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Egypt, J. Plast. Reconstr. Surg., Vol. 29, No. 2, July: 119-125, 2005

Dermabrasion Again and Again

ASSEM H. KAMEL, M.D.* and HATEM ZEDAN, M.D.**
The Departments of Plastic & Reconstructive Surgery* and Dermatology & Andrology**, Faculty of Medicine, Assiut University.

ABSTRACT skin appendages, primarily the pilosebaceous units

[3]. Dermabrasion forces the growths of new tissue
Dermabrasion is a surgical procedure that, as its name
implies, wears away or abrades successive layers of skin,
in which fibers are more plentiful and better orga-
permitting a controlled removal of the epidermis and upper nized. Although it may take as long as 12 weeks
dermis to a depth sufficient to treat disease, tumor, or deformity. for skin to recover from dermabrasion, the end
The outcome of any resurfacing procedure depends upon: result is skin that is smoother and more youthful
1- Type of the skin, according to Fitzpatrick classification, looking [4].
2- The depth of excision. 3- Homogenecity of the procedure.
4- The anatomical site. 5- Exposure to the sun (Ultraviolet Indications of Dermabrasion: Acne scarring is
rays).
the most common indication for dermabrasion
Patients and Methods: We did our assessment within the [5,6,7]. It is often done after surgery to make a scar
period from Jan. 1999 to Feb. 2003 in Plastic and Reconstruc- less noticeable. It is best if it is done approximately
tive Surgery Department, Assiut University Hospital, Egypt. 8 weeks after the surgery [8]. It can also be used
It included 60 patients, their ages ranged from 3-37 years,
male to female ratio was equal. All patients included in this
to remove wrinkles and tattoos [9]. Other indications
study were examined by a team of plastic surgeon and derma- described in the literature are, Telangiectases,
tologist (Assiut University Hospital) for proper patient selection Melasma, Epidermal nevi, Adenoma sebaceum,
and to prepare them for the operation. Strict promise was Actinic keratoses, Syringomas, Rhytides, Cysts
obtained from the patient to avoid direct and indirect exposure and milia, Trichoepitheliomas, Rhinophyma, Re-
to sun from 7am to 4pm every day for 3 months postoperatively,
the technique was described, post operative care explained,
calcitrant acne, Seborrheic keratoses [10,11]. The
we started the application of corticosteroid containing cream choices of modalities for resurfacing procedures
immediately. now include microdermabrasion [12], chemical peel
[13], dermabrasion, pulsed CO2 laser, scanned CO2
Results and Conclusions: Although there were two risk
factors in our patients, 1- The climates in Assiut-Egypt is
laser, long pulsed Erbium laser [14] and electrical
sunny all over the year. 2- All our patients had skin type III, heating, as well as various new modalities that are
IV and V (i.e. Susceptible for Hyperpigmentation and Hyper- presently undergoing testing.
trophic Scarring). Complications were minimal and respond
to medical treatment. Explanation will be discussed. Early Outcome of any Resurfacing Procedure: This
application (immediate post-operative) of corticosteroid in depends upon 1- Type of skin, Types III, IV and
small dose for 3 months did not interfere with healing and it V, according to Fitzpatrick classification are re-
had a rule in improvement of the results.
spectively susceptible for hyperpigmentation and
INTRODUCTION hypertophic scarring after resurfacing procedures,
while type I and II are susceptible for hyperemia
Dermabrasion is a surgical procedure that, as [15]. 2- Depth of excision should not extend beyond
its name implies, wears away or abrades successive the level of the papillary dermis, otherwise there
layers of skin, permitting a controlled removal of will be risk of hypertrophic scarring [16]. 3- Ho-
the epidermis and upper dermis to a depth sufficient mogenecity of the procedure [17]. 4- Anatomical
to treat disease, tumor, or deformity. The Ancient site, favorable healing is seen in the regions of the
Egyptians first performed dermabrasion in 1550 skin that have the largest number of adnexal struc-
B.C.; they recommended alabaster and pumice, tures and where the skin is thickest [2]. 5- Exposure
for smoothing skin and removing blemishes [1,2]. to sun (Ultraviolet rays) after a single exposure to
The physiological basis of healing after dermabra- ultraviolet light in vivo, the skin of Caucasoid,
sion rests upon the capacity of the skin to regenerate when examined with the dopa reaction showed no
its epidermal cover by epithelialization through increase in the density of melanocytes population

119
120 Vol. 29, No. 2 / Dermabrasion Again and Again

but does show an increase in the size and functional ranged from 3-37 years, male to female ratio were
activity of the existing melanocytes [18]. Repeated equal. All patients included in this study were
exposure to ultraviolet light; however, causes an examined by a team of plastic surgeon and derma-
increase in the concentration of dopa-positive tologist (Assiut University Hospital) for proper
melanocytes as well as an increase in their size patient selection and to prepare them for the oper-
and functional activity [19]. ation. Pre-and postoperative instructions were
explained to the patients as avoiding aspirin and
Contraindications for Dermabrasion: 1- De- aspirin containing products for two weeks before
crease or absence of skin appendages such as dermabrasion. Strict promise was obtained from
patients with deep thermal burns (of the third the patient to avoid direct and indirect exposure
degree). Similarly split thickness skin graft, and to sun from 7am to 4 pm every day for 3 months
patients who have received radiation therapy for postoperatively. Clinical assessment was done to
active cystic acne diseases that cause epidermal determine whether there was any contraindication
atrophy such as discoid lupus, scleroderma, and or exclusive criteria to the procedure.
chronic radiodermatitis are relative contraindication
to dermabrasion. 2- Hypertrophic scars and keloids Operative Procedure: Certain precautions were
[20] . But some consider them among indication. done before doing dermabrasion, like wearing
3- Blood diseases such as clotting disorders present surgical masks to guard against sprayed blood and
a contraindication to dermabrasion. 4- Certain aerolization of blood particles, wearing glasses to
medical conditions such as, uncontrolled diabetes guard against absorption of blood through the
mellitus, or severe cardiovascular diseases, and conjunctiva. The patient’s eyes then were covered
congenital dermal aplasia. 5- Viral infections such with gauze after applying sterile ointment. Steril-
as herpes simplex, verruca plana or molluscum ization was done by alcohol 70% then the face (in
contagiosum should be treated prior to surgery. case of post-acne scars) was painted with gentian
6- Infectious diseases. Before dermabrasion, all violet to map the area to be abraded and to act as
patients should be screened for chronic systemic a guide for the dermabrasion. Then we injected
diseases like, serum hepatitis or AIDS. Patients adrenaline diluted to 1:200 000 with saline at the
with positive serological tests for AIDS or serum site of dermabrasion in all cases. We impacted a
hepatitis (active one) should not undergo any type piece of gauze within the buccal cavity to over-
of dermabrasion and 7- Neurotic patients some stretch the skin. Sustained traction by the operator
patients are poor candidates for dermabrasion, and the assistant was maintained by triangular
because of their neurotic attitude. Usually those stretch with the assistant’s two hands forming the
patients do not understand the procedure and its base and the operator free hand forming the apex.
goal. Also, those patients do not understand that We used wire brush abrasive end piece for all cases
the operation has its limitation, and may have some and we pulled it in the direction of handle perpen-
defects and complications, even if done by skilled dicular to the plane of rotation. Back and forth or
surgeons [6]. circular movement was done in certain situations
but carefully because it may gauge the skin. Sug-
Following dermabrasion, some skinreactions gested rotational speeds of 15,000-20,000rpm for
are expected to occur as: Hemorrhage, edema, the abrading heads result in a controlled gradual
exudates, discomfort and crust formation. These planning of the treated surface. The procedure of
reactions occur in the first week, where epithelial- dermabrasion was started from the outermost and
ization process is going on. After completion of dependent areas toward the central and upper most
the latter, other reactions are expected like erythe- areas of the face to take the advantage of gravity
ma, pruritus, milia, pustule, flushing and acne- and keep blood out of the next operative field. The
form like lesions. Purpura, petechiae and pigmen- rotating wire brush was moved with steady and
tary disorders are also reported. Complications of firm manner and with applying greater pressure to
dermabrasion include: Skin necrosis, persistent areas of deeper scarring. We planned the dermabra-
erythema, infection, hyperpigmentation, hypo pig- sion to end at a natural fold, a line of demarcation,
mentation and scarring [21,22]. or at a relatively hidden site (e.g., at the nasolabial
fold, at the hairline, or under the jaw line, respec-
PATIENTS AND METHODS tively). We did feathering at the periphery of the
area that was abraded by decreasing the number
We did our assessment within the period from of strokes and the pressure on the hand piece. This
Jan. 1999 to Feb. 2003 in Plastic and Reconstructive feathering gave the skin a more uniform appear-
Surgery Department, Assiut University Hospital, ance. So, obvious demarcation was avoided. We
Egypt. It included 60 patients, their ages were knew that we reached the superficial papillary
Egypt, J. Plast. Reconstr. Surg., July 2005 121

dermal layer by smooth, sparse, and punctate bleed- after re-epithelialization. Hydroquinone-containing
ing surface. The deep papillary dermal layer was cream applied once daily at night from the third
reached when the surface became rougher with month for approximately 3 months postoperatively
more evident bleeding points. Controlling the depth to all cases (Table 1).
of dermabrasion is an indicator of the experience
of the surgeon. RESULTS

After dermabrasion, we applied a topical prep- The results of our study revealed that most of
aration containing antibiotic and corticosteroid our patients (55%) were between 21-30 years. 30
cream followed by sterile gauze impregnated with males and 30 females with a ratio of 1:1. The
vaseline petroleum jelly to avoid drying of the commonest indication in our patients was post
abraded areas and covered with sterile dressing. acne scars (29 patients 48%) followed by hyper-
Bandages were applied to stabilize the underlying pigmentation (13 patients 22%), other indications
dressing and to enhance absorption of the trasudate were presented in Table (2) and Figs. (1-4). The
that will occur. We used systemic antibiotics from site of dermabrasion was in the face in 52 patients
the day of surgery till complete healing, analgesics (87%), upper limbs in 4 patients (6.5%), and lower
for one week, and vitamin C for 3 months to all limbs in 4 patients (6.5%). Four (6.5%) out of the
cases. The whole dressings were removed by run- 60 patients needed more than one session of derm-
ning water 24 hours after dermabrasion and washing abrasion with 6 months interval, three had post-
with saline was done, then a thick film of topical acne scar, and one had pigmented skin lesion
antibiotic cream and corticosteroid cream (0.5mg (Lentigenes). We did face lift in one patient in
per gram betamethasone) is applied by the patient conjunction to three sessions of dermabrasion to
himself twice daily till complete healing. Areas of treat severe acne scarring with dimples (Fig. 1).
persistent soft crust in sites of slower healing were The duration of healing after dermabrasion ranged
not removed forcibly but were treated with the from 10-21 days (Mean 15±4). The risk factors in
regimen of ointment applications and warm water our patients were: The climate in Assiut which is
soaks until healing occurred. Throughout the post- sunny all over the year. All our patients had skin
operative period till complete healing, the patient type III, IV and V according to Fitzpatrick skin
was instructed to avoid hard exercise, straining, types classification (i.e. susceptible for hyperpig-
lifting heavy objects, bending, and excessive heat, mentation and hypertrophic scarring). Complica-
cold, and sun exposure. Also, we avoided the tions developed in 6 (10%) out of the 60 patients.
contact of the patients with persons who have The first was infection in 2 patients (3.3%), one
herpes simplex, herpes zoster, chicken pox, impe- in the upper and the second in the lower limb, it
tigo, and other skin diseases. After complete heal- responds rapidly to frequent dressing. The second
ing, we continue to apply the same combination complication was hyperpigmentation, it was de-
(antibiotic and corticosteroid containing cream) tected in 2 patients (3.3%) underwent dermabrasion
once daily for two weeks, then every other day for in the face, it responded well to the application of
two months the patients were instructed to avoid Hydroquinone (4%) and completely faded within
sun exposure (direct and indirect) for 3 months 6 months postoperatively. The third complication
postoperatively. Sunscreen cream (factor > 50) was hypopigmentation in 2 patients (3.3%), in the
was prescribed to all patients after the 3rd month upper limb, it persisted and did not disappear up
for at least 3 months. The patients were advised to one year. The healing time was delayed up to 3
to avoid astringents, exfoliatives or abrasives on weeks in patients showed infection and hyperpig-
the new delicate skin for approximately 6 months mentation.
Table (1): Medication used for patients undergoing dermabrasion.
Drugs Start of treatment End of treatment Remarks
Systemic antibiotic Just before surgery Complete healing Suggested group was 1st
generation cephalosporin
Topical antibiotic cream At the end of surgery 3 Months* Gentamycin sulphate 1mg/gram
Corticosteroid cream At the end of surgery 3 Months* 0.5 mg/gram betamethasone valerate
Hydroquinone 0.4% cream 3rd post-operative month 3 Months Applied once at night
Multivitamins and minerals 2 weeks before surgery 6 Months Three times daily
(C,A, zinc) Vit. C 500 mg/3 times daily
Sun block cream SPF < 50 3rd post operative month 3 Months Applied before exposure to the sun
Note:*The combination of antibiotic and corticosteroid cream applied once daily for 2 weeks, then every other day for the remaining 3 months.
122 Vol. 29, No. 2 / Dermabrasion Again and Again

Table (2): Indication of dermabrasion in our study.

Post acne Hyperpigmented skin lesion
Indications Facial scars Verrocus naves Tricho epithelioma Total No.
scar (Freckles and Lentigenes)
No. of patients 29 13 6 6 6 60

Fig. (1): Post-acne scarring. Pre

and after 2 sessions of
dermabrasion and face
lift to detach the fibrous
attachment of deep scars.

Fig. (2): Pre and post operative view

of pigmented skin lesion
(Lentigenes).

Fig. (3): Trichoepitheliomas pre

and early post operative.

Fig. (4): Verrocus epidermal nevus.

Egypt, J. Plast. Reconstr. Surg., July 2005 123

DISCUSSION mal naevi when the excision of the lesion with

closure cannot be achieved.
Dermabrasion is an extremely useful modality
when employed for the proper indication. Although, Old facial scars were improved but not eradi-
laser resurfacing has many advantages over derm- cated by dermabrasion. This was consistent with
abrasion because of its blood less field, no risk of the results of Yarborough JM [27] who stated that
blood born pathogens to the operator can be used scars of long duration from 3 months to 13 years
in the eyelids, and the learning curve is lesser with are improved but not eradicated by dermabrasion.
laser than with dermabrasion [23]. We agree with But dermabrasion of facial scars 4-8 weeks after
Baker [24] and Hruza [25], that dermabrasion re- injury frequently eliminates visible evidence of
mains an effective and reliable resurfacing option scar formation. All scars were hypertrophic; we
for many dermatologic allesions. It has some ad- did not trust that dermabrasion is the procedure of
vantages over laser, as it is inexpensive, portable, choice in management of atrophic scars.
and widely available. It is well taught in most
plastic surgical training programs and therefore, Prieto and Shea [28] in 2002 found that when
does not require expensive secondary training multiple facial lesions of Trichoepitheliomas were
courses. Dermabrasion requires no specialized surgically flattened by dermabrasion, they tended
accessory equipment and possesses no fire hazard to regrow into elevated papules or nodules. This
in the operating room. The surgeon can go deeper regrowth may occur rapidly within months or may
into the dermis in a layered manner in one setting, take several years. Some patients find a prolonged
so, it requires fewer sessions. In expert hands, cosmetic improvement to be worthwhile even if
dermabrasion can achieve results comparable with repeated procedures are necessary. So, close follow
laser resurfacing. When performed by an infrequent up and early interference in case of recurrence was
user of the procedure, however, the results achieved important. Our study included small number of
can be expected to be far less predictable than laser cases, we did not face recurrent cases with three
resurfacing. years follow up.
Patients with mild and moderate form of acne Although, there were two risk factors in our
scarring or superficial scars gave satisfactory results patients, 1- The climate in Assiut-Egypt is sunny
and responded very well to only one setting of
all over the year. 2- All our patients had skin type
dermabrasion. Patients with severe form of acne
III, IV and V (i.e. Susceptible for Hyperpigmenta-
scarring showed minimal improvement after one
tion and Hypertrophic scarring). The complications
stage but satisfactory results obtained after multiple
were minimal and respond to medical treatment.
stages with 3 months interval and after doing
This could be explained by the following:
undermining of the skin to detach the fibrous septa
between the skin and the underlying structures, 1- In spite of the preoperative use of topical
this procedure allowed lifting of the skin at the tretinoin has become a routine part of dermabrasion
same time. because it may enhance wound healing [29], we
Superficial dermabrasion for hyperpigmented did not use this line because it was suggested that
skin lesions in the face specially Freckles and pre treatment with topical tretinoin contributes to
Lentigenes gave rapid and satisfactory results, the prolonged erythema which often persists for
while medical treatment, by the use of Hydro- months [30].
quinone 2-5% twice daily for months, only de-
creases the intensity of pigmentation but not erad- 2- Tumescent technique: We injected xylocaine
icate it. and adrenaline diluted to 1: 200 000 (Tumescent
Technique) as advised by Goodman [31] and im-
We agree with Rook [26] who stated that derm- pacted a piece of gauze within the buccal cavity.
abrasion tends to produce only temporary benefit These two steps in addition to the assistant’s hands
in case of verrocus epidermal naevi because this resulted in overstretch of the skin and gives a firm
type of naevi tends to recur unless much of the surface to dermabrade against skin easily which
underlying dermis is removed or destroyed at the reduces the bleeding markedly, and allow adequate
same time as the epidermal component. So, excision visualization of the depth of the abrasion. We
with the underlying dermis is the only completely stopped the use of topical skin refrigerants to avoid
reliable way of ablating lesion permanently, but their side effects, which were mentioned in the
dermabrasion may be the only reliable method for literature (prolonged erythema, delayed wound
improving the extensive cases of verrocus epider- healing and scarring).
124 Vol. 29, No. 2 / Dermabrasion Again and Again

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