Dermabrasion

20. Dermabrasion

George Broughton II, James L. Baker, Jr.

PREOPERATIVE EVALUATION^1–4

■ Consultation with the patient to establish realistic goals and expectations (see Chapter 4)

■ Comprehensive medical and surgical history and physical examination. Some medical conditions are contraindications to dermabrasion (see Box 20-2).

Box 20-1 CONDITIONS TREATABLE WITH DERMABRASION

Acne rosacea	Lichenified dermatoses
Actinically damaged skin	Linear epidermeral nevus
Active acne	Discoid lupus erythematosus
Adenoma sebaceum	Mibelli porokeratosis
Angiofibromas of tuberous sclerosis	Multiple pigmented nevi
Basal cell carcinoma (superficial type)	Multiple seborrheic keratoses
Blast tattoos (gunpowder)	Multiple trichoepitheliomas
Chloasma	Neurotic excoriations
Chronic radiation dermatitis (mild)	Postacne scars
Congenital pigmented nevi	Pseudofolliculitis barbae
Darier’s disease	Rhinophyma
Dermatisis papillaris capillitii	Scleromyxedema
Early operative scars	Smallpox or chickenpox scars
Facial rhytids	Striae distensae
Favre-Racouchot syndrome	Syringomas
Fox-Fordyce disease	Syringocystadenoma papilliferum
Freckles	Tattoos (decorative and traumatic)
Hair transplantation (elevated recipient sites)	Telangiectasias
Hemangiomas	Traumatic scars
Hypertrophic scars	Verrucous nevus
Keratoacanthomas	Vitiligo
Lentigines	Xanthelasma
Lichen amyloidosis	Xeroderma pigmentosum

Box 20-2 CONTRAINDICATIONS TO DERMABRASION

Absolute	Relative
Isotretinoin therapy within the last 6-12 months*	History of hypertrophic scars
Congenital ectodermal defects	History of keloids
Radiodermatitis (only if severe)	Burns—deep thermal or chemical
Pyoderma	Fitzpatrick skin types IV, V, VI (test patch should be tried first)
Psychosis	History of hepatitis or HIV†
Active herpes labialis

*Seven patients with atrophic acne scars on the face taking oral isotretinoin to treat facial acne had manual dermabrasion on an area approximately 1 cm.² At the 6-month follow-up, all patients had normal cicatrization, and the atrophic acne scar revision was deemed excellent.⁵ In another study, 10 patients treated with oral isotretinoin for acne had a medium-depth chemical peel applied to the entire face and manual sandpaper dermabrasion (until the appearance of a blood dew) 1-3 months after the isotretinoin therapy was concluded. At the 6-month follow-up, all patients had normal cicatrization, and no hypertrophic scars or keloids were observed. Depressed acne scar revision was satisfactory.⁶

†Personal decision of the surgeon.

• Bleeding complications/risks from prescription and herbal medicine

► Is the patient taking isotretinoin, birth control pills, or immunosuppressants?

• Is the patient pregnant?

• History of cold sores requires herpes simplex prophylaxis

• History of hypertrophic or keloid scars?

• History or risk of hepatitis or HIV?

TIP: Dermabrasion results in aerosolization of tissue and blood. Physicians and their assistants (including the anesthesiologist) must take appropriate measures to protect themselves. This involves wearing a gown, face shield, face mask, and gloves.

• History of connective tissue disorders, cold intolerance, or Raynaud phenomenon? (These patients may not be candidates if a refrigerant is used.)

• Current and past skin regimens and their results?

• Prior history of skin rejuvenation? When and what kind? Results/problems from those treatments?

• Tanning history: Does the patient have hyperpigmentation or hypopigmentation?

• Documentation of patient’s skin type (Fitzpatrick skin type classification) (Table 20-1) and photoaging grouping (Table 20-2), degree of actinic damage, sebaceous gland density, dyschromias, suspicious lesions, and scarring.

Table 20-1 Fitzpatrick Skin Type Classification

Skin Type	Characteristics	Sun Exposure History
I	Pale white, freckles, blue eyes, blond or red hair	Always burns, never tans
II	Fair white, blue/green/hazel eyes, blond or red hair	Usually burns, minimally tans
III	Cream white, any hair or eye color	Sometimes burns, tans uniformly
IV	Moderate brown (Mediterranean)	Rarely burns, always tans well
V	Dark brown (Middle Eastern)	Rarely burns, tans easily
VI	Dark brown to black	Never burns, tans easily

Table 20-2 Glogau Photoaging Scale

	Description	Features
I (mild)	Wrinkles not present or minimal	Early photoaging No keratoses, pigmentary changes Patient generally wears minimal or no makeup Typical age range: 20s-30s
II (moderate)	Wrinkles present only when skin is in motion	Early to moderate photoaging Early actinic keratoses Sallow color Smile lines begin Patient generally wears some makeup Typical age range: Late 30s-40s
III (advanced)	Wrinkles present when skin is at rest	Advanced photoaging Dyschromias, telangiectasias Actinic keratoses Persistent wrinkling Patient always wears makeup Typical age range: 50s or older
IV (severe)	Only wrinkles	Severe photoaging Yellow-gray skin Dynamic/gravitational wrinkling throughout Actinic keratoses ± skin malignancies No normal skin Patient wears makeup, but coverage is poor (it cakes or cracks) Typical age range: 60s or older

• Skin excess and gravitational changes that will not be corrected by dermabrasion are pointed out.

SENIOR AUTHOR TIP: Skin types I through III will have a uniform blended skin color postoperatively. Types IV proceed with caution and best to not dermabrade types V and VI due to hyperpigmentation postoperatively.

■ Standard preoperative photographs for surgical planning

• Patients evaluated for facial rejuvenation or scar improvement are asked to provide photographs of themselves (in repose) when they were younger.

• Preoperative and postoperative photographs are helpful for those who had prior surgery on their face.

■ Preoperative arrangement and discussion of financial responsibilities for revisions

■ Analysis and operative planning based on patient desires, clinical examination, and photographs

■ Patients are given an antibacterial cleanser to wash and shampoo with the night before and the morning of surgery and prescriptions for cephalexin 500 mg twice per day for 5-7 days, acyclovir 1 g once per day (twice per day for patients with history of oral herpes, start the day before the procedure) for 5-7 days, diazepam (or similar relaxant), and narcotic pain medication.

■ Test spot close to the area to be treated should be considered. This allows the patient to experience the procedure in a limited fashion and provides some information about expected results. Usually a 1 cm area is abraded with the patient under local anesthesia.

TIP: The test spot should be placed close to the area to be treated but in an obscured area that can be easily camouflaged or hidden if further treatment is not performed. For example, for patients who will have facial or neck dermabrasion, the spot can be made behind the ear. Stressing that the test spot is not predictive of the overall outcome is critical.

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