Dermabrasion Clinical Presentation

Updated: Sep 08, 2016
  • Author: Gaurav Bharti, MD; 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. [12]

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. [13, 14]

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. [15] 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. [16] .

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.

Next:

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. [17] 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 [18] (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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