Debrisan as a Postoperative Dressing After Dermabrasion BRYAN C. SCH ULTZ M .D., AND H EN R Y H. R O EN IG K , JR ., M.D.
Beads o f the material that is commercially purveyed as Debris a n ® were used as a postoperative dressing after dermabrasion in 24 patients. Fifteen o f seventeen patients so dressed on only h a lf o f the dermabraded area ex pressed preference fo r it. The beads absorbed drainage and were protective o f the dermabraded half. Five o f the seventeen patients developed milia one month after derm abrasion and three o f the five had them only on the side treated with the beads o f Debrisan.
INTRODUCTION E a r l y p o s t o p e r a t i v e c a r e of the dermabraded pa tient has been various in method. One way has been simply to let the abraded skin dry in air, but to permit the patient to pat away excessive oozing with gauze the first few days.' Most methods involve removal of exudation and blood and prevention of thick crusting. Frequent soaks with plain water or a physiologic solu tion of sodium chloride may be satisfactory enough2 if applied almost continuously the first few days2. The first 24 hours after dermabrasion is the most trouble some, because serous drainage and bleeding may be profuse. There frequently is severe pain until a fine crust forms after a day or two. In an attem pt to find a more satisfactory postoperative dressing, we turned to the synthetic, hydrophilic and porous beads (De brisan®) that have recently been reported to be useful for absorption of exudates in ulcers and other w ounds.3
FIGURE 1. M ode o f application o f beads to one side o f the face immediately after dermabrasion.
METHODS The beads were used as a postoperative dressing in 24 patients after dermabrasion. In 17 patients, the mate rial was applied immediately to the one side of the face only (Fig. 1). Active capillary bleeding promoted a covering o f beads several millimeters thick to build up and adhere. To keep the beads in place a pliable plastic covering was loosely placed over the beads (Fig. 2). Dr. Schultz is A ssistant Professor o f Clinical D erm atology, De partment o f D erm atology, N orthw estern U niversity Medical School, Chicago, Illinois. Dr. Roenigk is Professor and C hairm an, Departm ent o f Derm atol ogy, Northw estern U niversity Medical School, Chicago, Illinois. A ddress reprint requests to Dr. H enry H. Roenigk, Jr., D epart m ent o f Dermatology, N orthw estern U niversity Medical School, 303 E. Chicago Avenue, Chicago, Illinois 60611.
FIGURE 2. Application o f plastic film over the beads.
J. D erm atol. Surf>. Oncol. 5:12 D ecem ber 1979
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DEBRISA N A F TE R DERM A BRASIO N
FIGURE 3. The clinical appearance one day after the dermabrasion. The beads were applied on the left side and Polysporin ointment on the right side. In the flesh, the beadtreated side was seen to be drier.
FIGURE 4. The appearance o f the right side (Polysporin-treated) one day after dermabrasion.
The other side of the face was dressed in our usual manner with Polysporin® ointment, Telfa®, an ab sorbent abdominal pad, and an outer wrap of Keriix®. Patients returned the next day for a change of dressing. Patients were then instructed to gently wash the face daily with a hand-held shower attachment or by simply pouring water on it and letting beads come away by themselves. They were strictly enjoined not to attempt
972
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FIGURE 5. The appearance o f the left side (beadtreated) one day after dermabrasion.
removal of adherent beads by force. They were in structed to reapply beads as needed for oozing for up to three days at which time active oozing was likely to have stopped. Usually only one or two additional reapplications of beads were all that was necessary. In patients who had beads applied to but half the face, the other half was soaked frequently with a sterile solution of physiologic saline or tap water.
S C H U L TZ AN D ROE NIG K
FIGURE 6. The appear ance one week after derm abrasion. Both sides were observed to be heal ing equally well under good crust formation.
FIGURE 7. The appearance o f the right side (Polysporin-treated) six weeks after dermabrasion.
Patients were examined on the first postoperative day and then at one week. The following ten signs or symptoms were assessed in each of the 24 patients: (1) comfort of the beads as a dressing, (2 ) inflammation, (3) thickness of crust, (4) oozing, (5) purulence, (6 ) edema, (7) pain, (8 ) burning sensation, (9) itching, and (10) infection. Photographs were taken in each case.
FIGURE 8. The appearance o f the left side (beadtreated) six weeks after dermabrasion. RESULTS
Eighteen cases of scarring from acne, three of tattoos, one of a traumatic scar, one of multiple tricho epitheliomas, and one of nodular elastosis with cysts were dermabraded and then dressed with the beads. Sixteen of the dermabrasions for scarring from acne and the one for the trichoepitheliomas had only half
J. D erm atol. Surg. Oncol. 5:12 D ecem ber 1979
973
DEBRISAN AFTER DERMABRASION
the dermabraded area treated with the beads. Fif teen patients asserted that they had less discomfort on the bead-treated side. Drainage was nearly no longer evident after the first postoperative day in all patients on the bead-treated side (Figs. 3, 4, and 5). The other side always continued to ooze blood and serum pro fusely for a few days. This required the patient to pat the side not treated with beads frequently with an ab sorbent material for those few days. Nothing more than a brief superficial cleansing to remove beads was necessary on the bead-treated side after a day or two. The crust that formed was usually thicker on the bead-treated side, but that crust consisted mostly of the beads and suspended material between them (Fig. 6 ) and usually fell off spontaneously after about ten days. No patients had infection or purulent accumula tion on either side. No difference was found with re spect to inflammation or edema on either side. Two patients asserted there was less of burning sensation and one patient said there was less itching on the bead-treated side at the end of one week. There was no difference in the rate of healing on either side (Figs. 7 and 8 ). The patient who had dermabrasion for nodular elas tosis and the one for a traumatic scar were treated with beads on the entire abraded area. The beads made an excellent dressing from which no drainage or pain was experienced. The beads also were excellent dressings for the three patients dermabraded for tattoos. The beads seemed to lift the adventitious pigments from the tattoos. One patient had several tattoos abraded previ ously and he asserted that more pigment was removed by the dermabrasion that was followed with dressings of beads, which, moreover, became stained with pigment. The development of milia one or two months after dermabrasion is not an unusual finding. Five of our patients developed milia. The complication was more prominent on the bead-treated side in three of those five patients. Two of the afflicted three patients had applied heavy layers of beads and consequently had very thick crusts. C OM M ENTS
The beads marketed under the trade name of Debrisan are dextranomers that are 0.1 to 0.3 mm in diameter and, as macromolecules, have a three-dimensional ar rangement as chains. Molecules of other substances
974
J. Derm atol. Surg. Oncol. 5:12 D ecem ber 1979
with molecular weights of less than 1000 may penetrate the beads, but molecules greater than 5000 in molecu lar weight move or are taken in between the beads .3 Molecules between these sizes may or may not enter the beads. One gram of beads is capable of holding 4 cc of water in proportions of 2.5 cc within the beads and 1.5 cc between them. It is advantageous then to apply beads dry so that tissue water will carry other mole cules into or between the beads with it. A layer of beads three millimeters thick generates capillary forces equivalent to 200 mm of mercury. The beads are not degraded by tissues or their exu dates and are for all practical purposes inert. They are too large to be engulfed by phagocytes and tend to stay above granulating or re-epithelizing tissue .4 Proteins and degradation products of fibrinogen have been shown to be absorbed from exudates by the beads .3 This action may be helpful in preventing heavy forma tion of crust on the surface of wounds. It also has been shown that the beads may remove or inhibit prosta glandin E 2 and, if true, such an action may reduce in flammation following wounds .3 Studies on adsorption of microorganisms have shown that most bacteria are brought to the upper surface of layers of beads .3,5 This phenomenon must have a beneficial effect in preventing infection of wounds. Milia formation is a common complication following dermabrasion. They usually resolve spontaneously or with extraction. In all of the cases where milia forma tion occurred, extraction of milia over several weeks resulted in their complete resolution. In future studies, we intend to investigate further the seeming extractive effect of the beads on pigments used in tattoos. REFEREN CES 1. 2. 3.
4.
5.
B urks, J. W. D erm abrasion and Chemical Peeling. Springfield, Illinois. Charles C Thom as, 1979, pp. 108-109. Albom , M. J. Postoperative m anagem ent o f the derm abraded face. J. Derm atol. Surg. Oncol. 3:590-591, 1977. Jacobsson, S., Rothm an, U ., Arturson, G ., et al. A new princi ple for the cleansing o f infected wounds. Scand. J. Plast. Reconstr. Surg. 10:65-72, 1976. Jacobsson, S., Jonsson, L ., R ank, F., and Rothm an, U. Studies on healing o f D ebrisan-treated w ounds. Scand. J. Plast. Reconstr. Surg. 10:97-101, 1976. Juhlin, I. The distribution o f m icroorganism s in a D ebrisan col umn. Sven. Kir. (Proc. Sw ed. Surg. Soc.) 31:2-4, 1974.
Beads o f the material that is commercially purveyed as Debris a n ® were used as a postoperative dressing after dermabrasion in 24 patients. Fifteen o f seventeen patients so dressed on only h a lf o f the dermabraded area ex pressed preference fo r it. The beads absorbed drainage and were protective o f the dermabraded half. Five o f the seventeen patients developed milia one month after derm abrasion and three o f the five had them only on the side treated with the beads o f Debrisan.
INTRODUCTION E a r l y p o s t o p e r a t i v e c a r e of the dermabraded pa tient has been various in method. One way has been simply to let the abraded skin dry in air, but to permit the patient to pat away excessive oozing with gauze the first few days.' Most methods involve removal of exudation and blood and prevention of thick crusting. Frequent soaks with plain water or a physiologic solu tion of sodium chloride may be satisfactory enough2 if applied almost continuously the first few days2. The first 24 hours after dermabrasion is the most trouble some, because serous drainage and bleeding may be profuse. There frequently is severe pain until a fine crust forms after a day or two. In an attem pt to find a more satisfactory postoperative dressing, we turned to the synthetic, hydrophilic and porous beads (De brisan®) that have recently been reported to be useful for absorption of exudates in ulcers and other w ounds.3
FIGURE 1. M ode o f application o f beads to one side o f the face immediately after dermabrasion.
METHODS The beads were used as a postoperative dressing in 24 patients after dermabrasion. In 17 patients, the mate rial was applied immediately to the one side of the face only (Fig. 1). Active capillary bleeding promoted a covering o f beads several millimeters thick to build up and adhere. To keep the beads in place a pliable plastic covering was loosely placed over the beads (Fig. 2). Dr. Schultz is A ssistant Professor o f Clinical D erm atology, De partment o f D erm atology, N orthw estern U niversity Medical School, Chicago, Illinois. Dr. Roenigk is Professor and C hairm an, Departm ent o f Derm atol ogy, Northw estern U niversity Medical School, Chicago, Illinois. A ddress reprint requests to Dr. H enry H. Roenigk, Jr., D epart m ent o f Dermatology, N orthw estern U niversity Medical School, 303 E. Chicago Avenue, Chicago, Illinois 60611.
FIGURE 2. Application o f plastic film over the beads.
J. D erm atol. Surf>. Oncol. 5:12 D ecem ber 1979
971
DEBRISA N A F TE R DERM A BRASIO N
FIGURE 3. The clinical appearance one day after the dermabrasion. The beads were applied on the left side and Polysporin ointment on the right side. In the flesh, the beadtreated side was seen to be drier.
FIGURE 4. The appearance o f the right side (Polysporin-treated) one day after dermabrasion.
The other side of the face was dressed in our usual manner with Polysporin® ointment, Telfa®, an ab sorbent abdominal pad, and an outer wrap of Keriix®. Patients returned the next day for a change of dressing. Patients were then instructed to gently wash the face daily with a hand-held shower attachment or by simply pouring water on it and letting beads come away by themselves. They were strictly enjoined not to attempt
972
./. Derm atol. Surg. Oncol. 5:12 D ecem ber 1979
FIGURE 5. The appearance o f the left side (beadtreated) one day after dermabrasion.
removal of adherent beads by force. They were in structed to reapply beads as needed for oozing for up to three days at which time active oozing was likely to have stopped. Usually only one or two additional reapplications of beads were all that was necessary. In patients who had beads applied to but half the face, the other half was soaked frequently with a sterile solution of physiologic saline or tap water.
S C H U L TZ AN D ROE NIG K
FIGURE 6. The appear ance one week after derm abrasion. Both sides were observed to be heal ing equally well under good crust formation.
FIGURE 7. The appearance o f the right side (Polysporin-treated) six weeks after dermabrasion.
Patients were examined on the first postoperative day and then at one week. The following ten signs or symptoms were assessed in each of the 24 patients: (1) comfort of the beads as a dressing, (2 ) inflammation, (3) thickness of crust, (4) oozing, (5) purulence, (6 ) edema, (7) pain, (8 ) burning sensation, (9) itching, and (10) infection. Photographs were taken in each case.
FIGURE 8. The appearance o f the left side (beadtreated) six weeks after dermabrasion. RESULTS
Eighteen cases of scarring from acne, three of tattoos, one of a traumatic scar, one of multiple tricho epitheliomas, and one of nodular elastosis with cysts were dermabraded and then dressed with the beads. Sixteen of the dermabrasions for scarring from acne and the one for the trichoepitheliomas had only half
J. D erm atol. Surg. Oncol. 5:12 D ecem ber 1979
973
DEBRISAN AFTER DERMABRASION
the dermabraded area treated with the beads. Fif teen patients asserted that they had less discomfort on the bead-treated side. Drainage was nearly no longer evident after the first postoperative day in all patients on the bead-treated side (Figs. 3, 4, and 5). The other side always continued to ooze blood and serum pro fusely for a few days. This required the patient to pat the side not treated with beads frequently with an ab sorbent material for those few days. Nothing more than a brief superficial cleansing to remove beads was necessary on the bead-treated side after a day or two. The crust that formed was usually thicker on the bead-treated side, but that crust consisted mostly of the beads and suspended material between them (Fig. 6 ) and usually fell off spontaneously after about ten days. No patients had infection or purulent accumula tion on either side. No difference was found with re spect to inflammation or edema on either side. Two patients asserted there was less of burning sensation and one patient said there was less itching on the bead-treated side at the end of one week. There was no difference in the rate of healing on either side (Figs. 7 and 8 ). The patient who had dermabrasion for nodular elas tosis and the one for a traumatic scar were treated with beads on the entire abraded area. The beads made an excellent dressing from which no drainage or pain was experienced. The beads also were excellent dressings for the three patients dermabraded for tattoos. The beads seemed to lift the adventitious pigments from the tattoos. One patient had several tattoos abraded previ ously and he asserted that more pigment was removed by the dermabrasion that was followed with dressings of beads, which, moreover, became stained with pigment. The development of milia one or two months after dermabrasion is not an unusual finding. Five of our patients developed milia. The complication was more prominent on the bead-treated side in three of those five patients. Two of the afflicted three patients had applied heavy layers of beads and consequently had very thick crusts. C OM M ENTS
The beads marketed under the trade name of Debrisan are dextranomers that are 0.1 to 0.3 mm in diameter and, as macromolecules, have a three-dimensional ar rangement as chains. Molecules of other substances
974
J. Derm atol. Surg. Oncol. 5:12 D ecem ber 1979
with molecular weights of less than 1000 may penetrate the beads, but molecules greater than 5000 in molecu lar weight move or are taken in between the beads .3 Molecules between these sizes may or may not enter the beads. One gram of beads is capable of holding 4 cc of water in proportions of 2.5 cc within the beads and 1.5 cc between them. It is advantageous then to apply beads dry so that tissue water will carry other mole cules into or between the beads with it. A layer of beads three millimeters thick generates capillary forces equivalent to 200 mm of mercury. The beads are not degraded by tissues or their exu dates and are for all practical purposes inert. They are too large to be engulfed by phagocytes and tend to stay above granulating or re-epithelizing tissue .4 Proteins and degradation products of fibrinogen have been shown to be absorbed from exudates by the beads .3 This action may be helpful in preventing heavy forma tion of crust on the surface of wounds. It also has been shown that the beads may remove or inhibit prosta glandin E 2 and, if true, such an action may reduce in flammation following wounds .3 Studies on adsorption of microorganisms have shown that most bacteria are brought to the upper surface of layers of beads .3,5 This phenomenon must have a beneficial effect in preventing infection of wounds. Milia formation is a common complication following dermabrasion. They usually resolve spontaneously or with extraction. In all of the cases where milia forma tion occurred, extraction of milia over several weeks resulted in their complete resolution. In future studies, we intend to investigate further the seeming extractive effect of the beads on pigments used in tattoos. REFEREN CES 1. 2. 3.
4.
5.
B urks, J. W. D erm abrasion and Chemical Peeling. Springfield, Illinois. Charles C Thom as, 1979, pp. 108-109. Albom , M. J. Postoperative m anagem ent o f the derm abraded face. J. Derm atol. Surg. Oncol. 3:590-591, 1977. Jacobsson, S., Rothm an, U ., Arturson, G ., et al. A new princi ple for the cleansing o f infected wounds. Scand. J. Plast. Reconstr. Surg. 10:65-72, 1976. Jacobsson, S., Jonsson, L ., R ank, F., and Rothm an, U. Studies on healing o f D ebrisan-treated w ounds. Scand. J. Plast. Reconstr. Surg. 10:97-101, 1976. Juhlin, I. The distribution o f m icroorganism s in a D ebrisan col umn. Sven. Kir. (Proc. Sw ed. Surg. Soc.) 31:2-4, 1974.
