Kapsul Buka Aura

 

  SEJARAH  DERMABRASI Synergy
 
History of Dermabrasion
Naomi Lawrence, MD,* Stephen Mandy, MD, John Yarborough, MD, and Thomas Alt, MD

DERMATOLOGIC SURGERY 26(2),95-101


Resurfacing Perspective

Resurfacing has had a cyclical history. Interest in skin rejuvenation rises and falls on the crest of each new skin resurfacing modality. With the advent of new technology there is always the promise of the ideal resurfacing tool: one that is reliable and technically easy to use, having the capacity for superficial to deep resurfacing, with no morbidity, no risk of adverse effects, and no exposure of the operator to blood products. If one observes the cycles, they are either reassuring or confounding.

Even the nonablative laser can only provide dermal augmentation without epidermal renewal leaving us short of our ideal mark. To date, no new technology can accomplish complete skin rejuvenation without wounding. The common denominator, the level playing field for resurfacing, is the depth of the wound. The term dermabrasion aptly describes wounding to the level of the dermis. Wounding to this depth stimulates a controlled fibrosing response that can improve deep scarring and rhytides. Because of the tremendous reparative properties of the skin, deep partial thickness wounds take only a few days longer to heal than superficial wounds. Most patients are healed in 7–10 days. For scarring and deep rhytides, it is not the ablation of an abnormal epidermis but rather the stimulation of dermal fibroblasts to lay down collagen that brings improvement. When treating precancerous actinic keratoses, the ablation of the abnormal epidermis deep into the follicular infundibulum provides a longer lasting remission from new cancers than more superficial resurfacing.

Trends in resurfacing swing from superficial to deep approximately every 5 years. Deep resurfacing produces the most dramatic results, but carries with it significant morbidity. Dermabrasion is considered a “deep” resurfacing modality, but has a range from medium to deep.


Hot versus Cold Resurfacing

Resurfacing Perspective  Time Line  Dermabrasion for Actinic Damage  Dermabrasion for Scars  Other Conditions Treated by Dermabrasion  References 

Much of the current debate over the best resurfacing modality centers on the relative merit of the ultrapulsed CO2 laser versus the Er:YAG laser. Ross et al.1 believe that it is this controlled thermal injury that produces a uniform fibroplasia which maximizes fibroplasia thickness per micrometer depth of injury compared to cold modalities such as Er:YAG laser, dermabrasion, and chemical peel. According to Ross et al., controlled thermal damage provides an advantage by decreasing interpatient variability and operator unpredictability.

Dermabrasion, like Er:YAG laser, is a method of cold ablation. Tissue is mechanically removed with no residual thermal injury. Because of the absence of char, most dermabrasion experts maintain that infection is less common. Because there is no thermal injury, vascular stimulation in the healing phase appears to be less prominent, resulting in less intense, faster resolving postoperative erythema. Resurfacing experts that favor cold ablation feel that they have more manual control to vary the level of destruction, tailoring it to each scar without adding a zone of thermal damage to the skin. A few studies have compared dermabrasion and laser resurfacing. Nehal et al.2 showed comparable improvement with high-energy pulsed CO2 laser in the clinical appearance and surface texture of scars. Campbell et al.3 showed no difference in the ultrastructure of collagen fibers laid down 180 days postdermabrasion or CO2 laser in the pig.


Time Line

Resurfacing Perspective  Hot versus Cold Resurfacing  Dermabrasion for Actinic Damage  Dermabrasion for Scars  Other Conditions Treated by Dermabrasion  References  1500

BC Egyptian physicians used sandpaper to smooth scars.

1905    

Kromayer, a German dermatologist, published on motorized dermabrasion. He described a technique of creating skin turgor and topical anesthesia with the use of CO2 snow. He used rapidly rotating burrs to remove the skin at various depths and determined that ablation into the reticular dermis would result in healing without a scar.4,5

1947    

Iverson, an American plastic surgeon, described the use of sandpaper for the treatment of acne scars and traumatic tattoos.6

1953    

Kurtin, a dermatologist, collaborated with Robbins to modify power dental equipment for use in dermabrasion. He advanced modern dermabrasion technique with the use of topical refrigerants and the wire brush.7 Robbins also developed the diamond fraise.

L

owenthal developed punch graft removal of scars prior to dermabrasion.8

1955    

Burks described his method of wirebrush dermabrasion for active acne, scars, wrinkles, lentigenes, melasma, keratoses, adenoma, sebceun, acne keloidalis, and skin grafts.9 (See Figure 1.)

1956    

Wilson et al. study skin refrigerants and indicate dichlorotetrafluoroethane as the skin refrigerant of choice.10

1956    

Burks publishes Wire Brush Surgery.11

1957    

Burks reports on the physiopathology of wound healing following dermabrasion. In a study at Tulane Medical center in New Orleans, LA, he assessed the healing in 1500 patients postoperative for dermabrasion.12 Using serial biopsies (342 in total), he chronicled the histologic changes from predermabrasion to 10 months postdermabrasion. He noted the absence of granulation tissue, evidence of epidermal repletion from appendages, and a zone of new “connective tissue.”

1963    

Burks et al. described the use of dermabrasion for extensive actinic damage.13

1968    

Clabaugh detailed a method for removal of superficial tattoos with dermabrasion.14

1969    

Orentreich publishes a review outlining the current method for dermabrasion and the range of conditions that can be treated with dermabrasion.15

1977    

Stagnone introduces chemabrasion, the combination of a deep full-face chemical peel followed immediately by dermabrasion. He felt that the combination had advantages over either procedure done alone.16

1983    

Mandy introduced polyethylene oxide gel for postoperative dermabrasion care. He noted decreased postoperative pain and healing time (reepithelization within 4–5 days rather than the standard 6–7 days).17

1985    

Hanke et al. evaluated the skin refrigerants used in dermabrasion. They found Freon 114 and Freon 114-ethyl chloride efficacious and safe for skin, but pure Freon 12 or Freon 12 mixed with Freon 11 were too cold.18

1985    

Silverman et al. advocated the preoperative prophylactic administration of oral acyclovir in patients at risk for developing herpes simplex labialis.19

1986    

Rubenstein et al. recommended delay of dermabrasion after recent isotretinoin therapy. He reported postoperative keloids in atypical locations in six patients who had dermabrasion while on isotretinoin (or having recently finished a course of therapy).20

1986    

Mandy demonstrated the benefits of use of tretinoin 0.05% cream at least 2 weeks prior to dermabrasion. Full- or half-face dermabrasions were performed on 123 patients. Of these, 88 received tretinoin 2 weeks prior and showed faster reepithelization (5–7 days) when compared to the patients without pretreatment (7–11 days).21 (See Figure 2.)

1988    

Yarborough published on the use of dermabrasion during the early postoperative period to improve scars.22 (See Figure 3.)

1992    

Weber and Wule described the use of a contained breathing apparatus to isolate the operator and assistant from aerosolization of blood during dermabrasion.23

1992    

Coleman and Klein described the use of tumescent anesthesia for dermabrasion.24

1994    

The task force on dermabrasion published the “Guidelines of care for dermabrasion.”25 Harris and Noodleman revived dermasanding using various grades of silicone carbide wet or dry sandpaper to buff the skin. They advocate manual dermasanding as easier to master than motorized dermabrasion and more versatile in difficult areas such as the periocular and perioral areas.26

1995    

Tsai et al. reported on aluminum oxide crystal microdermabrasion. Through subjective physician assessment on 41 patients treated in their practice they found clinical results “good to excellent.” This new technique needs to be evaluated as part of a comparison trial to another established resurfacing technique (such as chemical peels) and evaluated objectively.27


Dermabrasion for Actinic Damage

The use of dermabrasion for precancerous skin changes has a rich history. As seen on the timeline, Burks9 first reported this indication in his 1955 article in the Southern Medical Journal.

In 1958 Epstein28 reported on planing for precancerous skin. In 1960 Burks and Brewer29 presented results of planing for prevention of skin cancer in 58 patients with full-face planing. They found an incidence of incomplete removal in 14% and documented the frequency of adverse sequelae. The most common adverse sequelae was hypopigmentation (57%). Some patients had a 4.5-year follow-up with no recurrence. In 1963 Burks et al.13 followed up with a study of 15 half-face planings. Immediate improvement was marked and follow-up showed fewer recurrences on the planed side in 9 of 15 patients. He again established the fibrogenic zone replacing solar elastosis and the development of new elastic fibers on histologic examination. In 1966 Epstein30 published a 10-year evaluation on planing for precancerous skin. He found no recurrences in four cases and partial success in four patients (recurrences but still a significant benefit). He had a poor result in two cases, with early recurrence and development of malignant neoplasms.30

In 1970 Spira et al.31 compared chemical peeling, dermabrasion, and 5-fluorouracil (5-FU) in the treatment of senile keratoses. They found longer remission with dermabrasion (6 months) than with chemical peeling. They felt the results were best with 5-FU but do not quantitate the difference. In 1971 Spira et al.32 published a follow-up report on the efficacy of these modalities for cancer prophylaxis. With 4 months to 3 years follow-up, they report the best results with 5-FU, but again do not quantitate results.

In 1982 Stegman33 compared 60% trichloroacetic acid (TCA), 100% phenol, and Baker's phenol to dermabrasion. He established the similarity in wounding between normal and sun-damaged skin. He also found that the thickness of the reparative response in the papillary dermis was directly proportional to the depth of the wound and not related to the method of wounding.

In 1986 Winton and Salasche34 compared the use of dermabrasion for extensive actinic damage in five patients with alopetic scalps to a 6-week course with 5-FU. They found similar results but greater morbidity with 5-FU.

In 1992 Benedetto et al.35 published clinical and histologic results on 12 patients who had full-face dermabrasion with follow-up ranging from 1 year 9 months to 8 years. They showed excellent remission, with only 2 of 12 patients having new actinic keratoses (AKs) after 4 years in the dermabraded area. Many of these patients required multiple procedures for skin cancers before their dermabrasion. Histologic examination confirmed previous reports of a new grenz zone of collagen and remission of dyskeratotic epidermal cells.

In 1994 Nelson et al.36 examined the molecular and histologic events in photoaged skin treated with dermabrasion. By Western blot analysis they demonstrated an increase in procollagen I + 4.2 1.5 at 3 weeks and 0 + 2.7 0.7 at 12 weeks. In situ hybridization showed a sixfold increase in procollagen I mRNA in papillary dermal fibroblasts at 3 and 12 weeks. The increase in procollagen I mRNA correlated with reduction in wrinkling.

In 1996 Coleman et al.37 reviewed the clinical course of 23 patients who were dermabraded for actinic damage. Over a 5-year period of follow-up, they found 96% remained clear at 1 year, 83% at 2 years, 70% at 3 years, 64% at 4 years, and 54% at 5 years. The average time to recurrence of AKs was 4 years. No cancers were seen in the first 3 years of follow-up. Three patients subsequently developed five basal cell carcinomas but no squamous cell carcinomas.

Also in 1996 Nelson et al.28 performed an elegant comparative study comparing wirebrush (WB) to diamond fraise (DF) dermabrasion in the treatment of photoaged skin. In eight patients with photoaged skin they used a split-face design treating half the face with WB dermabrasion and half the face with DF dermabrasion. For clinical analysis they used a graded scale to assess lentigenes, AKs, and wrinkles. They found moderate to marked improvement but no significant differences between the two modalities. Both modalities generated a measurable dermal repair zone evident on Masson's trichrome, with no statistically significant difference between WB and DF. Immunohistologic examination showed a significant increase in extracellular papillary dermal fibroblast staining for amino terminal procollagen (type I pN collagen). Western blot analysis confirmed an increase in type I pN collagen. In addition, transforming growth factor beta 1 showed increased dermal extracellular staining. All of these increases were statistically significant, but there was no significant difference between the two modalities.

Today dermabrasion remains a viable, efficacious treatment for actinic damage. Although some consider 5-FU to be the gold standard for the treatment of patients with multiple AKs, the literature supports dermabrasion as an equivalent or better treatment. The deeper one carries the dermabrasion, the longer lasting the remission. Certainly atypia in the follicular epithelium plays a role in the recurrence of AKs.


Dermabrasion for Scars

Through the work of Kurtin,7 Burks,9 and Rein and Blau,39 dermabrasion was established as a treatment for scarring. Adjunctive procedures, such as the punch graft introduced by Lowenthal, and later punch elevation of scars, also improved results with acne scarring.8,40

In 1980 Caver41 reported his use of dermabrasion of wound edges before closure to minimize scarring. In 1984 Collins and Farber42 reported their experience with dermabrasion on postsurgical scars on the nose. In 1987 Robinson43 studied postoperative dermabrasion of 192 full-thickness skin grafts of the nose, periorbital area, and ears. She found the greatest improvement in elevated grafts on the nose, however, elevated grafts in any location showed improvement. In 1988 Yarborough22 advocated the early use of dermabrasion, within 4–8 weeks of the primary wound, to obtain the best resolution of the cicatrix. In 1991 Katz and Oca44 used a split-scar model to compare the scar revision accomplished with diamond fraise dermabrasion at 4, 6, and 8 weeks after initial wounding. They found the best results at 8 weeks, although all dermabraded scars on the face, trunk, and extremities showed improvement. Harmon et al.45 performed electron microscope and immunohistochemical examination on pre- and postdermabrasion biopsies to better elucidate the ultrastructural changes responsible for scar improvement postdermabrasion in 1995. They found an increase in collagen bundle density and size, with a reorientation of collagen fibers parallel to the epidermal surface. In addition, there was an upregulation of tenascin expression throughout the papillary dermis and of a6/b4 integrin subunit on the keratinocytes throughout the stratum spinosum.

Dermabrasion is still the technique best supported by the literature and surgical experience for abrasive scar revision. A further advantage of dermabrasion over laser for abrasive scar revision is that the postoperative erythema resolves more rapidly.


Other Conditions Treated by Dermabrasion

Table 1 lists all the conditions that have been reported to have a favorable response to dermabrasion. A benign growth that has an epithelial origin responds completely to dermabrasion without recurrence. Benign tumors with a dermal component, such as angiofibromas, trichoepitheliomas, etc., are dramatically improved by dermabrasion but recur over time. With the advent of lasers that can treat most tattoo pigment without a scar, dermabrasion is a second-line choice. In conditions with disordered epidermal growth, such as Darier's or Hailey–Hailey dermabrasion replaces the lesion with a scar. Dermabrasion is thought to create a reverse Koehner phenomenon in psoriasis. In pigmentary conditions such as melasma, dermabrasion has the same problems with recurrence as any other resurfacing procedure. Treatment of pigmented tumors with resurfacing is still controversial because of concern for a masking of malignant degeneration. Dermabrasion is still an excellent modality in the treatment of rhinophyma. The hyperplastic sebaceous glands seem to provide a heat sink, increasing the risk of scarring in “hot” resurfacing such as laser or electrosurgery.



Abstract

Dermabrasion is a surgical procedure conceived and developed by dermatologists. It remains an extremely valuable tool in the resurfacing armamentarium. As our specialty becomes more surgical, it is important that we take the time to teach residents this technique-sensitive modality. It is imperative that we compare new deep resurfacing modalities to the gold standard of a dermabrasion that is “well done.”


References

 

 









 

 

 

 

 


 

   

 


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