Am J Clin Dermatol 2005; 6 (2): 89-92

LEADING ARTICLE 1175-0561/05/0002-0089/$34.95/0

© 2005 Adis Data Information BV. All rights reserved.

Microdermabrasion
James M. Spencer
Department of Dermatology, The Mount Sinai School of Medicine, New York, New York, USA

Abstract Microdermabrasion is a simple, safe, office cosmetic procedure in which aluminum oxide crystals or other
abrasive substances are blown onto the face, then vacuumed off, using a single handpiece. This procedure has
rapidly become widely utilized for a variety of cosmetic objectives, including the improvement of photoaging,
hyperpigmentation, acne, scars and stretch marks. Despite its widespread use, little is known about its actual
mechanism of action. The few published studies suggest that patients and physicians alike report a mild benefit
when microdermabrasion is utilized for photoaging. Histologic evaluation reveals little actual abrasion of the
skin with the procedure, yet changes are seen in the dermis. Given the safety, simplicity and patient satisfaction
associated with microdermabrasion, it is likely to remain a popular treatment.

Since its introduction in 1985, microdermabrasion has become open partial thickness wound that requires weeks of healing time.
one of the most popular cosmetic treatments currently performed. Both techniques also carry the risk of scarring and infection. An
It is a simple procedure that is associated with little or no risk, alternative that was blood-free, safer and associated with less
involves no down time for the patient, and is widely available in down time was sought.
physicians’ offices and spas. The American Academy of Cosmetic
Surgery estimates that microdermabrasion is the second most 2. Development
widely utilized cosmetic procedure after injection of botulinum In 1985, Marini and Lo Brutto, working in Italy, developed
toxin.[1] Despite the wide popularity of microdermabrasion, little is microdermabrasion as an alternative to more aggressive wounding
actually known about how and why the procedure works. techniques.[2] As implied by the term, microdermabrasion was
intended to abrade the skin mechanically. The system operates by
1. Rationale
pulling the skin into a handpiece with a vacuum line (suction).
It has been known for centuries that abrading the skin, and thus Within the handpiece, a second line blows aluminum oxide crys-
producing a partial thickness wound, results in the formation of tals onto the skin, with the intention of causing gentle mechanical
new skin with an enhanced cosmetic appearance as part of the abrasion. Following impact on the skin, the crystals and any
wound healing process. To a point, the deeper the wound, the abraded material are carried away by the vacuum into a waste
greater the rejuvenation. If the wound is superficial to the mid- receptacle. In most devices, the operator can control only the
reticular dermis, it will heal with an enhanced cosmetic appear- amount of suction, measured in millimeters of mercury. However,
ance. Wounds deeper than the mid-reticular dermis heal with a this also indirectly affects the forward flow rate of aluminum oxide
scar. particles. The handpiece is slowly moved across the skin by the
During the twentieth century, chemical peels and dermabrasion operator, and the speed and number of passes over the skin are
were widely utilized to produce partial thickness wounds. Chemi- presumed to affect the result.
cal peels induce a controlled chemical burn, whereas dermabrasion The system was originally introduced as a medical device in the
utilizes a rotary wire brush or diamond fraise to mechanically US, which normally would require US FDA approval. The FDA
abrade the skin. The deepest chemical peel is obtained with approval process requires completion of phase III clinical trials
phenol-containing mixtures, which can induce hypomelanosis, demonstrating both safety and efficacy. However, the FDA classi-
and which are cardiotoxic and nephrotoxic if absorbed system- fied the device as a type I device (non-life-sustaining). This
ically. Dermabrasion requires significant operator experience and classification does not require the manufacturer to establish per-
expertise, and when the blood vessels of the papillary dermis are formance standards, but only to follow good manufacturing prac-
reached, produces significant aerosolization of blood into the tice guidelines. The device also received an exemption status from
procedure room. Phenol peels and dermabrasion both produce an the FDA, releasing it to be sold without a clearance letter from the
90 Spencer

FDA. This has had two consequences: (i) no phase III clinical These investigators also undertook histologic evaluation of a
trials of microdermabrasion devices have ever been conducted, small number of samples. First, to assess the acute effects of a
which means their efficacy has never been established; and (ii) the single session, 20 passes were performed on an excised piece of
devices can be sold to and used by anyone, including spas and abdominal skin, which was then biopsied and evaluated histologi-
beauty parlors. cally. After 20 passes, only partial ablation of the stratum corneum
was seen. There was compaction of the remaining stratum corne-
3. Study Results um, and no viable epidermis was abraded. Three patients received
a total of six treatments every 2 weeks to the dorsal forearm. Ten
passes were performed each session. Following completion of the
Microdermabrasion has become very popular, and there are
six sessions, post-treatment biopsies were compared with pretreat-
now over 36 models on the US market. Clearly, both the public
ment biopsies. In these three subjects, thickening of the epidermis
and operators are pleased with this technique. Microdermabrasion
with no change in the stratum corneum was seen. Fontana-Masson
has been advocated as a treatment for photoaging, dyschromias,
staining revealed a more regular distribution of melanosomes and
scars, acne and stretch marks. However, for such a popular device,
less melanization of the epidermis. Elastin stains revealed an
remarkably little in the way of objective evaluation of this proce-
increased elastin content in two of the three subjects, while no
dure has been published in the medical literature.
consistent change was seen in papillary mucin content or collagen
The first published paper on microdermabrasion appeared in
content.[4]
1995 by Tsai et al.[3] In this study, 41 patients with a variety of
scars, including acne, traumatic, varicella and burn scars, were This study has several interesting implications. First and most
treated with microdermabrasion. An aggressive vacuum setting obvious is that patients like the procedure. This point is also clear
was utilized (76mm Hg), and multiple treatment sessions were from the current popularity of this treatment. Also of particular
required. A setting this aggressive can produce petechiae and interest is the discrepancy between what is observed during per-
purpura, and even pinpoint bleeding. To achieve ‘good to excel- formance of the technique and what the abdominal skin biopsy
lent’ clinical improvement, a mean 9.1 sessions were required. showed. The authors reported that 20 passes to acne scars pro-
Acne scars required a mean of 15.2 treatments for improvement. duced pinpoint bleeding, presumably indicating that the level of
Mild postinflammatory hyperpigmentation was the only adverse abrasion extended to the blood vessels in the papillary dermis.
effect seen. Although this study reported encouraging results, it However, 20 passes on excised abdominal skin did not even
did not provide objective data other than the physician’s visual completely abrade the stratum corneum. If the level of abrasion is
evaluation, and it also provided no information on mechanism of not even to viable epidermis, how are petechiae, purpura and
action. bleeding produced? Furthermore, histologic evaluation of forearm
Objectively evaluating aesthetic improvement is difficult. The skin after six sessions showed changes in the epidermis and
human eye is remarkably sensitive to small aesthetic improve- dermis. How would these changes take place if no epidermal or
ments, and a physician observer may report ‘the patient looks dermal abrasion occurs?
better’. But measuring and quantifying such aesthetic judgments In another study of microdermabrasion, Hernandez-Perez and
objectively is difficult indeed. However, several recent papers Ibiett[5] confirmed some of these observations. In this study, seven
have attempted to do this, and in doing so have shed some light on patients with facial photodamage underwent microdermabrasion
mechanisms of action. treatment (consisting of three passes) once per week for 5 weeks.
Shim et al.[4] treated 14 patients with photoaging every 2 weeks The appearance of oily skin, dilated pores, thick skin, fine wrin-
using a mild vacuum setting and a total of 6–7 treatments. Eleven kles, and general appearance was evaluated by the patients them-
of the 14 patients also had comedomal acne or milia, and 3 had selves, the nurse and the physician. There was a perception of
acne scarring. Following completion of 6–7 treatments, patients improvement in all parameters by patients and microdermabrasion
completed a questionnaire. Overall, patients were pleased with the operators alike. The patients agreed to a pretreatment 3mm punch
treatment, reporting perceived benefits in overall complexion, skin biopsy of the left malar region, and another after the fifth treat-
roughness, and mottled pigmentation. The patients did not report ment. As in the previous study, an increase in epidermal thickness
significant self-perceived benefits in fine wrinkling and was seen. These investigators also reported an improvement in the
comedomal acne or milia. The physician evaluator, who was polarity of the epidermal cells, and a decrease in basal cell lique-
unblinded, evaluated before and after photographs of the three faction. They also reported a decrease in solar elastosis in the
patients with acne scars. These were treated much more aggres- papillary dermis, as well as a slight improvement in the degree of
sively, usually with more than 20 passes being performed. One dermal telangiectasia, edema and inflammation.
patient was felt to have ‘good’ improvement, one ‘fair’ improve- Tan et al.[6] included objective noninvasive measurements as
ment, and one no improvement. well as histology to evaluate microdermabrasion. In this study, 10

© 2005 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2005; 6 (2)
Microdermabrasion 91

subjects with photodamage were treated weekly for 5–6 sessions. The most interesting findings were from cutometer analysis.[6]
The vacuum line was set at the manufacturer’s recommended There was a significant decrease in skin stiffness and an increase
pressure (30mm Hg), and patients received four passes per ses- in skin compliance on the cheek throughout the study. This is
sion. Patients and a blinded physician provided a subjective as- consistent with increased edema and hydration of the skin, much
sessment of degree of improvement as well as assessments on a like a dry sponge becoming soft as it absorbs water. This finding
variety of objective measures. First, a sebumeter was utilized to was consistent with the dermal edema and vasodilatation seen on
measure sebum content at the surface of the skin. The biomechani- the forearm biopsies. It was confirmed by the results of the pre-
cal characteristics of the skin were also measured before and after auricular biopsies taken before and 1 week after the final treat-
treatment with an advanced cutometer. This device applies suction ment. Increased orthokeratosis, mild flattening of the rete ridge
to the skin through a plastic tube. Infrared light is used to measure pattern, and persistent edema, vascular ectasia, and perivascular
how much the skin moves over a range of negative pressures. Once inflammation extending to the upper reticular dermis were ob-
the suction is released, the device measures the return to presuc- served.
tion position. Skin elasticity, stiffness and compliance can thus be The implications of this study are that microdermabrasion
calculated. Lastly, skin surface topography was measured using produces very little abrasion of tissue, but is able to induce
silicone skin replicas of the skin surface. A silicone impression of persistent edema, vasodilatation and perivascular inflammation
the canthal region (crow’s feet) and an area of the forehead were deep into the dermis.[6] Microdermabrasion has two potential
taken before and after treatment, then analyzed for surface topog- methods of action: (i) the abrasion of tissue by aluminum oxide
raphy. In addition, two patients agreed to undergo skin biopsies of crystals; and (ii) the effects of a suction line on the skin. The
the pre-auricular region before and 1 week after the final treatment dermal changes seen are more likely to be produced by the suction
session. Moreover, two additional patients consented to treatment line.
of the ventral forearm using an aggressive setting (65mm Hg), Objective evaluation of entirely different parameters was re-
with biopsies being taken before and immediately after one treat- ported by Rajan and Grimes.[7] These investigators focused on the
ment. barrier function of the epidermis by measuring transepidermal
The biopsies of forearm skin immediately after one aggressive water loss (TEWL), stratum corneum hydration, skin surface pH
treatment showed that little abrasion had actually occurred.[6] and sebum content. Patients were treated with aluminum oxide
There was thinning of the stratum corneum, but no abrasion of the microdermabrasion on one side of the face, and with a similar
viable epidermis at all. However, dermal edema, vasodilatation device using sodium chloride as an abrasive on the other side.
and perivascular inflammation were noted. The treated areas de- TEWL scores increased on both sides 24 hours after the procedure,
veloped significant erythema, and remained in this state for 1 but decreased when measured at 7 days. Stratum corneum hydra-
week. Despite the fact that only slight abrasion of the stratum tion increased on both sides 24 hours after the procedure, and
corneum was produced in these two subjects, a visible biologic remained increased on the sodium chloride side at 7 days. There
response lasting for 1 week occurred. It is unlikely that these were no sustained changes in pH or surface sebum content. This
clinical and histologic changes in the dermis were created by study indicates that microdermabrasion does indeed produce a
abrasion as a result of the impact of the aluminum oxide crystals; measurable change in epidermal barrier function, a change which
rather, they may have been effects of the suction line. could account for the perceived clinical benefit.
Finally, a recently conducted study emphasizes the fact that
Subjective reports after 5–6 treatments revealed that the
microdermabrasion is a mild treatment that produces mild results.
majority of patients perceived at least a mild improvement in the
In this study, microdermabrasion was compared with another mild
appearance of the skin.[6] Physician evaluation of photographs
treatment, glycolic acid peels.[8] Ten patients received six
also indicated at least a mild improvement in most patients. Again,
microdermabrasion treatments to one side of the face while six
both the patients and the physician perceived a benefit from
patients received 20% glycolic peels to the other side. Seven of
microdermabrasion. Sebumeter readings showed a significant de-
ten patients preferred the glycolic side, one preferred the
crease in surface sebum content immediately after each treatment,
microdermabrasion side, and two had no preference. Unblinded
but this effect was no longer present 1 week later. Silicone
analysis of before-and-after photographs by the investigators indi-
impressions revealed a temporary increase in skin roughness and
cated no significant improvement on either side.
mild flattening of some wrinkles immediately after treatment,
consistent with abrasion of the stratum corneum. This effect was 4. Discussion
also no longer present after 1 week. However, in two patients who
showed the greatest immediate increase in skin roughness (i.e. Taken together, the results of the studies discussed above
greatest abrasion), a significant decrease in skin roughness was suggest that patients and physicians alike perceive a mild clinical
apparent 1 week after the final treatment. benefit from microdermabrasion, that objective biologic changes

© 2005 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2005; 6 (2)
92 Spencer

in the skin can be detected, and that the technique produces very pressure line that ‘blows’ the crystals forward. The effect of this
little actual abrasion. Therefore, it seems likely that the benefit of modification is unknown.
microdermabrasion is achieved in some way other than by produc-
ing a partial thickness wound. 5. Conclusion
Regardless of how microdermabrasion works, the simplicity
and safety of the procedure suggests its popularity will continue. Microdermabrasion has clearly found a popular role in
However, one potential area of concern that has been raised is the cosmetic practice. However, it is a mild treatment that produces
use of aluminum oxide. This is of concern not for the patient, but mild results. Thus, it is important to provide patients with realistic
for the operator. There has been inconclusive epidemiologic evi- expectations of what they can expect from this procedure. When
dence that long term exposure to aluminum (but not aluminum patients are educated and understand the degree of benefit they are
oxide) may be associated with impaired cognitive function[9] and likely to receive, they are on the whole very pleased with this
the development of Alzheimer’s disease.[10,11] However, these technique.
associations have been reported in relation to exposure to alumi-
num powder in aluminum miners or factory workers, not to Acknowledgment
exposure to aluminum oxide.
No sources of funding were used to assist in the preparation of this
Aluminum oxide has been used for many years as a dental manuscript. The author has no conflicts of interest that are directly relevant to
abrasive and in joint replacements. It is used as an abrasive the content of this manuscript.
because the crystals have sharp edges, and are second in hardness
only to diamonds. Importantly, there has been no suggestion that
References
aluminum oxide could play a role in the development of neuro- 1. American Academy of Cosmetic Surgery. 2004 Procedural Consensus. Procedural
logical dysfunction or Alzheimer’s disease. Aluminum oxide is Statistics [online]. Available from URL: http://www.cosmeticsurgery.org/Med-
an inert ceramic which is insoluble in water and thus cannot enter ia/statistics.asp [Accessed 2005 Feb 21]
2. Hopping S. The power peel: its emergence and future in cosmetic surgery. Int J
the blood stream.[12] Furthermore, the particle size used in Cosmet Surg 1999; 6: 98-100
microdermabrasion is quite regular at around 100μm, and particles 3. Tsai R, Wang C, Chan H. Aluminum oxide crystal microdermabrasion: a new
technique for treating facial scarring. Dermatol Surg 1995; 21: 531-42
larger than 50μm are unlikely to be inhaled and reach the alveoli 4. Shim EK, Barnette D, Hughes K, et al. Microdermabrasion: a clinical and
where they could be systemically absorbed.[12] The particles are histopathologic study. Dermatol Surg 2001; 27 (6): 524-30
also quite heavy and drop to the floor when sprayed in the air. 5. Hernandez-Perez E, Ibiett EV. Gross and microscopic findings in patients undergo-
ing microdermabrasion for facial rejuvenation. Dermatol Surg 2001; 27 (7):
Nevertheless, while there is no reason to suspect that aluminum 637-40
oxide is a neurologic hazard, it is possible that it could cause 6. Tan MH, Spencer JM, Pires LM, et al. The evaluation of aluminum oxide crystal
microdermabrasion for photodamage. Dermatol Surg 2001; 27 (11): 943-9
corneal abrasion if sprayed into patients’ eyes, and long term
7. Rajan P, Grimes PE. Skin barrier changes induced by aluminum oxide and sodium
inhalation could theoretically cause respiratory problems. The chloride microdermabrasion. Dermatol Surg 2002; 28 (5): 390-3
Occupational Safety and Health Administration (OSHA) consid- 8. Alam M, Omura NE, Dover JS, et al. Glycolic acid peels compared to
microdermabrasion: a right-left controlled trial of efficacy and patient satisfac-
ers aluminum oxide to be a ‘nuisance dust’ that does not stimulate tion. Dermatol Surg 2002; 28 (6): 475-9
a biologic response. Nonetheless, OSHA recommends limiting 9. Rifat SL, Eastwood MR, McLachlan DR, et al. Effect of exposure of miners to
total exposure to 10–15 mg/m3 unless respiratory protection is aluminum powder. Lancet 1996; 336 (8724): 1162-5
10. McLachlan DR. Aluminum and Alzheimer’s disease. Neurobiol Aging 1986; 7:
worn.[12] It seems prudent for operators to wear a mask, and to 525-32
provide eye protection for patients. 11. Candy JM, Oakley AE, Klinowski J, et al. Aluminosilicates and senile plaque
formation in Alzheimer’s disease. Lancet 1986; I (8477): 354-7
In response to theoretic concerns that aluminum oxide may be 12. Sittig M. Aluminum and aluminum oxide. In: Sittig M, editor. Handbook of toxic
harmful, alternative abrasives have been tried. For example, both and hazardous chemicals and carcinogens. Vol 1, 3rd ed. Park Ridge (NJ):
Noyes Publications, 1991: 175-7
sodium bicarbonate and sodium chloride have been used in place
of aluminum oxide. This has required a modification of the
Correspondence and offprints: Dr James M. Spencer, Spencer Dermatology
microdermabrasion equipment. Devices using sodium chloride or and Skin Surgery Center, 900 Carillon Parkway, Suite 403, Saint Petersburg,
bicarbonate do not have a vacuum line, as these materials clog the FL 33716, USA.
system. Rather, they only have one line in the handpiece, a positive E-mail: [email protected]

© 2005 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2005; 6 (2)