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Chemical Peeling as an Adjunct to Facelift and Eyelid Surgery


In this day and age of high technology, younger patients and surgeons often think that only devices or new technology is the answer to skin rejuvenation. Although contemporary technology has in fact opened new doors, the historic chemical peel still stands as a stalwart in skin rejuvenation. Many colleagues have spent upward of $200,000 for a skin rejuvenation device that produced the same results that could have been achieved with $1.50 worth of 30% trichloroacetic acid (TCA). Just because something is new does not mean it is better. Chemical peeling has been around in some shape or form for millennia and is one of the few cosmetic procedures that has withstood the test of time in safety and results.

Chemical peeling is an appealing procedure for cosmetic practitioners for many reasons. First and foremost, it is predictable and is capable of producing significant results. Another important factor associated with the popularity of chemical peeling is the low cost of the materials. In reality, TCA chemical peeling may be the most profitable treatment in the entire cosmetic panoply. One ounce of 30% TCA can be purchased (at the time of this writing) for $28.00 from dermatologic supply companies ( www.Delasco.com ). Similar products can be purchased on the Internet for much less, but practitioners should only trust products purchased from a qualified and certified vendor. There are numerous ways to concoct TCA preparations, including volume/volume, weight/volume, etc. In addition, the quality of product is unpredictable when purchasing medications on the Internet. Remember, this is an acid, and it can cause permanent scarring and other health problems. There is no such thing as a good deal on fire extinguishers, parachutes, seat belts, and TCA!

Chemical peeling is seemingly a very simple procedure, right? After all, it was performed by laypersons long before it became an accepted medical procedure. The skin is degreased with acetone, and a coat of acid solution is placed on the skin surface. There are even self-peeling videos available online. However, this sentiment is far from the truth. When I reflect on my own 25-year experience with chemical peeling, I believe I had some of my most sleepless nights related to chemical peeling and laser resurfacing. This is a simple procedure with a lot that can go wrong. It is imperative that the novice peeler has a complete understanding of the anatomy and healing of the skin, as well as the specific agents used for wounding the epidermis and dermis. As I will mention numerous times in this chapter, failure to do so can result in complications, permanent scarring, and lawsuits.

There are many articles and textbooks about chemical peeling, and Dr. Suzan Obagi is internationally recognized as an expert in this field. I recommend reading the articles and various book chapters she has written on the subject. Another excellent source is an older text by expert cosmetic dermatologist Mark Rubin, MD. The first edition (1995) of Manual of Chemical Peels: Superficial and Medium Depth (Lippincott Williams & Wilkins) was truly my bible. Dr. Rubin has more contemporary texts on peeling, and they are all good. The first edition, however, was especially useful because it covered skin anatomy, skin aging, skin pathology, peeling agents, peeling technique, peeling case presentations, and complications in one compact text.

Peeling Agents

There are more peeling agents than chapters in this book, and these are covered in depth in other chapters. It makes sense for the prudent practitioner to experiment with various agents and techniques to see what works best in his or her hands. I use the word “experiment” very cautiously, because any peeling agent can cause serious and permanent damage. A doctor new to chemical peeling should never “experiment.” Before ever peeling a patient, a novice doctor should study books and videos and observe seasoned practitioners. After that, the first series of peels should be performed with a proctor to ensure safety. The golden rule of cosmetic surgery is to start conservatively, because one can always go back and do more. On the other hand, it is impossible to reverse some complications. Walk before you run, and you will rarely go wrong. After experimenting with Jessner’s, TCA, glycolic acid, and phenol, I personally settled on TCA. It is not only important what agent one uses, but how it is used. The depth of penetration is subject to many variables, including but not limited to the following:

  • Type of acid

  • Strength of acid (%)

  • Number of coats applied (volume)

  • Patient’s skin thickness

  • Patient’s skin oiliness

  • The body part being peeled (thin eyelid skin versus thicker forehead skin)

  • The amount of actinic damage and rhytids a patient has

All of these variables and many others can influence the depth of wounding of the skin. The effectiveness of any peel is directly related to the depth of wounding and the related healing. A very aggressive peel can equal the skin rejuvenation of a CO 2 laser, whereas a light peel may not produce any noticeable difference.

Depth of Peeling

Peels can vary from very superficial to superficial, medium, and deep, and the depth of wounding is generally proportional to the length of healing and the final result. Medium-depth peels are among the safest types of chemical peeling, producing noticeable results and having low complications. Peels that do not extend into the papillary dermis provide minimal results for wrinkles and more pronounced photodamage. A medium-depth TCA peel will extend into the papillary dermis.

Skin Types

With all resurfacing, lighter-skinned patients (Fitzpatrick I and II) are safer to peel, as they have less pigmentation problems. The same can be said for very dark-skinned patients. It is the midrange patients (Fitzpatrick IV and V) that can have the most pigmentation problems, and too aggressive of a peel can make them permanently lighter or darker. In my experience, any patient with brown eyes will have a higher incidence of postinflammatory hyperpigmentation (PIH). PIH will generally manifest at about 30 days and is generally responsive to hydroquinone 4%, retin A, and sunscreen within several weeks. PIH can be very disconcerting to patients, so it is imperative to educate them preoperatively about the possibility.

Technically, any skin type can be peeled with experience. I frequently peel Asians, Latinos, and African-Americans who I would not think of treating with a CO 2 laser.

Prepeel Skin Conditioning

The basis of chemical peeling requires that the peeling agent be able to penetrate the skin. Preconditioning the skin is discussed in greater detail in Chapter 3 . Preconditioning the skin with retin A will thin the stratum corneum and facilitate penetration as well as afford many other positive attributes to the skin health. Starting 4% hydroquinone will also help precondition the melanocytes, which many doctors feel can lessen PIH after a peel. Sunscreen should also be added to this basic regimen. Pretreating patients also gives the doctor an idea of the patient’s level of compliance. If a patient cannot maintain a simple three-step cream regimen, they may not be great candidates for proper postpeel aftercare. I start all light-skinned chemical peel patients on this triad 30 days before a peel in the ideal situation. On patients with pigmented skin, I prefer an 8- to 12-week pretreatment cycle.

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