Dermabrasion Procedures Treatment & Management

All patients should receive antiviral prophylaxis. Patients with a history of herpes simplex virus (HSV) infections may require a greater prophylactic dosage (ie, valacyclovir at 500-1000 mg/d for 10-14 d or famciclovir at 500-1000 mg/d for 10-14 d). Because the herpes virus requires viable epidermal cells to establish an infection, antiviral prophylaxis is continued for 10-14 days, which is longer than the time required for reepithelialization to occur. Patients with a history of very recent or frequent herpetic infections and those patients with postoperative breakthrough HSV infections require a higher dose of antiviral medication, such as valacyclovir at 500 mg 5 times per day for 14 days or famciclovir at 500 mg 3 times per day for 14 days. (Cosmetic surgeons use a variety of dosing strategies, usually using a dosing range because they do not all agree on any one particular dose.)

While most patients do not require antibiotic prophylaxis, patients who are immunosuppressed, patients with a history of impetigo, or carriers of Staphylococcus species may benefit from prophylactic antibiotics (ie, cephalexin at 1000-2000 mg/d for 10-14 d or ciprofloxacin at 500-1000 mg/d for 10-14 d). If prophylactic antibiotics are administered, fluconazole at 200 mg/d for 10 days prevents secondary yeast infections. Also see The Role of Antibiotics in Cutaneous Surgery.

Tretinoin cream applied for 2-3 weeks prior to dermabrasion has been shown to decrease the time for reepithelialization.^[17] Similarly, some surgeons report that the use of topical hydroquinone for several weeks prior to surgery decreases the incidence of postoperative hyperpigmentation.

Sleep deprivation can be prevented with sedating medications (flurazepam [Dalmane] at 15-30 mg administered the night before surgery and each night following surgery while patients are sleeping in a full face mask). Thirty to 60 minutes prior to surgery, the following is administered: 5-10 mg of diazepam (Valium) sublingually; 50-75 mg of meperidine intramuscularly; and 25 mg of hydroxyzine intramuscularly. Regional nerve blocks of the mental, infraorbital, supraorbital, and supratrochlear nerves are achieved with 1% lidocaine and epinephrine (1:100,000 concentration of epinephrine).

Instrumentation

With mechanical dermabrasion, a diamond fraise or wire brush abrading tip is driven by a handheld engine at speeds of 15,000 to 30,000 rotations per minute (RPMs). Current hand engines include the Osada, Ram, and Urawa Kohgyo Acrotorque handpieces. The classic Bell hand engine (see image below) is no longer available from the manufacturer, but it may occasionally be found as a refurbished item through select vendors.

Diamond fraises come in a range of shapes and sizes, such as pears, cones, bullets, and wheels, and vary in coarseness from fine to extra-coarse. Alternatively, the wire brush is a 3-5 mm wide by 17 mm diameter wheel with steel bristles radiating from the center in a clockwise fashion when viewed from the shaft. The wire brush is the most aggressive type of end piece and can be more technically difficult to master, yet it is considered more efficacious by those experienced with its use. The microlacerations created with the wire brush are the most efficient means of removing the nodules of rhinophyma, the thick plaques of hypertrophic scars, and deep acne scars. See end pieces in the image below.

Standard technique

Treating surgical scars, rhinophyma, and partial-thickness Mohs defects provides an excellent point of entry into the practice of dermabrasion prior to practicing advanced techniques such as full-face dermabrasion. If the treatment area is limited in size, local anesthesia (1% lidocaine with epinephrine 1:100,000) or tumescent technique is adequate. When treating the entire nose, a ring block also may achieve an appropriate degree of anesthesia. Prior to abrasion, the area to be treated is cleansed with a 4% chlorhexidine solution.

The body of the hand engine is grasped in the palm of the dominant hand with 4 fingers, allowing the thumb to project along the neck for stabilization (see image below). Finger position is similar to a "thumbs-up" sign or to that seen when gripping a golf club, yet the hand and instrument are pronated, with the palm facing downward.

Freon-114 refrigerant spray (Frigiderm; see image below) is applied to the treatment area in an amount necessary to achieve a 5- to 10-second thaw time, during which time abrasion is performed on the frozen area. Refrigerant spray accomplishes 2 important functions: decreasing pain by cryoanesthesia and a providing a firm substrate upon which to achieve recontouring.^{[18, 19]} Refrigerants containing Freon-12 have a freezing point of -30°C to -60°C, which is too cold and can produce hypertrophic scarring.

Immediately after freezing, 3-point retraction is obtained by the 2 hands of the surgical assistant and the nondominant hand of the surgeon. The frozen skin is thus stabilized by retraction, and the lesion is recontoured with the wire brush rotating in a counterclockwise direction (with the angle of the radiating bristles) as determined from the point of view of the body of the hand engine. The wire brush is passed over the treatment area in an arciform motion with the long axis perpendicular to the rotating handpiece (parallel to the body of the hand engine). See video below.

Counterclockwise rotation of the wire brush offers a less aggressive technique of wire brush surgery, which is especially well-suited for spot dermabrasion of Mohs defects or surgical scars without cryoanesthesia. With counterclockwise rotation, the radiating bristles are less prone to gouge unfrozen skin. This counterclockwise direction of rotation is also useful when dermabrading free margins of the face such as the lips and nasal alae, in order to prevent the inadvertent "grabbing" of tissue by the rotating wire brush when dermabrading from the right side with the dominant right hand.

Regular pinpoints of bleeding signal abrasion to the level of the papillary dermis. As depth increases to the reticular dermis, the bleeding foci become larger, and frayed collagen bundles become apparent. Surgical scars frequently disintegrate upon abrasion, which is a desirable endpoint. Contouring should often include "feathering," or graduating zones of treatment around the central scar, to provide a smooth transition between different planes and improved pigment transition. Alternatively, the treatment zone may be stopped at the border of a cosmetic unit or carried to an inconspicuous endpoint, such as 1 cm beyond the mandible.

Advanced technique

While local or tumescent anesthesia may be adequate for scar or spot dermabrasion, full-face abrasion of acne scarring or rhytides is best accomplished with a combination of oral or intramuscular light sedation, nerve blocks, and cryoanesthesia. A standard regimen consists of meperidine at 50-75 mg intramuscularly, hydroxyzine at 25 mg intramuscularly, and diazepam at 50 mg orally or sublingually 30-60 minutes prior to the start of the procedure. After preparation with chlorhexidine, nerve blocks to the supratrochlear, supraorbital, infraorbital, and mental nerves may also be performed.

In contrast to the counterclockwise rotation typically used for less aggressive dermabrasion, more experienced practitioners may opt to use a clockwise rotation of the abrasive wire brush. Rotation in a clockwise direction occurs against the angle of the radiating wire bristles and causes the tip to pull away from the thumb rather than driving toward it. Deeper planing and recontouring are possible with clockwise rotation, but this direction is much less forgiving. Additionally, clockwise rotation used by a dominant right hand increases the risk that free margins of the face, such as lips and nasal alae, will be grabbed by the rotating bristles rather than brushed away, resulting in unintentional, deeper abrasion in these areas.

When performing full-face dermabrasion, beginning at the periphery of the cheek or mandible and working toward the center of the face allows the practitioner to avoid gravity-dependent bleeding as the procedure progresses (see video below). A surgical towel, surgical cap, or petrolatum may also be used to help prevent entanglement of hair at the periphery of the treatment area. Surgical towels are also preferable to cotton gauze as sponges on the surgical field because gauze becomes more easily entangled in the wire brush and hand engine.

The most important components of the preoperative consultation are determining the patient’s specific motivation for resurfacing and establishing realistic expectations regarding the treatment outcome. The ultimate goal of any resurfacing treatment should be an improvement of the given defect rather than a complete eradication. Dermabrasion consistently achieves 30-50% improvement in the appearance of deep acne scars and rhytides, but the patient who seeks and expects the elimination of all scars and rhytides will rarely be satisfied. Reviewing before and after photographs with the patient during consultation, particularly when considering full cosmetic unit or full-face dermabrasion, may foster realistic expectations for improvement.

The preoperative consultation should also include a complete history, addressing bleeding disorders, prior herpes simplex infection, impetigo, keloidal or hypertrophic scarring, koebnerizing conditions, prior isotretinoin therapy, and immunosuppression.^[20] The risk-to-benefit ratio of an iatrogenically induced wound is unfavorable in patients who are immunosuppressed, who have a history koebnerizing conditions such as lichen planus and psoriasis, or who demonstrate a propensity towards keloidal or hypertrophic scar formation. Because of the increased risk of scarring in patients on isotretinoin, dermabrasion should be delayed until 6 months after finishing an oral retinoid course.

Caution should also be exercised when planning to dermabrade patients who have recently undergone extensive procedures involving the area to be dermabraded, such as a facelift, because a robust blood supply is necessary for appropriate wound healing. Many surgeons prefer to wait 6 months after a facelift before subsequent dermabrasion.

Antiviral prophylaxis should be instituted in individuals with a history of herpes simplex outbreak in the area to be spot dermabraded or in those who are undergoing full-face or multiple cosmetic unit dermabrasion. The antiviral agent acyclovir or valacyclovir may be used, and patients should remain on prophylactic therapy for 10 days after the procedure (eg, valacyclovir [Valtrex] 50 mg bid for 10 d). Similarly, antibacterial prophylaxis with an antistaphylococcal agent should be instituted in patients with a history of impetigo.

Particular attention should also be paid to the Fitzpatrick skin type of the patient. Persons with Fitzpatrick skin types IV, V, and VI are much more prone to both postoperative hyperpigmentation and permanent, clinically significant hypopigmentation, the latter of which may not appear for several months following the procedure.

Preoperative photographs are highly recommended, and these should include a frontal view, 45° and 90° views from both sides, and a close-up view of the areas to be treated. Additionally, all preoperative and postoperative expectations should be discussed. The patient should particularly be made aware of the nature of the postoperative recovery routine, which includes extensive facial dressings with multiple changes over several days, and clinically apparent erythema for several weeks.

The correct hand position for holding the abrading instrument places the forefingers around the body of the hand engine, while the thumb stabilizes the neck. The direction of rotation of the abrading end piece can be clockwise or counterclockwise. For right-handed surgeons, counterclockwise rotation directs the momentum of rotation toward the thumb in a stabilizing fashion. Make passes with archiform horizontal strokes perpendicular to the direction of the rotating brush or fraise.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best. This method allows blood from a previously abraded area to flow in an inferior, gravitational direction away from the next area to be abraded. With this approach, the nose, the mid upper lip, and the mid forehead are the last areas to be abraded in a full-face procedure.

For regional or spot dermabrasion, gentian violet can be used to outline the borders of the treated cosmetic unit. Abrading an entire cosmetic unit reduces the risk for noticeable pigmentary variations between abraded and nonabraded skin. Lightly feather the borders of the cosmetic unit to blend with nonabraded areas.

A surgical landmark for abrading into the superficial papillary dermis is the presence of cornrow bleeding produced by an eruption of the small vascular loops in the dermal papilla. As the depth of abrasion moves into the reticular dermis, these vascular channels and the subsequent red dots become larger. White parallel lines are frayed, and collagen can be observed after abrading normal reticular dermis, whereas the fibrosis of acne scars or severe solar elastosis crumbles and disrupts. The yellow globules of sebaceous glands or larger frayed collagen bundles herald entry into the lower dermis and a likelihood of scarring.

Gauze soaked with 1% lidocaine with 1:100,000 epinephrine may be immediately applied to the post-abraded area for a period of 5-10 minutes to assist with hemostasis. A closed-technique, layered bandage is then applied, composed of a semipermeable hydrogel dressing (Vigilon, Second Skin) in contact with the wound, a nonadherent dressing (Telfa) above, and paper tape or surgical netting to secure the bandage in place. Semipermeable hydrogel dressings provide 2 important advantages over other types of dressings: decreased patient discomfort in the postoperative period and decreased time to reepithelialization by up to 40%. The dressing should be changed daily for 3-5 days. See dressing in the image below.

If full-face dermabrasion has been performed, the most convenient plan is to have the patient return to the office for dressing changes during this period. For smaller areas, the patient may change the bandage at home. After 3-5 days, the patient begins an open wound care technique at home. Acetic acid (0.25%) soaks (1 tablespoon white vinegar into 1 pint of warm water) are followed by topical petrolatum ointment until reepithelialization is complete, usually 7-10 days after the procedure. Strict adherence to this regimen reduces the risks of secondary infection and scarring.

If full-face dermabrasion is performed, a short course of oral or intramuscular steroids may also be given immediately after the procedure to help reduce facial swelling. Swelling is an anticipated consequence of full-face dermabrasion and may be expected to resolve over several weeks to a few months. All previously prescribed antivirals and antibacterials should be instituted or continued, and patients should be given a prognosis and expected recovery timeframe. Once reepithelialization has occurred, sunscreens and sun avoidance should be strictly adhered to for several weeks in order to minimize postprocedure pigment alteration. Makeup also may be used to cover erythema after reepithelialization.

See Postoperative details.

The most common complications encountered after dermabrasion are milia and acne flares. These minor adverse effects should be anticipated and may be treated by comedone expression, topical tretinoin, and oral antibiotics.

Infection, pigment alteration, and scarring are the more portentous complications that may be encountered after dermabrasion.^[21] Vigilance in the immediate postoperative period is necessary to identify these complications at an early stage and institute treatment. HSV infection still may occur while the patient is on prophylactic antiviral medications, and it manifests clinically as painful (out of proportion to healing phase) erythematous lesions 7-10 days post procedure. Larger doses of antiviral medications are then necessary for treatment (valacyclovir at 1 g, 3 times per day for 7-10 more days). Bacterial and fungal infections may likewise produce persistently painful, erythematous lesions. Lesions should be cultured, and empiric therapy with an antistaphylococcal agent, anticandidal agent, or both should be implemented as warranted based on clinical suspicion.

Transient, postoperative hyperpigmentation is a common complication, usually beginning 4-6 weeks after dermabrasion. Implement 4-8% hydroquinone or formulations containing hydroquinone, tretinoin, and a mild steroid at the earliest signs of hyperpigmentation, and continue these for 4-8 weeks.

A more difficult complication to treat is hypopigmentation. While not quite as common as with fully ablative carbon dioxide laser resurfacing, nearly one third of patients develop permanent hypopigmentation after full-face wire brush dermabrasion. Furthermore, such hypopigmentation often does not develop until several months post procedure. Female patients may camouflage such hypopigmentation with makeup, but male patients have fewer options for improvement. The 309-nm excimer laser has been shown to improve hypopigmented scars and vitiligo, and it also may be an option for improvement after dermabrasion.^[22] True hypopigmentation should be differentiated from the pseudohypopigmentation seen when resurfaced skin without actinic damage simply appears lighter than the surrounding actinically damaged skin. Fulton et al reported successful blending of hypopigmentation using laser-assisted chemoabraison,^[23] and Grimes et al reported success with topical photochemotherapy.^[24]

Finally, persistent erythema in the absence of infection is the harbinger of scar formation. Scars should be treated early and proactively in order to minimize sequelae. Flat, erythematous scars may be managed by topical steroids or steroid-impregnated tape (Cordran) worn nightly. However, indurated scars also require intralesional corticosteroid injections and/or pulsed dye laser treatments on a regular basis. These may be repeated every few weeks until stabilization and improvement occur.

With the armamentarium of resurfacing modalities increasing, mechanical dermabrasion remains an important dermatosurgical procedure, particularly for the improvement of cystic acne, postsurgical scars, and partial-thickness Mohs defects. Selecting appropriate patients and establishing realistic treatment goals are prerequisites.

Small areas may be easily and safely treated with proper technique, and these areas demonstrate rapid recovery. Although experience and skill are necessary in order to avoid serious complications with full-face dermabrasion, its efficacy for the treatment of acne scarring and deep rhytides currently remains unmatched for the patient who is willing to endure the resultant recovery period.

Close follow-up during the postoperative period is important in order to recognize and treat the most serious potential complications of infection and scarring at the earliest stages. While new technologies continue to emerge, mechanical resurfacing will likely remain an essential and unmatched modality for scar improvement.