster healing process than the latter one. Clinical intervention suggests that, as compared to the fractional CO2 ablative laser techniques, clients face different skin issues while they undertake the full field resurfacing such as burning or damaging of surrounding skin tissues, skin infection, slow healing of the skin after the resurfacing and skin irritation (Micheletti et al. 2020).

In this context, Pozner et al. (2021) mentioned that, as compared to full-field CO2 ablative laser resurfacing, fractional CO2 ablative resurfacing is more comfortable in recent years as it does not need full anaesthesia and sedation like full-field CO2 laser. Evidence suggests that it takes more than 1 year for facial skin to completely receiver after the full field CO2 ablative technique is performed. As mentioned by Nicoli et al. (2019), the slower recovery of facial skin in the full field CO2 laser resurfacing as compared to the fractional resurfacing makes it difficult to maintain a normal social life for the client who has undergone this process. PHE (2019), mentioned that there are many cases in England and Wales in which after undertaking the full field CO2 ablative laser resurfacing, people quit attending a social gathering or any social occasion for a long period till their face is fully recovered (PHE, 2019). On the contrary in the case of the fractional CO2 laser techniques, the CO2 laser beam is scattered specifically on the target skin areas as a dot, thereby reducing the risk of damaging the surrounding skin. This is why the healing process of facial skin under this fractional ablative CO2 laser technique is faster than the full field techniques. While comparing the basic techniques of these two ablative CO2 laser resurfacing, it is acknowledged by researchers that the fractional CO2 laser technique is simpler than that in the full field laser technique (Patel et al. 2019). In the case of the full field CO2, ablative laser resurfacing, shortly after activation of the laser device a red square is illuminated on the skin which covers 100% of the topmost layer (epidermis) of skin. Then the CO2 laser beam is scattered over the full facial skin thereby generating heat within the red square thereby leading to the full treatment coverage of the facial skin (Pirakitikulr et al. 2020). This laser beam causes vaporisation of the water of skin thereby removing the damaged cells or tissues that are targeted on the epidermis and dermis. In the case of fractional ablative CO2 laser resurfacing, after activating the CO2 laser beam device, a red square is placed on the particular point of the skin in which the resurfacing needs to be done (Mani et al. 2021). Then the CO2 laser is accumulated on the point of the ski thereby generating heat in the underlying layer of that point (epidermis and dermis). This process of generating heat on the skin thereby causing vaporisation of the water inside the epidermis and dermis of the skin is known as photo-thermolysis. During this process of photo thermolysis, a microscopic thermal zone (MTZ) is developed at the tissue in the epidermis and dermis in which the laser beam is placed (Zhang et al. 2019). The dead and damaged tissues that are located in this MTZ are removed by generating the natural healing capacity of the skin. Therefore, the hyaluronic acid and collagen fibre are generated from the tissues under the MTZ thereby forming the new tissues in the MTZ thereby making the face look younger and beautiful. As compared to this process, in the case of the fractional CO2 ablative laser techniques when the CO2 laser device is activated the red square is placed on the particular target area of skin in which the damaged tissues are located rather than placing the laser square on the full face. In this process, only the target region of the epidermis and some areas of the dermis are vaporised (Pozner et al. 2021). Many clinical interventions show that as compared to the full field ablative CO2 laser techniques, the majority of people in the UK prefer that fractional CO2 ablative laser rejuvenation as the fractional process is simpler and have less risk of skin infection skin irritation and damage to the surrounding tissues.

Although the majority of the clinical researchers have acknowledged the usefulness of the fractional CO2 laser resurfacing over the full field laser techniques. There are many criticisms regarding this comparison. As argued by Rasheed et al. (2021), although fractional ablative CO2 laser techniques have fewer side effects and fewer chances of damaging or surrounding tissues other than the target skin tissues, there are many cases in which dermatologists have no other option but to perform the full field laser resurfacing. For example, in the case of removing the full-face wrinkles, huge burning marks on facial skin, deep spots and loose skin all over the face, full-field ablates CO2 resurfacing more relevant than fractional resurfacing (Sharma et al. 2020). On the contrary, many clinical interventions suggest that in the case of fractional CO2 ablative laser resurfacing dermatologists can easily treat pigmentation on the chin area and the fine lines along on neck regions without having any risk of damages in the other surrounding tissues. On the other hand, as in case of full-field ablative laser techniques, there is no scope for placing the CO2 laser beam on a particular point of the face or neck so that dermatologist is often worried about the risk of damaging on the sensitive skin of neck and chin region (Shehadeh et al. 2021).

1.1.4 Comparative discussion on the usefulness of full-field and fractional laser CO2 techniques in the UK:

In UK fractional CO2 laser is a more demanding and highly preferred method over the full field CO2 ablative method (Shrestha and Karki, 2018). NHS (2019) mentioned in its report that, in the aesthetic field, the fractional CO2 laser is considered as a revolutionary invention, which enables people in the UK to treat all kinds of facial skin issues such as scars, pigmentation, acne, burning sorts, dark spots, loose skin, superficial hyperpigmentation and stretch marks (NHS, 2019). As mentioned by Sipprell et al. (2020), while it comes to the cost-effectiveness of these two CO2 laser resurfacing, the fractional CO2 ablative laser technique is more cost-effective than the full field process. In full-field CO2 resurfacing laser beam is placed all over 100% of that topmost layer (epidermis) of the facial skin thereby more CO2 laser is used as compared to fractional resurfacing techniques which enhance the management and operation cost. PHE (2019) mentioned that more than 34% of women aged 45 or above in the UK face facial skin issues that impact adversely their mental and social wellbeing (PHE, 2019). As stated by Tabaie et al. (2018), nowadays aesthetic science becomes one of the most demanding fields with high scope improvement this is because, people in the UK and other developed countries such as the US are more concerned with their facial beauty, which leads to the prioritisation of different aesthetic process for facial rejuvenation and skin resurfacing. NHS (2019) mentioned that in the recent year more than 36% of people go through ablative CO2 laser surgery for maintaining that facial rejuvenation, out of which more than half of people undertake the fractional ablative CO2 treatment (NHS, 2019). Not only the clients in the UK but also the majority of dermatologists and aesthetic surgeons in the UK prefer to use the fractional CO2 laser techniques for facial skin resurfacing over the full field ablative CO2 resurfacing because the fractional technique is simpler and less risky as compared to the full field techniques (Vanaman et al. 2017). On the other hand, the management and administration cost in the case of performing the fractional techniques is lower than that of the full field techniques which helps the middle class and upper-middle-class people to better afford the fractional resurfacing over the full-field resurfacing. Aesthetic surgeons and dermatologists in the UK acknowledged that a high level of expertise and skill is needed in performing both the full field and fractional ablative CO2 laser technique (Verma and Raggio, 2020). Although fractional CO2 laser is widely used as well as a more demanded process in the UK over the full field laser technique, there are some limitations of fractional laser technique that need to be considered by aesthetic surgeons while performing this resurfacing process (Waibel et al. 2020). First, as compared to the full field CO2 laser, in the case of factional laser the risk of reappearance of acne, hyperpigmentation, wrinkles and stretch marks on facial skin is higher. This is because as in the fractional CO2 laser, only a particular point of skin is treated under the CO2 laser beam, if not performed by the skilled and well-trained surgeon, the entire target tissues of the epidermis may not be covered under the CO2 laser beam (Zhang et al. 2021). Therefore, the part of the dermis that is connected to the target tissues of epidermis that are not under the CO2 laser beam can again develop the scars and acene in near future which need further resurfacing. This is the reason why some people UK still prefer the full field ablative CO2 laser treatment (Zhang et al. 2019). PHE (2019) mentioned that there are many cases in the England in which people who have undergone the fractional laser treatment suffer from further skin pigmentation and infection as the procedure is not performed skilfully (PHE, 2019). On the other hand, while performing the fractional laser, aesthetic surgeon must consider that they must be well trained and highly skilled in placing the laser beam device in such a manner so that the red square of the CO2 laser will scatter over the target area but not on the areas other than the target tissue. Many cases have been registered in the UK in which due to the negligence and lack of skill of the aesthetic surgeon the laser beam is not placed on the target skin tissues properly which led to the burning and infection of the other skin area.

1.1.5 Overview of drawbacks of the fractional ablative CO2 laser and the full field ablative CO2 laser techniques:

Although both the fractional and full-field ablative CO2 laser treatment is highly useful in skin rejuvenation (Ansari et al. 2018). There are some associated drawbacks or risk factors that need to be considered by aesthetic surgeons while performing these processes. Clinical intervention suggests that, unlike the full field ablative CO2 laser technique which is invasive process, the fractional CO2 laser technique is a non-invasive process. Therefore, the risk of post-operative skin issues is less in case of fractional CO2 laser techniques. As mentioned by Artzi et al. (2019), in the fractional and full field laser process, the CO2 beam is scattered on the facial skin to vaporise the topmost layer of the damaged or aged skin by causing absorption of CO2 laser into water in the epidermis and some portions of the dermis. NHS (2019) mentioned that, in the fractional ablative resurfacing process, the post-operative damages on the facial skin are well controlled by using modern techniques and tools thereby fastening the overall healing process (NHS, 2019). If not performed skillfully, adverse impacts of these two ablative CO2 laser techniques are the redness of the face, extra dryness of skin, loss of the normal pigmentation, dullness on skin, skin infection and inflammation. Any negligence in performing a fractional or full field ablative process can cause the vaporisation of the surrounding skin that is associated with bacterial colonisation or pathogenic attack on the skin. In the UK, aesthetic surgeons and dermatologists must comply with the guidelines of NICE for ensuring the patients' safety before, during and after the ablative CO2 laser surgery (Datz et al. 2018). Under NICE (2019), while performing the fractional or fulfilled ablative CO2 techniques, aesthetic surgeons in the UK must conduct an effective physical health assessment of the client to get detailed information regarding their physical health condition (NICE, 2019). In both cases of fractional and full-field ablative CO2 laser resurfacing, aesthetic surgeons need to obtain medical reports of their clients to check whether they have any chronic health condition, complex health condition, allergies, COPD, skin infection to different antibiotics and genetic history of sensitive skin. As mentioned by Filippini et al. (2017) the types and characteristic features of skin are different in various people. This is why each skin type reacts differently to various pathogens and antigens. Thereby while performing the ablative fractional or full field CO2 laser resurfacing, the aesthetic surgeon ensures that there are no chances of any bacterial or pathogenic infection on the skin due to the use of the laser devices. NMC (2019) mentioned the healthcare staff who work in the team of aesthetic surgery must have clear knowledge on medicined administration and medicine management which will enable them to ensure that the rights antibiotics and anaesthesia are administered into patient's body during the process of fractional and full-field CO2 laser resurfacing thereby eliminate the risk of any; pathogenic infection (NMC, 2019). NICE (2019) mentioned that on both the fractional and full-field ablative CO2 laser resurfacing, aesthetic surgeons, dermatologists, nurses and other health staff must use the ANTT (Aseptic Non-Touch Technique) in terms of maintaining the hygienic and aseptic environment in the operating room. In this context, Hamilton et al. (2018) mentioned that, while performing any of the fractional or full field ablative CO2 laser, aesthetic surgeons, make sure that medical equipment, dermatological devices, laser devices and surgical instruments are maintained in aseptic condition to restrict the entry of any kind of pathogens into patient's body.

1.2 Research aim:

This research study aims to compare the efficiency of fractional ablative CO2 laser resurfacing with full-field ablative CO2 laser in relation to discuss the benefits and limitations of both processes.

1.3 Research objectives:

To determine the usefulness and efficiency of full-field ablative CO2 laser resurfacing in relation to facial rejuvenation

To identify limitations and drawbacks of full-field ablative CO2 laser in terms of performing skin rejuvenation

To analyse the efficiency of the fractional ablative CO2 laser in performing facial rejuvenation

To determine the limitations and side effects of the fractional ablative CO2 laser resurfacing

To make a comparative analysis on the effectiveness and limitations of the fractional and full fielded ablative CO2 laser resurfacing

To recommend some effective strategies to the aesthetic surgeon and dermatologist that they can use in both full field and fractional CO2 laser resurfacing for improving the outcomes of these process

1.4 Research questions:

In a patient having (facial hyperpigmentation, ageing and photodamage) is the (full field ablative CO2 laser treatment) would be effective, useful and safe for performing (facial rejuvenation)?

In a patient having (facial hyperpigmentation, ageing and photodamage) on the face is the (fractional ablative CO2 laser technique) wound be relevant, safe and useful in carrying out the successful (facial rejuvenation)?

Comparative discussion of full field and fractional ablative CO2 laser resurfacing in treating a patient having (facial hyperpigmentation, ageing and photodamage)

1.5 Research rationale:

In recent years there is a trend of facial beautification through undertaking laser resurfacing techniques (Kang et al. 2021). Two major laser resurfacing techniques that are widely performed by modern aesthetic surgeons are the full field ablative CO2 laser resurfacing and the fractional ablative CO2 laser resurfacing. These two laser techniques are highly useful in treating a wide range of skin issues such as the face, facial hyperpigmentation, scars, stretch marks, wrinkles, fine lines, dark spots, ageing, loose skin on the face and facial burning marks. Although both the full field and fractional laser techniques are useful and effective in carrying out a safe facial rejuvenation, fractional laser techniques are more proffered by the clients and dermatologists in the UK as well as in other developed countries than the full field laser techniques (Lueangarun and Tempark, 2018). This is because the fractional ablative CO2 laser resurfacing is cost-effective, has less recovery time, work on only the target skin tissues and has a lower risk of skin infection inflammation and eczema. Clinical intervention suggests that as compared to the fractional laser, in the case of full-field laser there is high risk of healthcare-associated infections such as the needle stick infection or blood-borne infection if proper controlling measures are not taken by the aesthetic surgeons while performing the process (Hessler and Trujillo, 2021). While performing the fractional or full field ablative CO2 laser resurfacing, modern aesthetic surgeons and dermatologists can use the Fitzpatrick Skin Type Chart in determining the risks of severity of infection, burn and redness on different types of skin after applying CO2 laser beam (Lueangarun and Tempark, 2018). Fitzpatrick Skin Type Chart provides the option to the aesthetic surgeon in determining the possible impacts of ablative CO2 laser on 6 different skin types such as white and very fair, white of fairy, beige, beige with that brown tint, black and dark brown (Hessler and Trujillo, 2021). After observing the skin type of a client, dermatologists and aesthetic surgeons can easily use this chart to determine what possible risk factors are associated with the skin type of the client on applying the ablative CO2 laser. As mentioned by Sipprell et al. (2020), the Fitzpatrick Skin Type Chart is proved to be highly useful and widely preferred tools in modern aesthetic world, which enables the aesthetic surgeon to use proper safety measures to apply appropriate methods and procedures of CO2 laser resurfacing to avoid chances of any skin issue.

In modern aesthetic world, the effective and safe implementation of the CO2 ablative laser techniques has become a major issue, because any kind of negligence in performing the fractional or full field CO2 ablative laser resurfacing can lead to severe skin infection and incurable inflammation (Pirakitikulr et al. 2020). On the other hand, there is severe conflict and contradiction in the viewpoint regarding the comparative usefulness and safety of fractional ablative CO2 laser and the full field ablative CO2 laser process which makes it confusing for the modern aesthetic surgeons and dermatologists to choose the more effective techniques (Pozner et al. 2021). In this context the selection of this research topic, ‘the comparative analysis of the fractional ablative CO2 laser resurfacing with the full field CO2 ablative laser resurfacing" is best suited and highly relevant to current context of the facial rejuvenation. This topic will provide a new insight on the comparative discussion of fractional and the full field CO2 laser resurfacing by presenting the clear discussion on the effectiveness, safety and drawbacks of each of these two techniques in relation to conduct the facial rejuvenation. Additionally, this research study will also present the evidence-based information regarding comparative use of fractional and full field; CO2 laser resurfacing in the UK, which will assist the modern dermatologist and aesthetic surgeons regarding which process of these two (fractional and full field) techniques can be more effective in term s of treating skin issues. Through conducting the research study, the researcher will not only present the clear comparative discussion on the efficiency and safe use of the fractional ablative CO2 laser and the full field ablative CO2 laser resurfacing but also the researcher will also determine the factors that need to be considered by the modern dermatologists in the UK to overcome all the limitations as well as challenges associated with these techniques. These factors are the current physical health condition of client, presences of critical or chronic health condition in client, the presence of complex health condition, asthma or COPD, whether the client undergone any previous surgery and client’s mental health condition. Additionally, this study will also provide the effective health care information to public for improving their ability to select the best suited ablative laser resurfacing between the fractional and full field CO2 laser techniques to get the better facial skin.

Chapter 2: Methodology

2.1 Materials and methods:

2.1.1 Search strategy:

Good research must mention a clear and concise research methodology in which there must be a detailed description of which methods, as well as research tools, are used by the researcher to accomplish the entire research (Feng et al. 2017). A search strategy can be defined as the methods that are used by a researcher to search for the relevant research articles on the research topic while conducting any secondary research study (Eriksen and Frandsen, 2018). Many theorists defined the research methodology as the technique that is used in a research study to collect the relevant database for meeting research objectives as well as answering all the research questions (Snyder, 2019). There is various processes or techniques of gathering relevant database for conducting a successful research study such as survey, semi-structured interview, direct observation in case of the primary research study. On the other hand, in the case of conducting secondary research methodology, researchers use online databases to retrieve appropriate research papers on the selected research topic (Bramer et al. 2018). This is a secondary research study in which the researcher has used the appropriate online database in terms of retrieving the relevant research papers that are highly useful in providing evidence-based information on the research topic. As mentioned by Dowd et al. (2018), each secondary research must have a detailed discussion on the search strategies such as inclusion and exclusion criteria, keywords, Boolean operators, limiters and expanders and the online database. In this secondary research study, the researcher has used appropriate online database such as CINAHL, British National Index (BNI), PubMed, PsycINFO via OVID and Cochrane Library (Central Register of Controlled Trials) (Feng et al. 2017). The researcher has used the appropriate key terms while using these online databases to retrieve the research articles that have valid and highly relevant information on the research topic (the comparative analysis of the fractional ablative CO2 laser and full-field ablative CO2 laser resurfacing) (Oztemel and Gursev, 2020). After retrieving the research articles by using an online database such as Cochrane Library (Central Register of Controlled Trials) it is seen that there are many duplicates and repetitions of the research papers (Bramer et al. 2018). Due to these issues the entire search by using Cochrane Library (Central Register of Controlled Trials) has been removed from the selection list and the only research articles that are retrieved by using other online databases (CINAHL, British National Index (BNI), PubMed, PsycINFO via OVID) are used in this research study. As mentioned by Paul and Criado (2020), while retrieving the relevant research papers by using appropriate keywords and relevant online database, the researcher needs to ensure that sufficient keywords are used in the online database for generating the search result that is enough to provide the sufficient evidence-based information on the research topic (Eriksen and Frandsen, 2018). Many theorists have mentioned that there are many cases in which the number of keywords used by the researcher while using the online database is not enough in obtaining sufficient search result which then interferes with the generalisability and validity of the entire secondary research study (Eriksen and Frandsen, 2018). As mentioned by Paul and Criado (2020), generalisability can be defined as the quality of any research study to present evidence-based information on the research topic thereby benefiting the entire community by providing new insight on the selected research topic. In this research study, the researcher has used few highly relevant key terms such as fractional laser* OR, ablative, resurfacing* AND, full filed laser* OR ablative CO2 laser* And facial rejuvenation* OR facial beautification. After using these keywords, it has been seen that the search result that is obtained through using these keywords is not sufficient to have enough evidence-based information on the research topic which can interfere with the ability of this research in meeting the research objectives. In this context the research has used some other related keywords to expand the; literature searches such as non-ablative* OR resurfacing* AND *hyperpigmented treatment AND* skin ageing OR neck resurfacing* OR microscopic thermal zone * AND photo thermolysis*.

Following keywords have been used by the researcher in this secondary research study:

2.1.2 Keywords:

2.1.3 Inclusion and exclusion criteria:

Inclusion criteria:

In this secondary research study, the researcher has used inclusion criteria to search for the relevant research papers that could provide evidence evidence-based and highly authentic information on the research topic thereby assisting this research study to meet the research objectives. As stated by Feng et al. (2017), the inclusion criterion can be defined as the checklist that contains different parameters that are used in a secondary research study to measure the validity and authenticity of all the research papers that are retrieved by using the online database. Many theorists have mentioned that inclusion criteria are the sets of criteria that are used by researcher to select highly relevant research articles on the research topic (Eriksen and Frandsen, 2018). Here the researcher has set a time scale of 5 years, in which only the research papers that are published within the 2016–2021-time frame is selected in this research study. As mentioned by Snyder (2019), the time frame is the most important inclusion criterion that enables the researcher to select current and UpToDate research papers on the research topic. In this research study, the researcher has set the five years times frame because it assists the researcher to retrieve such research articles that represent modern viewpoints and highly relevant database on the fractional and full-field laser resurfacing that can be used in this research study to meet all the research objectives. The English language has been set as the prime language for selecting research articles in this research study which has assisted the researcher to select such research articles that are published only in English but not in other languages (Bramer et al. 2018). As mentioned by Paul and Criado (2020), language is one of the most important inclusion criteria that a researcher needs to select for ensuring that future researchers and readers will easily understand the language of this research study thereby ensuring the beneficence and transferability of this research findings. Many theorists mentioned in this context that, English is the international language that can be understood by all people across the world. In this context, the selection of the English language for retrieving the relevant research papers for this study is highly valid and appropriate which assists the researcher of this study to maintain the generalisability and transferability of this research findings (Eriksen and Frandsen, 2018). While using the online database such as CINAHL, PubMed and BNI, many research papers are retrieved that are not published in English that are excluded from the selection list. The research papers that are fully accessed from the internet are selected for this secondary research (Bramer et al. 2018). While using the online database and keyword for retrieving relevant research articles for this research study, many articles are paid research papers and could not be accessed freely from the internet. These research papers are not included in the list.

In this secondary research study, the researcher has checked the relevance of the content of each research papers by evaluating the appropriateness of the abstract, data collection, data analysis, reference list, finding and conclusion of the research papers. As mentioned by Oztemel and Gursev (2020), while collecting research papers for conducting any secondary research study the researchers need to ensure that all research papers that are retrieved from the online database must be highly relevant to the selected research topic. Here the researcher has analysed the validity and authenticity of all the research elements of each research article thereby ensuring that all the research papers that are in the section list are highly relevant to the selected research topic.

Exclusion criteria:

According to Paul and Criado (2020), exclusion criteria can be defined as parameters to measure the level of irrelevance and inappropriateness of the selected research papers for excluding them from the selection list to maintain the validity of the literature search. Here the researcher has used the exclusion criteria to narrow the literature search and retrieve the only researcher papers that are highly relevant and appropriate to the selected research topic (Feng et al. 2017). Here the research articles that discuss laser resurfacing but not specifically discuss the full field and fractional ablative Co2 laser resurfacing are excluded from the list. The research articles that are published before 2016 are excluded from the selection list (Bramer et al. 2018). Moreover, the research papers that are published in a language other than English are not selected for this study. Research articles that although having the relevant content on the fractional and full-field CO2 ablative laser resurfacing do not contain proper research methodology and abstract are also excluded from the selection list.

2.1.4 Boolean operators:

While using the above-mentioned key terms Boolean operators (OR, AND NOT) are used to expand or limit the search results. As mentioned by Snyder (2019), in any secondary research Boolean operators are generally used by the researchers to expand the entire search for obtaining more search results or narrowing or limiting the entire search for reducing the search results. AND and OR operators are used in this secondary research to expand the search result (Bramer et al. 2018). On the other hand, the NOT operator has been used to narrow the entire search. As mentioned by Paul and Criado (2020), while narrowing or limiting the literature search the researcher needs to ensure that at the end of the search, the search result that will be obtained would be sufficient to provide the high value and highly relevant evidence-based information on the research topic. In this secondary research while retrieving the research articles on the full field ablative CO2 laser resurfacing all the Boolean operators such as AND, OR and NOT are used which retrieve the huge number of research papers from which it has been difficult to collect the relevant and evidence-based information on the research topic (Eriksen and Frandsen, 2018). In this context, NOT and AND Boolean operators are again used to narrow the entire search thereby retrieving only relevant and highly applicable research articles. On the other hand, while retrieving research papers on the fractional ablative CO2 laser resurfacing only the OR and AND operators are used by the researcher because unlike the full field ablative laser CO2 resurfacing, while using keywords on fractional ablative resurfacing on the online database the number of search items is few. Therefore, further narrowing of the literature is not needed in case of retrieving research papers on the fractional ablative CO2 resurfacing. By expanding and narrowing the literature search finally, 11 research papers are selected for this research study.

2.1.5 Search result:

By using the online database, inclusion and exclusion criteria and Boolean operators following search results are generated:

Chapter 3: Results:

By using the above-mentioned online database (CINAHL, PubMed, BNI) total of five research papers are selected for this study, which is highly relevant and appropriate to provide evidence based and authentic information on the selected research topic. From these five research papers, the evidence based and highly authentic database are extracted which are used to develop different themes. By conducting the effective data extraction following total 4 themes are developed which are as follows:

Theme 1: Efficiency of full-field ablative CO2 laser vs fractional ablative Co laser resurfacing for skin rejuvenation:

CO2 laser skin resurfacing is highly useful method in ablating the UV-damaged skin, acne, scars, deep spots on skin, superficial skin, fine lines and deep wrinkles and burning marks on the facial skin (Tierney et al. 2011). In the modern aesthetic world, ablative Co2 resurfacing is a highly demanding technique that provides the face a flawless and balanced tone by tightening the facial tissues located in the underlying layers (epidermis and dermis)(Trelles et al. 2011). The CO2 laser resurfacing is performed in two ways as either the entire superficial or outer layer of the facial skin which is called ablative layer is removed by using the CO2 laser, (in case of full-field) or only a fraction or percentage of the tissues located in the epidermis is removed (fractional laser method) (Chen et al. 2017). Although both the full field and fractional ablative CO2 laser resurfacing are useful in treating all types of above-mentioned facial skin issues in the modern aesthetic field, modern dermatologist, as well as aesthetic surgeons, generally prefer to use the fractional ablative techniques more than the full field ablative CO2 laser resurfacing process (Mani et al. 2021).

Subthemes:

Effectiveness of the photo thermolysis (PT) process in fractional ablatives resurfacing vs full field resurfacing:

As mentioned by Mani et al. (2021), while comparing the effectiveness of the full field and fractional laser resurfacing, it needs to be acknowledged that although both techniques provide the expected results to clients, fractional ablative CO2 resurfacing is a more demanding and preferred technique in recent times as compared to full-field resurfacing. As mentioned by Zhu et al. (2016), many factors are associated with this more preferences of fractional ablative CO2 resurfacing over the full-field resurfacing. The most important factors in considering the comfort zone of clients while carrying out entire laser techniques. Majority of the aesthetic surgeons in the UK prefer to use the fractional CO2 ablative process, because the overall process of scattering and illuminating the laser beam on the facial skin is simpler that than in the full field process which makes the client feel more comfortable while performing the fractional process (Mei and Wang , 2018). During the fractional resurfacing the CO2 laser device is placed at such an angle to the facial skin of the client in which the CO2 laser would directly focus on the particular fraction or point of the facial skin. As stated by Zhu et al. (2016), in the fractional CO2 ablative laser resurfacing, the CO2 beam is placed on the particular point of facial skin thereby generating heat on the skin tissues located in the epidermis and dermis thereby causing the ablation or removal of superficial skin tissues. As compared to the full field resurfacing, in the case of the fractional resurfacing only particular points of the underlying skin tissues are targeted such as the areas in which the fine lines or wrinkles are prominent on the face under eyes or neck (Garcia and Badin, 2019). During the fractional laser resurfacing, when the CO2 laser device is activated a red illumination square is placed on the target skin of client’s face thereby generating heat on the topmost layer (epidermis) which leads to vaporisation of water inside this layer (Nistico et al. 2021). During this vaporisation of water in underlying skin layers, the tissues located in the epidermis are damaged and removed from the target area. As compared to the fractional resurfacing, in case of the full field laser resurfacing as the red illumination square covers all over the face, more heat is generated on the face which is absorbed inside the entre superficial layer (epidermis) and the layers beneath the epidermis (Verma and Raggio, 2020). This is why in case of full field laser resurfacing there are high chances of burn, infection and inflammation on the facial skin

Remodelling of collagen on facial skin:

According to Mei and Wang (2018) although in recent years both the full field and fractional ablative CO2 laser resurfacing do their jobs effectively, the result of the fractional ablative resurfacing is more dramatic and amazing as compared to the full field process. As mentioned by Nistico et al. (2021), collagen fibre is the long fibrous protein that plays crucial roles in proving proper structure to the skin tissues and cells by holding them together. On the other hand, hyaluronic acid present in the facial skin after birth but as the age grows this compound is reduced in the skin and finally, it disappears in the middle age skin. Hyaluronic acid plays crucial roles in retaining the moisture inside the epidermis and dermis of the facial skin thereby making the skin looks younger (Hui et al. 2017). As compared to the full field laser resurfacing, as the entire face is covered under the illumination square, therefore the amount of heat that is generated in this process is higher than that in the fractional resurfacing. This is why in the full field laser resurfacing the high amount of heat is absorbed in the topmost layer of the skin which makes it difficult for the skin to regenerate the college remodelling and natural healing ability, in this context Robati and Asadi (2017) mentioned that, as the fractional resurfacing is associated with collagen remodelling of facial skin, in the process clients experience fewer recovery times( only 3-4 months) and more brightened and balanced tone on the skin which make people more attracted towards the fractional laser technique over the full filed resurfacing.

Downtime process and healing period of the fractional vs full filed laser resurfacing:

Downtime for performing the ablative laser CO2 resurfacing is lower in the case of fractional resurfacing than in full-field resurfacing. As mentioned by Robati and Asadi (2017), downtime can be defined as the actional time that is required to perform an entire technique or process. In the modern era, the majority of the people in the UK and other developed countries prefer fractional laser resurfacing due to its less downtime which allows clients to be exposed to the CO2 laser for less time as compared to the full field laser resurfacing there reducing the chances or risk of harm to the facial skin during the resurfacing process (Hui et al. 2017). The healing period in the case of fractional laser resurfacing is lower than that in the full field ablative Co2 laser resurfacing. As mentioned by Riggs et al. (2007), the less healing time in case of clients who undergo the fractional resurfacing as compared to the clients who undergo the full field resurfacing enhances the attraction and demand for undertaking the fractional ablative CO2 laser resurfacing for the skin rejuvenation in the UK. In case of the fractional laser resurfacing as only a fraction of the facial skin tissues is removed or ablated and the remodelling of collagen fibre is instigated through absorption of the laser deep into the underlayer of the dermis, the facial skin heals faster as compared to the full field laser resurfacing (Hedelund et al. 2006). Clinical intervention suggests that in case of the facial laser resurfacing while the laser is applied on a particular point of facial skin a microscopic thermal zone (MTZ) is developed inside the skin in the epidermis (Hui et al. 2017). The tissues that are located in the MTZ absorbed the laser beam from the skin and then undergoes vaporisation. Following this vaporisation, the natural healing capacity of the skin is encouraged by instigating the production of collagen fibre. This is why in fractional laser resurfacing it takes hardly 3-4 months for the facial skin to heal completely as compared to the more than 2-3 years in case of the full field ablative laser resurfacing. PHE (2019) mentioned that there are many cases in the UK, in which the healing times is so long that makes people feel difficulties to maintain the normal social life, as they feel embarrassed to meet with friends, relatives and neighbours with the improperly healed face.

Risk factors associated with full-field vs fractional ablatives resurfacing:

The clinical intervention has shown that the risks of postoperative infection, irritation and inflammation of the face are associated with the fractional ablative CO2 resurfacing is lower than that in the full field ablative resurfacing. As mentioned by Garcia and Badin (2019), although there are risks of severe inflammation and infection on the face in case of both the full field and fractional laser resurfacing of the techniques is not performed by an expert, the severity and chances of different types are higher in case of the full field resurfacing as compared to the fractional resurfacing. Evidence based report suggests that if proper controlling measures are taken while performing the fractional ablative laser resurfacing the risk of facial irritation, inflammation, redness and dryness can easily be overcome (Mani et al. 2021). Many aesthetic surgeons in the UK believe that as in the case of full-field ablative CO2 laser resurfacing the risks of infection, dryness, redness, burn and inflammation of the facial skin are more as compared to the fractional process, because of many factors that are associated with the full field ablative CO2 laser resurfacing. One of these factors is the exposure of the entire face to the CO2 laser beam for long period during the surgery which generates more heat all over the face which is absorbed by the topmost layers of the skin (epidermis) even in the underlying layer (dermis) (Wei et al. 2021). If the full field laser resurfacing not performed by the experts, the photo thermolysis can cause a burn on the facial tissues located in the superficial layer of the skin thereby causing severe scars, redness and inflammation of the skin. Additionally, there are also risks of needle stick infection and blood-borne infection at the pre-operative phase of both fractional and full-field resurfacing due to the negligence or lack of skill of aesthetic nurses in taking safety measures while collecting blood from the client’s body (Robati and Asadi, 2017). On the other hand, as compared to the fractional laser resurfacing in which local anaesthesia is done in the particular fraction or point of the face in which the laser beam is going to be applied which does not lead to any health risk or life risk for the client.

Theme 2: safety measures that are considered both full filed and fractional ablatives CO2 laser resurfacing:

As mentioned by Tierney et al. (2011), although fractional CO2 resurfacing is the more preferred and demanding technique as compared to the full field resurfacing in the modern era, while performing both these techniques dermatologists as well as aesthetic surgeons need to maintain the important controlling measures in terms of avoiding the risk of any kind of errors before during and after the CO2 laser resurfacing. NICE (2019), mentioned that aesthetic surgeons must ensure that they have an in-depth understanding and expertise in performing fractional or full field laser resurfacing for ensuring patient’s safety throughout the process (NICE, 2019). NMC (2019) mentioned that before performing the ablative laser resurfacing, nurses must take the informed consent from the client to ensure that client is agreed with the procedure, terms and conditions of the laser resurfacing (NMC, 2019). During this informed consent, aesthetic surgeons must ensure that their clients are properly informed about the entire methods, benefits, healing time, downtime and the associated risks of the CO2 ablative laser resurfacing. Professional expertise and clear knowledge on performing the safe process of ablative laser resurfacing are important for aesthetic surgeons to eliminate the chances of any kind of errors or flaunts (Robati and Asadi, 2017). Proper controlling measures that the aesthetic surgeons must take while performing any of the full field or fractional laser resurfacing are, safe intramuscular administration of the anaesthesia, safe use of the laser device, maintain proper control on scattering and illuminating high-resolution CO2 laser and use of ANTT techniques (Aseptic Non-Touch Technique) (Chen et al. 2017). If any of these safety measures are not taken into consideration while performing any of the fractional and full-field ablative CO2 lasers resurfacing then clients can experience the following risks after the laser surgery

Redness and dryness on facial skin (Robati and Asadi, 2017)

Facial skin infection such as needle stick infection and blood-borne infection

Swelling on facial skin and severe pain

Infection in the neckline (Chen et al. 2017)

Scarring on skin

Dyspigmentation and hyperpigmentation

Burn on the skin

Pruritus’

Theme 3: complications of the fractional ablatives CO2 laser resurfacing:

As mentioned by Robati and Asadi (2017), although fractional ablative CO2 laser resurfacing is more useful in treating different types of facial skin issues as compared to full-field ablative laser resurfacing, if not performed with the proper expertise, clients may face several complications on their face. The common risk or complication on the facial skin that the client face after the fractional laser resurfacing surgery is eyelid scarring. As mentioned by Galal et al. (2019), in the case of people aged above 55 years the risk of lower eyelid scarring is higher after the fractional ablative laser surgery as compared to young people. The reason behind this is considered as the adverse impacts of different preoperative medicines such as oral diazepam, lidocaine and prilocaine cream and lidocaine and epinephrine nerve blocks on the facial skin of clients (Borges et al. 2016). The authors also stated that there are many cases of clinical negligence and medication errors, in which aesthetic surgeons do not check whether these preoperative medicines would be relevant to the current health condition of the patients which then interferes with the overall success of the fractional laser resurfacing. Other common complications experienced by the client after the fractional skin resurfacing surgery are the appearance of scarring bands on the neckline and Staphylococcus aureus infection on the neck and jawline (Clementoni et al. 2013). this infection is caused at the post-operative period of the fractional laser resurfacing due to negligence and lack of skill of aesthetic nurses in using the proper aseptic techniques, and ANTT process. Many studies have mentioned that, although the fractional laser is more effective than the full field laser resurfacing in case of fractional resurfacing as only a fraction of facial skin tissues is treated by applying CO2 beam on target areas or fraction of skin tissues, there are high chances of the redevelopment of scars, pigmentation and acne on the skin (Yalici-Armagan and Elcin 2018). Moreover, while it comes to overcoming the complication that are associated with both fractional and full field laser resurfacing aesthetic surgeons and dermatologist must use the Fitzpatrick Skin Type Chart. It will provide the option to the aesthetic surgeon in determining the possible impacts of ablative CO2 laser on 6 different skin types such as white and very fair, white of fairy, beige, beige with that brown tint, black and dark brown (Clementoni et al. 2013). The following table shows the six-skin type of Fitzpatrick Skin Type Chart that is used in the CO2 ablative laser resurfacing. [see the table of Fitzpatrick Skin Type Chart in appendix 3}

Chapter 4: Critical appraisal:

Tierney et al. (2011) present a systemic literature review on facial skin rejuvenation by using fractional CO2 laser resurfacing. This research paper highlights the usefulness of fractional photo thermolysis by using the CO2 ablative laser beam to remove the hyperpigmentation and photodamaged skin by improving the texture and appearances of the facial skin by treating photoaging. In this context, Chen et al. (2017), mentioned that skin rejuvenation by using fractional and full laser resurfacing is a highly demanding technique in which skin issues on the face occurring due to ageing and photodamage on the skin can easily be treated with Co2 laser beam that offers patients with high-quality facial skin rejuvenation. The research paper by Tierney et al. (2011) is useful in highlighting the importance of fractional laser resurfacing in performing skin rejuvenation by treating wide ranges of facial skin issues such as hyperpigmentation, facial photodamaged skin on the face and loosening of facial skin due to ageing. Alternatively, the research paper by Trelles et al. (2011) argued that while it comes to facial skin rejuvenation by using either fractional or the full field ablative CO2 laser resurfacing there are some associated health complications and challenges that the modern aesthetic surgeons must take into consideration. These health complications are post-operative infection, burning marks on the face of the patient, lack of moisture on the patient's face and scaring. Although the research article by Tierney et al. (2011) has successively discussed the importance of fractional CO2 laser in performing skin rejuvenation, it is failed to discuss all these health complications that are associated with fractional laser resurfacing. Also, this research paper by Tierney et al. (2011) fails to discuss the controlling measures that modern aesthetic surgeons in the UK and USA take to overcome all these risks to patients after facial skin rejuvenation surgery. Zhu et al. (2016) mentioned in their research paper that the safety and efficacy of fractional ablative laser resurfacing while it is used in combination with topical type A botulinum toxin for treating photodamaged skin and facial ageing. This research paper has mentioned that, in the case of conducting fractional laser resurfacing for skin rejuvenation, the patients need to undertake multiple series of therapies which pose economically as well as psychological burdens on patients. Additionally, in this fractional laser resurfacing there is a high chance of different facial skin issues such as post-inflammatory hyperpigmentation (PIH), facial acne, scars, infection, erythema and rhytids which not only interred with the facial appearance of people but also spoil their social life. Zhu et al. (2016) perfumed a randomised controlled trial in which fractional laser resurfacing had been applied on 20 female patient's faces along with topical type A botulinum toxin (BTX-A) for performing skin rejuvenation. BTX-A is one of the seven most effective neurotoxins which is strongly associated with an increased rate of collagen production by reducing its degradation rate under the facial skin.

On supporting this view Mei and Wang (2018) mentioned in their research articles that, although in the modern aesthetic field, the majority of patients demand fractional laser resurfacing for skin rejuvenation, many risk factors are associated with this process. () mentioned that in the case of performing fractional laser patients can face several facial skin issues if proper controlling measures are taken while performing epidermal and dermal removal, trans-epidermal administration of different drugs and removal of bone marrow mesenchymal stem cells. Zhu et al. (2016) mentioned in their research paper that the Stem Cells Secreting Factors are activated during using the fractional laser resurfacing along with the BTX-A which not only increase the production of stem cells but also leads to reepithelialisation by increasing the formation of fibre and proteoglycans, thereby replacing the dead, old and damaged facial skin tissue by the new one. One of the major drawbacks of the research paper by Zhu et al. (2016) is that it fails to discuss the challenges that can be faced by modern aesthetic surgeons while performing fractional laser resurfacing along with BTX A. Also this research paper fails to discuss the controlling measures that aesthetic surgeons and dermatologists need to consider while performing the fractional laser along with BTX-A for providing the client with the good facial appearances by conducting high-quality skin rejuvenation. Garcia and Badin (2019) described in their retrospective study that, ablative CO2 laser resurfacing with the incision is highly effective as well as safe techniques in terms of treating the two common issues of facial ageing such as dermatochalasis and periocular rhytids. This research paper presented the findings from the observation that has been conducted on 263 patients with Hester type I skin which undergone ablatives CO2 resurfacing for importing the local rhytids in the low eyelids and dermatochalasis. By analysing the finding of this research study it can be stated that, there is an amazing transformation of patinate skin after treating with a CO2 laser which removes the epidermal and dermal layers in the target areas of facial skin. In this context, Nistico et al. (2021) mentioned that, by using sutures along with using the ablative CO2 laser beam, dermatologists can improve the dermatochalasis and rhytids of photodamaged and aged skin thereby offering high-quality facial skin rejuvenation to patients. Although the paper by Garcia and Badin (2019) successfully discuss the effectiveness of CO2 laser resurfacing in treating different skin issues (dermatochalasis and periocular rhytids) of facial ageing, it however fails to discuss the side-effects of suturing while using fractional laser resurfacing. As argued by Mei and Wang (2018), that while carrying out incision during performing fractional ablative CO2 laser there are many patients with sensitive skin who are highly vulnerable to the risk of post-inflammatory hyperpigmentation (PIH) and severe infection on the face with dryness and redness. This is why in developed countries such as the UK, aesthetic surgeons generally avoid using incision while performing the ablative CO2 laser resurfacing. Nistico et al. (2021) have conducted a randomised control trial of 22 patients in which the patients with photodamaged skin are divided into two groups. One group (experimental group) is treated with the therapeutic dose of fractional ablatives CO2 laser and another group (control group) is treated with fractional laser in combination with rhodamine-intense pulsed-light (r-IPL). All the patients undertake three sessions of this laser treatment in a 2-month interval. After 4 months a follow, up has been done which shows that the control group that has been treated with fractional laser in combination with the rhodamine-intense pulsed-light (r-IPL) shows better results in facial skin rejuvenation. Modern clinical intervention suggests that fractional ablative CO2 laser resurfacing while performing in combination with rhodamine-intense pulsed-light (r-IPL), there is a high capacity of the laser light to redevelop the natural healing capacity of the facial skin by instigating the formation of collagen fibre and hyaluronic acid inside the epidermal and dermal layers (Mei and Wang, 2018). Evidence also suggests that while treating the photoaging g facial skin, the fractional CO2 laser beam is applied on the target skin areas thereby developing the microscopic thermal zone. (MTZ) the facial skin tissues located in their MTZ regain the natural healing capacity due to the secretion of growth factors that leads to the formation and rearrangement of collagen fibre in the Extracellular matrix of epithelial cells (Trelles et al. 2011).

Alternatively, Zhu et al. (2016) mentioned in their research paper, with using a combination of rhodamine-intense pulsed-light (r-IPL) and fractional ablative CO2 laser, the IPL act as the facilitator of improving the cellular oxidation thereby increasing the formation of fibroblast, elastin fibre and collagen fibre which leads to replacement of the photodamaged and dead tissues with the new tissues. (Tierney et al. 2011). On the contrary, there is a major drawback of the paper by Nistico et al. (2021), in relation to discuss the factors that can influence the overall surgery of fractional laser in combination with rhodamine-intense pulsed-light (r-IPL). On the other hand, this paper fails to discuss the financial burden and the psychological challenges the patients face while they undergo the fractional laser in combination with rhodamine-intense pulsed-light (r-IPL) due to it is more costly than the only fractional laser therapy. Hui et al. (2017) has presented a clear and concise discussion on the usefulness of the combination of Ultra-pulsed fractional CO2 laser and the autologous platelet-rich plasma (PRP) in conducting the precise, safe ad effective therapeutic intervention of facial skin rejuvenation. Although Ultra-pulsed fractional CO2 is also effective in treating photodamaged facial skin and facial skin issues, it is accompanied by different postsurgical skin issues such as erythema and prolonged oedema (Mei and Wang, 2018). In this research paper by Hui et al. (2017) 13 patients with photoaging skin are treated under both the combination of Ultra-pulsed fractional CO2 laser and the autologous platelet-rich plasma (PRP) in one side of their face and with a normal fractional CO2 laser at the other side of their face. After three months of these two facial skins resurfacing treatment the follow up has been conducted which shows that the face side which is treated under the combination of Ultra-pulsed fractional CO2 laser and the autologous platelet-rich plasma (PRP) has better skin texture, skin appearance and tightening if the facial skin as compared to the other side. On the contrary, Robati and Asadi (2017) argued in their research paper, autologous platelet-rich plasma (PRP) although fasten the healing process and has less downtime while using in combination with fractional laser surgery thereby resulting in high-quality skin rejuvenation, also raises the operation and management cost which makes it difficult for the middle-income people in the developed and developing countries to afford this treatment process. Alternatively, Chen et al. (2017) argued their research study that, when applying Ultra-pulsed fractional CO2 laser along with autologous platelet-rich plasma (PRP) on the fraction of facial skin there are high chances of instant burning or infection on the skin if proper controlling measures are not maintained. This is baicai with ageing there is a loss of collagen and elastin fibre under the facial skin tissues which make skin highly sensitive and vulnerable to infections while applying any kind of high-resolution laser beam. The research paper by Hui et al. (2017) fails to address these issues that need to be considered by aesthetic surgeons while performing Ultra-pulsed fractional CO2 laser and the autologous platelet-rich plasma (PRP) for skin rejuvenation. The research paper by Riggs et al. (2007) discusses the usefulness of the different ablative CO2 laser resurfacing, their beneficial effects in resulting in better skin rejuvenation and their long- and short-term side effects. This systematic review presents the fact that the CO2 laser beam has a resolution of 10,600 nm which can easily be absorbed into the intracellular water in the epidermal and dermal skin tissues. Therefore, during performing fractional of full-field laser resurfacing by using Co2 laser beam, this beam causes heating and vaporisation of the intracellular water thereby ablating or removing the photodamaged sin tissues in the epidermal and dermal layers. This research paper is highly useful in providing new insight on the benefits and side-effects of ablatives CO2 laser resurfacing. Both fractional and full-field laser resurfacing is highly effective in facial skin rejuvenation by treating different facial skin issues such as c facial wrinkles, acne, scarring, rhytids, photodamaged skin ad hyperpigmentation. On the contrary of all ate controlling measures are not maintained properly there are many long terms and short-term effects on facial skin after the ablative laser surgery, the short-term effects are peeling dryness, fragility and redness of the face and the long-term effects is severe inflammation and hyperpigmentation on the photodamaged face. The major limitation of this research is that this research paper although present a clear discussion on the efficacy of laser resurfacing in improving facial skin rejuvenation it fails to present a clear comparison between the usefulness of the full field laser resurfacing in this modern aesthetic field.

Alternatively, Hedelund et al. (2006) present a comparison between the efficacy of the fractional CO2 laser resurfacing and the Intense Pulse Light (IPL) rejuvenation treating periocular rhytids. Here 27 women patients suffering from periocular rhytids undertook either treated with fractional/full field CO2 laser resurfacing or with IPL. After 4 months of the surgery, the comparative efficacy and side effects of these two types of treatment had been conducted. The finding of this research paper highlights the factors that the fractional or full field CO2 laser resurfacing is more effective and safer in resulting in improved and high-quality facial skin rejuvenation with a high level of patient's satisfaction as compared to IPL. In this context Hedelund et al (2006) supporting this viewpoint by mentioning that, although but the IPL and ablative CO2 laser resurfacing are highly effective in performing high-quality skin rejuvenation, as compare to the IPL, the ablative CO2 laser has less downtime, less healing times and fewer risks of postoperative health complications of patients. Alternatively, Tierney et al. (2011) mentioned that as compared to ILP, the cost of ablative CO2 laser is higher which can poser a financial burden on patients. Hedelund et al. (2006) argued in this context by mentioning that, although, although the ablative CO2 laser is costly due to its high maintenance cost, this laser technology is associated with a higher level of improvement in the photodamaged and aged facial skin as compared to the other laser technique in the market. Alternatively, Garcia and Badin (2019) mentioned in their research articles, that while it comes to improve the facial skin texture and facial appearance through carrying out high-quality skin rejuvenation by using fractional or full-field laser surgery, aesthetic surgeons must consider some aspects that are strongly associated with safety and effectiveness of the surgery. These aspects are the facial skin types of the patients by using Fitzpatrick Skin Type Chart, amount of the trans-epidermal water loss (TEWL), skin elasticity, tolerance of skin to the ultrasound and CO2 laser and skin reflectance. Clinical intervention suggests while treating the photodamaged skin and hyperpigmentation of the facial skin during the skin rejuvenation, aesthetic surgeons must ensure that that they have made the proper physical and psychological health assessment of patients before conducting the surgery (Wei et al. (2021). Additionally, aesthetic surgeons while using full-field laser resurfacing must ensure that the antibiotics and drugs that are prescribed to the patients before and after the surgery are well tolerable to the biological system of patients. Robati and Asadi (2017) presented a cross-sectional study in which it shows the comparative analysis of the efficacy of fractional CO2 large resurfacing and the Er:YAG lasers on the cutaneous photodamaged facial skin. 40 patients suffering from facial ageing have undergone the skin rejuvenation process with fractional ablative CO2 laser or by Er:YAG lasers. Here researchers have found from the finding that, while it comes to facial skin rejuvenation, both the fractional CO2 laser and Er:YAG lasers are effective in improving the texture, cellular arrangement and tissue construction of photodamaged skin thereby resulting in high-quality skin rejuvenation. But this research paper also mentioned that in the case of patients who undergo the fractional CO2 laser, feel more discomfort than the patients who are treated with the Er:YAG lasers. Alternatively, Tierney et al. (2011) mentioned in this context that facial ageing is a very complex process that generally occurs due to high exposure of skin to UV radiation that causes structural changes of epithelial cells in the epidermal and dermal layers. The skin rejuvenation process by using laser technology is highly applicable in patients with photodamaged and aged skin to provide them with a satisfactory and cost-effective result. However, as compared to the fractional laser resurfacing, Er:YAG laser is more useful in the modern aesthetic field as it has less discomfort and risk of skin complication at the postoperative stage., this research paper by Robati and Asadi (2017) fails to provide the clear discussion on the histological and pathophysiological reason behind the more discomfort felt by patients who undergo the fractional laser resurfacing as compared to the patients who undergo Er:YAG lasers.

Chen et al. (2017) stated in their systematic review that while it comes to treat photodamaged and aged skin, fractional ablative CO2 laser resurfacing is more effective as compared to erbium: yttrium-aluminium-garnet (erb:YAG). This research paper also stated that in both types of skin rejuvenation laser surgery the side-effects are mild and well-tolerable by patients. As mentioned by Gold et al. (2014), modern clinical intervention for the facial skin rejuvenation suggests that in both the fractional laser and erbium: yttrium-aluminum-garnet (erb:YAG) there is improvement in the facial photodamaged skin, wrinkles and rhytids, but in case of fractional laser resurfacing, patients experiences; less healing times, high improvement of photodamaged areas on the face, and less downtime for the surgery. Many modern aesthetic surgeons mentioned that, if considering the histological reason, in case of the fractional laser resurfacing the ability if of the CO2 laser beam is more in instigating the natural construction capacity I epidermal and dermal cells for producing collagen fibre that assists cells in these tissues to hold close together. On the other hand as compared to erbium: yttrium-aluminum-garnet (erb:YAG) , in case of fractional laser resurfacing the Co2 laser has the resolution that can assist this lure to absorbed deep into the intracellular water of the epidermal cells thereby arranging and constricting the cells and tissues in a systematic form by developing hyaluronic acid that results into high improved skin rejuvenation. Railan and Kilmer (2005) presented a comparative discussion on the efficacy and side effects of ablative CO2 laser resurfacing and Er:YAG lasers. This research paper highlighted the fact that both these laser surgeries are effective in skin rejuvenation in terms of providing a high level of patient's satisfaction by treating all types of facial skin issues. But the full field CO2 laser resurfacing is more useful in tightening skin by instigating the natural healing capacity of the epidermal and dermal tissues, on the other hand, the Er:YAG laser is more effective in sculpting. Alternatively, Papadavid and Katsambas (2003) argued in their research study that there are many side effects and health complications that are associated with ablatives Co2 laser resurfacing such as prolonged erythema, redness, postoperative inflammation, infection and peeling on facial skin. Modern dermatologists believe that there are several side effects and health complications that are associated with both fractional and Full-field laser resurfacing, but these side effects or complications can be well-tolerable and mild if the entire process is done by experts and all the controlling measurers are maintained (Zhu et al. 2016). On the other hand, Mei and Wang (2018) argued that modern asthenic surgeons must consider that the importance of safe and effective medicine admin administration for increasing the chances of high-quality skin rejuvenation by applying CO2 ablatives laser resurfacing.

Alternatively, Galal et al. (2019) presented a comparative discussion on the efficacy of the fractional CO2 resurfacing and a combination of platelet-rich plasma (PRP) and fractional ablative CO2 laser in treating the ageing problem and the photodamage skin of the face in women. Here a cross-section study had been conducted on 30 patients with photodamaged and aged skin with acne and hyperpigmentation. Here one side of patient was treated with only fractional ablative CO2 resurfacing and the side of their face was treated under the combination of fractional CO2 laser resurfacing along with PRP. The evaluation of the finding and observation show that, that the face side which had been treated with a combination of PRP and fractional CO2 laser resurfacing shows more improvement as compared to the side which had been treated with only fractional Co2 laser. On supporting this viewpoint Wei et al. (2021) mentioned that fractional Co2 laser resurfacing is although highly effective in treating the skin issues that are developed due to skin ageing and photo damages in the skin, PRP accelerate the ability of the fractional laser resurfacing by causing more tightening of the skin tissues under the epidermal and dermal layers and also fasten overall healing time of wound after the resurfacing surgery. Galal et al. (2019) stated that while using fractional CO2 laser in combination with the PRP, it reaches deep into the innermost layer (dermal layer) of photodamaged and aged skin tissues by being absorbed into the intracellular areas of epithelial cells. After quick absorption of fractional Co2 laser into these dermal and papillary layers it instigates the higher level of collagen formation and also the formation of the high number of proteoglycans and fibroblasts thereby accelerating the natural; healing capacity of the epidermal and dermal tissues. Alternatively, Borges et al. (2016) argued in their research study that, although the ultra-pulsed fractional ablative CO2 laser is a highly precise ad safe therapeutic intervention for facial skin rejuvenation, it is more useful while used in combination PRP (platelet-rich plasma). According to Clementoni et al. (2013), autologous platelet gel (APG) work impressively on the photodamaged and aged skin tissues thereby fastening the epithelialization and granulation inside the epithelial layer. Additional, while using the combination of fractional CO2 laser and PRP, granulation starts earlier due to the platelets counts is six times more in the bloodstream as compared to the autogenous fractional laser resurfacing. Alternatively, Galal et al. (2019) mentioned PRP is strongly associated with secreting a high number of GF or growth factors that fasten the healing process of the wound. This is why in the case of facial skin rejuvenation, the majority of the modern aesthetic surgeon uses a combination of PRP and fractional laser resurfacing in treating hyperpigmentation, ageing and photodamaged skin. Although both these research studies by Galal et al. (2019) and Borges et al. (2016) mentioned a well-constructed discussion on the usefulness of the combination of the PRP and fractional CO2 laser resurfacing in generating growth factors (GF) and granulocytes into the circulation thereby festering the wound healing, they are failed to discuss the proper connection between these aspects with collagen formation and fibroblast proliferation. On the contrary Hui et al. (2017) argued in their research study that while treating photodamaging, ageing and hyperpigmentation for promoting high-quality facial skin rejuvenation, PRP plays a crucial role in increasing the rate of collagen formation inside epidermal and derma tissues, PRP does this secreting higher amount of growth facts as compared to the fractional laser resurfacing. As stated by Wei et al. (2021), PRP is the natural reservoir of gfs which are secreted into the circulation while PRP is absorbed into the dermal and papillary tissues along with the fractional CO2 laser. These gfs then cause the proliferation of fibroblasts and endothelial thereby causing the activation to start the production of the high amount of collagen fibre and hyaluronic acids. Alternatively, Yalici-Armagan and Elcin (2018) stated that as compared to full-field laser resurfacing fractional ablative CO2 laser resurfacing is more effective and safer while performing skin rejuvenation for treating photo damages and hyperpigmented facial skin. This research paper presented a research study in which 29 women with facial ageing undertook three sessions of the fractional ablative CO2 resurfacing at one-month intervals. Before and after the surgery, the mean facial ageing score had been measured to check whether there is any improvement in skin ageing on the face in each patient. Self-assessment had been conducted to gather a database on the feeling and perspectives of the women patients on the efficacy of this facial skin resurfacing in facial skin rejuvenation. Then mean facial ageing scores before and after were 11,24 ± 4,30 and 10,51 ± 3,86 respectively. Therefore, this finding has shown that fractional Co2 laser resurfacing is highly effective in reducing the skin ageing on the face thereby tightening the facial skin by reducing the gaps between the intracellular areas and tissues in the epidermis and dermis. Alternatively, Wei et al. (2021) argued in their research paper that, although any aesthetic surgeon, as well as clients in the modern era, prefer to use fractional ablative CO2 laser resurfacing for treating skin issues due to the photodamaging and facial ageing, it is evident that while using an only fractional laser instead of a combination with other facilitating agent patients have high chances for proinflammatory infection and hyperpigmentation.

Clementoni et al. (2013) supported this viewing by mentioning that autogenous fractional laser resurfacing although is claimed to be a safe therapeutic intervention in facial skin rejuvenation, several cases in the UK have been registered in the aged patients in which patients suffer from postsurgical infection and pigmentation on that skin. Here the researchers have conducted a study on 312 patient who has photodamaged skin in which all the patients are treated with random fractional ultra-pulsed CO2 laser. The observation of the photographs of patients before and after the surgery shows that there is an impressive level of improvement in photodamaged skin. The authors mentioned in this research paper that random fractional ultra-pulsed CO2 laser is a more useful and precise treatment process than the other ablative laser process while it comes to treat the photodamaged skin. The random fractional ultra-pulsed CO2 laser leads to the secretion of the high numbers of growth factors (gfs) which lead to the re-epithelialisation which is strongly associated with rearrangement of the college fibroblast and epithelial cells. On the other hand, fractional Co2 laser also initiates collagen formation at a faster rate which replaces the old and damaged extracellular matrix with the new one thereby ablating the aged and photodamaged tissues in the dermis and epidermis. Wei et al. (2021) conducted a randomised controlled trial in which 60 Chinese patients had post-inflammatory hyperpigmentation (PIH) on their face after the fractional ablatives CO2 laser resurfacing. Here researchers formed two patient's groups such as the control group that was treated with fusion acid cream at the post operating condition and the experimental group that had been treated with erythromycin ointment. Evaluation of the finding has shown that fusion acid cream is more effective in treating PIH on facial skin after the fractional laser resurfacing as compared to the erythromycin ointment. Alternatively, Hui et al (2017) argued that, while treating photodamaged and hyperpigmented facial skin with fractional laser resurfacing, the aesthetic surgeon must ensure that the fusion acid cream would be effective and safe to the particulate skin type of patients. Clinical intervention suggests that al all the patients do not have the same types of skin while using the fractional Co2 laser in combination with any additional agent such as PRP or fusion acid cream, aesthetic surgeons must conduct thorough research on whether these agents are safe to be to use used on the particular skin type of patient. The major drawback of the research paper by Wei et al. (2021) is it fails to present a clear discussion on the associated risk or health complications that patients of different skin types can face while applying the fusion acid cream or erythromycin ointment for treating the PIH after fractional laser resurfacing. Borges et al. (2016) mentioned in their systematic review that, in the modern era people the most common facial skin issue that people face is photodamaging of facial skin tissues that not only cause the ageing of skin but also make the facial skin dry and rough. Fractional CO2 ablative laser resurfacing is one of the most preferred cosmetic surgery that the majority of people demand to get a balanced tone and good appearance of their face. According to Mani et al. (2021), photoaging occurs due to the massive creation of collagen fibre, proteoglycans and elastic fibre that are located in the extracellular matrix (ECM). Borges et al. (2016) stated that during the treatment of the photodamaged skin on face, the fractional CO2 laser while incise on the facial skin leads to the development of the necrosis column. This necrosis column plays a crucial role in replacing the damaged ECM with new ECM by conducting the reformation and rearrangement of new collagen and fibroblasts. According to Yalici-Armagan and Elcin (2018) as compared to the full-field ablative CO2 laser, fractional laser is highly effective in the resettlement of the collagen, elastin and fibroblast into the ECM thereby causing proper tightening of the tissues present in the epidermis and dermis and improves the facial skin texture and appearance.

Alternatively, Daniely et al. (2021) have conducted a retrospective study on 24 patients with photodamaged skin on the face which undergo a thermo-mechanical fractional injury therapy (TMFI). In this research study, fractional ablative CO2 laser resurfacing has been used to treat the photodamaged skin of the selected patients. This research study highlights the importance of thermo-mechanical fractional injury therapy (TMFI) in improving the facial skin texture, tone and overall facial appearance by creating collagen formation and tightening the skin tissues. As mentioned by Gold et al (2014), there are three layers inside the facial skin, such as epidermis which is the superficial layer, the papillary dermis, the middle layer and the dermis the innermost layer. In this research study, 10 healthy women (skin type I-IV) with photodamaged skin have undertaken three sessions of the fractional ablative CO2 resurfacing at one-month intervals. As in the case of the fractional ablative laser resurfacing the CO2 laser is applied on the fraction of percentage of the face, the CO2 laser can hold its energy till it reaches the innermost layer of the facial skin. After reaching the innermost it works on the water on the intracellular arras thereby causing vaporisation of the water and thereby degenerating microscopic thermal zone, under this zone, it activates the growth factors which are associated with developing collagen fibre thereby causing the resettlement of proteoglycans, collagen and hyaluronic acids which are the major component in anti-ageing of skin. However, the research paper by Daniely et al. (2021) have successfully discussed the working process and safe therapeutic benefit of fractional laser in treating photodamaged skin, it fails to discuss the factors that aesthetic surgeons need to consider to protect skin from post-operative inflammation and infection. Alternatively, Mei and Wang (2018) have conducted a cross-sectional study in which they have shown the operational effectiveness of the combination of the ablative fractional laser (AFL) and Intense pulse light vs only Intense Pulse Light (IPL) in treating photodamaged skin. Here 28 Chinese patients who have photodamaged skin have been selected for this study in which one side of their face has been treated with a combination of AFL and IPL and the other side of their face have been treated with IPL. The findings show that while using fractional ablative CO2 laser along with IPL it works better than the only IPL or only fractional laser/. In this context, Yalici-Armagan and Elcin (2018) mentioned that facial ageing can be referred to as the multifactorial process which involves solar elastosis, skin laxity, facial rhytids ad skin laxity. Facial ageing leads to pigmentary change, alternation of the college fibre insides the epithelial tissues, reducing skin volume and changing skin texture. Techapichetvanich et al. (2018) mentioned in this context that, the skin issues that are associated with facial ageing is possible to be removed and improved through fractional ablative laser resurfacing which cause the re-epithelialization in epidermis thereby reinstituting new collagen formation in the papillary dermal and dermal layer. This research paper provides new insight on the importance and effectiveness of Epidermal growth factors (EGF) ointment in fastening the healing of post-inflammatory hyperpigmentation (PIH) in the case of facial skin rejuvenation by using the fractional ablative Co2 laser resurfacing. Here a total of 19 patients have been selected who suffer from the PIH. After three months of application of EGF ointment the facial skin texture and appearance of each patient has been observed. The findings of this research study show that, as compared to the fusion acid cream, the EGF ointment is more effective with fewer side effects in treating the PIH.

On the contrary Mani et al. (2021) have conducted a randomised control trial on 109 patients in terms of determining the efficacy of a combination of both full field and fractional ablative laser resurfacing in treating photodamaged skin. This research study is highly useful in providing new insight on whether the combination of these both fractional and full field laser resurfacing is far better than the only fractional or only full field laser resurfacing in treating the facial skin related issues due to facial ageing or photodamaging. Here on experimental group is treated with a combination of the fractional CO2 ablatives laser and full fielded deep ablative laser. The control group is treated under either fractional laser or the full field deep ablative laser. The findings show that the experimental group which has been treated under the combination of both the fractional and full field laser resurfacing obtain maximum benefit in a single treatment in removing their photodamaged and aged skin on that face. Marini, (2018) present a cooperative analysis on the efficacy of spring thermal white petroleum vs film-forming gel formula in wound healing after the full face fractional and full field laser resurfacing. Here 9 inpatients have been selected for conducting the research study in which two groups, the control group and the experimental group have been developed. One group has been treated with full field laser (control), and the other group (experimental) is treated with the fractional. Then in both the patient group, one side of face is treated with petroleum gel and another side is treated with the full film gel. The findings show that in the both groups the full film formula is more effective in fastening the wound healing in on face after surgery, but in the case of the full field laser the healing time is more is as compared to the fractional laser resurfacing. Although this study by Marini, (2018), has successfully presented a comparative discussion of the fractional and full fielded laser resurfacing, it fails to highlight the reasons or factors that ate associated with the fast healing in case of the fractional laser as compared to the full field laser. These factors are, the presence of skin tissue barriers, the ability of the laser to improves the alteration of the collagen and fibroblast, the ability of secreting gfs and process of the reepithelialisation inside the skin tissues. On the contrary Daniely et al. (2021) mentioned in the research study that, as compared to the full field laser resurfacing fractional laser is more effective in reaching the innermost layer( the dermal layer) of the photodamages skin thereby generating proteoglycans which enhance secretion of growth factors onto the Extracellular matrix, these Gfs in extracellular matrix the instigate the creation of collagen , fibroblast and elastin protein which are the aesthetic components in holding the ski tissues tightly thereby maintaining youthfulness of skin.

Rasheed et al. (2021) had conducted a pilot study on determining the usefulness of the fractional ablatives CO2 laser resurfacing in treating the post-traumatic atrophic scars on facial skin. Atrophic scars are the marks that are left on the skin after an injury or wound is healed (Mossaad, et al. 2018). Ochi et al. (2017) stated the reason behind fractional laser resurfacing reduces the depth of the atrophic scars instigate and redeem the natural healing properties of the epidermis, reticular dermis and papillary tissues situated underlying the scars by remodelling of the collagen fibre. On the contrary Vanaman et al. (2017) argued that many times the target tissues on the epidermis are not covered under the fractional CO2 beam, therefore all the scares or hyperpigmentation are not proper removed from the facial skin, this is why as compared to the fulfilled ablative CO2 laser, in case of the fractional laser there are higher chances of the client to face the needs of undertaking further resurfacing surgery as the skin issues are not properly solved after the first resurfacing. On the contrary Sipprell et al. (2020) argued that in the case of fractional ablative resurfacing there is a chance of occurrence of eyelid scares in aged people is due to their skin cannot tolerate the high-resolution CO2 beam thereby causing the burning and damaging of the surrounding tissues that are associated with the target tissues. NICE (2019) mentioned that for overcoming the risks of infection, irritation and scarring on the skin, aesthetic surgeons need to ensure that while performing the fractional laser resurfacing, they must check the skin type of the client by using the Fitzpatrick Skin Type Chart. Evidence suggests that, in the UK, modern aesthetic surgeons recommend their clients to undertake the fractional CO2 ablative laser resurfacing over the full field process, because as the downtime of the fractional technique is less it will enable the surgeons to invest less time in performing this entire laser technique to get the expected results (Hamilton et al. 2018). In this context, Zhang et al. (2021) mentioned in their study that, fractional CO2 laser generally targets a particular point of the skin tissues in the topmost or superficial layers of the skin. While the fractional laser is applied on the skin the laser only works on the target tissues on the epidermis but not on the surrounding tissue. Mossaad et al. (2018) have conducted a cross-sectional study in which a total of 6 menopausal women suffering from cleft lip scars are selected for applying the fractional ablative CO2 beam for treating these scars. Cleft lip scars are common in people in which people experience acne on their face and lips. In the study conducted by Waibel et al (2020), all the participants have undergone three sessions of the fractional; laser resurfacing with 8-month interval between each session. Waibel et al (2020) has clearly mentioned in their findings that fractional laser resurfacing is highly useful and safe treatment while it comes to treat the burning marks, injuries and scars on facial skin. Additionally, this research paper also highlighted the histological aspects that are associated with the faster healing in the case of the fractional laser resurfacing while treating the burn marks and scars as compared to the full field laser resurfacing. The histological database that is presented in this research paper shows that, while treating by fractional CO2 laser beam, laser rays are absorbed by the water presented under the dermis and epidermal layers which then cause vaporisation of water. On the contrary Abdel-Maguid et al. (2021) argued in their research study, that although fractional laser resurfacing along with 5-fluorouracil is more effective than the normal fractional or full field laser resurfacing, some many side effects or complications are associated with this process if not done by experts. This complication is the lower eyelid scarring, hyperpigmentation, acne, cornea infection and inflammation in the region of the traumatic scarring. This research paper by Lee et al. (2018) fails to highlight the strategies that are associated with overcooling all these complications associated with fractional laser resurfacing while used with 5-fluorouracil.

Conclusion:

From the above-mentioned discussion, it can be concluded that, in modern aesthetic field, facial skin rejuvenation is most demanding process among people as it enables people to get rid of photodamaged skin and facial ageing. Skin rejuvenation is the process through which the overall appearance and texture of the facial skin can be improved. In modern era there is a trend of using fractional ablative CO2 laser resurfacing in treating the photodamaged and aged skin. In the developed countries such as UK and USA, majority of the aesthetic surgeons and dermatologist prefer to use fractional laser resurfacing as compared to the full field laser resurfacing due to the more impressive result in fractional laser resurfacing with less side effects and lass healing times as compared to other laser technique. In both the fractional and full field ablative CO2 laser resurfacing, Co2 laser beam is applied on face to ablate the damaged and dead tissues inside the facial skin. In case of the fractional laser resurfacing, the CO2 laser beam is placed on the fraction or percentage of the facial skin. On the other hand, in case of the full field laser resurfacing the laser beam is placed on all-over facial skin to cover 100% of the facial skin. As compared to the full field laser resurfacing, fractional ablatives Co2 laser is more effective in treating the photodamaged skin, because in this process CO2 laser beam reaches the innermost layers of the facial skin, the dermal layer and thus absorbed into the intracellular water of epithelial cells. After absorbing into the intercellular areas, fractional laser is able to form the microscopic thermal zone (MTZ),. In this MTZ, reepithelialisation occurs which leads to activation and secretion of the high amount of Growth Factors (Fs) which then instigate the resettlement of the proteoglycans and fibroblast by increasing the collagen formation manty research have suggested that, although fractional laser resurfacing is more effective than a full-field laser to create collagen fibre and increase the natural healing capacity of the epidermis, papillary dermis and dermis, if the fractional laser ins applied with other facilitators such as fusion acid cream or platelet Rich plasma (PRL. It improves the overall work process of the fractional laser.

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