Guidelines of care for dermabrasion

Guidelines of care for dermabrasion

This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the result...

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This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Guidelines of care for dermabrasion Committee on Guidelines of Care: Lynn A. Drake, MD, Chairman, Roger 1. Ceilley, MD, Raymond L. Cornelison, MD, William L. Dobes, MD, William Dorner, MD, Robert W. Goltz, MD, Charles W. Lewis, MD, Stuart J. Salasche, MD, Maria L. Chanco Turner, MD, and Barbara J. Lowery, MPH Task Force on Dermabrasion: Stephen H. Mandy, MD, Chairman, Kenneth G. Gross, MD, and John M. Yarborough, MD

1. Introduction The American Academy of Dermatology's Committee on Guidelines of Care is developing guidelines of care for our profession.The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration. II. Definition Dermabrasion is the surgical process by which the skin is resurfaced by planing or sanding, usually by means of a rapidly rotating abrasive tool such as a wire brush, diamond fraise, or serrated wheel. III. Rationale A. Scope Dermabrasion is a useful and widely practiced procedure for cutaneous lesions or scars that are superficial in nature and may not require advanced surgicalintervention. Indications for this procedure include, but are not limited to, the following: 1. Scars-postacne, traumatic, surgical 2. Tattoos-professional, amateur, traumatic 3. Telangiectases 4. Melasma

Reprint requests: AmericanAcademy of Dermatology, P.O. Box4014, Schaumburg, IL 60168-4014. JAM ACAD DERMATOL 1994;31:654-7. Copyright © 1994 by the American Academy of Dermatology, Inc. 0190-9622/94 $3.00 + 0 16/1/57561


5. Epidermal nevi 6. Adenoma sebaceum 7. Actinic keratoses 8. Syringomas 9. Rhytides 10. Cysts and milia 11. Trichoepitheliomas 12. Rhinophyma 13. Recalcitrant acne 14. Seborrheic keratoses IS. Other B. Issue Physician qualifications 1. General a) Completed residency training or board certified in appropriate specialty such as dermatology b) Knowledge of the skin and subcutaneous tissues c) Knowledge of the management of potential complications d) Knowledge of appropriate anesthesia techniques 2. Specific a) The physician should have had training in dermabrasion in residency; or b) Attendance at an appropriate dermabrasion course or preceptorship, which may include video and live surgery demonstrations. c) All physicians performing dermabrasions should have experience at the surgical table under the supervision of a physician experienced in this technique. IV. Diagnostic criteria A. Clinical Selection and evaluation of the patient are es-

Journal of the American Academyof Dermatology Volume 31, Number 4

sential in determining the feasibility of the operation. 1. History In addition to the general medical status, the history may include relevant factors such as the following: a) Clotting disorders or bleeding b) Herpes simplex or other infections c) Hypertrophic or keloidal scarring d) Adverse reaction to medications e) Cold intolerance .f} Lupus erythematosus g) Immunosuppression h) Koebnerizing conditions i) Recent history of taking 13-cis-retinoic acid (Accutane) j) Use of any systemic medications that interfere with clotting, and/or drugs that may potentiate or interfere with analgesics and/or anesthetics k) Use of topical medications I) Other 2. Physical examination The skin should be examined for the following: a) Tone b) Elasticity c) Symmetry d) Signs of previous normal or abnormal healing e) Specific pathology in the area to be treated, such as the following: 1) Scarring 2) Pigmentary alterations 3) Telangiectases 4) Bacterial or viral infections (e.g., verrucae, molluscum, herpes simplex) fJ Pigmentation Dermabrasion is not restricted on the basis of skin pigmentation, although patients with skin of intermediate or dark color have a greater propensity for pigmentary alteration. g) Other B. Diagnostic tests Physicians may obtain laboratory studies predicated on the history and physical examination of the patient. 1. Specialized tests Because of the aerosolization of blood and tissue products in particles of sufficiently small size that they maybe inhaled through surgical masks and may settle deep within the lungs, strong consideration should be

Drake et al. 655 given to obtaining any special tests the physician may deem appropriate. 2. Biopsy Histologic documentation and/or confirmation of pathologic lesions to be treated may be necessary before dermabrasion. 3. Photographs may be obtained preoperatively. C. Inappropriate diagnostic tests Not applicable D. Exceptions Not applicable E. Evolving diagnostic tests Not applicable V. Recommendations A. Treatment I. Medical Not applicable 2. Surgical (See "Guidelines of Care for Office Surgical Facilities, Parts I and II") Regional dermabrasion may be util ized for various indications such as scars. It usually can be accomplished with local anesthesia without additional supplemental analgesia. Full-face dermabrasion or dermabrasion for large areas may require supplemental analgesia in addition to local anesthesia. a) Anesthesia 1) Local and/or topical 2) Local with sedation, which may include oral, intramuscular, or intravenous medication 3) Cryoanesthesia 4) Regional nerve blocks 5) General anesthesia b) Monitoring Monitoring should conform to standards generally recognized as appropriate for the type of anesthesia employed. c) Procedure Most dermabrasive techniques employ a rapidly rotating wire brush or diamond fraise applied to lightly frozen skin. Variations such as sal abrasion or rapidly moved fine grit emery papers are employed in certain instances. 1) Diamond fraise is more easily utilized and has a greater margin of safety. Coarseness varies from fine to extra coarse, and the selection depends on the indication and the experience of the surgeon. 2) The wire brush is generally agreed to have greater abrasive capability than the diamond fraise. In general, the


Drake et al. wire brush requires considerable supervised training. 3) Intraoperative freezing Intraoperative freezing with cryoanesthetic materials makes the skin rigid and preserves anatomic landmarks to facilitate the abrasive technique. Prolonged freezing and repeated freeze/thaw cycles should be avoided. Intraoperative freezing is utilized at the discretion of the physician. 4) Sterility (a) Dermabrasion of the skin cannot be a completely sterile technique. (b) Techniques of preoperative skin cleansing vary among the surgeons. (c) Surgical instruments in contact with the skin should be sterile. d) Surgical setting 1) Dermabrasion may be performed in a physician's office, ambulatory surgery center, or hospital operating room. 2) Officeor surgical center settings are the most common. (a) They are convenient for patients and physicians. (b) They decrease the risk of nosocomial infection. (c) They are cost effective. e) Safety All applicable OSHA regulations includingpracticing universal precautions should be followed. j) Preoperative 1) Patient education and informed consentSpecial attention should be paid to ensure that the patient understands the procedure and its limitations and that the patient has realistic expectations. 2) Patients with active acne should be successfully treated for acne before dermabrasion. 3) The effect of preoperative l3-dsretinoic acid in the treatment of acne on postoperative healing has not yet been fully defined. Some reports in the literature suggest that 13-cisretinoic acid taken before dermabrasion may cause atypical postoperativescarring. Other reports deny this association. All patients who have

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been treated previously with I3-cisretinoic acid should be warned of the potential for atypical scarring. 4) Acyclovir may be given prophylactically to patients with a history of herpes simplex and continued until the abrasion is healed. 5) Topical treatmentwith tretinoin may shorten the time for reepithelialization after dermabrasion. Preoperative use is at the discretion of the surgeon. g) Postoperative care 1) Hemostasis Postoperative bleeding is rarely a problem after dermabrasion. 2) Biosynthetic dressings Biosynthetic dressings may decrease healing time and the degree of pain and are used at the discretion of the surgeon. 3) Antiinflammatory agents Systemic corticosteroids maybe used postoperatively to attempt to reduce facial swelling and patient discomfort. 4) Analgesics Biosynthetic dressings may substantially reduce postoperative pain. The use of mild narcotic-containing analgesics may be helpful for pain relief in the immediate postoperative period. Pain after 2 days is unusual and may herald infection (herpetic or bacterial). 5) Postoperative activity Most patients are ambulatory after surgery but are encumbered by the facial bandages necessary to maintain occlusivedressings. They should not drive immediately after surgery. 6) Sun protection Prudent sun protection of dermabraded areas is indicated until erythema fades. Protective clothing and/or use of high SPF sunscreen may facilitate this. 7) Antibiotics The use of antibiotics preoperatively and/or postoperatively is at the surgeon's discretion. 8) Other h) Usual postoperative findings 1) Edema 2) Bleeding 3) Serous drainage

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4) Discomfort 5) Erythema after reepithelialization 6) Itching 7) Milia formation 8) Pigment alteration 9) Other i) Occasional postoperative occurrences 1) Persistent edema 2) Persistent erythema 3) Persistent telangiectasia 4) Hyperpigmentation 5) Hypopigmentation 6) Scarring 7) Adverse drug reaction 8) Acne flare 9) Vasolability 10) Persistent sensitivity to sunlight 11) Depression 12) Other j) Complications (rare) 1) Marked and disfiguring pigmentary change 2) Scarring 3) Infection 4) Avulsion laceration of lip or eyelid 5) Other 3. Other Adjunctive therapy a) Dermal filling agents b) Chemical peels c) Punch grafting d) Lipoaugmentation e) Topical retinoids and a-hydroxy acids j} Repeated dermabrasions are sometimes useful g) Other B. Miscellaneous Not applicable VI. Supporting evidence See Bibliography (Appendix) VII. Disclaimer Adherence 'to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments

Drake et al. 657 may include agents that are not currently approved by the U.S. Food and Drug Administration.

Appendix. Bibliography Alt TH. Facial dermabrasion: advantages of the diamond fraise technique. J Dermatol Surg OncoI1987;13:618-24. Alt TH. Technical aids for dermabrasion. J Dermato1 Surg Oncol1987;13:638-48. Alvarez OM, Mertz PM, Eag1steinWHo The effect of occlusive dressings on collagen synthesis in superficial wounds. J Surg Res 1983;35:142-8. Burke J. Wire brush surgery. Springfield, Ill: Charles C Thomas, 1956. Burke J. Marascalco J, Clark W. Half-face planing of precancerous skin after five years. Arch DermatoI1963;88:140. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for office surgical facilities. Part I. J AM ACAD DERMATOL 1992;26:763-5. Drake LA, Dorner W, Goltz RW, et al. Guidelines of care for officesurgical facilities. Part II. J AM ACAD DERMATOL (In press.) Dzubow LM. Survey of refrigeration and surgical techniques used for facial dermabrasion, J AM ACAD DERMATOL ] 985;13:287-92. Dzubow LM, Miller WH Jr. The effect of 13-cis-retinoic acid on wound healing in dogs. J Dermatol Surg Oneal 1987; 13:265-8. Field L. Dermabrasion versus 5 fluorouracil in the management of actinic keratoses. In: Epstein I. Controversies in dermatology. Philadelphia: WB Saunders, 1984:62-102. Hanke CW, O'Brien JJ, Solow EE. Laboratory evaluation of skin refrigerants used in dermabrasion. J Dermato1 Surg Oncol1985;1l:45-9. Hanke CW, Roenigk HH Jr, Pinski JE. Complications of dermabrasion resulting from excessively cold skin refrigeration. J Dermato1 Surg OncoI1985;11:896-900. Hung VC, Lee JV, Zitelli JA, Hebda PA. Topical tretinoin and epithelial wound healing. Arch Dermatol 1989;125:65-9. Kurtin A. Corrective surgical planing of the skin. Arch Dermatal SyphiloI1953;68:389. Maibach H, Rovee D. Epidermal wound healing. Chicago: Year-Book Medical Publishers, 1972, Mandy SH. A new primary wound dressing made of polyethylene oxide gel. J Dermatol Surg Oncol 1983;9:153-5. Mandy SH. Tretinoin in the preoperative and postoperative management of dermabrasion. J AM ACAD DERMATOL 1986;15:878-9, 888-9. Moy R, Zitelli J, Ditto J. Effects of systemic 13-cisretinoic acid on wound healing in vivo [Abstract]. J Invest Dermatol 1987;88:508. Roenigk HH Jr, Pinski JB, Robinson JK, et al. Acne, retinoids, and dermabrasion. J Dermatol Surg Oneal 1985;11:396-8. Rubenstein R, Roenigk HH Jr, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J AM ACAD DERMATOL 1986;15:280-5. Wentzell JM, Robinson JK, Wentzell JM Jr, et al. Physical properties of aerosols produced by dermabrasion. Arch DermatoI1989;125:1637-43. Yarborough JM Jr. Dermabrasion by wire brush. J Dermatol Surg Oneol 1987;13:610-5. Yarborough 1M Jr. Dermabrasive surgery: state of the art. Clin DermatoI1987;5:75-80.