Dermabrasion in our practice

Journal of Drugs in Dermatology, Feb, 2008 by Ross M. Campbell, Christopher B. Harmon

Abstract

Dermabrasion is a technique of facial resurfacing that allows the physician to sculpt the skin surface by surgically abrading, or planing the contours of the skin. User technique, device settings, and the combination of dermabrasion with other skin resurfacing treatments enable the physician to treat a wide variety of skin defects.

Introduction

Dermabrasion in its simplest form, using a pumice and alabaster, has been used to treat the skin surface since circa 1500 BC. (1,2) Modern dermabrasion devices consist of an electric engine, which rotates an abrasive tip (wire brush or diamond fraise). The tips vary in size, shape, and texture and can achieve speeds of 33000 revolutions per minute. (2) The technique used, tips selected, the speed and rotation movement, and the pressure applied to the skin surface enable the surgeon to control the depth of injury.

As a means of scar revision, dermabrasion interrupts the remodeling phase of wound healing. Histologically, dermabrasion creates an abrasive injury in the papillary or mid reticular dermis that superimposes a second intention wound healing mechanism on the primary scar. Histological examination of scars treated with dermabrasion demonstrate increased collagen bundle size as well as unidirectional orientation of the collagen fibers parallel to the epidermal surface. Altered levels of alpha6 and beta4 integrin expression have been identified in the stratum spinosum, and changes in tenascin expression have also been identified. (3)

Patient Selection

Dermabrasion is ideally suited to treat skin defects that involve the epidermis, papillary dermis, and upper reticular dermis since it enables the surgeon to recontour both the defect and the surrounding skin. Acne scars, partial thickness Mohs defects, rhinophyma, traumatic and surgical scars, and tattoos are often treated by dermabrasion either alone or in combination with other modalities. Other lesions that may be treated with dermabrasion include actinic and seborrheic keratoses, angiofibromas, solar elastosis, and rhytides. (4)

The key to obtaining excellent results and satisfied patients is to clearly identify patient expectations and manage them appropriately. Especially when performing dermabrasion for cosmetic purposes, it is important to have the patient explain clearly what they want treated and expect as the end result. It is often helpful to have preoperative and postoperative photographs from other patients that may assist in defining expectations.

It is important to identify patients preoperatively who may have preexisting conditions that may increase the probability of postoperative complications. Careful history should be obtained to identify any previous history of koebnerizing conditions such as lichen planus or psoriasis. A family or personal propensity towards hypopigmentation or hyperpigmentation, keloids, or hypertrophic scars should be examined thoroughly. Patients who have undergone extensive undermining of the area to be abraded are not ideal candidates since the underlying vasculature and blood supply have been compromised. For example, for patients who have recently undergone facelifts, a 6-month delay before dermabrasion is appropriate. (5) Similarly, many patients seeking treatment with dermabrasion for acne scars have been treated with isotretinoin, and it is important to carefully identify the date of their last isotretinoin treatment. Treatments within 6 months of taking isotretinoin have been associated with an increased risk of scarring. (6)

Several pretreatment considerations may lead the physician to obtain pretreatment labs or preoperative skin preparation. Since dermabrasion aerosolizes skin particles, preoperative HIV and hepatitis evaluations are appropriate. Patients with a history of atopy or impetigo may be prescribed antibiotic prophylaxis. All patients undergoing perioral or full-face dermabrasion should be prescribed antiviral prophylaxis.

Pretreating the skin with topical medications may also be useful in certain dermabrasion patients. A 2- to 3-week pretreatment course of daily tretinoin has been shown to increase re-epithelialization, and therefore, speed recovery times. In Fitzpatrick's types 2 and 3 skin, a 2- to 4-week course of 4% hydroquinone is useful to minimize postoperative hyperpigmentation as well.

Technique

The use of correct dermabrasion techniques cannot be overemphasized. Held incorrectly, or without attention given to the direction of rotation, one may inadvertently cause deep injury to the skin, particularly in regions over bony prominences such as the malar eminence, or free margins such as the upper lip.

Dermabrasion technique begins with the physician's contact with the hand engine of the dermabrader. The engine is held with the forefingers of the hand placing the butt of the engine into the palm with the neck stabilized by the extended thumb (Figures 1a and 1b). A tight skin surface is necessary to prevent gouging of the skin and thus a 3-point retraction should be obtained using both hands of the assistant and the free hand of the surgeon to stretch the treatment surface. Refrigerant spray (Frigiderm, containing Freon 114) can be applied to the treatment area to provide a more solid substrate for controlled dermabrasion. When used, it should be applied to obtain a 5- to 10-second freeze time. The refrigerant spray also provides some amount of anesthesia and is particularly helpful when dermabrading acne scars.