Introduction
The face is arguably the most critical aesthetic unit of the human body. The art of facial rejuvenation has been practiced since ancient civilizations, and the interest in this subject continues to grow. Various options exist to perform skin resurfacing of the face, including dermabrasion, laser resurfacing, and chemical peels.1,2,3 All skin resurfacing modalities aim to remove damaged skin and stimulate normal wound healing. Dermabrasion is a simple, cost-effective means of skin resurfacing that can provide repeated and reliable results when used on the face or many other areas of the body.
History of the Procedure
Dermabrasion is an effective technique of skin resurfacing that has been in use for nearly 100 years. The core principle of dermabrasion involves the use of various abrasive instruments to remove superficial layers of skin using appropriate anesthesia, most often with high-speed rotary instruments with abrasive end pieces. The epidermis then regenerates from epidermal appendages in the deep dermis. The end result following dermabrasion is an organized remodeling of the dermis, yielding rejuvenated skin that is smoother and firmer than before.
Physicians in ancient Egypt used sandpapering techniques similar to dermabrasion to treat scars. In 1905, Kromayer first reported controlled abrasion of the skin using carbon dioxide snow and ether spray for anesthesia.4 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, tattoos, hair, nevi, and areas of hyperpigmentation. Despite this early report of success, dermabrasion did not gain widespread popularity until the early 1950s, when Abner Kurtin renewed interest in the procedure.5
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 1953.5 Various abrasive end pieces were described, such as rasps, burrs, and wire brushes. 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.
Dermabrasion has had a bimodal peak in its popularity in the 1950s and the 1980s. With the advent of new modalities such as carbon dioxide cutaneous lasers and various chemical peels, dermabrasion has fallen in its popularity because of concerns regarding which method provides optimal aesthetics and safety.6
Numerous studies have demonstrated that dermabrasion is a reliable and effective method for skin resurfacing and should be a part of a plastic and dermatologic surgeon's repertoire in resurfacing damaged skin and the aging and damaged face.7 It has features that make it superior to chemical peels and lasers, including the ability to use it in focal segments of the face, the lower likelihood of injury to the pigment-containing melanocytes resulting in pigmentary changes, and the much lower cost compared to laser treatments. With experience, the risks of scarring and skin sloughing due to traction injuries are very low.Presentation
History and physical examination
A detailed history and physical examination should be performed, including preoperative photography. The severity and depth of the patient’s condition needs to be assessed. Patients should be questioned about previous exposure or any outbreaks of herpes simplex (ie, cold sores). For patients with a positive history of exposure or outbreaks, high dose prophylactic antiviral medications are recommended. Prophylaxis with oral acyclovir 400 mg taken 3 times per day before and continued after the procedure can help reduce the risk of a herpetic outbreak.
A detailed drug history is important, specifically regarding isotretinoin because isotretinoin is a relative 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; however, case reports have described delayed wound healing and keloid formation after treatment with dermabrasion.8 Therefore, notable controversy remains regarding the use of isotretinoin in the setting of dermabrasion. In 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. Use of medications that result in excessive bleeding (eg, aspirin, clopidogrel bisulfate [Plavix], warfarin sodium [Coumadin]) should also be noted.
When obtaining the patient history, physicians must determine if the patient may have infectious diseases that can be transferred by blood contact, such as HIV or hepatitis C. Dermabrasion causes a bloody field and aerosolization of blood. Even with the use of personal protective equipment such as goggles, masks, and scatter shields, the risk of viral transmission is not eliminated. Thus, dermabrasion is not recommended in patients who are HIV-positive; other resurfacing options should be implemented.
Patient selection
As mentioned above, physicians should first obtain a detailed medical history and physical examination. Preoperative photographs should also be obtained. Next, the physician should determine the severity and depth of the condition to be treated and the need for additional or alternative procedures. The patient's skin type should be assessed using the Fitzpatrick classification (see Table below). This classification is used to categorize the skin according to its ability to tan or its likeliness to burn when it is exposed to ultraviolet (UV) light.
Fitzpatrick Skin Classification9
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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 |
In general, light skin types (types I-II) are most likely to heal without permanent color change, or dyschromia. Dark skin types are associated with increased rates of hypopigmentation and hyperpigmentation. 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, as these findings indicate that patient has tendency to scar poorly. 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.10 Patients should expect only partial improvement and not complete eradication of the treated defects. They should understand that repeat treatments may be necessary as well as the use of other resurfacing modalities. In addition, patients should recognize the possibility of scar formation and hypopigmentation.
Indications
Dermabrasion was initially developed to combat acne scars; this is the most common indication for its use. It can also be used to effectively treat traumatic or surgical scars, irregular scarring from skin grafts, photo-damage, some benign tumors, actinic keratoses, rhinophyma, and perioral rhytides.7 Manual dermasanding has also been used in the treatment of periorbital wrinkles and fine lines.11
Dermabrasion has been used to manage superficial malignancies such as squamous cell carcinoma in situ and superficial basal cell carcinoma.12 Also, pigmentary changes due to melasma, tattoos, or postinflammatory hyperpigmentation can be lightened with dermabrasion. Dermabrasion can be comparable to laser resurfacing in the treatment of these conditions and may be used in conjunction with laser resurfacing for optimal results.13
Dermabrasion is used for specific areas of the face more often than laser resurfacing or chemical peeling because it is less likely to cause pigmentary changes by injuring the pigment-containing melanocytes. When laser resurfacing and chemical peeling are applied to only a portion of the face, they often leave lines of demarcation between treated and untreated regions. Dermabrasion, however, can soften sharp edges of demarcated scars, making them inconspicuous. In addition, dermabrasion may be much less costly to the patient than laser resurfacing or chemical peeling.
The high concentration of pilosebaceous glands and the rich vascular network of the face aid in wound healing. This makes the face the most common and ideal site for dermabrasion, though other areas of the body can also undergo dermabrasion. The results of dermabrasion on areas other than the face are satisfactory but not as good, and scar formation is often increased.
Acne scars that are narrow, pitted, and sharply edged and 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.14 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. Often, the surgeon can use electrofulguration and laser resurfacing of contractive tissue as an adjunct to dermabrasion.
Dermabrasion has also been used for the treatment of burn scars. It has been used as an adjunct for the treatment of deep dermal burn scars of the face with excellent results. It can be used for the treatment and management of acute burn injury to the face as well as for the treatment of mature hypertrophic burn scars and the resurfacing of split-thickness skin grafts. Abrasion can be performed using high-speed rotary instruments or, more simply, using sandpaper wrapped around a digit or test tube.
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. An important 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.
Skin anatomy.
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.
Areas of the body where the skin adheres closely and tightly to underlying structures are referred to as adherent or tight structures. Those areas where the skin can be very loose, such as the neck and upper and lower eyelids, are referred to as loose areas. Dermabrasion must be performed evenly across the entire area to be treated, and the leading edge needs to be as deep as the trailing edge of the abrader. This is very difficult to perform in areas that are very loose, even with cooling of the skin. Wherever possible, progression should go from fixed areas to looser areas rather than in the opposite direction. Areas of the skin have been caught within a mechanical dermabrader and sheared off completely, leaving a severe deficit. Extremely loose areas should be approached with caution and only by an experienced dermabrasion specialist.
Contraindications
Recent or ongoing use of isotretinoin was once thought to be an absolute contraindication to dermabrasion but is now regarded as a relative contraindication. Isotretinoin causes atrophy of pilosebaceous glands, which delays reepithelialization and increases the risk of hypertrophic scarring. No definitive study provides a clear-cut correlation between isotretinoin treatment and postdermabrasion scarring. Increased scarring in patients who were treated with isotretinoin has been reported; patients in whom no adverse outcomes occurred with dermabrasion and the use of isotretinoin have also been reported.8 To avoid a possible adverse outcome, physicians should inform patients of potential risks and instruct them to stop using isotretinoin for a period of 6-12 months before dermabrasion.
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 collagen disorders due to abnormal adnexal structures.
Dermabrasion is contraindicated if recent surgery (eg, rhytidectomy) has involved undermining the skin that is slated to undergo dermabrasion. 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 delayed healing with excessively deep dermabrasion 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.
Dermabrasion should be avoided over small areas in patients with freckled skin because the freckles may disappear in those areas (but not elsewhere).
Although deep rhytides and excessive facial skin are not definitive contraindications, these conditions may not be significantly improved with dermabrasion. Patients with these findings are likely best served with traditional face-lift procedures. For more information, see the Rhytidectomy section of eMedicine's Plastic Surgery journal.
Dermabrasion is also contraindicated in patients with active herpetic lesions and in women who are pregnant or nursing.
Dermabrasion should be avoided in patients who develop atypical scars such as keloids.
Dermabrasion should be avoided in patients who are HIV positive because of the risk of the aerosolization of viral particles.More on Skin Resurfacing, Dermabrasion |
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Further Reading
Keywords
skin resurfacing, dermabrasion, cutaneous plastic surgery, microdermabrasion, acne scars, dermabrasion technique, dermabrasion treatment, scar removal, acne scar removal, skin planing, controlled skin abrasion, hyperpigmentation, diamond fraise, wire brush, Fitzpatrick skin classification, Fitzpatrick's skin classification, rhytidectomy, acne scar, traumatic scars, surgical scars, photodamage, actinic keratoses, perioral rhytides, rhinophyma, skin treatments, scar treatment, skin rejuvenation, facial rejuvenation
