Journal of Cosmetic and Laser Therapy, 2012; 14: 172–178

ORIGINAL RESEARCH REPORT

Treatment of acne scars by fractional bipolar radiofrequency energy

MICHAEL H. GOLD1,2 & JULIE A. BIRON2

1Gold Skin Care Center, 2000 Richard Jones Rd, Suite 220, Nashville, TN, United States, and 2Tennessee Clinical
Research Center, Nashville, TN, USA
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Abstract
Background/Objective: A variety of modalities are available for the treatment of acne scars. This prospective, IRB-approved
study evaluates the efficacy and tolerance of fractional bipolar RF energy in the treatment of facial acne scars. Methods:
Healthy subjects (n ⫽ 15, 13 females, aged 35.7 ⫾ 5.6 years [mean ⫾ SD], skin types I–V) with mild to moderate acne scars
received three monthly treatments with a fractional bipolar RF device. Improvement and tolerance were evaluated at each
visit, including a 1-month and 3-month follow-up visit. Results: Ten subjects completed the study. Physician-assessed acne
scar severity was significantly reduced at 1 month and 3 months. Adverse effects were limited to transient erythema. Dry-
ness, bruising and crusting erosion were limited. Subject-assessed stinging/burning, stinging (alone), tingling, itching and
burning were also limited and consistent with each treatment. Subject-assessed fine lines and wrinkles, brightness, tightness,
acne scar texture, pigmentation were all improved significantly. Satisfaction was high in 67–92% of subjects. Conclusion:
Fractional bipolar RF energy is a safe and effective modality for the treatment of acne scars.
For personal use only.

Key Words: acne scars, fractional, radiofrequency, bipolar

Introduction
Facial acne scars result in considerable physical and
emotional distress, particularly in adolescents. The
appropriate treatment depends on the types of scars
present. Ice pick scars have been treated by punch
excision, subcision or the CROSS technique with
100% TCA (1); rolling scars by laser resurfacing,
subcision or both; boxcar scars by punch elevation,
laser resurfacing or subcision; shallow boxcar scars
by laser resurfacing and deep boxcar scars by punch
excision. Combinations of modalities have also been
used (2).
Nonsurgical options such as dermal fillers (2,3–5),
chemical peels (6) and dermabrasion (7) are also
available, and subdermal minimal surgery has been
reported (8). However, surgical revision followed by
full-face resurfacing with either the 2940-nm
erbium:yttrium-aluminum garnet (Er:YAG) laser
device or 10,600-nm CO2 laser device, or both, has
been suggested for most scar types (9), including
those in dark skin. (10). These ablative devices are
also associated with long recovery times and adverse
effects such as postinflammatory hyperpigmentation
have been reported. Nonablative and fractional laser
devices have fewer side effects but multiple treat-
ments are required to achieve acceptable outcomes
(11–14).
Fractional lasers produce patterns of tiny thermal
wounds surrounded by undamaged tissue whose
cells act as a reservoir for rapid healing (15–18).A
treatment called ‘sublative rejuvenation™’ with frac-
tional bipolar radiofrequency (RF) energy has
recently been shown to improve mild rhytids, skin
texture, skin tightening and skin smoothness with
little downtime and rapid healing (19). With this
modality only 5% of the epidermis is affected com-
pared to 10–70% with fractional ablative laser treat-
ments (19). An evaluation of a similar technology has
been reported for acne scars (20).
The present study evaluates the efficacy and tol-
erance of fractional bipolar RF energy in subjects
with acne scars.

Correspondence: Michael H. Gold, MD, Medical Director, Tennessee Clinical Research Center, 2000 Richard Jones Road, Suite 223, Nashville, TN 37215,
USA. Tel: ⫹ 1 615-383-9660. Fax: ⫹ 1 615-385-6995. E-mail: research@goldskincare.com

(Received 11 January 2012 ; accepted 16 April 2012 )

ISSN 1476-4172 print/ISSN 1476-4180 online © 2012 Informa UK, Ltd.
DOI: 10.3109/14764172.2012.687824

Material and methods
Subjects
Healthy subjects (n ⫽ 15, 13 females, aged 35.7 ⫾ 5.6
years [mean ⫾ SD], skin types I–V) with mild to
moderate acne scars enrolled in this prospective
study. All female subjects of child-bearing potential
used an acceptable form of birth control during the
study and for at least 6 months before the study
began. All subjects provided signed informed con-
sent for the study and the publication of photographs,
and the study was approved by Independent Investi-
gational Review Board, Plantation, FL. Exclusion
criteria were pregnancy, active electrical implant,
permanent implant in the treated area, botulinum
toxin A facial injection within the previous 6 months,
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dermal filler injection in the treated area within the
past 9 months, a large amount of facial hair and
excessive exposure to sunlight or UV light during the
previous 30 days. Allergy to anaesthesia, history or
evidence of medical or psychological disorder which,
in the investigator’s opinion, would preclude
enrolment; and participation in a research study
within the previous 30 days were also grounds for
exclusion.
For personal use only.
Treatment device
The treatment device was a hand-held applicator
(Matrix RF, Syneron, Inc.) powered by a system
(eMatrix, Syneron) designed for deep dermal pro-
duction of bipolar RF energy. The applicator had a
small square disposable tip at its distal edge for deliv-
ery of fractional RF energy to skin. The tip consisted
of an array of positively and negatively changed elec-
trode pins, 64 per tip. Current flow between the pairs
of oppositely changed electrodes produced RF energy
in the target location. Treatment resulted in an
imprint of ablated spots surrounded by undamaged
tissue, similar to those produced by fractional pho-
tothermolytic laser irradiation. Pulses could be emit-
ted in three different programs, each for a different
depth of penetration (100–300 μm, 300–500 μm,
and 1000–1500 μm). These programs permit the
operator to control the depth and intensity of dermal
Table I. Study protocol.
Investigator assessments of erythema, edema, erosion/ulceration,
dryness/scaling, scabbing/crusting; global assessments
Subject assessments of itching, burning, pain, and satisfaction
Subject improvement questionnaires
ECCA grading
Adverse events
Adverse events
Clinical photography
Treatment of acne scars by fractional RF 173
heating with minimal epidermal effects. Details of
the technology have been reported (19,20).
Study design
The study protocol is shown in Table I. Subjects
with acne scars received three treatments in at least
two facial (or neck) areas at 4-week intervals. Topical
anaesthesia (benzacaine [20%], lidocaine [6%], tet-
racaine [5%]) was applied after the test spot only if
requested by the subject. Treatment parameters were
based on the subject response to a test spot. Pro-
grams B (mid-depth) or C (deep) was used for skin
types IV–V and I–III, respectively. Energy ranged
from 32 to 56 mj/pin. Care was taken to keep skin
dry during treatment and to minimise overlap of
treatment imprints. Treatment consisted of a single
pass. Emollient cream was applied to the treated
areas immediately after treatment. Subjects were
instructed to allow scabs to shed off naturally, apply
moisturiser several hours after each treatment and
regularly between treatments, use sunscreen (SPF at
least 30) regularly until treatment-induced crusts
resolved and avoid tanning during the study
period.
Scars were evaluated at each time point according
to the ECCA grading scale (Table II) (21), which
permits the investigator to score each kind of scar
(0 ⫽ no scar, 1 ⫽ a few scars, 2 ⫽ limited number of
scars and 3 ⫽ many scars) and assign a weighting fac-
tor. The ECCA grade was arrived at by multiplying
the semi-quantitative score by the weighting factor.
Global scores, cosmetic appearance and tolerance
were evaluated by the physician while subjects rated
efficacy and tolerance (Table III).
Evaluation of results
Non-parametric statistics were used to analyse data
because grades were not continuous and datasets
were not always normally distributed as shown by the
Shapiro–Wilk test.
Differences were evaluated for significance by
Friedman’s test, the Wilcoxon Signed Rank test and
Pearson’s chi-square test.
Treatment visits Follow-up visits
1 (baseline) 2 3 4 weeks 12 weeks
x x x x x
x x x – –
– – – x x
x x x x x
x x x x x
x x x x x
x x x x x
 174 M. H. Gold & J. A. Biron

Table II. The ECCA grading scale used to evaluate scars (21).

Weighting Grading
Description Factor (a) Semi-quantitative Score (b) (a ⫻ b)

V-shaped atrophic scars, diameter of less than 2 mm, and 15 0 ⫽ no scar ()

punctiform 1 ⫽ a few scars
2 ⫽ limited number of scars
3 ⫽ many scars
U-shaped atrophic scars, diameter 2–4 mm, with sheer edges 20 0 ⫽ no scar ()
1 ⫽ a few scars
2 ⫽ limited number of scars
3 ⫽ many scars
M-shaped atrophic scars, diameter ⬎ 4 mm, superficial and 25 0 ⫽ no scar ()
irregular surface 1 ⫽ a few scars
2 ⫽ limited number of scars
3 ⫽ many scars
Superficial elastolysis 30 0 ⫽ absent ()
1 ⫽ mild
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2 ⫽ moderate
3 ⫽ intense
Subgrading∗ 1
Hypertrophic inflammatory scars, scars of less than 2 years of age 40 0 ⫽ no scar ()
1 ⫽ a few scars
2 ⫽ limited number of scars
3 ⫽ many scars
Keloid scars, hypertrophic scars, of more than 2 years of age 50 0 ⫽ no scar ()
1 ⫽ a few scars
2 ⫽ limited number of scars
3 ⫽ many scars
Subgrading† 2
For personal use only.

Global Score (subgradings 1 ⫹ 2) ()

Reproduced from Dreno B, Khammari A, Orain N, Noray C, Mérial-Kieny C, Méry S, Nocera T. ECCA grading scale: an original validated
acne scar grading scale for clinical practice in dermatology. Dermatology. 2007;214(1):46–51 (21) with permission from S. Karger AG,
Basel.
∗Grading of first 4 items.

†Grading of last two items.

Results and discussion were compared to baseline (Tx1) by the Wilcoxon

Physician assessments
Efficacy. Only subjects with 3-month follow-up data
(n ⫽ 10) were included in the analyses. No subject
discontinued the study due to treatment-induced
adverse events. The Tx1 data are considered baseline
because they were obtained immediately before the
first treatment.
ECCA grading. The collective ECCA grading data
were analysed by Friedman’s test, the non-parametric
equivalent to an analysis of variance. The analysis
showed the existence of a significant reduction in the
median grades compared to baseline (p ⬍ 0.0001)
across the study period. To determine the locations
of significant differences, grades at each time point
Signed Rank test. Since four comparisons with base-
line were made, the Bonferroni correction was applied
to obtain the appropriate cut-off level. The tradi-
tional level (p ⫽ 0.05) was adjusted by dividing 0.05
by 4, the number of comparisons with baseline, to
obtain the p ⫽ 0.0125 cut-off level.
The median ECCA grade was significantly lower
than baseline at the 1-month (p ⫽ 0.0018) and
3-month (p ⬍ 0.0001) follow-up visits.
Global scores. Global score data were also analy-
sed by Friedman’s test and the Wilcoxon Signed
Rank test. The analysis shows the existence of a sig-
nificant reduction in the median global scores com-
pared to baseline across the study period (p ⫽ 0.0014).
Using the Bonferroni correction, the cut-off level for

Table III. Efficacy as shown by ECCA grades and global scores.

PreTx2 PreTx3 1 Mo. FU 3 Mo. FU

ECCA Grades †p ⫽ 0.8330 (ns) †p ⫽ 0.0434 (ns) †p ⫽ 0.0018 (s) †p ⬍ 0.0001 (s)
Global Scores †p ⫽ 0.3750 (ns) †p ⫽ 0.6875 (ns) †p ⫽ 0.1953 (ns) †p ⬍ 0.0039 (s)

PreTx1 ⫽ baseline.
FU ⫽ follow-up, s ⫽ significant, ns ⫽ non-significant.
†The p value obtained with the Wilcoxon Signed Rank Test.

the individual comparisons with baseline became
p ⫽ 0.0125.
Global scores were significantly reduced only at
the 3-month (p ⬍ 0.0039) follow-up visit.
Cosmetic appearance. Improvement in cosmetic
appearance was assessed by comparing photographs
at the Tx3, 1-month follow-up and 3-month
follow-up visits with the Tx2 photograph (taken just
before Tx2). Improvement was graded as no change,
improved, much improved, very much improved or
worse. The data are shown in Table IV. The Pearson
chi-square test of the entire dataset showed a sig-
nificant difference among the proportions of subjects
(p ⫽ 0.0009) at the various time points. When indi-
vidual comparisons with the Tx2 photograph, using
p ⫽ 0.017 as the Bonferroni-adjusted cut-off level,
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improvement in cosmetic appearance was significant
only at the 1- and 3-month follow-up visits (p ⫽ 0.0041
and p ⬍ 0.0052, respectively). Clinical examples are
shown in Figures 1 and 2.
Tolerance. Erythema, dryness, bruising and crusts/
erosions were assessed at each visit, using the follow-
ing scale: 0 ⫽ absent, 1 ⫽ slight (rare for crusts and
erosions), 2 ⫽ mild, 3 ⫽ moderate and 4 ⫽ severe.
For personal use only.
The distribution of subjects among grades of ery-
thema was evaluated by the Pearson chi-square test.
Differences among proportions across the study
period were significant (p ⫽ 0.0002). As shown in
Table V, the distribution of subjects at Tx2 and Tx3
did not differ significantly from baseline (Tx1) while
the distribution at the 1-month follow-up visit was
significantly different (improved) (p ⫽ 0.0101) with
the cut-off level at 0.017. The 3-month follow-up
data could not be tested because all grades were zero.
Dryness, bruising and crusting/erosion data were not
statistically evaluated, as all but a single data point
were graded zero.
Subject assessments
Efficacy. Subjects were also asked to evaluate their
results via a questionnaire. Acne scar texture, fine
lines and wrinkles, brightness, tightness, pigmenta-
tion, overall improvement, satisfaction and comfort
Table IV. Distribution of subjects among the five levels of improvement.
Improvement Level PreTx2 PreTx3
Very much improved 0 0
Much improved 0 0
Improved 3 6
No change 7 4
Worse 0 0
†p ⫽ 01775 (ns)
PreTx1 ⫽ Baseline.
FU ⫽ follow-up, s ⫽ significant, ns ⫽ non-significant.
†The p value obtained with the Pearson chi-square test.
Treatment of acne scars by fractional RF 175
were graded by subjects throughout the study. Grades
were based on a 5-point scale in which 1 ⫽ improved
significantly, 2 ⫽ improved moderately, 3 ⫽ no change,
4 ⫽ worsened slightly and 5 ⫽ worsened significantly.
Data are presented in Table VI. Distributions of sub-
jects among grade levels for each time point were
tested for significant differences by Pearson’s chi-
square test with use of the Bonferroni correction for
multiple comparisons were appropriate.
Overall improvement was significant at PreT3
(p ⬍ 0.0001), 1 month (p ⫽ 0.0043) and 3 months
(p ⫽ 0.0019). For satisfaction, 67–92% of subjects
were satisfied to very satisfied at all-time points. Sub-
ject comfort (comfortable to very comfortable)
ranged from 40% at Tx1 to 67% at 1 month.
Tolerance. Stinging/burning, tingling, itching and
burning were graded by subjects at each treatment
visit, using a 4-point scale in which 0 ⫽ none and
3 ⫽ severe. Stinging/burning was also graded at the
1-month and 3-month follow-up visits. The distribu-
tion of subjects among the grade levels of stinging/
burning was tested for significant differences by
Pearson’s chi-square test. When all time points were
included the proportions differed significantly
(p ⬍ 0.0001). When only the treatment visits were
included the differences were not significant
(p ⫽ 0.8207). When the 1-month and 3-month
follow-up distributions of subjects were compared
individually with baseline (Tx1), the difference was
significant (p ⫽ 0.0003).
Stinging (alone), tingling, itching and burning were
also tested across all treatment visits. Distributions
of subjects did not differ significantly for these four
subject-assessed sensations.
Discussion
The results of the present study show that fractional
bipolar RF energy is a safe and effective treatment of
acne scars. The median ECCA grade for acne sever-
ity was significantly lower than baseline at the
1-month and 3-month follow-up visits, global scores
were significantly reduced at the 3-month follow-up
visit, and improvement in cosmetic appearance was
1 Mo. FU 3-Mo. FU
0 0
3 6
6 3
0 1
0 0
†p ⫽ 0.0041 (s) †p ⬍ 0.0052 (s)
 176 M. H. Gold & J. A. Biron
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Figure 1. A 28-year-old female, skin type II, before treatment (A) and 12 weeks after the third treatment (B).

significant at the 1- and 3-month follow-up visits. For
erythema the distribution of subjects at the 1-month
follow-up visit was significantly improved from base-
line and at 3 months erythema was absent from all
For personal use only.
follow-up visit; brightness was significantly improved
at the third treatment and 3-month follow-up visit;
tightness was significantly improved at the 1-month
and 3-month follow-up visits; acne scar texture was

subjects. Dryness, bruising and crusting/erosion were
absent (except for a single data point) in subjects
throughout the study.
Subject-assessed stinging/burning was signifi-
cantly less at the 1-month and 3-month follow-up
visits than at baseline. Stinging/burning, stinging
(alone), tingling, itching and burning did not differ
significantly across the three treatment visits.
Subject-assessed fine lines and wrinkles were signifi-
cantly improved compared to baseline at the 3-month
significantly improved at the second and third treat-
ment visits and at the 1-month and 3-month
follow-up visits; pigmentation was significantly
improved at the third treatment and the 3-month
follow-up visits; overall improvement was signifi-
cantly greater at the third treatment and the 3-month
follow-up visits; most subjects (67–92%) were satis-
fied to very satisfied with the treatment; and subject
comfort ranged from 40% at the first treatment to
67% at the 1-month follow-up visit.

Figure 2. A 29-year-old female, skin type IV, before treatment (A) and 12 weeks after the third treatment (B).
 Treatment of acne scars by fractional RF 177

Table V. Distribution of subjects among erythema grades during study period.

Erythema

Grade∗ PreTx1 PreTx2 PreTx3 1-month FU 3-month FU

0 0 0 0 7 0
1 2 1 2 1 0
2 6 6 2 2 0
3 2 3 6 0 0
4 0 0 0 0 0
†p ⫽ 0.7659 (ns) †p ⫽ 0.1353 (ns) †p ⫽ 0.0101 (s) All grades ⫽ 0

FU ⫽ follow-up, s ⫽ significant, ns ⫽ non-significant.

∗0 ⫽ absent, 4 ⫽ severe.
†The p value obtained with the Pearson chi-square test.

Ramesh and colleagues (20) treated facial acne skin types I through III. Although both studies
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scars of 30 subjects (skin types IV–VI) with a ‘matrix-
tunable radiofrequency’ device similar to the device
used in the present study. Subjects had ice-pick, box
and rolling type scars of varying depths, sizes and
numbers present. Subjects were pretreated with oral
antibiotics and topical tretinoin (0.025%) and
received up to four monthly treatments (10–20
joules). Deep, box-type scars of eight subjects were
treated by subcision before RF treatment. Percentage
improvement of the entire face at 2 months and 6
For personal use only.
included all types of scars, Ramesh and colleagues
analysed the different scar types separately. Ramesh
and colleagues followed their patients for 6 months
compared to 3 months in the present study.
Despite these differences, both studies show that
fractional bipolar RF technology is both safe and
effective for the treatment of acne scars in skin types
IV and V, and that patients are generally satisfied with
the results. The present study involved skin types I
through V while Ramesh and colleagues treated skin

months after the final treatment was assessed by
visual comparison of post-treatment and baseline
photographs. Improvement was generally greater at
6 months (20%–70%) than at 2 months (10%–50%).
Cosmetic results was good to excellent in 73% of all
30 subjects and in 100% of subjects whose scars were
pretreated with subcision. Improvement in ice pick
scars was generally greater than with box-type scars
while improvement in rolling types scars was vari-
able. Adverse effects were limited to transient treat-
ment-site edema, a burning sensation (1 hour) and
pink-coloured skin for several days. A few patients
reported mild scaling and crusting. The authors con-
cluded that matrix-tunable radiofrequency technol-
ogy was effective against ice pick scars and rolling
type scars and, when combined with subcision before
treatment, box type scars.
Comparison of the results of the present study
with those of Ramesh and colleagues is difficult
because they pretreated their subjects with oral anti-
biotics, topical tretinoin and, in 8 patients, subcision.
Improvement was also evaluated differently and the
patients of Ramesh and colleagues did not include
types IV through VI. The collective results therefore
suggest that fractional bipolar RF technology may be
used to treat acne scars in all skin types, and improve-
ment may continue for at least 6 months.
A major advantage of the matrix-tunable RF
technology is that the user can select the depth of
treatment via three programs. In program A (2–8 J),
RF energy penetrates 100–300 μm for heating sub-
necrotic tissue with reduced downtime and minimal
coagulation of the epidermis and dermis. Program B
(8–16 J) provides moderate depths of penetration
(300–500 μm) with minimal ablation and coagula-
tion for medium depth acne scars and fine wrinkles.
Program C (16–25 J), with its 1000–1500 μm pen-
etration with greater tissue ablation and reduced
coagulation and subnecrotic heating, is appropriate
for deeper acne scars and deep wrinkles (19,20). Pro-
gram C, as suggested, (19) was used in most subjects
of the present study.
The encouraging results justify additional studies
with more subjects and suggest that such studies be
carried out for 1 year or longer to more fully evaluate
longevity of the treatment effects.

Table VI. Efficacy for skin attributes.

Attribute Time point (s) with significant improvement

Fine lines, wrinkles 3 months (p ⫽ 0.0031)

Brightness PreT3 (p ⫽ 0.0011), 3 months (p ⫽ 0.0031)
Tightness 1 month (p ⫽ 0.0122), 3 months (p ⫽ 0.0096)
Acne scar texture PreT2 (p ⫽ 0.0064), PreT3 (p ⫽ 0.0003), 1 month (p ⫽ 0.0053), 3 months (p ⫽ 0.0008)
Pigmentation PreT3 (p ⫽ 0.0099), 3 months (p ⫽ 0.0031)
 178 M. H. Gold & J. A. Biron
Conclusion
Fractional bipolar RF energy is a safe and effective
modality for the treatment of acne scars. The encour-
aging results warrant additional studies to further
characterise this modality.
Disclosure of interest: Dr. Gold performs research
and speaks on behalf of Syneron, Inc., Irvine, CA.
This study was funded by Syneron, Inc.
References
1. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of
acne scars with trichloroacetic acid: Chemical reconstruction
J Cosmet Laser Ther Downloaded from informahealthcare.com by Osaka University on 10/29/14
of skin scars method. Dermatol Surg. 2002;28:1017–1021;
discussion 1021.
2. Shamban AT, Narurkar VA. Multimodal treatment of acne,
acne scars and pigmentation. Dermatol Clin. 2009;27:459–
471, vi.
3. Jemec GB, Jemec B. Acne: Treatment of scars. Clin Dermatol.
2004;22:434–438.
4. Lee DH, Choi YS, Min SU, Yoon MY, Suh DH. Comparison
of a 585-nm pulsed dye laser and a 1064-nm Nd:YAG
laser for the treatment of acne scars: A randomized split-face
clinical study. J Am Acad Dermatol. 2009;60:801–807.
5. Beer K. A single-center, open-label study on the use of
For personal use only.
injectable poly-L-lactic acid for the treatment of moderate to
severe scarring from acne or varicella. Dermatol Surg. 2007;
33(Suppl 2):S159–S167.
6. Fabbrocini G, Annunziata MC, D’Arco V, De Vita V, Lodi G,
Mauriello MC, Pastore F, Monfrecola G. Acne scars: Patho-
genesis, classification and treatment. Dermatol Res Pract.
2010;2010:893080 (Epub 2010 Oct 14).
7. Bagatin E, dos Santos Guadanhim LR, Yarak S, Kamamoto
CS, de Almeida FA. Dermabrasion for acne scars during
treatment with oral isotretinoin. Dermatol Surg. 2010;36:
483–489.
8. Lee JW, Kim BJ, Kim MN, Lee CK. Treatment of acne scars
using subdermal minimal surgery technology. Dermatol Surg.
2010;36:1281–1287.
9. Jacob CE, Dover JS, Kaminer MS. Acne scarring: a classifica-
tion system and review of treatment options. J Am Acad Der-
matol. 2001;45:109–117.
10. Manuskiatti W, Triwongwaranat D, Varothai S, Eimpunth S,
Wanitphakdeedecha R. Efficacy and safety of a carbon-diox-
ide ablative fractional resurfacing device for treatment of
atrophic acne scars in Asians. J Am Acad Dermatol. 2010;
63:274–283.
11. Hu S, Chen MC, Lee MC, Yang LC, Keoprasom N. Frac-
tional resurfacing for the treatment of atrophic facial acne
scars in asian skin. Dermatol Surg. 2009;35:826–832 (Epub
2009 Apr 6).
12. Chrastil B, Glaich AS, Goldberg LH, Friedman PM. Second-
generation 1,550-nm fractional photothermolysis for the treat-
ment of acne scars. Dermatol Surg. 2008;34:1327–1332.
13. Mahmoud BH, Srivastava D, Janiga JJ, Yang JJ, Lim HW,
Ozog DM. Safety and efficacy of erbium-doped yttrium alu-
minum garnet fractionated laser for treatment of acne scars
in type IV to VI skin. Dermatol Surg. 2010;36:602–609 (Epub
2010 Apr 1).
14. Yoo KH, Ahn JY, Kim JY, Li K, Seo SJ, Hong CK. The use
of 1540 nm fractional photothermolysis for the treatment of
acne scars in Asian skin: A pilot study. Photodermatol Pho-
toimmunol Photomed. 2009;25:138–142.
15. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR.
Fractional photothermolysis: A new concept for cutaneous
remodeling using microscopic patterns of thermal injury.
Lasers Surg Med. 2004;34:426–438.
16. Geronemus RG. Fractional photothermolysis: current and
future applications. Lasers Surg Med. 2006;38:169–176.
17. Hantash BM, Mahmood MB. Fractional photothermolysis: A
novel aesthetic laser surgery modality. Dermatol Surg.
2007;33:525–534.
18. Jih MH, Kimyai-Asadi A. Fractional photothermolysis: A
review and update. Semin Cutan Med Surg. 2008;27:63–71.
19. Hruza G, Taub AF, Collier SL, Mulholland SR. Skin rejuve-
nation and wrinkle reduction using a fractional radiofre-
quency system. J Drugs Dermatol. 2009;8:259–265.
20. Ramesh M, Gopal M, Kumar S, Talwar A. Novel technology
in the treatment of acne scars: The matrix-tunable radiofre-
quency technology. J Cutan Aesthet Surg. 2010;3:97–101.
21. Dreno B, Khammari A, Orain N, Noray C, Mérial-Kieny C,
Méry S, Nocera T. ECCA grading scale: An original validated
acne scar grading scale for clinical practice in dermatology.
Dermatology. 2007;214:46–51.v