You are in: eMedicine Specialties > Plastic Surgery > SKIN Skin Resurfacing, DermabrasionArticle Last Updated: Mar 6, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Danielle M Dauria, MD, Resident, Division of Plastic and Reconstructive Surgery, St Louis University Danielle M Dauria is a member of the following medical societies: American Medical Student Association/Foundation Coauthor(s): Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine; Margaret Napolitano, MD, Clinical Instructor of Plastic Surgery, University of Louisville; Consulting Surgeon, Department of Plastic Surgery, Kleinert, Kutz and Associates; Michael Brent Seagle, MD, Associate Professor, Division of Plastic Surgery, University of Florida College of Medicine; Consulting Staff, Florida Surgical Center Editors: Tolbert Wilkinson, MD, Consulting Staff, Department of Surgery, Southwest Texas Methodist Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: cutaneous plastic surgery, skin planing, controlled skin abrasion, hyperpigmentation, diamond fraise, wire brush, Fitzpatrick skin classification, Fitzpatrick's skin classification, rhytidectomy, acne scars, traumatic scars, surgical scars, photodamage, actinic keratoses, perioral rhytides, rhinophyma INTRODUCTIONSection 2 of 10
  History of the ProcedureDermabrasion is a technique of skin resurfacing in which a high-speed rotary instrument with various abrasive end pieces is used to remove chosen layers of skin. The epidermis then regenerates from epidermal appendages in the deep dermis. Organized remodeling of the dermis yields rejuvenated skin that is smoother and firmer than it was before. Physicians in Ancient Egypt used sandpapering techniques similar to dermabrasion to treat scars. In 1905, Kromayer first reported controlled abrasion of the skin. His technique involved the use of rotating wheels and rasps, which differed little from tools used for present-day dermabrasion. He treated acne scars, keratoses, and areas of hyperpigmentation. Despite this early report of surgical planing, dermabrasion did not gain widespread popularity until the early 1950s. Abner Kurtin, a dermatologist at Mount Sinai Hospital in New York, was the first to present a series of patients who underwent dermabrasion with modified dental equipment in 1953. Various abrasive end pieces were described. Blau and Rein then coined the term dermabrasion in 1954. Alt and Yarborough further contributed to this field by advocating use of the diamond fraise and of wire-brush end pieces, respectively. The development of antiviral medications, semipermeable dressings, tumescent anesthesia and cryoanesthesia has further refined the procedure. Despite the advent of the cutaneous laser and of chemical peels, dermabrasion should remain a useful tool for skin resurfacing. ClinicalHistory and physical examination Obtain a detailed history and perform physical examination, including preoperative photography. Question the patient about previous exposure to or outbreaks of herpes simplex or cold sores. For patients with a positive history of exposure or outbreaks, increased doses of prophylactic antivirals are recommended. Prophylaxis with oral acyclovir 400 mg taken 3 times per day before and after the procedure can help reduce the risk of a herpes outbreak. Obtain a detailed drug history, specifically a history about previous and current use of isotretinoin because this is an absolute contraindication to dermabrasion. Shrunken sebaceous glands due to recent use of isotretinoin can delay reepithelialization and increase the risk of hypertrophic scarring. To the authors' knowledge, no controlled studies have examined this problem. Therefore, notable controversy remains regarding the use of isotretinoin in the setting of dermabrasion. With the current medicolegal climate, avoiding dermabrasion for at least 6 months after the completion of isotretinoin therapy is recommended. The use of other medications, such as exogenous estrogens, oral contraceptives, or other photosensitizing drugs, may predispose patients to pigmentary changes after dermabrasion. The physician should ask about drug allergies, particularly allergies to topical petrolatum products or local anesthetics, to help prevent adverse reactions before and after the procedure. Patient selection The physician should first obtain a detailed medical history and carefully perform the physical examination, including preoperative photographs. The physician should then determine the severity and depth of the condition to be treated and the need for additional or alternative procedures. In addition, the patient's skin type should be assessed by using the Fitzpatrick classification (see Table). This classification is used to categorize the skin according to its ability to tan or its likeliness to burn when it is exposed to UV light. Fitzpatrick Skin Classification*
*Fitzpatrick, 1988 In general, light skin types (types I-II) are most likely to heal without permanent dyschromia. Dark skin types are associated with increased rates of hypopigmentation and hyperpigmentation. These skin types may fare best with nonablative resurfacing techniques, such as rhytidectomy. Preexisting discolorations should be documented. Although dermabrasion produces some dyschromia in all patients, this effect can be minimized with appropriate patient selection. The physician should examine the patient's ear lobes, upper chest, and shoulders for existing keloids or hypertrophic scarring. The physician should also inquire about a history of psoriasis, lichen planus, pyoderma gangrenosum, or other pathergic diseases. For patients with any of these findings, dermabrasion should first be done in a test spot and the results evaluated. Finally, the patient's specific motivation should be identified, and realistic expectations about outcomes should be established before the procedure. Patients should expect only partial improvement and not complete eradication of the treated defects. See also Counseling. INDICATIONSSection 3 of 10
The most common indication for dermabrasion is the treatment of acne scars, traumatic or surgical scars, photodamage, some benign tumors, actinic keratoses, and perioral rhytides. Some physicians may perform dermabrasion to manage superficial malignancies, such as squamous cell carcinoma in situ and superficial basal cell carcinoma. Also, pigmentary changes due to melasma, tattoos, or postinflammatory hyperpigmentation can be lightened with dermabrasion. Dermabrasion is as effective as laser resurfacing in the treatment of these conditions. Dermabrasion is used for specific areas of the face more often than laser resurfacing or chemical peeling because it does not injure melanocytes and because it is less likely to cause pigmentary changes. Laser resurfacing and chemical peeling, when applied to only a portion of the face, often leave lines of demarcation between treated and untreated regions. In addition, dermabrasion is much less costly to the patient than laser resurfacing or chemical peeling. The high concentration of pilosebaceous glands in the face that aid in wound healing make the face the most common and the ideal site for dermabrasion, though other areas of the body can also undergo dermabrasion. Acne scars that are narrow, pitted, and sharply edged and that cast shadows on the face are most amenable to dermabrasion. Some acne scars are deep and extend into the subcutaneous tissue. Dermabrasion of the epidermis, papillary dermis, and upper reticular dermis is possible. However, abrasion below these levels is prohibitive and results in scarring. Therefore, deep lesions are best managed by first excising them with punch biopsy with or without use of a full-thickness graft; after healing, these lesions can be treated with dermabrasion. Dermabrasion can also be used to treat rhinophyma, a condition marked by swelling and redness of the nose caused by hyperplasia of the sebaceous glands and prominent vascularization of the skin. Thickening hyperplasia is often present, especially in the tip of the nose and in the alar regions. Dermabrasion allows the physician to substantially reduce this condition, and a full-thickness skin graft is rarely required. Reepithelialization is rapid, usually occurring within several days. RELEVANT ANATOMYSection 4 of 10
The most important element in dermabrasion is recognition of the appropriate depth of treatment. The skin is composed of 2 mutually dependent layers, the epidermis and the dermis, which rest on a fatty subcutaneous layer. The epidermis contains no blood vessels and protects the underlying dermis from the external elements. The epidermis is entirely dependent on the underlying dermis to deliver nutrients and to remove waste by means of diffusion across the dermoepidermal junction. The primary function of the dermis is to sustain and support the epidermis. The dermis is divided into 2 layers: the relatively superficial papillary dermis and the relatively deep reticular dermis. Collagen, elastic tissue, and reticular fibers are present throughout both layers. Epidermal appendages are intradermal epithelium-lined structures that can divide and differentiate. They develop as downgrowths of the epidermis into the dermis. They include sebaceous glands, sweat glands, apocrine glands, mammary glands, and hair follicles. Epidermal appendages serve an important role as a source of epithelial cells. These appendages are responsible for reepithelialization if the overlying epidermis is removed or destroyed in situations such as partial-thickness burns, chemical peeling, dermabrasion, traumatic abrasions, or harvesting of split-thickness skin grafts. Controlled dermabrasion can be performed on the epidermis and on the upper layers of the dermis. The wound heals by means of reepithelialization from the remaining epidermal appendages, similar to the healing of partial thickness burns. Reepithelialization begins within 24 hours of wounding and is usually complete after 7-10 days. Collagen remodeling continues for 3-6 months and results in dermal thickening and contraction, which further enhance the smoothing effect. CONTRAINDICATIONSSection 5 of 10
Recent or ongoing use of isotretinoin is an absolute contraindication to dermabrasion. Isotretinoin causes atrophy of pilosebaceous glands, which delays reepithelialization and increases the risk of hypertrophic scarring. Avoiding dermabrasion for 6 months to 1 year after the completion of isotretinoin therapy is imperative. Ablative resurfacing may exacerbate certain inflammatory conditions that impair reepithelialization and lead to scarring. Examples of such conditions are scleroderma, cutis laxa, psoriasis, congenital ectodermal dysplasia, and collagenous disorders due to abnormal adnexal structures. Recent surgery that involved undermining the skin that will undergo dermabrasion, such as face lifts, is a contraindication. Dermabrasion should be postponed for at least 6 months to allow the underlying vascular bed to heal. The risks of necrosis and delayed wound healing are increased because of the compromised blood supply. Previous radiation therapy leading to radiodermatitis is a relative contraindication because the skin is thinned in irradiated areas. Therefore, the risk of excessively deep dermabrasion and delayed healing is increased. Bleeding disorders, immunosuppression, and diabetes mellitus may also delay healing and increase the risk of surgical infection. Therefore, these conditions are relative contraindications. Avoid dermabrasion over small areas in patients with freckled skin because the freckles will disappear in those areas (but not elsewhere). Although deep rhytides and excessive facial skin are not definitive contraindications, patients with these findings are likely best served with traditional face-lift procedures. Dermabrasion is also contraindicated in patients with active herpetic lesions and in women who are pregnant or nursing. TREATMENTSection 6 of 10
Preoperative DetailsEquipment The dermabrader consists of an electric hand engine with a high-speed rotary motor and an interchangeable abrading end piece. The surgeon controls the speed with a foot pedal. Pressure exerted on the hand piece and the revolutions per minute of the hand piece are the 2 most important variables. Avoiding excessive pressure on the hand piece is important because this can result in gouging. Suggested rotational speeds of 12,000-15,000 rpm for the abrading heads result in controlled gradual planing of the treated surface. The most commonly used end pieces are diamond fraises or wire brushes. Fraises are available in many shapes, sizes, degrees of coarseness, and levels of quality. Small devices are used in confined spaces, such as around the nose or eyelids. Large wheels are used on broad, flat surfaces, such as the forehead and cheeks. Diamond fraises can be used without a spray refrigerant, whereas wire brushes require cooling. The wire brush produces microlacerations in the skin but causes little thermal injury. The diamond fraise is easiest to learn to use, but it can increase thermal injury because several passes applied with pressure are required for deep resurfacing. Because of the high rate of rotation, the surgical field should be cleared of sponges, towels, and other equipment that may become entangled and injure the physician, assistant, or patient. Preoperative counseling is imperative to ensure realistic patient expectations. In general, dermabrasion yields 35-50% improvement. Patients should not expect restoration of perfect skin, and dermabrasion does not affect skin redundancy or eliminate the possible need for rhytidectomy. Patients should be told that the greatest improvement is usually observed 6 months after surgery. Patients should avoid sun exposure before and after the procedure. All patients should receive antiviral prophylaxis, and patients with a history of herpes simplex should receive strong prophylactic doses of valacyclovir or famciclovir. The herpes virus requires viable epidermal cells to establish an infection. Therefore, antiviral therapy should continue for 10-14 days to allow complete reepithelialization to occur. Prophylactic antibiotics are usually not needed. However, patients with a history of impetigo, staphylococcal skin infections, or immunocompromise may benefit from antibiotics. Trans-retinoic acid (Retin-A, Renova), a topical exfoliative agent, is believed to increase the rate of epidermal turnover. This turnover promotes rapid reepithelialization after dermabrasion. Trans-retinoic acid may be applied every night or every other night for several weeks before dermabrasion, depending on the degree of skin irritation and the patient's tolerance. An alternative product relatively new to the market is Kinerase (Valeant Pharmaceuticals North America, Costa Mesa, CA), which is reported to be less irritating and less sensitizing to sunlight than trans-retinoic acid. Topical hydroquinone applied for several weeks before dermabrasion may decrease hyperpigmentation. Dermabraded areas respond well to this treatment. After a patient is appropriately selected, the physician obtains written informed consent. This process includes a thorough discussion of possible complications (see Complications). Intraoperative DetailsThe physician's preference determines the type of anesthesia needed. Dermabrasion may be performed by using general anesthesia, a regional block, or tumescent anesthesia with or without conscious sedation. The skin should be pretreated for 20-30 minutes with an ice pack. Refrigerant sprays (eg, fluoroethyl, freon-114), which produce topical anesthesia, decrease bleeding by means of vasoconstricting, and stiffen the surface of the skin, are also frequently used immediately before dermabrasion. The areas to be treated are marked in sections and then prepared and draped in a sterile fashion. Three-point retraction is performed by using the surgical assistant's 2 hands and the surgeon's nondominant hand. The surgeon and staff should practice strict exposure precautions, including the wearing of protective face shields, to avoid contact with aerosolized matter and blood-borne pathogens. The abrading instrument is correctly held by placing the forefingers around the body of the instrument with the thumb outstretched on the shaft for stability and control. Irregular or imperfect facial surfaces are abraded to yield a smooth and even surface (see Images 1-3). The results of dermabrasion depend on the coarseness of the abrading tip, the length of time the tip is applied to the skin, and the pressure used to apply the tip. Begin the abrasion in dependent areas, eg, along the sides of the face, and work toward the center. This approach prevents bleeding from obscuring the skin to be abraded. It is best to abrade cosmetic units as a whole to decrease the risk of noticeable pigmentary changes. The key to successful dermabrasion is controlling the wound created. The rotating head should be kept parallel to the skin surface, and the hand piece should be in motion at all times. Begin by planing the epidermis down to the dermal junction. No bleeding occurs during dermabrasion through the epidermis because of a lack of blood vessels in this layer. Decreased pigmentation is encountered when the process continues through the epidermis. The dermoepidermal junction is reached next, followed by the papillary layer of the dermis. This layer is marked by uniform bleeding from punctate sites over a smooth, shiny surface. The deep papillary dermal layer is encountered when the surface becomes rough and when bleeding points increase. Although each site bleeds only minimally, the multitude of bleeding sites can result in considerable blood loss. As the depth of abrasion increases, the superficial reticular dermis is reached, and bleeding becomes brisk and confluent. This layer is rougher than the deep papillary dermis and represents exposed dermal collagen. This surface has a whitish yellow appearance. Dermabrasion should not be performed below the superficial reticular dermis. Below this level, yellow fat globules are encountered, and clinically significant scarring would result if dermabrasion were continued here. At the periphery of the abraded area, lightly feather the borders by decreasing the pressure and the number of strokes to yield a uniform appearance. Exercise caution over bony prominences, where excessively deep dermabrasion commonly occurs. As the skin thaws, bleeding occurs. Saline-moistened sponges or sponges soaked in dilute epinephrine solution with or without lidocaine can be applied to the treated area for 5-10 minutes to decrease stinging and provide hemostasis. Postoperative DetailsPostoperative care is aimed at providing an ideal environment for moist wound healing. After the procedure, a topical petroleum product should be applied to all treated areas. Scented or mentholated antibiotic ointments should be avoided because of their potential to cause hypersensitivity reactions. An open or closed wound-care regimen may be followed. In a typical open wound-care regimen, compresses moistened with sodium chloride solution or 25% vinegar are applied 4-5 times per day, followed by the petroleum product mentioned above. Reepithelialization requires 10-14 days. A closed wound-care regimen may decrease the time for complete reepithelialization to only 5-7 days. The semipermeable dressings are applied directly to the skin and covered with non-stick dressings, gauze, and net dressing. The medical staff changes these dressings for 3-5 days, then open wound care is provided. Follow-upIn the early stages of wound healing, the patient should be reexamined early and repeatedly, generally within 48 hours and again every several days. Any buildup of fibrin should be removed to prevent infection, delayed healing, and possible scarring. Some physicians use intramuscular steroid injections or oral steroids to reduce periorbital and cheek edema. After reepithelialization is complete, the new skin is bright pink or red, with deeply abraded areas appearing most erythematous. This coloration fades within 8-12 weeks. Patients may use makeup to camouflage the appearance, though they should be instructed not to apply makeup, trans-retinoic acid, or sunscreen until the face is healed to the satisfaction of the treating physician. Some practitioners have used topical agents that contain platelet products or growth factors after dermabrasion. Although these products improve wound healing in clinical situations other than dermabrasion, the present authors know of no data from randomized controlled clinical trial that support their use in this setting. Further research continues in this area. Patients must use sunblock to protect the new sensitive skin after it reepithelializes to prevent burning and dyschromia. Patients should use sunscreen every day for 6-12 months after dermabrasion. Some patients have transient hyperpigmentation for 4-6 weeks after surgery. Bleaching creams, such as hydroquinone, may be used 3 weeks after surgery to help prevent this effect. Postoperative edema continues to improve for 3 months. As the edema resolves, deep rhytides and acne scars may initially appear to be persistent. Collagen remodeling continues for another 3-6 months, and new collagen fills deep defects. Patients should be told that the greatest improvement is usually observed 6 months after surgery. COMPLICATIONSSection 7 of 10
Postoperative spot bleeding, erythema, milia formation, and flare-ups of acne are normal sequelae of dermabrasion and should be discussed with the patient preoperatively. A common effect is hyperpigmentation 4-6 weeks after the procedure, but this is usually transient and responds well to hydroquinone. Patients at increased risk include those taking oral contraceptives, exogenous estrogens, or other photosensitizing medications. When hyperpigmentation does not respond to topical treatment, nonablative laser therapy can be done to diminish the pigment. The most clinically significant complications are hypertrophic scarring and permanent hypopigmentation. The risk of prolonged erythema, scarring, and hypopigmentation is directly proportional to the depth of dermabrasion and to the delay of wound healing after the normal time for reepithelialization. Therefore, every effort should be made to control these 2 factors. No good treatment is available to manage the complication of hypopigmentation. This complication occurs to varying degrees in 20-30% of patients. Hypopigmentation is due to the destruction or inhibition of melanocytes. Because they originate from neural crest cells, melanocytes cannot regenerate or divide. Hypopigmentation is most noticeable in darkly pigmented patients. It may be difficult to assess until erythema subsides; however, it is permanent at this point. Pigmentary changes are less likely to occur with dermabrasion than with alternate techniques, such as chemical peeling or laser resurfacing. Camouflage methods are currently the best options to treat hypopigmentation, though certain lasers may be used to stimulate the melanocytes in some patients. Hypertropic scarring is the most worrisome complication and results from dermabrasion through the deep dermis or an exaggerated inflammatory response (eg, keloid formation). Persistent erythema and delayed reepithelialization should alert the physician and patient that scarring is imminent. Erythema after dermabrasion typically lasts only 8-12 weeks as opposed to 3-6 months of erythema after laser resurfacing. Wounds that demonstrate a lack of reepithelialization by day 14 are at risk for hypertrophic scarring. Early recognition and aggressive treatment are essential. Mid- to high-potency topical steroid creams may be used. If induration is present, intralesional steroids (eg, triamcinolone acetonide [Kenalog]) should be given every 2-3 weeks. Aggressive measures, such as the application of compressive silicone sheets, scar massage, topical or intralesional steroids, and/or pressure garments, may minimize the appearance of the scar. Pulsed-dye vascular lasers have been used with some success during the erythematous phase of hypertrophic scarring. Scar excision or further dermabrasion may be necessary if the results of these therapies are unsatisfactory. Infectious complications are unusual but must be recognized quickly to prevent undesirable scarring. Postoperative viral infections, especially those due to herpes simplex virus, may occur despite prophylaxis. If pain, erythema, or ulcerations appear 7-10 days after the procedure, viral infection should be suspected, and a full-strength antiviral therapy should be administered (valacyclovir 1 g 3 times a day for 7 days or famciclovir 500 mg 3 times a day for 7 days). Infections due to staphylococcal, streptococcal, pseudomonal, or candidal bacteria may occur. If they do, wound cultures should be ordered, and appropriate oral or topical antibiotics or antifungal treatment should be started. Milia, or intraepidermal collections of keratinaceous debris, are commonly observed after dermabrasion. These collections appear as small, white cysts. Treatment consists of electrodesiccation, unroofing, or lancing the cysts with a needle or scalpel. OUTCOME AND PROGNOSISSection 8 of 10
Dermabrasion is a well-established technique for skin resurfacing. It may yield excellent results if a well-trained surgeon performs the procedure in an appropriate patient. Careful patient screening is crucial to ensure realistic expectations. With meticulous postoperative care, the results are highly satisfying to most patients. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Skin Resurfacing, Dermabrasion excerpt Article Last Updated: Mar 6, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||
