Dermabrasion- For Dermatologists-2 (عمليات صنفرة البشرة)

Dermabrasion
Part-2

Equipment:

1- The electric hand engines used in dermabrasive surgery produce 15,000-30,000 rpm. Bell, Osada, Ellis, and Schuman manufacturers produce the most popular models. These high-speed rotary motors are used to drive an abrading end piece, such as a serrated wheel, a diamond fraise, or a wire brush.

2- Fraises come in a variety of shapes, sizes, and grades of coarseness.

§ Typically, smaller shapes, such as cone or pear shapes, are used in confined areas around the nose, the eyelids, and the mouth.

§ Fraises and wire brush wheels are used on the broad flat surfaces of the forehead, the cheeks, and the nonfacial areas.

§ Diamond fraises are more forgiving and easier to learn to use than the wire brush, which tends to grab and gouge loose skin or free edges. The outer surface of an orange or a grapefruit often provides a convex surface for surgeons to gain the feel of applying an abrading instrument to the skin.

§ Fraises can be used without spray refrigerant, whereas the wire brush requires a firm frozen surface to safely abrade large areas. The wire brush produces microlacerations in the skin with little thermal injury because of the light hand pressure needed for deep resurfacing. When the diamond fraise is used for deep resurfacing, choose a coarse or extra course grade, and perform several passes with heavy downward pressure. Consequently, the potential for thermal injury is greater with fraises than with the wire brush for deep resurfacing.

Anesthesia

The most readily available spray refrigerant on the market is Frigiderm, which uses Freon-114. In the early 1980s, refrigerants containing Freon-12 were found to be too cold (-30°C to -60°C) and produced scarring in the skin. A 10-second spray time with the refrigerant produces cryoanesthesia and a firm surface on which to abrade.

Prechilling with an ice pack decreases the sting of spraying the refrigerant. Freezing an area no larger than can be abraded at one time is helpful. Freeze defects and rhytides in their relaxed state without stretching or distorting so that they may be sculpted and recontoured.

Once the area to be abraded is frozen, 3-point retraction is performed by using the surgical assistant's 2 hands and the surgeon's nondominant hand. Cotton towels can be used for blotting and retraction. Do not use gauze in the surgical field because it can easily become entangled in the dermabrader.

Alternatively, tumescent anesthesia may be used to produce a firm anesthetic surface for abrading. This methodology is often preferred by those experienced in tumescent liposuction. The spray refrigerant and potential for freeze-induced scarring is eliminated. A full-face dermabrasion can be performed with a 0.1% lidocaine solution (250-500 mL) placed in a superficial plane that produces blanching and distension of the skin.

Intraoperative details:

The correct hand position for holding the abrading instrument places the forefingers around the body of the hand engine, while the thumb stabilizes the neck.

The direction of rotation of the abrading end piece can be clockwise or counterclockwise. For right-handed surgeons, counterclockwise rotation directs the momentum of rotation toward the thumb in a stabilizing fashion.

Make passes with archiform horizontal strokes perpendicular to the direction of the rotating brush or fraise.

For full-face procedures, beginning abrading at the dependent areas along the mandible or the chin and working toward the center of the face is best. This method allows blood from a previously abraded area to flow in an inferior, gravitational direction away from the next area to be abraded. With this approach, the nose, the mid upper lip, and the mid forehead are the last areas to be abraded in a full-face procedure.

For regional or spot dermabrasion, gentian violet can be used to outline the borders of the treated cosmetic unit. Abrading an entire cosmetic unit reduces the risk for noticeable pigmentary variations between abraded and nonabraded skin. Lightly feather the borders of the cosmetic unit to blend with nonabraded areas.

A surgical landmark for abrading into the superficial papillary dermis is the presence of cornrow bleeding produced by an eruption of the small vascular loops in the dermal papilla. As the depth of abrasion moves into the reticular dermis, these vascular channels and the subsequent red dots become larger. White parallel lines are frayed, and collagen can be observed after abrading normal reticular dermis, whereas the fibrosis of acne scars or severe solar elastosis crumbles and disrupts. The yellow globules of sebaceous glands or larger frayed collagen bundles herald entry into the lower dermis and a likelihood of scarring.

Postoperative details:

· Once the dermabrasion is completed, a compress with gauze soaked with 1% lidocaine and epinephrine (a 1:100,000 concentration of epinephrine) for 5-10 minutes decreases stinging and provides hemostasis.

· An open or closed wound care regimen can then be initiated. Most open wound care routines use sodium chloride solution or 25% vinegar compresses applied 4-5 times daily followed by an occlusive ointment, such as petrolatum or white petroleum jelly ointment. Avoid mentholated, scented, or antibiotic topical preparations because they may irritate or sensitize the patient.

· In the mid 1980s, the development of closed wound care techniques by using semipermeable dressings significantly decreased the time for reepithelialization from 10-14 days to 5-7 days, as with most open techniques. Usually, the dressings are applied directly to the skin and covered with Telfa dressings, absorbent gauze, paper tape, and Surgilast net dressing. The nursing staff should change this full face mask daily for 3-5 days following surgery. After this time, an open wound care technique can be used. With open and closed wound care techniques, make every attempt to remove any coagulum or yellow fibrin buildup (especially around the mouth and the nose) and prevent scabbing. The development of crusts or scabs not only provides a nidus for infection but also requires that new epithelial cells migrate beneath the scab in search of a plane of critical humidity required for reepithelialization. This downward migration can reestablish the initial defect or depression.

· A postoperative intramuscular injection of 6 mg of betamethasone and 40 mg of triamcinolone acetonide or oral methyl prednisolone helps reduce swelling around the eyes and the cheeks.

· As previously mentioned, continue antiviral prophylaxis for several days beyond a complete reepithelialization (usually 10-14 d of treatment).

· Sedatives, such as diazepam (Valium) and flurazepam (Dalmane), help prevent insomnia and feelings of claustrophobia while wearing a full face mask.

· Antibiotics and antifungal medication are necessary only if bacterial or fungal infections arise. Once reepithelialization is complete, which usually occurs in 7-10 days, the new skin is bright pink or red.

· This erythema progressively fades within 2-3 months and can be covered with concealing makeup. Green and yellow base foundations are the most effective at camouflaging postoperative erythema.

· Bleaching creams formulated with retinoic acid, hydrocortisone, and hydroquinone can be used 3 weeks after surgery with minimal irritation.

· Such regimens help prevent the transient hyperpigmentation that frequently occurs 4-6 weeks following surgery.

· Likewise, strict sun avoidance during the 2-3 months of postoperative erythema protects against this hyperpigmentation.

· Intradermal postoperative edema continues to improve for 3 months. As the swelling resolves, deep rhytides and acne scars may initially appear to have persisted; however, collagen remodeling of the defect continues for another 3-6 months. During the remodeling phase of wound healing, fibroblast activity produces new collagen that fills in scars and heavy rhytides. Consequently, the greatest improvement in scars and rhytides is usually observed 6 months after surgery. Explain this timetable of events in detail to patients during the preoperative consultation so that they do not become discouraged.

Follow-up care:

Anticipate certain events following dermabrasion or other resurfacing surgery, and predict these events as normal postoperative sequelae rather than considering them to be complications. Such events include:

1. Spot bleeding for several days after surgery

2. The resulting postoperative erythema, milia formation, and a flare-up of acne. A flare-up of acne is frequently the result of the occlusive ointment used during wound healing, and it can be treated as any other acne outbreak. These exacerbations are usually short lived and do not produce any acne scars.

3. Likewise, the transient postoperative hyperpigmentation that occurs in skin types II, III, IV, and V at 4-6 weeks following surgery is reliably corrected with a hydroquinone-bleaching regimen and sun avoidance. The more permanent problem of hypopigmentation usually does not appear for 12-18 months after surgery. This pigmentary alteration occurs in 20-30% of patients; however, recent work with the 308 nm excimer laser may provide a method of stimulating melanocytes to replace lost pigment.

4. Postoperative viral infections can occur despite prophylaxis. Always suspect viral infections when pain, erythema, or ulcerations begin 7-10 days following surgery. The development of painful lesions following any resurfacing procedure is most frequently caused by a breakthrough HSV infection. Treatment of infection with zoster doses (valacyclovir 1 g tid or famciclovir 500 mg tid for 7 d) improves pain and usually prevents scarring.

5. Contact dermatitis is observed as worsening erythema, pruritus, or oozing and is usually caused by antibiotic ointments, especially neomycin, or scented lotions. Discontinuation of the offending agent and treatment with midpotency steroids is usually sufficient.

6. Persisting erythema heralds the onset of scarring. Early scar recognition and aggressive treatment are essential in preventing hypertrophy and other sequelae. Mid- to high-potency topical steroid creams are useful during the initial hyperemic phase of scar development. The presence of induration requires the use of intralesional steroids (Kenalog 5-40 mg/mL) or injectable 5-fluorouracil administered every 2-3 weeks. Cordran tape is also a useful adjunct in scar treatment. If telangiectasias develop as a result of aggressive intervention, these vessels may be treated with vascular lasers, such as potassium titanylphosphate (KTP), diode, or pulsed dye lasers. Furthermore, the pulsed dye yellow light lasers are effective in reducing erythema and induration of some scars. With early detection and appropriate intervention, local scars can usually be arrested.

Postoperative contraindications:

1- donot use aspirin or its derivatives

2- Donot leave any escab on the face

3- Donot expose to sun for 2 weeks after surgery and avoid unimportant sun exposure thereafter.

4- Donot put any makeup except that approved by the surgeon.

5- Donot use reaccutane or tetracycline after the surgery.

6- Donot scratch or touch the skin.

Getting Back to normal:

1- you can expect to be back to work in about two weeks.

2- Put sun screen for 6-12 months.

3- No swimming in chlorinated water for about 4 weeks

4- No heavy sports for about 3 months.

5-

As a method of resurfacing, dermabrasion continues to provide effective treatment for a wide variety of skin conditions and defects. The use of a wire brush is uniquely suited for treating deep acne scars and heavy rhytides because of the deeply penetrating microlacerations and the lack of thermal injury. Detailed patient counseling, realistic outcome expectations, and comprehensive postoperative care maximize the results of dermabrasive resurfacing surgery.

Thanks Dr. Wael for the information you stated in this useful toipc. Meanwhile, I need to know about "Checmical Peeling", which we -girls- may need within 10 years or more to look yonger or so Laughing

Thanks Miss Eyman, and I promise u that u will find a topic about chemical peeling in the following few days. I hope that it will be of great benefit for u and for all. Many thanks

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