Dermabrasion Clinical Presentation

Updated: May 18, 2018
  • Author: Gaurav Bharti, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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Presentation

History

The history should address bleeding disorders, prior herpes simplex infection, impetigo, keloidal or hypertrophic scarring, koebnerizing conditions, prior isotretinoin therapy, and immunosuppression. [9]

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. Dermabrasive surgery in patients with active herpetic lesions should be postponed. [10, 11]

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.

A detailed drug history is important, specifically regarding isotretinoin, because recent isotretinoin exposure is a relative contraindication to dermabrasion. Shrunken sebaceous glands resulting from recent use of isotretinoin exposure 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. [12] 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; some authorsadvocateupto1 year. [13] .

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 [Plavix], warfarin [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.

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.

Preexisting cardiac, hepatic, and renal disease may influence treatment decisions and choice of anesthetics. A history of a collagen disorder, cutis laxa, congenital ectodermal dysplasia, or scleroderma is a contraindication for dermabrasion because patients with these conditions often have abnormal adnexal structures and reepithelialize unpredictably.

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Physical Examination

A detailed physical examination should be performed, including a determination of the patient’s motives for the procedure, preoperative photography, and skin type determination. The severity and depth of the patient’s condition needs to be assessed.

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. Finally, patients likely to be noncompliant or unable to avoid sun exposure because of occupation are unsuitable candidates for dermabrasion.

Patient motivation

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. [14] Identifying this goal and establishing realistic outcome expectations is critical.

One of the most important components of the preoperative consultation is 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.

Preoperative photography

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.

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.

Skin type determination

The patient's skin type should be assessed using the Fitzpatrick classification and Glogau Scale (see Tables 1 and 2 below). The Fitzpatrick 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. The Glogau Scale is used to determine the overall amount of aging the face has undergone.

Table 1. Fitzpatrick Skin Classification [15] (Open Table in a new window)

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.

Quantitative analysis of facial aging can be classified using the Glogau Scale of facial rhytides formation and photoaging.

Table 2. Glogau Scale of Facial Rhytides Formation and Photoaging (Open Table in a new window)

Skin Type

Age (y)

Clinical Findings

I (mild)

20-30

Early photoaging, fine wrinkling

II (moderate)

30-40

Early to moderate photoaging, present with motion, no keratoses

III (advanced)

50 and over

Advanced photoaging, wrinkles with rest, visible keratoses, noticeable discolorations

IV (severe)

60 and over

Severe photoaging, wrinkles throughout, dynamic and gravitational wrinkling, actinic keratoses

The Glogau scale is useful in evaluating the overall amount of aging the face has undergone and can be helpful in discussing potential results of facial cosmetic procedures with patients.

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Complications

Postoperative spot bleeding, erythema, milia formation, hair avulsion, 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 skin typically is sensitive to the sun following dermabrasion, and this also may be a source of hyperpigmentation. Instruct patients to use sunscreen daily for 6-12 months following dermabrasion.

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.

Milia

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.

Hypopigmentation

No reliably 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, although certain lasers may be used to stimulate the melanocytes in some patients.

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. [16] 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 chemabrasion, [17] and Grimes et al reported success with topical photochemotherapy. [18]

Hypertropic scarring and keloid formation

Hypertrophic scarring and keloid formation are the most worrisome complications and can result from dermabrasion through the deep reticular 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

Infectious complications are unusual but must be recognized quickly to prevent undesirable scarring. Postoperative viral infections, especially those due to herpes simplex virus (HSV), may occur despite prophylaxis. If pain, erythema, or ulcerations appears 7-10 days after the procedure, viral infection should be suspected and 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.

Hair avulsion

Hair avulsion injury can be a dreaded complication of facial dermabrasion. Extreme care must be taken when performing this procedure on the face anywhere near hair. Areas of caution are near the side burns, temples, and forehead. The hair must be isolated away from the operative field. If hair is in contact with the dermabrader it can become entangled and large areas of hair can quickly become avulsed, leading to temporary alopecia.

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