Microdermabrasion Technique

Results achieved with microdermabrasion can be enhanced with medical therapies such as topical skin treatments. Adjuncts include tretinoin, alpha-hydroxyl acids, retinoic acid, and topical vitamin C. In patients treated for hyperpigmentation, the application of hydroquinone between treatments can be useful, along with the liberal use of sunscreen and moisturizers. The long-term benefits include reduction of sun damage and photoaging and improved skin moisture.

Kaushik and Keck found that microdermabrasion treatment removes approximately 23% of the stratum corneum, permitting greater penetration of transdermal agents. ^[20] In a study of 14 women with acne vulgaris, a split-face study showed that microdermabrasion with 40% pyruvic acid produced significantly less sebum secretion and increased stratum corneum hydration than treatment with 40% pyruvic acid alone. ^[21]  In a study of 30 female patients of Fitzpatrick skin type IV-V with melasma, microdermabrasion with 70% glycolic acid produced significantly superior results when compared to treatment with 70% glycolic acid alone. ^[22]

Chhatbar et al demonstrated that microdermabrasion can reduce the electrical resistance of skin, allowing for transcranial direct current stimulation (tDCS) treatment at higher amplitudes with less pain and pruritis. ^[23]

Patients should be instructed on proper skin care before the procedure. They should avoid waxing, electrolysis, and laser hair removal 1 week before procedure and avoid excessive sun exposure 2 weeks before procedure. ^[24]

No premedication is necessary, unless desired. Prior to the procedure, the skin is cleaned of all makeup and oil. No topical or local anesthetic is necessary, although its use is not precluded. Contact lenses are removed, and eye protection is placed to prevent injury from stray particles.

To ensure even exfoliation, the handpiece should make consistent contact with the treatment surface and an effective vacuum should be achieved. The operator uses the nondominant hand to stretch the treatment area taut in order to avoid excessive suction and abrasion in any one area, which could lead to pinpoint bleeding.

The vacuum pressure is controlled by a foot pedal, which allows the operator to vary the pressure on different treatment areas. The first pass is performed by gliding the handpiece over the treatment surface and allowing gentle suction of the skin. The second pass is made perpendicular to the first in order to avoid streaking. All subsequent passes should follow this alternating pattern. The desired endpoint is erythema. Typically, two passes per session are sufficient to treat the face.

Thicker skin, such as on the forehead, chin, and nose, can be treated more aggressively by adjusting the speed of the handpiece movement or increasing the number of passes. The thinner skin of the lower eyelids and the upper cheek can be treated with lower pressures. When treating the neck, it should be placed in extension to maximize the skin tension. The strokes should all be vertically oriented. This is different from the perpendicular approach that should be used on the face.

The face should be cleaned of any residual crystals in between passes. Any specific areas such as acne scars or age spots can be focally treated with additional passes. The treatment sessions typically last 30-40 minutes for the face and 20 minutes for the neck but can vary.

Once the treatment is completed, the area should be cleaned with a wet cloth to remove any residual crystals and to brush any residual crystals away from the eyes. Once dry, a moisturizer or ointment with sunscreen should be applied. Patients should avoid keratolytic agents such as retinoids, alpha-hydroxy acids, and benzoyl peroxide for 3 days following the procedure. ^[24] Continue the application of moisturizer or ointment postoperatively because exfoliation may occur.

The patient may experience a mild sunburnlike sensation for a few days, and photosensitivity may be increased during this time. Erythema usually resolves within hours of the treatment.

Effective microdermabrasion typically requires a series of 5-12 treatments, but this can vary according to the issue being treated. Initially, the frequency of treatments is weekly or biweekly and can be followed by monthly or biannual maintenance treatments.

Microdermabrasion is a relatively benign procedure, as it only produces superficial wounding of the skin, which is one of the major advantages of this resurfacing technique. Erythema is minimal and typically resolves within hours of the treatment, allowing for a rapid return to daily activities.

In the early years of its use, some reports of eye redness, photophobia, and epiphora after the procedure emerged. Physical examinations revealed conjunctival congestion, crystals adherent to the cornea, and superficial punctate keratopathy. These complications are virtually eliminated with the use of eye protection by both the patient and the operator, although corneal abrasion and eye irritation from stray crystals remains a theoretical risk.

Pulmonary fibrosis, tracheal papillomas, and laryngeal papillomas have been linked to aluminum oxide dust exposure. ^[24] Additionally, findings of aluminum in the brain senile plaques of Alzheimer disease patients have raised the question of the whether chronic exposure to aerosolized aluminum dust could place patients and operators at risk for cognitive impairment in the future. ^[24] The aluminum oxide crystals used for microdermabrasion are 100-120 μm and are much larger than the 24- to 50-μm particles used in dentistry. To date, the smaller particles used for dental air abrasion have not been found to pose a significant health hazard. Furthermore, the larger particles used in microdermabrasion are too heavy to become aerosolized and likely do not pose a risk to the respiratory system or impair cognition.

Microdermabrasion produces a host of microscopic changes that account for its clinical effectiveness. Photodamage and aging lead to thickening of the stratum corneum, thinning of the epidermis overall, and lengthening of the rete ridges. Microdermabrasion treatment promotes thinning of the stratum corneum, thickening of the remaining epidermis, and flattening of the rete ridges. ^[1]

Photodamage also leads to pigmentary abnormalities such as hyperpigmentation and irregular melanization. Microdermabrasion has been found to cause redistribution of melanosomes and to decrease melanization. ^[25]

As skin ages, it loses its collagen and elastin, which leads to decreased elasticity and the development of fine rhytides. ^[1] Some studies have found elastin content to be increased in treated skin. Studies point to increased collagen in microdermabrasion-treated skin. Coimbra et al demonstrated that weekly microdermabrasion performed for 8 weeks resulted in thickening of the epidermis, increased collagen content, and newly deposited collagen with greater organization than that seen in control samples. ^[25]

Karimipour et al found that a single microdermabrasion treatment resulted in significant elevations of molecules that are well known as regulators of matrix-degrading enzymes (activator protein 1 [AP-1], nuclear factor kappa-light-chain-enhancer of activated B cells [NFKB], interleukin 1-beta (IL-1beta), and tumor necrosis factor-alpha [TNF-alpha]), such as matrix metalloproteinases. ^[26] These enzymes remove damaged collagen and help set the stage for new collagen replacement. Twenty percent of patients in this study also demonstrated type I collagen deposition. Even though the stratum corneum was not found to be significantly disrupted with the single microdermabrasion treatment, these findings suggest that even minimally invasive resurfacing techniques may have a significant effect on the dermis.

Other studies have found that microdermabrasion decreased transepidermal water loss and improved hydration in the 7 days following treatment, resulting in “supple and more hydrated looking skin.” ^[27] Microdermabrasion is also thought to regenerate the skin lipid barrier. This group also found that the pH of the skin was decreased and sebum secretion levels were increased 7 days following treatment, suggesting that the acidic pH may have created a more favorable environment to rebuild the lipid barrier of the stratum corneum.

In appropriately selected patients, microdermabrasion can be a very effective technique. Patients with photodamage, fine rhytides, age spots, enlarged pores, and certain very superficial acne scars can experience significant improvement in the quality and uniformity of the appearance of their skin. Improvement is accomplished with little downtime or disruption of daily living and minimal risk. Microdermabrasion is well suited for the patient with a busy lifestyle and superficial skin conditions. The number and frequency of treatments can be tailored to the individual patients and depending on the condition and desired result.

Microdermabrasion is not effective for deep wrinkles and scars or icepick acne scars because these lesions extend into the deeper layers of the dermis. It is also not effective for pigmentary problems such as melasma or postinflammatory hyperpigmentation, since these issues arise in the dermis. Patients with these problems are best treated with the more traditional resurfacing modalities, such as chemical peeling, dermabrasion, and laser resurfacing.

The role of microdermabrasion in the treatment of acne vulgaris is still unclear, as there are limited well-designed, randomized, and controlled clinical trials to clearly address this issue. ^[28] Patients with active erythematous papular and pustular acne should avoid microdermabrasion since it may lead to increased inflammation and erythema. ^[25] Comedonal acne can improve after a series of exfoliative microdermabrasion treatments. ^[25] . Microdermabrasion may enhance the absorption of topical medications and increase the penetration of light into the epidermis during use of phototherapy for mild-to-severe acne vulgaris. ^[29]

The improvement of fine rhytides with microdermabrasion has been inconsistent. Studies have demonstrated the improvement in fine rhytides after treatment as noted by lay observers; however, these same changes were not noted by experienced clinicians. ^[30] Some studies suggest that the immediate apparent improvement of fine lines may be secondary to transient posttreatment edema. ^[25] Neoplastic growths such as seborrheic keratosis, actinic keratosis, and milia have shown only occasional improvement with microdermabrasion and require numerous passes with the hand piece for partial or complete ablation. Other modalities are more efficient and efficacious. ^[25]

In the future, microdermabrasion may play a role in enhancing skin permeability for the purpose of the transdermal delivery of small hydrophilic molecules, insulin, vaccines, and other therapeutic molecules. ^[31]