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Conventional Diamond Fraise vs Manual Spot Dermabrasion With Drywall Sanding Screen for Scars From Skin Cancer Surgery
Montgomery Gillard, MD;
Timothy S. Wang, MD;
Charles M. Boyd, MD;
Rodney L. Dunn, MS;
Darrell J. Fader, MD;
Timothy M. Johnson, MD
Arch Dermatol. 2002;138:1035-1039.
ABSTRACT
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Objective To directly compare cosmetic improvement and postoperative sequelae
resulting from dermabrasion of surgical scars with conventional motor-powered
diamond fraise vs manual dermabrasion with medium-grade drywall sanding screen.
Design Patients were randomly assigned to receive treatment with conventional
diamond fraise dermabrasion to one half of the scar and manual dermabrasion
with a drywall sanding screen to the other half in a prospective, comparative
clinical study. Blinded observers assessed clinical variables during a 6-month
follow-up period.
Setting University hospital/cancer center–based cutaneous surgery unit.
Patients Twenty-one healthy volunteers, Fitzpatrick skin type I to III, with
contour irregularities resulting from granulation (7 patients) or reconstruction
(14 patients) after skin cancer excision.
Interventions One half of the patient's scar was treated with motor-powered diamond
fraise dermabrasion and the other half was treated with manual dermabrasion
with medium-grade drywall sanding screen.
Main Outcome Measures Correction of contour, scarline visibility, time to reepithelialization,
presence or absence of milia, degree of postoperative erythema, hypertrophic
scarring, patients' subjective reports of postoperative pain, and presence
of pigmentary changes were observed for both methods. Standardized scoring
systems were used to quantify outcome measures.
Results According to the standardized scoring systems, no differences were found
between the 2 methods at any point. In addition, no significant differences
were found between the methods for any measure at any of the time points.
Conclusion Both dermabrasion techniques are equally effective in improving the
cosmetic appearance of surgical scars.
INTRODUCTION
DERMABRASION IS an effective surgical procedure for the treatment of
a variety of dermatologic disorders, including photodamage, acne scarring,
and scarring from surgery or trauma. Spot dermabrasion has been shown to improve
the appearance of surgical scars.1-6
Dermabrasion is usually performed at 6 to 12 weeks after a reconstructive
procedure. Yarborough2 first reported the use
of dermabrasion during the early postoperative period, 4 to 8 weeks, to improve
scars.
Conventional dermabrasion uses either a diamond fraise (DF) or a wire
brush as a cutting tool powered by a handheld motor rotating at 20 000
rpm. Many authors have reported excellent results achieved with this device.1-6
The disadvantages of the powered tool include aerosolizing of infectious particles;
blood splatter; the need for protective clothing; risk of lip, eyelids, hair,
or gauze being caught in the instrument; and the added cost of the power instrument.
Several authors have reported manual use of abrading devices for dermabrasion,
including wire brush, DF, sandpaper, Bovie scratch pads, abrasive cloth, and
drywall or plaster sanding screen (SS).7-10
These instruments are used manually in a back-and-forth or circular motion.
The use of sandpaper for dermabrasion was first described by plastic
surgeon Iverson in 1947.11 Zisser et al12 reported on the benefits and advantages of this technique
compared with conventional dermabrasion by using a simple and inexpensive
device, drywall or plaster SS, medium grade (3M Corp, St Paul, Minn) wrapped
around the barrel of a 3-ml syringe (Figure
1 and Figure 2). 12 A controlled comparison between conventional motor-powered
and manual dermabrasion has not been previously performed, to our knowledge.
Our controlled study was designed to directly compare spot dermabrasion using
conventional motor-powered DF with manual dermabrasion using the drywall SS
for facial scars resulting from Mohs micrographic surgery for skin cancer.
We used a split-scar model, one half treated with conventional DF dermabrasion
and the other half treated with manual dermabrasion, to control for intersubject
variation.
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Figure 1. Manual spot dermabrasion instruments:
sanding screen and a 3-mL syringe.
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Figure 2. Sanding screen wrapped around
syringe.
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PATIENTS AND METHODS
STUDY DESIGN
The primary focus of this comparison study was to determine whether
manual dermabrasion using a medium-grade drywall SS is as effective as the
motor-powered DF dermabrader in treating surgical scars. Postoperative sequelae
between the 2 dermabrasion techniques were also examined. The study was performed
at the Cutaneous Surgery and Oncology Unit at the University of Michigan Health
System, Ann Arbor. The study protocol was reviewed and approved by both the
University of Michigan Comprehensive Cancer Center Protocol Review Committee
and the Institutional Review Board of the University of Michigan Medical School.
PATIENTS
Twenty-one patients aged 34 to 86 years were initially enrolled in the
study. Nine (43%) were men and 12 (57%) were women. Eighteen patients successfully
completed all follow-up visits. Data were complete for all 21 patients at
1 and 4 weeks after dermabrasion. One missed a visit at 2 weeks, 2 at 3 weeks,
2 at 3 months, and 3 at 6 months. All patients were included in the comparison
analysis for the time points they completed. All scars were on the face, with
18 on the nose, 1 on the forehead, 1 on the chin, and 1 on the upper lip.
Fourteen patients had soft-tissue reconstruction (8 full-thickness grafts,
3 complex closures, and 3 flap closures) after Mohs excision of a skin cancer
6 to 12 weeks previously. Seven patients had wounds that had healed by second
intention 4 to 32 weeks previously.
Inclusion criteria were ages from 20 to 90 years, willingness and ability
to comply with the follow-up interval requirements, and scarring after skin
cancer surgery. Exclusion criteria included significant medical history or
concurrent illness that, in our judgment, was deemed unstable or not safe
for the patient's participation; unlikeliness to follow medical instructions
and/or comply with the interval postoperative visits; and history of abuse
of alcohol or other drugs or intellectual or emotional problems that might
limit compliance or requirements for informed consent. An additional exclusion
criterion was a history of blood-borne infectious disease such as human immunodeficiency
virus, hepatitis B, or hepatitis C infection, which might preclude the use
of dermabrasion with the DF. All patients who met the inclusion and exclusion
criteria were enrolled in the study after they were informed of the investigational
nature of this research study and read and signed a statement of informed
consent before participation.
DERMABRASION PROCEDURES
Surgical scars were delineated and divided in halves, either patient's
left and right or inferior and superior, depending on the type of scar and
its orientation. The right and left or superior and inferior halves of the
scars were randomly assigned to receive 1 of the 2 dermabrasion techniques.
An instrument legend was completed and was placed in an envelope in the patient's
study chart along with the randomization assignment. A team of 4 surgeons
(T.S.W., C.M.B., D.J.F., and T.M.J.), using uniform techniques, performed
all procedures. After the scar was divided into halves, the area to be dermabraded
was outlined by means of a black surgical marking pen (VWR International,
West Chester, Pa). When appropriate, entire cosmetic units were abraded on
each half.
The area to be dermabraded was anesthetized with 1% buffered lidocaine
with epinephrine 1:400 000. The skin was prepared with chlorhexidine
gluconate and isotonic sodium chloride solution wash and draped with surgical
towels. Patients underwent conventional dermabrasion with a motor-powered
handheld abrader with a DF cutting tool to one half of their scar and manual
dermabrasion with the drywall-plaster SS, medium grade, to the other half
of the scar (Figure 3). Diamond
fraise dermabrasion was performed with a motor-driven 17 x 8-mm or 17
x 4-mm, cylinder-shaped coarse DF (Robbins Instruments, Inc, Chatham,
NJ). Cryogen spray was not used. The other half was manually dermabraded with
the drywall-plaster SS, medium grade (3M Corp), wrapped firmly around the
barrel of a 3-ml syringe as described by Zisser et al.12
Dermabrasion was performed to complete contour correction. Hemostasis was
achieved with pressure that was followed by application of bacitracin ointment
and a nonstick pressure dressing.
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Figure 3. Immediately after dermabrasion
of a full-thickness skin graft scar (patient's right half of scar, diamond
fraise; left half of scar, sanding screen).
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All patients followed the same preprinted postoperative care instructions,
which consisted of cleaning the area with soap and water followed by application
of bacitracin ointment for 3 days, followed by petroleum jelly once to twice
daily. After reepithelialization, the patients were encouraged to apply SPF
15 sunscreen and avoid unnecessary sun exposure (Figure 4).
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Figure 4. Three months after dermabrasion.
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OUTCOME MEASURES
The patients were monitored for 6 months after dermabrasion: 1 week,
2 weeks, 3 weeks, 4 weeks (±2 days), and 3 and 6 months (±14
days). Each side of the dermabraded scar was evaluated independently in a
blinded fashion by a different physician from the one performing the dermabrasion.
Outcome measures were evaluated by physical examination of the abraded site
and not from photographs. At week 1, 2, 3, and 4 visits, posttreatment scars
were assessed for (1) percentage of skin reepithelialization (25%, 50%, 75%,
or 100%); (2) skin erythema according to a 0-to-4 standardized color scale,
in which 0 indicates no erythema and 4, severe erythema; (3) presence or absence
of milia (if present, actual count was recorded); (4) scar-line visibility
(one side more visible than the other or no difference); (5) correction of
contour (unchanged, partial, or complete); (6) presence or absence of infection;
(7) patient's self-reported pain score (absent, mild, moderate, or severe);
and (8) presence or absence of hypertrophic scarring. At the 3- and 6-month
follow-up visits, patients were examined for (1) erythema, by means of the
same standardized color scale; (2) scar-line visibility; (3) correction of
contour; (4) presence or absence of hypertrophic scarring; and (5) presence
of hypopigmentary or hyperpigmentary changes. Outcome measures were scored
and recorded.
STATISTICAL METHODS
The 2 techniques were compared by means of a standardized scoring scheme
that incorporated information on each healing measure. Table 1 shows the amount of difference between the 2 halves of the
scar that would be counted as "different" for the purpose of creating the
standardized measure.
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Table 1. Definitions of Difference Between Healing Variables*
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At 1, 2, 3, and 4 weeks, the 2 techniques were considered to have differing
efficacy if 3 or more of the 8 end points measured were considered different
(Table 1). At the 3-month and
6-month time points, the techniques were considered to have differing efficacy
if 2 or more of the 5 end points measured at those times were considered different.
The percentage of cases for which the techniques led to different results
were reported, along with an exact binomial confidence interval.
To further explore the differences, each healing measure at each time
point was compared by means of actual number differences on an absolute scale
between the 2 techniques with the use of a contingency table (Table 2). Bowker test of symmetry was then used to test for differences
between the techniques. A P value of <.05 was
considered statistically significant, and SAS software (SAS Institute Inc,
Cary, NC) was used for all analyses.
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Table 2. Actual Number Differences Between Techniques for Each Healing
Measure According to an Absolute Scale in 21 Cases*
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RESULTS
For all 21 cases accrued to this study, there were no differences between
techniques according to the standardized scoring system developed before study
accrual and described in Table 1. Table 2 shows the actual number of differences
between the 2 groups, with differences on an absolute scale. For example,
if a case had an erythema score of 1 on the DF side and 2 on the SS side,
they would be marked as being different (Table 2), even though the standardized scoring system required a
difference of at least 2 for that measure (Table 1). If no actual difference was found between these 2 techniques,
a 0 was recorded.
Most of the cases had exactly the same scores for both techniques at
every time point (Table 2). For
correction of contour, infection, and hypertrophic scarring, no differences
were found for any case at any time point. The number of milia was equal for
19 of 21 cases at week 1. At week 1, 1 patient had 5 more milia on the SS
half, while another had 1 more on the DF half. In 1 case at month 3, a difference
in hypopigmentation was present on the SS half but absent on the DF half.
However, no differences were observed at 6 months for any case. Three patients
had mild pain on the SS side and no pain on the DF side at week 1 (2 cases)
and week 4 (1 case), with no differences at weeks 2 and 3. Scar-line visibility
was greater in 1 patient on the DF side at week 2, on 2 DF sides and 1 SS
side at 6 months, and on 1 DF side and 1 SS side at week 3 and month 3. No
differences in scar-line visibility were noted at weeks 1 and 4. Erythema
was greater in 1 case on the DF side at weeks 2 and 4, with greater erythema
in 2 cases on the DF side at week 3. No erythema differences were noted at
months 3 and 6. The percentage of reepithelialization was greater in 1 more
case on the DF side in weeks 1 and 2. None of the differences for the healing
measures were statistically significant at any time point (all P>.57 except one P = .16).
COMMENT
Granulation and/or reconstructive surgery after skin cancer excision
may result in prominent incision lines or contour irregularities that may
be unacceptable to the patient or surgeon. Spot dermabrasion represents a
known, proven technique to improve the appearance of scars. Spot dermabrasion
for scars performed in the early postoperative period has been reported with
the use of both motor-powered DF and drywall SS techniques.12-15
The 2 dermabrasion techniques have never been compared for outcome in a controlled
fashion. Recently, Holmkvist and Rogers13 compared
dermabrasion and carbon dioxide laser in the treatment of perioral rhytides.
In their study, they used motor-powered DF in 8 patients and manual dermabrasion
with the drywall SS in 7 patients, compared with laser. Although the 2 dermabrasion
techniques were not directly compared with each other according to the study
design, no appreciable differences in outcome or complications between the
2 dermabrasion methods were reported.
Using a controlled split-scar model, our study was able to directly
compare clinical outcomes for spot dermabrasion of facial scars by means of
2 techniques: the drywall SS manually vs the conventional motor-powered DF.
Our results indicate that both techniques equally improve cosmesis and have
few side effects. The 2 techniques did not demonstrate appreciable differences
in speed of reepithelialization, postoperative erythema, milia formation,
pigmentary changes, pain, infection, or cosmetic result. Previous studies
have shown that both the DF and SS produce few, if any, significant postoperative
sequelae such as hypertrophic scarring, infection, or postinflammatory hyperpigmentation.12, 15 Katz and Oca15
noted that several scars did manifest mild postoperative hypopigmentation
with the use of conventional dermabrasion.15
Cryogen spray was used in that study.
One potential criticism of our study, as well as other split-scar models,
is the accuracy of grading with respect to area treated.15
No physical measurements were taken to exactly delineate the area treated
by the 2 instruments for the postoperative grader. Therefore, overlap in grading
the 2 areas could have occurred. However, the 2 methods did not demonstrate
any significant differences in cosmetic result or postoperative sequelae.
The intent of the study was to show that the 2 techniques are equal in outcome
measures.
Manual dermabrasion with the sanding screen offers several advantages
over motorized dermabrasion with either DF or wire brush, including cost and
safety. The equipment has minimal cost, requires no maintenance, is easy to
prepare, and is disposable. The cost of the screen and syringe is $0.61. The
cost of the motor-driven dermabrader is $1365 for initial purchase. The cost
of a single DF is $32. In addition, the fraises must be cleaned and gas sterilized,
another added cost. Additional costs for conventional dermabrasion include
face shields and extensive draping for surgeon and patient. There is no appreciable
risk of injury from equipment getting caught on gauze, eyelid, or lip with
the SS. The technique is easy to learn, and SSs, as well as sandpaper, come
in various grades, allowing the beginner to use finer grades.
One of the most compelling advantages of manual SS dermabrasion is the
absence of aerosolized particles and blood splatter that are generated by
motor-powered dermabrasion. The father of motor-powered dermabrasion, the
late New York City dermatologist Abner Kurtin, MD, initially performed dermabrasion
while wearing a raincoat.16 He also described
having to wash off the blood and debris from his face after each case. Motor-powered
dermabrasion produces a considerable amount of airborne blood and skin debris
that is potentially hazardous to operating room personnel and requires specialized
barrier methods. Furthermore, evidence exists that dermabrasion can generate
aerosolized particles that may be transferred large distances and may still
linger hours after barrier protection devices have been removed.17
It is uncertain whether these particles can transmit infectious diseases such
as hepatitis or human immunodeficiency virus, but concern regarding this possibility
has been reported.18-20
Recently, a hydration-suction apparatus was described to reduce this risk;
however, this again increases costs.21
One disadvantage of manual dermabrasion is greater difficulty in concave
areas such as the alar groove and nasolabial fold. Insertion of cotton swabs
in the nasal vestibule with outward pressure facilitates manual dermabrasion
in the alar groove. Still, the surgeons in our study noted that motorized
dermabrasion with a pear-shaped fraise was easier. In addition, the motorized
unit was faster than manual dermabrasion. However, the difference in procedure
time for spot procedures is minimal (a few minutes).
Manual dermabrasion has been reported with the use of a variety of instruments,
including a variety of types of sandpaper, Bovie scratch pads, DF, wire brush,
and abrasive cloth, in addition to the drywall SS. The SS is available from
a number of manufacturers. It can be cut into an appropriate size and flash
autoclaved and is then ready for single use. The drywall sanding screen has
a distinct advantage over sandpaper. Its mesh porosity prevents clogging with
blood and skin debris and, to date, with many hundreds of cases reported,
no silicone granulomas have been noted.
The mechanism responsible for clinical improvement of scars after dermabrasion
is unknown. Yarborough2 proposed that dermabrasion
restructures and layers collagen parallel to the lines of tension to smooth
contour irregularities and eliminates the epidermal component by upward and
horizontal migration of epithelial cells from viable adnexal structures. Nelson
et al22 demonstrated an increase in collagen
type I synthesis after superficial dermabrasion for photoaged skin. Harmon
et al23 examined the ultrastructural and cell-cell
and cell-matrix interactions after conventional DF dermabrasion. They reported
that DF dermabrasion resulted in an increase in collagen bundle density and
size with unidirectional orientation parallel to the epidermal surface when
examined ultrastructurally. They also observed that dermabrasion alters cell-cell
and cell-matrix interactions between the epidermis and the dermis. This was
demonstrated by an up-regulation of tenascin (an extracellular matrix glycoprotein)
expression throughout the papillary dermis and of  6/ 4 integrin
(a transmembrane adhesion receptor) subunit on the keratinocytes throughout
the stratum spinosum epidermidis after dermabrasion. The alteration in tenascin
expression may promote both epithelial cell migration along the basement membrane
zone and fibroblast movement across scar boundaries. The postdermabrasion
alteration of integrin expression coincides with an increase in cell migration
and may promote reepithelialization across the scar, which leads to a more
blended epidermal contour.
In conclusion, dermabrasion with manual and motorized techniques is
equally effective in improving the cosmetic appearance of surgical scars.
Manual dermabrasion with the medium-grade drywall SS offers distinct advantages
over conventional motor-powered dermabrasion with the DF. These advantages
include lower cost, ease of use, and absence of blood splatter or aerosolized
particles.
AUTHOR INFORMATION
Accepted for publication October 10, 2001.
Reprints not available from the authors.
From the Departments of Dermatology (Drs Gillard, Wang, Boyd, Fader,
and Johnson) and Otorhinolaryngology (Drs Boyd, Fader, and Johnson), the Division
of Plastic Surgery, Department of Surgery (Dr Johnson), and the Biostatistics
Unit (Mr Dunn), University of Michigan Comprehensive Cancer Center and University
of Michigan Health System, Ann Arbor.
REFERENCES
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1. Kurtin A. Corrective surgical planing of skin: new technique for treatment of
acne scars and other skin defects. Arch Dermatol Syphilol. 1953;68:389-397.
2. Yarborough JM Jr. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol. 1988;14:292-294.
PUBMED
3. Fulton JE Jr. Modern dermabrasion techniques: a personal appraisal. J Dermatol Surg Oncol. 1987;13:780-789.
PUBMED
4. Collins PS, Farber GA. Postsurgical dermabrasion of the nose. J Dermatol Surg Oncol. 1984;10:476-477.
PUBMED
5. Kirschbaum JO. Dermabrasion on scars. Clin Plast Surg. 1977;4:283-287.
PUBMED
6. Yarborough JM, Beeson WH. Dermabrasion. In: Beeson WH, McCollough EG, eds. Aesthetic Surgery
of the Aging Face. St Louis, Mo: CV Mosby Co; 1986:142-181.
7. Mokal NJ, Patel J, Thatte RL. Sandpaper mounted on a safety razor: a simple device for dermabrasion. Br J Plast Surg. 1990;43:502.
PUBMED
8. Lusthaus S, Benmeir P, Neuman A, Weinberg A, Wexler MR. The use of sandpaper in chemical peeling combined with dermabrasion
of the face. Ann Plast Surg. 1993;31:281-282.
PUBMED
9. Tuerk M. A new material for dermabrasion. Plast Reconstr Surg. 1972;49:661.
PUBMED
10. Gross DJ. Spot dermabrasion. J Dermatol Surg Oncol. 1994;20:699.
11. Iverson PC. Surgical removal of traumatic tattoos of the face. Plast Reconstr Surg. 1947;2:427-432.
FULL TEXT
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ISI
12. Zisser M, Kaplan B, Moy RL. Surgical pearl: manual dermabrasion. J Am Acad Dermatol. 1995;33:105-106. [published correction appears in J Am Acad Dermatol. 1996;34:714].
13. Holmkvist KA, Rogers GS. Treatment of perioral rhytides: a comparison of dermabrasion and superpulsed
carbon dioxide laser. Arch Dermatol. 2000;136:725-731.
FREE FULL TEXT
14. Shriner DL, McCoy DK, Goldberg DJ, Wagner RF Jr. Mohs micrographic surgery. J Am Acad Dermatol. 1998;39:79-97.
FULL TEXT
|
ISI
| PUBMED
15. Katz BE, Oca AGS. A controlled study of the effectiveness of spot dermabrasion ("scarabrasion")
on the appearance of surgical scars. J Am Acad Dermatol. 1991;24:462-466.
PUBMED
16. Robins N. Dr. Abner Kurtin, father of ambulatory dermabrasion. J Dermatol Surg Oncol. 1988;14:425-431.
ISI
| PUBMED
17. Wentzell JM, Robinson JK, Wentzell JM Jr, Schwartz DE, Carlson SE. Physical properties of aerosols produced by dermabrasion. Arch Dermatol. 1989;125:1637-1643.
FREE FULL TEXT
18. Sawchuk WS, Felten RP. Infectious potential of aerosolized particles. Arch Dermatol. 1989;125:1689-1692. [published correction appears in Arch Dermatol. 1990;126:481].
FREE FULL TEXT
19. Kemsley GM. Transmission of hepatitis B in dermabrasion [letter]? Plast Reconstr Surg. 1975;56:440.
20. Mahaffey P. AIDS and dermabrasion [letter]. Plast Reconstr Surg. 1987;80:757.
FULL TEXT
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ISI
| PUBMED
21. Cox III AJ, Cook TA, Wang TD. Decreased splatter in dermabrasion. Arch Facial Plast Surg. 2000;2:23-26.
FREE FULL TEXT
22. Nelson BR, Majmudar G, Griffiths CEM, et al. Clinical improvement following dermabrasion of photoaged skin correlates
with sythesis of collagen I. Arch Dermatol. 1994;130:1136-1142.
FREE FULL TEXT
23. Harmon CB, Zelickson BD, Roenigk RK, et al. Dermabrasive scar revision: immunohistochemical and ultrastructural
evaluation. Dermatol Surg. 1995;21:503-508.
PUBMED
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