Introduction
History of the Procedure
Dermabrasion 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.
Presentation
History 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*
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Table
| Type | Skin Color | Characteristics |
|---|---|---|
| I | Very white | Always burns, never tans |
| II | White | Usually burns, tans with difficulty |
| III | White or light brown | Mildly burns, average ability to tan |
| IV | Brown | Rarely burns, tans easily |
| V | Dark brown | Very rarely burns, tans very easily |
| VI | Black | Never burns, darkly pigmented |
| Type | Skin Color | Characteristics |
|---|---|---|
| I | Very white | Always burns, never tans |
| II | White | Usually burns, tans with difficulty |
| III | White or light brown | Mildly burns, average ability to tan |
| IV | Brown | Rarely burns, tans easily |
| V | Dark brown | Very rarely burns, tans very easily |
| VI | Black | Never burns, darkly pigmented |
*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.
Indications
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 Anatomy
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.
Contraindications
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.
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References
Baker TM. Dermabrasion. As a complement to aesthetic surgery. Clin Plast Surg. Jan 1998;25(1):81-8. [Medline].
Demas PN, Bridenstine JB. Diagnosis and treatment of postoperative complications after skin resurfacing. J Oral Maxillofac Surg. Jul 1999;57(7):837-41. [Medline].
Field LM. Dermabrasion and premalignant disease. Dermatol Surg. Aug 1997;23(8):714. [Medline].
Fitzpatrick RE. Resurfacing procedures: how do you choose?. Arch Dermatol. Jun 2000;136(6):783-4. [Medline].
Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. Jun 1988;124(6):869-71. [Medline].
Fulton JE. Dermabrasion, chemabrasion, and laserabrasion. Historical perspectives, modern dermabrasion techniques, and future trends. Dermatol Surg. Jul 1996;22(7):619-28. [Medline].
Goodman GJ. The limitations of skin resurfacing techniques. The necessity to combine procedures. Dermatol Surg. Jun 1998;24(6):687-8. [Medline].
Gupta S, Handa S, Saraswat A, Kumar B. Conventional cold excision combined with dermabrasion for rhinophyma. J Dermatol. Feb 2000;27(2):116-20. [Medline].
Iverson PC. Further developments in the treatment of skin lesions by surgical abrasion. Plast Reconstr Surg. Jul 1953;12(1):27-40. [Medline].
Kromayer E. Rotationsinstrumente ein neues technisches Verfahren in der dermatologischen Kleinchirugie. Chir Dermatol Ztschr. 1905;12:26.
Kurtin A. Corrective surgical planing of skin; new technique for treatment of acne scars and other skin defects. AMA Arch Derm Syphilol. Oct 1953;68(4):389-97. [Medline].
Kurtin S. Dermabrasion. Arch Dermatol. Jul 1968;98(1):87. [Medline].
Manaloto RM, Alster TS. Periorbital rejuvenation: a review of dermatologic treatments. Dermatol Surg. Jan 1999;25(1):1-9. [Medline].
McEvitt WG. Treatment of acne pits by abrasion with sandpaper. J Am Med Assoc. Mar 4 1950;142(9):647. [Medline].
Nehal KS, Levine VJ, Ross B, Ashinoff R. Comparison of high-energy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars. Dermatol Surg. Jun 1998;24(6):647-50. [Medline].
Orentreich N, Orentreich DS. Dermabrasion. As a complement to dermatology. Clin Plast Surg. Jan 1998;25(1):63-80. [Medline].
Roy D. Ablative facial resurfacing. Dermatol Clin. Jul 2005;23(3):549-59,viii. [Medline].
Smith R. Dermabrasion. Is it an option?. Aust Fam Physician. Sep 1997;26(9):1041-4. [Medline].
Solish N, Raman M, Pollack SV. Approaches to acne scarring: a review. J Cutan Med Surg. May 1998;2 Suppl 3:24-32. [Medline].
Williams LA. Facial rejuvenation. Nurs Clin North Am. Dec 1994;29(4):741-51. [Medline].
Zdinak LA, Summerfield ME. Nonablative skin therapies. Ophthalmol Clin North Am. Jun 2005;18(2):237-48, v. [Medline].
Further Reading
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
