Combination of Fractional Resurfacing and Dermabrasion Techniques to Improve Aesthetic Outcomes of Facial Grafts

The use of full-thickness skin grafts (FTSG) in facial re-construction during dermatologic surgery is well-es-tablished. Surgical sites that commonly receive a skin graft include the scalp, nose and ear. Cosmesis with FTSG is an important consideration as the donor skin must closely match the texture, color, and photodamage of the skin adjacent to re-cipient site. Highly visible areas like the nasal dorsum and tip are less tolerant of a visible margin and may camouflage less readily than concave surfaces. Flaps were aesthetically superior on the nose in one systematic review.1 However, flaps are not always possible or desired. Surgical scar revision through the use of dermabrasion has been performed to even FTSG and scar texture, contour, and color-match with the surrounding skin. Many different techniques of performing dermabrasion have been tried including manual, electrical, and using a scratch pad. The use of fractional CO2 laser has been used more re-cently. However, there are no reports of combination treatment. Here, we describe the combination use of fractional ablative CO2 laser (FACL) in combination with manual dermabrasion to synergistically blend FTSGs with the surrounding skin to create a more seamless transition between native and donor skin. Description of the Technique Two patients underwent repair with pre-auricular FTSG for Mohs surgery defects, one on the nasal tip and one below the right eye. Pre-operative consultation had advised them on the surgery, repair, and possible need for a skin graft. Photographs of patients similar to them were shown at this visit as well as intra-operatively. Nylon tacking sutures were placed followed by running plain gut sutures to complete the graft. Each pa-tient was seen at 2 weeks to assess the health of the graft and remove the tacking sutures. At 2 months after the initial sur-gery, we discussed the benefit of pursuing scar remodeling treatments for an improved aesthetic outcome (Figure 1 A,C). A combination of FACL (CO2RE, Syneron Candela) with adju-vant manual dermabrasion using a sterilized diamond fraise was recommended. CO2RE Fusion mode with 30% fractional coverage, ring 116, core 70 was utilized with two orthogonal passes. Treated areas included the surface of the skin graft and the graft-native skin junction with 50% overlap on to the native skin. This was followed by light to medium pressure manual dermabrasion of the edges and graft in 3 random pattern or-thogonal passes that overlapped the graft edges. Results were reviewed at 4 months after the revision and assessed for requir-ing repeat treatment (Figure 1 B and D). Patients may require additional sessions for full improvement and camouflaging with the surrounding skin. Persistent redness after resolution of height and texture changes can be treated with pulsed dye laser as needed for those with type 1 rosacea, fair skin types, or for patient preference (Vbeam, Syneron Can-dela, 7.5 J/cm2, 6 ms, 10 mm spot size, 30 ms cryogen cooling spray). A second pass with a prolonged pulse duration may be considered if mild purpura is not achieved. However, redness can improve spontaneously over time.

Both dermabrasion and fractional ablative resurfacing (CO2 or Erbium) stimulate collagen by creating controlled injury within and adjacent to the scar to modify the remodeling process. In the case of lasers, photothermolysis and collagen denaturation causes collagen contraction, scar tightening, and water vapor-ization to improve scar texture. Metalloproteinases degrade any damaged collagen and a rapid phase of wound healing begins to replace fibrotic collagen. In contrast to dermabrasion and tradi-tional resurfacing techniques, more adjacent epidermal cells are recruited compared to regeneration from the adnexal structures. The use of fractional resurfacing and dermabrasion in facial sur-gical scars has previously been compared in a split-scar study.² High-energy pulsed CO2 laser-resurfaced areas have the ad-vantages of being bloodless with less postoperative crusting. Time-to-reepithelialization was identical, as was the textural ap-pearance. A second split scar study compared these methods and found less post-procedural erythema, bleeding, and edema at 1 week, with fractionated CO2. Efficacy data at 3 months were equivalent.³ Overall, both studies suggested the equivalency of CO2 laser and dermabrasion. Still, the aesthetic resolution of the appearance of the scar after either monotherapy was incomplete.

The use of a scratch pad, drywall screen or sandpaper have been suggested as low-cost methods of dermabrasion. While the various methods produce equivalent results,4 use of a diamond fraise provides greater individualization of the treatment. Diamond fraises come in a variety of shapes, angles and sizes that permit greater precision of abrading a given scar by hand. The operator requires less experience to perform the procedure effectively with this tool due to what we feel is greater precision using this small, ergonomic surgical instrument. Further, these diamond fraise hand pieces are easily re-sterilized with an autoclave; reducing the risk of infection as well as the cost for a surgical practice.We found that combing FACL and hand-held dermabrasion to camouflage FTSG takes advantage of the photothermolysis effects of modifying collagen within the scar to better match the surrounding skin in height and texture. Dermabrasion synergistically evens skin color and assists in softening the graft to native skin transition. Overall, we have found an additive benefit that appears to exceed the results of prior studies – with more improvement per session and usually fewer overall sessions. FAEL (Sciton) in ProFractional mode with 33% fractional coverage at 300 microns, coagulation 2 settings with dermabrasion has also been similarly successful in our hands. Further procedures that may augment the results include the addition of topical prostaglandin for hypopigmentation5 or concomitant topical platelet-rich plasma to reduce down-time of laser treatment and augment neocollagenesis. We have not pursued these adjuvant procedures as patients have achieved a satisfactory result with a short downtime.In summary, we feel that our proposed strategy of combination fractional ablative laser plus focal hand-held autoclaved diamond-fraise dermabrasion merits consideration for patients who want improvement of the aesthetic appearance of their facial FTSG. We hope this pilot project technique will lead to further study and innovation related to camouflaging surgical scars. A split-scar study would firmly demonstrate the benefit of the combination treatment.

Dr. Cohen provides consulting services for Sciton. There are no other relevant conflicts of interest.