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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 ► 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 .

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 , keloids, traumatic Christophel et al studied six patients using standard derm-

scars, surgical scars, facial rhytides, , rhino- abrasion diamond fraise technique versus a fractionated CO2 phyma, and .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.

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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 the 30 minutes in the office and is associated with no downtime. fi left nasal sidewall and ala. Dermabrasion was completed in the of ce It is best for patients hoping to cosmetically improve the tone 6 weeks after her Mohs closure and revision. Images represent appearance 15 fi 12 weeks after scar and perioral dermabrasion. and texture of minimally photoaged skin. The ef cacy of microdermabrasion to treat scars is much less than that of dermabrasion because microdermabrasion only penetrates the stratum corneum. Thus, it is only beneficial for the most superficial of facial rhytid or scar.15 The use of isotretinoin within a year of treatment, prior radiation therapy to the affected area, and patients with hypertrophic scarring are poor candidates for both dermabrasion and microdermabra- sion. Microdermabrasion decreases skin sebum content, in- creases epidermal concentration of ceramide, decreases epidermal water loss, and enhances texture of the skin.

Preparation

Some patients may be placed on topical tretinoin and or hydroquinone 2 to 6 weeks before therapy.5 Other surgeons prefer a combination of hydroquinone, mild topical steroid, A B Fig. 3 ( , ) Pre- and postoperative appearance of a patient with repaired and retinoic acid in a cream form 2 to 6 weeks before basal cell carcinoma of the left face and revision Mohs reconstruction of the dermabrasion to reduce postoperative hyperpigmentation. left nasal sidewall and ala. Dermabrasion was completed in the office 6 weeks after her Mohs closure and revision. Images represent appearance Sun exposure should be kept to a minimum for 2 months 12 weeks after scar and perioral dermabrasion. before and after the procedure to avoid complications.

Regional dermabrasion can be achieved with the use of Downloaded by: University of Virginia Libraries. Copyrighted material. nerve blocks. If full facial dermabrasion is to be performed, intravenous sedation or general anesthesia is an easy option for both the patient and the surgeon. However, others have proposed tumescent anesthesia to avoid sedatives and gen- eral anesthetics. A comprehensive sequence for providing facial anesthesia in this manner is best described by Hanke.16 Before the procedure povidone-iodine 10% or other ophthalmologically safe surgical scrubs should be used to prepare the skin surface that will be dermabraded. Betadine is easy to use, and because of its color, can serve as a map for areas that have yet to be abraded when large areas are involved. Hats, masks, gloves, and other standard Occupa- tional Safety and Health Administration (OSHA) precautions are mandatory.

Fig. 4 (A, B) Pre- and postoperative appearance of a patient with repaired basal cell carcinoma of the left face and revision Mohs reconstruction of the Instrumentation and Surgical Technique left nasal sidewall and ala. Dermabrasion was completed in the office 6 weeks after her Mohs closure and revision. Images represent appearance Usually a diamond fraise or rotating wire brush is employed on 12 weeks after scar and perioral dermabrasion. a handheld drill device. Yet, some use sterilized sand paper

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with excellent results. Appropriate technique is nonetheless process across the treatment region. Some use opposing right paramount in all ablative resurfacing techniques, as misuse can angles, others back and forth, left to right, or superior to cause further scarring and infection. Most surgeons commonly inferior. Care is always taken around loose, nontense struc- employ an electric-powered, handheld device with a rotating tures, such as eyelids, lips, and the ala.3 The temple areas, tip that will accept multiple fraises or wire brushes. Many likewise, have fewer follicular units and are more susceptible devices have the ability to adjust speeds of rotation from 5,000 to scarring if too much pressure and depth of penetration are to 85,000 rpm. Most machines can rotate the fraise clockwise applied. or counterclockwise. The faster the rate of spin, the more As with most chemical peels, dermabrasion is performed powerful the device becomes, decreasing the need for pres- best by facial subunits or sections. Starting with the outer sure, and increasing the risk of accidental depth penetration most areas and working inward allows the surgeon to work in and thermal injury. Thus, speed and pressure of the device areas where gravity keeps blood from running into and should be taken into account and adjusted separately. obscuring the field. Dabbing at bleeding areas is permissible, To maintain consistency and control over the procedure, but be leery of gauze near the rotating attachment, as it is the skin should be drawn taught, so that the fraise cannot skip easily caught up in the attachment and can cause damage to or rip loose skin. Refrigerant sprays can be used for both pain the patient or surgical team. Feathering to avoid lines of modulation and to keep the skin cool during dermabrasion to demarcation is important; the dermabrasion should be taken prevent secondary thermal injury. The skin is placed on to the hairline and rolling slightly beneath the chin and edge stretch by the surgeon and the assistant, to maintain tightness of mandible. Blending at the edges with a lighter touch of the area being abraded. When a new area is to be abraded, feathers the edges and makes them less noticeable. This the device is halted, and tension is readjusted to the new feathering technique should be used at any transition, such region before proceeding. It is wise to avoid gauze and other as from the face to neck or the neck to the chest. cloth in the field, as these can become easily wrapped around Diffuse pinpoint bleeding signals entry into the papillary the circulating fraise or brush and cause injury to the patient dermis. A yellow chamois color indicates the reticular dermis, or the treatment team. with the superficial layer characterized by parallel oriented The diamond fraise is a diamond studded tip that can be strands within the dermis. The deeper reticular dermis is found in a variety of shapes, sizes, and grit. Shapes include marked by frayed, white strands. Entry into the deep reticu- wheel, cylinder, cone, bullet, pear, and more.2 Fraise grit can lar dermis should be avoided, as it is associated with vary from fine to coarse diamond. Larger burs with greater scarring.19 grit are more aggressive and can be used for full face dermabrasion and deeper scars. The diamond fraise has a Postoperative Considerations high contact surface area with the skin, and thus the higher the rotational speed, the greater the thermal and frictional In truth, there are multiple ways to treat the face during the injury that can occur. Manual dermabrasion with sand paper re-epithelialization period. Some common products include and other nonmechanical devices has shown no statistical petroleum-based or nonpetroleum-based creams and emol- differences in scar revision cosmesis and texture over me- lients, petroleum-based and nonpetroleum-based antibiot- chanical dermabrasion machines. ics, hydrating creams, occlusive dressings, and biologic The rotary wire brush is another instrument employed by dressings. Surgeons must be careful with products that many. The tip consists of a cylinder with wires protruding 2 to contain neomycin, as contact dermatitis can occur, leading

3mmfromthecentralcore.Thewirebrushesalsocomeina to confusion between allergic reaction, superinfection, and Downloaded by: University of Virginia Libraries. Copyrighted material. variety of sizes, shapes, and coarseness. The wire brush produces viral infection. Cleaning and reapplication of ointments microlacerations to the skin instead of the frictional injury should be done two to four times daily. One of the most caused by the fraise.17 These wire brushes have the ability to important aspects is keeping the area well hydrated to allow cut through skin with even mild pressure; thus, rotation rates of proper re-epithelialization. Erythema, edema, and some greater than 25,000 rpm are not recommended.18 crusting are to be expected, but epithelialization should be No matter which attachment is used, proper manipulation, well on its path within 10 days.20 Sun avoidance and frequent pressure, and control are imperative to prevent unnecessary application of sunscreen are paramount following re-epithe- injury. Multiple techniques have been described, and each lialization. Hyperpigmentation and hypopigmentation can surgeon must find the practices that are best suited for each occur if avoidance of UV radiation is not monitored. situation. The dermabrader can be gripped like a pencil, or the device can be gripped like the handle of a spatula. The latter of Skin Changes the two grips affords better control and minimizes the risk of ricochet of the device during treatment. Both grips allow the Evaluating the success of dermabrasion is often difficult instrument to be handled accurately, and the attachments to because the measurement criteria are subjective. One study be beveled when necessary. Occasionally, the pencil grip can evaluated the efficacy of dermabrasion with the diamond lead to inadvertent edge beveling, reducing the surface area of fraise and wire brush and found that both techniques led to the device in contact with the skin, and increasing the sharp statistically significant moderate to marked improvements in cutting edge, which can lead to skin injury. There are multiple the appearance of photoaged skin at both 3 and 12 weeks. working patterns that can be used during the dermabrasion There was no statistical difference between the diamond

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17 fraise and the wire brush technique. Other studies have 6 Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. Atypical shown similar results between the diamond fraise and the keloids after dermabrasion of patients taking isotretinoin. J Am – brush, and the diamond fraise and sterile sanding paper.21,22 Acad Dermatol 1986;15(2 Pt 1):280 285 7 Perkins SW, Sklarew EC. Prevention of facial herpetic infections Multiple studies have supported the fact that dermabrasion after chemical peel and dermabrasion: new treatment strategies fi leads to clinically and statistically signi cant improvements in the prophylaxis of patients undergoing procedures of the 23–26 in lentigines, actinic keratosis, and rhytides. perioral area. Plast Reconstr Surg 1996;98(3):427–433, discussion The histologic and clinical improvements following derm- 434–435 abrasion occur because mechanical resurfacing induces col- 8 Yarborough JM Jr. Ablation of facial scars by programmed derm- – lagen remodeling and changes in other proteins in the dermis. abrasion. J Dermatol Surg Oncol 1988;14(3):292 294 9 Brenner MJ, Perro CA. Recontouring, resurfacing, and scar revision There is an increase in the organization and amount of in skin cancer reconstruction. Facial Plast Surg Clin North Am collagen infrastructure, leading to both histologic and clinical 2009;17(3):469–487, e3 3,23 improvements. 10 Katz BE, Oca AG. A controlled study of the effectiveness of spot dermabrasion (’scarabrasion’) on the appearance of surgical scars. J Am Acad Dermatol 1991;24(3):462–466 Adverse Events 11 Jared Christophel J, Elm C, Endrizzi BT, Hilger PA, Zelickson B. A randomized controlled trial of fractional laser therapy and In the hands of a skilled surgeon, adverse events and poor dermabrasion for scar resurfacing. Dermatol Surg 2012;38(4): outcomes are rare. However, proper patient selection and 595–602 preparation are keys to good clinical results. Skin can be 12 Mandy S. Commentary: a randomized controlled trial of fractional streaked, hyperemic, and blotchy if pressure is not constant laser therapy and dermabrasion for scar resurfacing. Dermatol across the areas treated. Hyperpigmentation and milia are Surg 2012;38(4):603 13 Holmkvist KA, Rogers GS. Treatment of perioral rhytides: a com- two other common postoperative occurrences. Milia can be parison of dermabrasion and superpulsed carbon dioxide laser. treated with extraction, microdermabrasion, abrasive soaps, Arch Dermatol 2000;136(6):725–731 and retinoids after re-epithelialization. Hyperpigmentation 14 NehalKS,LevineVJ,RossB,AshinoffR.Comparisonofhigh- usually is self-limited, but can be reduced with hydroquinone, energy pulsed carbon dioxide laser resurfacing and dermabra- starting 4 to 6 weeks after dermabrasion if necessary. If the sion in the revision of surgical scars. Dermatol Surg 1998;24(6): – surgeon should encounter subcutaneous fat during the pro- 647 650 15 Alkhawam L, Alam M. Dermabrasion and microdermabrasion. cedure, scarring and infection are likely; therefore, the dermis Facial Plast Surg 2009;25(5):301–310 must be reapposed with sutures, and the area must be closely 16 Hanke CW. The tumescent facial block: tumescent local anesthesia monitored with follow-up. and nerve block anesthesia for full-face laser resurfacing. Dermatol Postoperative infections are usually associated with Staph- Surg 2001;27(12):1003–1005 ylococcus aureus, herpes simplex virus (HSV), and Candida. 17 Nelson BR, Metz RD, Majmudar G, et al. A comparison of wire brush fi Staphylococcal infections usually present by the third post- and diamond fraise super cial dermabrasion for photoaged skin. A clinical, immunohistologic, and biochemical study. J Am Acad operative day with honey-crusted lesions, edema, erythema, Dermatol 1996;34(2 Pt 1):235–243 and occasional fevers. HSV infection is recognized by pain out 18 Alt TH. Facial dermabrasion: advantages of the diamond fraise of the ordinary for the procedure, usually within 72 hours of technique. J Dermatol Surg Oncol 1987;13(6):618–624 the dermabrasion. The patient usually has a known risk of 19 Koranda F. Dermabrasion. In:Thomas JR, Roller J, eds. Cutaneous HSV infections and can be treated with acyclovir or valacy- Facial Surgery. New York: Thieme; 1992 20 Roy D, Sadick NS. Ablative facial resurfacing. Ophthalmol Clin clovir, which is advocated for a minimal of 10 days postoper- North Am 2005;18(2):259–270, vi vi. atively. The best way to avoid HSV infections is to pretreat the 21 Holmkvist KA, Rogers GS. Treatment of perioral rhytides: a com- Downloaded by: University of Virginia Libraries. Copyrighted material. 7 patient, starting 2 days before the procedure. Candida in- parison of dermabrasion and superpulsed carbon dioxide laser. fections usually present 5 to 7 days after the procedure, Arch Dermatol 2000;136(6):725–731 heralded by delayed healing, exudates, edema, and itching. 22 Gillard M, Wang TS, Boyd CM, Dunn RL, Fader DJ, Johnson TM. Candida can be treated with topical or oral antifungals. Conventional diamond fraise vs manual spot dermabrasion with drywall sanding screen for scars from skin cancer surgery. Arch Eczema and dermatitis can be treated with topical or systemic Dermatol 2002;138(8):1035–1039 27 steroids. 23 NelsonBR,MajmudarG,Griffiths CE, et al. Clinical improvement following dermabrasion of photoaged skin correlates with synthesis of collagen I. 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