Skin resurfacing is a very useful facial rejuvenation procedure that brightens one’s complexion and helps reduce or eliminate the appearance of fine wrinkles. Once done exclusively by chemical peels, the introduction and evolution of laser technologies  have pushed the use of topical chemicals to the background. Most people recognize laser treatments such as CO2 and fractional as the most cutting edge skin resurfacing approaches.

While laser skin treatments can provide some significant skin improvements, they are not without their downsides. They are expensive, in the range of thousands of dollars per full face treatment, and have significant social recovery. Such shortcomings make them not ideal for many patients.

Chemical peeling may be old, dating back thousands of years, but it has a long history of successful results.  Phenol is the most aggressive facial peel and was the gold standard for a deep result. But its use required a lot of experience and expertise to avoid problems such as tissue burns, loss of skin pigment, and cardiac reactions and toxicity. The replacement of chemical peels with the laser was spurned by a method of skin resurfacing that was more controllable and posed less systemic risks.

Lost in this shuffle has been the trichloroacetic acid (TCA) peel.. This peel, while not as deep, is much safer and predictable than that of phenol. It is a very versatile peel, being available in concentrations from 10% to 70% , which produces different depths of penetration and results. TCA exerts its action by the almost immediate coagulation of dermal proteins, which produces a classic white frost as the coagulation proceeds because of temporary blood vessel constriction.

TCA peeling can be safely used on all skin types, unlike laser resurfacing. However, it is not without some risk of pigment changes. Therefore, darker skin types in the Fitzpatrick four to six classification should be done only with lower TCA peel concentrations and with the use of before and after hyperpigmentation topical treatments.

One of the big advantages to TCA peels is the various concentrations available for different amounts of results and associated recoveries. As a general rule, the higher the concentration of TCA the deeper the peel, the better the results, and the longer the facial recovery.

A good office-based peel is 15% TCA. This limits the damage to the epidermis and the recovery would be 2 to 3 days without much noticeable peeling. When the recovery is this short with no peeling, significant results will not be seen. This falls more into the category of an upper end superficial chemical peel. As long as no more than two coats is applied, it can be done without any form of anesthesia. The traditional use of topical anesthetic creams (e.g.,  4% LMX) that is used with microlaser peeling should not be used with peels as it excessively hydrates the skin and limits their penetration. Oral sedation (10mg valium, 25 mg phenergan) taken 30 minutes before can be very helpful for reducing anxiety during the peel.

Applying more costs of 15% TCA increases the depth of the epidermal damage and will increase healing up to around five or six days. This use of 15% TCA improves the results and helps reduce the finest lines and wrinkles.

In stronger concentrations of 25%  35% TCA, the upper to mid-dermis is damaged with more laser-like results and is best described as a medium-depth peel. This is my favored use of TCA and is usually done in the operating room in conjunction with  facelifts and transconjunctival and pinch lower blepharoplasties.This depth of TCA peel is fully re-epithelialized in 1 week and the patient can then wear makeup. While there is some temporary redness, it does not last very long unlike that of deeper laser treatments. This type of peel works really well for brown skin discolorations and fine to moderate wrinkling.

While higher concentrations do exist and can be used (e.g., 70% TCA), their risks of skin problems rival that of the laser. If one is seeking this depth of skin penetration, the laser is more predictable and safer in my opinion.

Despite the avalanche of available laser technologies for skin rejuvenation, The TCA peel remains an economical and safe treatment that can be done in conjunction with facial plastic surgery procedures or as a stand alone skin treatment. Its ability to be used in different skin types safely and predictably is another valuable advantage.

Dr. Barry Eppley

http://www.eppleyplasticsugery.com

Indianapolis, Indiana

Wrinkles, tiny blood vessels and brown spots are very typical signs of aging and can add years to your facial appearance. While many feel that these are just the effects of aging, in reality they are the long-term effects of unseen sun damage from years ago.What may have been a love affair with the sun in our early years eventually appears as something we hate decades later.

Fortunately, there are numerous treatments to help treat these chronic signs of sun damage known as photoaging. Lasers, peels and light treatments, and many combinations thereof, can help offset the damaging effects of our lifelong exposure to ultraviolet light.

While there are many available skin treatments, their sheer number makes it very confusing to patients. Here is a brief overview:

PEELS. For patients with light skin damage and fine wrinkles, a chemical peel can be a great treatment. By removing several superficial layers of outer skin, one can smooth the skin and get rid of some brown spots. There are many types of peels but those that provide real therapeutic benefit are light TCA and the newer Vi peel. These peels are usually combined with a microdermabrasion which helps prep the skin to receive the peel. In general, peels help most with pigmented skin problems and less for significant wrinkle issues.

LIGHT and LASERS. Light treatments, known as IPL or BBL, are excellent for brown spots and telangectasias. They work by emitting a polychromatic light with multiple absorption targets. (melanin in brown spots and hemoglobin in telangectasias) Since they pass through the skin and only hit the target, there is no real downtime. Lasers work by burning off the top layers of skin. As of now, there are two fundamental laser skin resurfacing approaches, micropeeling and fractional. Micropeeling removes 100% of the outer surface at a set depth. Fractional punches holes in the skin but only treats about 10% of the surface area in a single treatment. When it comes to which is better for skin resurfacing, the jury is still out. Fractional is the newest laser toy so it receives a lot of press, but it is not magic and the choice between the two (or combination) is up to the practitioner’s experience.

COMBINATION APPROACHES. If a patient has significant wrinkles or skin texture problems, then I would recommend a laser resurfacing with the depth based on how much recovery they can allow. This is often combined with some Botox for muscle action decrease and injectable fillers for volume loss. If the photoaging damage is less, then BBL and chemical peels can suffice.

Many times, the combination of BBL for brown spots, laser resurfacing for wrinkles and texture and Skin Type (for tightening some loose skin) can be safely combined in a single treatment. While this will not create the same results as a facelift, for those with lesser amounts of skin laxity it can create a really significant improvement with much less recovery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

The use of lasers and light therapies has dominated the talk about skin retexturing and resurfacing over the past decade. While they do produce some wonderful results, their use has overshadowed the historical approach of chemical peeling of the face. Chemical peeling today has been largely relegated to the superficial peels done by aestheticians and not physicians. When combined with microdermabrasion, they are known to produce a nice refreshening effect but the results are not comparable with laser treatments.

Most chemical peels that produced any significant results, such as trichloroacetic acid (TCA) and phenol, have involved significant recovery and discomfort. Medium to deep-depth peels done by physicians required significant skin penetration to produce their results. This produces significant upper layer skin sloughing and downtime. Personally, I had assumed that ‘state-of-the-art’ chemical peeling was more about technique than the chemical compositions of the solutions.

My understanding of chemical peeling has undergone a change in the past year since we have begun using the Vi Peel. This chemical peel is an innovative combination of different ingredients. Cleverly combining TCA, phenol and salicylic acid peels with retinoic acid, Vitamin C and a proprietary mineral blend, a very interesting chemical peel has been created. It can create a significant skin change (repair) without the associated pain on application and with very little downtime. I am not sure of the chemistry of exactly how it works since skin results from peeling have been historically associated with the concept of ‘deeper = better results = more pain and recovery’.

My Indianapolis plastic surgery experience with the Vi Peel has shown that it is a real revolutionary peel. I say this for the following four reasons. First and initially important is that the peel produces a significant anesthetic effect on the skin on application. So one can have the peel without pain. That is really important to patients and encourages them to return for further treatments. I assume that the anesthetic effect is from the phenol component of the solution. Secondly, it does produce real skin improvement that appears to be equivalent to that obtained from micropeel laser treatments. (less than 50 microns) A series of Vi Peels can be a comparatively cost-effective skin rejuvenation program. Third, it can be safely used on all skin types (even a Fitzpatrick V or VI) as well as on the more sensitive areas of the neck and the chest. (historical ‘no-peel’ zones) Eliminating sunspots from the hands and chest and decreasing wrinkles in the décolletage areas has always been problematic with traditional peel solutions. Lastly, the peel can be safely applied by a trained aesthetician and does not require a physician to do so.

The Vi Peel is not a complete substitute for laser and light therapies. But it is a valuable addition to skin rejuvenation by providing a real effective option for the under 100 micron retexturing  needs in the face. For the neck and chest, however, this might be the best option that currently exists for real improvement without the risk of scarring.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

The statements expressed herein are unsolicited and uncompensated by the manufacturer. I have never even met our local sales representative.

Contrary to the perception of many, upper and lower eyelid (blepharoplasty) surgery will not do much to improve wrinkles around the eyes. Eyelid procedures are for removing redundant skin and herniated fat. For wrinkle improvement around the eyes, chemical peels are one good option for wrinkle reduction.

If chemical peeling is to be done at the same time  as a lower eyelid procedure, it can only be done if the lower eyelid technique is transconjunctival. (meaning no formal skin-muscle flap is raised) If a more formal blepharoplasty is being done, one should wait at least 3 months after  before doing so. The combination of the two together will likely result in scarring and ectropion. (pulling down of the lower eyelid)

Chemical peeling is not usually done on patients with any significant skin pigment. This would eliminate many ethnic groups such as most African-Americans, Asians, and Hispanics. There is a real risk of losing some color (pigment) and the risk simply isn’t worth it.

Medium depth and deep peels are commonly used for the lower eyelids because they are effective and have a good margin of safety given that the eyelid skin is very thin. The depth of peeling when using medium peels is directly related to the amount of solution applied, the concentration of the peel, and how the skin is prepared for the peel. Peel concentration alone does not necessarily indicate how deep the peel will penetrate.

The use of medium-depth peels are usually done  in two layers, applying two superficial wounding agents. In my Indianapolis plastic surgery practice, I use a first layer of a Jessner’s solution, a keratolytic agent, before putting on a 35% trichloroacetic acid solution. This enhances penetration and the overall result while retaining a good margin of safety. The peel will develop an immediate frost which is then covered with antibiotic ointment. It can be performed under topical anesthesia in the office.

Deeper eyelid peels are most commonly done with a phenol solution. While full face phenol peels have largely faded since laser resurfacing became popular, they are still a good technique in the lower eyelid when significant wrinkles are present. Concentrations of either 50% or 88% are used which causes injury to the medium depth of the skin thickness. The phenol peel produces the greatest change in skin pigment and wrinkle reduction while also producing some skin tightening. Phenol lower eyelid peels should be done in the operating room because they cause more pain and any tearing into the peel will cause it to penetrate deeper and create a full-thickness burn.

Lower eyelid chemical peels can be done simultaneously with a transconjunctival lower blepharoplasty, as a delayed treatment for wrinkles three months after, or as  stand alone chemical peel when blepharoplasty is not needed.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis Indiana

Chemical peels have a long history in skin rejuvenation and pre-date the use of lasers by decades. More than one million skin peels are performed each year which makes them one of the most common non-surgical cosmetic skin treatments. Their popularity is due to their relatively low cost of use and how they can be used in combination with microdermabrasion and light and laser skin therapies.

Chemical peels result in numerous clinical benefits  including a visible reduction in fine lines and wrinkles, lightening hyperpigmentation, improving acne and rosacea, and as a treatment method for precancerous skin lesions. Despite how many peels are currently done, they are probably underutilized in many plastic surgery practices.

The most common chemical peels are the superficial AHA peels of lactic and glycolic acids whose effects are limited to the stratum corneum.  (epidermis) They are the mainstay of skin rejuvenation due to their ability to do them in the office without any form of anesthesia and their quick recovery. They are essentially the mainstay of what most estheticians use. They are excellent refreshening peels but should not be thought of by patients as a therapeutic peel that will have an immediate effect on fine lines and wrinkles. They simply do not penetrate that deep.

They have historically been applied as single-acid peels but they have more downtime when used this way due to increased inflammation and irritation. This is why the use of blended peels has been a real chemical peel advance in recent years and now dominates how they are used. Many different combinations are available and the historic Jessner’s solution (salicylic acid, lactic acid, and resorcinol) is the ‘grandfather’ of the blended peel approach. Most recently, new ingredients have become available for use in making blended peel solutions. These include pyruvic acid, azelaic acid, and mandelic acid. These new ingredients are excellent exfoliating agents with very low risk profiles. Most major manufacturers now make blended peels, each one which touts the merits of their own mixtures. All of them are good, and when used in the right hands, probably produce similar results.

For greater therapeutic effect, one must consider medium-depth peels which can rival what similar-depth lasers can do. The most versatile chemical peel that I as a plastic surgeon use is the combination Jessner’s and Trichloroacetic acid (TCA) peel. This is a peel that can be done in the office as a stand alone procedure or the operating room in combination with other procedures. The application of a Jessner’s solution first acts as a keratolytic agent that allows the subsequent application of TCA to penetrate deeper and more evenly. For superficial wrinkles, a 25% TCA can be used but deeper wrinkles require a 35% concentration. This peel penetrates deep enough that both dermis and epidermis need to be regenerated, resulting in significant skin changes. The great thing about this peel is its versatility, being able to be done comfortably in the office (with a little sedation) or on top of raised facelift flaps in the oeprating room. It has a great margiin of safety and range of effectiveness, not being too deep but with more effect than a superficial AHA peel.

Despite the hype and marketing of lasers and mechanical methods of skin treatments, chemical peels have persisted in this highly competitive field. They provide an inexpensive and very safe alternative. With the many new peels that are available, more patients with various skin types and conditions can be treated. Between AHA peels for refreshening and maintenance and TCA peels for visible wrinkle reduction, good results can be safely and predictably obtained. Light-based (hyperpigmentation) and laser (vascular)therapies can be done and peels put on right after, allowing for multimodality skin rejuvenation treatments.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis