Dermabrasion Treatment & Management

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

Treatment Overview

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, although 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.

Carbon dioxide resurfacing, Er:YAG resurfacing, and deep chemical peels may improve facial rhytides, but dermabrasion proves as efficacious or more efficacious at removal of both fine and moderate facial rhytides, with a slightly lower risk of permanent hypopigmentation. [19, 20, 21]

The major disadvantage of dermabrasion compared with other modalities is that it is much more operator dependent. Unlike laser and light devices, the depth of penetration is not preprogrammed. Successful treatment relies not only on the physician’s knowledge of the modality and application settings, but also on his or her skilled execution. In the novice’s hands, dermabrasion exhibits a narrower window or buffer between effective treatment depth and inappropriate scarring depth. However, this can be quickly overcome with experience.

Indications

Dermabrasion was initially developed to improve 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. [8] Yarborough demonstrated that surgical and traumatic scars respond best to dermabrasion performed 6-8 weeks during the interval following incision or injury. [22]

Manual dermasanding has also been used in the treatment of periorbital wrinkles and fine lines. [23]

Dermabrasion has been used to manage superficial malignancies such as squamous cell carcinoma in situ and superficial basal cell carcinoma. [24] In addition, 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. [25]

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. [26, 27] 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.

Dermabrasion has also proven to be a useful technique in the armamentarium of the Mohs surgeon (also see Mohs Micrographic Surgery). Thin carcinomas in cosmetically sensitive or high-risk areas can often be completely removed with a shallow Mohs layer to the level of the superficial reticular dermis. After clearance, these partial-thickness defects, particularly on the nose and scalp, may lend themselves to healing by secondary intention rather than primary closure, yet with slightly increased risk of an evident contour discrepancy or sharp pigmentary transition. Dermabrasion of the edges surrounding the partial-thickness Mohs defect greatly improves the final contour by replacing the steeply beveled wound edge with a more gradual slope. Additionally, dermabrading the remainder of an involved cosmetic subunit of the nose results in a less obvious scar by placing the pigmentary demarcation linesatthelessperceptiblesubunitboundaries.

Contraindications: Absolute and relative

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. [12] 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.

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 or with hepatitis C because of the risk of the aerosolization of viral particles.

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Medical Prophylaxis

All patients should receive antiviral prophylaxis. Patients with very recent or frequent herpetic infections and those patients with postoperative breakthrough herpes simplex virus (HSV) infections may require a greater prophylactic dosage (ie, valacyclovir at 500-1000 mg/day for 10-14 days or famciclovir at 500-1000 mg/day for 10-14 days). Because the herpes virus requires viable epidermal cells to establish an infection, antiviral prophylaxis is continued for 10-14 days, which is longer than the time required for reepithelialization to occur.

While most patients do not require antibiotic prophylaxis, patients who are immunosuppressed, patients with a history of impetigo, or carriers of Staphylococcus species may benefit from prophylactic antibiotics (ie, cephalexin at 1000-2000 mg/day for 10-14 days or ciprofloxacin at 500-1000 mg/day for 10-14 days). If prophylactic antibiotics are administered, fluconazole at 200 mg/day for 10 days prevents secondary yeast infections. Also see The Role of Antibiotics in Cutaneous Surgery.

Sleep deprivation can be prevented with sedating medications (flurazepam at 15-30 mg administered the night before surgery and each night following surgery while patients are sleeping in a full face mask). Thirty to 60 minutes prior to surgery, the following is administered: 5-10 mg of diazepam sublingually, 50-75 mg of meperidine intramuscularly, and 25 mg of hydroxyzine intramuscularly. Regional nerve blocks of the mental, infraorbital, supraorbital, and supratrochlear nerves are achieved with 1% lidocaine and epinephrine (1:100,000 concentration of epinephrine).

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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.

Tretinoin cream applied for 2-3 weeks prior to dermabrasion has been shown to decrease the time for reepithelialization. [28]

Some surgeons report that the use of topical hydroquinone for several weeks prior to surgery decreases the incidence of postoperative hyperpigmentation.

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

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Equipment

Dermabrasion is typically performed in an office-based setting, generally not requiring inpatient hospitalization or general anesthesia. [14] 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 handpiece and the revolutions per minute of the handpiece are the most important variables in technique. Avoiding excessive pressure on the handpiece 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. [29, 30] 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.

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Preparation

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 from 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.

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Technique Overview

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. See the image below. The direction of rotation of the abrading end piece can be clockwise or counterclockwise. For right-handed surgeons, counterclockwise rotation directs the momentum of rotation toward the thumb in a stabilizing fashion. Make passes with archiform horizontal strokes perpendicular to the direction of the rotating brush or fraise.

Technique and hand position for dermabrading raise Technique and hand position for dermabrading raised scars.

Irregular or imperfect facial surfaces are abraded to yield a smooth and even surface. See the images below.

Dermabrasion of a raised scar. Dermabrasion of a raised scar.
Technique of dermabrasion for a depressed scar. Technique of dermabrasion for a depressed scar.

The results of dermabrasion depend on the coarseness of the abrading tip, the length of time the tip is applied to the skin, and the pressure used to apply the tip. The abrasion should begin in dependent areas, such as along the sides of the face, working toward the center. This approach prevents bleeding from obscuring the skin to be abraded. In critical areas of the face, abrade cosmetic units as a whole to decrease the risk of noticeable pigmentary changes.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best. This method allows blood from a previously abraded area to flow in an inferior, gravitational direction away from the next area to be abraded. With this approach, the nose, the mid upper lip, and the mid forehead are the last areas to be abraded in a full-face procedure.

The key to successful dermabrasion is controlling the wound created. The rotating head should be kept parallel to the skin surface, and the handpiece 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 gauze or nonadherent dressings (Telfa) 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.

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Standard Technique

Treating surgical scars, rhinophyma, and partial-thickness Mohs defects provides an excellent point of entry into the practice of dermabrasion prior to practicing advanced techniques such as full-face dermabrasion. If the treatment area is limited in size, local anesthesia (1% lidocaine with epinephrine 1:100,000) or tumescent technique is adequate. When treating the entire nose, a ring block also may achieve an appropriate degree of anesthesia. Prior to abrasion, the area to be treated is cleansed with a 4% chlorhexidine solution.

The body of the hand engine is grasped in the palm of the dominant hand with 4 fingers, allowing the thumb to project along the neck for stabilization (see image below). Finger position is similar to a "thumbs-up" sign or to that seen when gripping a golf club, yet the hand and instrument are pronated, with the palm facing downward.

To hold the hand engine properly, the forefingers To hold the hand engine properly, the forefingers grasp the body of the hand engine while the thumb stabilizes the neck.

Freon-114 refrigerant spray (Frigiderm; see image below) is applied to the treatment area in an amount necessary to achieve a 5- to 10-second thaw time, during which time abrasion is performed on the frozen area. Refrigerant spray accomplishes 2 important functions: decreasing pain by cryoanesthesia and a providing a firm substrate upon which to achieve recontouring. [31, 32] Refrigerants containing Freon-12 have a freezing point of -30°C to -60°C, which is too cold and can produce hypertrophic scarring.

Frigiderm is an effective spray refrigerant used i Frigiderm is an effective spray refrigerant used in wire brush and diamond fraise dermabrasion.

Immediately after freezing, 3-point retraction is obtained by the 2 hands of the surgical assistant and the nondominant hand of the surgeon. The frozen skin is thus stabilized by retraction, and the lesion is recontoured with the wire brush rotating in a counterclockwise direction (with the angle of the radiating bristles) as determined from the point of view of the body of the hand engine. The wire brush is passed over the treatment area in an arciform motion with the long axis perpendicular to the rotating handpiece (parallel to the body of the hand engine). See video below.

Freeze defects and rhytides in their relaxed state without stretching or distorting so that they may be sculpted and recontoured.

Counterclockwise rotation of the wire brush offers a less aggressive technique of wire-brush surgery, which is especially well-suited for spot dermabrasion of Mohs defects or surgical scars without cryoanesthesia. With counterclockwise rotation, the radiating bristles are less prone to gouge unfrozen skin. This counterclockwise direction of rotation is also useful when dermabrading free margins of the face such as the lips and nasal alae, in order to prevent the inadvertent "grabbing" of tissue by the rotating wire brush when dermabrading from the right side with the dominant right hand.

Regular pinpoints of bleeding signal abrasion to the level of the papillary dermis. As depth increases to the reticular dermis, the bleeding foci become larger, and frayed collagen bundles become apparent. Surgical scars frequently disintegrate upon abrasion, which is a desirable endpoint. Contouring should often include feathering, or graduating zones of treatment around the central scar, to provide a smooth transition between different planes and improved pigment transition. Alternatively, the treatment zone may be stopped at the border of a cosmetic unit or carried to an inconspicuous endpoint, such as 1 cm beyond the mandible.

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Advanced Technique

While local or tumescent anesthesia may be adequate for scar or spot dermabrasion, full-face abrasion of acne scarring or rhytides is best accomplished with a combination of oral or intramuscular light sedation, nerve blocks, and cryoanesthesia. A standard regimen consists of meperidine at 50-75 mg intramuscularly, hydroxyzine at 25 mg intramuscularly, and diazepam at 50 mg orally or sublingually 30-60 minutes prior to the start of the procedure. After preparation with chlorhexidine, nerve blocks to the supratrochlear, supraorbital, infraorbital, and mental nerves may also be performed.

In contrast to the counterclockwise rotation typically used for less aggressive dermabrasion, more experienced practitioners may opt to use a clockwise rotation of the abrasive wire brush. Rotation in a clockwise direction occurs against the angle of the radiating wire bristles and causes the tip to pull away from the thumb rather than driving toward it. Deeper planing and recontouring are possible with clockwise rotation, but this direction is much less forgiving. Additionally, clockwise rotation used by a dominant right hand increases the risk that free margins of the face, such as lips and nasal alae, will be grabbed by the rotating bristles rather than brushed away, resulting in unintentional, deeper abrasion in these areas.

When performing full-face dermabrasion, beginning at the periphery of the cheek or mandible and working toward the center of the face allows the practitioner to avoid gravity-dependent bleeding as the procedure progresses (see video below). A surgical towel, surgical cap, or petrolatum may also be used to help prevent entanglement of hair at the periphery of the treatment area. Surgical towels are also preferable to cotton gauze as sponges on the surgical field because gauze becomes more easily entangled in the wire brush and hand engine.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best.
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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.

Another closed-technique, layered bandage is composed of a semipermeable hydrogel dressing (Vigilon, Second Skin) in contact with the wound, a nonadherent dressing (Telfa) above, and paper tape or surgical netting to secure the bandage in place. Semipermeable hydrogel dressings may provide 2 important advantages over other types of dressings: decreased patient discomfort in the postoperative period and decreased time to reepithelialization by up to 40%. The dressing should be changed daily for 3-5 days. See dressing in the image below.

Dressing for full-face dermabrasion is shown. Dressing for full-face dermabrasion is shown.

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.

Instruct patients to reapply the bland topical petroleum product throughout the day any time the face feels tight or dry. The patient is allowed to shower and gently wash the face with nonresidue soap using fingertips only. After showering, the face should be patted dry and a new coating of ointment applied. Instruct patients not to pick at their wounds during the recovery period. The patient should understand the process of reepithelialization and the importance of compliance with the prescribed posttreatment regimen.

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Long-Term Monitoring

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.

If full-face dermabrasion has been performed, the most convenient plan is to have the patient return to the office for dressing changes during this period. For smaller areas, the patient may change the bandage at home. After 3-5 days, the patient begins an open wound care technique at home. Acetic acid (0.25%) soaks (1 tablespoon white vinegar into 1 pint of warm water) are followed by topical petrolatum ointment until reepithelialization is complete, usually 7-10 days after the procedure. Strict adherence to this regimen reduces the risks of secondary infection and scarring.

If full-face dermabrasion is performed, a short course of oral or intramuscular steroids may also be given immediately after the procedure to help reduce facial swelling. Swelling is an anticipated consequence of full-face dermabrasion and may be expected to resolve over several weeks to a few months.

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, although 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.

All previously prescribed antivirals and antibacterials should be instituted or continued, and patients should be given a prognosis and expected recovery timeframe. 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.

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