Avoiding Complications

Published on 15/03/2015 by admin

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15 Avoiding Complications

Useful Strategies

Always test first. I will not carry out a phenolic peel without testing beforehand. Patients are informed that testing is not a perfect way to predict outcomes, but it allows me to observe the healing process. I use a very wet Q-tip (cotton bud) to apply Baker’s solution in the left preauricular area (Figs 15.1 and 15.2) and straight phenol on the right. I tell patients I want to produce the worse scenario I can where it is easily concealed. Patients are not charged for these tests or follow-ups to evaluate them. Tests not only give you a chance to observe a patient during the healing process and look for common complications (particularly hyper- or hypopigmentation (Figs 15.3 and 15.4) or prolonged erythema), but they also give you a chance to get to know the patient well enough to determine both their psychological and medical suitability for deeper peels. Prolonged erythema (lasting several months) is often an indication that hypopigmentation will occur. Rarely a patient will develop hyperpigmentation following these tests (Fig. 15.5).

See Boxes 15.1 and 15.2.

Educating Patients

The most important thing you can do when discussing chemical peels with patients is to be totally transparent about the indications, advantages, and drawbacks for the peels you employ. Be blunt, and keep it simple; patients should be told that shallow or deep, successful chemical peels are nothing more than well-controlled burns. If the patients can be made to understand the factors which make the skin heal well or poorly after a burn they will understand the complications and drawbacks of chemical peels. Get to know your patients and share with them your knowledge about the advantages, risks, and benefits of specific peels for their particular problems. An adequately informed patient must understand first the general risks involved in any chemical peel, and whether any features in her or his history or physical examination suggest the possibility of greater risks or greater benefits.

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.

The Psychology of Peels

Certain types of patient are easier or harder to please. Far and away the patients who are happiest with peel outcomes are those with Fitzpatrick skin type I or II who have very deep wrinkles, who use make-up, and are willing to put up with hypopigmentation. Hardest to please are patients with minimal wrinkling who use magnifying mirrors and scrupulously point out every single defect. There are four phases to chemical peels: the anticipatory, the intraoperative, the early (1–6 weeks) postoperative, and the late postoperative (6 months). Each phase requires a careful description which details the possibility of minor and major complications as well as specific skin care instructions. It is worthwhile discussing all of these phases well in advance with your patient. Following medium peels there is often a ‘honeymoon’ phase in which the fresh-scrubbed texture of the face and mild edema may produce a stunning improvement in patient appearance. Patients should be prepared for this phenomenon and learn how to prolong their improvement by using home programs, sunscreens, and so forth.

Evaluating the Patient

Patients exhibit their history on their skin (Fig. 15.9). Unlike other organs, this one is accessible. I ask them if they have been burned and look where they were burned. I ask them if they have had a brown spot after a burn or a light spot (Fig. 15.10). Look for surgical scars, ask about previous experience with burns (i.e., with curling irons) and whether the patient has had any procedures before. You frame your questions in the context of what effect something might have on the peel outcome. Do not forget to examine non-sun-exposed skin to see the patient’s true skin color.

Get a good drug history. Photosensitizing drugs (such as minocycline, St. John’s wort, topical benzoyl peroxide, amiodarone, sulfonamides, thiazide diuretics, tricyclic antidepressants), and oral contraceptives may increase the risk of pigmentary problems. Previous dermabrasions or deep resurfacing procedures may increase the potential for scarring following deeper peels, possibly on the basis of impaired wound healing due to subclinical fibrosis. Patients with atopy may be more sensitive to superficial peels. Stronger peeling agents are suitable for older patients with more chronic sun exposure, solar lentigines, and deep wrinkles. This may be due to the accumulation of solar elastosis. Thicker, more sebaceous quality skin often tolerates deeper peels better than thinner, less sebaceous skin.

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).

Table 15.1 Factors in patient evaluation for phenol-based chemexfoliation

General General state of physical and mental health
Medications
Pregnancy history
History of herpes simplex
Skin pigmentation classification evaluation
History of hypertrophic scarring
History of facial radiation or use of isotretinoin (Accutane)
Realistic expectations
Relative contraindications Cardiac disease
Renal disease
Hepatic disease
Hormone replacement therapy
Continued exposure to ultraviolet light
History of radiation exposure or use of isotretinoin
Contraindications History of hypertrophic scarring or keloid formation
Fitzpatrick skin classification of IV–VI
Recent facelift (deep chemical peeling in areas of recently undermined skin may result in vascular compromise and resultant scar formation)

Palpation

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