- Email: [email protected]
Facial Dermabrasion
MARCH 1990, VOL. 51, NO 3
______
AORN JOURNAL
Facial Dermabrasion MODERN
TECHNIQUES AND PROTOCOLS
Candace C. McKinnon, RN; James E. Fulton, Jr, MD
D
ermabrasion is an effective method for removing facial scars, premature wrinkles, solar keratoses, and related skin 1esions.l With proper patient selection and proper surgical techniques, a patient can have significant improvement (Fig 1). Results, however, are never perfect. Standard checklists, operative techniques, and patient follow-up procedures have improved the results and reduced the complications. Avoiding medical and legal pitfalls can be achieved best by using forms and protocols that ensure full disclosure between the patient and the surgeon. The techniques and standard protocols that have been developed at the Acne Research Institute, Newport Beach, Calif, are presented in this article.
emphysema or postnasal drip because they may cause problems during intravenous (IV) sedation. Habitual use of drugs such as diazepam, amphetamines, tranquiliz,ers,sedatives, marijuana, or alcohol also influences the effect of anesthesia. It is crucial to assess the patient’s dietary history because unbalanced nutrition, especially low protein intake, can compromise wound healing. Review of mental status. It is important to
Patient Selection
P
roper patient selection is probably the most important factor to ensure positive results and patient satisfaction. Three to four weeks before surgery, the surgeon and nurse complete a predermabrasion evaluation. The evaluation includes the following. Current evaluation of the skin condition. The best results are obtained if the underlying skin condition is under control. Any previous history of facial planing, x-ray treatments, or chemical peels will affect the results. Facial pigmentation also is evaluated. Blotchy, very dark, or discolored skin tones may cause pigmentary problems after the procedure. Evaluation of medical history. Of special importance are respiratory problems such as
Candace C. McKinnon, RN,is a senior acne nurse special&, Acne Research Institute, Newport Beach, Calif: She earned her associate of science degree in nursingfrom Brigham Young University, Provo, Utah. James E. Fulton, Jr, MD, PhD, is a research scientist, Acne Research Institute, Newport Beach, Calg He earned his doctor of medicine degree at Tulane Medical School, New Orleans, and his doctorate of philosophy in biochemistryfrom the University of Miami. 739
AORN J O U R N A L
MARCH 1990, VOL. 51, NO 3
Fig I . Patients before and after dermabrasion procedures. Patient with typical ice pick scarring underwent two dermabrasions (top); a patient with more extensive scamng needed two dermabrasions,excision and suturing of scarred areas, and liquid collagen injections to fill residual valley-like lesions (bottom). 740
MARCH 1990, VOL. 51, NO 3
assess the patient’s general attitude and expectations, and how he or she copes with stress. A patient expecting perfect results will be disappointed. A previous history of a nervous breakdown or mental disorder, such as schizophrenia, may indicate the patient will have difficulty handling the emotional stress during or after the procedure. Group discussion. The patient, physician, registered nurses, and office manager all participate in the group discussion. It is important because one group member may uncover something the others should know and consider. All members in the group discussion should agree that the patient is a qualified candidate before proceeding with a dermabrasion. Laboratory workup. Routine tests include a complete blood count, prothrombin time, and complete serum chemistries along with a hepatitis and human immunodeficiency virus (HIV) screen. We obtain special permission to check for the HIV. The patient should not have any significant blood abnormalities.
Patient Education
T
he surgeon and registered nurses complete the patient education in five phases. In the first phase, they discuss with the patient the dermabrasion technique and potential complications. During the session, patients are required to read a handout describing the technique, watch a videotape demonstration of an actual dermabrasion procedure, and review a series of before-and-after photographs. The photographs show positive previous results, the appearance of the face at intervals during the healing phase, and potential complications such as milia, hypopigmentation or hyperpigmentation, and keloid formation. The surgeon and nurse also review the risks of wound infections, delayed wound healing, and intravenous sedation. This is done approximately two weeks before the procedure to allow the patient adequate time to consider the procedure in-depth and to answer all his or her questions. In the second phase, extensive step-by-step predermabrasion and postdermabrasion instruc-
___-
AORN J O U R N A L
Home Care Kit Contents antiseptic :scrub (povidone-iodine) hydrogel dressings wash cloths hydrogen peroxide cloth tape antibiotic ointment shaving cream petrolatum disposable forceps and scissors thermometer a home-care record extra surgery instruction sheets 4x4-inch cotton sponges roller gauze
tion sheets are reviewed with the patient to clarify the procedures and terminology. Patients take the sheets home to review. They are encouraged to write down any further questions to discuss at the next visit. In the nest phase, the patient signs an initial informed consent form. This is an important part of the education process because it serves to review and solidify the information previously discussed. Patients sign the informed consent two weeks before the procedure so they will not be surprised by the wording on the form on their surgery day. Patients, however, must re-sign the informed consent form on the day of surgery because it must be signed within 48 hours of the procedure. In the fourth phase, the patient receives a 60minute audiotape to take home. One side of the tape reviews the technique and instructions; the other side teaches deep-breathing and relaxation exercises to use during surgery. The patient is instructed to listen to the tape several times. In the final phase five days before the procedure, the patient and his or her primary postoperative caretaker (eg , parent, spouse) receive the home care kit. (See “Home Care Kit Contents.”) At this point, the nurse answers any questions the patient may have and reviews the preoperative and postoperative instructions, which include instructions on shampooing the scalp and face with (+
741
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
Fig 2. The turbogrinder and three fraises equipped with 40- to 50-grit diamond dust. The variable speed dermabrader, which is powered by compressed nitrogen gas, will rotate up to 85,000 rpm. povidone-iodine soap the night before and the morning of the procedure. The nurse also teaches the patient and caretaker how to use the home care kit for postoperative wound care. The kit contains essentially everything needed during the first 10 days of postoperative care. The patient also receives prescriptions for ampicillin, acetaminophen with codeine, and flurazepam hydrochloride (Dalmanes).
Preoperative Phase
T
he patient begins sedation the night before surgery by ingesting 100 to 200 mg of dimenhydrinate (Dramamine@). In the office one hour before the procedure, the patient takes another 100 to 200 mg of dimenhydrinate plus 100 mg of secobarbital sodium (SeconaP). These two agents have been suggested by physicians as safe, reliable preoperative medications. They provide sedation with minimal cardiac complications. Before the dermabrasion begins, the nurse starts an intravenous drip of dextrose 5%in water. Five to 10 minutes before the procedure starts, the nurse administers IV meperidine hydrochloride 50 mg and diazepam 5 mg. These agents help alleviate 744
the anxiety and discomfort of the surgery. One or two additional IV injections may be repeated, as needed, during the procedure, provided the patient’s vital signs are stable. The most important anesthetic effect is achieved by regional blocking of facial sensory nerves. The physician injects into the facial nerves approximately 20 to 40 mL of lidocaine hydrochloride (Xylocaines) and bupivacaine hydrochloride (Marcaines) at a 3:l ratio. On a steriledraped Mayo stand, the scrub nurse sets up the turbogrinder and diamond fraises, 4x4inch cotton sponges, needle holders, Loo punches, sutures, forceps, #15 scalpels, and vis scissors. The nurse scrubs the patient’s face with povidoneiodine and drapes him or her with sterile plastic sheeting.
Surgical Phase
T
he surgeon begins the surgical procedure on the right cheek, proceeds to the left cheek, and then to the forehead, nose, and perioral area. In all patients, care is taken to go approximately %-inch below the jawline and %inch into the hairline to achieve a uniform color and smooth appearance postoperatively.
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
The surgeon also performs a dermabrasion on the lower eyelid and eyebrow area to improve fine lines and to reduce the tendency for a noticeable periorbital pigment change. To achieve the required depth and to make sure that the abrasion is uniform, each section of the face usually is replaned three or four times. At the Acne Research Institute, the surgeons alternate between three fraise tips equipped with 40- to 50-grit diamond dust embedded onto a stainless steel shaft (Fig 2). The turbogrinder, which is powered by compressed nitrogen gas, can rotate up to 85,000 revolutions per minute (rpm). The rotating speed of the fraise is controlled by regulating the gas pressure. Usually, the surgeon begins the procedure at a slow speed (10,000 to 20,000 rpm) and progresses to higher speeds (40,000 to 50,000 rpm) because the tissue turgor increases during surgery. This allows the operator to develop a feel for the skin texture and to achieve a deeper cutting effect from the rapid rotation. For large or deep lesions, the surgeon may excise them with a Loo punch or scalpel after the facial planing is completed. He or she closes the excisions with 7-0 polypropylene sutures. The patient then is taken to the recovery room.
Postoperative Phase
W
‘henthe patient is in the recovery room, the caretaker is brought into the room. The nurse gives the caretaker instructions and demonstrates the wound dressing technique. The nurse dresses the patient’s face with water-based hydrogel dressings (Hydragel Vigilone) held in place with cloth tape, 4x4-inch cotton sponges, and roller gauze. After the vital signs have stabilized, the patient is discharged, usually about one hour after the procedure is completed. At home, every 12 hours the patient removes the hydrogel dressings and compresses the surgery sites continuously for 15 to 30 minutes with washcloths soaked in lukewarm tap water. This is an active compress during which four white terry cloths are rotated from tap water to the face every minute. The cloths are pulled down across
the face each time they are changed to provide more debriding Any excessive crust formation is compressed and gently debrided with a 4x4-inch gauze soaked in one-half strength hydrogen peroxide. After cleaning, the sites are dresed with hydrogels, 4x4inch cotton sponges, and roller gauze. The nurse telephones the patient twice daily for the first three days to offer encouragement and to answer any questions. The nurse makes sure that the patient is performing the facial compressions and that he or she does not have an elevated temperature. The patient returns to the office on the second or third day so the surgeon and nurses can evaluate: the healing, check the effectiveness of the patient’s facial compressions, and offer additional encouragement and support. On the fifth or seventh day, the patient returns for suture removal. After the sutures are removed, the patient continues the facial compressions twice a day and the hydrogel is replaced with polymyxin bacitracin (Polysporine) ointment. The purpose of postoperative care is to minimize crusting and to reduce possible bacterial contamination. New skin begins to replace the open wound by the eighth or 10th day. The patient is reexamined between the 10th and 14th day. The patient must avoid excessive sun exposure for one year and use a sunscreen with a protection factor of at least 15. Patients who have had dermabrasion to remove sun-damaged skin must change their living habits so the skin will not be damaged further by more exposure to sunshine. Thirty to 60 days after the procedure, any large tissue defects are filled with liquid collagen or silicone. Repeat dermabrasions may be performed as early as three to four weeks after the procedure. A few patients require two or three procedures to obtain optimal results. Spot dermabrasions can be done as follow-up procedures if no pigmentation problems have developed during the healing phase.
ResultdLIiscussion
M
oderately damaged actinic skin actually responds to the procedure better than acne scars. Of the acne lesions, ice pick-
d) 745
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
Fig 3. Patient (leji) has a hypopigmentation area from a spot dermabrasion done years earlier. A complete facial dermabrasion resulted in a uniform pigmentation on face (right).
type scars respond the best. Results can be improved by excising and suturing larger or deeper scars and using postoperative implants of collagen or silicone for valley-type lesions. Fine wrinkles around the eyes and mouth are uniformly improved. To avoid pigmentation problems, spot dermabrasions are avoided unless previous planings have not caused pigmentation problems (Fig 3). Lesions such as rhinophyma and traumatic scars also respond well (Fig 4). Dermabrasion became popular in the early 1 9 5 0 ~Since ~ then, technical developments have significantly improved results. The use of regional anesthetic blocking of the facial nerves3has made dermabrasion a tolerable office procedure, especially if a long-acting local anesthetic is used. The development of high-speed diamond fraise equipment has provided surgeons with the necessary torque for uniform planing! Also, the Loo punches of different diameters allow surgeons 748
to excise large ice pick scars during dermabrasion. Large linear scars can be excised with a conventional scalpel during the dermabrasion. If the sutures are removed early enough, usually at the five- or seven-day office visit, the excisions leave no significant scarring. The development of hydrogel wound dressings have improved wound healing and reduced scarring.5 Postoperative augmentation with liquid collagen or silicone has enabled surgeons to complete aesthetic improvements. By completing the standard forms and protocols developed at the Institute, surgeons and nurses can ensure that no patient undergoes surgery without a complete evaluation. It is imperative to separate those who are good candidates from those who are seeking unrealistic results or who are emotionally incapable of withstanding the rigors of this surgery. Formal psychological testing and evaluation may be necessary for some patients.
MARCH 1990, VOL. 51, NO 3
AORN JOURNAL
Fig 4. Dermabrasions removed patient’s rhinophyma lesions (above) iind traumatic scars caused by an automobile accident (below).
749
AORN JOURNAL
Standardized checklists are needed to ensure that the necessary blood work is completed and to avoid serious emergencies that can occur when equipment is out of order or improperly set up. It also is needed to ensure that patient photographs are taken to document progress, both before and after surgery. A well-trained medical and nursing support group is needed to ensure full patient education and disclosure. The more the patient understands, the more cooperative, relaxed, and satisfied he or she will be. The purpose of extensive preoperative preparations and postoperative wound care is to stimulate wound healing. Although the skin often will heal after the dermabrasion with no particular wound care oust letting the crusts fall off naturally in 12 to 14 days), an occasional bacterial contamination or fissure may retard wound healing, which can cause a keloid or hypopigmented area. To minimize that risk, it is best to keep the wound moist with hydrogels and gently and thoroughly remove the crust. At the Institute, the surgeons and nurses prefer dermabrasion over chemical peels for acne scars. Previously, we combined dermabrasion with a chemical peel using phenol around the eyes and lips. As surgeons became accustomed to the diamond fraise technique, they discovered that they could do the lower eyelid and around the lips, so phenol peels became unnecessary. Finally, surgeons and nurses must develop excellent patient rapport. Following the patient closely before, during, and after the procedure builds trust, increases communication, and provides confidence. By using the forms and following established protocols, they can thoroughly prepare the patient and staff, thus ensuring the best possible result. 0 Notes 1. J W Burks, Dermabrasion and Chemical PeeIing in the Treatment of Certain Cosmetic Defects and Dkeases ofthe Skin, second ed (Springfield, Ilk Charles C Thomas Publishing, 1979); H H Roenigk, Jr,
“Dermabrasions for miscellaneous cutaneous lesions,” J o u m l of Dermatologic Surgery and Oncology 3
(May/June 1977) 322-328. 2. A Kirtin, “Corrective surgical planing of skin: New technique for treatment of acne scars and other skin 750
MARCH 1990, VOL. 51, NO 3
defects,” Archives ojDermatology 68 (1953) 389-397; J W Burks, Wire Brush Surgery in the Treatment of Certain Cosmetic Dejects and Diseases of the Skin (Springfield, Ill: Charles C Thomas Publishing, 1956). 3. W R Panje, “Local anesthesia of the face,” Journal of Dematologic Surgery and Oncology 5 (April 1979) 311-315; D M Abadir, A R Abadir, “Dermabrasion under regional anesthesia without refrigeration of the skin,” Journal of Dematologic Surgery and Oncology 6 (February 1980) 119-121. 4.J E Fulton, “Dermabrasion by diamond fraises revolving at 85,000 revolutions per minute,” Journal o j Dermatologic Surgery and Oncology 4 (October 1978) 777-779; R Stolar, “Abrasive planing with highspeed cutting tool (30,000 to 85,000 rpm) Dermatologic Clinics 2 (1984) 285-291. 5. W C Coats, The Silent Healer: A Modern Study o j Aloe Vera (Dallas: W C Coats, 1987) 6 8 L Z Lornezetti et al, “Bacteriostatic property of aloe Vera,” Journal of Pharmaceutical Science 53 (1964) 12871291; S H Mandy, “A new primary wound dressing made of polyethylene oxide gel,” Journal o j Dermatologic Surgery and Oncologv 9 (February 1983) 153155.
Role Playing Increases Nurse Morale Nontraditional methods of teaching can improve morale and patient relations skills of nursing staff members. According to an article in the Nov 22, 1989, issue of Legislative Network for Nurses, role playing using case vignettes increases the amount of information adult learners retain. Lectures and assigned reading material are the least effective ways of teaching in terms of students’ retained information. Vignettes should be based on the real world and on instructors’ experiences when possible. They should be brief, contain no single correct solution, and include suggested questions. According to the article, this technique sharpens students’ analytical skills, provides a forum for sharing ideas, and encourages creative thinking. The article is a report on the Annual Scientific Meeting of the Gerontological Society of America.
______
AORN JOURNAL
Facial Dermabrasion MODERN
TECHNIQUES AND PROTOCOLS
Candace C. McKinnon, RN; James E. Fulton, Jr, MD
D
ermabrasion is an effective method for removing facial scars, premature wrinkles, solar keratoses, and related skin 1esions.l With proper patient selection and proper surgical techniques, a patient can have significant improvement (Fig 1). Results, however, are never perfect. Standard checklists, operative techniques, and patient follow-up procedures have improved the results and reduced the complications. Avoiding medical and legal pitfalls can be achieved best by using forms and protocols that ensure full disclosure between the patient and the surgeon. The techniques and standard protocols that have been developed at the Acne Research Institute, Newport Beach, Calif, are presented in this article.
emphysema or postnasal drip because they may cause problems during intravenous (IV) sedation. Habitual use of drugs such as diazepam, amphetamines, tranquiliz,ers,sedatives, marijuana, or alcohol also influences the effect of anesthesia. It is crucial to assess the patient’s dietary history because unbalanced nutrition, especially low protein intake, can compromise wound healing. Review of mental status. It is important to
Patient Selection
P
roper patient selection is probably the most important factor to ensure positive results and patient satisfaction. Three to four weeks before surgery, the surgeon and nurse complete a predermabrasion evaluation. The evaluation includes the following. Current evaluation of the skin condition. The best results are obtained if the underlying skin condition is under control. Any previous history of facial planing, x-ray treatments, or chemical peels will affect the results. Facial pigmentation also is evaluated. Blotchy, very dark, or discolored skin tones may cause pigmentary problems after the procedure. Evaluation of medical history. Of special importance are respiratory problems such as
Candace C. McKinnon, RN,is a senior acne nurse special&, Acne Research Institute, Newport Beach, Calif: She earned her associate of science degree in nursingfrom Brigham Young University, Provo, Utah. James E. Fulton, Jr, MD, PhD, is a research scientist, Acne Research Institute, Newport Beach, Calg He earned his doctor of medicine degree at Tulane Medical School, New Orleans, and his doctorate of philosophy in biochemistryfrom the University of Miami. 739
AORN J O U R N A L
MARCH 1990, VOL. 51, NO 3
Fig I . Patients before and after dermabrasion procedures. Patient with typical ice pick scarring underwent two dermabrasions (top); a patient with more extensive scamng needed two dermabrasions,excision and suturing of scarred areas, and liquid collagen injections to fill residual valley-like lesions (bottom). 740
MARCH 1990, VOL. 51, NO 3
assess the patient’s general attitude and expectations, and how he or she copes with stress. A patient expecting perfect results will be disappointed. A previous history of a nervous breakdown or mental disorder, such as schizophrenia, may indicate the patient will have difficulty handling the emotional stress during or after the procedure. Group discussion. The patient, physician, registered nurses, and office manager all participate in the group discussion. It is important because one group member may uncover something the others should know and consider. All members in the group discussion should agree that the patient is a qualified candidate before proceeding with a dermabrasion. Laboratory workup. Routine tests include a complete blood count, prothrombin time, and complete serum chemistries along with a hepatitis and human immunodeficiency virus (HIV) screen. We obtain special permission to check for the HIV. The patient should not have any significant blood abnormalities.
Patient Education
T
he surgeon and registered nurses complete the patient education in five phases. In the first phase, they discuss with the patient the dermabrasion technique and potential complications. During the session, patients are required to read a handout describing the technique, watch a videotape demonstration of an actual dermabrasion procedure, and review a series of before-and-after photographs. The photographs show positive previous results, the appearance of the face at intervals during the healing phase, and potential complications such as milia, hypopigmentation or hyperpigmentation, and keloid formation. The surgeon and nurse also review the risks of wound infections, delayed wound healing, and intravenous sedation. This is done approximately two weeks before the procedure to allow the patient adequate time to consider the procedure in-depth and to answer all his or her questions. In the second phase, extensive step-by-step predermabrasion and postdermabrasion instruc-
___-
AORN J O U R N A L
Home Care Kit Contents antiseptic :scrub (povidone-iodine) hydrogel dressings wash cloths hydrogen peroxide cloth tape antibiotic ointment shaving cream petrolatum disposable forceps and scissors thermometer a home-care record extra surgery instruction sheets 4x4-inch cotton sponges roller gauze
tion sheets are reviewed with the patient to clarify the procedures and terminology. Patients take the sheets home to review. They are encouraged to write down any further questions to discuss at the next visit. In the nest phase, the patient signs an initial informed consent form. This is an important part of the education process because it serves to review and solidify the information previously discussed. Patients sign the informed consent two weeks before the procedure so they will not be surprised by the wording on the form on their surgery day. Patients, however, must re-sign the informed consent form on the day of surgery because it must be signed within 48 hours of the procedure. In the fourth phase, the patient receives a 60minute audiotape to take home. One side of the tape reviews the technique and instructions; the other side teaches deep-breathing and relaxation exercises to use during surgery. The patient is instructed to listen to the tape several times. In the final phase five days before the procedure, the patient and his or her primary postoperative caretaker (eg , parent, spouse) receive the home care kit. (See “Home Care Kit Contents.”) At this point, the nurse answers any questions the patient may have and reviews the preoperative and postoperative instructions, which include instructions on shampooing the scalp and face with (+
741
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
Fig 2. The turbogrinder and three fraises equipped with 40- to 50-grit diamond dust. The variable speed dermabrader, which is powered by compressed nitrogen gas, will rotate up to 85,000 rpm. povidone-iodine soap the night before and the morning of the procedure. The nurse also teaches the patient and caretaker how to use the home care kit for postoperative wound care. The kit contains essentially everything needed during the first 10 days of postoperative care. The patient also receives prescriptions for ampicillin, acetaminophen with codeine, and flurazepam hydrochloride (Dalmanes).
Preoperative Phase
T
he patient begins sedation the night before surgery by ingesting 100 to 200 mg of dimenhydrinate (Dramamine@). In the office one hour before the procedure, the patient takes another 100 to 200 mg of dimenhydrinate plus 100 mg of secobarbital sodium (SeconaP). These two agents have been suggested by physicians as safe, reliable preoperative medications. They provide sedation with minimal cardiac complications. Before the dermabrasion begins, the nurse starts an intravenous drip of dextrose 5%in water. Five to 10 minutes before the procedure starts, the nurse administers IV meperidine hydrochloride 50 mg and diazepam 5 mg. These agents help alleviate 744
the anxiety and discomfort of the surgery. One or two additional IV injections may be repeated, as needed, during the procedure, provided the patient’s vital signs are stable. The most important anesthetic effect is achieved by regional blocking of facial sensory nerves. The physician injects into the facial nerves approximately 20 to 40 mL of lidocaine hydrochloride (Xylocaines) and bupivacaine hydrochloride (Marcaines) at a 3:l ratio. On a steriledraped Mayo stand, the scrub nurse sets up the turbogrinder and diamond fraises, 4x4inch cotton sponges, needle holders, Loo punches, sutures, forceps, #15 scalpels, and vis scissors. The nurse scrubs the patient’s face with povidoneiodine and drapes him or her with sterile plastic sheeting.
Surgical Phase
T
he surgeon begins the surgical procedure on the right cheek, proceeds to the left cheek, and then to the forehead, nose, and perioral area. In all patients, care is taken to go approximately %-inch below the jawline and %inch into the hairline to achieve a uniform color and smooth appearance postoperatively.
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
The surgeon also performs a dermabrasion on the lower eyelid and eyebrow area to improve fine lines and to reduce the tendency for a noticeable periorbital pigment change. To achieve the required depth and to make sure that the abrasion is uniform, each section of the face usually is replaned three or four times. At the Acne Research Institute, the surgeons alternate between three fraise tips equipped with 40- to 50-grit diamond dust embedded onto a stainless steel shaft (Fig 2). The turbogrinder, which is powered by compressed nitrogen gas, can rotate up to 85,000 revolutions per minute (rpm). The rotating speed of the fraise is controlled by regulating the gas pressure. Usually, the surgeon begins the procedure at a slow speed (10,000 to 20,000 rpm) and progresses to higher speeds (40,000 to 50,000 rpm) because the tissue turgor increases during surgery. This allows the operator to develop a feel for the skin texture and to achieve a deeper cutting effect from the rapid rotation. For large or deep lesions, the surgeon may excise them with a Loo punch or scalpel after the facial planing is completed. He or she closes the excisions with 7-0 polypropylene sutures. The patient then is taken to the recovery room.
Postoperative Phase
W
‘henthe patient is in the recovery room, the caretaker is brought into the room. The nurse gives the caretaker instructions and demonstrates the wound dressing technique. The nurse dresses the patient’s face with water-based hydrogel dressings (Hydragel Vigilone) held in place with cloth tape, 4x4-inch cotton sponges, and roller gauze. After the vital signs have stabilized, the patient is discharged, usually about one hour after the procedure is completed. At home, every 12 hours the patient removes the hydrogel dressings and compresses the surgery sites continuously for 15 to 30 minutes with washcloths soaked in lukewarm tap water. This is an active compress during which four white terry cloths are rotated from tap water to the face every minute. The cloths are pulled down across
the face each time they are changed to provide more debriding Any excessive crust formation is compressed and gently debrided with a 4x4-inch gauze soaked in one-half strength hydrogen peroxide. After cleaning, the sites are dresed with hydrogels, 4x4inch cotton sponges, and roller gauze. The nurse telephones the patient twice daily for the first three days to offer encouragement and to answer any questions. The nurse makes sure that the patient is performing the facial compressions and that he or she does not have an elevated temperature. The patient returns to the office on the second or third day so the surgeon and nurses can evaluate: the healing, check the effectiveness of the patient’s facial compressions, and offer additional encouragement and support. On the fifth or seventh day, the patient returns for suture removal. After the sutures are removed, the patient continues the facial compressions twice a day and the hydrogel is replaced with polymyxin bacitracin (Polysporine) ointment. The purpose of postoperative care is to minimize crusting and to reduce possible bacterial contamination. New skin begins to replace the open wound by the eighth or 10th day. The patient is reexamined between the 10th and 14th day. The patient must avoid excessive sun exposure for one year and use a sunscreen with a protection factor of at least 15. Patients who have had dermabrasion to remove sun-damaged skin must change their living habits so the skin will not be damaged further by more exposure to sunshine. Thirty to 60 days after the procedure, any large tissue defects are filled with liquid collagen or silicone. Repeat dermabrasions may be performed as early as three to four weeks after the procedure. A few patients require two or three procedures to obtain optimal results. Spot dermabrasions can be done as follow-up procedures if no pigmentation problems have developed during the healing phase.
ResultdLIiscussion
M
oderately damaged actinic skin actually responds to the procedure better than acne scars. Of the acne lesions, ice pick-
d) 745
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
Fig 3. Patient (leji) has a hypopigmentation area from a spot dermabrasion done years earlier. A complete facial dermabrasion resulted in a uniform pigmentation on face (right).
type scars respond the best. Results can be improved by excising and suturing larger or deeper scars and using postoperative implants of collagen or silicone for valley-type lesions. Fine wrinkles around the eyes and mouth are uniformly improved. To avoid pigmentation problems, spot dermabrasions are avoided unless previous planings have not caused pigmentation problems (Fig 3). Lesions such as rhinophyma and traumatic scars also respond well (Fig 4). Dermabrasion became popular in the early 1 9 5 0 ~Since ~ then, technical developments have significantly improved results. The use of regional anesthetic blocking of the facial nerves3has made dermabrasion a tolerable office procedure, especially if a long-acting local anesthetic is used. The development of high-speed diamond fraise equipment has provided surgeons with the necessary torque for uniform planing! Also, the Loo punches of different diameters allow surgeons 748
to excise large ice pick scars during dermabrasion. Large linear scars can be excised with a conventional scalpel during the dermabrasion. If the sutures are removed early enough, usually at the five- or seven-day office visit, the excisions leave no significant scarring. The development of hydrogel wound dressings have improved wound healing and reduced scarring.5 Postoperative augmentation with liquid collagen or silicone has enabled surgeons to complete aesthetic improvements. By completing the standard forms and protocols developed at the Institute, surgeons and nurses can ensure that no patient undergoes surgery without a complete evaluation. It is imperative to separate those who are good candidates from those who are seeking unrealistic results or who are emotionally incapable of withstanding the rigors of this surgery. Formal psychological testing and evaluation may be necessary for some patients.
MARCH 1990, VOL. 51, NO 3
AORN JOURNAL
Fig 4. Dermabrasions removed patient’s rhinophyma lesions (above) iind traumatic scars caused by an automobile accident (below).
749
AORN JOURNAL
Standardized checklists are needed to ensure that the necessary blood work is completed and to avoid serious emergencies that can occur when equipment is out of order or improperly set up. It also is needed to ensure that patient photographs are taken to document progress, both before and after surgery. A well-trained medical and nursing support group is needed to ensure full patient education and disclosure. The more the patient understands, the more cooperative, relaxed, and satisfied he or she will be. The purpose of extensive preoperative preparations and postoperative wound care is to stimulate wound healing. Although the skin often will heal after the dermabrasion with no particular wound care oust letting the crusts fall off naturally in 12 to 14 days), an occasional bacterial contamination or fissure may retard wound healing, which can cause a keloid or hypopigmented area. To minimize that risk, it is best to keep the wound moist with hydrogels and gently and thoroughly remove the crust. At the Institute, the surgeons and nurses prefer dermabrasion over chemical peels for acne scars. Previously, we combined dermabrasion with a chemical peel using phenol around the eyes and lips. As surgeons became accustomed to the diamond fraise technique, they discovered that they could do the lower eyelid and around the lips, so phenol peels became unnecessary. Finally, surgeons and nurses must develop excellent patient rapport. Following the patient closely before, during, and after the procedure builds trust, increases communication, and provides confidence. By using the forms and following established protocols, they can thoroughly prepare the patient and staff, thus ensuring the best possible result. 0 Notes 1. J W Burks, Dermabrasion and Chemical PeeIing in the Treatment of Certain Cosmetic Defects and Dkeases ofthe Skin, second ed (Springfield, Ilk Charles C Thomas Publishing, 1979); H H Roenigk, Jr,
“Dermabrasions for miscellaneous cutaneous lesions,” J o u m l of Dermatologic Surgery and Oncology 3
(May/June 1977) 322-328. 2. A Kirtin, “Corrective surgical planing of skin: New technique for treatment of acne scars and other skin 750
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Role Playing Increases Nurse Morale Nontraditional methods of teaching can improve morale and patient relations skills of nursing staff members. According to an article in the Nov 22, 1989, issue of Legislative Network for Nurses, role playing using case vignettes increases the amount of information adult learners retain. Lectures and assigned reading material are the least effective ways of teaching in terms of students’ retained information. Vignettes should be based on the real world and on instructors’ experiences when possible. They should be brief, contain no single correct solution, and include suggested questions. According to the article, this technique sharpens students’ analytical skills, provides a forum for sharing ideas, and encourages creative thinking. The article is a report on the Annual Scientific Meeting of the Gerontological Society of America.