Introduction
Dermabrasion involves mechanically resurfacing the skin with an abrasive tip driven by a high-speed rotary hand engine. Either a wire brush or a diamond fraise may be used as the abrading tip to create an open wound that heals by secondary intention. An irregular or scarred cutaneous surface may be surgically abraded in order to achieve a more regular plane, or a more gradual transition between different planes, thereby improving skin contour.1
History of the Procedure
Kurtin2 presented the first series of patients who underwent dermabrasion to Mount Sinai Hospital in 1953. Kurtin described the use of high-speed rotary abraders, intraoperative freezing, and a variety of abrasive end pieces. Publications by Orentreich and Orentreich and Burks and Thomas further refined Kurtin's technique.3,4,5 Alt has expertly promoted the use of the diamond fraise,6 while Yarborough has encouraged application of the wire brush.7
The development of antiviral medications, semipermeable dressings, tumescent anesthesia, and cryoanesthesia has advanced the technique of dermabrasion as well as other resurfacing surgeries, such as chemical peeling, ablative laser resurfacing (see Cutaneous Laser Resurfacing, Carbon Dioxide and Cutaneous Laser Resurfacing, Erbium-YAG), nonablative laser resurfacing, and microdermabrasion. A comprehensive understanding of the advantages and the disadvantages of each of these resurfacing procedures is necessary to achieve optimal surgical results in patients who undergo resurfacing surgery.
Presentation
Careful examination of the skin lesion or defect and a detailed history is paramount in the evaluation of a patient for dermabrasion.
- As part of the preoperative examination, meticulous attention should be given to the patient's skin type.
- Midrange skin types (III-IV) are more likely to become transiently hyperpigmented 4-8 weeks after surgery and hypopigmented 12-18 months after surgery.
- Lighter skin types (I-II) and the darkest skin type (VI) are less likely to heal with permanent discoloration.
- Examine the patient's earlobes and sternum for areas of keloids or hypertrophic scarring. For patients with a history of keloid formation, a test spot is recommended prior to any full-face resurfacing or ablation of large nonfacial areas. Likewise, a history of koebnerizing or pathergic conditions, such as psoriasis, lichen planus, or pyoderma gangrenosum, may require test sites.
- Note the presence of facial telangiectasias and variation of pigment between the cosmetic units of the face.
- Once the patient's skin and defects have been closely examined, an in-depth consultation should follow.
- The most important aspect of preoperative consultation is listening closely to the patient's specific motivation for undergoing dermabrasion. Identifying this goal and establishing realistic outcome expectations is critical.
- Reviewing before and after photographs helps establish the expected measure of improvement. The anticipated outcome for patients undergoing resurfacing should be partial improvement (35-50%), rather than complete eradication of the treated defects.
- Clinical photographs and a detailed discussion of the preoperative regimen, the proceedings on the day of surgery, and postoperative wound care are helpful in preparing patients undergoing dermabrasion.
- Lastly, take a standardized set of preoperative photographs of each patient. These photographs can be taken directly in front of the patient at 45° angles (right and left sides) and at 90° angles (right and left sides). Close-up photographs of the defects are also helpful. For details on technique and equipment, see eMedicine article Digital Photography.
Indications
The most common indications for dermabrasion are desired improvement of acne scars, traumatic and surgical scars, rhinophyma, deep rhytides, and partial-thickness Mohs defects. However, dermabrasion has also been described for improvement of actinic keratoses,8 seborrheic keratoses, angiofibromas, syringomas, solar elastosis, epidermal nevi, and tattoo removal.
With regard to acne scarring, even in the era of laser devices, fractionated delivery approaches, and noninvasive tissue-tightening procedures, dermabrasion remains an important tool in the combination approach to the improvement of cystic acne scarring. While the shallow and wide, undulating, or "rolling-type" acne scars are better treated with subcision, dermal grafts, fillers, or fractionated laser devices, the slightly deeper and narrower "boxcar-type" acne scars that demonstrate step-off vertical borders respond best to mechanical dermabrasion. Additionally, the deepest and narrowest "icepick-type" acne scars respond best to dermabrasion subsequent to punch excisions, punch grafts, or trichloroacetic acid cross-destruction.9,10
For traumatic and surgical scars, the thickness, contour, and overall appearance is routinely improved with postoperative dermabrasion. Also known as scarabrasion, this procedure is best performed 6-8 weeks after the initial surgery or wounding event. When performed during this 6- to 8-week window, the late proliferative and early remodeling phases of wound healing are interrupted and partially reset, resulting in an improved final cosmetic result.
While several modalities, including wire loop electrosurgery and carbon dioxide laser resurfacing, have been described for the treatment of rhinophyma, dermabrasion remains unmatched in the operator’s ability to reestablish the complex contour of the many cosmetic subunits of the nose. Furthermore, although carbon dioxide resurfacing, Er:YAG resurfacing, and deep chemical peels may improve facial rhytides, dermabrasion proves as efficacious or more efficacious at removal of both fine and moderate facial rhytides, with a slightly lower risk of permanent hypopigmentation.11,12,13
Finally, dermabrasion has proven to be an incredibly useful technique in the armamentarium of the Mohs surgeon (also see Mohs Micrographic Surgery). Thin carcinomas in cosmetically sensitive or high-risk areas can often be completely removed with a shallow Mohs layer to the level of the superficial reticular dermis. After clearance, these partial-thickness defects, particularly on the nose and scalp, may lend themselves to healing by second intention rather than primary closure, yet with slightly increased risk of an evident contour discrepancy or sharp pigmentary transition. Dermabrasion of the edges surrounding the partial-thickness Mohs defect greatly improves the final contour by replacing the steeply beveled wound edge with a more gradual slope. Additionally, dermabrading the remainder of an involved cosmetic subunit of the nose results in a less obvious scar by placing the pigmentary demarcation lines at the less perceptible subunit boundaries.
Contraindications
In addition to careful examination of the skin lesion or defect, a detailed history is paramount in the evaluation of the patient for dermabrasion. For example, do not perform dermabrasion for 6-12 months following isotretinoin therapy. Delayed reepithelialization and hypertrophic scarring have been reported in patients who underwent dermabrasion during or shortly after isotretinoin therapy. This complication is believed to be related to the effect of the isotretinoin molecule on epithelial cells and fibroblasts. Postpone dermabrasive surgery in patients with active herpetic lesions.14,15
Bleeding disorders and immunosuppression may cause delayed healing and an increased risk for postoperative infection.
Yarborough demonstrated that surgical and traumatic scars respond best to dermabrasion performed 6-8 weeks during the interval following incision or injury.16 In contrast, do not perform dermabrasion on overlying skin for at least 6 months following certain surgical procedures that involve extensive undermining, such as face lifts or brow lifts, to allow reestablishment of the underlying vascular bed.
As compared to fully ablative resurfacing with the carbon dioxide and Er:YAG lasers, dermabrasion demonstrates similar or greater efficacy for the treatment of scars, rhytides, and precancerous lesions, with less postoperative erythema and more rapid reepithelialization. While newer, fractionated delivery protocols result in even less erythema and quicker reepithelialization than dermabrasion, their efficacy for the improvement of scars, rhytides, and precancerous lesions does not currently match that seen with mechanical dermabrasion. Dermabrasion has also been shown to be more efficacious than 5-fluorouracil for the treatment of actinic keratoses.
The major disadvantage of dermabrasion compared with the above-mentioned modalities is that it is much more operator dependent. Unlike laser and light devices, the depth of penetration is not preprogrammed. Successful treatment relies not only on the physician’s knowledge of the modality and application settings, but also on his or her skilled execution. In the novice’s hands, dermabrasion exhibits a narrower window or buffer between effective treatment depth and inappropriate scarring depth. However, this is quickly overcome with experience.
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References
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Further Reading
Keywords
dermabrasion, cutaneous resurfacing, resurfacing surgery, dermabrasive resurfacing, skin resurfacing
