Chemical Peels in Plastic Surgery Treatment & Management

Although essentially a continuum of treatments bridges superficial and deep chemical peels, the pretreatment, intratreatment, and posttreatment protocols are better divided within these categories rather than along the lines of agents or lasers used.

Superficial skin peel

• After proper patient selection, history, physical examination, and preparation of the patient regarding appropriate expectations, begin the procedure.
• The patient may take 1-2 ibuprofen tablets (400 mg) 1 hour prior to the procedure.
• Mix the solution to be applied and/or ensure freshness and proper concentration.
• Wash the skin the night before the procedure and again the morning of the procedure with any detergent soap. The skin may be dry and flaky; this is desired. If the skin remains oily, a degreaser (eg, alcohol, weak acetone solution) may be used immediately prior to the procedure (see image below). Ether was used in the past and is an excellent degreaser; however, storage and hazardous goods concerns in an office setting preempt its use today. Patient's neck area after preparation with 20% methanol.
• Cover areas adjacent to the area to be peeled and protect clothing.
• Many commercially available peels have applicators and are thickened with glycerin or similar substances so that they do not run. Avoid pooling of peeling solutions to ensure an even application. Only a thin coat is necessary, but it must be even (see images below). Patient 2 minutes after application of 40% trichloroacetic acid (TCA) solution. Patient 8 minutes after application of additional trichloroacetic acid (TCA) to even the peeled surface.
• Peeling agents vary from fruit acids to weaker solutions of TCA. A superficial peel results in partial loss of the epidermis. Some light frosting of the skin may occur, but skin loss should not be obvious at the time of the procedure.
• The length of time that the agent is used depends on the solution and the desired depth of peel.
• Wash with copious amounts of water to end the reaction (see image below). When TCA is used, a fan helps to decrease intensity of the tingling sensation. Patient following completion of the chemical peel at 10 minutes and after neutralization with water.
• Usually, 2 days of redness followed by superficial peeling of the skin for another 3-5 days follows the procedure.
• Use of cosmetics and moisturizers during the time of the peel generally is avoided if at all possible.

Deep skin peel

• Skin preparation is essentially the same as that for the superficial peel. For 2 weeks prepeel, use tretinoin or some other irritant to potentiate the healing process. Tretinoin can cause severe skin irritation (which is why it is used in this capacity), redness, flaking, and sun sensitivity. Allergic reactions are possible (eg, anaphylaxis, hives, rash, nausea, vomiting), and prolonged inflammation poses a risk of worsening pigmentation. Use it sparingly and for a defined length of time. Tretinoin is approved by the Food and Drug Administration (FDA) only for treatment of acne, which it can transiently worsen. Skin improvement is an off-label use of this substance.
• A bleaching agent is often used to prevent postinflammatory hyperpigmentation.
• Begin use of perioperative antibiotics and antiviral agents the night before the procedure and continue use for approximately 10 days.
• If phenol is used, demarcate the areas of treatment to disallow overlap or nonapplication of the agent to any areas.
• Some form of sedation or anesthesia is required for this depth of peel.
• The solutions used are usually higher concentrations of TCA (>35% unbuffered) or phenol solutions.
• Apply the solution, usually in an operating room with continuous monitoring when phenol is used. Leave the solution on for the desired effect and then wash it off with copious amounts of liquid. Thymol can be used to stop the phenol peel.
• Use occlusion (either taping or a nonpermeable membrane or substance [usually petroleum jelly]) if a deeper peel is desired. A semipermeable membrane often is used afterward for patient comfort, or the petroleum jelly can be continued.
• The length of time of peeling usually is similar to that for superficial peels, but because of the depth of peel, redness may be present afterward for 6-8 weeks.
• Caution the patient against sun exposure during this period.
• After re-epithelialization occurs, re-institute the bleaching agent used preoperatively.
• Take care to prevent infection in the healing period and to provide prophylaxis for activation of oral herpes. If an outbreak of oral herpes occurs, quadruple the dose of the antiviral agent and use it for treatment rather than prophylaxis. This generally subdues the outbreak.
• Follow-up care is frequent, with visits every 2-3 days until re-epithelialization is complete, then every week until the redness is gone.
• Avoid steroids so as not to interfere with the maturation and thickening process of the new skin.

Patients are seen frequently following the procedure for the above-mentioned reasons and also, in the case of deep peels, to lend assurance that all is proceeding normally. The skin takes many months to heal completely and goes through many changes during this time. An experienced physician can allay many fears on the patient's part by making certain that all is proceeding normally.

The risk of complication is not observed with superficial peels, nor is great benefit. In patients prone to hyperpigmentation, pretreatment and posttreatment with a bleaching agent are necessary. Sun exposure must be avoided, especially in these individuals. Deep peeling is a risk. Avoiding the ever-present risk of scarring is of paramount importance, but this is difficult when a marked result is desired and when little control over many of the variables of depth is possible. Conscientious attention to every detail of the peel and experience with the procedure are necessary. Hypopigmentation in white persons after a deep peel is almost universal and should be an accepted sequela of the procedure.

Many more complications and scars are recorded from TCA peeling than from phenol peeling, perhaps because of the care with which phenol peels must be performed and the implied safety of TCA. Deep peels can be performed readily with TCA; take care not to peel too deeply. Other complications of infection, severe postoperative pain, and either too deep or too superficial a peel for the particular situation can be minimized with experience and vigilance.

The outcome generally is excellent once patient expectations are adjusted to the procedure. The patient must know what to expect from the surgery and during the healing process. Giving the patient realistic expectations for each stage of healing is imperative to the success of the entire procedure.

After a deep peel, the skin is new and supple. Some of the rhytides return as the swelling resolves. Approximately 1 month after the peel, the skin appears wrinkled. After it begins to thicken, many of these rhytides resolve over the ensuing months. A repeat peel can be performed after 1 year if necessary. Superficial peels can be repeated every few weeks if needed. Many superficial peels do not produce the same effects as a deep peel. The skin continues to weather and age after the procedure, but the effects of the peel are permanent.

Deep chemical peels have mostly been supplanted with laser peels, and controversy remains over which is better. Deep laser resurfacing is a more controlled and elegant procedure, with faster postoperative healing than chemical peels of similar depth. Laser peels also have less effect on pigment than chemical peels performed to the same depth. Both have risks, but when performed by experienced practitioners, both are safe and effective. The author prefers to use lasers for deep resurfacing and chemical peels for more superficial procedures, since using an incredibly expensive apparatus for a simple superficial peel is not necessary. The results from superficial chemical peels and superficial erbium:YAG laser resurfacing procedures are similar.

Microdermabrasion largely has supplanted epidermal peels because the procedure has no downtime and peeling does not occur to any extent afterward.

A newer fractional resurfacing device is very encouraging, especially for acne scarring. It allows for the resurfacing of one small area at a time, with several treatments required to complete the process. This device reduces the downtime from each procedure, but each procedure is still painful and requires about 7-10 days of recovery time, which is not that much shorter than a true, complete resurfacing procedure. Second-generation fractional resurfacing devices are being introduced that have less downtime and are, essentially, pain free.^[7]

Sublative rejuvenation is a means by which laser energy enters the top layers of skin through small portals, with the vast amount of radiofrequency energy then dissipating under the skin. It can be tailored to many different coverage and energy settings with, often, very little topical evidence of the procedure having been done. The question remains whether any fractional means or sublative means of energy transfer offers the same results as more invasive procedures.