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DERMATO SURGERY
Year : 2000  |  Volume : 66  |  Issue : 2  |  Page : 79-84

Facial dermabrasion in acne scars and genodermatoses-A study of 65 patients



Correspondence Address:
S S Savant


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PMID: 20877033

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  Abstract 

bermabrasion is sequential planing of the raised skin/lesions to the desired depth. Facial dermabrasion was carried out in 65 patients (acne scars -48, adenoma sebaceum 12, multiple trichoepitheliomas 4, barier's diease-1). Preancillary acne scar revision in 34/48 patients and excision of larger papules and electrodesiccation was performed in 10/12 adenoma sebaceum. In acne scars, 35/48 showed good to excellent and 13/48 poor results. In adenoma sebaceum, 9/12 had excellent and 3 satisfactory results. Preancillary procedures enhanced results in both conditions. Excellent results were obtained in 3/4 multiple trichoepitheliomas and in barier's disease. Repeat dermabrasion was helpful in 7/65 patients. Side effects seen were persistent hypopigmentation 41, persistent erythema 30, milia 20, hyperpigmentation 15 and exacerbation of acne 3. Complications encountered were small deep scars 8, recurrence of adenoma sebaceum 3, gouging 2, secondary infection 2, oval large atrophic hypo-depigmented scar I and hypertrophic linear scar 1. Facial dermabrasion is a useful dermatosurgical modality to treat various skin disorders.


Keywords: Dermabrasion, Acne scars, Trichoepitheliomas, Adenoma sebaceum, Darier′s disease


How to cite this article:
Savant S S. Facial dermabrasion in acne scars and genodermatoses-A study of 65 patients. Indian J Dermatol Venereol Leprol 2000;66:79-84

How to cite this URL:
Savant S S. Facial dermabrasion in acne scars and genodermatoses-A study of 65 patients. Indian J Dermatol Venereol Leprol [serial online] 2000 [cited 2019 Aug 20];66:79-84. Available from: http://www.ijdvl.com/text.asp?2000/66/2/79/4875



  Introduction Top


Dermabrasion (DA) consists of sequential planing of the raised skin/lesions with electrical and/ or manual abraders and allowing the wound to heal by secondary intention, so as to achieve a levelling effect to make the lesions less conspicuous. [1],[2] Facial DA carried out on entire face is primarily utilised for its cosmetic as well as therapeutic value in treating exophytic genodermatoses or various facial skin tumours such as adenoma sebaceum, multiple trichoepitheliomas, Darier's disease, multiple neurofibromatosis, syringomas etc. [1],[2],[3],[4],[5] In this study, facial DA performed in 65 patients for various conditions such as acne scars, adenoma sebaceum, multiple trichoepitheliomas and Darier's disease is reported herewith.


  Materials and Methods Top


Sixty-five patients (45 females and 20 males, age range 16-54) participated in this study. Facial DA was carried out in -acne scars 48, adenoma sebaceum 12, multiple trichoepitheliomas 4, and Darier's disease 1. The acne scars varied in shape from circular, oval, linear to irregular and had depressed bases. They were either shallow or deep, varied in size from 2 to 50mm and ranged in number from 30 to 70. Nineteen patients gave a history of sporadic activity. These were first treated with broad spectrum antibiotic and local exfoliating agents and then subjected to DA. Prior acne scar revision (ASR) was carried out in 34/48 patients in one or more sittings, 6-8 weeks prior to DA. These were subcision followed by cryoslush punch excision and suturing, punch incision and elevation, punch excision and graft replacement and elliptical excision and suturing. The other 14 patients were taken up directly for DA because they had scars covering more than 70% of the face. Small to medium sized papular lesions in 10/12 cases of adenoma sebaceum were electrodesiccated and large lesions were excised 6-8 weeks prior to DA. Four cases of multiple trichoepitheliomas, two cases of adenoma sebaceum and single case of Darier's disease were taken up directly for DA.

Haemogram, blood sugar, BT, CT, PT, routine urinalysis, X-ray chest, ECG and screening for syphilis (VDRL), HIV and hepatitis B were done for all patients. Biopsy was performed to confirm all genetic disorders. BCG scars or old scars were examined for keloidal tendency and written consent was obtained along with fitness for general anaesthesia (GA).

Main instruments used were manual metallic dermabraders, motor driven wire brushes or diamond fraises mounted on electric hand machine and number 80 and 110 sand (water) papers. After surgical preparation and isolation, 60 patients were given GA of IV ketamine hydrochloride combined with local tumescent anaesthesia consisting of 1 litre of normal saline, 50 ml of 1% xylocaine, 1 ml of 1: 1000 adrenaline and 12.5 ml of sodabicarbonate 1 m eq. The other 5 patients were given GA of halothane after napentothal induction and intubation combined with local tumescent anaesthesia. In acne scar cases, first the marked scars were individually smoothened out by abrading their bases and edges.Submandibular margin was established in all cases by dermabrading along the marked line from ear to the chin on both sides. The infraorbital margin was then established by dermabrading downwards on to the cheeks and sideways on to the temporal regions leaving 2-3 cm of the skin around the eyes unabraded. Initially the face was abraded superficially to get rid of epidermis and reach the superficial papillary dermis. Further deep DA was carried out in the following order of cosmetic units-right cheek, chin, left cheek, forehead, glabella, nose and upper lip till the junction of deep papillary and upper reticular dermis. In patients of adenoma sebaceum, multiple trichoepitheliomas and Darier's disease, all the raised lesions were flattened with proper contouring. DA was then continued with manual metallic dermabraders, till the junction of upper and mid reticular dermis. Important landmarks corresponding to the level of depth in the skin were standardised while dermabrading and were as follows:

1. Loss of skin pigment-epidermis

2. Multiple tiny punctate bleeding points-Superficial papillary dermis.

3. Change in bleeding pattern with appearance of larger rapidly bleeding points with low field density­Junction of mid to deep papillary dermis.

4. Whitish pink parallel ridges - Junction of upper and mid reticular dermis.

5. Break in these ridges with fraying - Junction of upper and mid reticular dermis. (Optimum depth and termination point).

Finally two rubs were given with no. 80 followed by no. 110 water papers to smoothen out the surface. Haemostasis was achieved by pressure and the wounds were covered with double layer of framycetin tulle. All patients were given broad specrum antibiotic, anti-inflammatory drugs and analgesics for the first few days. Tapering doses of steroids were used IV or orally (1-4mg of dexamethasone) for first 3-4 days. There was considerable oedema, pain and serous discharge in the first 48-72 hours. Gradually the discharge reduced and the tulle adhered to the underlying wound surface. It came off completely by 10th - 15th day. Patients remained hospitalised for first 10-15 days and were further sun protected by avoiding direct sunlight or by using umbrella, sun screening agents with SPF of 15 and above and emollients for next 2­3 months. All 65 patients were followed up for 6 months, 52 for one year, and16 for 3 years.


  Results Top


In all patients abraded area healed with erythema, hypopigmentation and demarcation at the submandibular margin which reduced over next 3­12 months. Out of the 48 patients of acne scars the cosmetic result was excellent (>60% improvement) in 15, good (35-60% improvement) in 20, and poor (<35% improvement) in 13. Repeat DA after 12-15 months in 3 of them yielded excellent result. Of the 34 patients who underwent ASR prior to DA, results were excellent in 15, good in 16 and poor in 3. Out of the remaining 14 patients who were directly dermabraded 4 had good result and 10 poor. Of the 19 patients who complained of sporadic activity of acne, 12 showed more than 50% reduction in their activity. Excellent results were obtained in 9/12 patients of adenoma sebaceum, whose lesions were preancillarily treated with electrodesiccation and surgical excision. The remaining 3 patients (2 directly dermabraded) showed recurrence and repeat dermabrasion after 9-15 months, gave excellent cosmetic results. Excellent cosmetic results were achieved in 3/4 patients of multiple trichoepitheliomas. In one patient with massive nodules repeat DA after 6 months yielded improved cosmetic results. The single patient of Darier's disease healed very well with smooth uniformity pigmented skin surface.

Side effects seen were persistent hypopigmentation 41, persistent erythema 30, milia 20, hyperpigmentation 15 and exacerbation of acne 3 patients. Complications encountered were small deep pitted scars 8, recurrence of adenoma sebaceum 3, gouging 2 and localised secondary infection 2 patients (3 sites). Of this, one site responded well to higher antibiotic whereas other two sites healed with scarring (linear hypertrophic 0.5cm X 2.5 cm and oval atrophic 1.5 cm diam).


  Discussion Top


Acne vulgaris depending on its severity, can end with a variety of scars. Many treatment modalities for scar improvement such as cryoslush with carbon dioxide snow, liquid nitrogen cryopeel, surgical scar revision, electrosurgical planing, chemical peeling, filler substance implantation, iontophoresis, DA, laser abrasion, etc have been developed. [6],[7] The affected skin of post acne scarring has an abnormal contour with most scars being depressed below the adjacent normal skin. DA is primarily performed on the surrounding normal skin for the levelling effect. [1],[2] There is regeneration of the collagen tissue during the wound healing process. This further remodels and undergoes contraction during maturation process causing flattening effect, thus improving the overall appearance of the acne scars. [1],[2] DA carried to optimum depth appears to be the key solution for the improvement of acne scars. It does not significantly improve scars with wide atrophic base, punched out deep scars and ice pick scars. [1],[2],[3],[4],[5],[6],[7] Aronsonn et all in their study of 25 cases observed that 50% improved with DA and concluded that those with small and superficial scars showed better results than those with deep scars. In the present study also it was noted that the superficial scars disappeared completely whereas deep pitted ice pick or irregular scars did not improve unless they had been revised before DA. Various ASR procedures tailored to improve individual scars have been described in literature. [2],[3],[4],[5],[6],[7] They were carried out in 31/34 patients with good to excellent results 6-8 weeks before DA.

In acne scars, 37.5% had 60% or more improvement; 41.7% had 35-60% and 20.8% had less than 35% improvement. The improvement obtained in this series is less than those attained by Alt et al. [2] They have achieved overall improvement of 60% to 70% in more than 75% of the patients. The higher improvement obtained could be due to difference in the techniques followed. In this study, patients were dermabraded using combination of general and local tumescent anaesthesia whereas Alt et al, [2] Roenigk [3] and Yarborough et al have all used cryoanaesthesia (freon + ethyl chloride mixture - fluro ethyl). Alt et al have pointed out that when the skin is frozen during cryoanaesthesia it is firm, nonpliable, nonmobile and hence can be abraded easily. Cryoanaesthesia also causes haemostasis and the landmarks like capillary loops, yellow sebaceous glands etc can be easily visualised, and thus DA can be effectively carried out to the optimal desired depth. Despite all these advantages, cryoanaesthesia was not used in this study as it is not available in India. Alt et al have stated that manual stretching of the skin during DA should be avoided as stretching will flatten out the scars. Marking of the acne scars prior to anaesthesia helped in better visualisation and easy abrasion. The advantage of tumification and manual stretching was that the skin surface remained firm and the dermabraders could be moved freely. Tumescence also safeguards the underlying important tissues from injury [1],[2] and has haemostatic effect due to its physical pressure and the adrenaline added to it. Maneksha has achieved excellent results in small pox and acne scars with manual metallic dermabraders and sandpapers. [10] In this study initial DA was carried out electrically with hand motor till the junction of deep papillary and upper reticular dermis and further deep DA was done manually with metallic dermabraders and sandpapers. This way the procedure was faster and provided safety to deeper and surrounding structures. Many workers advocate repeat DA rather than a single aggressive DA to achieve better cosmetic result and avoid complications. [1],[2] The same was confirmed in 3 patients with severe acne scarring in this study. It has been observed that DA is effective in improving chronic active acne, [1],[2],[3] which was confirmed in this study as 12/19 sporadically active patients of acne showed reduction in their activity. Exact mechanism of this therapeutic benefit of DA is not known but may be due to drainage and deroofing of comedones and cysts or its direct effect on the pilosebaceous apparatus. [1],[2]

Facial lesions of adenoma sebaceum pose a problem of cosmesis and consist of multiple angiofibromas of various sizes. Treatment has included excision, DA, cryosurgery, lasers etc. [1],[2],[3],[4] Alt et all have recommended DA alone. Verheyden [4] found excellent results combining shave excision with DA in 3 patients. Kaufman et al [11] who have treated 9 patients with copper vapour laser, found that 50% of them had recurrence needing further treatment. In this study combining electrodesiccation for small lesions and surgical excision for large lesions with DA after a gap of 6-8 weeks was found to give good cosmetic results in 9 patients. Remaining 3 patients had to be dermabraded again for recurrence, thus confirming that combining two methods can be advantageous in providing excellent cosmetic result and avoiding or reducing recurrence.

Multiple trichoepitheliomas are benign neoplasms of the hair follicles and present as flesh­coloured round papules and nodules with centrofacial distribution. [12] Multiple methods of treatment including surgical excision, DA, cryosurgery and laser surgery have been reported in literature to treat this cosmetic problem. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12] In this study DA was carried out on 4 cases with excellent results. Roenigk [3] has reported impressive results in 3 patients by using wire brush. He has further reported regrowth of tumours on follow up in 1 patient but with less severity. In this study too, wire brush followed by manual DA was used to plane away hundreds of lesions and the wounds healed with smooth flattened skin surface without scarring thus providing a very high cosmetic relief with safety to the patients.

In Darier's disease medical modalities of treatment have only temporary success. [13] Hyperkeratotic localised lesions have been treated by surgical excision and grafting, cryosurgery, laser abrasion or DA. [14] Surgical modality of full face DA has been indicated for facial lesions, [1],[2],[3] and this was confirmed in this study.

Most common side effect seen was persistent hypopigmentation which although gradually reduced in 3-9 months, persisted permanently in 41 patients. During DA, facial skin along with its melanocytes is lost suddently. This couples with sun restriction measures contribute towards early and prolonged hypopigmentation. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Erythema was another side effect which persisted and then improved completely over a period of 3-6 months in 30 patients. Post operative erythema represents angiogenesis and occurs during wond healing in all the patients. It persists for longer time where DA has been carried to greater depth. [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] as was seen in this study. Hyperpigmentation was observed in 15 patients which reverted completely to normal on treatment with hydroquinone creams and sunscreens in 3-6 months. It is a known phenomenon that skin trauma or many inflammatory skin diseases induce post-inflammatory hyperpigmentation [16] in Fitzpatrick skin type IV,V and VI and hence it is recommended that resurfacing should be done with caution. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Milia formation (20) and flare up of acne (3) occurred 1-4 months after the surgery. These have been described as postoperative sequelae due to the occlusion effect to the petrolatum based ointments and sunscreen agents used postoperatively. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

DA when carried into deep reticular dermis can lead to scarring. [1],[2] This was seen in 8 patients of acne scars and can be avoided by accurate planing. Recurrence of adenoma sebaceum was noted in 3/12 patients. The lesions of any exophytic condition such as multiple trichoepitheliomas, multiple neurofibromatosis, adenoma sebaceum etc. are situated deep in dermis and hence liable for regrowth if partially removed. [3],[4] Also being genetic disorders new lesions can always crop up at a later date. [11] However, pre-ancillary procedures can help minimise recurrence as was seen in this study. In 2 patients of acne scars gouging occurred because the lax skin got caught in the wire brush as it was not properly stretched, thus bringing out the importance of stretching during DA. [1] Secondary bacterial infection as a result of improper compliance on part of patients was seen in 2 patients (3 sites) and led to scarring at 2 sites in one patient. Of these one remained permanent (oval atrophic) and the other (linear hypertrophic) showed considerable improvement on treatment with intralesional steroid injection and silastic gel sheet dressing.

Facial DA, in this study, was found to be very useful for acne scars and exophytic genodermatoses such as adenoma sebaceum, multiple trechoe­pitheliomas and Darier's disease, thus bringing out the importance of it being an excellent modality for both cosmetic and therapeutic application. This study also brings out the usefulness of preancillary treatment before final resurfacing in acne scars and adenoma sebaceum and the importance of repeat DA to further improve cosmesis, treat recurrences and avoid complications of single aggressive DA. various technical adaptations adjustable to the Indian scenario were followed in this study. [1] Combination anaesthesia (IV ketamine and local tumescent) used to non-availability of surface cryoanaesthetic agents in India, was found to be safe, was easily available, economical and achieved desired optimal anaesthetic effects. The local tumescent was useful in making the skin taut and for achieving better haemostasis. This helped in proper visualization of various landmarks and DA could be carried out to the desired optimum depth. Various landmarks were standardised in this study, corresponding to the related level of depth in the skin. This is the most important finding of this study. Another useful adaptation followed in this study was the combined technique of using electrical and manual DA. This cuts down the total time required for the procedure and makes it safe. All these adaptations, help in minimising side effects, complications and achieve good therapeutic and cosmetic results.

Other modalities useful for facial skin resurfacing apart from DA are chemical peeling [17] and lasers. [18],[19] However DA is found to be superior to peeling in removing acne scars. [17] Also exophytic growths cannot be treated by peeling. [17] Lasers are easy to operate and achieve precise desired depth through micrometer accuracy. [18] Carbon-dioxide laser causes haemostasis and immediate skin tightening through collagen contraction. [18] However it can cause pigmentary problems in skin type V [18],[19],[20] Erbium Yag laser is suitable for darker skin type but it cannot reach the optimum depth to correct acne scars. [19] Also the cost of lasers is as yet prohibitive and no long term studies have standardised the technique on Indian skin types. Dermabrasion thus still remains the only major effective, inexpensive cosmetic as well as therapeutic skin resurfacing modality available in India for successfully treating a vast variety of skin conditions. Although the procedure is complex, once mastered, the results are gratifying for both the patient and surgeon. However proper patient selection, technical perfection and good post­operative management are the keys to its success.







 
  References Top

1.Savant SS. Dermabrasion. In: Savant SS, Shah RA, Gore D eds. Textbook and Atlas of Dermatosurgery and Cosmetology. 1st edn. Mumbai: ASCAD, 1998; 162-168.  Back to cited text no. 1    
2.Alt TH, Goodman GJ, Coleman WP, et al. Dermabrasion. In: Coleman WP, Hanke CW, Alt TH, et al. eds. Cosmetic Surgery of the Skin. 2nd edn. St. Louis: Mosby Year Book Inc., 1997; 112-151.  Back to cited text no. 2    
3.Roenigk HH Jr. Dermabrasion for miscellaneous cutaneous lesions exclusive of scarring of acne. 3 Derm Surg Oncol 1977; 3: 322-328.  Back to cited text no. 3    
4.Verheyden CN. Treatment of facial angiofibromas of tuberous sclerosis. Plast Reconst Surg 1996; 98: 777-783.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Rossiter JL. Dermabrasion : clinical uses in otolaryngology. 3 Oto Rhino Laryngo 1994; 23; 347-353.  Back to cited text no. 5    
6.Savant SS, Mehta N. Acne and its scars. In: Savant SS, Shah RA, Gore D eds. Textbook and Atlas of Dermatosurgery and Cosmetology. 1° edn. Mumbai: ASCAD, 1998; 338-341.  Back to cited text no. 6    
7.Savant SS. Pitted facial scar revision. In: Savant SS, Shah RA, Gore D eds. Textbook and Atlas of Dermatosurgery and Cosmetology. 1st edn. Mumbai: ASCAD, 1998; 156-161.  Back to cited text no. 7    
8.Aronsson A, Erikssen T, Jacobsson S, et al. Effect of dermabrasion on acne scars- a review and study of 25 cases. Acta Derm Venereol 1997; 77: 39-42.  Back to cited text no. 8    
9.Yarborough IM Jr, Bessan WH. Dermabrasion. In: Bessan WH, Mc Collaugh EH eds. Aesthetic Surgery of the aging face. V edn. Toronto: CV Mosby, 1986; 142-81.  Back to cited text no. 9    
10.Maneksha RJ. Scars. In: Maneksha R) ed. Plastic Surgery in the Tropics. 1st edn. Mumbai: Bombay Popular Prakashan 1965; 20: 31.  Back to cited text no. 10    
11.Kaufman Al, Grekin RC, Giesse JK et al. Treatment of adenoma sebaceum with copper vapour laser. J Am Acad Dermatol 1995; 33: 1770-1774.  Back to cited text no. 11    
12.Fitzpatrick JE, Golitz LE. Unusual Tumours. In: Ronigk RK, Roenigk HH Jr. eds. Dermatologic Surgery Principles and Practice 2nd edn., New York Marcel Dekker Inc., 1996 : 585 - 601.  Back to cited text no. 12    
13.Pavithran K. Disorders of keratinization. In: Valia RG, Valia AR eds. IADVL Textbook and Atlas of Dermatology. 1st edn. Mumbai: Bhalani Publishing House 1994; Vol 2: 697-739.  Back to cited text no. 13    
14.Miller PK, Azhary RA, Roenigk RK. Newer uses for the CO 2 laser. In: Roenigk HH Jr. eds. Surgical Dermatology. Advances in Current Practice. 1st edn. London : Martin Dunitz Ltd. 293-305.  Back to cited text no. 14    
15.Goldman MP, Fitzpatrick RE, Smith SR. Resurfacing complications and their management. In: Coleman WP, Lawrence N eds. Skin Resurfacing. 1st edn. Baltimore : Williams and Wilkins Co. 1998; 295-301.  Back to cited text no. 15    
16.Epstein JH. Postinflammatory hyperpigmentation. Clinic Dermatol 1989; 7: 55-65.  Back to cited text no. 16    
17.Brody HJ. Current advances and trends in chemical peeling. J Dermatol Surg Oncol 1995; 21: 385-387.  Back to cited text no. 17    
18.Cox SE, Cockerell CJ. Skin response to laser resurfacing. In: Coleman WP, Lawrence N eds. Skin resurfacing. 1st edn. Baltimore: Williams and Wilkins Co. 1998; 143-153.  Back to cited text no. 18    
19.Kaufman R. Hibst R. Pulsed Erbium YAG Laser ablation. In: Cutaneous Surgery. Laser Surg Med 1996; 19: 324-330.  Back to cited text no. 19    
20.Betnstein U, Kanvar AN, Grossman MC, et al. The short and long term side effects of carbon dioxide laser resurfacing. 3 Dermatol Surg Oncol 1997; 23: 519-525.  Back to cited text no. 20    


Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]



 

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