Introduction

Chemical peeling or chemoexfoliation, is the process in which the skin is wounded or burned with a chemical agent. The zone of cellular destruction and depth of the wound is dependent on several variables including the peeling agent, the concentration of the agent, skin thickness and skin permeability.¹ The immediate reaction of the skin is a second-degree, chemically induced burn. Inflammation begins shortly after the peel and extends variably into the epidermis and dermis. The inflam-matory response peaks at 48 hours but skin rejuvenation and collagen remodeling may last for weeks or months. Regeneration of the surface epithelium begins almost immediately and is usually complete by 5–14 days.

No matter which technique is utilized, if the wounding depth is significant there will be some permanent changes to the skin. The papillary dermal collagen changes from a wavy pattern to straight and parallel beneath the epidermal layer. The dermis shows fibroblastic proliferation and replacement of much of the old deformed elastic fibers with new elastic fibers.² Depending upon the degree of wounding and chemicals used, there may be fewer melanocytes both in the basal layer as well as in the dermis. This accounts for the lightening in color after peeling. This lightening, again, is a spectral change and may be permanent depending again upon the degree and agent of wounding. With fewer melanocytes the ability to tan is diminished accordingly. In terms of texture, the skin itself becomes smoother and more light reflective (shinier) which is generally a healthy replacement for the previously sun-damaged skin (Fig. 21-1). The potential increased sun sensitivity due to decreased melanocytes makes sun protective measures very important.

In general, the deeper the wound, the deeper the zone of replacement of old, damaged, and disorganized skin structural elements with new, healthy, and well-organized elements.³ By the same token, the deeper the wound, the greater the potential for scarring and pigment changes. Chemical peels may be divided into three types, graded by the depth of the wound (Table 21-1). Superficial-depth wounding is to the stratum granulosum, papillary dermis. Medium-depth wounding is to the upper reticular dermis. Deep-depth wounding is to the mid-reticular dermis.

Indications and patient selection

Chemical peeling is indicated in any patient whose skin may benefit from greater elasticity, increased smoothness, removal of fine wrinkles, softening or obliteration of deep creases and lessening of pigmentary irregularities. Chemical peeling replaces the sallow, aged appearance of sun-damaged skin with a healthy and youthful glow. Thus, virtually all patients requesting blepharoplasty or any other facial cosmetic procedures have indications for chemical peeling.

Chemical peeling is often performed in conjunction with blepharoplasty, endoscopic brow lifting and facelifting. In general, skin that has been surgically undermined is not peeled at the same time as surgery. If the depth of surgical dissection is subcutaneous, it is possible that superficial damage to the skin from the chemical peel may result in full thickness skin necrosis. However, if the depth of dissection preserves the subdermal vasculature, as in subperiosteal facelifting or transconjunctival blepharoplasty procedures, simultaneous peeling is considered safe.

Simultaneous transconjunctival blepharoplasty and chemical peeling has been performed since 1989.⁴ The primary aim of lower blepharoplasty is either the removal or repositioning of fat in order to address the undesirable convexity (bulging) of the lower eyelid and/or central midface concavity. Approximately 70 percent of patients who want to undergo lower blepharoplasty have such a small component of excess skin that the risk of the transcutaneous approach outweighs the advantage of removing a few millimeters of vertical skin, particularly when the skin problem is mostly due to actinic damage. The authors have been performing only transconjunctival blepharoplasty approaches on these patients for the past 20 years.

One of the authors (DMM) developed and has refined the technique of simultaneous transconjunctival blepharoplasty and chemical skin peeling since 1989.⁴ We now all routinely use this combination procedure (Fig. 21-2). The 70 percent of patients in whom skin removal has too great a potential risk will all potentially benefit from simultaneous transconjunctival blepharoplasty and chemical peel rejuvenation of the skin of the lower eyelids; in fact, many of the 30 percent in whom the risk of blepharoplasty is acceptable can also significantly benefit from this simultaneous blepharoplasty and chemical peel without the risk of an infralash incision.

Figure 21-2 (Surgeon: JAH) A 67-year-old woman before (A) and after (B) upper blepharoplasty, lower transconjunctival blepharoplasty, and simultaneous eyelid chemical peel and facial laser resurfacing. An improvement in skin texture is evident.

Chemical peeling is also performed in conjunction with facelifting procedures. In general, lower facelifting procedures will improve the jowls and tighten the neck. It does little to improve the perioral rhytids, general loss of skin elasticity and dyschromia. Upper facelifting procedures (forehead lifts) will elevate the brows and reduce dynamic wrinkles. It will, however, not delete the permanent creases that are often found in the glabella and forehead regions. Depending on the degree and depth of these wrinkles, a variety of chemical peels can safely be performed simultaneously in areas that have not been surgically undermined. Thus, it is common for us to simultaneously perform an upper and lower facelift, transconjunctival blepharoplasty along with perioral, forehead and lower eyelid chemical peeling.

Evaluating the skin⁵

Hypopigmentation after chemical peel is a concern. Certainly, the issue of skin color change must be thoroughly discussed with the patient preoperatively. The deeper the wounding the more potential for hypopigmentation. In addition, as a chemical, phenol is melanotoxic. Originally it was thought that permanent hypopigmentation presented little or no problem for light-skinned patients (Fitzpatrick’s classifications I–II⁶) (Table 21-2). We have come to realize that these very light skinned patients will have significant whitening of their skin, especially after deep peels. If a full-faced peel is performed and the edges of the peeling are feathered onto the neck, the hypopigmentation can be easily camouflaged. If, however, individual regions are only peeled, the color contrast between the peeled and non-peeled zones can be quite noticeable. This will force the patient to require a base or foundation make-up to blend the peeled and non-peeled regions.

Table 21-2 Reaction to sun by skin pigment type

Moderately dark patients (Fitzpatrick II–III) have less of an issue with permanent hypopigmentation. These patients often develop splotchy post-inflammatory hyperpigmentation during the first 3 months after a moderate to deep peel. The hyperpigmentation is usually temporary and easily controlled with bleaching agents. Peeling in darker skinned patients (Fitzpatrick’s classification IV–VI) can be fraught with significant pigmentation issues. Postoperatively, these patients may develop areas of hyperpigmentation and hypo-pigmentation, which cannot be readily camouflaged with make-up.

Contraindications

There are few absolute contraindications to chemical peeling. Three groups of patients must be considered cautiously as candidates. First are those with olive or darkly pigmented skin. The peel may permanently remove too much pigment or may result in a blotchy or hyperpigmented appearance. The second group is composed of patients whose skin is fair but has been frequently sun-exposed for many years. These patients now have permanently pigmented skin, and chemical peeling may result in an obvious demarcation between the treated area and the untreated area, even if careful feathering is performed. The third group is made up of the fair skinned and freckled. These patients risk an odd appearance if they lose all their facial freckles in one area while retaining freckles in adjacent areas.

Chemexfoliation and wounding agents

Chemical peeling is a commonly performed procedure. The depth (and, therefore, effectiveness) varies with the chemical agent used, its concentration, and the conditions under which it is applied. The wide spectrum of agents and formulas for peeling includes retinoic acid (Retin-A), solid carbon dioxide, sulfur solutions, resorcinol, salicylic acid, alpha-hydroxy acids, trichloroacetic acid (TCA), and phenol and phenol formulas. Table 21-1 lists the most common peeling agents, concentrations, and formulations and the depth to which they can wound.

The surgeon must determine the depth to which he or she wishes to wound the skin, since it is wound depth that determines the potential for the final result. Unfortunately, depth is not simplistically determined by chemical formulas and concentrations, as implied in Table 21-1. Other major factors that help determine wound depth are skin type (Fitzpatrick’s skin classifications I–VI), skin condition and thickness, pretreatment with retinoic acid (Retin-A), alpha-hydroxy acids, alpha-keto acids, low dose cis-retinoic acid, epidermabrasive exfoliants, and defatting preparations. These agents alter the permeability of the skin to the wounding agent. Furthermore, the larger the amount of agent applied, the longer and harder the agent is rubbed onto the skin, and the longer the duration of contact between agent and skin, the deeper the wounding caused by the same agent. Finally, applying tape over the agent (occlusion) drives the chemical deeper into the skin.

Each of the several chemical wounding agents (see Table 21-1) may be used in various strengths. The most common agents, in increasing order of strength, are TCA (15, 20, 25, 35%) and phenol 89 percent. Most wounding agents can be driven deeper into the skin, and thus cause a deeper burn, by occlusion (taping or ointments), wetter applications, multiple applications, or vigorous scrubbing of the agent into the skin. Due to the increased risk of scarring due to uneven penetration, the authors do not use taping as a method of penetration enhancement. Thus, we will not discuss taping in this chapter.

The 15 percent and 20 percent dilutions of TCA are used as ‘freshening peels’ and in a single application have a minimal potential for complications and only provide minimal long term improvement. We suggest to participants in our teaching courses that they begin their experience in chemical peeling with these 15–20 percent TCA freshening peels independent of or in conjunction with lower transconjunctival blepharoplasty. Compared to blepharoplasty alone, patient healing time is only minimally increased. Usually the skin is fully re-epithelialized, such that the patient can return to comfortably meeting the public and wearing make-up (or not needing make-up), within 7–10 days – at which time there are still usually telltale signs of surgery after a blepharoplasty anyway.

After a great deal of experience has been achieved, we find our most commonly used agent is TCA 35 percent for combined simultaneous transconjunctival blepharoplasty and chemical peeling. In our experience, this concentration produces satisfactory results with one application in most patients, assuming that the patient selection, application of the chemical, and aftercare are appropriately carried out. There is still some minimal risk of scarring, textural change, eyelid contracture, or undesirable pigmentary changes. On occasion, and for selected patients, we use phenol 89 percent or Baker’s phenol mixture combined with transconjunctival blepharoplasty. However, these agents are not for the novice. They carry much more risk of complications.

Routinely for eyelid skin peeling, other than in conjunction with blepharoplasty, we often use the phenol preparations. Phenol wounds more deeply than trichloroacetic acid and as such is very effective in treating deeper rhytids and creases in the eyelids.

It is thought, though still not conclusively proven, that phenol’s ability to wound increases with the dilution. (That is to say, the more dilute the phenol preparation, the greater the penetration.) Phenol preparations such as Baker-Gordon formula (Table 21-3) dilute the phenol and use additional ingredients. Studies have shown that the most toxic phenol preparation is a phenol and water combination of 2 : 1. Thus, any dilution of full-strength phenol preparation, as occurs when tears run onto the eyelid, may increase the depth of penetration.

Table 21-3 Baker-Gordon chemical peel formula

In choosing the chemical agent, the surgeon must keep in mind differences in wounding agents, the preparation of the skin as well as the anatomic variations in the skin of each area of the face. For example, one may apply Baker-Gordon formula laterally, to the crow’s feet and in the deep rhytids of the glabella and perioral region; 35 percent TCA to the forehead and infrabrow area; 25 percent TCA inferiorly to the upper blepharoplasty incision line, on the medial canthus, and over the bridge of the nose at the radix; and continue with 25 or 35 percent TCA from the lower eyelid lash line inferiorly over the remainder of the face. The solutions should be applied in a feathered fashion to provide a natural look without a demarcation line. It is imperative that the solutions are not applied inferior to the jawline for this may result in scarring.

To determine the appropriate depth of wounding in any one area, the surgeon must consider at least the following skin factors: amount of redundancy, thickness, quality, degree of oil production, laxity of the lower eyelid margin, prior upper or lower blepharoplasty or skin peel, actinic damage, rhytids, and pigment and skin color. This customized approach is utilized for all peeling procedures regardless of whether the full face or only specific anatomic regions are peeled. After consideration of these factors, the appropriate chemical agent is selected.

The chemical solutions themselves must be reliably mixed and fresh. TCA solutions are mixed from crystals every 180 days and stored in amber colored bottles. The mixed solution may be purchased from a pharmacy. A 35 percent TCA concentration is obtained by mixing 35 g of TCA (USP) crystals with 100 ml of distilled water. The solution should be stirred before use in case some of the crystals may have come out of solution. Evaporation increases the concentration of TCA, therefore, bottles must be securely closed. Baker-Gordon formulas are mixed fresh daily. Full-strength phenol (89 percent) remains stable on a long-term basis in the manufacturer’s amber glass bottle. Acetone may be purchased from the pharmacy and is used straight out of the bottle on a gauze pad (2 × 2 or 4 × 4 in) to cleanse the skin.

Pretreatment with retinoic acid (retin-A) and bleaching agents

Topical retinoic acid (Retin-A) is the acid form of vitamin A. Studies of daily use of retinoic acid for 6 months have demonstrated it to be an effective treatment for wrinkling, actinic and pigmentary changes.⁷ Pretreatment with retinoic acid for 2 weeks before chemical peeling usually results in a more even uptake and penetration of the chemicals, and a quicker re-epithelialization. In addition, this pretreatment may allow for deeper wounding with a given chemical concentration and application technique. Retinoic acid is available in varying concentrations. The most potent and irritating forms, in descending order, are: 0.025 and 0.01 percent gel, and 0.1, 0.05, and 0.025 percent cream. We usually have the patients use the 0.1 percent cream, applied nightly to the affected regions. Retinoic acid commonly causes a retinoid dermatitis, which is a pharmacologic irritation and not an allergy. The potency and frequency of application should be adjusted to minimize excessive irritation, but the patient must recognize that some degree of irritation must be manifest to attain benefit.⁸ Beginning again 2 weeks after peeling (after resolution of significant inflammation), regular use of retinoic acid may be continued indefinitely. The use of retinoic acid (just like the chemical peel itself) causes an acceleration in healing and a reduction of blotches, pigmentary changes, and fine wrinkling, with a smoothing of the surface and an improvement in color from the sallow complexion of actinically damaged and intrinsically aged skin to a healthy, rosy glow. All of these results should enhance all types of cosmetic surgery of the face.

Since chemoexfoliation induces inflammation there is always a risk of post-inflammatory hyperpigmentation. All patients are at risk, although the darker the skin the greater the risk. Hydroquinone, kojic acid and azelaic acid are agents that inhibit tyrosinase and decrease the skin’s ability to produce melanin. These bleaching agents come in various strengths and combinations. We prefer to use 4 percent hydroquinone or a combination of 2 percent hydroquinone and kojic acid (Pigment Gel, Physician’s Choice of Arizona). These bleaching agents should be started along with the retinoic acid two weeks prior to the peel and restarted approximately two weeks after the peel and continued for several months.

Skin cleansing

The presence of skin oils or grease on the skin inhibits even and predictable penetration of the wounding agent. The patient’s face and eyelids should be clean, dry, and free of oil before the procedure begins. The patient is therefore asked to wash the face with soap and water the night before and the morning of surgery and to not wear make-up or put skin cream, sunscreen or lotion on the face or eyelids on the day of surgery. Cleansing with soap may be adequate but also may leave soap residue. For these reasons, the already clean face is degreased by the physician with acetone as the first step in the procedure. Even the acetone degreasing must be standardized, because more rubbing will disrupt the epidermal barrier and allow for greater penetration. The skin should be stretched during acetone degreasing to assure degreasing at the depth of the rhytids.

Timing relative to surgery

Chemical peeling causes a contraction of the skin in both horizontal and vertical meridians, while improving the texture and quality of the skin. Upper and lower eyelid chemical peeling may be performed without surgery or before, in conjunction with, or subsequent to eyelid surgery. Chemical peeling may also be used as an adjunct to endoscopic eyebrow and forehead elevation procedures. As long as the blood supply to the skin has not been disrupted there is no contraindication to perform a chemical peel at the same time of surgery. For example, we commonly perform an endoscopic eyebrow lift and simultaneously peel the skin of the forehead. In contrast, at the time of a facelift we will peel the central portion of the face: The forehead, eyelids, perioral and medial midfacial skin but not the preauricular or skin of the lateral cheeks, since this skin has been undermined and its vascular supply theoretically may be compromised. When chemical peeling is performed simultaneously with upper eyelid surgery (immediately upon completion of the surgical procedure, while still in the operating room), the upper eyelid skin incision and the skin between the upper eyelid incision and the upper eyelid margin are not treated (or, at the surgeon’s discretion, the pretarsal skin may be treated very lightly).

Anesthesia and patient monitoring

The patient is kept comfortable throughout the procedure and during the postoperative course. Some reports state that specific regional skin anesthesia is not necessary for 35 percent TCA and lighter peels. We have found that many patients do, in fact, have pain with these peels and, thus, we use regional block anesthesia for all chemical peels of 35 percent TCA and the phenol preparations. For greater patient comfort, the regional block anesthesia may be administered along with intravenous sedation. In all cases of simultaneous blepharoplasty and chemical peeling, adequate infiltrative anesthesia exists such that regional block using 0.5 ml of 2 percent lidocaine (Xylocaine) with epinephrine and 0.5 ml of 0.25 percent bupivacaine (Marcaine) with epinephrine may be infiltrated around the supratrochlear, supraorbital, zygomaticofacial, and infraorbital nerves. For chemical peels performed independent of surgery, the same regional blocks are given provided the wounding agent is TCA 35 percent. The pain from 35 per cent TCA used in eyelid and facial peels seems to last no longer than a few minutes as long as iced compresses are used. Since phenols may burn for several hours after application, a higher percentage (0.5%) bupivacaine (Marcaine) with 1 : 200,000 epinephrine is used. Marcaine provides postoperative anesthesia for 4–6 hours and may be repeated if desired.

Cardiac monitoring is standard procedure for full face phenol peels. Phenol is absorbed systemically and is cardiotoxic and may cause arrhythmias. The amount of phenol in the blood stream at any one time is controlled by applying the phenol to segments of the face at 15-minute intervals. If arrhythmias develop, the applications are stopped until the cardiac rate has been regular for 15 minutes. Subsequent phenol applications are applied in smaller surface areas, timed further apart. Lidocaine can be injected intravenously in doses of 5–10 mg to control arrhythmia.

The authors have never seen or heard of a localized application of phenol to the eyelids resulting in an arrhythmia. Therefore, the authors do not specifically use cardiac monitoring for regional applications of phenols. TCA is not absorbed and produces no systemic symptoms other than transient pain.

When performing full face peels independent of surgery, many patients will desire intravenous sedation. For those who choose not to have intravenous medication we routinely administer a cocktail of clonidine, which controls acute rises in blood pressure, demerol for pain control and valium which has a sedative and hypnotic effect. The patient is then given regional blocks as described above.

Chemical peeling technique

The same techniques of application are used for all chemical peeling agents. As stated earlier, different wounding agents may be used in different areas and in different manners for each area of the face. When eyelid chemical peeling is performed simultaneously with surgery, the method of application differs from that used for eyelid chemical peel performed independent of surgery, because the agent must avoid the suture lines. The independent procedure is described fully first, and the modifications to be used when chemical peel is performed in conjunction with blepharoplasty are then detailed.

In all peeling procedures, the skin surface must be adequately prepared. As instructed, the patient has already washed the face before surgery. The surgeon vigorously scrubs the patient’s skin with an acetone-moistened gauze pad.

Application of 35 percent TCA

The TCA is applied to the skin using one or two non-sterile, cotton-tipped applicators with wooden sticks. (The use of wooden stick applicators allows the physician to rub the acid vigorously into the skin without breaking the applicator.) The applicator is dipped into the TCA. The cotton tip of the applicator is pressed against the side of the container until excess liquid is removed, so that TCA does not drip onto the skin. The TCA is applied in the desired manner, with one or more applications depending on the depth of wounding desired.

The chemical is applied preferably with the patient lying supine. The chemical may be applied to corresponding segments of the eyelids sequentially, that is, to the right lower eyelid, and then to the left lower eyelid, while the amount of chemical and anticipated depth of wounding in the first segment is still fresh in the surgeon’s mind.

Some surgeons prefer the eyelids to be closed during application as additional protection for the cornea, others prefer the eyelids open to avoid the ‘wick’ phenomenon of pulling the chemical agent along rhytid creases (especially in the canthi) into the eye by capillary attraction. Some surgeons advocate using no bland ointment in the eye for fear it will get onto the skin and cause uneven wounding, and others prefer using ointment to protect the cornea and avoid tearing, which will dilute the chemical agent. We place a drop of topical tetracaine and a small amount of bland ophthalmic ointment in each eye.

On the upper eyelid, we prefer to apply the chemical while the patient’s eyelids are closed. We recommend beginning with the crow’s feet superior to the lateral canthal angle and proceeding across the upper eyelid laterally to medially along the inferior border of the eyebrow, then inferiorly down to the eyelash margin, the inner canthus, and the radix of the nose. This is in contrast to the method of McCollough and Hillman,⁸ who peel no closer than 2–3 mm from the eyelash margin. The chemical is carried into the eyebrow. There is no damage to the eyebrow cilia from chemical peeling in the eyebrow. (By the same token, the chemical peeling on the forehead is carried into the scalp in a full-face peel.)

On the lower eyelid complex, we apply chemicals with the patient’s eyelids open and the patient looking superiorly. The application proceeds from the lateral malar area and orbital rim, across the crow’s feet, moving superiorly and medially to the eyelash margin, in contrast to the method of McCollough and Hillman. The chemical is applied more lightly to the extremely thin skin on the inner canthus and the thin skin over the tarsal plates. The thicker skin of the crow’s feet, infrabrow areas, and upper and lower eyelids can tolerate a stronger application applied with one or two cotton-tipped applicators. Wherever the solution is applied, the edges should be feathered to avoid a sharp line of demarcation and objectionable color contrast.

When peeling the entire face, the TCA solution is applied with two or three cotton tip applicators. It is best to apply the solution in a methodical manner to each anatomic region so that areas are not skipped. For example, the solution is first applied to the right cheek then the left cheek then the right jowl then the left jowl etc. For areas with deeper rhytids the solution can be applied more vigorously, thereby achieving a deeper peel.

Once applied, the chemical will produce a white blanching or frosting of the skin. This frosting becomes more prominent over 5–10 minutes, signifying a deeper chemical burn. The extent and speed of frosting are determined by the concentration and amount of TCA applied and by how briskly the applicators are rubbed into the skin (Fig. 21-3). In another 5–10 minutes, the frosting begins to fade, and a deep erythema manifests itself. The surgeon must look through the frosting to see the erythema. With experience, the surgeon can judge the depth of wounding by the relative timing of onset and density of the frosting and the erythema. Generally, the ‘whitening’ of the skin signifies epidermal protein coagulation and is the end point of the application. Deep frosting may last 20–30 minutes before beginning to fade.

Figure 21-3 Application of chemical wounding agent. Anatomic segments are peeled. The perioral, glabella and forehead regions have been peeled (A). After application of the TCA the skin turns white (frosting). The deeper the peel the more opaque the color. The remainder of the face is peeled (B). Note that the entire face is frosted with varying degrees of whiteness. Several minutes after the peel regions that have not frosted can be repeeled.

Technique for chemical peel combined with blepharoplasty

Chemical wounding, performed immediately after the completion of blepharoplasty, is performed in the same way and following the same general scheme just described. If the procedure was an isolated lower transconjunctival blepharoplasty, the upper eyelid and, in fact, all skin surfaces may be treated exactly as if the peel were being performed entirely independent of the surgical procedure. If the surgical procedure was an upper blepharoplasty and a lower transconjunctival blepharoplasty, the chemicals are applied as described previously, except that a feathering begins 1 or 2 mm superior to the suture line in the upper eyelid and the chemical application becomes denser up to approximately 3–5 mm superior to the suture line, where the wounding depth is the same as it would be without surgery. A very light ‘feathering depth’ application may be applied on the pretarsal skin, beginning several millimeters inferior to the suture line and continuing to within 1 mm of the lash line. The medial canthus and lower eyelid are peeled exactly as if there had been no surgery.

In the lateral canthus, care is again taken to stay several millimeters away from the suture line and to feather the edge of the chemical peel adjacent to the suture line to avoid a demarcation line. When a lateral canthal procedure has been performed, the chemical agent is kept away from the suture line as described.

Upon completion of the chemical peel, non-sterile gauze pads soaked in ice water are applied immediately to the eyelids and peeled areas. Acid applied to the surface of the skin burns to completion very rapidly. If there is any question as to whether the chemical peeling agent remains on the skin, the skin is immediately dried with the gauze before the application of the cool compresses.

The gauze pads are changed frequently to keep them cool. To minimize the discomfort and burning sensation after a chemical peel, many surgeons instruct patients to use continuous cool compresses for the first day after application of 35 percent TCA, and two days following phenol applications.

A thin coat of petroleum jelly or polymyxin Bbacitracin ointment (Polysporin) is applied to the peeled skin once the patient is comfortable in the recovery room. Patients are instructed to continue cool compresses at home (primarily to offset postoperative swelling) until bedtime and to sleep with the head elevated on two pillows.

The theory and techniques for peeling the remainder of the face in conjunction with facial cosmetic surgery are similar to that of the eyelid. When peeling the forehead region we routinely use TCA 35 percent or other agents depending on the desired depth of penetration. In the glabella region, if deep rhytids exist a Baker’s phenol solution can be applied specifically to those rhytids. The perioral rhytids are often difficult to eradicate and often require a phenol or Baker’s Gordon phenol peel. Peeling of the perioral region can be performed in conjunction with a face lifting procedure.

Management after chemical peel

Management is similar after all chemical peeling procedures, varying only with regard to the total area peeled and the depth of wounding in that area. A partial thickness of the peeled skin dies on the first postoperative day. This dark or ashen gray skin begins to spontaneously peel off usually on the third day (Fig. 21-4). Beginning on the first day after chemical peel, the patient should institute a regimen of facial cleansing twice a day, followed by application of a thin film of ointment.

Figure 21-4 Day 5 post full face 35 percent TCA peel. Note the regions that have peeled are pink and healthy. The non-peeled regions are dark brown.

This regimen begins with the cleansing afforded by either cool or warm water compresses, followed by the application of 3 percent hydrogen peroxide applied to the skin peel area with cotton-tipped applicators. After the slough of skin has started, it should be encouraged by light scrubs with the non sterile cotton-tipped applicators dipped in 3 percent hydrogen peroxide to remove debris and dead skin that comes off easily. (Skin should never be peeled off manually.) Then, with the use of cotton-tipped applicators, a coating of petroleum jelly or polymyxin B–bacitracin ointment is applied to keep the skin smooth, supple, and lubricated.

It should be noted that if a patient doesn’t take off enough dead skin after a large area of skin is peeled with TCA 35 percent or deeper peeling agent, the area may become hot and inflamed and the patient may even develop a fever manifesting a cellulitis. This does not happen after peel with less than 35 percent TCA. The patient must be specifically reminded that showers and scrubs always must be followed by coating the area with petroleum jelly to prevent skin desiccation and to promote re-epithelialization. Mechanical debridement with scissors and forceps should never be performed because it may damage tissue and cause scarring.

Following both blepharoplasty and chemical peels, we generally advise the use of cool water compresses on the first two postoperative days, and warm water compresses to increase circulation and carry away edema beginning on the third postoperative day. The patient may, of course, add cool water compresses for comfort as needed. Although codeine or hydrocodone (Vicodin) is often prescribed for post blepharoplasty pain, no pain medicine is generally required following TCA skin peels.

This regimen of cleansing and compresses is con-tinued until the skin is fully re-epithelialized, which occurs in 7–10 days. When the upper and lower eyelids have been peeled without surgery, the upper eyelids generally heal 1–2 days more slowly than the lower eyelids. This may be due to the fact that the upper eyelid folds in upon itself at the crease, which continually reopens the skin and delays re-epithelialization in this area.

Once eyelids are fully re-epithelialized, the patient may again apply make-up. During the first 2 weeks after the peel, the patient is instructed not to wipe the eyelids when drying with a towel because this may damage new skin. All drying in the peeled area should be done by patting. Sunscreen should not be applied until 4 weeks after peel, because there is a significantly increased likelihood of contact allergy before then. For the first postoperative month, the patient is instructed to stay out of the sun and to wear a hat when outside. Sunlight burns the skin and causes hyperpigmentation.

Repeated chemical peels

Chemical peeling may be repeated one or more times to achieve the desired result. Whereas some authors encourage deep-depth wounding on the first peel, theorizing that the first peel has the least risk of scarring and complications, other authors advise the use of repeated medium-depth peels, to lessen the shock of pigment changes and reduce the risk of complications. We discuss the options with the patient and decide on the depth of peeling and considerations for subsequent peeling on the basis of all factors, including how soon afterwards the patient must resume appearing in public. We frequently perform a simultaneous upper blepharoplasty, lower transconjunctival blepharoplasty, and chemical peel with 35 percent TCA. This may be followed as early as 14 days later or at any subsequent time by a repeat peel using TCA 35 percent or 89 percent phenol if so deemed appropriate. If further improvement is desired, a third peeling procedure may be performed after completion of healing of the second peel usually at 4 days or longer.

Needless to say, the same basic parameters must be assessed for each repeat chemical peel as though it were the first time. These parameters are the amount of redundant skin, the degree of laxity of the lower eyelid margin, the existence of lagophthalmos, the possibility of precipitating corneal exposure, the degree of actinic damage, and skin color.

Chemicals may be applied to scar lines from previous blepharoplasties. Peeling over the scar does not cause hypertrophy of the scar and does tend to lighten its color.

The repeated application technique with milder chemical solutions also is appropriate for those individuals whose skin is dark (Fitzpatrick’s classifications IV–VI) and who want to reduce the risk of hypopigmentation as well as for those who want a brief and easy recovery after each application.

Complications

Complications include ocular damage, prolonged erythema, unexpected hypopigmentation, splotchy hyperpigmentation, scarring (including textural changes), cicatricial ectropion, eyelid retraction, and lagophthalmos.

Authors’ collective experience with complications

The authors have performed over 10,000 chemical peels over the past 25 years. In general the procedure has been extremely safe and effective. In our combined experience we have not had any complications with peels of TCA 25 percent or less. The complications that have occurred were in TCA 35 percent and the phenol peels. There were two cases of herpetic infections after full face phenol peels that resulted in scarring. Both of these patients were on prophylactic acyclovir and had breakthrough infections. At that time acyclovir was the only antiviral available. Currently, patients are placed on valcyclovir 500 mg twice a day for 7 days. Our recommendation is that if a patient develops a herpetic infection despite being on valcyclovir, a second antiviral agent should be added to the medical regimen.

Approximately 1 percent of patients who underwent perioral phenol peels developed mild hypertrophic scarring. We have been able to reduce these scars with a combination of silicone gels, pulse dye laser, and intralesional steroid/5-fluorouracil injections. Many patients developed mild textural skin changes even after a 35 percent TCA peel. In general these changes are mild but problematic to the patient, since make-up will not adhere well to these areas to provide camouflage. We recommend if textural changes are noticed early on in the postoperative period, that the patient should start using a mild topical steroid.

Two of us (NS and JH) have performed lateral canthal resuspension with a SOOF and cheek lift^11–15 with satisfactory final results in seven patients referred with lower eyelid retraction after chemical peel. The use of a hard palate graft, which is successful for lower eyelid retraction following transcutaneous blepharoplasty, is usually not necessary after chemical peel, because the mid-lamella has not been manipulated and therefore is not scarred.

Conclusion

Chemical peeling alone or in conjunction with surgery can vastly improve the quality of the skin. The procedure is safe and effective but does require a knowledge of skin pathology, wounding and its management, and proper patient selection. The potential for improvement by adding chemical peeling to blepharoplasty or facelifting is significant. The risk of significant complications in properly selected patients is relatively small. With the above in mind, we routinely perform upper blepharoplasty and lower transconjunctival blepharoplasty, facelifting and endoscopic browlifting combined with simultaneous chemical peeling.