The History and Evolution of Skin Resurfacing

Beauty, as a philosophical concept, is an intangible element of human existence. You cannot measure it with a scientific instrument. Nevertheless, we know that it exists because we know it when we see it. Beauty is a component of our lives that affects each of us in varying degrees. Some care about it greatly―some not at all. For many of us, there is an undeniable urge to surround ourselves with beauty. Some choose to live in an environment where we see the beauty of the earth from every angle. We decorate our homes with colors and materials that stimulate an internal reaction that causes our own personal elation. We adorn our bodies with colors and fabrics that please us, make us feel confident, and hopefully please other human observers as well. We know that the perception of beauty pleases the one who perceives it. And human nature leads human beings to secure their own success. That is the impetus behind why human beings choose to amplify their own facial and body beauty.

Of all the elements of the body, the appearance of the face is the most critical to our success. The face is how a person sees the world and it is the first part of the body that is seen by the world. Therefore, it is the first part of us that is judged by the world. Communication begins without words. It begins with projection of intention by facial expression and body language. The interpretation of that projection is performed through the observer’s eye. That is why when a human being communicates with another human being, they look into the eyes to do so. For that reason, the eye is the most important feature of the face. When an observer glances at another person, the observer instinctively and instantly assesses the age, health, and beauty of the person being observed by amassing a collection of subliminal judgments based upon shape of the face, shadows within the face, colors across the face, and quality of the skin. A heart-shaped face equals youth; a square face equals aging. Round cheeks equal youth; flat cheeks equal aging. Shadows under the eyes and in front of the jowls equal aging; no shadows in those areas equal youth. A light, rosy glow on round cheeks equals health; bright red across the cheeks and around the nose equals infirmity. Skin that is smooth in color, firm, and reflects light equals youth and health. Skin that is mottled with brown and red, loose, and unable to adequately reflect light equals aging disease.

There are many methods that human beings use to amplify their facial beauty. Long before there were means to supplement volume or to surgically remove or reconfigure tissue, people actively worked to augment their facial attractiveness. They did so by making their skin as beautiful as possible and by using cosmetics to create illusion. One of the goals when attempting to improve the appearance of skin was to make it “glow.” Another objective was to make it look like “porcelain” (the goal of the geisha of ancient Japan). Thus, in our analysis of how we have come to accomplish these objectives over the centuries, it is appropriate to understand what changes happen histologically that result in an increase in glow and the achievement of a porcelain look.

Glowing, radiant, luminous skin. Each of these descriptions speaks in terms of light. The observer of such skin is appreciating some improvement in the way that light leaves the skin of the person being observed. Obviously, the person being observed does not have an internal light source that is emanating rays of visible light. Rather, the person with luminous skin is simply doing a better job of reflecting ambient light. When light is not trapped, absorbed, or scattered, it will more directly bounce off a surface. Imagine, if you will, that you are walking along a beach on a sunny day. The light reflected off the water surface can be blinding because it is bouncing off a surface that is not porous and does not diffuse light; however, the light coming off the sand is diffuse because so much of it is absorbed and scattered by the grains of sand. If you look at the skin of a 6-year-old child and compare it to the skin of a 70-year-old adult, you will immediately appreciate the difference in the ability of the younger skin to reflect light.

Porcelain skin. What does this mean? This descriptive term refers to skin that is homogenous in color (no brown or red spots) and smooth in landscape (not interrupted by large pores or depressed scars). The most effective way to accomplish this is by the illusion of makeup. However, makeup will do an even better job if the skin it is covering is closer to ideal. A child has not yet accumulated the effects of photodamage such as dyschromias or telangiectasias, or the large pores from teenage hypertrophic sebaceous glands, or the effects of scarring from acne. This is why, in the observer’s quickly assessing, subconscious judgment, smooth skin of all the same color not interrupted by brown or red is a sign of youth and health―which goes hand in hand with beauty.

Human beings have learned that if you resurface the skin, that is, remove the outer layers of keratinized epithelium to produce a new-and-improved superficial surface, you can actually improve the reflectivity, color consistency, and micro-landscape of the skin, thus improving the beauty of the skin. In this chapter, the history of how mankind has developed this art is reviewed.

1.2 Dermabrasion

Woodworking, stone sculpture. In an effort to adorn his world, ancient man worked with the materials in his environment and turned them into moments of beauty. He cut and polished wood, stone, and gems to turn them into pieces of art. He learned that rubbing them over and over again with an abrasive substance would file the surface down until it gleamed. This smooth surface was considered pleasing. A “polished” article was viewed as finished or complete. It wouldn’t have taken long to learn that scrubbing the skin also made it shinier and smoother. There are references to a number of cosmetic rituals that have been passed down from antiquity and incorporate mechanical abrasion (exfoliation) to remove the outer surface of the skin to help it appear more beautiful.

It is said that for hundreds of years, Indonesian women would exfoliate their skin with coffee grinds. (The caffeic acid in coffee beans is a powerful antioxidant and may boost collagen.¹ Caffeine is often used in skin-tightening products today. Furthermore, caffeic acid is one of the main ingredients in argan oil, a popular antiaging oil used in many cosmetics today.) In India, cleansing the skin with milk mixed with wheat husk or gram flour was recommended (lactic acid and protein-infused mechanical exfoliation). An ancient Asian skin treatment was exfoliation by rubbing the skin with a mixture of cream, starch, and husk followed by an application of rosewater to tone (rose water is said to be a mild astringent, causing tightening of the skin that reduces pore size).

Egyptians also employed the techniques of dermabrasion by use of a mixture of pumice, alabaster, salts, and animal oils on the skin. They would also rub the skin with a mixture of animal oil, lime, and chalk (an abrasive).² In 1500 BC, Egyptian physicians attempted to improve scars with sandpaper. In India, women would use a mixture of urine and pumice to exfoliate their faces.³ (Urine is mostly water followed by urea, which is neither acidic nor basic. Urea is included in many topical cosmetics for it is hydrophilic at low concentrations and is keratolytic at high concentrations [even used in products designed for wound débridement and for treatment of hyperkeratotic conditions].⁴) In ancient Japan, geishas would polish their skin with salt and cream scrubs. Masks of rice bran and cream would be scrubbed on the skin and allowed to remain for a period as a treatment (reported to have been used since 1100 AD. Rice bran is high in gamma oryzanol, which is a powerful antioxidant and collagen stimulator.⁵).

As the centuries went on and the Industrial Revolution blossomed, mechanical means of polishing were developed. At the turn of the 20th century, Kromayer made application of such a tool for use on the skin. He first described the means of resurfacing the skin by applying rotating burs to skin lesions.⁶ Abner Kurtin, in the 1940s, modified this approach to develop the wire brush technique, adapting this to a powered dental tool.⁷ In the 1950s, Burke modified the wire brush technique, leading to the techniques that are more likely to be used today.⁸ Also in the 1950s, the term dermabrasion began to be used as the class of treatment used to plane irregularities of the skin.⁹

Over the next 20 years, dermabrasion was applied to many cutaneous conditions beyond just scars and acne pits, conditions that produce irregularities of the skin such as acne rosacea, rhinophyma, seborrheic keratoses, sebaceous hyperplasia, fibrous tumors of tuberous sclerosis, and discoid lupus erythematosus, just to name a few.^{10,11,12,13,14} It was also widely applied in the removal of tattoos.¹⁵ During this period, histological studies showed the significant dermal remodeling that takes place, an effect that is comparable to that seen in laser and deep peels.^16,17,18

The primary application of dermabrasion has been to mechanically remove the epithelium and damage the papillary dermis to mid-dermis to induce restructuring and laying down of new type I and type III collagen in areas of hypertrophic scarring and depressions such as the sharp wrinkles around the mouth or acne scars―without creating new scars.^18,19 In general, any area of skin that has a sudden elevation or depression will cause light to be reflected (if the skin is elevated) or will cause shadow to be caught (if the skin is depressed), and the observer’s eye will notice this unexpected attention-getter and will be drawn to it. The notice of this moment of deviation from “average skin” is perceived as a “flaw.” One of the great powers of dermabrasion is to “level the playing field,” to reduce the difference between high and low in terms of skin topography so that there is less material to induce inappropriate light reflection or shadow catching. However, dermabrasion has also been useful in resurfacing photodamaged skin as well, by removing the damaged epithelium and inducing dermal remodeling.^18,19

Dermabrasion is an undeniably useful tool with predictable outcome. However, its application has become less frequently utilized in the last two decades because lasers have provided another means of inducing collagen re-conformation while at the same time accomplishing surface rejuvenation. Furthermore, the issue of blood splatter is another aspect of this technique that requires consideration. Dermabrasion produces a certain amount of splatter of blood and tissue particles. In the 1980s and 1990s, with blossoming awareness of the dangers of viruses such as the human immunodeficiency virus (HIV), the hepatitis B virus (HBV), and the hepatitis C virus (HCV), there naturally developed a heightened awareness of the need to protect the surgical staff from aerosolized, potentially infectious particles. There was a report of a possible transmission of HBV by contact with conjunctivae during dermabrasion.²⁰ Therefore, universal precautions are advisable during dermabrasion performance, and protection is easily accomplished for the surgical staff and patient with proper outfitting and proper room sterilization techniques. However, with the development of techniques that could produce similar results without the splatter of blood, attention turned toward the use of these other applications.

The ability of dermabrasion to effectively and soundly treat a wide number of conditions is as attractive as the low cost of the instrument (compared to the laser). Nevertheless, the laser has become the gold standard of resurfacing now, leaving fewer opportunities for facial plastic surgeons to master the art of dermabrasion.

1.2.1 Microdermabrasion

A subtler application of mechanical exfoliation to effect skin resurfacing is microdermabrasion, a technique first introduced by Tsai et al in 1995.²¹ The initial technology incorporated applying a vacuum-suctioning device to the skin and then showering the suctioned skin with streams of aluminum oxide crystals to produce an exfoliation of the external stratum corneum. Studies have shown that there is a degree of dermal remodeling that takes place after this treatment (induction of procollagen I and III among other effects).²² Modifications to the initial design include substituting sodium chloride crystals for aluminum oxide crystals, or substituting crystals entirely with a diamond fraise applied to the skin after it is sucked into the apparatus. It has been shown that there is improved absorption of topical medications (such as d-aminolevulinic acid for photodynamic therapy or topical anesthetic prior to laser resurfacing) after microdermabrasion.²³ For this reason, microdermabrasion as a resurfacing tool is often incorporated before other techniques to improve their performance.

1.3 Topical Agents and Chemical Peeling

In ancient Egypt, women would use sour milk (lactic acid) mixed with alabaster, animal oils, and salt to help remove the external surface of the skin and promote beauty.²⁴ There has also been found a vintage Egyptian recipe to combat wrinkles: senetjer resin (likely frankincense, one of the most antique antiaging ingredients), wax, fresh balanos oil (a nut that grew on a native tree whose oil was considered fine and suitable for perfumery), and cyperus grass are to be ground and mixed with fermented plant juice (source of alpha hydroxy acid most likely) and applied to the face daily.² The Greeks and Romans were said to apply a poultice of sulfur, mustard, and a corrosive sublimate of limestone to the skin. They would use tree resins including frankincense and myrrh mixed with pumice to lighten the skin and remove wrinkles and freckles.³ In the Middle Ages, women would treat their skin with old wine (with active ingredient tartaric acid, which is an alpha hydroxy acid) to accomplish rejuvenation. Lemon juice has been used as a brightening agent for as long as anyone can recall across multiple cultures. Also in the Middle Ages, women would use curdled milk (lactic acid) to treat acne, cucumber juice to remove freckles, and boiled nettles to produce a smooth, even complexion. In Japan, a mask of droppings from the nightingale bird has been used for hundreds of years. Initially, the droppings were used to bleach silk and then were later applied to the skin. A paste of the droppings is applied to the skin and then rinsed. The excrement was dried in the sun and then pulverized into a powder. (In modern times, the material is irradiated with ultraviolet radiation to kill bacteria.) Water was added to turn it into paste which was then applied to the skin. (These same ingredients are part of a geisha facial that is offered currently in some parts of the world. The primary ingredient, the droppings, is called uguisu no fun.)

Because man has known that certain chemicals on the skin can induce a change for the better, eventually prolonged application of these chemicals in a controlled fashion to produce a more profound effect was used. However, such historical references from antiquity are not available.

There are records of a Viennese dermatologist, Ferdinand Hebra, using various combinations of exfoliating chemicals to remove freckles and melasma in the mid-1800s. There were experiments by dermatologists with various compounds to lighten freckles and dyschromias with tinctures of iodine and lead, croton oil, and cantharides, as well as sulfuric, acetic, hydrochloric, and nitric acids. Lime-based compresses were applied to the skin for 4 hours, after which the ensuing blisters would be broken and treated with starch. Removal of the resultant crust was found to lighten the skin. In 1871, William Tilbury Fox mentioned using phenol to lighten the skin, and in 1881 croton oil as a compound that causes skin inflammation was recorded by Henry Piffard. In 1882, a dermatologist from Germany, P. G. Unna, described the use of trichloroacetic acid (TCA) as a peeling agent.

1.3.1 Phenol

Many peeling agents were experimented with in the late 1800s and early 1900s, but the one that garnered the most attention was phenol. The first American article on phenol was in 1917 by the dermatologist Douglass Montgomery. He described the use of phenol under bandages, using the agent as a “beautifier.”³ This was at the same period of time as the activities of the American lay “skinners” listed in Hetter’s history described in a subsequent paragraph. Concomitantly, in Europe, it is said that Sir Harold Gillies was the first to use phenol for chemical surgery by applying it to lax lower eyelids.²⁵

MacKee reported in 1952 his use of phenol to treat acne scars, beginning as early as 1903. He had a clinic at New York University through the 1940s, where he used phenol to treat acne scars and noticed the improvement in his patients’ skin long term. His report was the first to attempt to correlate the histology of peeling with clinical results. He would apply phenol to the skin for a 30- to 60-second interval and then wash it off with ethanol. This would be repeated four to six times at 2-month intervals.^3,26

However, a much more entertaining, fascinating, and rich history of the development of the phenol peel in America as a tool to achieve beauty can be acquired in Hetter’s “An Examination of the Phenol-Croton Oil Peel: Part II. The Lay Peelers and Their Croton Oil Formulas.”²⁷ This article provides a history gleaned from personal interviews and research of personal memoirs to uncover the development of a practice that was actually widely used in the first half of the 1900s by the starlets of Hollywood and the wives of wealthy Americans. The women who had the means to undergo this quietly held beauty treatment maintained skin that was more beautiful than their average contemporaries. The original practitioners were not physicians. They were lay peelers called “skinners.” There were a select few of them in America who made quite a good living. They jealously guarded the recipes of their peels, which, of course, were eventually discovered. These were the sources of the phenol peels known today. It is said that, initially, use of phenol as a cosmetic peel originated in Europe and was learned by these lay peelers. These American skinners were also the same people who recognized that croton oil is the additive that produces a deeper effect than just phenol alone. Eventually, as plastic surgery became a specialty after World War II, and plastic surgeons realized that this was a tool their patients desired, they published articles against the lay peelers―many of whom had stumbled upon the complications of full thickness burns and hypertrophic scars in the necks of their clients. Plastic surgeons filed charges of inappropriate practice of medicine against some lay peelers, acquired their formulas, and began to take over that market.²⁷

In 1941, Eller and Wolff described the use of a paste of resorcinol and phenol along with solid carbon dioxide (CO₂

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