Dermabrasion

Dermabrasion, or skin resurfacing, is a mechanical method of "cold steel", consisting in the removal of the epidermis to the papillary dermis. Subsequent production of new collagen and re-epithelialization due to deeper located, less sun damaged cells exerts an excellent cosmetic effect on actinically damaged, aged or scarred-altered skin. Pre and postoperative tactics that optimize wound healing are well developed and predictable, and complications are rare.

Modern dermabrasion originated in the late 40s of the last century with Kurtin, who modified the technique, first described at the turn of the century Kronmayer. The Kurtin wire brush technique, which was modified by Bruke in the mid-1950s, laid the foundation for the techniques currently used. The impact of a fast rotating wire brush or diamond disc, skillfully applied to chilled skin, is considered effective in treating many conditions.

[1], [2]

Selection of patients and indications for dermabrasion

Among the many indications for dermabrasion, the most frequent at present is the treatment of post-acne scars, wrinkles, pre-malignant sunny keratoses, rhinophyma, traumatic and surgical scars and tattoos. Post-acne scars are the main, most common indication for dermabrasion. With scars formed after acne, a significant improvement can be achieved, but the ideal result is unattainable. Patients should have realistic expectations regarding surgical outcomes. The most often good results are achieved in those patients who for 4-6 weeks before dermabrasion had a deep impact on these scars or their aiming excision with suturing. Patients with significant post-hot scarring should be warned about the possible progression of scars as a result of dermabrasion. Patients with dark skin after surgery may have hypopigmentation or hyperpigmentation. This is often a temporary phenomenon, and the pigmentation returns to normal within a few months. Occasionally, when scarring and dermabrasion affect the deep layers of the skin, pigmentation can be permanently disrupted. This is especially true for people of Asian descent.

Patients planning for dermabrasion often received systemic treatment with 13-cis retinoic acid for acne. This powerful anti-acne agent causes atrophy of the sebaceous glands, and from the time of its use it was suggested that it should slow the healing of wounds after dermabrasion. The first literature reports showed that the previous treatment with isotretinoin (Accutane) does not affect the healing of wounds after dermabrasion. However, in later works, it is indicated that atypical scarring occurs in patients who have undergone skin polishing after Accutane treatment. After these reports, other authors cited a number of cases where patients were treated with Accutane and then underwent dermabrasion without consequences. This anxious contradiction has clear medical and legal consequences. Clear cause-effect relationships between the use of Accutane and atypical scarring have not been established. In fact, laboratory studies failed to establish any deviations in the activity of fibroblasts in Accutane treated skin. Until the answer to this question is found, it is probably reasonable for the doctor to refrain from conducting dermabrasion in patients who have completed Accutane intake less than 6 months ago.

The human immunodeficiency virus (HIV) is the last factor to consider when selecting patients for dermabrasion. Of all the existing surgical procedures, dermabrasion is most definitely accompanied by the spraying of particles of blood and tissues, and, consequently, of living viral particles. A recent study showed that aerosol particles formed during dermabrasion have dimensions that facilitate their retention by the surface of the mucous membrane of the airways. Moreover, it has been demonstrated that commonly used protective equipment such as masks, goggles and shields does not protect against the inhalation of these particles. In addition, the deposition rate of such small particles can support infection for many hours after the procedure, thereby exposing personnel who do not participate directly in the procedure. Another problem related to HIV is the inability to detect it if the patient is in a latent period between infection and seropositivity. Refusal to the patient with positive laboratory analysis entails legal consequences. It is certain that there is a risk for the doctor, assistants and other personnel. Dermabrasion should not be performed without careful collection of information indicating a high risk of this procedure, without the availability of appropriate protective equipment and the understanding that even with these funds a certain risk remains. The same precautions must also be followed for hepatitis.

An increasingly frequent reason for dermabrasion is aging skin, especially with actinic damage and a pathology such as pre-malignant sunny keratoses. It has been shown that dermabrasion is as effective, if not more so than the local application of 5-fluorouracil in the treatment of precancerous skin lesions. When studying the polishing of a half of a face with actinically damaged skin, it was shown that the area affected by skin precancerous changes significantly decreased, and their further development slowed down for more than 5 years. These facts, combined with significant regression of cracks, make dermabrasion a real tool in the treatment of aging skin. The results were recently confirmed.

It has been demonstrated that dermabrasion performed for traumatic or surgical scars about 6 weeks after injury often leads to the complete disappearance of these scars. In fact, surgical scars respond so well to dermabrasion that most patients dermabrasion can be performed as early as 6 weeks after surgery. Although this is usually not necessary, comprehensive information to the patient facilitates further communication with him. Dermabrasion is particularly successful in patients with sebaceous skin or in such areas of the face as the nose, where improvement after this procedure is most significant. Reduction of scars after dermabrasion is further enhanced by the use in the postoperative period of biosynthetic dressings, which significantly affect the synthesis of collagen. Tattoos can be removed with the help of superficial dermabrasion, followed by local application for 10 days of gauze dressings impregnated with 1% gentianviolet and vaseline. Gentianviolet restrains healing, facilitating the washing out of the pigment into the bandage, and supports inflammation, creating conditions for the phagocytosis of the remaining pigment. Erasing only to the tops of the papillae of the dermis prevents scarring. Do not attempt to remove the pigment only by abrasion. Professional tattoos are more amenable to removal than amateur or traumatic, but improvement can be achieved with any type of tattoo. Usually about 50% of the pigment leaves after the first procedure, which can be repeated every 2-3 months until the desired result is achieved. Working with tattoos is a good practice when mastering dermabrasion.

Benign tumors, such as adenomas from the sebaceous glands and syringomas, are successfully and successfully treated with dermabrasion, but they tend to gradually recur. Excellent results can also be achieved with rhinophyma, when dermabrasion is combined with electrocoagulation.

Anatomical and reparative bases of dermabrasion

To achieve favorable results with the use of dermabrasion techniques, it is necessary to understand the basics of microscopic anatomy of the skin. For all practical purposes, three layers are distinguished in the skin:

• epidermis,
• dermis, and
• subcutaneous tissue.

The most important for dermabrasion of the dermis, which consists of two layers: the superficial papillary layer and the deep mesh layer. Damage to the epidermis and the papillary layer of the dermis heal without scarring, while lesions that extend to the mesh layer always lead to the formation of scar tissue. The goal of dermabrasion is the reorganization or restructuring of the collagen of the papillary layer without damaging the mesh layer of the dermis. The thickness of these layers of the dermis varies in different areas of the body and, although dermabrasion can be used without the formation of scars everywhere, the face is ideal for it. This is partly due to the healing of the wound after dermabrasion. Re-epithelialization begins from the edges of the wound and from epidermal appendages that persist after grinding. The initial bud of this re-epithelization is the sebaceous-hair follicle, and the face is generously endowed with sebaceous glands. It was shown that such damage leads to a significant increase in procollagen I and III type, as well as to the transformation of the growth factor beta in the papillary layer. The results of the studies suggest that the increased activity of fibroblasts, leading to the synthesis of type I and III collagen, causes clinical manifestations of improved collagen formation, noted after dermabrasion.

Clinically and laboratory it has been shown that applying 0.5% tretinoin for several weeks before partial dermabrasion accelerates healing. Wounds in patients who received tretinoin for several weeks before the procedure, heal in 5-7 days. The same process without tretinoin takes 7-10 days. Another important factor in accelerating wound healing after skin resurfacing is the use of closed bandages. After the work of Maibach and Rovee, it was understood that the wounds heal under the occlusal bandages are 40% faster than the wounds that are in contact with the open air. This is especially true for closed wounds covered by appropriate biosynthetic dressings, which heal much faster than those where the formation of a scab is allowed. Moreover, biosynthetic bandages reduce postoperative pain response almost immediately after application to fresh wounds. Biosynthetic dressings keep wounds moist, thereby allowing the migration of epithelial cells along the surface. They also allow a wound fluid containing growth factors that stimulate healing to be in direct contact with the wound surface. The number of laboratory evidence that the presence of an occlusive dressing regulates the synthesis of collagen and leads to the formation of a cosmetically more satisfactory surface is increasing.

[3], [4]

Dermabrasion: equipment

A wide variety of abrasion tools are available for sale, from manual to electric, with mains or batteries. The newest are pneumatic devices for "microdermabrasion", supplying the skin with a jet of air with small particles of aluminum or glass. Important for power supplies is that they must provide the torque required for a constant, monotonous and uniform movement of the grinding surface, wire brush or diamond disc. Excellent descriptions of the technique of dermabrasion using a wire brush and diamond disk, made by Yarborough and Alt, require only small refinements. However, one can not but emphasize that no publication can replace the comprehensive practical experience obtained in training, when students have the opportunity to observe and assist a specialist experienced in dermabrasion. Most authors agree that the technique of a wire brush requires more skill and carries a greater risk of potential damage, since the epidermis is cut deeper and faster than with a diamond disc. But, if you do not consider diamond discs with a rather rough surface, the best results are obtained by a wire brush.

One of the constant contradictions associated with the technique of dermabrasion is the use of pre-cooling skin. Experimental and clinical studies with a variety of cryo-anesthetic materials used to cool the skin before grinding have shown that materials that cool the skin below -30 ° C and especially below -60 ° C can cause skin necrosis and subsequent scarring. Freezing the skin before dermabrasion is necessary in order to have a hard surface that will wear out evenly, and preserve anatomical landmarks that are broken when thawing tissues. Since cold damage can lead to excessive scarring, it must be remembered that the use of cryoanesthetics, which freezes the skin no lower than -30 ° C, is prudent and just as effective as the application of deeper frost. Due to the fact that the rules for handling fluorocarbons make it difficult for them to be delivered to medical facilities, many surgeons use infiltration anesthesia instead of cooling to effect tissue turgor.

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Methods of dermabrasion

Anesthesia

Stepwise preoperative anesthesia allows you to perform dermabrasion in outpatient settings. Diazepam, administered approximately 45 to 60 minutes prior to surgery, in combination with intramuscular injection of 0.4 mg of atropine, with its amnestic and anticholinergic action, allows the patient to feel calmer and more confident. To reduce the discomfort associated with the implementation of regional anesthesia with a mixture of xylocaine and bupivacaine, before this, either 1 ml of fentanyl intravenously or meperidine is administered intramuscularly with midazolam. After achieving the analgesic effect, local anesthesia is performed in the supraorbital, infraorbital and chin holes, which covers 60-70% of the facial tissues. When combined regional anesthesia with the spraying of the cooling agent, dermabrasion does not cause pain in most patients. If the patient begins to feel discomfort during the procedure, nitrous oxide is used to maintain anesthesia, which allows the procedure to continue without interruption.

[6], [7]

Grinding procedure

After curing the skin with a cooling spray, the grinding procedure begins in areas that can be processed in about 10 seconds, or in areas of about 6 cm2. The tool for dermabrasion, firmly held in the hand, should be applied only along the handle and perpendicular to the plane of rotation. Reciprocating or circular movements can make a skin in the skin. Wire brush almost does not require pressure and creates micro-fractures, which are a sign of the adequacy of the depth of processing. Sufficient depth is determined by several landmarks, as it passes through the layers of the skin. Removing the skin pigment means moving through the basal layer of the epidermis. When moving to the papillary layer of the dermis, as the tissue thinens, small capillary loops, with dotted hemorrhage, appear and tear. Deeply noticeable are the small parallel beams of collagen. The erasure of these parallel beams means that the dermabrasion is produced to the desired level. Progressing deeper can lead to scarring.

Many authors suggest using cotton towels and gloves to absorb blood and formed tissue detritus, rather than gauze, which can be wrapped in tools for dermabrasion. The entanglement of gauze in the instrument leads to loud beating, which frightens the patient and can disrupt the work of the instrument.

It is easiest to start dermabrasion in the center, near the nose and further to move outwards. Since these are usually areas with the greatest defects and the lowest sensitivity, the procedure of dermabrasion causes here minimal discomfort for the patient, the surgeon has the longest time. When dermabrasion in the lip area, special attention should be paid to fixing it by stretching, otherwise the lip can be tightened into the instrument and significantly injured. It is necessary to constantly keep the plane of the tool nozzle parallel to the surface of the skin, especially in areas with complex curvature, such as chin and cheekbones. Dermabrasion should always be carried out within the aesthetic units of the face, to prevent demarcation due to pigmentation. Dermabrasion down slightly below the line of the lower jaw, outwards to the anterior region and up to the infraorbital area, guarantees a uniform surface appearance. Then, 35% trichloroacetic acid (TCA) can be applied to improve the color tone transition on unbrushed skin, for example, on the eyebrow area and a few centimeters from the hair growth line.

Postoperative period

The biosynthetic bandage applied at the end of the procedure contributes to the relief of painful sensations. After the operation, patients for 4 days are prescribed prednisolone at 40 mg / day, which significantly reduces postoperative edema and discomfort. One of the most important recent achievements is the successful use of acyclovir in patients who have a history of infection with the herpes simplex virus. When administered after 24 hours after the operation, 400 mg of the drug 3 times a day for 5 days, postoperative viral infection does not develop. Currently, many authors recommend the prevention of acyclovir or similar drugs for all patients, regardless of anamnesis.

In most patients with the use of biosynthetic bandage, complete re-epithelialization occurs between the 5th and 7th days after the operation. Some bandages, such as Vigilon, need to be changed every day. Others can be applied directly after dermabrasion and left in place until self-contained. Biosynthetic dressings must first be covered with gauze, held in place by a flexible surgical mesh. After re-epithelization of the skin, a sunscreen is applied daily; patients usually resume taking tretinoin on the 7th-10th day after surgery. If the patient has a history of pigment disorders, such as melasma, hydroquinone is administered concomitantly with tretinoin. If from the tenth to the fourteenth day, the patient shows signs of a common erythema, local application of 1% hydrocortisone begins. After surgery, patients are warned that their skin will return to normal appearance no earlier than a month. However, with the application of light make-up, most patients can return to work 7-10 days after the operation.

Comparison of dermabrasion with other methods

All methods of skin polishing lead to the formation of a wound to the surface or middle layers of the skin. The dermabrasion is based on the mechanical erasing of the skin, acid peeling gives "corrosive" damage, and lasers - thermal damage. Recent studies on pigs comparing skin treatment with carbon dioxide laser, TCA and dermabrasion by Fitzpatrick, and also by Campell, showed that the histological and ultrastructural changes after these procedures are comparable. When comparing dermabrasion with chemical peeling, significant differences in the disruption of the histological and mechanical properties of the elastic fibers were found. Six months after treatment with phenol, the skin was more rigid and weaker than the skin after dermabrasion. It was also reported that a comparison of the half-face dermabrasion in the perioral region with the polishing of the other half of the face with a carbon dioxide laser produced clinically identical results, but the healing after dermabrasion occurred almost twice as fast, with significantly less postoperative erythema and fewer complications. Similar results were obtained by Gin et al. Most surgeons practicing skin resurfacing agree that erythema and hypopigmentation after laser resurfacing and phenol peeling last longer and are more pronounced than after dermabrasion. In his review, Baker noted that equipment for dermabrasion is inexpensive, portable, widely available, does not require additional equipment and does not carry the danger of a fire in the operating room.

[8], [9], [10], [11]

Complications of dermabrasion

Prosoid rashes (milia) are the most common complication of dermabrasion, usually manifested in the 3-4th week after surgery. If tretinoin is used after the operation, these rashes are rare. Another common complication in patients predisposed to acne is acne. If a patient shortly before dermabrasion had aggravation of acne, the appearance of rashes can often be prevented by tetracycline in the early postoperative period. When the rash has arisen, tetracycline usually quickly stops it. Although dermabrasion of erythema is expected, prolonged or unusually severe erythema after 2-4 weeks, to prevent hyperpigmentation and scarring, should be treated with topical steroids. Daily use of sunscreen needs to start after healing and continue for several months after the operation. If hyperpigmentation occurs after a few weeks after dermabrasion, it can be resolved by topical application of hydroquinone and tretinoin.

As a result of dermabrasion, although infrequently, infection can occur. The most common pathogens are Staphylococcus aureus, herpes simplex virus and fungi of the genus C andida. Staphylococcal infection usually manifests itself 48-72 hours after dermabrasion with unusual facial edema and the appearance of honey crusts, as well as systemic symptoms such as fever. Viral infection often develops in patients who have not been prevented with acyclovir, and is recognized by severe asymmetric pain, usually 48-72 hours after surgery. Candidiasis usually manifests as delayed healing and is clinically diagnosed somewhat later, on the 5th-7th day, for exudation and swelling of the face. Treatment with an appropriate antibiotic, either acyclovir or ketoconazole, leads to the arrest of the infection without consequences.

[12], [13], [14]