Patient Selection

While almost any patient will benefit from exfoliation with MDA, patients with mild to moderate photoaging changes of solar lentigines, rough texture, and fine lines (e.g., Glogau types I and II) typically derive the most noticeable benefits (see Chapter 19, Aesthetics Principles and Consultation, for a description of Glogau types). Results with MDA are slow and progressive, requiring a series of treatments for visible improvements. Assessment of patients’ expectations at the time of consultation and commitment to a series of treatments is essential to the success of these treatments.

Patients of all Fitzpatrick skin types may be treated with MDA (see Chapter 19 for a description of Fitzpatrick skin types). It is advisable to treat darker skin types (IV through VI) conservatively because they have increased risks of pigmentary changes such as postinflammatory hyperpigmentation. Elderly patients with thin and friable skin and patients with erythematous conditions such as rosacea, telangiectasias, and poikiloderma of Civatte are also treated conservatively, because they have greater risks of abrasion and worsening of erythema respectively.

Cosmetic Indications¹

Alternative Therapies

The depth of skin resurfacing with MDA is comparable to a light chemical peel, which is a reasonable alternative treatment for skin rejuvenation. MDA offers certain advantages over chemical peels such as greater control over the depth of exfoliation, comparatively less discomfort, and no “downtime” for skin flaking and peeling. Superficial dermaplaning, performed with a specialized scalpel blade gently scraped across the skin, is a good alternative to MDA for patients with erythematous conditions such as rosacea, because there is no vacuum suction with this procedure to potentially exacerbate erythema. Dermaplaning requires greater treatment times and takes longer to acquire proficiency than MDA.

For more aggressive skin resurfacing, procedures such as medium-depth chemical peels, dermabrasion, or laser resurfacing are required. Dermabrasion involves the use of a high-speed rotating brush to abrade the skin and can penetrate to the reticular dermis. Laser resurfacing can also penetrate to the reticular dermis, and may be performed as an ablative procedure, where the epidermis is removed (e.g., with 2940 nm wavelength), or as a nonablative procedure, where the epidermis remains intact (e.g., with 1550 nm wavelength). Relative to MDA, these more aggressive resurfacing procedures offer significantly greater reduction of wrinkles and improvements in photodamaged skin. However, deeper resurfacing procedures such as these have longer recovery times and can be associated with complications such as scarring, dyspigmentation, and infection.

Microdermabrasion will not improve deep wrinkles and folds related to volume loss or hyperdynamic musculature, which respond to treatment with dermal fillers and botulinum toxin, respectively.

Microdermabrasion Devices Currently Available

Most MDA devices utilize a closed-loop vacuum system, which draws the skin up to an abrasive element on the handpiece tip. The handpiece is passed across the skin and cellular debris is removed and suctioned up into a collection container and disposed of after treatment. The process of MDA exfoliation using a diamond-tipped device is shown in Figure 23-1. Abrasive elements used by MDA devices vary and the most commonly used elements are:

FIGURE 23-1 Microdermabrasion exfoliation process.

(SilkPeel™ Envy Medical, Los Angeles, CA.)

Aluminum oxide (typically 100 µm in diameter) is the crystal most often used for MDA. It is inert, very hard, water insoluble, and its crystalline structure has multiple sharp edges, making it good for abrasion. Other types of crystals less commonly used include sodium chloride, sodium bicarbonate, and magnesium oxide. Most crystal devices blow crystals across the skin and aspirate them along with skin debris into a closed container. Some devices use crystal covered pads rather than aerosolized crystals. Aerosolized crystal devices have the disadvantage of leaving a dust residue, and have risks of ocular injury and dust inhalation. Crystals are not reusable but their expense is modest.

Crystal-free MDA devices have become popular because they lack these ocular and inhalation risks. Common crystal-free abrasive elements include diamond-tipped pads and bristles. Figure 23-2 shows a MDA handpiece with diamond-tipped treatment heads of various coarseness. Most of these devices have reusable treatment heads that can be sterilized following treatment. Some crystal-free devices combine simultaneous application of topical solutions during exfoliation, called infusion. The intent is to deliver topical products more effectively to the skin by taking advantage of the transient disruption of the epidermal barrier. Selection of topical solutions is based on the presenting condition. For example, hydroquinone or cosmeceuticals such as kojic acid and decapeptide-12 may be used for patients with hyperpigmentation; erythromycin and salicylic acid for acne and rosacea; and hyaluronic acid and glycerin for dehydrated skin.

FIGURE 23-2 Microdermabrasion handpiece and diamond-tipped treatment heads.

(SilkPeel Envy, copyright Rebecca Small, MD.)

MDA devices are classified by the FDA as type I devices, which do not require the manufacturer to establish performance standards or perform clinical trials to demonstrate efficacy. With more than 30 MDA devices available, this presents a challenge to providers when selecting a device. Most MDA machines are either manufactured for estheticians (“esthetician grade”) or for clinical providers (“medical grade”), with the latter capable of deeper exfoliation with higher vacuum pressures and more abrasive treatment heads. Commonly used MDA devices are listed in the Resources section at the end of the chapter.

Contraindications¹

Advantages of Microdermabrasion

Disadvantages of Microdermabrasion

Anatomy

Histologic evaluation of skin immediately after treatment with MDA demonstrates smoothing of the stratum corneum.¹³ Each pass of an aluminum oxide crystal MDA handpiece removes approximately 10 to 15 µm of skin, two passes fully remove the stratum corneum, and four passes penetrate to the stratum granulosum layer of the epidermis.¹⁴ The epidermal barrier function is transiently disrupted for 2 to 3 days after treatment with increased transepidermal water loss. These effects, however, are reversed 1 week after treatment, and a more compacted stratum corneum is regenerated with improved barrier function and increased skin hydration compared to pretreatment skin.^15,16

In addition to short-term improvements in epidermal barrier function, longer term improvements have also been demonstrated in the epidermis and dermis following repeated MDA treatments. Epidermal thickness increases by up to 40% due to increased cellularity,⁷ and dermal collagen and elastin deposition increase, which can be seen clinically as a reduction of coarse pores and fine lines.⁶

Equipment

Procedure Preparation

Microdermabrasion: Steps and Principles

The following recommendations are guidelines for microdermabrasion treatments on the face using the SilkPeel (manufactured by Envy), which is a crystal-free device that utilizes diamond-tipped pads as the abrasive element with simultaneous infusion of topical solutions. Comparisons and recommendations for crystal and bristle MDA devices are also included where possible. Recommended treatment parameters vary according to the device used, and specific manufacturer guidelines should be followed at the time of treatment.

Safety Zone

The area within which MDA treatments can be safely performed on the face, called the Microdermabrasion Safety Zone, is shown in Figure 23-3. All areas of the face may be treated, apart from the area within the bony orbital rim and, for most devices, the lips. Some MDA devices have nonabrasive smooth treatment tips that may be used on the lips (Figure 23-2). MDA can be used on the face, neck, chest, hands, back, and almost any area of the body requiring exfoliation.

FIGURE 23-3 Microdermabrasion Safety Zone for facial treatments.

Performing Microdermabrasion

1. Comfortably position the patient supine on the treatment table.

2. Place a headband or surgical cap on the patient to pull hair away from the face. Cover the patient’s eyes with protective eye shields. If using crystal MDA, the provider should also wear protective eyewear and a mask.

3. Clean the treatment area with a cleanser and then degrease with alcohol or an alcohol-based astringent. Wait for the skin to dry completely before starting the procedure.

4. Select the size of the treatment head based on the treatment location, use larger heads for most body treatment areas, and smaller heads for the face.

• With the SilkPeel, use the 6-mm head for face, neck, chest and hands, and 9-mm head for other body areas.

5. For devices with abrasive treatment heads, such as diamond-tipped heads, select the coarseness of the head based on the aggressiveness of treatment. Recommended treatment parameters using the SilkPeel are shown in Table 23-1.

 

TABLE 23-1 Treatment Parameters for SilkPeel Microdermabrasion

Treatment Intensity	Tip Coarseness	Vacuum Pressure (psi)
Mild	140 grit	3.0–4.0
Moderate	120 grit	3.5–4.3
Aggressive	100 grit	4.4–5.0

6. Select the vacuum setting by inverting the handpiece and occluding the tip with a gloved finger (Figure 23-4). The strength of the vacuum affects the depth of resurfacing, and small adjustments in this parameter can fine-tune the intensity of a treatment. Vacuum pressures are device dependent and the manufacturer’s recommended settings should be used. In general, conservative vacuum settings should be selected for initial treatments.

TIP: Reduce vacuum pressure in the thin-skinned periorbital areas.

7. If using a device that infuses solutions, select a topical product appropriate for the presenting condition, then select a flow rate of infusion per the manufacturer’s guidelines.

• For hyperpigmentation, use lightening agents such as hydroquinone, kojic acid, arbutin, or brightening peptides (e.g., decapeptide-12).

• For dehydration and fine lines, use hyaluronic acid, allantoin, and glycerin.

• For photodamage, use vitamin C.

• For acne, use erythromycin and salicylic acid.

TIP: Two topical solutions may be infused during a treatment to address two conditions. For example, hyaluronic acid may be used with the first pass and to improve dehydration and decapeptide-12 for hyperpigmentation with the second pass.

8. The direction of handpiece strokes on the face are from the medial face toward the periphery (Figure 23-5). Begin at the forehead, then proceed down the nose, cheeks, chin, and lastly, around the mouth.

9. Stretch the skin between two fingers, hold the handpiece perpendicular to the skin and bring the tip gently in contact with the skin. Move the handpiece smoothly and slowly across the skin with even pressure, parallel to the tension line between the fingers (Figure 23-6).

TIP: Exfoliation with the SilkPeel will not occur unless the tip is moving across the skin.

CAUTION: With crystal MDA, do not leave the handpiece in one spot because this will increase the abrasion depth.

CAUTION: With crystal MDA and devices with nonrecessed abrasive treatment heads, avoid excessive downward pressure because this increases the abrasion depth.

10. Observe the skin for the desired clinical endpoint of mild erythema.

11. Overly aggressive treatment is indicated by:

• Petechiae and purpura

• Patient intolerance (pain of 6/10 or more)

If either of these occur, settings should be promptly modified by reducing vacuum pressure and other parameters affecting treatment intensity.

12. After completing treatment of the entire area, a second pass to the same treatment area may be performed by moving the handpiece perpendicular to the previous stroke direction (Figure 23-7).

13. Other treatment areas:

• Neck: Patient should lift the chin to extend the neck. Perform only one pass using vertical strokes with mild treatment parameters.

• Chest: Perform two passes with strokes from the midline to the periphery.

• Hands: Have the patient make a fist while holding a soft ball or rolled towel. Perform the first pass with strokes parallel to the axis of the forearm and a second pass with perpendicular strokes.

14. At subsequent visits, parameters may be increased to intensify treatments. In general, either the number of passes or the grit coarseness is changed to intensify treatments in any given visit. It is advisable to change only one parameter during a treatment to safely escalate treatment intensity.

TIP: It is important to reassess the skin at each visit prior to treatment, because the condition of the skin is dynamic and may vary between treatments.

15. Apply a soothing topical moisturizer (e.g., Epidermal Repair by SkinCeuticals) and a zinc or titanium sunscreen with SPF 30 or higher (e.g., products by Solar Protection, SkinCeuticals, and Skin Medica) after the treatment. If using a crystal device, ensure that all crystal debris is removed with moist gauze, especially in the periorbital area prior to application.

16. Sanitize and sterilize reusable equipment parts between treatments per the manufacturer guidelines. This is commonly performed by circulating a disinfectant solution through the machine. Dispose of used crystals and topical solutions. Diamond-tipped and other reusable abrasive heads require debridement with a brush and enzyme bath, followed by autoclaving after procedures.

FIGURE 23-4 Handpiece occlusion for selection of microdermabrasion vacuum settings.

(SilkPeel Envy, copyright Rebecca Small, MD.)

FIGURE 23-5 Direction guide for microdermabrasion treatment of the face and neck.

FIGURE 23-6 Technique for microdermabrasion first pass.

(Copyright Rebecca Small, MD.)

FIGURE 23-7 Technique for microdermabrasion second pass.

(Copyright Rebecca Small, MD.)

Results

Microdermabrasion is a progressive treatment. A slight improvement in skin texture or skin brightness after a single treatment may be evident. However, for more marked results and improvements in pigmentation, acne, fine lines, and other conditions, a series of six treatments is usually necessary.

Figure 23-8 shows a patient demonstrating signs of moderate photodamage with solar lentigines, dullness, and fine lines (A) before and (B) after a series of six treatments with a bristle MDA using an infusion of topical solutions containing glycolic and lactic acid, and cosmeceutical lightening agents of kojic and azelaic acids, bearberry, and licorice.

FIGURE 23-8 Moderate photodamage changes of solar lentigines, dullness, and fine lines before (A) and after (B) six bristle (DermaSweep™) microdermabrasion treatments.

(Courtesy of CosMedic R&D, Inc., Roseville, CA.)

Figure 23-9 shows a patient with papulopustular acne (A) before and (B) after a series of six MDA treatments with a diamond-tipped MDA using an infusion of topical solutions containing salicylic, glycolic and kojic acids and arbutin.

FIGURE 23-9 Acne vulgaris (A) before and (B) after six diamond-tipped (SilkPeel) microdermabrasion treatments.

(Courtesy of Envy Medical, Los Angeles, CA.)

Figure 23-10 shows a patient with darker Fitzpatrick skin type with solar lentigines and dullness (A) before and (B) after a series of six MDA treatments with a diamond-tipped MDA using an infusion of topical solutions containing a lightening peptide, decapeptide-12 (Lumixyl™).

FIGURE 23-10 Postinflammatory hyperpigmentation and acne in a patient with darker Fitzpatrick skin type (A) before and (B) after six diamond-tipped (SilkPeel) microdermabrasion treatments.

(Courtesy of A. Bhatia, MD, using SilkPeel, Envy Medical, Los Angeles, CA.)

Aftercare

Patients may experience mild erythema, dryness, and/or tingling for 1 to 3 days after treatment, more so with crystal MDA and devices without infusion of topical solutions. A nonocclusive moisturizer (e.g., SkinCeutical’s Epidermal Repair) may be applied as frequently as needed for dryness during this time. Patients are instructed to avoid irritating products including retinoids, astringents, depilatories, and exfoliants such as glycolic acid, for 2 weeks, or until the skin has no more signs of irritation. Botulinum toxin treatment may be performed on the same day, immediately following MDA if desired. Patients are instructed to avoid direct sun exposure for 4 weeks and use a daily sunscreen with SPF 30 or higher (containing zinc or titanium) during the course of their treatments. If a scab or abrasion occurs, a topical antibiotic ointment (e.g., Bacitracin) may be used daily until healed and patients are advised to avoid picking, as this can increase the risk of scarring and other complications.

Follow-Up

Treatments may be performed every 2 to 4 weeks during a series of six treatments. Maintenance treatments thereafter may be done every 4 to 6 weeks, or as deemed necessary by the provider.

Advanced Microdermabrasion

As providers gain experience and skill with microdermabrasion, they may choose to broaden its applications and combine it with other procedures to increase treatment intensity. Microdermabrasion can be used as part of skin preparation prior to the application of certain chemical peels to allow for more even peel penetration and to enhance the depth of penetration into the skin. Providers are advised to use established manufacturer protocols when combining these two exfoliation modalities because peel penetration can be significantly altered by the lack of the stratum corneum barrier that is removed by microdermabrasion.¹²

Microdermabrasion may also be used as part of photodynamic therapy (PDT), an FDA-approved treatment for nonhyperkeratotic actinic keratoses of the face and used off label to enhance photorejuvenation treatments with lasers (see Chapter 27, Photorejuvenation with Lasers, for more information about PDT). Prior to application of topical photosensitizing medications, such as 5-aminolevulinic acid (Levulan^®), MDA can be performed which enhances product penetration and increases intensity of the treatment.¹⁷

Complications

MDA has minimal risks of side effects and complications.¹ One study of more than 100 patients receiving MDA during a 2-year period reported no instances of infection, long-term hyperpigmentation, or scarring.¹⁸ However, complications are possible with any procedure, and knowledge of these is important to help ensure the best possible outcomes.

Postprocedure erythema is common and the duration depends on the aggressiveness of the procedure and inherent reactivity of the patients’ skin. Most erythema resolves spontaneously within a few hours to 1 day. Prolonged erythema of more than 5 days, particularly in patients with darker Fitzpatrick skin types (IV through VI), can result in postinflammatory hyperpigmentation (PIH). If erythema is marked immediately after treatment, ice can be applied to the skin for 15 minutes every hour followed by a topical steroid cream. A high-potency topical steroid cream may be used in the office (e.g., triamcinolone 0.5%) and the patient sent home with a low-potency steroid (e.g., hydrocortisone 2.5% or 1%) to be used twice daily for 3 to 5 days or until erythema resolves. Sun avoidance is very important to reduce the risk of PIH when erythema is present.

Excessive dryness or pruritis can be managed with application of moisturizers. Use of highly occlusive moisturizers, such as Aquaphor, will reduce these symptoms but can be associated with development of acne and milia. Therefore, thinner, less occlusive moisturizer formulations (e.g., Epidermal Repair by SkinCeuticals) with frequent application is preferable to manage dryness and pruritis.

Superficial abrasions can occur with deeper MDA penetration. These are usually erythematous immediately after treatment and can either hyperpigment or crust slightly. Superficial abrasions are also referred to as striping, due to the appearance of lines on the skin. Abrasions may also be circular if the tip has dwelled too long or excessive downward pressure was applied in one spot. Crusting is managed with moist wound care using a topical antibiotic ointment (e.g., Bacitracin) as needed daily until healed.

Hyperpigmentation can be treated with lightening agents such as hydroquinone or cosmeceutical agents such as kojic acid, arbutin, and licorice (see Chapter 24, Skin Care Products). In darker Fitzpatrick skin types, resolution of hyperpigmentation typically takes several months. Hyperpigmentation usually resolves, but in rare instances can be permanent.

Urticaria has been reported as a rare complication after MDA,¹⁹ and is presumed to be dermatographic or pressure-induced. Products applied during treatment may also trigger an allergic response. Ice may be applied, an oral antihistamine (e.g., cetirizine 10 mg) given to the patient, and a high-potency topical steroid applied to the treatment area. Although extremely unlikely, it is also advisable to assess patients for signs and symptoms of more severe allergic responses such as bronchospasm or anaphylaxis if an allergic reaction occurs.

Petechiae and purpura can occur with overly aggressive vacuum settings, particularly in older patients with thin skin or if using anticoagulants. If petechiae occur, vacuum settings should be decreased and the affected area avoided for the remainder of treatment. Petechiae resolve more rapidly than purpura, which can take up to 2 weeks to clear.

Scarring is a remote possibility and can occur if treatment parameters are aggressive, and is more likely if infection occurs or crusts are excoriated. Hypopigmentation is also a rare possibility, with greater risks in darker Fitzpatrick skin types. Hypopigmentation can be a temporary or permanent complication.

Ocular injury due to crystal adherence to the conjunctiva or punctuate keratopathy can occur with crystal MDA devices. Symptoms include ocular pain, photophobia, and conjunctival erythema.¹¹ Protective eye shields or moist gauze is advised with crystal MDA to cover patients’ eyes, appropriate eyewear and masks for providers, and removal of all crystals from the face following treatment.

Treating Specific Lesions

FIGURE 23-11 Poikiloderma of Civatte.

(Copyright Rebecca Small, MD.)

FIGURE 23-12 Caution areas for microdermabrasion treatments in patients with facial erythema and rosacea.

Learning the Techniques

Providers are encouraged to practice first on themselves, on the anterior thigh, and then on the face of staff and friends prior to treating patients.

Current Developments

Financial Considerations

Medical-grade MDA devices, capable of more aggressive treatments, are priced higher than esthetician-grade MDA devices. Crystal MDA machines need continuous replacement of crystals, because these are not recyclable. Diamond-tipped MDA machines use either disposable or reusable diamond treatment heads. The use of disposables should always be kept in mind when purchasing a system. Solutions for infusion are one such disposable.

Insurance does not reimburse for microdermabrasion procedures. The charges for treatments vary and are largely determined by local prices. Patients may pay for individual treatments, which generally range from $75 to $100. However, MDA is most effective as a series of treatments, and packages of treatments (usually six) may be offered so that patients achieve the best possible results and satisfaction with the procedure. Box 23-1 lists codes for MDA procedures.

Conclusion

Microdermabrasion is a popular cosmetic procedure for aesthetic skin rejuvenation. From a patient perspective, it is safe, noninvasive, has relatively no recovery time, has minimal adverse effects, and is reasonably priced. From a provider perspective, it is technically straightforward and easily integrated into a practice. Microdermabrasion may be safely combined with skin care treatments, such as topical products, and with other minimally invasive aesthetic procedures such as chemical peels, lasers, or injectables, to enhance results.

Resources