Dermabrasion

Chemabrasion
Laser Resurfacing
PIL-YOUNG YUN, D.D.S., M.S.D.

Dept. of Oral & Maxillofacial Surgery,

College of Dentistry, Seoul National University
Facial Skin Resurfacing

Purpose
 Obtain resurfacing
 Smoother skin contour
 Better texture
 Tightening - Rejuvenation
Applications
 Exophytic skin lesion
 Solar keratosis / Seborrhoeic keratosis
 Epidermal nevus / Angiofibroma
 Xanthelasma / Rhinophyma
 Actinic damage
 Pitted acne scar
 Remodeling post trauma & surgical scar
Anatomy
of the Skin
Epidermis

Papillary layer
Dermis
Reticular layer

Subcutaneous tissue
Facial Skin Resurfacing
Dermabrasion
 performed by using abrasive substances s
uch as wire brushes or by dermatome
 useful in smoothing surface irregularities p
roduced by acne pits or scars
Chemabrasion - Chemical peeling
 performed with a chemical solution
 useful for the removal of fine wrinkles and
abnormal pigmentation
Laser Resurfacing
 Dermabrasion
Introduction
 Dermabrasion and Dermaplaning is the
surgical scraping on the epidermis and
upper part of the dermis of skin to refini
sh the skin's uneven top layer.
 This procedure removes the pigmentati
on of the skin at the same time.
 Dermabrasion
History
 B.C. 1550 Speckle removal with natural
stone
 1887 Edward Round knife fabrication fo
r removal of explosion tattoo
 1905 Kromayer The Father of Modern D
ermabrasion First use of rotary device
 1950 Kurtin Introduce to American Asso
ciation of Dermatology
 Dermabrasion
Applications
 Dermabrasion is applied to wrinkles, tat
toos, smallpox scars, burn scars, kerato
ses, or acne marks.
 It can also be used in thinning the skin l
ayer and decolorizing the skin-grafted a
rea.
 Re-epithelialization and new cellagen pr
oduction induce healing.
 Dermabrasion
Advantages
 Inexpensive
 Large area
 Short time
 Some visualization of the desired end
point is possible
 Minimal heat injury to deeper structures
 Dermabrasion
Disadvantages
 Bloody procedure, so clear visualizatio
n of desired end point may difficult
 Aerosol producion persists in the atmo
sphere for 48 hours
 Livevirus ( HIV, HVB HVC ) may transmitte
d to operator
 Instruments are relatively bulky
 Fine control is difficult
 Dermabrasion
Disadvantages
 Mobile regions are impossible
 eyelidarea - significant risk of injuring the
eye or eyelashes
 Unwanted thermal injury
 Frictional
heat induced by rotary device
 Some anesthesia needs freezing the skin

 Permanent splotchy
 Hypopigmentation
 Dermabrasion
Anesthesia
 Local anesthesia can be used for small l
esions.
 Sometimes cryoanesthesia with ethyl c
hloride is applied.
 General anesthesia should be used for l
arge lesions to achieve sufficient peelin
g.
 Dermabrasion
Surgical Procedure
 Use of a motor-driven machine with a
stainless brush or diamond fraise yields
the best results.
 The layer of peeling should not go
further than the upper layer of dermis.
- The level where many small blood spots are
seen in the papillary layer of dermis cutting
away is most appropriate.
 If necessary, it can be tried 2 - 3 times.
 Dermabrasion
Surgical Procedure
Dermabrasion and
dermaplaning can s
mooth scars left by
acne, accidents, or
previous surgery, a
s well as fine facial
wrinkles, especially
those around the m
outh.
 Dermabrasion
Surgical Procedure
In dermabrasion , th
e surgeon scrapes a
way the top layers o
f skin using an elect
rically operated instr
ument with a rough
wire brush or diamo
nd-
impregnated bur.
 Dermabrasion
Surgical Procedure
The cross section s
hows how dermabr
asion smooths irreg
ularities in the outer
most layer of skin.
 Dermabrasion
Surgical Procedure
Dermaplaning uses
a dermatome to ski
n off surface layer o
f skin that surround
facial defects.
 Dermabrasion
Surgical Procedure
Several months
after procedure,
pigmentation
returns and the skin
is much smoother
than before.
 Dermabrasion
Surgical Procedure
 Dermabrasion
Surgical Considerations
 Depth control
 Skin of periorbital area
 Skin of submandibular area
 Pre-operative marking
 Bleeding control
 Dermabrasion
Histologic Examination
 Same as the healing process of the STS
G
 Epidermal cell of the remained skin app
endages - major role of regeneration
 Grenz zone - New-forming collagen laye
r substitutes the pre-existing collagen l
ayer of dermis
 Dermabrasion
Histologic Examination
Dense collagen layer

Pre-Treatment Post-Treatment
 Dermabrasion
Post-operative Care
Purpose of Dressing
 lead wound healing within 2 weeks
 more than 2 weeks : recommend aggres
sive intervention

Types of Dressing
 Open dressing - Antibiotic ointment
 Occlusive dressing - Duoderm
 Dermabrasion
Complications
 Imperfect removal
 Milea
 Erythema
 Dispigmentation
 Hypertrophic scar
 Chemabrasion
Introduction
 The application of chemical caustics is
an effective procedure to improve the
surface of the skin that has been
blemished by pigmentation, wrinkles,
solar damage, and certain scars.
 Chemabrasion
History
 1903 phenol and trichloroacetic acid for
the removal of superficial blemishes
 Eller and Wolff 1941 discussed the use
of phenol, resorcinol pastes.
 In the 1940s Sir Harold Gillies, the fathe
r of modern plastic surgery, was known
to have used pure carbolic acid for the
correction of "slight laxity of the lid"
 Chemabrasion
History
 Ayres, a dermatologist, extensively inve
stigated the use of phenol and TCA on a
ctinically damaged skin and reported hi
s observations in 1962.
 Brown and associates in 1960 reviewed
the technique, complications, and histol
ogic changes in the skin brought about
by the application of phenol.
 Chemabrasion
Indications
 Chemical face peeling is the procedure o
f choice for the eradication of fine wrinkl
es when there is no gross sagging of the
facial skin.
 more prolonged effect than dermabrasion
 Moderate tightening of the forehead skin
may be achieved by chemabrasion, with
out the risks of hair loss or obvious scar
s.
 Chemabrasion
Indications
 Adjunctive procedure - blepharoplasty
or rhytidectomy
 If peeling is limited to the lips or forehe
ad, or both, it may be performed at the s
ame time as the eyelid or facial surgery.
 If a full face peel - deferred for a period
of 3 weeks after facial plasty
 Chemabrasion
Various Agents
 Phenol
 Resorcinol
 Salicyclic acid
 Glycolic acid
 Trichloroacetic acid
 Jessner's solution
 Combination of salicyclic acid, lactic acid,
and resorcinol
 Chemabrasion
Advantages
 Equipment and set-up cost are minimal
 Applicable to Large area & Quickly &
Evenly with improvement skin texture
 Little technical skill is need
 Chemabrasion
Disadvantages
 Blind procedure
 No sign to indicate depth ( esp. TCA )
 Pure-white appears = indicating the upper r
eticular dermis
 Yellow gray = indicating deep reticular der
mis ( increase risk of hypertrophic scar)
 Toxicity ( esp. Phenol )
 Cardiotoxic / Melanotoxic / Painful
 Chemabrasion
Disadvantages
 Errors in concentration solution
 Consistent eradication of deeper wrinkl
e in the perioral and periocular regions i
s not possible without significant risk of
hypertrophic scarnng.
 Rarely effective to acne scar
 Exophytic lesions (e.g., seborrhoeic ker
atoses) may remain after chemical peeli
ng.
 Chemabrasion
Considerations
 Skin color
 Thickness of skin
 Dangerous area
 Application of Chemicals
 Chemabrasion of the perinasal area
 Chemabrasion
Interview
 One of the major problem
 Difference between expectation and
results of peeling
 Correct information
 Chemabrasion
Pre-operative Treatment
Kligman Formula
 Vitamin A cream : irritation to newly-for
ming skin
 Hydroquinone
 Steroid : Solve the problem of post-oper
ative discoloration, decoloration
 Chemabrasion
Anesthesia
 Anesthesia isn’t required for phenol or
TCA peels because the chemical
solution acts as an anesthetic.
 However, sedation may be used before
and during the procedure for relaxation
and comfort.
 No anesthesia is needed for AHA peels
since they cause only a slight stinging
sensation during application.
 Chemabrasion
Alphahydroxy Acid
 Apply AHA solution to cleansed facial s
kin
 Usually takes no more than 10 minutes
 Add Retin-A or bleaching agent to at-ho
me treatment schedule
 After several weeks of at-home use
 Follow-up : Skin evaluation
 Chemabrasion
TCA
 The patient may feel stinging sensation
as the peel solution is applied, but this
feeling will quickly pass.
 A full-face TCA peel usually takes no
more than 15minutes.
 Two of more peels may be needed to
obtain the desired results, and those
may be spaced out over several months.
 Chemabrasion
Phenol
 A full-face phenol peel generally takes
one or two hours to perform, while a
phenol peel to a smaller region may
take only 10 or 15 minutes.
 A single treatment usually suffices.
 After application of phenol solution,
petroleum jelly or waterproof adhesive
tape may be coated to treated area.
 Chemabrasion
Surgical Procedure
Chemical peel is
especially useful
for the fine wrinkles
on cheeks,
forehead, and
around the eyes,
and the vertical
wrinkles around the
mouth.
 Chemabrasion
Surgical Procedure
The chemical
solution can be
applied to the entire
face, or to a specific
area - for example,
around the mouth -
sometimes in
conjunction with a
facelift.
 Chemabrasion
Surgical Procedure
At the end of a
phenol peel, a thick
layer of petroleum
jelly may be applied
to the treated area.
 Chemabrasion
Surgical Procedure
A protective crust
may be allowed to
form over the new
skin. When it’s
removed, the skin
underneath will be
a bright pink.
 Chemabrasion
Surgical Procedure
After healing, the
skin is lighter in
color, tighter,
smoother, and
younger looking.
 Chemabrasion
Surgical Procedure
 Chemabrasion
Surgical Procedure
 Chemabrasion
Surgical Procedure
 Chemabrasion
Surgical Procedure
 Chemabrasion
Surgical Procedure
 Chemabrasion
Surgical Procedure
 Chemabrasion
After Treatment
 Swelling
 Crab Formation
 Tension
 Itching sense or Burning sensation
 Discharge
 Chemabrasion
Complications
 Severe redness
 Pigmentation
 Increasing roughness
 Hypertrophic scar
 Kelloid
 Permanent discoloration
 Ectropion
 Laser Resurfacing
Introduction
 Laser was developed by Dr. Theodore Ma
imon in 1960.
 Aesthetic - relatively recent
 Technology : concept of selective photo-ther
molysis
 Pediatric port wine stains

: with the pulsed dye vascular lasers

 Tattoos and pigmented lesions

: with the Q switched pigment lasers

 Laser Resurfacing
Introduction
 1970s Thermal injury to normal structure
and unacceptable risk of scarring
 "Super pulsed" CO2 laser - minimize hea
t conduction
 1990s high-energy outputs over very sh
ort time
 Destruction of abnormal tissue more rapidly
= selective photothermolysis
 Laser Resurfacing
Principles of Laser
 Long wave length of 10,600 nm ( CO2 )
 Strong water absorption
 Epidermis is 90% water, it is readily
vaporized when temperatures of 100°C
 Dermis (contains type 1 collagen) is
also exquisitely heat sensitive, 60 to
70°C
 Laser Resurfacing
Indication
 Wrinkle, Senile keratosis
 Actinic keratosis
 Epidermal nevus, Leukoplakia
 Seborrheic keratosis
 Syringoma, Xanthelasma
 Rhinophyma
 Acneic scar, Smallpox scar
 Laser Resurfacing
Contraindications

 Long-term Vitamin-A User for Acne

 Drug alters appendageal structure function
 Normal mechanism re-epithelialization is i
mpaired
 At least 2 years after cease

 Loss of appendages due to scarring

Ex.) Burn, Chemical peeling, Scleroderma
- Normal healing cannot be expected
 Laser Resurfacing
Contraindication
 Poor blood supply : Smokers
 At least 2 weeks prior to & after procedure
 Undergoing face lifting procedures
 Safely
6 weeks after rhytidectomy
 Endoscopic lifting may be combined

 Sun-ray sensitive Skin

 History of Shingles
 Psychopathic / Unrealistic expectation
 Laser Resurfacing
Advantages
 Bloodless visualization of desired endpoint
 Precise depth can be controlled in a stepwi
se manner.
 Computerized pattern generator
 Successful & safe in periocular region
 Risk of transmitting viruses - minimal
 HIV, Hepatitis compared with dermabrasion
 If smoke evacuation use
 Laser Resurfacing
Advantages
 Not Cardiotoxic nor Melanotoxic
 Low risk of Scarring, Hypopigmentation
 Post-op pain is rare
 Heat by CO2 has specific effect on colla
gen fibers
 Type 1 collagen : Sensitive to temperatures
as low as 50 to 60°C
 Resulting in shortening and rearrangement
of collagen
 Laser Resurfacing
Disadvantages
 Economic problem : High cost
 Specific training
 Technique sensitive
 Adjudgment of endpoints
 Safety : protect patients eyes
 avoidance of oxygen non-flammable drape
s and skin preparation solutions
 specific endotracheal tubes
 Laser Resurfacing
Depth Control
Depth of resurfacing depends on
 Dermal thickness in the treated area
 Depth of the appendages in the treated
region
 Density of the appendages in the region
 Laser Resurfacing
Depth Control
 Laser Resurfacing
Surgical Procedure
 Laser resurfacing is relatively quick pro
cedure. It usually takes from a few minu
tes to 1 ½ hours, depending on how lar
ge area is involved.
 During the procedure, the activated lase
r is carefully passed back and forth ove
r the skin until the level that wil make th
e wrinkle or scar less visible is reached.
 Laser Resurfacing
Surgical Procedure
The ideal patient for
laser resurfacing
has fair, healthy,
non-oily skin.

When healing is
complete, the face
has a more youthful
appearance.
 Laser Resurfacing
Surgical Procedure
Fine, vertical creases
or lipstick lines are
commonly treated with
laser resurfacing.

Within about five

weeks after treatment,
the upper lip is
noticeably smoother.
 Laser Resurfacing
Surgical Procedure
 Laser Resurfacing
Surgical Procedure
 Laser Resurfacing
Surgical Procedure
 Laser Resurfacing
Surgical Procedure
 Laser Resurfacing
Surgical Procedure
 Laser Resurfacing
Open dressing
 Antibiotic optic ointment, Vaseline
 Normal saline or Diluted acetic acid
Advantage
 Possible to wash face
 No accumulation of sebaceous matter
 Evaluate the wound and inflammation
Disadvantage
 Painful / Dryness / Stiffness
 Laser Resurfacing
Occlusive Dressing
 Colloid or semi-permeable membrane
 Duoderm, Askina, Lasersite, Flexzan
Advantages
 No Dryness & Stiffness
 No need to change dressing
Disadvantages
 Accumulation of sebaceous matter
 Impossible to evaluate the wound
 Laser Resurfacing
Postoperative Care
 Prevention of Hyperpigmentation
 Pre- and Post-operative Treatment
 Vitamin A cream
 Glycolic acid
 Hydroquinone
 Steroid
 Sunblock cream
 Concealor
 Laser Resurfacing
Complication
 Erythema
 Hyperpigmentation
 Aggrevation of acne
 Milia formation
 Hypertrophic scar
 Contour change
 Infection
Herpes Simplex / Candidiasis / Staphylococci