Dermabrasion

Dermabrasion, or skin resurfacing, is a mechanical “cold steel” method of removing the epidermis down to the papillary dermis. The subsequent production of new collagen and re-epithelialization from deeper, less sun-damaged cells provides excellent cosmetic benefits to actinically damaged, aged, or scarred skin. Pre- and post-operative strategies to optimize wound healing are well established and predictable, and complications are rare.

Modern dermabrasion began in the late 1940s with Kurtin, who modified a technique first described at the turn of the century by Kronmayer. Kurtin's wire brush technique, modified by Bruke in the mid-1950s, laid the foundation for the techniques used today. The action of a rapidly rotating wire brush or diamond disc, skillfully applied to cooled skin, is considered effective in treating many conditions.

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Patient selection and indications for dermabrasion

Among the many indications for dermabrasion, the most common currently is the treatment of post-acne scars, wrinkles, pre-malignant solar keratoses, rhinophyma, traumatic and surgical scars, and tattoos. Post-acne scars constitute the main, most common indication for dermabrasion. Significant improvement can be achieved in acne scars, but ideal results are not achievable. Patients should have realistic expectations regarding surgical results. Good results are most often achieved in patients who have had deep cerebral excision or targeted suturing of these scars 4-6 weeks prior to dermabrasion. Patients with significant post-acne scarring should be warned of the possibility of scar progression as a result of dermabrasion. Patients with dark skin may experience hypopigmentation or hyperpigmentation after surgery. This is often temporary, and pigmentation returns to normal within a few months. Rarely, when scarring and dermabrasion reach deeper layers of the skin, pigmentation may be permanently affected. This is especially common in people of Asian descent.

Patients scheduled for dermabrasion have often received systemic treatment with 13-cistretinoic acid for acne. This potent anti-acne agent causes sebaceous gland atrophy and, from the beginning of its use, it was thought to delay wound healing after dermabrasion. Early reports in the literature showed that previous treatment with isotretinoin (Accutane) did not affect wound healing after dermabrasion. However, more recent work has indicated that patients who underwent skin resurfacing after Accutane treatment developed atypical scarring. Since these reports, many other authors have cited cases in which patients were treated with Accutane and then underwent dermabrasion without sequelae. This disturbing contradiction has clear medical and legal implications. A clear cause-and-effect relationship between Accutane use and atypical scarring has not been established. In fact, laboratory studies have failed to show any abnormalities in fibroblast activity in Accutane-treated skin. Until that question is answered, it is probably prudent for physicians to refrain from performing dermabrasion on patients who have been off Accutane for less than 6 months.

Human immunodeficiency virus (HIV) is a final factor to consider when selecting patients for dermabrasion. Of all the surgical procedures available, dermabrasion most certainly involves aerosolization of blood and tissue particles, and therefore live viral particles. A recent study has shown that the aerosol particles generated by dermabrasion are of a size that makes them retained by the mucosal surface of the respiratory tract. Furthermore, it has been demonstrated that the protective equipment commonly used by staff, such as masks, goggles, and shields, do not prevent the inhalation of these particles. Furthermore, the rate of deposition of such small particles can maintain infection for many hours after the procedure, thereby putting non-participating staff at risk. Another problem associated with HIV is the inability to detect it if the patient is in the latent period between infection and seropositivity. There are legal consequences for refusing a patient with a positive laboratory test. There is certainly a risk to the physician, assistants, and other staff. Dermabrasion should not be performed without careful information indicating the high risk of the procedure, adequate protective equipment, and an understanding that even with these protective equipment, some risk remains. The same precautions should be taken with respect to hepatitis.

An increasingly common reason for dermabrasion is aging skin, especially with actinic damage and conditions such as premalignant solar keratoses. Dermabrasion has been shown to be as effective, if not more effective, than topical 5-fluorouracil in treating premalignant skin lesions. In a study of half-face resurfacing of actinically damaged skin, the area of premalignant skin lesions was significantly reduced and their further progression was slowed by more than 5 years. These findings, coupled with significant regression of cracks, make dermabrasion a viable option for treating aging skin. The results have recently been confirmed.

Dermabrasion of traumatic or surgical scars performed approximately 6 weeks after injury has been shown to often result in complete resolution of the scars. In fact, surgical scars respond so well to dermabrasion that most patients can have dermabrasion as early as 6 weeks after surgery. Although this is usually not necessary, full patient education facilitates further communication. Dermabrasion is particularly successful in patients with oily skin or in areas of the face such as the nose, where the improvement from this procedure is most dramatic. Scar reduction following dermabrasion is further enhanced by the postoperative use of biosynthetic dressings, which significantly affect collagen synthesis. Tattoos can be removed by superficial dermabrasion, followed by topical application of 1% gentian violet and petrolatum gauze dressings for 10 days. Gentian violet delays healing by washing pigment into the dressing and maintains inflammation, creating conditions for phagocytosis of the remaining pigment. Abrasion only to the tips of the dermal papillae prevents scarring. Do not attempt to remove pigment by abrasion alone. Professional tattoos are more easily removed than amateur or traumatic ones, but improvement can be achieved with any type of tattoo. Typically about 50% of the pigment is removed after the first treatment, which can be repeated every 2-3 months until the desired result is achieved. Working with tattoos is good practice when mastering dermabrasion.

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

Anatomical and reparative principles of dermabrasion

To achieve favorable results using the dermabrasion technique, it is necessary to understand the basic microscopic anatomy of the skin. For all practical purposes, the skin is divided into three layers:

• epidermis,
• dermis, and
• subcutaneous tissue.

The most important part of dermabrasion is the dermis, which consists of two layers: the superficial papillary layer and the deep reticular layer. Injuries to the epidermis and papillary layer of the dermis heal without scarring, whereas injuries extending to the reticular layer always result in scar tissue formation. The goal of dermabrasion is to reorganize or restructure the collagen of the papillary layer without damaging the reticular layer of the dermis. The thickness of these dermal layers varies in different areas of the body, and although dermabrasion can be applied without scarring anywhere, the face is ideal for it. This is partly due to the peculiarities of wound healing after dermabrasion. Re-epithelialization begins from the wound edges and from the epidermal appendages that remain after polishing. The initial germ of this re-epithelialization is the sebaceous hair follicle, and the face is generously endowed with sebaceous glands. This injury has been shown to result in significant increases in procollagen types I and III and in the transformation of growth factor beta in the papillary layer. The results suggest that increased fibroblast activity leading to the synthesis of collagen types I and III is responsible for the clinical improvement in collagen formation seen after dermabrasion.

It has been shown clinically and in vitro that application of 0.5% tretinoin for several weeks prior to partial dermabrasion accelerates healing. Wounds in patients treated with tretinoin for several weeks prior to 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 dressings. Following the work of Maibach and Rovee, it was realized that wounds heal under occlusive dressings 40% faster than wounds exposed to open air. This is especially true for wounds covered with appropriate biosynthetic dressings, which heal much faster than those where eschar formation is allowed. Moreover, biosynthetic dressings reduce the postoperative pain reaction 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 wound fluid containing growth factors that stimulate healing to be in direct contact with the wound surface. There is increasing laboratory evidence that the presence of an occlusive dressing regulates collagen synthesis and results in a more cosmetically pleasing surface.

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Dermabrasion: Equipment

A wide variety of abrasion instruments are commercially available, from hand-held to electric, mains-powered, or battery-powered. The newest are pneumatic "microdermabrasion" devices that deliver a jet of air containing fine aluminum or glass particles to the skin. The important thing about the power source is that it must provide the torque necessary to produce a steady, monotonous, and uniform motion of the abrading surface, wire brush, or diamond disc. The excellent descriptions of the wire brush and diamond disc dermabrasion technique by Yarborough and Alt require only minor modifications. It must be emphasized, however, that no publication can replace the extensive practical experience gained in training, where students have the opportunity to observe and assist an experienced dermabrasion practitioner. Most authors agree that the wire brush technique requires greater skill and carries a greater risk of potential injury, since it cuts deeper and more rapidly into the epidermis than with a diamond disc. But, unless you consider diamond discs with a fairly rough surface, a wire brush gives the best results.

One of the persistent controversies associated with the technique of dermabrasion is the use of pre-cooling of the skin. Experimental and clinical studies with a variety of cryoanesthetic materials used to cool the skin prior to abrasion 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 prior to dermabrasion is necessary to provide a rigid surface that will abrade evenly and to preserve anatomical landmarks that are disrupted by tissue thawing. Since cold injury can lead to excessive scarring, it should be remembered that using a cryoanesthetic that freezes the skin at or above -30°C is prudent and as effective as using deeper freezing. Because handling regulations for fluorocarbons make them difficult to supply to medical facilities, many surgeons use infiltration anesthesia instead of cooling to influence tissue turgor.

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Dermabrasion technique

Anesthesia

Staged preoperative anesthesia allows dermabrasion to be performed on an outpatient basis. Diazepam, administered approximately 45-60 minutes before surgery, in combination with intramuscular injection of 0.4 mg atropine, with its amnestic and anticholinergic effects allows the patient to feel calmer and more confident. To reduce the discomfort associated with regional anesthesia with a mixture of xylocaine and bupivacaine, either 1 ml of fentanyl intravenously or meperidine intramuscularly with midazolam is administered beforehand. After achieving the analgesic effect, local anesthesia is performed at the supraorbital, infraorbital and mental foramina, which covers 60-70% of the facial tissue. When regional anesthesia is combined with spraying of a cooling substance, 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.

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Grinding procedure

After the skin has hardened with a cooling spray, the polishing procedure begins in areas that can be treated in about 10 seconds, or in areas of about 6 cm2. The dermabrasion instrument, held firmly in the hand, should be pressed only in the direction of the handle and perpendicular to the plane of rotation. Reciprocating or circular movements can make a groove in the skin. A wire brush requires almost no pressure and creates micro-tears, which are a sign of adequate treatment depth. Sufficient depth is determined by several landmarks as it passes through the layers of the skin. Removal of skin pigment means advancing through the basal layer of the epidermis. When advancing into the papillary layer of the dermis, as the tissue thins, small capillary loops become visible and rupture, with pinpoint bleeding. Deeper, small parallel bundles of collagen become barely visible. Erasing of these parallel bundles means that dermabrasion has been performed to the desired level. Going deeper may result in scarring.

Many authors suggest using cotton towels and gloves to absorb blood and tissue debris rather than gauze, which can become tangled in dermabrasion instruments. Tangling of gauze in the instrument causes a loud beating sound that frightens the patient and can interfere with the instrument's operation.

It is easiest to start dermabrasion in the center, near the nose, and then move outward. Since these are usually the areas with the greatest defects and the least sensitivity, the dermabrasion procedure here causes the least discomfort for the patient, the surgeon has the most time. When dermabrading the lip area, special attention should be paid to fixing it by stretching, otherwise the lip can be pulled into the instrument and significantly injured. It is necessary to constantly keep the plane of the instrument nozzle parallel to the skin surface, especially in areas with complex curvature, such as the chin and zygomatic eminences. Dermabrasion should always be carried out within the aesthetic units of the face, to prevent demarcation due to pigmentation. Dermabrasion downwards slightly below the line of the lower jaw, outwards to the pre-auricular area and upwards to the infraorbital area ensures a uniform appearance of the surface. Then, to improve the color transition, 35% trichloroacetic acid (TCA) can be applied to unabrased skin, such as the eyebrow area and the first few centimeters from the hairline.

Postoperative period

A biosynthetic dressing applied at the end of the procedure helps relieve pain. After surgery, patients are given prednisolone 40 mg/day for 4 days, which significantly reduces postoperative swelling and discomfort. One of the most important recent achievements is the successful use of acyclovir in patients with a history of herpes simplex virus infection. When 400 mg of the drug is prescribed 24 hours after surgery 3 times a day for 5 days, postoperative viral infection does not develop. Currently, many authors recommend prophylaxis with acyclovir or similar drugs for all patients, regardless of history.

Most patients with a biosynthetic dressing achieve complete reepithelialization between 5 and 7 days postoperatively. Some dressings, such as Vigilon, must be changed daily. Others can be applied immediately after dermabrasion and left in place until spontaneously released. Biosynthetic dressings should initially be covered with gauze held in place with flexible surgical mesh. Once the skin has reepithelialized, sunscreen is applied daily; patients usually resume tretinoin on the 7th to 10th postoperative day. If the patient has a history of pigmentary disorders such as melasma, hydroquinone is given concurrently with tretinoin. If the patient develops signs of generalized erythema between the 10th and 14th days, topical 1% hydrocortisone is started. Postoperatively, patients are advised that their skin will not return to its normal appearance for at least one month. However, with light makeup, most patients can return to work within 7-10 days after surgery.

Comparison of dermabrasion with other techniques

All skin resurfacing techniques result in a wound to the superficial or middle layers of the skin. Dermabrasion is based on mechanical abrasion of the skin, acid peeling produces "corrosive" damage, and lasers produce thermal damage. Recent studies on pigs comparing skin treatment with carbon dioxide laser, TCA, and Fitzpatrick and Campell dermabrasion have shown that the histological and ultrastructural changes after these procedures are comparable. When comparing dermabrasion with chemical peeling, significant differences were found in the disruption of the histological and mechanical properties of elastic fibers. Six months after phenol treatment, the skin was more rigid and weaker than the skin after dermabrasion. It has also been reported that a comparison of perioral hemiface dermabrasion with CO2 laser resurfacing of the other hemiface yielded clinically identical results, but healing after dermabrasion was nearly 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 peels last longer and are more severe than after dermabrasion. In his review, Baker noted that dermabrasion equipment is inexpensive, portable, widely available, does not require additional equipment, and does not pose a fire hazard in the operating room.

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Complications of dermabrasion

Milia is the most common complication of dermabrasion, usually occurring 3 to 4 weeks after surgery. If tretinoin is used postoperatively, milia are uncommon. Another common complication in patients predisposed to acne is acneiform eruption. If the patient has had an acne flare-up shortly before dermabrasion, milia can often be prevented by giving tetracycline in the early postoperative period. Once milia have occurred, tetracycline usually provides rapid resolution. Although erythema is to be expected after dermabrasion, prolonged or unusual erythema after 2 to 4 weeks should be treated with topical steroids to prevent hyperpigmentation and scarring. Daily sunscreen use should begin after healing has occurred and be continued for several months after surgery. If hyperpigmentation occurs several weeks after dermabrasion, it may be resolved with topical hydroquinone and tretinoin.

Although uncommon, infection may occur as a result of dermabrasion. The most common pathogens are Staphylococcus aureus, herpes simplex virus, and C andida fungi. Staphylococcal infection usually presents 48 to 72 hours after dermabrasion with unusual facial swelling and honey-colored crusts, as well as systemic symptoms such as fever. Viral infection often develops in patients who have not received acyclovir prophylaxis and is recognized by severe asymmetric pain, usually 48 to 72 hours after surgery. Candidiasis usually presents with delayed healing and is clinically diagnosed somewhat later, on the 5th to 7th day, by exudation and facial swelling. Treatment with an appropriate antibiotic, either acyclovir or ketoconazole, results in resolution of the infection without sequelae.

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