When properly applied, microdermabrasion is a useful tool for improving the appearance of hypertrophic and keloid scars in highly pigmented skin
A esthetic plastic surgery has gained significant exposure through the print and visual media in recent years. Along with that exposure has come more acceptance, greater popularity, and an increase in the frequency of surgical and nonsurgical procedures.
Racial and ethnic minorities accounted for approximately 16% of all aesthetic plastic surgeries performed in 2004, and that percentage is rising every year. Hispanics comprised approximately 6% of the total, or 550,000 procedures; African-Americans 5% (460,000); and Asians 3% (280,000). Other non-Caucasians made up the remaining 1%.1
As more and more people of color want to improve their appearance, they seek clinicians who are sensitive to their ethnic physical and aesthetic characteristics and have expertise in treating their skin types. Securing a surgeon who can provide the most aesthetically pleasing postsurgical scars is also important to them.
People of color have Fitzpatrick skin types that range from I to VI.2 Treating patients with skin types IV–VI is particularly difficult because their skin has higher melanin contents, more skin-pigmentation abnormalities, and greater propensities to heal with an abnormal scar than other skin types. Currently, one of the least understood and most unpredictable aspects of plastic surgery is the formation of scars that result from surgical incisions or traumatic wounds, and the greatest challenges occur in people of color with skin types IV–VI.
The potential risks associated with the development of hypertrophic and keloid scars in people of color are high. The risks are especially high for those who undergo aesthetic surgery, and they are of significant concern to the treating physician and, more importantly, the patient. Even with the best planning and the most meticulous surgical techniques, an incision can result in severe and dangerous scar formation, and can negatively affect the patient emotionally and functionally.
Scar Formation and Treatment
The principles of excessive scarring were first discussed in the Edwin Smith surgical papyrus about 2,700 years ago.3 From then until now, the scientific community has conducted a large amount of basic scientific and clinical research to better understand the extremely complex mechanisms of scar formation and wound healing. However, there is still no conclusive etiology and no successful, reproducible therapeutic regimen for preventing excessive scar formation.
Over the years, a wide range of treatment options have been used to treat hypertrophic and keloid scars, with varying degrees of success.4
Scars often improve over time; therefore, it is prudent to wait at least 1 year before considering any attempt at scar revision. For many, a “wait and watch” approach will provide satisfactory improvement in the scar’s appearance. Sometimes simply applying external pressure will give beneficial results.
A prescribed topical gel or silicone sheet may be beneficial if it is used over an extended period of time. Topical or injected corticosteroids will potentially flatten the scar and lessen the severity of pruritis. The pharmaceutical armamentarium used by physicians today consists of agents that target several extremely complicated processes (such as fibroblast and melanocyte activity) involved in wound healing and have been prescribed for hypertrophic and keloid scars with mixed results.
Surgical revision of the scar may be indicated if it interferes with the patient’s emotional or physical function. Surgery may be followed by radiotherapy or used in combination with topical treatments. Surgical scar revision does, however, carry with it some risks. Healing of the revised scar is unpredictable at best, and there is always the possibility that the pre-existing scar will be replaced by a scar that is more aesthetically displeasing.
For patients with Fitzpatrick skin types IV–VI, microdermabrasion is an excellent nonaggressive and noninvasive skin-resurfacing procedure for improving the appearance of hypertrophic scars. Serial microdermabrasion in conjunction with prescribed pharmaceuticals can be the cornerstone of the treatment of scars in skin of color.
Microdermabrasion has been widely accepted in Europe for the past 15–20 years.5 It is fast becoming one of the most-requested aesthetic procedures in the United States; almost 860,000 procedures were performed in 2004,1 and this number is expected to increase. The procedure is office-based, it requires no downtime, it produces immediate results, and it is very affordable.6
In the microdermabrasion process, streams of a finely divided crystalline oxide or salt (usually aluminum oxide) are propelled through a vacuum-driven, handheld device that is moved slowly across the surface of the skin. The particles bombard the superficial layer of the skin, resulting in “microtrauma” to the epidermis.7 Dead cells and debris are then vacuumed away, thereby stripping away the stratum corneum of the epidermis. The resurfaced skin is thicker, more uniformly pigmented, smoother, and more permeable to topical treatments than before.
Results vary and they are operator-dependent and machine-dependent. Variables include particle size of the crystals, pressure settings of the microdermabrasion instrument, the number of passes across the skin, and the amount of manual pressure the operator applies on the handpiece.
Side effects are unusual, but can include, among others, mild to moderate discomfort during the treatment session, transient redness, a tingling sensation, and, in rare instances, herpetic outbreak and infection in patients with a preprocedure history. If microdermabrasion is performed too aggressively, especially in highly pigmented skin types, postinflammatory hyperpigmentation can occur. This condition is usually temporary and can be easily treated with topical bleaching agents and sunscreens.
The following equipment and materials are usually used:
Commercial microdermabrasion instrument
Crystalline aluminum oxide (100-mm particle size)
Mild alcohol toner
Eye shield (optional)
The area to be treated is cleansed with soap and water and patted dry. The area is then degreased with the alcohol toner and allowed to air-dry completely. The patient is placed in a reclining position. The scar to be treated is divided into sections. The microdermabrasion vacuum level is maintained at a low setting (20–25 kPA).
The skin is pulled taut with the thumb and forefinger, and several repetitive passes are made slowly over one section of the scar, just to the “point of erythema.” After completion of one small section of the scar, another section is treated, allowing the previous section to recover from any erythema. The procedure is repeated for each section and is always stopped at the “point of erythema.”
When the operator performs a second set of passes, he or she should view the scar through the magnifying lamp to observe the degree of erythema. When working with highly pigmented skin, it is particularly important to use magnification to detect subtle nuances of hyperemia and to monitor the amount of leveling of the scar. It is also important to avoid making more passes than necessary and to use only moderate manual pressure.
After the procedure is completed, the residual debris is brushed away with dry gauze and the area is wiped with moist gauze. The skin is then hydrated with mineral water, and bleaching agents and sunscreen are applied.
The patient is given home-care instructions that include avoiding intense sun and chemical irritants for the next 24–48 hours and using a full-spectrum sunscreen of SPF 30 or greater. A bleaching agent is prescribed to treat postinflammatory hyperpigmentation.
Microdermabrasion can be performed at weekly intervals. The process can be repeated as long as there is visible improvement of the scar.
The successful microdermabrasion of skin of color, specifically Fitzpatrick skin types IV–VI, depends on strict adherence to a conservative approach. This includes low vacuum settings, slow passes of the microdermabrasion tool with minimal manual pressure, and critical assessment of “endpoint erythema” under direct visualization using lighted magnification. The endpoint assessment will determine the advisability of performing additional passes to the treatment area. If erythema progresses to hyperemia or inflammation, the patient is almost certain to develop postinflammatory hyperpigmentation, which, although transient and treatable, can be disturbing to the patient.
In my clinical experience, patients comply with scheduled appointments, are extremely satisfied with their results, and generally seek treatment for other scars. Microdermabrasion, properly applied, is predictable, reproducible, and highly satisfying to the patient and the physician alike.
Rosetta Garries, MD, is the president and CEO of Le Pavillon Garries Aesthetic Skin Surgery Center in New York City. She can be reached at (212) 234-3859 or [email protected]
1. American Society of Plastic Surgeons. 2004 statistics. Available at: http://[removed]www.plasticsurgery.org/public[/removed]_education/2004Statistics.cfm Accessed May 25, 2005.
2. Rubin MG. Manual of Chemical Peels. Hagerstown, MD: Lippincott Williams & Wilkins; 1995:3.
3. Breasted JH. The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press; 1980.
4. Brent B. The role of press therapy in management of earlobe keloids: Preliminary report of a controlled study. Ann Plast Surg. 1978;1:579.
5. Coimbra M, Rohrich RJ, Chao J, Brown SA. A prospective controlled assessment of microdermabrasion for damaged skin and fine rhytides. Plast Reconstr Surg. 2004; 113:1438–1443.
6. Jones GM, Jones RH. Maximizing Medical Microdermabrasion. Self-published; 2002.
7. Rubin MG. Microdermabrasion: An epidermal abrasion. Aesthetic Surg J. 2003;23: 137–139.