Dermabrasion: A Review in 2001
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Mark A. Chastain, M.D.
Instructor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, AL

Resurfacing techniques popularized in the 20th century began with Kronmayer’s first description of modern dermabrasion as a technique for debriding and for treatment of scars. Kurtain and then Burke later modified it in the 40’s and 50’s and their initial wire brush techniques have been little changed to the present day. During a period of the 60’s and 70’s, deep dermabrasion was the premiere technique for resurfacing photoaging skin, acne scars and dermatologic growths. Wire brush dermabrasion with refrigerants and little usage of anesthesia made this dermatologic technique difficult for the patient to endure. In addition, the dry healing techniques of wet dry debridements and Neosporin powder to create thick crusts prolonged the healing and contributed to post-operative problems such as hypopigmentation and scarring. These problems along with the advent of controlled chemical peeling and then later in the 90’s with pulsed lasers for resurfacing greatly decreased the popularity of dermabrasion. It fell out of favor in the late 80’s and 90’s and only now is it being re-studied as to its value compared to those other techniques for superficial, medium depth and deep resurfacing.

Levels of resurfacing were first popularized by Stegman in his histologic controlled studies with varying concentrations of trichloracetic acid. He was able to divide chemical peel resurfacing into superficial and deep. The definitions became the standard index of measurement for both chemical peeling and laser resurfacing. It not only reflected the histologic level of destruction found but also the consequent degree of improvement to the condition being treated. The adage “the more you get, the deeper you go,” was confirmed with these studies and further investigators have categorized which patients with degrees of photodamage and scarring – Glogau scale, Monheit Index of Photoaging Skin – will respond to levels of skin destruction with specific procedures.

Superficial resurfacing is defined as destruction of or removal of the superficial epidermis or a major portion of the epidermis. Medium depth resurfacing involves removal of or destruction of the epidermis entirely along with a portion of papillary dermis. Deep resurfacing involves removal of or destruction of epidermis, papillary dermis and a portion of reticular dermis to the level of mid reticular dermis. Utilizing this classification, resurfacing lasers, chemical peel solutions and now dermabrasion can be classified as to the injury pattern desired.

The same measuring guide of tissue destruction now can be applied to dermabrasion with the advent of the new less invasive techniques of microdermabrasion and manual dermasanding.

Microdermabrasion involves the removal of the stratum corneum only with little disruption of the lower epidermis or basal cell layer. The most aggressive microdermabrasion may involve penetration to the basal cell layer. It, thus, is classified as a very light resurfacing technique or a superficial method of disrupting the upper epidermis. The theoretical construct of the procedures explains that the removal of stratum corneum and surface debris will stimulate a more rapid epidermal proliferation and thus a freshening in surface feel and appearance. The microdermabrasion unit’s handpiece is a closed system, which propels aluminum oxide crystals at the skin at high speeds and simultaneously removes them with suction. The units were originally developed in Europe in the 1980’s but have become commercially available in the 90’s and are now widespread in physician offices and in non-medical aesthetic spas. It is commonly indicated for superficial epidermal conditions such as acne with open and closed comedones, improving the texture of photoaging skin especially in its early phases of development, stimulating epidermal regeneration for conditions such as pigmentary dyschromias, melasma and superficial epidermal lesions. It is a “lunchtime” procedure with little or no downtime. Postoperatively, it produces erythema, edema and occasionally skin sensitivity for a number of hours. The patient, though, is well able to return to work, use make-up and daily cleansing on a regular basis almost immediately after treatment. Patients and physicians have reported improvement after repeated treatments but there is presently little objective evidence in the scientific literature of documented histologic changes in photoaging skin. Patients seem to appreciate the little downtime and the smooth texture of their skin to feel and there are many anecdotal stories of flattened rhytides, improved acne scars and even changes in striae distensi. Well-documented studies of these conditions must be done to reproduce these findings in a broader population of physicians and patients.

Medium depth abrasive injury is that in which the epidermis is destroyed and the papillary dermis is entered. Though this level of injury can be extended with microdermabrasion equipment medium depth procedures are beyond the reach of these instruments. The injury produced by microdermobrasion is not well controlled at a deeper level and can produce sequelae and side effects. For this reason, medium depth abrasive injury is generally performed with light mechanical diamond fraize dermabrasion and manual dermasanding.

Manual dermasanding involves abrading the skin by hand power using silicone carbide sandpaper or wall screen commercially available at any hardware store. It is gaining popularity for skin resurfacing because it has several advantages over power-driven dermabrasion at this level of injury. Those advantages include a greater control over depth injury, particularly on localized areas such as the lips and orbital rims. Its use in blending borders for other resurfacing techniques such as chemical peeling and laser resurfacing can be done easily as a combined procedure. It, of course, is of lower cost with greater simplicity of instrumentation and set-up than with mechanical dermabrasion or for that matter, erbium YAG laser. In comparison to mechanical dermabrasion, there is no risk of aerosolization of infectious particles during the procedure with less risk of intraoperative injury.

The depth of penetration in manual dermasanding is dependent upon the type of paper or “grit” used, the force applied by the surgeon and the duration of contact with the skin. Although it can be used to produce a wound almost as deep as wire brush dermabrasion with multiple passes, manual dermasanding is most commonly used as a medium depth or minimally deep resurfacing modality. The silicone carbide sandpaper is classified in a variety of grades: fine grade (#400), medium grade (#220-320) and coarse grade (#180). The sandpaper is cut into small pieces and then steam autoclaved. A 1 ½ x 2 inch gauze pad is moistened with saline and sandpaper wrapped around it. The sandpaper is always kept moist with saline so it will glide easily over the skin surface. Back and forth circular motions are used to gradually abrade the skin layer by layer through the epidermis and into the papillary dermis. Blending of traumatic scars, acne scars and post surgical scars can be obtained with dermasanding and without the use of a refrigerant. The skin is stretched tightly and the skin is abraded with both back and forth and circular motions. The surgeon chooses the grade necessary to obtain the results desired. Fine grit sandpaper is used for blending purposes, to remove necrotic debris after laser resurfacing and over demarcation zones of other procedures for blending. This is especially true after laser resurfacing to blend the upper third of the neck, the hairline, the eyebrows and areas of eyelid skin. It is also used after a Jessner – 35% TCA chemical peel in selective areas where deeper injury is necessary to remove and blend perioral rhytids and periorbital crow’s feet. It can also be used to remove the thick epidermal lesions that medium depth chemical peeling cannot remove. The opportunity of using this simple tool as an adjunct in our other skin resurfacing procedures is widespread and open to the imagination of the surgeon.

Deep abrasive resurfacing techniques are mechanical dermabrasion, both diamond fraize and wire brush. A topical refrigerant spray is used to produce anesthesia and harden the skin prior to abrasion. It immobilizes the topographic features so that there is no distortion by the pressure of the abrasive instrument. The wire brush is composed of small caliber stainless steel wires that project from the curved side of the cylindrilical hub producing micro incisions as it removes superficial skin. The diamond fraize consists of a stainless steel cylinder to which industrial grade diamonds are bonded to create an abrasive surface. There continues to be debate over which item is best for which condition but both can be used for deep abrasive resurfacing. The technique is generally accepted as the primary method for treating acne scars. Motorized dermabrasion is best suited for full-face resurfacing though it can be used for localized spot dermabrasion. Conditions amenable and best treated by mechanical dermabrasion include acne scars, surgical or traumatic scars, epidermal growths especially hyperkeratotic actinic keratoses and rhinophyma.

Now that we have a decade of experience with laser resurfacing, the two methods can be compared back to back. Though laser resurfacing does produce better results on thin and atrophic skin such as eyelids, results are comparable to other areas such as photoaging lips and cheeks. A comparable depth dermabrasion will heal faster than a similar laser resurfacing with less postoperative erythema and less risk of post inflammatory hyperpigmentation. This is because abrasive injury does not create thermal damage, which will produce pigmentary dyschromias. It, though, will not have the salutary effect of thermally induced collagen contraction that improves the final phase of laser resurfacing. Thus the resurfacing laser has an advantage in the treatment of photoaging skin with thermally induced collagen contraction. Conversly, dermabrasion can sculpt irregular skin surfaces and is the choice agent for acne scars and surface contour deformities.

In summary, we now have brought dermabrasion into the new millennia. Its purpose and function is well appreciated as both a superficial, medium depth and deep resurfacing technique and its applications will continue to grow as we learn to combine our present resurfacing techniques.