You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Skin Resurfacing: DermabrasionArticle Last Updated: Jul 22, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Daniel R Olney, MD, FACS, Fellow in Facial Plastic and Reconstructive Surgery, St John's Clinic of Facial Plastic Surgery, University of Missouri Daniel R Olney is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association Coauthor(s): Benjamin Daniel Liess, MD, Resident Physician, Department of Otolaryngology, University of Missouri Hospitals and Clinics; Don R Revis Jr, MD, Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine; Michael Brent Seagle, MD, Associate Professor, Division of Plastic Surgery, University of Florida College of Medicine; Consulting Staff, Florida Surgical Center Editors: J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: dermabrasion, mechanical removal of skin, skin resurfacing, removing damaged skin, skin anatomy, treatment of scars, treatment of acne, treatment of premalignant actinic damage, surgical scarring, traumatic scarring, acne scars, removal of epidermis, skin pigmentation, removal of facial blemishes, reversal of the aging process INTRODUCTIONSection 2 of 11
  The desire to reverse the aging process and remove facial blemishes has generated tremendous interest throughout history. Ancient texts describe various attempts to rejuvenate the appearance of facial skin via treatment. The goal of dermabrasion is to remove a controlled thickness of damaged skin to stimulate normal wound healing and skin rejuvenation while avoiding the complications of scarring and pigmentary changes. For additional reading, please see the Aesthetic Medicine resource center at Medscape. HISTORYSection 3 of 11
In 1905, Kromayer first reported controlled abrasion of the skin.1 His technique involved the use of rotating wheels and rasps and, except for technical improvements of the equipment, differed very little from present-day dermabrasion. He treated acne scars, keratoses, and areas of hyperpigmentation. Despite this early report of the use of surgical planing, dermabrasion did not gain widespread popularity until the early 1950s, when Kurtin, McEvitt, and others published numerous articles on dermabrasion, leading to a rediscovery of the technique.2, 3 Dermabrasion is easy to learn and perform, does not require expensive equipment, and has minimal complications when performed correctly. These qualities led to widespread acceptance of dermabrasion throughout the medical community. Although in recent years the emphasis in treating facial skin aging has shifted away from dermabrasion and chemical peels and toward laser treatment, dermabrasion remains a useful modality with which the facial plastic surgeon should be familiar and prepared to offer to patients when the proper indications exist. SKIN ANATOMYSection 4 of 11
Before beginning dermabrasion, the surgeon must have a thorough knowledge of skin anatomy and normal wound healing. Skin covers the entire external surface of the human body and is the principle site of interaction with the surrounding environment. It serves as a protective barrier preventing internal tissues from exposure to trauma, ultraviolet radiation, extremes of temperature, toxins, and bacteria. Other important functions include sensory perception, immunologic surveillance, thermoregulation, and control of insensible fluid loss. The skin is composed of 2 mutually dependent layers, the epidermis and dermis, that rest on a fatty subcutaneous layer. The epidermis contains no blood vessels and is entirely dependent on the underlying dermis for nutrient delivery and waste disposal via diffusion through the dermoepidermal junction. The primary function of the dermis is to sustain and support the epidermis. Epidermal appendages are intradermal epithelial structures lined with epithelial cells with the potential for division and differentiation. They are named as such because they develop as downgrowths or diverticula of the epidermis into the dermis. Epidermal appendages serve an important role as a source of epithelial cells, which are responsible for reepithelialization if the overlying epidermis is removed or destroyed in situations such as partial-thickness burns, chemical peeling, dermabrasion, traumatic abrasions, or split-thickness skin graft harvesting. Epidermal appendages include sebaceous glands, sweat glands, apocrine glands, mammary glands, and hair follicles. Sebaceous glands are found in highest concentration on the face and scalp, which may contain as many as 900/cm2. Epithelial appendages are located deep within the dermis and, in the face, may lie in the subcutaneous fat beneath the dermis. The deep location of these structures and their density in the face account for the remarkable ability of the face to reepithelialize even the deepest cutaneous wounds. With aging, the skin undergoes atrophy. This process typically begins during the fourth decade of life. The outermost portion of the epidermis, the stratum corneum, becomes disorganized and less effective as a protective barrier to the external environment. A gradual decline also occurs in the number of melanocytes populating the basal layer of the epidermis. The dermoepidermal junction becomes flattened because fewer dermoepidermal papillae are present. The most significant changes occur in the dermis, where an overall loss of organization occurs as the dermis thins with age. The amount of ground substance decreases and elastic fibers degenerate, making the skin less resistant to deformational forces. Collagen is also lost, and the proportion of type I collagen relative to type III collagen is reduced. Actinic damage also produces changes in the skin, resulting in skin that actually thickens. Actinic keratoses and lentigines form. Dermal elastosis results from accumulation of thickened degraded collagen and elastic fibers. Ground substance also increases, while mature forms of collagen decrease. Facial rhytides occur, probably as the result of a combination of aging, photodamage, gravity, and repeated use of the muscles of facial expression. Dermabrasion is the process of mechanically removing the damaged outer layers of skin. The epidermis then regenerates from the epidermal appendages located in the remaining dermis. This process begins within 24 hours of wounding and is usually complete after 7-10 days. The new epidermis shows greater organization and vertical polarity with the disappearance of actinic keratoses and lentigines. Dermal regeneration is a slower process but is usually complete within several months. The regenerated dermis demonstrates less elastosis and improved organization, with compact horizontally arranged bundles of collagen interspersed with elastic fibers. Ground substance is decreased, and telangiectasias are absent. The overall result is soft supple skin that appears more youthful and has fewer rhytides and dyschromias. Destruction confined to the epidermis results in rapid healing without scarring, although some pigmentation change may occur if melanocytes are damaged. This superficial wounding has the disadvantage of producing less dramatic results but is very safe. Deeper wounding, extending into the papillary and sometimes reticular dermis, produces more dramatic results. However, deeper penetration eradicates a portion of the epidermal appendages, increasing healing time and making scarring more likely. Penetration into the reticular dermis entails a high risk of scarring. By the same token, dermabrasion of full-thickness scars results in full-thickness wounds. These heal by wound contraction and reepithelialization and have a much higher likelihood of wound problems and hypertrophic scarring. These types of lesions generally are best treated by full-thickness excision with a punch biopsy or scalpel. PATIENT SELECTIONSection 5 of 11
Adequate evaluation and photographic documentation of patients before dermabrasion are absolutely essential. Evaluation includes consideration of the severity and depth of the condition being treated and the need for additional or alternative procedures. The patient with deep rhytides and excessive facial skin is likely to be better served with traditional rhytidectomy. The patient with severe generalized photodamage and medium-to-fine rhytides may be an optimal candidate for chemical peeling or laser resurfacing. Patients may benefit from rhytidectomy and resurfacing rather than dermabrasion because rhytidectomy addresses skin quantity whereas peeling addresses overall skin quality. Dermabrasion is indicated for surgical or traumatic scarring, acne pits and scars, rhinophyma, chickenpox scars, premalignant actinic damage, melasma, tattoos (both traumatic and intentional), and perioral rhytides and has been demonstrated to be as efficacious as laser resurfacing in treatment of these conditions. Whereas chemical peeling and laser resurfacing usually are applied globally to the face, dermabrasion more often is used for specific areas of troubling scarring or wrinkling. Acne scars most amenable to dermabrasion are those that are narrow, pitted, and cast a shadow on the face. Extensive scarring extending down to and involving the subcutaneous tissue should not be dermabraded because no epithelial cells will remain to resurface the wound. Incidence of further scarring and pigmentation disturbances greatly increases in this situation. In these instances, the scars should be excised with a punch biopsy or scalpel and closed appropriately. A cornerstone of the evaluation of facial skin is the Fitzpatrick scale of sun-reactive skin types, which denotes patients' reactions to ultraviolet radiation and the existing degree of pigmentation. Patients are classified as follows:
Patients with lighter skin types can expect to undergo dermabrasion with minimal pigmentation alteration, whereas those with darker skin are at a higher risk for hyperpigmentation or hypopigmentation. Quantitative analysis of facial aging can be classified using the Glogau scale of facial rhytides formation and photoaging. Glogau Scale of Facial Rhytides Formation and Photoaging
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. Other considerations highlight the importance of obtaining a thorough medical history and review of systems to supplement the physical examination. Preexisting cardiac, hepatic, and renal disease may influence treatment decisions and choice of anesthetics. A history of 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. Use of exogenous estrogens, oral contraceptives, or other photosensitizing medications may predispose patients to pigmentary changes following dermabrasion. A history of herpes simplex infections should alert the physician to the need for prophylaxis in the immediate perioperative period until reepithelialization is complete to prevent an outbreak. Some authors advocate prophylaxis in all patients. Any existing lesion should be allowed to heal completely before proceeding with dermabrasion in that region. Patients must be aware that cooperation and compliance with the postprocedure regimen are required to ensure normal wound healing and avoid complications. Patients likely to be noncompliant or unable to avoid sun exposure because of occupation are unsuitable candidates for dermabrasion. Men are less likely to be willing to use camouflage makeup in the event of pigmentary disturbances. Although the technique of dermabrasion is relatively simple, the real challenge lies in selecting appropriate patients and achieving the correct depth of wounding. In general, the more severe the problem being treated, the more aggressive treatment should be. Once the patient is appropriately selected to undergo dermabrasion, obtain informed consent, including a thorough discussion of possible complications. PRECONDITIONING OF THE SKINSection 6 of 11
Preconditioning the skin is a useful adjunct to improve results. Trans-retinoic acid (Retin-A, Renova), an exfoliative agent, is believed to normalize polarity of the skin and increase epidermal turnover. This promotes a thinning of the stratum corneum with shedding of keratinocytes and activates fibroblasts, promoting more rapid reepithelialization following dermabrasion. Trans-retinoic acid may be applied nightly or every other night for several weeks before dermabrasion, depending on the degree of skin irritation and patient tolerance. An alternative product relatively new to the market is Kinerase, which is reported to be less irritating and less sensitizing to sunlight. The patient should thoroughly cleanse the face with nonresidue soap on the evening before and morning of dermabrasion. Instruct the patient not to apply makeup or moisturizers. PERFORMING DERMABRASIONSection 7 of 11
Anesthesia usually involves general anesthesia, conscious sedation, and/or local anesthesia depending on patient preference and extent of dermabrasion to be performed. Once the patient is adequately anesthetized, prepare and drape the face in the usual sterile fashion. Cleanse the face with saline to remove any residues of soap, and mark the areas to be dermabraded with a marking pen. Dermabrasion requires rather simple tools and, in comparison to laser resurfacing, does not require specialized safety equipment for surgeon or patient, with the exception of protective face shields for the surgeon and staff. The surgeon uses a handheld device to abrade a controlled depth of facial skin. The hand piece has a rapidly spinning tip to which multiple interchangeable abrading devices may be attached. These include sandpaperlike burrs, curettes, diamond fraises, rasps, and wire brushes. The tip generally spins at a speed of 12,000-15,000 rpm. The surgeon can control speed, usually with a foot pedal. Irregular or imperfect facial surfaces are abraded to yield a smooth and even surface. The only danger in performing dermabrasion is abrading too deeply into the facial skin. The results of dermabrasion depend on the coarseness of the abrading tip, the length of time applying the tip to the skin, and the pressure used to apply the tip. In general, the abrading tip is applied in smooth strokes to gradually remove the damaged outer layers of the skin until a smooth uniform surface of bleeding tissue remains. The skin is held taut and maintained in a stationary position by the nonoperating hand (see Images 1-3). An alternate technique employs a freezing spray to create a hard skin surface to facilitate the abrasion. Avoid excessive pressure with the handpiece because this results in grooving of the skin. When reaching the periphery of the area to be treated, feathering is appropriate to avoid any demarcation between treated and untreated regions. This is best performed by decreasing pressure applied to the skin on the periphery and making fewer passes. As the outer layers of the epidermis are removed, no bleeding occurs. This is because the epidermis contains no blood vessels. Once the dermoepidermal junction is breached and the plane of dermabrading reaches the papillary dermis, a uniform bleeding from punctate sites over a smooth, shiny surface occurs. Sponges moistened with saline or epinephrine may be useful in controlling bleeding during the procedure. Once the level of planing reaches the deeper papillary dermis, bleeding becomes more voluminous and the surface has a rougher appearance. Although each site bleeds only minimally, the multitude of bleeding sites can result in considerable blood loss. Once the reticular dermis is entered, bleeding becomes brisk and confluent. This layer is even rougher than the deep papillary dermis and represents exposed dermal collagen. This is a depth at which most physicians become uncomfortable with dermabrasion. The risk of hypertrophic scarring, delayed wound healing, and pigmentary changes are highest when dermabrasion is carried this deeply.Contemporary techniques for dermabrasion use different modalities in combination. Often combining dermabrasion techniques with chemical peels or laser resurfacing can tailor a resurfacing procedure to each individual. Dermasanding with sterile silicone carbide sandpaper is a technique that can address deep facial wrinkling. It may be combined with laser resurfacing (coined laserbrasion) or after conventional dermabrasion with a powered unit. Dermasanding following CO2 laser resurfacing may also remove a portion of the thermal damaged skin, allowing a shortened healing time. This technique may be performed with the sandpaper wrapped around a finger or surgical block. Perpendicular brush strokes are used and frequent visual inspection is required. The depth of dermabrasion may be controlled and adjusted depending on the location or severity of facial wrinkles or scarring. The goal of dermasanding is to achieve uniform bleeding at the level of the reticular dermis. Manual dermasanding is a cost-effective maneuver that may be easily performed by itself or in combination with other resurfacing techniques. This method is safer for use around the eyes and nose because no powered mechanism could potentially cause unintended injury. Splattering of blood is almost nonexistent. POSTOPERATIVE CARESection 8 of 11
Postoperative care is aimed at providing an ideal environment for moist wound healing. Initially apply a generous amount of ointment to the entire treated area. This should be a bland ointment such as white petrolatum, A+D Ointment, or vegetable shortening. Instruct patients to reapply the ointment 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. Some practitioners have used topical agents that contain platelet products or growth factors following dermabrasion. Although these products have been shown to improve wound healing in other clinical situations, no randomized controlled clinical trial presently supports their use in this setting. Further research continues in this area. The patient should understand the process of reepithelialization and the importance of compliance with the prescribed posttreatment regimen. Antiviral therapy, if instituted, should be continued until reepithelialization is complete. In the early stages of wound healing, the patient should be reexamined early and repeatedly, generally within 48 hours and again every several days. Instruct patients not to reapply trans-retinoic acid, sunscreen, or makeup until the face is healed to the satisfaction of the treating physician. COMPLICATIONSSection 9 of 11
Dermabrasion may produce profound improvement in the quality of facial skin, but it also has potential complications. Results and complications are generally related to the depth of wounding, with deeper wounding providing more marked results and a higher incidence of complications. Complications are also more likely with certain skin types. Erythema generally subsides within 90 days, but postinflammatory hyperpigmentation may occur. Patients at increased risk include those taking oral contraceptive pills, exogenous estrogens, or other photosensitizing medications. Application of topical hydrocortisone lotion and/or a short course of systemic steroids may lead to earlier resolution of erythema. Other treatment options include trans-retinoic acid, glycolic acid, or hydroquinone. Accompanying pruritus may be treated with oral antihistamines. 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. Patients also should be instructed in the appropriate application of camouflage makeup. Hypopigmentation is the result of melanocyte destruction or inhibition. Being of neural crest cell origin, these cells do not possess the ability to regenerate or divide. Hypopigmentation has been encountered most frequently when using phenol as the peeling agent, and this has led many to abandon phenol in favor of other agents. Hypopigmentation is more noticeable in more darkly pigmented patients. Hypopigmentation may be difficult to assess until erythema has subsided, and, unfortunately, is permanent at this point. Pigmentary changes are much less likely with dermabrasion than with alternative techniques such as chemical peeling or laser resurfacing. Delayed healing may lead to hypertrophic scarring, which is the most devastating complication following dermabrasion. Hypertrophic scarring requires close follow-up care and aggressive early treatment. Topical or intralesional steroids, silicone sheeting, pressure application, and scar massage may improve outcome. 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 for unsatisfactory results. Infectious complications are unusual but demand vigilance and aggressive therapy with oral and topical antibiotics. Treat pseudomonad infections by washing the face with equal parts water and distilled vinegar. Treat herpes flare-ups with oral and topical acyclovir until resolution. Most of these lesions respond rapidly and completely to treatment and rarely cause scarring. Milia, ie, intraepidermal collections of keratinaceous debris, appear as small white cysts. Treatment consists of lancing the cysts with a needle or scalpel. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Skin Resurfacing: Dermabrasion excerpt Article Last Updated: Jul 22, 2008 | |||||||||||||||||||||||||||||||||||||||||
