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Dermabrasion 35 Dermabrasion Jesse Ellis Smith, MD, FACS1 1 Department of Facial Plastic and Reconstructive Surgery, UT Address for correspondence Jesse Ellis Smith, MD, FACS, University of Southwestern Medical Center at Dallas, Fort Worth, Texas Texas Southwestern Medical Center at Dallas, 923 Pennsylvania Avenue, Fort Worth, TX 76104 (e-mail: [email protected]). Facial Plast Surg 2014;30:35–39. Abstract For many patients, sun damage, trauma, prior cutaneous carcinomas, and aging have created a less than optimal skin appearance. There are currently multiple forms of ablative therapy to correct such concerns. Dermabrasion is a form of resurfacing that mechanically alters the skin at the level of the dermis, to promote collagen remodeling and re-epithelialization. Facial skin has a rich vascular and adnexal network, allowing the rapid healing of controlled damage because blood, macronutrients, and oxygen are readily available. Sebaceous glands and hair follicles are important in the regeneration Keywords process of the dermis. Dermabrasion can be taken down layer by layer to remove the ► dermabrasion proper level of skin, so that the desired effect is obtained. By completely removing the ► ablative resurfacing epidermis and penetrating into the reticular and papillary dermis, controlled damage is ► scar revision obtained and remodeling of the skin’s structural proteins, into a more organized ► scar manner, occurs during the healing process. This abrasion technique leads to clinically ► rhytides significant improvements in skin structure, quality, and appearance. Anatomy basale of the epidermis. The papillary dermis has multiple sensory nerve endings and a rich vascular plexus. As the The skin is composed of the epidermis, dermis, and subcuta- abrasion proceeds through the epidermis, a small amount neous tissue. The dermis is further subdivided into the of diffuse pinpoint bleeding can be observed upon entry papillary and reticular dermis. To safely perform dermabra- into the papillary dermis. The reticular dermis is the lower sion, a surgeon must know what each layer looks like as it is levelofthedermisandiscomposedoflargebundlesof encountered in the operative field during dermabrasion. collagen, providing the skin its tensile integrity. Upon The epidermis is made up of four major strata of replicat- entering into the depth of the reticular dermis with derm- ing epithelial cells. The most superficial layer is the stratum abrasion, the surgeon will notice a relative decrease in corneum, composed of multiple layers of desiccated cells pinpoint bleeding, but an increase in a white-colored layer Downloaded by: University of Virginia Libraries. Copyrighted material. which have lost their cytoplasmic organelles, and are filled composed of parallel lines of collagen.2 Dermabrasion is with keratin deposits.1 The stratum lucidum is a thin, clear safe to the level of the superficial or mid-reticular dermis, layer of cells found just under the stratum corneum. Below and some have related the topography of this level to a this lies the stratum granulosum, so named for the intense finely woven laparotomy sponge, commonly used in sur- stain seen in histologic preparations. The next layer derives gery. As the collagen bundles sort into parallel bands, so do the name stratum spinosum from its characteristic spiny many of the blood vessels, thus leaving the pinpoint bleed- cytoplasmic appendages. The base layer, nearest to the der- ing behind. If dermabrasion continues beyond this depth mis is the stratum basale, which is a single layer basement into the subcutaneous tissue, scarring is likely. Sebaceous membrane of cells. glands and hair follicles are important in the regeneration Thedermisiscomposedoforganizedconnectivetissue process of the dermis.3 It is paramount to remember that in two separate major layers which interdigitate through a the deeper the reticular dermis is penetrated, the greater system of pegs and ridges. The papillary dermis is the more the likelihood of adverse events, such as scarring, hypo- superficial of the two and is located just below the stratum pigmentation, and hyperpigmentation. Issue Theme Classical and State-of-the- Copyright © 2014 by Thieme Medical DOI http://dx.doi.org/ Art Skin Rejuvenation; Guest Editors, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0033-1363759. Lisa D. Grunebaum, MD, and Noëlle S. New York, NY 10001, USA. ISSN 0736-6825. Sherber, MD, FAAD Tel: +1(212) 584-4662. 36 Dermabrasion Smith wound formation, when collagen remodeling is at its Selection and Contraindications – height.8 10 Before initiating any procedures, an accurate history and Patients should be well informed of the risks, benefits, and physical exam should be obtained. The surgeon should ask realistic outcomes of dermabrasion. Re-epithelialization can about previous history of poor scarring and keloids, thyroid take 4 to 10 days, depending on the depth. Hyperpigmenta- disorders, anemia, malnutrition, clotting disorders, use of tion and redness can occasionally persist for 6 weeks or more. anticoagulants and nonsteroidal anti-inflammatory drugs Thorough counseling about the procedure is recommended to (NSAIDs), organ transplants, prolonged use of steroids, chron- avoid postoperative patient confusion and dissatisfaction. ic leukemia, hepatitis C, human immunodeficiency virus, and previous herpetic outbreaks. Blood can become aerosolized CO versus Dermabrasion during dermabrasion; therefore, patients with blood-borne 2 pathogens should be excluded from treatment with rotating Small observational studies propose that fractionated CO2 fraises and brushes. laser has less erythema and edema than dermabrasion; – Dermabrasion can be employed to improve a wide variety however, the final outcomes were equivalent.11 14 Jared of skin anomalies, including acne scars, keloids, traumatic Christophel et al studied six patients using standard derm- scars, surgical scars, facial rhytides, actinic keratosis, rhino- abrasion diamond fraise technique versus a fractionated CO2 phyma, and tattoos.4 Although, caution should be employed laser with four passes over the scars of Mohs patients.11 in dermabrasion of keloids. Accurate assessment of the skin Mandy commented on the technique as well, siting his condition is critical to determining the success and utility of experience in both realms, and confirmed Jared Christophel dermabrasion. If the skin lesion is located within the papillary et al results.12 or superficial reticular dermis, there is a high likelihood that Similar long-term results have been reported from ablative dermabrasion will be a good therapeutic option. Dermabra- CO2 resurfacing versus dermabrasion as well. Yet, ablative sion is optimally appropriate for patients with Fitzpatrick CO2 resurfacing was associated with increased crusting and type I or II skin. Patients with Fitzpatrick type III and greater less rapid epithelialization than dermabrasion in a small have an increased risk of postprocedure pigment abnormali- study done by Holmkvist and Rogers.13 ties, such as hypo- or hyperpigmentation. Four to six weeks of High-energy, pulsed CO2 also shows comparable results to preprocedure 4% hydroquinone, used daily, reduces the risk of dermabrasion.14 Nehal et al looked at four patients to evalu- hyperpigmentation.5 ate differences. The study demonstrated that the erythema The current or recent use of isotretinoin is an absolute was comparable in both groups; however, crusting was worse contraindication to dermabrasion, as hypertrophic in the immediate postoperative period in the dermabrasion scarring may occur. Isotretinoin should be discontinued a areas. Both techniques demonstrated statistically significant minimum of 6 months before dermabrasion and other differences and improvement in scar cosmesis and texture; resurfacing techniques.6 Individuals with a recent history however, there was no statistical difference between the of herpetic outbreak should wait at least 6 to 8 weeks two.14 before undergoing dermabrasion. High-dose acyclovir is Progression of a patient with several basal cell carcinomas recommended, starting 2 days before the procedure and can be observed in ►Figs. 1 to 4, showing repaired basal cell continuing for a total of 2 weeks.7 The timing for postoper- carcinoma of the left face and revision Mohs reconstruction of ative scar dermabrasion remains variable, but usually the left nasal sidewall and ala. Dermabrasion was completed fi is accomplished within a 6- to 12-week window of in the of ce 6 weeks after her Mohs closure and Downloaded by: University of Virginia Libraries. Copyrighted material. Fig. 1 (A–C) Postoperative Mohs resection. Facial Plastic Surgery Vol. 30 No. 1/2014 Dermabrasion Smith 37 revision. ►Fig. 1 demonstrates the defects after the Mohs resection. ►Fig. 2 shows the (A) preoperative and (B) post- operative appearance after reconstruction and dermabrasion on frontal view. ►Fig. 3 shows the (A) preoperative and (B) postoperative appearance after reconstruction and derm- abrasion on lateral view. ►Fig. 4 shows the (A) preoperative and (B) postoperative appearance after reconstruction and dermabrasion on basal view. Microdermabrasion Microdermabrasion is a nonsurgical, office-based procedure used to exfoliate the skin. Superficial ablation of the stratum corneum is achieved by microdermabrasion to reveal new Fig. 2 (A, B) Pre- and postoperative appearance of a patient with repaired and healthy underlying skin. A session takes approximately basal cell carcinoma of the left face and revision Mohs reconstruction of
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