eMedicine Specialties > Plastic Surgery > Skin

Skin Resurfacing, Dermabrasion: Treatment

Author: Gaurav Bharti, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Coauthor(s): Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center; Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Sep 1, 2009

Treatment

Preoperative Details

Equipment

Dermabrasion is typically performed in an office-based setting, not requiring inpatient hospitalization or general anesthesia.¹⁰ Appropriate lighting is critical, and the operator and assistant must wear surgical gowns, gloves, and masks with eye protection. Because of the high rate of rotation, the surgical field should be cleared of sponges, towels, and other equipment that may become entangled and injure the physician, assistant, or patient.

The dermabrader consists of an electric hand engine with a high-speed rotary motor and an interchangeable abrading end piece. The surgeon may control the speed with a foot pedal or handheld device. Pressure exerted on the hand piece and the revolutions per minute of the hand piece are the most important variables in technique. Avoiding excessive pressure on the hand piece is important because excessive pressure can result in gouging. Suggested rotational speeds of 12,000-15,000 revolutions per minute (rpm) for the abrading heads result in controlled gradual planing of the treated surface.

The most commonly used end pieces are diamond fraises, wire brushes, or serrated wheels. Diamond fraises are available in many shapes, sizes, degrees of coarseness, and levels of quality. Small devices are used in confined spaces, such as around the nose or eyelids. Experienced surgeons tend to use the coarse or extra coarse fraises. Large wheels are used on broad flat surfaces, such as the forehead and cheeks. Diamond fraises can be used without a spray refrigerant, whereas wire brushes require cooling. The wire brush produces microlacerations in the skin but causes little thermal injury and is often preferred by experienced surgeons over the diamond fraise. The diamond fraise is easiest to learn to use, but it can increase thermal injury because deep resurfacing requires several passes applied with pressure. The wire brush is recommended for deeper scars and the diamond fraise is recommended for more superficial scars.

Use of sandpaper wrapped around a digit or cylinder (eg, a test tube) is the simplest means to perform dermabrasion.^15,16 It has been demonstrated to provide excellent outcomes and is extremely cost-effective. This technique is less likely to cause injury, but it is difficult to perform finer and deeper areas of resurfacing with this technique.

Counseling

Preoperative counseling is imperative to ensure realistic patient expectations. The patient's desired outcome must be clearly communicated and understood. Physicians may show patients preoperative and postoperative photos of patients treated with dermabrasion; complications should be included. In general, dermabrasion yields 35-50% subjective improvement of skin texture. Patients should not expect restoration of perfect skin, and dermabrasion does not affect skin redundancy or eliminate the possible need for rhytidectomy. Patients should be told that the greatest improvement is usually observed 6 months after surgery. Patients should be provided a reference list of alternative procedures as well and instructed that combining other procedures with dermabrasion is not uncommon.^17,18

Patients should avoid sun exposure before and after the procedure. Some surgeons prescribe antiviral prophylaxis to all patients, and patients with a history of herpes simplex should receive strong prophylactic doses of acyclovir 400 mg 3 times daily or valacyclovir 500 mg twice daily. The herpes virus requires viable epidermal cells to establish an infection. Therefore, antiviral therapy should continue for 10-14 days to allow complete reepithelialization to occur. Prophylactic antibiotics are usually not needed. However, patients with a history of impetigo, staphylococcal skin infection, or a compromised immune system may benefit from antibiotics.

After a patient is appropriately selected, the physician obtains informed consent for the procedure. This process includes a thorough discussion of possible complications. Select patients may require preoperative laboratory screening to include complete blood count and serum chemistries. In addition, at-risk individuals should be screened for HIV and infectious hepatitis.

Skin preconditioning

Trans-retinoic acid (Retin-A, Renova), a topical exfoliative agent, is believed to increase the rate of epidermal turnover. This turnover promotes rapid reepithelialization after dermabrasion. Trans-retinoic acid may be applied every night or every other night for several weeks before dermabrasion, depending on the degree of skin irritation and the patient's tolerance. An alternative product relatively new to the market is Kinerase (Valeant Pharmaceuticals North America, Costa Mesa, Calif.), which is reported to be less irritating and less sensitizing to sunlight than trans-retinoic acid.¹⁹

Topical hydroquinone applied for several weeks before dermabrasion may decrease hyperpigmentation. Dermabraded areas respond well to this treatment.

In addition, patients should be instructed to clean the face and avoid using moisturizers or makeup the morning prior to dermabrasion.

Intraoperative Details

The physician's preference determines the type of anesthesia needed. Patients should be given preoperative anesthetic medication prior to beginning the procedure. Patients may also be given an anxiolytic medication if needed. Dermabrasion may be performed with general anesthesia, a regional block, or local anesthesia with or without conscious sedation. The skin may be pretreated for 20-30 minutes with an ice pack. Refrigerant sprays (eg, fluoroethyl, freon-114) used prior to dermabrasion can produce topical anesthesia, decrease bleeding by means of vasoconstriction, and stiffen the surface of the skin. Care must be taken with refrigerant agents to prevent freezing too deeply and causing cell damage due to cryonecrosis. When using sedation or general anesthesia, the patient’s heart rate, blood pressure, and oxygen saturation must be monitored.

The areas to be treated are marked in sections and then prepared and draped in a sterile fashion. The patient’s skin should be held taut by using both of the surgical assistant's hands and the surgeon's nondominant hand. The surgeon and staff should practice strict exposure precautions, including the wearing of protective face shields, to avoid contact with aerosolized matter and blood-borne pathogens. In addition, the assistant should wear cotton gloves on top of rubber gloves to prevent injury, as the rotating handpiece can catch rubber gloves very quickly. Gentian violet staining of the treated area can be used to determine the degree of abrasion. 

The abrading instrument is correctly held by placing the forefingers around the body of the instrument with the thumb outstretched on the shaft for stability and control.

The key to successful dermabrasion is controlling the wound created. The rotating head should be kept parallel to the skin surface, and the hand piece should be in motion at all times. The motion should be deliberate, firm, steady, and with even pressure. Planing the epidermis down to the dermal junction begins the abrasion. No bleeding occurs during dermabrasion through the epidermis because of a lack of blood vessels in this layer. Decreased pigmentation is encountered when the process continues through the epidermis. The dermoepidermal junction is reached next, followed by the papillary layer of the dermis. Uniform bleeding from punctate sites over a smooth, shiny surface marks this layer. The deep papillary dermal layer is encountered when the surface becomes rough and when bleeding points increase.

Although each site bleeds only minimally, the multitude of bleeding sites can result in considerable blood loss. As the depth of abrasion increases, the superficial reticular dermis is reached, and bleeding becomes brisk and confluent. This layer is rougher than the deep papillary dermis and represents exposed dermal collagen. This surface has a whitish yellow appearance. Dermabrasion should not be performed below the superficial reticular dermis. Below this level, yellow fat globules are encountered, and clinically significant scarring would result if dermabrasion were continued here.

At the periphery of the abraded area, the borders are lightly feathered by decreasing the pressure and the number of strokes to yield a uniform appearance. Caution should be exercised over bony prominences, where excessively deep dermabrasion commonly occurs.

As the skin warms, increased bleeding may occur. Saline-moistened sponges or sponges soaked in dilute epinephrine solution with or without lidocaine can be applied to the treated area for 5-10 minutes to decrease pain and provide hemostasis.

Postoperative Details

Postoperative care is aimed at providing an ideal environment for moist wound healing to prevent dehydration and promote epithelial cell migration. After the procedure, a topical petroleum product should be applied to all treated areas. Scented or mentholated antibiotic ointments should be avoided because of their potential to cause hypersensitivity reactions.

An open or closed wound care regimen may be followed. In a typical open wound care regimen, compresses moistened with saline solution or 25% vinegar are applied 4-5 times per day to cleanse the area, followed by the petroleum ointment mentioned above. Reepithelialization requires 10-14 days. A closed wound care regimen may decrease the time for complete reepithelialization by 50% to only 5-7 days. Semipermeable dressings, such as petroleum-impregnated gauze, are applied directly to the skin and covered with nonstick dressings, gauze, and net dressing. Patients undergo dressing changes every 24 hours, and the patient is then serially evaluated to monitor progression.

Patients may be given prescription medications for pain relief, a course of systemic antibiotics (often cephalexin), or a short course of oral steroids with a quick taper to reduce instances of inflammation. If the patient has a history of herpes virus outbreaks, antiviral medications such as acyclovir or valacyclovir should be prescribed.

Follow-up

In the early stages of wound healing, the patient should be reexamined early and repeatedly, generally within 48 hours and again every several days. Any buildup of fibrinous exudate or significant eschar should be removed to prevent infection, delayed healing, and possible scarring. Some physicians use intramuscular steroid injections or oral steroids to reduce periorbital and cheek edema.

After reepithelialization is complete, the new skin may be bright pink or red, with deeply abraded areas appearing most erythematous. This coloration typically fades within 8-12 weeks. Patients may use makeup to camouflage the appearance, though they should be instructed not to apply makeup, trans-retinoic acid, or skin care products until the face is healed to the satisfaction of the treating physician.

Some practitioners have used topical agents that contain platelet products or growth factors after dermabrasion. Although these products have been shown to improve wound healing in clinical situations other than dermabrasion, the present authors know of no data from randomized controlled clinical trials that support their use in this setting. Further research continues in this area.

Patients must use sunblock to protect the new sensitive skin after it reepithelializes to prevent burning and dyschromia. Patients should use sunscreen every day for 6-12 months after dermabrasion. Some patients have transient hyperpigmentation for 4-6 weeks after surgery. Bleaching creams, such as hydroquinone, may be used 3 weeks after surgery to help prevent this effect.

Postoperative edema continues to improve for 3 months. As the edema resolves, deep rhytides and acne scars may initially appear to be persistent. Collagen remodeling continues for another 3-6 months, and new collagen fills deep defects. Patients should be told that the greatest improvement is usually observed 6 months after surgery.

Complications

Postoperative spot bleeding, erythema, milia formation, and flare-ups of acne are normal sequelae of dermabrasion and should be discussed with the patient preoperatively. A common effect is hyperpigmentation 4-6 weeks after the procedure, but this is usually transient and responds well to hydroquinone. Patients at increased risk include those taking oral contraceptives, exogenous estrogens, or other photosensitizing medications. When hyperpigmentation does not respond to topical treatment, nonablative laser therapy can be performed to diminish the pigment.

The most clinically significant complications are hypertrophic scarring and permanent hypopigmentation. The risk of prolonged erythema, scarring, and hypopigmentation is directly proportional to the depth of dermabrasion and to the delay of wound healing after the normal time for reepithelialization. Therefore, every effort should be made to control these factors.

No good treatment is available to manage the complication of hypopigmentation. This complication occurs to varying degrees in 20-30% of patients. Hypopigmentation is due to the destruction or inhibition of melanocytes. Because they originate from neural crest cells, melanocytes cannot regenerate or divide. Hypopigmentation is most noticeable in darkly pigmented patients and may be difficult to assess until erythema subsides; however, it may be permanent at that point. Pigmentary changes are less likely to occur with dermabrasion than with alternate techniques, such as chemical peeling or laser resurfacing. Camouflage methods are currently the best options to treat hypopigmentation, though certain lasers may be used to stimulate the melanocytes in some patients.

Hypertrophic scarring and keloid formation are the most worrisome complication and can result from dermabrasion through the deep dermis or an exaggerated inflammatory response. Therefore, any history of keloid formation in the patient's history should serve as a contraindication to dermabrasion.

Persistent erythema and delayed reepithelialization should alert the physician and patient that scarring is imminent. Erythema after dermabrasion typically lasts only 8-12 weeks as opposed to 3-6 months of erythema after laser resurfacing. Wounds that demonstrate a lack of reepithelialization by day 14 are at risk for hypertrophic scarring. Early recognition and aggressive treatment are essential. Aggressive measures, such as the application of compressive silicone sheets, scar massage, topical or intralesional steroids, or pressure garments, may minimize the appearance of the scar. Mid- to high-potency topical steroid creams may be used. If induration is present, intralesional steroids (eg, triamcinolone acetonide [Kenalog]) may be given every 2-3 weeks. Pulsed-dye vascular lasers have been used with some success during the erythematous phase of hypertrophic scarring. Scar excision or further dermabrasion may be necessary if the results of these therapies are unsatisfactory.

Infectious complications are unusual but must be recognized quickly to prevent undesirable scarring. Postoperative viral infections, especially those due to herpes simplex virus, may occur despite prophylaxis. If pain, erythema, or ulcerations appear 7-10 days after the procedure, viral infection should be suspected, and a full-strength antiviral therapy should be administered (valacyclovir 1 g 3 times a day for 7 days or famciclovir 500 mg 3 times a day for 7 days). Infections due to staphylococcal, streptococcal, and pseudomonal bacteria or candidal fungus may occur. If they do, wound cultures should be ordered, and appropriate oral or topical antibiotics or antifungal treatment should be started.

Milia, or intraepidermal collections of keratinaceous debris, are commonly observed after dermabrasion. These collections appear as small white cysts. Treatment consists of abrasive soaps, electrodessication, unroofing, or lancing the cysts with a needle or scalpel.

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