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CHAPTER 33
1
Microdermabrasion
Rebecca Small, MD
Assistant Clinical Professor, Department of Family and Community Medicine
University of California, San Francisco School of Medicine, Capitola, CA
M
icrodermabrasion (MDA) is a minimally invasive mechanical exfoliation procedure for superficial skin resurfacing. Most exfoliation modalities in use today
can be broadly classified as chemical exfoliants, which include glycolic and salicylic acid peels and mechanical exfoliants. Mechanical exfoliation treatments range from
simple microbead scrubs found over the counter, which partially remove the stratum
corneum, to operative procedures such as laser resurfacing and dermabrasion, which can
ablate the reticular dermis. The depth of resurfacing achieved with MDA is conservatively
in the middle of this spectrum. Although MDA exfoliation can vary from superficial thinning of the stratum corneum to penetration into the upper papillary dermis, the target
depth for most MDA procedures is removal of the stratum corneum.
Exfoliation treatments are based on the principles of wound healing. By wounding and removing
the uppermost layers of the skin in a controlled
manner, cell renewal is stimulated with regeneration of a healthier epidermis and dermis. Histological evaluation of facial skin after repeated MDA
treatments demonstrates a reparative wound-healing
process with regeneration of a compacted stratum
corneum and a smoother epidermis. Skin hydration
increases with improved epidermal barrier function,
and fibroblast stimulation increases dermal thickness through production of new collagen and
elastin.
MDA is commonly used to treat photo-damaged skin and reliably demonstrates improvement
in skin texture, coarse pores, comedonal acne, and
epidermal hyperpigmentation such as solar lentigines. Treatments may improve fine lines and superficial acne scarring. Certain MDA devices have also
shown positive results with rosacea and papulopustular acne.
Traditionally, MDA devices have used crystals as
the abrasive element. Negative pressure draws the skin to the hand-piece tip, and crystals
superficially abrade the skin’s surface as they pass across the epidermis. Used crystals and
cellular debris are aspirated and collected separately for disposal after treatment. Each pass
of the hand piece removes approximately 15 m of skin, and two passes of most MDA
devices fully remove the stratum corneum. The depth of resurfacing achieved with MDA is
comparable to a superficial chemical peel. MDA offers certain advantages over chemical
peel treatments such as greater control over the depth of exfoliation, comparatively
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Mature corneocyte
Stratum corneum
Dead skin
cells
Stratum granulosum
Stratum spinosum
Epidermis
Stratum basale
Living layer
Immature keratinocyte
Dermis
Figure 1
Aesthetic Procedures
266
minimal discomfort, and no “downtime” for skin flaking and peeling. Other alternatives to
MDA include ablative and nonablative laser resurfacing and dermaplaning, which utilizes a
specialized 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 immediately after exfoliation. These systems take advantage of the transient disruption to the
epidermal barrier that occurs with removal of the stratum corneum to better deliver
medications into the deeper dermal layers. Dermal infusion can enhance results for
conditions such as dehydration, hyperpigmentation, acne, and rosacea based on the
products that are used.
MDA is one of the most commonly performed cosmetic procedures in the United
States, with more than a half million treatments performed annually, according to data
from the American Society for Aesthetic Plastic Surgery. Treatments are technically
straightforward with a low risk of side effects, are associated with a high degree of patient
satisfaction, and are well suited to the outpatient office setting. MDA has become an
essential medical aesthetic rejuvenation treatment (ART) for primary care professionals
who desire to provide aesthetic care.
Anatomy
The outermost layer of the skin, the stratum corneum, is a nonliving layer of corneocytes
and lipids, which serves as a barrier against microbial pathogens and environmental irritants and keeps the skin hydrated and protected from injury. Constant renewal is necessary for the epidermis to maintain its integrity and function effectively. In healthy,
younger skin, epidermal renewal takes approximately 1 month for keratinocytes to
migrate from the living basal layer of the epidermis to the stratum corneum surface, from
which they are shed (see keratinocyte migration highlighted in Figure 1). In aged, photodamaged skin, keratinocyte maturation is slowed, and there is abnormal retention of cells,
leading to a thickened, rough stratum corneum. Disruption of the epidermal barrier
results in skin dehydration and may cause increased sensitivity. Photo-damaged skin is
dull and exhibits dyschromia with solar lentigines and uneven pigmentation. Dermal
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thinning with loss of collagen and elastin contributes to formation of fine lines. Through
stimulating cell renewal in the epidermis and dermis, MDA is able to address many of
these changes seen with photo damage and intrinsic aging.
Results and Follow-up
Preprocedure Checklist
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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 to
procedure, 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 retinoic
acid or alpha-hydroxy acids (e.g., glycolic acid); and avoid botulinum toxin injections
for 1 week.
Equipment
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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 only
to diamonds in hardness. Other crystals used include sodium chloride, sodium bicarbonate, and magnesium oxide. Crystal-free MDA devices have become popular because
of the lack of dust and associated risks of ocular injury. Diamond-tipped devices
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Chapter 33 / Microdermabrasion
MDA treatments are most commonly performed on the face, neck, chest, and hands. In
general, facial skin tolerates more aggressive treatments and tends to show greater
improvements than nonfacial areas. Epidermal healing is thought to be related to the density of adnexa (hair follicles and eccrine sweat glands) within a treatment area. The facial
epidermis has a greater density of adnexa relative to the nonfacial epidermis, such as the
neck and chest, which may account for its greater rejuvenation potential. Other treatment
areas include the back and hyperkeratotic areas such as elbows and knees. Treatments may
be performed for patients of all Fitzpatrick skin types (see Chapter 31 for Fitzpatrick classifications). However, aggressive treatments should be avoided in darker skin types (IV to
VI) because of to their increased risk of postinflammatory hyperpigmentation (PIH).
MDA combined with dermal infusion is associated with less posttreatment erythema and
reduced risks of PIH.
Results from MDA treatments are cumulative, and typically a series of six treatments is recommended at bimonthly intervals. Results are not usually clinically evident after a single treatment. However, patients who have had little or no skin care
previously may report improvements. Maintenance treatments may be performed
every 4 to 6 weeks.
The most marked results with MDA are achieved when MDA is used in combination
with other rejuvenation treatments such as chemical peels, topical skin care products,
laser and intense pulsed light (IPL) photo rejuvenation, and fractional resurfacing. For
example, 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-rejuvenation treatments. MDA performed prior to fractional resurfacing treatments may also
reduce the incidence of posttreatment complications such as milia and acne.
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GO!
employ diamond-tipped pads as the abrasive element and can be used with topical
solutions 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 postprocedure application.
Saline eyewash.
Aesthetic Indications
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Aesthetic Procedures
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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 demonstrated with certain MDA devices such as the SilkPeel (diamond-tipped with dermal
infusion).
STOP!
Contraindications
ABSOLUTE
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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
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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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The Procedure
The following procedure is for treatments performed
with SilkPeel, a crystal-free MDA that uses diamondtipped pads as the abrasive element and has simultaneous
dermal infusion of topical solutions (see Figure 2). Comparisons and recommendations for crystal MDA devices
are also included when possible.
Stratum
corneum
Epidermis
Stratum granulosum
Stratum spinosum
Stratum basale
Papillary layer
Reticular layer
Hypodermis
Courtesy of emed.
Figure 2
Results of MDA treatment for papulopustular acne are
shown before (Figure 3A) and after 6 treatments (Figure
3B) performed 2 weeks apart. The topical solution used
for dermal infusion included 2% salicylic acid.
PITFALL: Treatment of papulopustular
acne and rosacea are contraindicated with
crystal MDA devices.
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A
B
Courtesy of emed.
Figure 3
Chapter 33 / Microdermabrasion
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Results of MDA treatment for hyperpigmentation are
shown before (Figure 4A) and after 6 treatments
(Figure 4B) performed 2 weeks apart. The topical product used for dermal infusion included hydroquinone,
kojic acid, and arbutin.
A
B
Courtesy of emed.
Figure 4
Aesthetic Procedures
270
Results of MDA treatment for papulopustular rosacea
are shown before (Figure 5A) and after 6 treatments
(Figure 5B) performed 2 weeks apart. The topical solution used for dermal infusion was 2% erythromycin
and 2% salicylic acid.
A
B
Courtesy of Tejas Desai, MD
Figure 5
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Step 1. Perform a detailed skin evaluation prior to initiating treatment (see Skin Analysis Form in Step 1).
Fitzpatrick skin type classification is used to
describe background skin pigmentation and the
skin’s response to sun exposure (see Chapter 31 for
SKIN ANALYSIS FORM
Name:
DOB:
First
Fitzpatrick Skin Type Classification (check one):
Skin Type I
White
Skin Type II
White
Skin Type III
White
Skin Type IV
Moderately brown
Skin Type V
Dark brown
Skin Type VI
Black
Sun exposure reaction always burns, peels, never tans
Usually burns, tans with difficulty
Sometimes mild burn, tans average
Rarely burns, tans easily
Very rarely burns, tans very easilly
Never burns, tans very easilty
Glogau’s Photoaging Classification (check one):
Group I
Mild (28-35 years old)
Group II
Moderate (35-50 years old)
Group III
Advanced (50-65 years old)
Group IV
Severe (65-75 years old)
No keratoses, little wrinkling, no scarring, little
or no makeup
Early actinic keratoses, slight skin discoloration,
early wrinkling, parallel smile lines, mild scarring,
little makeup
Actinic keratoses, obvious skin discoloration,
telangiectasiaa, wrinkling, moderate acne
scarring, wears makeup always
Actinic keratoses, possible skin cancers,
wrinkling, gravitational aging, severe acne
scarring, wears makeup thickly
Skin Type
Dry
Oily
Combination
Pre-Procedure Evalution
Key
LP – Large Pores
D – Dryness
T – Telangectasia
R – Imitation
O – Oiliness
SC – Scarring
M – Milia
P – Pigmentation
Place abbreviations on facial zones in diagram to note areas of specific conditions and concerns
Zone I
Zone II
Other:
Zone III
Zone IV
Zone V
II
I
III
Zone VI
Zone VII
Zone Viii
Zone IX
VI VII VIII
IV
V
Zone X
Zone XI
XI
X
IX
Photo Taken:
Yes
No
Treatment Plan:
Date:
Step 1
Signature:
C – Comedones
W – Wrinkles
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Chapter 33 / Microdermabrasion
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additional information), which is integral to
determining how aggressive treatments may
be. The Glogau classification is a baseline
measure of a patient’s degree of photo damage.
MDA may be performed as a very superficial or superficial skin-resurfacing procedure (see Figure 6 for definitions of skin resurfacing terminology). Depths listed
in the figure are from the skin surface down to the
layer indicated. The depth of exfoliation with MDA
increases with increasing vacuum pressure, number of
passes, and a more acute hand piece handle. For
diamond-tipped devices, the depth of exfoliation also
increases with grit coarseness. Downward pressure on
the skin may increase the depth of exfoliation with
some diamond-tipped devices. The SilkPeel hand piece
has a recessed diamond-tipped pad, and downward
pressure on the skin does increase exfoliation depth.
For crystal devices, the depth of exfoliation also
increases by moving the hand piece more slowly over
the skin, using larger particle sizes and higher crystal
flow rates.
Aesthetic Procedures
272
■
PEARL: Two passes with the SilkPeel using
a 60-grit treatment head and vacuum setting of 5 psi (260 mm Hg) penetrates to 30
to 35 m and will fully remove the stratum
corneum.
■
PEARL: Two passes with most aluminumoxide crystal MDAs using a vacuum setting
of 4 psi (200 mm Hg) will fully remove the
stratum corneum.
■
PITFALL: Greater depths of penetration
have greater potential for improvements
but are also associated with greater complication risks. Once the dermis is breached,
which is typically evident as bleeding, scarring becomes a consideration.
Stratum corneum
Epidermis
Dermis
Papillary
Reticular
Hypodermis
Figure 6
Very superficial
Stratum corneum
30 micrometers
Superficial
Papillary dermis
100 micrometers
Medium
Upper reticular
dermis
450 micrometers
Deep
Mid-reticular
dermis
600 micrometers
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Step 2. Position the patient comfortably, lying supine
on the treatment table. Have the patient remove
contact lenses, and apply a headband. Cleanse
the treatment area with a gentle cleanser and
degrease the skin using an alcohol-based astringent. Ensure that the skin is completely dry
prior to treatment. Cover the patient’s eyes with
goggles or moist gauze. For crystal MDA
devices, the operator should wear clear eye protection and a mask to reduce particle inhalation.
■
PEARL: With the SilkPeel, most treatments
can be performed with the 100-grit head.
Hyperkeratotic areas such as elbows and
knees respond well to a coarser, 60-grit head.
The lips can be treated with the smooth head.
■
PITFALL: Treatment of the lips is contraindicated with crystal MDA.
Step 4. Set the vacuum flow by occluding the handpiece tip with a gloved finger, as shown in Step 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. Recommended vacuum settings
vary by manufacturer. In general, conservative
settings should be selected for initial treatments based on the patient’s Fitzpatrick skin
type, tolerance, and treatment area using the
manufacturer’s guidelines.
■
PEARL: The SilkPeel vacuum should be set
at 3.5 to 4 psi (180 to 200 mm Hg) for treatment on the face and chest, 2.8 to 3 psi (145
to 155 mm Hg) for the neck, and 5 to 6 psi
(260 to 310 mm Hg) for the hands and
back. For crystal MDA devices, initial treatment vacuum settings range from 50 to
200 mm Hg and are device dependent.
■
PEARL: Patients with higher Fitzpatrick
skin types are more prone to prolonged
postinflammatory erythema, PIH, and the
lower limits of the range for vacuum settings should be used.
■
PITFALL: Devices utilizing simultaneous
dermal infusion are associated with less
discomfort. Patients may experience superficial abrasions without reporting pain
Step 2
273
Step 3
Step 4
Chapter 33 / Microdermabrasion
Step 3. Select the size and coarseness of the diamondtipped treatment head (see Step 3). The
6-mm head should be used for the face and the
9-mm head for larger areas, such as the back.
Selection of the grit size is based on the aggressiveness of the treatment. The heads range in
coarseness from smooth with no diamond
chips, fine (120 grit) to coarse (30 grit).
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during treatment, and patient feedback
may be a less reliable indicator of treatment intensity. Observation of tissue
response is therefore particularly important in determining vacuum settings with
dermal infusion devices.
Step 5. For dermal infusion devices, select a topical
solution for dermal infusion based on the presenting condition. Commonly used products
include hydroquinone or other botanical lightening agents such as kojic acid and arbutin for
treatment of hyperpigmentation; erythromycin
and salicylic acid for acne and rosacea; and
hyaluronic acid, allantoin, and glycerin for
dehydration. Select a solution flow rate for dermal infusion using the manufacturers guidelines.
Aesthetic Procedures
274
■
PEARL: Two topical solutions may be used
during a treatment, for example, to address
dehydration and hyperpigmentation.
■
PEARL: Typical SilkPeel dermal infusion
rates range from 15 to 20 mL/min (see
Step 5).
Step 6. Move the hand piece smoothly and slowly across
the skin as shown in Step 6 for treatment of the
face. Exfoliation with the SilkPeel will not occur
unless the tip is moving across the skin. For the
first pass, strokes should be from the central face
to the periphery. The procedure usually starts at
the forehead, proceeds down the bridge of the
nose, and then covers the cheeks, chin, and
mouth. Stretch the skin between the fingers,
place the hand piece perpendicular to and in
good contact with the skin, and move the hand
piece across the skin parallel to the tension line
between the fingers. Observe skin for the desired
clinical endpoint of mild erythema. Reassess tissue response and patient tolerance throughout
the treatment and adjust settings accordingly.
After completion of the first pass for the entire
face, make a second pass following the same
stroke pattern as the first pass. The second pass
for crystal MDA is usually perpendicular to the
first pass. For treatment of the neck, have the
patient lift the chin to extend the neck, use vertical strokes, and perform only one pass. For treatment of the chest, perform two passes with
strokes from the midline to the periphery. For
treatment of the hands, have the patient make a
fist around a towel and perform two passes with
strokes parallel and then perpendicular to the
axis of the forearm.
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PITFALL: Petechiae or pinpoint hemorrhages indicate that the settings are too
intense and must be reduced.
Step 5
Step 6
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TABLE 33-1.
AREA
EPIDERMIS
THICKNESS (MICROMETERS)
DERMIS
SUBCUTANEOUS
Neck
Eyelids
Cheek
Nose
Forehead
Lower lip
Upper lip
Chin
115
130
141
111
202
113
156
149
138
215
909
918
969
973
1,061
1,375
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PEARL: Reduce treatment intensity near
thinned skinned areas such as the periorbital
area. With the SilkPeel, reduce the vacuum
pressure to 2.8 to 3 psi (145 to 155 mm Hg).
■
PITFALL: With crystal MDA, do not leave
the hand piece in one spot because this will
increase abrasion depth and may cause
injury to the skin.
544
248
459
735
1,210
829
931
1,020
Step 7. At subsequent visits, parameters may be
increased to intensify treatments. In general,
only one parameter should be changed to
intensify treatments in any given visit.
Typically, the number of passes is increased for
a few treatments to achieve the desired clinical
endpoints, and vacuum settings are increased
in the later treatments. A total of two to four
passes may be made on thicker skinned areas
(see Table 33.1 for skin thickness in different
facial areas) such as the forehead, upper lip,
and chin or problematic areas, taking into
account tissue response and patient tolerance.
Grit coarseness may also be increased at subsequent visits to intensify treatments.
275
PEARL: Acne scars require more aggressive
treatments. With the SilkPeel, a 100-grit
head with 6 psi and up to four passes crosshatched over the area may be performed.
Step 8. Apply a soothing topical product and a fullspectrum sunscreen with SPF 30 or greater
(containing zinc or titanium).
■
1,697
593
1,509
1,764
2,381
1,915
2,143
2,544
Chapter 33 / Microdermabrasion
■
TOTAL
PEARL: If using a crystal MDA, remove all
crystal debris from the face with moist
gauze prior to product application, paying
close attention to the periorbital area.
Step 8
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Step 9. Sanitize and sterilize reusable equipment parts
between patient treatments per the manufacturer guidelines. Step 9 shows the waste container after treatment with skin surface debris
and used dermal infusion solution for disposal.
After the patient’s treatment is completed, the
dermal infusion bottle is replaced with a disinfectant solution that is circulated to sanitize
the machine prior to the next patient. The diamond-tipped heads are autoclaved after each
treatment for sterilization.
Step 9
Complications
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Aesthetic Procedures
276
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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 contraindicated for pediatric patients.
Postprocedure Instructions
Patients typically experience mild erythema and dryness for 1 to 2 days posttreatment with
crystal MDA but may not experience these aftereffects with MDA utilizing dermal infusion.
A nonocclusive soothing moisturizer may be applied frequently as needed for dryness. The
patient should avoid irritating topical products such as retinoids, astringents, glycolic acid,
and depilatories and not undergo waxing, dermal filler injections, or laser or IPL treatments for 1 week. The patient should also avoid direct sun exposure for 1 week and use a
daily full spectrum sunscreen with SPF 30 or greater (containing zinc or titanium). If scabbing occurs, advise patients to avoid picking, because this may result in scarring, and apply
bacitracin daily until healed.
Coding Information and Supply Sources
MDA is not reimbursable by insurance. The charges for treatments vary widely and are
largely determined by local prices. Patients may pay for individual treatments, which generally range from $100 to $150. However, because MDA is most effective as a series of
treatments, packages of treatments (usually six) may be offered so that patients achieve
the best possible results and have the greatest satisfaction.
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ICD-9 CODES
Acne vulgaris
Melasma
Dyschromia, unspecified
Wrinkling of skin
Scarring
706.1
709.09
709.0
701.8
709.2
SUPPLY SOURCES
Microdermabrasion Devices
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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, Signal
Hill, CA 90755. Phone: 1-800-603-4996. Web site: http://www.edgesystem.net/microdermabrasion.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: 408764-3000. Web site: http://www.lumenis.com/wt/home/home/?flash=true.
Mattioli Engineering (crystal MDA), 7918 Jones Branch Drive, Suite 600, McLean, VA
22102. 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., Suite
200, Cardiff-by-the-Sea, CA 92007. Phone: 760-942-8815. Web site: http://medaestheticsolutions.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 Sutton Park Drive South, Suite 701, Jacksonville, FL 32224. Phone: 866-491-7546. Web
site: http://refineusa.com/micro-gem.html.
Sybaritic (dermal infusion and ultrasonic MDA), 9220 James Avenue South, Bloomington, 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, Richmond
Hill, ON L4B 1L5, Canada. Phone: 905-886-9235, 866-259-6661. Web site:
http://www.syneron.com/
Patient Education Handout
A patient education handout, “Microdermabrasion Treatments,” can be found on the
book’s companion Web site.
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277
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