This popular technique has become a staple of the skin-rejuvenation industry

Microdermabrasion may not be the most-talked-about procedure in the physician’s office, but it is an essential part of an aesthetic medical practice. In fact, microdermabrasion is near its all-time high in the total number of procedures performed, and it heads the list of the plethora of current treatments for skin rejuvenation. The procedure has become one of the most popular and sought-after treatments in the aesthetic industry.

Microdermabrasion was first performed in Italy, and it has been safely used in Europe for the past 25 years. It was introduced into the United States and cleared by the US Food and Drug Administration in 1997, and its popularity has increased steadily since then. Statistics from the American Society for Aesthetic Plastic Surgery show that more than 1 million treatments were performed in 2005.1

With the recent introduction of consumer-based “home” microdermabrasion kits—in topical form and using a handheld rotary device—the overall consumer awareness of the treatment’s benefits will almost certainly increase the number of office-based microdermabrasion procedures performed in the years to come. Microdermabrasion is clearly an integral part of anti-aging medicine, a market that only shows signs of growth as the Baby Boomer population ages.

How It Works
Microdermabrasion is an exfoliation process that rejuvenates the skin by using fine aluminum oxide or sodium bicarbonate crystals—or organic media such as ground walnut shells—to remove the superficial layer of skin, most notably the stratum corneum. The microdermabrasion instrument emits ultrafine crystals, and it is equipped with a vacuum device that removes both the crystals and the skin’s cellular debris.

The advent of crystal-free microdermabrasion has introduced the use of diamond particle–embedded tips or vibrating paddles to achieve exfoliation without having particles bombard the skin.

Through a series of six to twelve 30-minute microdermabrasion treatments, the rate of epidermal replacement is accelerated from the normal once per 28 days to once per 12 to 14 days. The idea is to remove or break up the matrix of the stratum corneum and cause epidermal injury. This leads to a new, rejuvenated stratum corneum and the well-known postmicrodermabrasion healthy, natural glow.

Microdermabrasion is an extremely safe procedure when properly performed. Burns, pigmentary changes, and scars are extraordinarily rare following microdermabrasion. The procedure does not result in downtime, and it does not affect the patient’s participation in regular activities. In general, microdermabrasion causes minimal discomfort to patients, requires no topical anesthesia or recovery time, and can be performed quickly. Patients can return immediately to their daily activities.

The procedure can be used on all skin types and is clearly more affordable than most other procedures performed in either the plastic surgeon’s or the aesthetic dermatologist’s office. In our office, microdermabrasion is the backbone of many of our aesthetic treatments.

Profitable and Versatile
Although the concept seems basic, the treatment is extremely profitable and its noticeable results create ongoing demand. Stand-alone microdermabrasion has been proven to be extremely effective in treating a variety of conditions, including acne, epidermal pigmentary changes, and photoaged skin; and it is part of an overall healthy skin care regimen for sun-damaged skin, fine lines, wrinkles, solar lentigines, enlarged or oily pores, comedonal acne, mild acne scars, and melasma.2,3

What should not be treated with microdermabrasion are malignant lesions, inflammatory dermatoses, or conditions that are currently being treated with oral retinoids. In addition, microdermabrasion should not be undertaken in any patients who have bacterial, fungal, of viral infection in the treatment area. Such infections include flat warts, human immunodeficiency virus, tuberculosis, and herpes simplex.

In addition, patients on warfarin are at risk of excessive bleeding. Finally, because microdermabraded skin is temporarily more sun sensitive, careful sun protection is required in patients who are taking a variety of antibiotics.

Although microdermabrasion can be used as a primary treatment modality, optimal results are seen when it is used in combination with other noninvasive treatment modalities, such as chemical peels, intense pulsed-light phototherapy, and other nonablative laser and laser-like treatments. When topical 5-aminolevulinic acid (ALA) is used for medical or aesthetic photodynamic therapy (PDT), better results are obtained when the stratum corneum has initially been treated with microdermabrasion.

A Typical Protocol
The following sequence of steps should be followed when performing microdermabrasion:

1) Informed consent. Remind the patient that six to 12 procedures are normally required for most people to achieve the desired results. Also remind him or her to pay careful attention to the recommended preprocedure and postprocedure skin care regimens to obtain the best results and to avoid complications. Topical alpha-hydroxy acid retinoid products should be stopped at least 3 days prior to and following treatment.

Some practitioners suggest that fillers should not be injected within 10 to 14 days of a microdermabrasion treatment. Others suggest that botulinum toxin Type A injections should not be scheduled any closer than 4 hours before the next microdermabrasion procedure. Such suggestions have no scientific basis and are not followed in many physician’s offices.

2) Medical history and physical examination of the skin. Evaluate the skin’s thickness (or thinness), current conditions, and relative age. Based on these factors, the treatment plan—including the microdermabrasion power setting and the desired number of passes—can be determined.

If there is any concern, testing a patch of skin is recommended prior to the first treatment to assess that particular patient’s skin reactivity. The skin on the back of the neck, the inside of the forearm, or the upper forehead near the hairline are all acceptable testing areas.

3) Cleansing the skin. All makeup and skin oils should be removed. Then, the skin should be thoroughly dried and degreased.

4) Power and vacuum settings. Begin with conservative settings (these vary with the particular instrument) while assessing results and skin reactivity. Increase or decrease the microdermabrader’s power setting, depending on the thickness of the skin, the desired results, and the patient’s response. It is recommended that the setting be lowered when performing the treatment around the eyes and temples, because the skin is thinner and more sensitive there. Very low settings should also be used for patients with rosacea or broken capillaries.

5) Stroke technique. Keeping the skin taut simplifies and speeds the procedure, and results in the least amount of patient discomfort. Use consistent speed and pressure in 2-inch strokes in three directions—horizontal, vertical, and oblique—to avoid streaking or missed spots. Roll the wrist to break the vacuum, and release the skin at the end of the last stroke to avoid patient discomfort.

The total number of passes per session is determined by the indications and the desired result for that session. Fewer passes should be used when combining microdermabrasion with a chemical peel or light-based treatment. Mild erythema is a relative end point. Bleeding should not occur as a result of a typical anti-aging treatment, although smokers and patients with very thin skin have a tendency to experience subcutaneous bleeding from fragile and dilated capillary loops during the initial treatments.

It should be noted that almost all patients will experience some crusting from dried serum after microdermabrasion in which pinpoint bleeding is the intended end point, as with active acne patients or when performing superficial scar revision. In these cases, this is normal and indicates that the procedure was performed properly. These clear spontaneously in 3 to 5 days after treatment. Such crusting can be avoided if the skin is kept moist in the days following the injury.

6) Postprocedure. To produce the therapeutic benefits of microdermabrasion immediately, a variety of skin care products can be—and should be—used to soothe irritation, moisturize, prevent crusting, and provide broad-spectrum protection against sun exposure. Excessive sun exposure may lead to hyperpigmentation of the now post-treatment, sun-sensitive skin.

7) Frequency. Six to 12 biweekly treatments are recommended initially. Afterward, monthly treatments are used to maintain the results achieved during the first series of treatments. The entire process can be repeated at 1-year intervals.

8) Follow-up. Treated patients should be reminded that experiencing initial dryness, flaking, and a feeling of a mild sunburn is a normal result of the procedure. Excessive swelling or pain must be reported, because it may indicate the onset of an infection. Combined UVA and UVB sun protection should be used to prevent potential hyperpigmentation. In addition, the skin should be kept well hydrated. Makeup can be applied immediately if there is no weeping in the treated area.

Case Studies
Case 1. A 56-year-old business executive with Fitzpatrick skin type I and a history of multiple skin cancers presented with multiple solar keratoses. PDT was chosen as the ideal treatment for this condition. To optimize the results, microdermabrasion was performed first; then, a 20% ALA solution was applied prior to treatment with a blue or red light source. The microdermabrasion enhanced the results of the PDT treatments and improved the odds of success for treating this patient’s precancerous changes.

Case 2. A 22-year-old woman who had been on a variety of oral antibiotics and topical agents sought a better approach to treating her acne without systemic side effects. She underwent nonablative laser treatment to improve the inflammatory component of her acne. Her comedonal acne was reversed after she received six microdermabrasion treatments (see photo).

Microdermabrasion is a noninvasive, nonsurgical, nonchemical procedure that can be performed safely and without impact on a patient’s daily activities. This mode of therapy has been well tolerated and has brought increased patient satisfaction. Microdermabrasion has become an integral part of every successful aesthetic practice.

David J. Goldberg, MD, JD, is a board-certified dermatologist and director of Skin Laser & Surgery Specialists of New York & New Jersey, headquartered in New York City. He is also a clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine and an adjunct professor of law at Fordham Law School, both in New York. He can be reached at [email protected]

References
1. American Society for Aesthetic Plastic Surgery. 2005 Cosmetic Surgery National Data Bank Statistics. Available at: www.surgery.org/download/2005stats.pdf Accessed August 9, 2006.

2. Lloyd JR. The use of microdermabrasion for acne. Dermatol Surg. 2001;27: 329–331.

3. Rajan P, Grimes PE. Skin barrier changes induced by aluminum oxide and sodium chloride microdermabrasion. Dermatol Surg. 2002; 28:390–393.