Microdermabrasion and Laser Skin Resurfacing

Many techniques have been used over the years in an attempt to rejuvenate the facial skin without surgery.  All have the goal of improving the epidermis and stimulating collagen regrowth below in the dermis. Microdermabrasion was introduced ten years ago in Italy. Now there are almost two dozen machine models available in the US, which are designed for physicians, their technicians and aestheticians. The aesthetician models use lower pressures compared with the physician models. Microdermabrasion (MDA) is the resurfacing of the epidermis by "sand-blasting" the skin with a pressurized stream of salts, aluminum oxide or diamond crystals. These are delivered by a 4 inch hand piece that also serves to vacuum the used crystals and exfoliated skin. Depending on the number of passes and pressure used, the epidermis and superficial dermis can be exfoliated on the face, neck, chest and hands. Clogged pores can be cleared easily of old oil and skin.

The treatment method consists of stretching the skin and passing the wand over the treatment area at a consistent speed. The system is closed so that the crystals are passed to the used chamber, but on occasion they may not be retrieved and need to be brushed off at the conclusion of the treatment. Occlusive glasses must be worn to avoid eye contamination with crystals and eyewash must be available immediately if eye irritation occurs. The procedure should last approximately 30 minutes and was most recently demonstrated on the E! channel. Experience dictates the crystal and vacuum settings for different conditions. Approximately 4 to 6 weekly sessions will be needed to treat fine wrinkles or sun damaged skin. Patients notice redness and mild facial sensitivity for the first 24 hours. There should be no bleeding because the techniques are minimally invasive. There have been no instances of hypopigmentation, scarring or infection reported thus far.  Sunscreens, moisturizer and makeup can be applied between treatments. Like sequential glycolic acid peels discussed earlier, this takes weeks to see definitive results. On rare occasion, the crystals can become embedded in the skin with resulting redness and granulomas increasing your exposure to aluminum. Other salt crystals may offer a less traumatic skin exposure, but these are in the experimental stage. The average patient is 30 to 40 years old and trying to maintain their appearance with an active skin care program. A second group about 10 years older who have already had some skin resurfacing can be maintained with this procedure. Patients who have taken Accutane are not to be treated for at least 1 year after discontinuing the medicine.

Dermabrasion (DA) was popular in the fifties only to decrease in the sixties and was revived in the seventies only to be replaced in the nineties by laser skin resurfacing.  DA should be used only for people with severe acne scarring, who can afford a minimum of two weeks of down time while healing proceeds. The procedure consists of a diamond fraise (burr) of varying coarseness or a wire brush with stiff stainless steel bristles, which literally scrapes the skin to the lower dermis resulting in heavy bleeding. At the conclusion of the procedure, bleeding is stopped by applying 1% lidocaine with dilute epinephrine to the denuded surface. Cryo-freezing with intravenous anesthesia helps the patient tolerate the procedure.  Can you say? "Oh my Gawd, what have I done!"  when you look in the mirror for 3 to 6 weeks. Gradual improvement is noticed over the next 12 to 18 months.  Remember, this is for serious facial scarring.

The good news is that lasers have been introduced which can penetrate the skin to exacting depths creating the desired changes in surface texture and color. Lasers work by photo (light) - thermo (heat) - lysis (destroy). The laser beam is not a magic wand but Light Amplification by Stimulated Emission of Radiation reflected into a coherent beam, where all the light travels in a straight unified line through a crystal with a wavelength specified for a specific absorption. The CO2 laser was the first laser available for skin resurfacing and is still used to remove warts, wrinkles and premalignant growths on the skin. But it has been known to cause thermal injuries resulting in hypopigmentation and scarring. Reepithelialization takes approximately 1-2 weeks with desired skin tightening and collagen formation continuing for the next year.

In 1996 the FDA approved the Erbium:Yttrium-Aluminum-Garnet (Er:YAG) laser which is ideally suited for the patient with fine wrinkles or mild photo-damage. These are now combined with a computerized pattern generator, which gives consistent repeatable area patterns from 2mm to 20 mm. Since the skin is almost 70% water by volume, the Er:YAG vaporizes the water with significantly less thermal damage to the surrounding skin. As opposed to other methods described above, this can be used on the delicate skin of the eyelids and vermilion border of the mouth. Post inflammatory hyperpigmentation is a known complication which can be mitigated by bleaching agents. Hyperpigmentation has been associated with the hormones of HRT, exogenous estrogens and progesterone.  Prevention of hyperpigmentation begins preoperatively with 6 weeks of skin therapy, using topical Retin-A, alpha-hydroxy acids and 4% hydroquinone bleaching cream continued postoperatively.  This results in more rapid reepithelialization and pigment suppression. Some surgeons add a steroid cream to reduce postsurgical inflammation. If treated promptly hyperpigmentation resolves in several weeks, but if persistent may need a glycolic acid peel.  Redness usually resolves over the next 2 to 4 weeks.  A new mid-infrared light laser is absorbed primarily by water and collagen and can be used to heat tissue uniformly independent of skin pigmentation. Combined with a cryogen cooling device this appears to be a successful investigational method for removing wrinkles in dark skinned people. Multiple treatments are also needed to reach the desired effect as the full effects of treatment cannot be appreciated until 3 to 6 months following treatment. Again, lasers are for serious wrinkling, not just for little creases.