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CHAPTER 1

icrodermabrasion (MDA) is a minimally invasive mechanical exfoliation proce-dure for superficial skin resurfacing. Most exfoliation modalities in use todaycan be broadly classified as chemical exfoliants, which include glycolic and sal-

icylic acid peels and mechanical exfoliants. Mechanical exfoliation treatments range fromsimple microbead scrubs found over the counter, which partially remove the stratumcorneum, to operative procedures such as laser resurfacing and dermabrasion, which canablate the reticular dermis. The depth of resurfacing achieved with MDA is conservativelyin the middle of this spectrum. Although MDA exfoliation can vary from superficial thin-ning of the stratum corneum to penetration into the upper papillary dermis, the targetdepth for most MDA procedures is removal of the stratum corneum.

Exfoliation treatments are based on the princi-ples of wound healing. By wounding and removingthe uppermost layers of the skin in a controlledmanner, cell renewal is stimulated with regenera-tion of a healthier epidermis and dermis. Histologi-cal evaluation of facial skin after repeated MDAtreatments demonstrates a reparative wound-healingprocess with regeneration of a compacted stratumcorneum and a smoother epidermis. Skin hydrationincreases with improved epidermal barrier function,and fibroblast stimulation increases dermal thick-ness through production of new collagen andelastin.

MDA is commonly used to treat photo-dam-aged skin and reliably demonstrates improvementin skin texture, coarse pores, comedonal acne, andepidermal hyperpigmentation such as solar lentig-ines. Treatments may improve fine lines and super-ficial acne scarring. Certain MDA devices have alsoshown positive results with rosacea and papulopus-tular acne.

Traditionally, MDA devices have used crystals asthe abrasive element. Negative pressure draws the skin to the hand-piece tip, and crystalssuperficially abrade the skin’s surface as they pass across the epidermis. Used crystals andcellular debris are aspirated and collected separately for disposal after treatment. Each passof the hand piece removes approximately 15 !m of skin, and two passes of most MDAdevices fully remove the stratum corneum. The depth of resurfacing achieved with MDA iscomparable to a superficial chemical peel. MDA offers certain advantages over chemicalpeel treatments such as greater control over the depth of exfoliation, comparatively

CHAPTER 33

MicrodermabrasionMicrodermabrasion

M

Rebecca Small, MDAssistant Clinical Professor, Department of Family and Community Medicine

University of California, San Francisco School of Medicine, Capitola, CA

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minimal discomfort, and no “downtime” for skin flaking and peeling. Other alternatives toMDA include ablative and nonablative laser resurfacing and dermaplaning, which utilizes aspecialized dulled scalpel blade that is passed across the skin.

Recent advances in MDA technology combine exfoliation with dermal infusion.During this process, topical products are delivered into the skin at the time of or imme-diately after exfoliation. These systems take advantage of the transient disruption to theepidermal barrier that occurs with removal of the stratum corneum to better delivermedications into the deeper dermal layers. Dermal infusion can enhance results forconditions such as dehydration, hyperpigmentation, acne, and rosacea based on theproducts that are used.

MDA is one of the most commonly performed cosmetic procedures in the UnitedStates, with more than a half million treatments performed annually, according to datafrom the American Society for Aesthetic Plastic Surgery. Treatments are technicallystraightforward with a low risk of side effects, are associated with a high degree of patientsatisfaction, and are well suited to the outpatient office setting. MDA has become anessential medical aesthetic rejuvenation treatment (ART) for primary care professionalswho desire to provide aesthetic care.

AnatomyThe outermost layer of the skin, the stratum corneum, is a nonliving layer of corneocytesand lipids, which serves as a barrier against microbial pathogens and environmental irri-tants and keeps the skin hydrated and protected from injury. Constant renewal is neces-sary for the epidermis to maintain its integrity and function effectively. In healthy,younger skin, epidermal renewal takes approximately 1 month for keratinocytes tomigrate from the living basal layer of the epidermis to the stratum corneum surface, fromwhich they are shed (see keratinocyte migration highlighted in Figure 1). In aged, photo-damaged skin, keratinocyte maturation is slowed, and there is abnormal retention of cells,leading to a thickened, rough stratum corneum. Disruption of the epidermal barrierresults in skin dehydration and may cause increased sensitivity. Photo-damaged skin isdull and exhibits dyschromia with solar lentigines and uneven pigmentation. Dermal

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Stratum corneumMature corneocyte

Immature keratinocyte

Stratum granulosum

Stratum spinosum

Dead skin cells

Epidermis

Living layerStratum basale

Dermis

Figure 1

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thinning with loss of collagen and elastin contributes to formation of fine lines. Throughstimulating cell renewal in the epidermis and dermis, MDA is able to address many ofthese changes seen with photo damage and intrinsic aging.

Results and Follow-upMDA treatments are most commonly performed on the face, neck, chest, and hands. Ingeneral, facial skin tolerates more aggressive treatments and tends to show greaterimprovements than nonfacial areas. Epidermal healing is thought to be related to the den-sity of adnexa (hair follicles and eccrine sweat glands) within a treatment area. The facialepidermis has a greater density of adnexa relative to the nonfacial epidermis, such as theneck and chest, which may account for its greater rejuvenation potential. Other treatmentareas include the back and hyperkeratotic areas such as elbows and knees. Treatments maybe performed for patients of all Fitzpatrick skin types (see Chapter 31 for Fitzpatrick clas-sifications). However, aggressive treatments should be avoided in darker skin types (IV toVI) because of to their increased risk of postinflammatory hyperpigmentation (PIH).MDA combined with dermal infusion is associated with less posttreatment erythema andreduced risks of PIH.

Results from MDA treatments are cumulative, and typically a series of six treat-ments is recommended at bimonthly intervals. Results are not usually clinically evi-dent after a single treatment. However, patients who have had little or no skin carepreviously may report improvements. Maintenance treatments may be performedevery 4 to 6 weeks.

The most marked results with MDA are achieved when MDA is used in combinationwith other rejuvenation treatments such as chemical peels, topical skin care products,laser and intense pulsed light (IPL) photo rejuvenation, and fractional resurfacing. Forexample, dramatic reduction of benign pigmented epidermal lesions, such as lentigines,can be achieved when MDA is alternated every 2 weeks with laser or IPL photo-rejuvena-tion treatments. MDA performed prior to fractional resurfacing treatments may alsoreduce the incidence of posttreatment complications such as milia and acne.

Preprocedure Checklist ! Perform an aesthetic consultation, and review the patient’s medical history (see Chapter

28).! Obtain informed consent (see Chapter 28).! Take pretreatment photographs (see Chapter 28).! Prophylax with an oral antiviral medication such as acyclovir or valacyclovir if there is

a history of herpes simplex or varicella in or near the treatment area for 2 days prior toprocedure, and continue for 3 days postprocedure.

! Prior to MDA, patients should avoid chemical peels, dermal filler injections, waxing,and direct sun exposure for 2 weeks; discontinue use of products containing retinoicacid or alpha-hydroxy acids (e.g., glycolic acid); and avoid botulinum toxin injectionsfor 1 week.

Equipment ! MDA device with abrasive element (e.g., crystals, diamond tips). Aluminum oxide is the

most commonly used crystal and is ideal for MDA because it is inert and second onlyto diamonds in hardness. Other crystals used include sodium chloride, sodium bicar-bonate, and magnesium oxide. Crystal-free MDA devices have become popular becauseof the lack of dust and associated risks of ocular injury. Diamond-tipped devices

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employ diamond-tipped pads as the abrasive element and can be used with topicalsolutions for dermal infusion.

! Headband.! Facial wash and astringent to cleanse and degrease the treatment area.! Towel to drape the patient.! Eye protection for the patient with small goggles or moist gauze. ! For crystal MDA devices, the operator should use clear goggles for eye protection and

a mask to reduce particle inhalation.! Gauze, 4 " 4 inches! Physical sunscreen (with zinc or titanium) and a soothing moisturizer for postproce-

dure application. ! Saline eyewash.

Aesthetic Indications ! Hyperpigmentation ! Rough texture, enlarged pores! Superficial acne scarring! Comedonal acne! Papulopustular acne! Rosacea and telangiectasias ! Fine wrinkles! Keratosis pilaris! Enhanced penetration of topical products

Improvements in papulopustular acne, rosacea, and telangiectasias have been demon-strated with certain MDA devices such as the SilkPeel (diamond-tipped with dermalinfusion).

ContraindicationsABSOLUTE

! Pregnancy ! Active infection in the treatment area (e.g., herpes simplex and verrucae)! Melanoma or lesions suspected of malignancy! Isotretinoin (Accutane) use in the past year! Dermatoses (e.g., eczema and psoriasis)! Autoimmune disease ! Sunburn

RELATIVE

! Rosacea and telangiectasias (not recommended with crystal MDA)! Papulopustular acne (not recommended with crystal MDA)! Very thin skin or excessive laxity and skin folds! Anticoagulant therapy! Unrealistic expectations

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GO!GO!

STOP!STOP!

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The Procedure

The following procedure is for treatments performedwith SilkPeel, a crystal-free MDA that uses diamond-tipped pads as the abrasive element and has simultaneousdermal infusion of topical solutions (see Figure 2). Com-parisons and recommendations for crystal MDA devicesare also included when possible.

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Papillary layer

Reticular layer

Hypodermis

Epidermis

Stratumcorneum

Stratum granulosumStratum spinosum

Stratum basale

Courtesy of emed.Figure 2

A

B

Courtesy of emed.Figure 3

Results of MDA treatment for papulopustular acne areshown before (Figure 3A) and after 6 treatments (Figure3B) performed 2 weeks apart. The topical solution usedfor dermal infusion included 2% salicylic acid.

! PITFALL: Treatment of papulopustularacne and rosacea are contraindicated withcrystal MDA devices.

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Results of MDA treatment for hyperpigmentation areshown before (Figure 4A) and after 6 treatments (Figure 4B) performed 2 weeks apart. The topical prod-uct used for dermal infusion included hydroquinone,kojic acid, and arbutin.

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A

B

Courtesy of emed.Figure 4

Results of MDA treatment for papulopustular rosaceaare shown before (Figure 5A) and after 6 treatments(Figure 5B) performed 2 weeks apart. The topical solu-tion used for dermal infusion was 2% erythromycinand 2% salicylic acid.

A

B

Courtesy of Tejas Desai, MDFigure 5

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Step 1. Perform a detailed skin evaluation prior to initiat-ing treatment (see Skin Analysis Form in Step 1).Fitzpatrick skin type classification is used todescribe background skin pigmentation and theskin’s response to sun exposure (see Chapter 31 for

I IIIII

VIIVI VIIIIV V

IXXIX

SKIN ANALYSIS FORM

Name: DOB:Last First

Fitzpatrick Skin Type Classification (check one):Skin Type I White Sun exposure reaction always burns, peels, never tansSkin Type II White Usually burns, tans with difficultySkin Type III White Sometimes mild burn, tans averageSkin Type IV Moderately brown Rarely burns, tans easilySkin Type V Dark brown Very rarely burns, tans very easillySkin Type VI Black Never burns, tans very easilty

Glogau’s Photoaging Classification (check one):Group I Mild (28-35 years old) No keratoses, little wrinkling, no scarring, little

or no makeupGroup II Moderate (35-50 years old) Early actinic keratoses, slight skin discoloration,

early wrinkling, parallel smile lines, mild scarring,little makeup

Group III Advanced (50-65 years old) Actinic keratoses, obvious skin discoloration,telangiectasiaa, wrinkling, moderate acnescarring, wears makeup always

Group IV Severe (65-75 years old) Actinic keratoses, possible skin cancers,wrinkling, gravitational aging, severe acnescarring, wears makeup thickly

Skin Type

Dry Oily Combination

Pre-Procedure Evalution

Place abbreviations on facial zones in diagram to note areas of specific conditions and concerns

KeyLP – Large Pores D – Dryness O – OilinessT – Telangectasia R – Imitation SC – Scarring

M – MiliaP – Pigmentation

C – ComedonesW – Wrinkles

Zone IZone IIZone IIIZone IVZone VZone VIZone VIIZone ViiiZone IXZone XZone XI

Other:

Photo Taken: Yes

Treatment Plan:

No

Date: Signature:

Step 1

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additional information), which is integral todetermining how aggressive treatments maybe. The Glogau classification is a baselinemeasure of a patient’s degree of photo damage.

MDA may be performed as a very superficial or super-ficial skin-resurfacing procedure (see Figure 6 for defi-nitions of skin resurfacing terminology). Depths listedin the figure are from the skin surface down to thelayer indicated. The depth of exfoliation with MDAincreases with increasing vacuum pressure, number ofpasses, and a more acute hand piece handle. Fordiamond-tipped devices, the depth of exfoliation alsoincreases with grit coarseness. Downward pressure onthe skin may increase the depth of exfoliation withsome diamond-tipped devices. The SilkPeel hand piecehas a recessed diamond-tipped pad, and downwardpressure on the skin does increase exfoliation depth.For crystal devices, the depth of exfoliation alsoincreases by moving the hand piece more slowly overthe skin, using larger particle sizes and higher crystalflow rates.

! PEARL: Two passes with the SilkPeel usinga 60-grit treatment head and vacuum set-ting of 5 psi (260 mm Hg) penetrates to 30to 35 !m and will fully remove the stratumcorneum.

! PEARL: Two passes with most aluminum-oxide crystal MDAs using a vacuum settingof 4 psi (200 mm Hg) will fully remove thestratum corneum.

! PITFALL: Greater depths of penetrationhave greater potential for improvementsbut are also associated with greater compli-cation risks. Once the dermis is breached,which is typically evident as bleeding, scar-ring becomes a consideration.

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Epidermis

Very superficialStratum corneum30 micrometersSuperficialPapillary dermis100 micrometersMediumUpper reticular dermis450 micrometersDeep Mid-reticulardermis600 micrometers

Stratum corneum

Papillary

ReticularDermis

Hypodermis

Figure 6

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Step 2. Position the patient comfortably, lying supineon the treatment table. Have the patient removecontact lenses, and apply a headband. Cleansethe treatment area with a gentle cleanser anddegrease the skin using an alcohol-based astrin-gent. Ensure that the skin is completely dryprior to treatment. Cover the patient’s eyes withgoggles or moist gauze. For crystal MDAdevices, the operator should wear clear eye pro-tection and a mask to reduce particle inhalation.

Step 3. Select the size and coarseness of the diamond-tipped treatment head (see Step 3). The 6-mm head should be used for the face and the9-mm head for larger areas, such as the back.Selection of the grit size is based on the aggres-siveness of the treatment. The heads range incoarseness from smooth with no diamondchips, fine (120 grit) to coarse (30 grit).

! PEARL: With the SilkPeel, most treatmentscan be performed with the 100-grit head.Hyperkeratotic areas such as elbows andknees respond well to a coarser, 60-grit head.The lips can be treated with the smooth head.

! PITFALL: Treatment of the lips is con-traindicated with crystal MDA.

Step 4. Set the vacuum flow by occluding the hand-piece tip with a gloved finger, as shown in Step 4.The strength of the vacuum affects the depthof resurfacing, and small adjustments in thisparameter can fine-tune the intensity of atreatment. Recommended vacuum settingsvary by manufacturer. In general, conservativesettings should be selected for initial treat-ments based on the patient’s Fitzpatrick skintype, tolerance, and treatment area using themanufacturer’s guidelines.

! PEARL: The SilkPeel vacuum should be setat 3.5 to 4 psi (180 to 200 mm Hg) for treat-ment on the face and chest, 2.8 to 3 psi (145to 155 mm Hg) for the neck, and 5 to 6 psi(260 to 310 mm Hg) for the hands andback. For crystal MDA devices, initial treat-ment vacuum settings range from 50 to200 mm Hg and are device dependent.

! PEARL: Patients with higher Fitzpatrickskin types are more prone to prolongedpostinflammatory erythema, PIH, and thelower limits of the range for vacuum set-tings should be used.

! PITFALL: Devices utilizing simultaneousdermal infusion are associated with lessdiscomfort. Patients may experience super-ficial abrasions without reporting pain

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Step 3

Step 4

Step 2

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during treatment, and patient feedbackmay be a less reliable indicator of treat-ment intensity. Observation of tissueresponse is therefore particularly impor-tant in determining vacuum settings withdermal infusion devices.

Step 5. For dermal infusion devices, select a topicalsolution for dermal infusion based on the pre-senting condition. Commonly used productsinclude hydroquinone or other botanical light-ening agents such as kojic acid and arbutin fortreatment of hyperpigmentation; erythromycinand salicylic acid for acne and rosacea; andhyaluronic acid, allantoin, and glycerin fordehydration. Select a solution flow rate for der-mal infusion using the manufacturers guide-lines.

! PEARL: Two topical solutions may be usedduring a treatment, for example, to addressdehydration and hyperpigmentation.

! PEARL: Typical SilkPeel dermal infusionrates range from 15 to 20 mL/min (see Step 5).

Step 6. Move the hand piece smoothly and slowly acrossthe skin as shown in Step 6 for treatment of theface. Exfoliation with the SilkPeel will not occurunless the tip is moving across the skin. For thefirst pass, strokes should be from the central faceto the periphery. The procedure usually starts atthe forehead, proceeds down the bridge of thenose, and then covers the cheeks, chin, andmouth. Stretch the skin between the fingers,place the hand piece perpendicular to and ingood contact with the skin, and move the handpiece across the skin parallel to the tension linebetween the fingers. Observe skin for the desiredclinical endpoint of mild erythema. Reassess tis-sue response and patient tolerance throughoutthe treatment and adjust settings accordingly.After completion of the first pass for the entireface, make a second pass following the samestroke pattern as the first pass. The second passfor crystal MDA is usually perpendicular to thefirst pass. For treatment of the neck, have thepatient lift the chin to extend the neck, use verti-cal strokes, and perform only one pass. For treat-ment of the chest, perform two passes withstrokes from the midline to the periphery. Fortreatment of the hands, have the patient make afist around a towel and perform two passes withstrokes parallel and then perpendicular to theaxis of the forearm.

! PITFALL: Petechiae or pinpoint hemor-rhages indicate that the settings are toointense and must be reduced.

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Step 6

Step 5

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! PEARL: Reduce treatment intensity nearthinned skinned areas such as the periorbitalarea. With the SilkPeel, reduce the vacuumpressure to 2.8 to 3 psi (145 to 155 mm Hg).

! PITFALL: With crystal MDA, do not leavethe hand piece in one spot because this willincrease abrasion depth and may causeinjury to the skin.

Step 7. At subsequent visits, parameters may beincreased to intensify treatments. In general,only one parameter should be changed tointensify treatments in any given visit.Typically, the number of passes is increased fora few treatments to achieve the desired clinicalendpoints, and vacuum settings are increasedin the later treatments. A total of two to fourpasses may be made on thicker skinned areas(see Table 33.1 for skin thickness in differentfacial areas) such as the forehead, upper lip,and chin or problematic areas, taking intoaccount tissue response and patient tolerance.Grit coarseness may also be increased at subse-quent visits to intensify treatments.

! PEARL: Acne scars require more aggressivetreatments. With the SilkPeel, a 100-grithead with 6 psi and up to four passes cross-hatched over the area may be performed.

Step 8. Apply a soothing topical product and a full-spectrum sunscreen with SPF 30 or greater(containing zinc or titanium).

! PEARL: If using a crystal MDA, remove allcrystal debris from the face with moistgauze prior to product application, payingclose attention to the periorbital area.

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Step 8

THICKNESS (MICROMETERS)AREA EPIDERMIS DERMIS SUBCUTANEOUS TOTAL

Neck 115 138 544 1,697 Eyelids 130 215 248 593 Cheek 141 909 459 1,509 Nose 111 918 735 1,764 Forehead 202 969 1,210 2,381 Lower lip 113 973 829 1,915 Upper lip 156 1,061 931 2,143 Chin 149 1,375 1,020 2,544

TABLE 33-1.

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Step 9. Sanitize and sterilize reusable equipment partsbetween patient treatments per the manufac-turer guidelines. Step 9 shows the waste con-tainer after treatment with skin surface debrisand used dermal infusion solution for disposal.After the patient’s treatment is completed, thedermal infusion bottle is replaced with a disin-fectant solution that is circulated to sanitizethe machine prior to the next patient. The dia-mond-tipped heads are autoclaved after eachtreatment for sterilization.

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Step 9

Complications ! Superficial abrasion ! Activation of herpes simplex! Pain or temporary discomfort ! Prolonged irritation and/or erythema! Postinflammatory hyperpigmentation (increased risk with high Fitzpatrick skin types)! Petechiae or purpura! Ocular injury! Urticaria (with crystal MDA)! Remote possibility of scarring (with crystal MDA)

Pediatric Considerations MDA may be performed for adolescents with parental consent but is otherwise con-traindicated for pediatric patients.

Postprocedure InstructionsPatients typically experience mild erythema and dryness for 1 to 2 days posttreatment withcrystal MDA but may not experience these aftereffects with MDA utilizing dermal infusion.A nonocclusive soothing moisturizer may be applied frequently as needed for dryness. Thepatient should avoid irritating topical products such as retinoids, astringents, glycolic acid,and depilatories and not undergo waxing, dermal filler injections, or laser or IPL treat-ments for 1 week. The patient should also avoid direct sun exposure for 1 week and use adaily full spectrum sunscreen with SPF 30 or greater (containing zinc or titanium). If scab-bing occurs, advise patients to avoid picking, because this may result in scarring, and applybacitracin daily until healed.

Coding Information and Supply SourcesMDA is not reimbursable by insurance. The charges for treatments vary widely and arelargely determined by local prices. Patients may pay for individual treatments, which gen-erally range from $100 to $150. However, because MDA is most effective as a series oftreatments, packages of treatments (usually six) may be offered so that patients achievethe best possible results and have the greatest satisfaction.

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ICD-9 CODES

Acne vulgaris 706.1Melasma 709.09 Dyschromia, unspecified 709.0Wrinkling of skin 701.8Scarring 709.2

SUPPLY SOURCES

Microdermabrasion Devices

! Aesthetic Technologies/Parisian Peel (crystal MDA and diamond-tipped MDA), EC-34,Sector I, Salt Lake City, Kolkata 700 064, India. Phone: 408-464-8893. Web site:http://www.mmizone.com/public/web/default.htm.

! Cosmetic R & D (dermal infusion and other abrasives), 4125 Pine Crest Court, Rocklin,CA 95677. Phone: 916-632-9134. Web site: http://dermasweep.com/.

! Edge Systems (crystal MDA and diamond-tipped MDA), 2277 Redondo Avenue, SignalHill, CA 90755. Phone: 1-800-603-4996. Web site: http://www.edgesystem.net/micro-dermabrasion.htm.

! emed (dermal infusion and diamond-tipped MDA), 31340 Via Colinas, Suite 101, Westlake Village, CA 91362. Phone: 1-888-848-3633. Web site: www.silkpeel.com.

! DermaMed International (crystal MDA), 394 Parkmount Road, P. O. Box 198, Lenni,PA 19052. Phone: 1-888-789-6342. Web site: http://www.megapeel.com/.

! Lumenis (crystal MDA), 5302 Betsy Ross Drive, Santa Clara, CA 95054. Phone: 408-764-3000. Web site: http://www.lumenis.com/wt/home/home/?flash=true.

! Mattioli Engineering (crystal MDA), 7918 Jones Branch Drive, Suite 600, McLean, VA22102. Phone: 703-312-6000, 877-MATTENG. Web site: http://www.matteng.com/pepita.html.

! Med-Aesthetic Solutions (crystal MDA and ultrasonic MDA), 2033 San Elijo Ave., Suite200, Cardiff-by-the-Sea, CA 92007. Phone: 760-942-8815. Web site: http://medaesthet-icsolutions.com/content/view/7/33/.

! RAJA Medical (dermal infusion and other abrasive), 801 South Olive Avenue, Suite 124,West Palm Beach, FL 33401. Phone: 877-880-4184. Web site: http://rajamedical.com/.

! Refine USA (dermal infusion, diamond-tipped MDA, and ultrasonic MDA), 13500 Sut-ton Park Drive South, Suite 701, Jacksonville, FL 32224. Phone: 866-491-7546. Website: http://refineusa.com/micro-gem.html.

! Sybaritic (dermal infusion and ultrasonic MDA), 9220 James Avenue South, Bloom-ington, MN 55431. Phone: 1-800-445-8418. Web site: http://www.sybaritic.com/.

! Syneron (crystal MDA and diamond-tipped MDA), 28 Fulton Way, Unit 8, RichmondHill, ON L4B 1L5, Canada. Phone: 905-886-9235, 866-259-6661. Web site:http://www.syneron.com/

Patient Education HandoutA patient education handout, “Microdermabrasion Treatments,” can be found on thebook’s companion Web site.

Bibliography

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Bhalla M, Thami GP. Microdermabrasion: reappraisal and brief review of literature. Derm Surg.2006;32(6):809–814.

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Coimbra M, et al. A prospective controlled assessment of microdermabrasion for damaged skinand fine rhytids. Plast Reconstr Surg. 2004;113:1438–1443.

Freedman BM, Rueda-Pedraza E, Waddell SP. The epidermal and dermal changes associated withmicrodermabrasion. Derm Surg. 2001;27(12):1031–1034.

Freeman MS. Microdermabrasion. Facial Plast Surg Clin North Am. 2001;9(2):257–266. Grimes P. Microdermabrasion. Derm Surg. 2005;31(9):1160–1165. Hernandez-Perez E, Ibiett EV. Gross and microscopic findings in patients undergoing microdermabra-

sion for facial rejuvenation. Derm Surg. 2001;27(7):637–640.Karimipour DJ, et al. Microdermabrasion with and without aluminum oxide crystal abrasion: a

comparative molecular analysis of dermal remodeling. J Am Acad Derm. 2006;54(3):405–410.Koch RJ, Hanasomo M. Microdermabrasion. Facial Plast Surg Clin N Am. 2001;9(3):377–381.Moy LS, Maley C. Skin management: a practical approach. Plas Surg Prod. 2007;Jan:24–28. Rajan P, Grimes P. Skin barrier changes induced by AL2O3 and NaCl microdermabrasion. Derm

Surg. 2002;28(5):390–393.Rubin MG, Greenbaum SS. Histologic effects of aluminum oxide microdermabrasion on facial

skin. J Aesth Derm Cosmetic Surg. 2000;1:237. Sadick N. A review of microdermabrasion. Cosm Derm. 2005;18:351–354.Spencer JM, Kurtz ES. Approaches to document the efficacy and safety of microdermabrasion

procedure. Derm Surg. 2006;32(11):1353–1357.Tejas DD, Moy LS, et al. Evaluation of the SilkPeel system in treating erythematotelangectatic and

papulopustular rosacea. Cosm Derm. 2006;19(1):51–57.

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