You are in: eMedicine Specialties > Dermatology > SURGICAL DermabrasionArticle Last Updated: Dec 4, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Christopher B Harmon, MD, Clinical Instructor of Dermatology, Department of Dermatology, University of Alabama at Birmingham Christopher B Harmon is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Laser Medicine and Surgery, and Medical Association of the State of Alabama Editors: Désirée Ratner, MD, Director of Dermatologic Surgery, George Henry Fox Assistant Clinical Professor, Department of Dermatology, Columbia Presbyterian Medical Center, New York Presbyterian Hospital; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: resurfacing surgery, dermabrasive resurfacing, skin resurfacing INTRODUCTIONSection 2 of 10
  Kurtin presented the first series of patients who underwent dermabrasion to Mount Sinai Hospital in 1953. Kurtin described the use of high-speed rotary abraders, intraoperative freezing, and a variety of abrasive end pieces. Publications by Orentreich and Burke further refined Kurtin's technique. Alt has expertly promoted the use of the diamond fraise, while Yarborough has encouraged application of the wire brush. The development of antiviral medications, semipermeable dressings, tumescent anesthesia, and cryoanesthesia have advanced the technique of dermabrasion as well as other resurfacing surgeries, such as chemical peeling, ablative laser resurfacing, nonablative laser resurfacing, and microdermabrasion. A comprehensive understanding of the advantages and the disadvantages of each of these resurfacing procedures is necessary to achieve optimal surgical results in patients who undergo resurfacing surgery. ClinicalCareful examination of the skin lesion or defect and a detailed history is paramount in the evaluation of the patient for dermabrasion.
INDICATIONSSection 3 of 10
The most common indications for dermabrasion include scars of cystic acne, deep rhytides, severe photodamage, and traumatic or surgical scars. Anatomically, lesions or defects of the epidermis, the papillary dermis, or the upper reticular dermis, which can be improved completely or partially by abrading to the level of the upper reticular dermis, are amenable to dermabrasion. Benign tumors, such as syringomas, seborrheic keratoses, angiofibromas, epidermal nevi, trichoepitheliomas, lentigines, cysts, milia, and molluscum, can be removed with dermabrasion. Dermabrasion frequently improves follicular inflammatory dermatoses, such as pseudofolliculitis barbae, cystic acne, and rhinophyma of acne rosacea. Likewise, dermabrasion can improve actinic keratoses, solar elastosis, and discoloration of photoaging. Additionally, the pigmented changes of melasma, tattoos, and postinflammatory hyperpigmentation can be lightened with dermabrasion followed by topical hydroquinone and tretinoin creams. Superficial malignancies, such as squamous cell carcinoma in situ and superficial basal cell carcinoma, can frequently be treated with dermabrasion. Specifically, the defects of deep acne scarring, bulbous rhinophyma, and heavy perioral rhytides are improved more by wire brush dermabrasion than many other resurfacing techniques because the microlacerations of the wire brush can resurface deeply with less risk for scarring. The abrading end piece can be used to soften the sharp shoulders of acne scars, rhytides, and nodules of rhinophyma. In contrast, diffuse rhytides or undulated acne scars and loose redundant skin are often improved better by using ablative laser resurfacing or deep phenol peels in which the more extensive thermal or chemical injury produces greater collagen shrinkage and skin tightening. Therefore, combining close examination of the skin defects to be treated with a comprehensive knowledge of resurfacing options is important to maximize the surgical outcomes in all patients. CONTRAINDICATIONSSection 4 of 10
In addition to careful examination of the skin lesion or defect, a detailed history is paramount in the evaluation of the patient for dermabrasion. For example, do not perform dermabrasion for 6-12 months following isotretinoin therapy. Delayed reepithelialization and hypertrophic scarring have been reported in patients who underwent dermabrasion during or shortly after isotretinoin therapy. This complication is believed to be related to the effect of the isotretinoin molecule on epithelial cells and fibroblasts. Postpone dermabrasive surgery in patients with active herpetic lesions. Bleeding disorders and immunosuppression may cause delayed healing and an increased risk for postoperative infection. Yarborough demonstrated that surgical and traumatic scars respond best to dermabrasion performed 6-8 weeks during the interval following incision or injury. In contrast, it is advisable not to perform dermabrasion on overlying skin for at least 6 months following certain surgical procedures that involve extensive undermining, such as face lifts or brow lifts, to allow reestablishment of the underlying vascular bed. WORKUPSection 5 of 10
Lab Studies
TREATMENTSection 6 of 10
Medical therapyAll patients should receive antiviral prophylaxis. Patients with a history of herpes simplex virus (HSV) infections may require a greater prophylactic dosage (ie, valacyclovir 500-1000 mg qd for 10-14 d or famciclovir 500-1000 mg qd for 10-14 d). 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. Patients with a history of very recent or frequent herpetic infections and those patients with postoperative breakthrough HSV infections require a higher dose of antiviral medication, such as valacyclovir 500 mg 5 times per day for 14 days or famciclovir 500 mg 3 times per day for 14 days. (Cosmetic surgeons use a variety of dosing strategies, usually using a dosing range because they do not all agree on any one particular dose). 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 1000-2000 mg qd for 10-14 d or ciprofloxacin 500-1000 mg qd for 10-14 d). If prophylactic antibiotics are administered, fluconazole 200 mg every day for 10 days prevents secondary yeast infections. Tretinoin cream applied for 2-3 weeks prior to dermabrasion has been shown to decrease the time for reepithelialization. Similarly, some surgeons report that the use of topical hydroquinone for several weeks prior to surgery decreases the incidence of postoperative hyperpigmentation. Sleep deprivation can be prevented with sedating medications (Dalmane 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 (Valium) sublingually; 50-75 mg of meperidine intramuscularly; 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). Surgical therapyA close examination of acne scars with careful attention to ice pick scarring and sharp-shouldered defects may identify the need for surgical excision, punch floats, subcision, or geometric closures prior to abrading. These surgical procedures set the timetable to schedule the dermabrasion in the following 6-8 weeks. Equipment The electric hand engines used in dermabrasive surgery produce 15,000-30,000 rpm. Bell, Osada, Ellis, and Schuman manufacturers produce the most popular models. These high-speed rotary motors are used to drive an abrading end piece, such as a serrated wheel, a diamond fraise, or a wire brush. Fraises come in a variety of shapes, sizes, and grades of coarseness. Typically, smaller shapes, such as cone or pear shapes, are used in confined areas around the nose, the eyelids, and the mouth. Fraises and wire brush wheels are used on the broad flat surfaces of the forehead, the cheeks, and the nonfacial areas. Diamond fraises are more forgiving and easier to learn to use than the wire brush, which tends to grab and gouge loose skin or free edges. The outer surface of an orange or a grapefruit often provides a convex surface for surgeons to gain the feel of applying an abrading instrument to the skin. Fraises can be used without spray refrigerant, whereas the wire brush requires a firm frozen surface to safely abrade large areas. The wire brush produces microlacerations in the skin with little thermal injury because of the light hand pressure needed for deep resurfacing. When the diamond fraise is used for deep resurfacing, choose a coarse or extra course grade, and perform several passes with heavy downward pressure. Consequently, the potential for thermal injury is greater with fraises than with the wire brush for deep resurfacing. Anesthesia The most readily available spray refrigerant on the market is Frigiderm, which uses Freon-114. In the early 1980s, refrigerants containing Freon-12 were found to be too cold (-30°C to -60°C) and produced scarring in the skin. A 10-second spray time with the refrigerant produces cryoanesthesia and a firm surface on which to abrade. Prechilling with an ice pack decreases the sting of spraying the refrigerant. Freezing an area no larger than can be abraded at one time is helpful. Freeze defects and rhytides in their relaxed state without stretching or distorting so that they may be sculpted and recontoured. Once the area to be abraded is frozen, 3-point retraction is performed by using the surgical assistant's 2 hands and the surgeon's nondominant hand. Cotton towels can be used for blotting and retraction. Do not use gauze in the surgical field because it can easily become entangled in the dermabrader. Alternatively, tumescent anesthesia may be used to produce a firm anesthetic surface for abrading. This methodology is often preferred by those experienced in tumescent liposuction. The spray refrigerant and potential for freeze-induced scarring is eliminated. A full-face dermabrasion can be performed with a 0.1% lidocaine solution (250-500 mL) placed in a superficial plane that produces blanching and distension of the skin. Intraoperative detailsThe correct hand position for holding the abrading instrument places the forefingers around the body of the hand engine, while the thumb stabilizes the neck. 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. 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. For regional or spot dermabrasion, gentian violet can be used to outline the borders of the treated cosmetic unit. Abrading an entire cosmetic unit reduces the risk for noticeable pigmentary variations between abraded and nonabraded skin. Lightly feather the borders of the cosmetic unit to blend with nonabraded areas. A surgical landmark for abrading into the superficial papillary dermis is the presence of cornrow bleeding produced by an eruption of the small vascular loops in the dermal papilla. As the depth of abrasion moves into the reticular dermis, these vascular channels and the subsequent red dots become larger. White parallel lines are frayed, and collagen can be observed after abrading normal reticular dermis, whereas the fibrosis of acne scars or severe solar elastosis crumbles and disrupts. The yellow globules of sebaceous glands or larger frayed collagen bundles herald entry into the lower dermis and a likelihood of scarring. Postoperative detailsOnce the dermabrasion is completed, a compress with gauze soaked with 1% lidocaine and epinephrine (a 1:100,000 concentration of epinephrine) for 5-10 minutes decreases stinging and provides hemostasis. An open or closed wound care regimen can then be initiated. Most open wound care routines use sodium chloride solution or 25% vinegar compresses applied 4-5 times daily followed by an occlusive ointment, such as petrolatum or white petroleum jelly ointment. Avoid mentholated, scented, or antibiotic topical preparations because they may irritate or sensitize the patient. In the mid 1980s, the development of closed wound care techniques by using semipermeable dressings significantly decreased the time for reepithelialization from 10-14 days to 5-7 days, as with most open techniques. Usually, the dressings are applied directly to the skin and covered with Telfa dressings, absorbent gauze, paper tape, and Surgilast net dressing. The nursing staff should change this full face mask daily for 3-5 days following surgery. After this time, an open wound care technique can be used. With open and closed wound care techniques, make every attempt to remove any coagulum or yellow fibrin buildup (especially around the mouth and the nose) and prevent scabbing. The development of crusts or scabs not only provides a nidus for infection but also requires that new epithelial cells migrate beneath the scab in search of a plane of critical humidity required for reepithelialization. This downward migration can reestablish the initial defect or depression. A postoperative intramuscular injection of 6 mg of betamethasone and 40 mg of triamcinolone acetonide or oral methyl prednisolone helps reduce swelling around the eyes and the cheeks. As previously mentioned, continue antiviral prophylaxis for several days beyond a complete reepithelialization (usually 10-14 d of treatment). Sedatives, such as diazepam (Valium) and flurazepam (Dalmane), help prevent insomnia and feelings of claustrophobia while wearing a full face mask. Antibiotics and antifungal medication are necessary only if bacterial or fungal infections arise. Once reepithelialization is complete, which usually occurs in 7-10 days, the new skin is bright pink or red. This erythema progressively fades within 2-3 months and can be covered with concealing makeup. Green and yellow base foundations are the most effective at camouflaging postoperative erythema. Bleaching creams formulated with retinoic acid, hydrocortisone, and hydroquinone can be used 3 weeks after surgery with minimal irritation. Such regimens help prevent the transient hyperpigmentation that frequently occurs 4-6 weeks following surgery. Likewise, strict sun avoidance during the 2-3 months of postoperative erythema protects against this hyperpigmentation. Intradermal postoperative edema continues to improve for 3 months. As the swelling resolves, deep rhytides and acne scars may initially appear to have persisted; however, collagen remodeling of the defect continues for another 3-6 months. During the remodeling phase of wound healing, fibroblast activity produces new collagen that fills in scars and heavy rhytides. Consequently, the greatest improvement in scars and rhytides is usually observed 6 months after surgery. Explain this timetable of events in detail to patients during the preoperative consultation so that they do not become discouraged. Follow-upCOMPLICATIONSSection 7 of 10
Anticipate certain events following dermabrasion or other resurfacing surgery, and predict these events as normal postoperative sequelae rather than considering them to be complications. Such events include spot bleeding for several days after surgery, the resulting postoperative erythema, milia formation, and a flare-up of acne. A flare-up of acne is frequently the result of the occlusive ointment used during wound healing, and it can be treated as any other acne outbreak. These exacerbations are usually short lived and do not produce any acne scars. Likewise, the transient postoperative hyperpigmentation that occurs in skin types II, III, IV, and V at 4-6 weeks following surgery is reliably corrected with a hydroquinone-bleaching regimen and sun avoidance. The more permanent problem of hypopigmentation usually does not appear for 12-18 months after surgery. This pigmentary alteration occurs in 20-30% of patients; however, recent work with the 308 nm excimer laser may provide a method of stimulating melanocytes to replace lost pigment. Postoperative viral infections can occur despite prophylaxis. Always suspect viral infections when pain, erythema, or ulcerations begin 7-10 days following surgery. The development of painful lesions following any resurfacing procedure is most frequently caused by a breakthrough HSV infection. Treatment of infection with zoster doses (valacyclovir 1 g tid or famciclovir 500 mg tid for 7 d) improves pain and usually prevents scarring. Contact dermatitis is observed as worsening erythema, pruritus, or oozing and is usually caused by antibiotic ointments, especially neomycin, or scented lotions. Discontinuation of the offending agent and treatment with midpotency steroids is usually sufficient. Persisting erythema heralds the onset of scarring. Early scar recognition and aggressive treatment are essential in preventing hypertrophy and other sequelae. Mid- to high-potency topical steroid creams are useful during the initial hyperemic phase of scar development. The presence of induration requires the use of intralesional steroids (Kenalog 5-40 mg/mL) or injectable 5-fluorouracil administered every 2-3 weeks. Cordran tape is also a useful adjunct in scar treatment. If telangiectasias develop as a result of aggressive intervention, these vessels may be treated with vascular lasers, such as potassium titanylphosphate (KTP), diode, or pulsed dye lasers. Furthermore, the pulsed dye yellow light lasers are effective in reducing erythema and induration of some scars. With early detection and appropriate intervention, local scars can usually be arrested. OUTCOME AND PROGNOSISSection 8 of 10
As a method of resurfacing, dermabrasion continues to provide effective treatment for a wide variety of skin conditions and defects. The use of a wire brush is uniquely suited for treating deep acne scars and heavy rhytides because of the deeply penetrating microlacerations and the lack of thermal injury. Detailed patient counseling, realistic outcome expectations, and comprehensive postoperative care maximize the results of dermabrasive resurfacing surgery. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Article Last Updated: Dec 4, 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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