JAAD ONLINE: SURGICAL PEARLS

Fractionated cryotherapy
Somesh Gupta, MD, DNB,a Savita Yadav, MD,a Suman Patra, MD,a and
Sanjeev Gupta, MD, DNBb
New Delhi and Ambala, India

Key words: aesthetics; cryotherapy; fractional.

SURGICAL CHALLENGE
Cryotherapy is a commonly performed procedure in dermatology outpatient departments for destruction of
pathologic tissue. It is an easy-to-perform, inexpensive, and sutureless technique and carries a minimal risk of
infection. However, the procedure is associated with many complications and sequelae such as blistering,
ulceration, necrosis, and permanent or longstanding pigmentary alterations. This limits its use on cosmetically
sensitive sites and for indications like facial rejuvenation, particularly in people with pigmented skin.

SOLUTION
We propose fractionated cryotherapy to reduce the complication rates and expand its indications in
rejuvenation and aesthetics. For this, we took thin plywood or transparent plastic plates (poor conductors of
heat) and created multiple uniform holes using a drill machine (Fig 1, A). The size and distance between holes
can be customized depending on the site and indication for which fractionated cryosurgery is planned. Closely
placed larger holes are suited for indications for more aggressive cryotherapy such as thick keloids on the chest
and shoulders. Templates with closely placed smaller holes and sparsely placed smaller holes with alternate
rows are suited for less aggressive cryotherapy on cosmetically sensitive sites such as post herpes zoster
hypertrophic scars on the face (Fig 1, A-C ). Sparsely placed smaller holes are well-suited for resurfacing, like
cold slush peels and rejuvenation.
The plate was firmly placed on the area of skin to be treated (Fig 2, A, video available at http://www.jaad.
org), and liquid nitrogen was sprayed by the spiral or paint brush method over the entire plate. The duration of
freezing is generally longer than that for conventional continuous freezing. Two to three 30-40esecond freeze-
thaw cycles (after repositioning of the template) may be used for thick nonfacial keloids, and one or two 15-
20esecond freeze-thaw cycles may be used for facial scars. This leads to fractionated freezing and a rapid
thawing of the frozen tissue resulting from the dispersion of thermal energy from intermittent areas of unfrozen
tissue. After treatment, improvement might be seen without pigmentary changes (Fig 2, B).
The procedure is much less painful as compared with conventional uniform freezing. Using this technique
multiple times can be safely done in 1 session, and the procedure can be repeated at frequent intervals. For
curved surfaces, mouldable plastic material can be used. Transparent plastic templates allow better visualization
of the area to be treated under the template. Fractionating has the potential to expand the indications for
cryotherapy in aesthetics and rejuvenation.

From the Department of Dermatology and Venereology, All India
Institute of Medical Sciences, New Delhia; and Department of
Dermatology and Venereology, Maharishi Markandeshwar
Institute of Medical Sciences and Research, Mullana, Ambala.b
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Dr Somesh Gupta, MD, DNB, Department of
Dermatology and Venereology, AIIMS, New Delhi 110029, India.
E-mail: someshgupta@hotmail.com.
J Am Acad Dermatol 2017;77:e69-71.
0190-9622/$36.00
Ó 2017 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2017.03.033

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e70 Gupta et al J AM ACAD DERMATOL
SEPTEMBER 2017

Fig 1. Fractionated cryotherapy. A, Multiple transparent plastic plates with holes of different
sizes and arrangements to be used for different indications. B, Liquid nitrogen sprayed over the
transparent plastic plate with multiple holes placed over the chin of the patient with postherpes
zoster hypertrophic scars. C, Skin with frozen areas in a grid pattern with spared normal skin in
between the frozen areas.
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VOLUME 77, NUMBER 3

Fig 2. A, Postacne hypertrophic scars before fractionated cryotherapy. B, Two weeks after a
single session of fractionated cryotherapy showing significant improvement and minimal
pigmentary changes.