• Discussing options

When discussing chemical peels with patients I arbitrarily divide them into three classes. Light peels, which are good for certain types of pigmentary disorder, textural abnormalities, and acne are described as ‘maintenance peels’ and do not require much downtime or carry much risk, but their results occur slowly (Fig. 15.7). Long term improvement is highly dependent on careful home programs which include the daily use of sunscreens and in many cases bleaching agents. Medium peels are described as capable of imparting a noticeable improvement in the patient’s appearance with the caveats of downtime while the patient is unpresentable, transient hyperpigmentation, and remote possibilities of more serious problems such as scarring. Deeper phenolic peels are described as more risky but absolutely necessary for deep wrinkles or severe photoaging. The possibility of serious complications, including hypopigmentation, scarring, systemic toxicity, and interaction with preexisting disease states or intraoperative medications, is carefully spelled out. I also discuss the medications we will be using or may need to use to carry out the procedure. These include local anesthetic with adrenaline, antibiotics, antiviral agents, and pain medications. It is also important to discuss the ‘no free lunch’ concept; that is, repeated applications of light peels ‘won’t make a dent in deep wrinkles’, but will often improve skin texture and dyspigmentation. Patients need to know that changes in skin color of either a transient or permanent nature are a major concern. As peels become deeper, the potential for permanent changes in skin color and lines of demarcation is greater (Fig. 15.8). Fair-skinned patients are told that there is a very high possibility of the skin being permanently lighter when deeper peels must be employed to efface deep rhytides. Very dark-skinned individuals are poor candidates for deep peels. Patients who tan well are told they might expect transient hyperpigmentation from any type of peel. Experience with curling irons and other forms of cutaneous trauma have often educated patients as to how their skin may respond to a peel.

Figure 15.7 Patients are often unhappy with the outcomes following a very light TCA or glycolic peel, as evidenced by this phone call

Figure 15.8 This patient developed a clear line of demarcation following a periocular phenolic peel and a Baker’s peel periorally. She preferred the use of make-up to further peeling

• You are what you wear

Patients who wear designer clothes and beautiful jewelry are often extraordinarily detail oriented and may be very hard to please. One of my patients suggested that patients in this category exhibit the ‘Rolex sign’. Do not hesitate to discuss the possibility of unmet expectations quite openly. The treatment of certain kinds of defects, which are amenable to both peels and volume changes, can be initiated using temporary soft tissue augmentation agents such as hyaluronic acid. Tissue fillers are often an excellent way to begin facial rejuvenation.

• The open door policy – making the patients feel welcome

When I carry out deep peels I give patients my home phone number. I want them to call me if they are frightened and I will see them as needed.

I follow medium and deep patients very closely, examining them every few days. If they are concerned they are encouraged to come to the office anytime they want to without an appointment. We often open a side door so that a patient does not have to walk through a waiting room full of curious patients wearing dressings or looking swollen.

• Personal habits/home regimens

Topical medications such as tretinoin (Retin-A), scrubs, cleansing granules, creams, and products bought at health food stores, as well as facial waxing, electrolysis, hair plucking, etc., can exert both preoperative and postoperative effects on peel outcomes (Fig. 15.11) Simple scrubbing to remove make-up immediately before a light peel can produce unexpectedly deep penetration of the agent. Sun exposure, certain types of medication, and certain skin types make a patient prone to specific types of complication.

Figure 15.11 Hypopigmentation and atrophic scarring occurred in this 34-year-old woman who vigorously scrubbed a ‘brown spot’ using an over the counter glycolic acid preparation

• Sorting out patients

The most important evaluations have to do with patients who are going to need deep chemical peels. Patients with histories of hypertrophic scarring, dark-skinned patients, and patients with serious medical problems are not candidates for phenolic peels. Patients who do not use cosmetics (e.g., male patients) may be very poor candidates for deep chemical peels although they can certainly tolerate light and medium peels. I am particularly careful about employing periocular phenolic peels on patients who have had multiple blepharoplasties (Fig. 15.12) or who have undergone recent (less than 6 months) undermining plastic surgery or other types of resurfacing procedure. Heavy smokers are notoriously poor healers and are often poor candidates for deeper peels (Table 15.1).

Figure 15.12 Ectropion PT/ST. This patient developed severe ectropion following a ‘light’ Baker’s peel. She had previously undergone three blepharoplasties

Table 15.1 Factors in patient evaluation for phenol-based chemexfoliation

Pickers

Get a good history of each patient before you carry out any form of a peel. Find out whether someone is an habitual excoriator. Patients will often be quite candid about this if you ask them without suggesting that this habit may be a relative contraindication to peeling (Fig. 15.13).

Figure 15.13 Pickers are notoriously poor candidates for chemical peels. The patient admitted having excoriated this area, which healed uneventfully following a 25% TCA peel

• Consultative ploys

I look for four things when I am evaluating a patient:

If the patient needs a phenolic peel, an exhaustive history must be taken, which catalogs illnesses, medications, and other features that correlate with specific types of complication when using phenol. Herpetic infections are ubiquitous. Patients are informed as to the risks if they have ever had a cold sore. All questions regarding complications are framed in the context of why they are being asked; for example, heavy smoking may predispose to impaired wound healing.

• Palpation

When considering deep peels, careful palpation of facial skin can reveal a great deal about the patient’s healing potential or the need for stronger peels. As a general rule, if you can feel the wrinkles with your fingertips the patient will need a deeper peel. Patients with thick dermis and sebaceous skin often heal very quickly and tolerate deep peels very well. Conversely, patients who have very thin, delicate skin may not tolerate deeper peels. Skin thickness and sebaceous density vary a great deal from one area to another on the face. I pay particular attention to the zygomata and jawline. I gently pinch the skin in these areas to determine dermal thickness.

• Perioral rhytides

There are two types of perioral rhytide: (1) atrophic, U-shaped rhytides in which tissue loss or muscular atrophy permit the skin to droop between muscle bundles; this type needs treatment with tissue augmenting agents, and (2) dynamic or pucker wrinkles. These V-shaped wrinkles are associated with muscular activity which often coexist with photoaging and thick sebaceous skin. When both types of perioral wrinkling are present, tissue augmentation and resurfacing must be combined.

• Eyelids

Periocular skin is particularly delicate and prone to ectropion. After discussing what ectropion is, I discuss the risk factors for its occurrence. These include blepharoplasties and previous resurfacing procedures. I perform a simple ‘snap’ test to determine the elasticity of the lower eyelids in patients who wish to reduce the wrinkling in that area. Lower eyelids which quickly return to the normal position after being pulled down may tolerate straight phenol without forming an ectropion. Patients whose eyelids very slowly return to full apposition should not receive phenolic peels of any kind on the lower lids. Loss of elasticity in the lower lid is common following blepharoplasty and in elderly patients.

• Perioral pallor

A certain percentage of patients have lighter skin involving the perioral area. In these patients hypopigmentation resulting from deeper peels is hardly noticeable.

• Sebaceous hyperplasia

The presence of sebaceous hyperplasia and thick sebaceous skin often suggest that the patient will tolerate deeper peels. A history of oily skin suggests that more degreasing and preparation may be valuable to insure even penetration.

• Light peels

Serious complications are a great rarity following light peels, although they can occasionally trigger herpetic infections or interactions with photosensitizing drugs. Unless patients understand that light peels are part of a maintenance program, in general, they are not going to be satisfied with the results. I have found glycolic peels to be the most useful for treating acne and melasma. The decision to use antiherpetic medications prophylactically is made on an individual basis. Unmet expectations, compounded by the inability to use sunscreens or home treatment regimens are the number one complication following this type of peel.

• Medium peels

Most of the complications following medium peels consist of temporary dyschromias (usually hyperpigmentation) in darker skinned individuals and unpresentability for at least a week (Figs 15.14 and 15.15). Scarring is rare, but herpetic activation in susceptible individuals is common; accordingly, everyone who undergoes a medium peel receives at least 10 days of valacyclovir (Valtrex) 500 mg twice a day. Although downtime and the persistence of deep wrinkles are potential drawbacks, for many patients the texture, color, and vitality of the fresh skin is an enormous morale builder.

Figure 15.14 This Fitzpatrick III patient developed hyperpigmentation following a 20% TCA peel. Bleaches and sunscreens proved efficacious

Figure 15.15 A 35% TCA peel produced biopsy-proven periorbital dermatitis and hyperpigmentation which responded to repeated glycolic peels and home bleaching agents

• Deep peels

Although 50% TCA with or without proprietary additives is less toxic than phenolic peels, its unpredictability makes it unsuitable for routine use. Phenolic peels, despite their potential for disastrous complications and toxicity do provide uniform and predictable results. They are the gold standard for the treatment of deep rhytides and severe photoaging. Patients who undergo deep peels are given 2 weeks of prophylactic valacyclovir hydrochloride 500 mg twice daily, starting on the day of the procedure. The principle complications of deep peels are hypopigmentation, persistent erythema (the need to use make up), and failure to eradicate rhytides at the vermillion border.

• Ectropion

One patient developed mild ectropion involving her right eye following a periocular straight phenol peel. This patient had several blepharoplasties and on preoperative examination had very slight ectropion to begin with. She responded well to intralesional and topical corticosteroids.

• Erythema

It takes experience to accurately judge the importance of the intensity and persistence of erythema as a marker of possible complications. The occurrence of erythema is directly related to peel depth as well as to hereditary and individual factors. In general, erythema fades following superficial peels in 3 to 5 days, medium peels in 15 to 30 days, and deep peels in 60 to 90 days. When intense erythema extends beyond these periods, it may be due to contact sensitization, the exacerbation of prior skin disease, or genetic susceptibility to erythema. Intense erythema may also be associated with scarring and delayed healing (Figs 15.16 and 15.17) One of the advantages in having tested patients for deeper peels is your ability to anticipate the duration of erythema. See Box 15.3.

Figure 15.16 This patient, who had received radiation for lymphoma, developed intense erythema several weeks after a Baker’s peel. Mild induration was noted at examination; class I corticosteroids effected a scar-free healing

Figure 15.17 This patient developed unexpected intense blanching following a 35% TCA test patch. Erythema was noted some 3 weeks later, an indication that this patient is abnormally sensitive to the concentrations of TCA that are routinely employed. My experience suggests that 35% TCA can produce much deeper wounding than 30%

• Scarring

Scarring is very rare following superficial and medium peels and uncommon following properly performed deep peels (Fig. 15.18). It can occur months after an uneventful deep peel, but quite often there will be signs or symptoms, most commonly in specific areas, which allow the practitioner to detect and treat these potential scars before they become hypertrophic.

Figure 15.18 The neck is a particularly precarious area for deeper peels. This patient received a Baker’s peel from a physician whose only training was a 2-day weekend course. Her contractile scarring made it impossible for her to extend her neck far enough to place food in her mouth and forced her to take nourishment through a straw

Textural Changes

I have had one patient who developed ‘peau d’orange’ cobblestone textural changes following a periocular peel using straight phenol. He preferred his posttreatment appearance to his pretreatment rhytides (Fig. 15.19).

Figure 15.19 (A) This preoperative photograph demonstrates mild periorbital wrinkling before the performance of a straight phenolic peel; (B) 9 months postpeel periorbital wrinkling is improved; however the patient has developed a cobblestone or ‘peau d’orange’ texture, which he nevertheless preferred to his pretreatment appearance

Areas of Predilection

Certain areas have a greater tendency for scarring. These include the zygomatic arch, the bony prominence of the jawline, the upper lips, and the chin (Fig. 15.20).

Figure 15.20 Scar-prone areas

Scarring: The Red Flags

Scarring is often preceded by prolonged intense erythema and palpable induration. Patients are told in advance what they should look for; they are advised to feel the treated areas and look for increased firmness.

If I detect induration during the postoperative exam, I immediately institute treatment with class I topical steroids. I will often provide samples of these agents to patients to limit their use and ensure the patient will return. When hypertrophic scarring does occur, intralesional corticosteroids (triamcinolone acetonide 2.5–10 mg per mL) and Cordran tape used nightly are employed. It is interesting to note that dermabrasions and lasers produce scars in the same anatomical areas as deeper chemical peels (Figs 15.21 and 15.22).

Figure 15.21 Hypertrophic scarring occurred in this patient 3 months after an uneventful Baker’s peel.

Courtesy of Dr Joel Barkoff

Figure 15.22 This patient developed hypertrophic scarring 5 months after a procedure in which 50% TCA was applied followed by dermabrasion.

Photo courtesy of Dr Joel Barkoff

Herpetic Scarring

In the era before antiviral medication, I observed four cases which developed mild atrophic scarring after herpes simplex complications. Two herpetic infections followed medium peels and two occurred following phenolic peels with atrophic scarring which was barely noticeable (Fig. 15.23).

Figure 15.23 Herpes simplex was a common complication before the antiviral therapy era. Both of these patients healed without scarring

• Dyschromias

In general, superficial peels cause hyperpigmentation, deeper peels produce hypopigmentation. Dyschromias occurring in fair-skinned individuals and lines of demarcation are the major limiting factor in patient satisfaction following deep peel. Patients are told it is easier to remove wrinkles than it is to deal with persistent color changes which occur in the skin following peels. I have never observed permanent hyperpigmentation following any type of peel.

• Infection

Although serious infections have been reported following deep peels, including bacterial pyodermas, toxic shock syndromes and Epstein Barr virus keratitis, I have to date only observed two types of infectious complication: (1) Herpes simplex, which has been virtually eradicated by the use of prophylactic antiviral medications. The onset of herpes is often heralded by increasing pain, and (2) superficial pyoderma, which is often associated with poor postoperative wound care.

• Acne

Acneiform eruptions can occur following any type of peel and are most common following glycolic peels (Fig. 15.24). I have never personally observed cystic acne following any type of peeling. Acne following all types of peels may be initiated by occlusive ointments. Since such ointments can promote acne, patients are urged to use a very thin coat of antibiotic ointments, which should be removed before using the medications that I generally employ to minimize infections following medium and deep peels. Certain patients are more prone to acneiform eruptions; that is, those who have histories of acne or folliculitis. One of the major contributing factors to acne has to do with the use of soapless cleansers. The reinstitution of mild soap and water 3 or 4 days after deep peels and immediately after lighter peels is discussed.

Figure 15.24 This patient developed perioral dermatitis following a 50% alpha-hydroxy acid peel

• Milia

Milia often appear 2 to 3 weeks after reepithelialization following medium or deep peels. Topical retinoids, incision and drainage, and electrocautery can be employed.

• Lines of demarcation

Deep peels routinely produce pigmentary changes (Fig. 15.25). I routinely feather the edge of deep peels with 25% to 30% TCA, particularly at the angle of the jaw and on the neck (Fig. 15.26) It is also worthwhile to peel earlobes when carrying out deep peels. Sun avoidance is the best treatment for patients who are prone to hyperpigmentation; it is also a good idea to carry out deeper peels during the winter months when there is simply less sun exposure. Lifestyle issues are a primary concern. Patients who cannot use or will not use sunscreens, or whose work or recreational habits keep them in the sun all the time, will be problematic. I do not routinely use any form of occlusion (tape, thymol iodide) except for deep rhytides involving the upper lip. Occlusion intensifies the wound, may increase the incidence of scarring and will definitely produce more hypopigmentation. When results are unsatisfactory I will repeat the peel again, sometimes using tape occlusion and salon-pas (oil of wintergreen) pads to promote a deeper peel. Patients are warned that the benefit–risk ratios change as the peel gets deeper.

Figure 15.25 50% TCA has produced an excellent cosmetic result with minimal hypopigmentation. It is worth remembering that, in general, men are not going to use cosmetics so hypopigmentation may be on display. This patient prefers his post treatment appearance, despite the slight difference in pigmentation. His TCA test area suggested he would have a good result

Figure 15.26 Lines of demarcation are easier to conceal when applied just under the jawline rather than partway down the neck as shown here

• Periorbital TCA

Repeated applications of agents such as 20% TCA will often produce a kind of plumping up of the area, which is probably due to edema. Patients with mild periorbital wrinkling are sometimes better served by regular use of botox and being talked out of the deeper peels.

• Cardiac arrhythmias

For those brave enough to do full face phenolic peels at the same sitting, hydration and pauses of 10 to 15 minutes between applications permit full faces to be done in a 1 to -hour procedure. Patients who undergo full face peeling should undergo cardiac monitoring to watch for phenol induced arrhythmias. I confine phenolic peels to one or two cosmetic areas at one sitting. Patients are hydrated by drinking several glasses of water prior to the procedure.

• Pruritus

Pruritus, which is a normal consequence of the healing process, often follows medium and deep peels, although it can be associated with more important complications. Some authorities recommend the use of aspirin or propranolol, after eliminating infectious processes or sensitization as a cause of pruritus. I ordinarily use low-strength topical steroids, reassurance, oral antihistamines and a mild moisturizer such as Kinerase if the skin is very dry.

Almost all patients develop some degree of pruritus. Severe pruritus should make you think of a contact dermatitis.

• Contact dermatitis

Contact dermatitis is rare following deeper peels and more commonly occurs in patients following light and medium peels. It is often associated with a history of ‘sensitive’ skin, atopy, or a history of intolerance with cosmetics (nickel dermatitis, etc.). Lipstick, nail-care products, hairspray, and cologne are common causes of postpeel contact dermatitis. If I suspect contact dermatitis, I routinely provide samples of fluorinated corticosteroids for a few days, followed by low strength corticosteroids to be used continually until the next visit.

• Delayed healing

Prolongation of the granulation tissue phase of healing beyond 1 week following a deep or medium peel, associated with painful unhealed erosions, suggests delayed wound healing. This process can be associated with bacterial, fungal or viral infections, isotretinoin use, or may occur when patients undergo undermining surgery in conjunction with a deep peel. Fortunately, I have not observed delayed wound healing in my practice. When the signs and symptoms of delayed wound healing occur, cultures should be carried out and treatment with antibiotics instituted on the basis of these cultures. Hydrogel wound dressings such as Vigilon (Bard Medical, Murray Hill, NJ) and 2nd Skin (Spenco Medical Corp., Waco, TX) have been effective. Harold Brody makes an interesting point regarding nutritional status, noting that poor nutritional status in vegetarians may affect epithelialization and collagen reorganization after TCA or phenol peels.

• Medications

Patients taking anticoagulants such as warfarin should avoid deep peels because of the possibility of blood oozing from the peel site. Even more importantly, patients on anticoagulants often have systemic diseases which make them poor candidates for phenolic peels.

• Epinephrine/drug interactions

Before using lidocaine with epinephrine for any procedure, patients fill out a form which details any problems they have had (rapid heartbeat, apprehension) following dental procedures associated with lidocaine and epinephrine. Before carrying out phenolic peels we discuss the possibility of certain drugs which predispose to cardiac arrhythmias; these include diuretics (hypokalemia, hypomagnesemia) which interact with epinephrine. Monoamine oxidase inhibitors, phenothiazine and tricyclic antidepressants potentiate the cardiac stimulatory effects of epinephrine. All should be stopped 1 to 2 weeks before any kind of surgery involving epinephrine. Propranolol has been reported to cause malignant hypertension and reflux bradycardia when combined with epinephrine. The possibility of this rare complication should be weighed against the necessity for using this drug in consultation with the patient’s primary care physician.

• Smoking

Nicotine is a potent vasoconstrictor and should be discontinued 2 weeks before, and until 2 weeks after, a deep peel. That being said, heavy smokers are notoriously uncompliant. I eliminate patients who smoke more than one pack a day as candidates for deep phenolic peels. As an aside, if you can smell cigarette smoke on the patient’s hair or clothing, they may be smoking more than they admit.

• Swelling

Swelling is common following medium and deep peels. Sometimes it is severe enough to literally shut the patient’s eyes. We employ ice bags and send the patients home with them with instructions to use a half-opened 4″ × 4″ (10 cm²) gauze pad to insulate the skin against the cold temperatures which result from refreezing these ice bags. These instructions are printed out. Patients are advised to use at least two pillows when sleeping. I have not found it necessary to employ oral corticosteroids.

• Pain

Glycolic acid and light TCA peels rarely require any kind of medication. Medium-depth TCA peels can be associated with brief but intense discomfort. For medium peels our usual method is to employ a combination of ice bags (Instant Cold Compresses, McKesson Medical-Surgical, Richmond, VA), a patient-held fan, and 2nd Skin. For medium peels the forehead seems to be the most uncomfortable area to peel and it is usually done first. A fan is provided as soon as the patient begins to report discomfort (Fig. 15.27) and then ice bags are applied long enough to chill the area (Fig. 15.28) The patient tells us when it is getting too cold. Immediately after blanching occurs, a hydrogel dressing is applied for several minutes (Fig. 15.29). This immediately stops the pain. Phenolic peels are not usually painful while they are being applied. Phenol itself is a topical anesthetic. However, the first night following a phenolic peel can be painful. Intraoperative pain is managed by nerve blocks and sublingual diazepam. Postoperatively following a deep peel the patient is sent home with an oral hydrocone/acetaminophen painkiller (Vicodin) for pain and zolpidem (Ambien) to aid sleep. Everything the patient is likely to need postoperatively should be prescribed well before the procedure is carried out and the use of these agents should be discussed. Having all the necessary medications at hand and discussing them before the peel, along with providing written instructions, is the best way to ensure compliance and proper post op care. Patients who are stoic and tolerate pain well are a particular risk for having complications associated with pain which they ignore.

Figure 15.27 Deployment of fan

Figure 15.28 Ice bag. The application of ice bags, and the use of handheld fans and hydrogel dressings are excellent ploys for controlling discomfort during chemical peeling

Figure 15.29 Hydrogel dressings such as 2nd Skin and Vigilon are an excellent way to reduce pain during the performance of TCA peels

• Preventing infection

Infections other than the activation of herpes are quite rare when the light peels are employed. Medium peels and deep peels can trigger herpetic infection so it is important to determine in advance whether patients are exposed to anyone with cold sores or fever blisters. Even if they deny ever having had herpetic infections, patients are advised that their skin will be more sensitive during the healing process and more susceptible to infections contracted from others. Patients are told to avoid any form of trauma (including kissing a husband with beard stubble) during the healing process. Patients who use acne scrubs, or indeed any skin care routine which involves the use of potentially irritating agents, must be told to avoid them until their healing is complete. They are also advised to avoid hair removal procedures or deep pore cleansing until the healing process is complete.

• Preoperative preparation

Although many authorities advocate the use of extreme measures to degrease and defat the skin, including acetone and careful scrubbing, I have found this to be problematic. Vigorous rubbing to remove make-up is a common cause of irregular and sometimes deeper results following light chemical peels (Fig. 15.30). Patients should not wear any make-up on the day of the procedure at all. This includes particularly eye make-up, lipstick, etc. I also have patients wear a bandana to keep their hair off of the forehead and a shirt which is easy to remove over dressings. I discontinue scrubs and tretinoin, and substitute only mild soap and water, for several days before carrying out any type of peel on an individual basis. When you consider the fact that more than 20 variables and only 1.1 mm of skin separate peels that can scar from those that have almost no effect, it is easier to understand the continuing search for preparatory strategies to precisely control peel penetration. The rationale for vigorous degreasing of the face prior to peeling is that ‘a degreased face will lead to a more even peel’. However, vigorous degreasing with acetone, soap, alcohol or any combination of these also injures or destroys the epidermal barrier and allows more penetration of the peeling agent, resulting in deeper wounding and more complete and rapid absorption of the agent.

Figure 15.30 Vigorous scrubbing before glycolic peels can produce unexpectedly deep penetration. Patients are warned not to use scrubs or make-up on the day of treatment and to discontinue any home topical medication programs at least several days to a week before

• Frosting

It has been suggested that the degree of lightness or pinkness of a frost is an indication of the depth of the peel. I have found that this is not always the case and the ability of the skin to frost after chemical peeling seems to vary a great deal from one person to the next. Certain anatomical areas seem to frost more readily and easily, and frosting is also affected by skin treatment regimens. Patients who have been using topical retinoids often exhibit delayed frosting.

• Alphahydroxy acid peels

The gradual nature of improvements effected by glycolic acid peels and the need for repeated treatments, combined with home regimens, sun avoidance, and the impact of female hormones is a common source of patient frustration and concerns. All these issues must be carefully discussed.

Younger patients often respond with vesiculation and unexpectedly deep peels to concentrations of alpha-hydroxy acids (AHAs) which are commonly used in older individuals (Fig. 15.31). We routinely use lower concentrations and shorter periods of contact in teenagers and young adults. Trivial changes in home treatment regimens (scrubs, tretinoin, exfoliants), as well as sun exposure, can produce unpredictably deep AHA peels. Some of our experiences with glycolic acid and light TCA peels are summarized in Tables 15.2 to 15.4. When carrying out AHA peels careful observation, looking for vesiculation, erythema or patient discomfort leads us to spot neutralize the area where this is occurring. We use soapless cleanser for this purpose. I have found the areas most susceptible to overly deep penetration to be the central and lateral cheek, the upper lip and the jawline. Patients with atopic dermatitis seem most susceptible to unexpectedly deep peels. Tolerance to AHA peels occurs over time and patients will often demand longer contact times. Exfoliation has been described as a felicitous event. Patients have associated desquamation with ‘getting their money’s worth’, particularly when undergoing a periocular peel. For patients with fine periocular wrinkling I sometimes combine full face AHA peels with 15% TCA periocularly, which will provide a little desquamation and satisfied patients.

Figure 15.31 A 4-minute application of 35% glycolic acid produced vesiculation and exudation on this 22-year-old patient. Young patients are particularly prone to this type of complication in this area following alpha-hydroxy acid peels. Transient hyperpigmentation also occurred

• TCA

TCA, versatile and effective in a variety of concentrations, is a workhorse of chemical peeling agents. It has the added advantage of lack of systemic toxicity. I routinely use no higher than 30% TCA, which I reapply until even frosting is obtained. I peel one unit at a time, controlling pain with ice, fans, and reassurance. I am more comfortable applying multiple layers of a lower concentration TCA until frosting is even rather than increasing concentration. I carefully examine the treated areas using magnifying lenses (5× optic aids, such as those distributed by Mattingly International, Inc., Escondido, CA) Skip areas such as areas of sebaceous hyperplasia or thin seborrheic keratosis can be lightly electrodesiccated or receive a quick application (1–3 seconds of straight phenol using a relatively dry Q-tip). I routinely neutralize TCA peels by quickly blotting up any excess solution with a dry 4″ × 4″ gauze. Simple dilution using saline solution or soapless cleanser is also effective. I rarely use bicarbonate of soda.

• Phenolic peels

88% phenol is most useful for periocular fine wrinkling. It will not produce the tightening effect that follows CO₂ lasers, but in patients without redundant skin it can produce excellent results. When I use straight phenol to carry out periocular peels, I use an almost completely dry Q-tip, quickly applied and blotted up using a dry 4″ × 4″ gauze. In the periocular area sometimes blanching will not give you an indication of peel depth. It is wise not to make repeated passes with phenol even though you are not certain how deep it has penetrated. I am often surprised at how much effect an almost dry swab with phenol can have on periocular tissues. When peeling the upper eyelid, peeling past the tarsal plate can result in severe edema.

• Baker’s solution

Baker’s solution is particularly useful for perioral rhytides and for crosshatched corrugated lateral facial rhytides which occur with severe photoaging. It can also be applied to minimize wrinkling in the vermillion part of the lip. For very deep wrinkles a broken wood applicator stick can be used to scrub the peeling agents into deep perioral rhytides.

Baker’s solution is particularly effective when patients have palpable wrinkles and thick skin (Fig. 15.32).

Figure 15.32 Type II Fitzpatrick patients with thick sebaceous skin are often ideal candidates for deep perioral peels. In this patient treated with unoccluded Baker’s solution, only the slightest depigmentation is noted associated with a ‘shinier’ skin. This is the kind of patient that would be most pleased with the procedure

Hypopigmentation has been my number one problem following the use of Baker’s solution. When only doing one or two anatomic units per day, systemic absorption and toxicity are minimal. When treating the crows feet, Baker’s solution can be applied, again using a relatively dry stick and immediately blotting the area at the first sign of frosting.

• Botulinum toxin and deep peels

When carrying out phenolic peels periocularly and periorally, I sometimes employ botulinum toxin as outlined in routine protocols for wrinkling in these areas. I will ordinarily use half the dose that I might employ for someone who uses Botox as monotherapy. Botox injections are usually carried out several weeks before peeling these areas.

• Avoiding procedural complications/spillage/neutralization

Periorbital peels must be carried out with particular care. They are usually performed as a last step in facial peeling. I have an assistant standing by with dry Q-tips who looks for tearing at the lacrimal puncta and lateral canthi and blots it up. This prevents peeling agents being wicked into the eyes by capillary attraction. When doing the lower lid I position myself behind the patient and have her look back over the top of her head as I peel within 3 mm of the ciliary margin. The dryer the stick, the safer the procedure.

Neutralizing Agents for Spillage

We use normal saline or bicarbonate of soda to neutralize TCA and AHA peels. The most important complication would be spillage into the eyes (an event which has fortunately never occurred in this office). In the case of TCA the eye is flooded with normal saline. If phenolic compounds are spilled into the eye, the eye should be flooded with mineral oil. The addition of water to phenolic agents increases their potency and absorption. We use a large syringe containing neutralizing agents as the easiest way to deliver them (Fig. 15.33).

Figure 15.33 Eye flushes: (A) for phenol peels, (B) for all other types of peels

• Setting up the table/avoiding procedural complications

Q-Tip Practice

When using superficial and medium depth wounding agents I often use an OB/GYN swab which permits faster application of the escharotic (Fig. 15.34). More rapid application can also be effected using 3 small Q-tips. Be sure to roll them around as you press them to the side of the container individually because shared solution between the approximated swabs may drip. It is also worthwhile to practice using these swabs to determine the exact amount of solution you are applying. There is a certain level of light reflection that you will note. You must become accustomed to precision in this process. Wooden tipped applicators can also be tailored to size by peeling off varying amounts of the cotton and then recompressing it to make a smaller Q-tip. I have also practiced on my own forearm using a variety of peeling agents quickly applied and blotted off. This is a good way to determine the effect of volume on peeling depth. I used a surgical light to visualize the skin and determine the degree of wetness as I applied the solution.

Figure 15.34 Standard cotton-tipped applicators (left). Large OB/GYN cotton swabs (right)

• Using antiviral agents

All antiherpetic agents act by inhibiting viral replication in the intact epidermal cell. Accordingly the skin must be reepithelialized before the agent has full effect.