This month’s Featured Archive Article:

Manual Dermal Sanding

For Surface Skin Imperfections

By James E. Fulton, Jr., Ph.D., and Caroline V. Caperton, M.D., M.S.P.H.

Manual dermal sanding is a controlled surgical scraping of the skin that aids in improving its surface texture by promoting dermal remodeling. This technique is often employed to treat skin surface irregularities following acne or other types of scarring that have left the skin rough or uneven in texture.

Indications

The indications for manual dermal sanding include acne, post-surgery or traumatic scarring; actinic keratoses; cosmetic improvement of fine lines; rhinophyma; dyschromias; or pigmentation issues such as melasma or photodamage. The contraindications to dermabrasion include active inflammation, infection, open wounds, uncontrolled diabetes or pregnancy. Patients must have at least a two-week wash-out period free from irritating skin care products like tretinoin (Retin-A®) and cigarette smoking, both of which hinder wound healing. Anticoagulants such as aspirin, ibuprofen, warfarin, or nutritional supplements such as St. John's wort, fish oil, vitamins D or E or ginkgo biloba must be discontinued 10 days before the procedure to avoid excess bleeding. Patients who are coming off isotretinoin (Accutane®) must wait at least six months to clear the body of the retinoid effects that delay wound healing. Patients with a history of developing keloids or hypertrophic scars are advised against dermal sanding of keloid-prone areas like the chest, shoulders or chin.

Method

At the initial evaluation, photographs with direct and side lighting are taken in order to assess changes in skin topography pre- and post-procedure (figure 1). The patient reads, understands and signs an informed consent that outlines the benefits and risks of the procedure. A complete history and physical is done to screen for systemic diseases such as uncontrolled diabetes.
The treatment area is prepared with either alcohol, povidone-iodine or chlorhexidine. The skin is anesthetized with a topical anesthetic gel preparation or infiltrated with local lidocaine 2-percent with epinephrine (1:100,000). For the exceptionally apprehensive patient, diazepam (Valium®) 10 mg is given sublingually at the time of the local anesthesia injection to quell anxiety. For small treatment areas, a diamond-tipped sanding wheel (fraise) is utilized. For larger areas, such as the entire cheek, a manual technique of dermal sanding described in several independent medical articles can be utilized with great efficacy.
The area of skin to be treated is held taut, either with manual pressure for full-cheek dermabrasion or pinched up for smaller areas. The procedure for the cheeks, forehead or chin is done with 120-grit drywall sanding screen that has been washed with mild detergent and a brush to remove any loose grit. After allowing the screen to dry, it is cut into two-inch sections and sterilized in an autoclave.
The sterile screen is placed into a basin of sterile water along with a 4-inch by 4-inch gauze. After the sandscreen is rolled around the wet gauze, the roll is applied with slight pressure in a back-and-forth or circular motion in multiple directions on one side of the face; then, the other side is sanded, allowing time for edema to develop on the previous area (figure 2). The procedure goes back and forth, from cheek to cheek, until pinpoint bleeding is visualized and the scars begin to disappear. This altering back and forth of the sides allows the operator to assess and control the depth of the treatment. When the sandscreen becomes saturated with debris, a new screen is utilized. It usually takes 15 to 20 minutes per treatment area to smooth out the dermis (figure 3).

Figure 1. This patient had severe cystic acne as a teenager and young adult. No treatments really helped and she was left with residual scarring.

Figure 2. Larger skin areas are planed with wet Norton sandscreen (120-grit). The large surface area of the sandscreen reduces the possibility of gouging that may follow electric wheel sanding.

Patients with a history of developing keloids or hypertrophic scars are advised against dermal sanding of keloid-prone areas like the chest, shoulders or chin.

Figure 3. Note the smooth dermis after the surface scarring is eliminated with the sandscreen. Usually three or four passes are adequate to remove imperfections.

Figure 4. Application of the Flexan® allows the skin to heal without crust formation. This dressing is held in place with tube-gauze.

Manual dermal sanding is often employed to treat skin surface irregularities following acne or other types of scarring that have left the skin rough or uneven in texture.

Figure 5. As the Flexan® loosened and was trimmed, the new tissue was moisturized with an aloe vera-petrolatum ointment.

Figure 6. Note the results. There is a 50 to 70 percent improvement. A repeat sanding may be done in three to four months, if needed.

Post-treatment procedure

When the treatment is complete, the skin is rinsed with sterile saline and the porous dressing (Flexan®) is applied (figure 4). Dry 4-inch by 4-inch gauze and a pressure dressing of tube netting is applied over the dressing prior to discharging the patient. These dressings are worn overnight. The gauze and netting are removed the following day.
The Flexan dressing is worn until it falls off, which is usually within five days (figure 5). New healing areas are kept moist with a petrolatum-based ointment. The patient is instructed to avoid sun exposure after the procedure until the erythema resolves, usually within 6 to 12 weeks.
If the patient is darker-skinned (Fitzpatrick skin types III to V) and the possibility of developing reactive hyperpigmentation exists, the patient should begin applying a hydroquinone bleaching cream around day 8 to 10 even though the darkening may not be seen until days 17 to 20. This is a preventive measure.

Results

The improvement of the cutaneous defects is usually between 50 to 75 percent. Certain areas may require a repeat procedure. This following case history will illustrate typical results.
Case history, female, 39-years-old. This patient suffered from severe cystic acne as a teenager and young adult. No treatments worked. As the acne traveled across her face, scars developed (figure 1). After a consultation, she opted for the procedure. She preconditioned her skin with a vitamin A-based skin care regimen. After reviewing the informed consent and taking documentary photographs, the sanding began with Norton 120-grit sandscreen. After several passes, the dermal irregularities were improved and the skin was dressed in Flexan. This dressing stayed in place until the new skin developed after four to five days. Then, recovery ointment was applied until the sensitivity and erythema abated. She was excited to see the improvement (figure 6) and is awaiting a touch-up procedure, if needed.

My Choice

by Mariamar Masso

My severely acne-prone adolescent life revolved around fighting the urge to pick my face and getting made fun of at school. The condition took a toll on me emotionally, physically and mentally, inhibiting me from participating in my favorite activities and affecting my life choices. I was left with scars as a constant reminder of my battle with acne. Being an esthetician and skin care educator, I was ashamed of my scars, and made it a goal to get rid of them.
Although I did see improvement in my years of antibiotics, microdermabrasion treatments and chemical peels, my scars were deep, and therefore led me to the Manual Dermal Sanding procedure. During my two-hour journey on the table, I was overwhelmed by a therapeutic wave of emotion resulting in the "release" of 30 plus years of anguish. As an esthetician, I was fascinated by the experience as I witnessed my scars being sanded away. However, I had no idea how intense the procedure would be. Dr. Fulton concentrated on my cheeks, where the majority of the scars occurred, periodically popping out and stitching up calcified cysts.
The healing process involved occasional dripping and leaking. It was painful to drink, eat, smile, laugh and talk, but an over-the-counter pain reliever kept discomfort at bay. Each day revealed beautiful new skin.
I am the acne patient who found a resolution, the esthetician who found an alternative for my clients and a mother of two acne-prone children who sees the light at the end of the tunnel. I am grateful for this journey and now have a greater understanding of skin, acne, scarring and the treatments that are available. Estheticians and physicians can work together in a partnership to create beautiful and healthy skin.

Possible complications

Manual dermabrasion may be as effective as conventional, electric-powered dermabrasion in improving the appearance of facial scars and dermal imperfections. However, it is a lot more operator-friendly and has much less chance of complications.
However, complications can occur, such as greater than expected intraprocedural bleeding, edema, infection, or rarely, outbreaks of herpes simplex virus (HSV) in predisposed individuals. Intraprocedural hemostasis can be achieved by using a diluted 3-percent hydrogen peroxide solution in the abrading solution. Patients predisposed to HSV infections may be prescribed prophylactic acyclovir or Famvir.
Reactive hyperpigmentation may develop around post-procedure day 19 or 20. To avoid this, the patient may begin daytime use of sunscreen and nighttime use of bleaching cream (if they are Fitzpatrick types III, IV or V) beginning on post-procedure day 10.

Conclusion

Manual dermal sanding is quite useful for the improvement of acne scarring, traumatic scars and surgery scars. Improvement is usually 50 to 70 percent. If necessary, repeat procedures can be performed. This technique is less traumatic than wire-brush abrasion and more cost-effective than the use of ablative CO2 or Erbium lasers. The sanding also avoids the additional trauma of the heat-induction by the lasers.

James E. Fulton, Ph.D., is the medical director for Vivant Pharmaceuticals, LLC. His other accomplishments include the development of the patented Benzoyl Peroxide gel delivery system and the co-development of Retin A®. Dr. Fulton was the first to use and patent vitamin A propionate in skin care products.

Caroline Caperton, M.D., M.S.P.H., holds a Master of Science degree in Public Health. She graduated with Research Distinction from the Miller School of Medicine at the University of Miami. Dr. Caperton has published extensively in the field of dermatology and is currently working as a Clinical Research Fellow in the Department of Dermatology and Cutaneous Surgery.