Management of Aging Skin

Key Points

Combined resurfacing modalities tailored to skin type and location are more effective than a single modality alone.
The ideal patient for skin resurfacing is the thin-skinned woman with a fair complexion and fine rhytids.
Impairment of liver and/or kidney function could slow the excretion of phenol and increase the likelihood of cardiac complications.
All patients should receive appropriate antiviral therapy to prevent and treat possible herpetic outbreaks prior to skin resurfacing.
Retinoic acid increases the depth of chemical peels by decreasing the thickness of the stratum corneum.
Fitzpatrick type III or higher should consider the use of 4% to 8% hydroquinone gel before and after resurfacing to prevent hyperpigmentation.
Superficial peels extend to the papillary dermis, medium-depth peels extend to the upper reticular dermis, and deep peels extend to the midreticular dermis.
Indications for medium-depth peel are moderate photoaging, actinic keratosis, pigmentary dyschromia, mild acne scarring, and blending of other modalities.
Pigmentary changes are the most common complication of chemical peels.
Carbon dioxide or erbium:yttrium-aluminum-garnet laser is particularly good for treating perioral vertical furrows, periocular crow's feet, glabellar rhytids, diffuse acne scarring, and age spots.
Nonablative resurfacing usually requires multiple treatments to obtain the desired effect.
Multiple superficial peels do not equate to single moderate or deep peels.

Aging skin is one of the primary characteristics of the aging face that must be addressed as a part of comprehensive facial rejuvenation. Proper skin care regimens can be started at an early age to decrease the amount of photoaging, dyschromias, and superficial scarring that a person accumulates over time. Even though these preventive measures are becoming more commonplace, many patients still seek treatment of their aging skin to “reverse” this process. This chapter focuses mainly on the resurfacing techniques available to treat advanced skin damage. Chemical peels and laser ablative techniques have been proven to produce substantial results in a consistent manner. We will also discuss the increased utilization of nonablative and fractionated ablative laser therapy. Additional topics, including dermabrasion and medical skin care regimens, will also be addressed. Each of these techniques alone can produce predictable results in selected patients. However, it has been our experience that combined modalities tailored to skin type and location can be most effective.

Chemical Peels

Histologic Changes of Aging Skin

The first scholarly report on phenol chemical peels was written by Brown and colleagues. Brown described the histologic changes that were induced, including laminated collagen in the epidermis with fibrous strands that consistently paralleled the newly formed epidermis. Later, Kligman and colleagues studied the skin taken from Baker and Gordon's facelift patients who had chemical peels 18 months to 20 years earlier. First, they described histologic changes of nonpeeled skin; these aging skin changes were typical of actinic exposure with a loss of orderly differentiation in the epidermis and degeneration of the elastic network, along with some mottled pigmentation and lymphocytic infiltration. The amount of collagen was decreased, and disordered degeneration of the dermal fibers, a flattening of the dermal-epidermal junction, and multiple actinic keratoses with atypia were evident. The number of melanocytes was increased in this actinic skin, but they were unevenly distributed and contained variable amounts of melanin.

The skin of patients who had undergone a previous chemical peel showed a new band of dermis 2 to 3 mm thick just beneath the epidermis and lying on top of the old elastotic dermis. The epidermis had returned to orderly cellular differentiation without irregularities or microscopic actinic keratoses. Although an abundance of melanocytes were present and contained some fine, evenly distributed melanin granules, impaired melanin synthesis with a generalized bleaching effect, or hypopigmentation, was apparent. Lentigines were not seen. Furthermore, the epidermal-dermal matrix was composed of thin, compact, parallel collagen bundles arranged horizontally in contrast to the usual wavy pattern. Elastotic fibers had actually regenerated, forming a network of fibers paralleling the new collagen. Finally, the lymphocytic infiltration was diminished compared with that of untreated skin. Kligman and colleagues believed that the dermal reconstruction lasted about 20 years based on their study. They further concluded that chemical peel reduced the development of new neoplasms. The laying down of a band of new connective tissue can adequately account for the effacement of the wrinkles seen clinically. The skin is smoother, fuller, and tighter. Stegman and Litton and colleagues showed the chemical peel solution penetrating deeper in the dermis of actinically damaged skin than in nonactinically damaged skin. Hayes and Stambaugh demonstrated that during the first 2 to 5 days of a chemical peel, epidermal necrosis, edema, and homogenization are seen with the lymphocytic infiltration all the way into the reticular dermis. At 2 weeks, new collagen formation had begun. Stegman, Alt, and Brody and Alt have illustrated that penetration of phenol is deeper with occlusion than with nonocclusion. According to Beeson and McCollough, this is apparently true but not necessarily desired.

Litton and others agreed with Kligman and colleagues that the rate of appearance with precancerous and early cancerous lesions of photoaged skin was decreased after a phenol chemical peel.

Brodland and Roenigk showed that trichloroacetic acid (TCA) destroys the epidermis and upper dermis and further showed that the new epidermis migrated from the cutaneous adnexa beneath the destroyed tissue. This is similar to phenol peel. Histologically, the atypical clones of keratinocytes are removed and replaced by normal epidermal cells.

Patient Evaluation, Classification, and Selection

The process or technique of chemical peels, as well as other resurfacing modalities, is relatively easy to learn. However, it takes a great deal of experience with many different types of patients to learn the wide variation in skin types and how these respond to peel solutions. It also takes a great deal of experience to predict how each area of the face will respond to light or deep resurfacing in an individual patient and to influence the method of application used. Careful selection of the appropriate patients for resurfacing is the first and most important consideration. According to McCollough and Hillman, “The ideal patient is a thin-skinned female with fair complexion and fine rhytids.”

Fitzpatrick described types of actinically damaged skin in a range, from type I to type VI ( Table 23.1 ). Brody stated that Fitzpatrick types I through III patients are suitable for a chemical peel. He describes the ideal patient as a light-complexioned person of Celtic or Northern European descent with skin type I or II.

TABLE 23.1

Fitzpatrick Sun-Reactive Skin Types

Type	Description
I	Fair-skinned, blue or hazel eyes, blond or red hair
I	Always burns, never tans
II	Fair-skinned; blond, red, or brown hair
II	Usually burns, tans less than average
III	Fair-skinned, largest group of U.S. citizens
III	Sometimes burns mildly, tans about average
IV	Still considered white skinned
IV	Rarely burns, tans more than average and with ease
V	Intermediate-colored skin (Asian, Latin, and Indian)
V	Brown skin
VI	Black skin
VI	Never burns

The Glogau classification system was created in 1994 and provides an objective assessment of the degree of photoaging, categorizing the patient's skin damage as mild, moderate, advanced, or severe (groups I to IV, respectively; Table 23.2 ). Patients in category I are often young with minimal photoaging and are best managed with a superficial peel in conjunction with a good medical skin care program. Patients in categories II and III are candidates for medium-depth peels in addition to long-term medical therapy, as with retinoids or α-hydroxy acids. Category IV photoaging patients are best treated with medium or deep chemical peels, ablative lasers, or dermabrasion in conjunction with long-term medical skin care regimens.

TABLE 23.2

Glogau Classification of Photoaging Groups

Group I (Mild)	Group II (Moderate)	Group III (Advanced)	Group IV (Severe)
Little wrinkling or scarring	Early wrinkling; mild scarring	Persistent wrinkling or moderate acne scarring	Wrinkling: photoaging, gravitational, and dynamic
No keratoses	Sallow color with early actinic keratoses	Discoloration with telangiectasias and actinic keratosis	Actinic keratoses with or without skin cancer or acne scars
28–35 years	35–50 years	50–65 years	60–75 years

Therapeutic Indications

Several aesthetic and therapeutic indications exist for chemical peels and resurfacing ( Box 23.1 ), and today's facial plastic surgeon must be aware of these to effectively rejuvenate aging skin. In addition, treating a patient based on his or her Fitzpatrick skin type and Glogau aging characteristics is essential to select the best type and depth of facial resurfacing.

Box 23.1

Data from McCollough EG, Hillman RA Jr: Symposium on the aging face. Otolaryngol Clin North Am. 13:353, 1980; Farber GA, Collins PS, Scott MW: Update on chemical peel. J Dermatol Surg Oncol. 10:559, 1984; and Litton C, Sachowicz EH, Trinidad GP: Present day status of the chemical face peel. Aesthetic Plast Surg 10:1, 1986.

Indications for Facial Resurfacing

Aesthetic

Fine facial rhytids
Atrophic changes in skin caused by excessive sun exposure
Spotty or splotchy hyperpigmentation
Multiple actinic and solar keratoses
Superficial acne scarring
Melasma
Excessively wrinkled skin
After blepharoplasty or facelift

Therapeutic

Multiple actinic, seborrheic, and solar pigmented keratoses
Superficial basal cell carcinomas
Lentigo maligna lentigenes
Melasma (discoloration of skin caused by pregnancy)

Contraindications

A few relative contraindications to chemical peels exist in addition to some absolute contraindications ( Box 23.2 ). In the past, a history of herpes simplex virus was a contraindication to chemical peel. However, with the advent of antiviral drugs, acyclovir or valacyclovir can be effectively used as a preventive or therapeutic intervention. Telangiectasias are relative contraindications in that they become more apparent after chemical peels or laser resurfacing. Confirmed malignant lesions should not be treated with chemical peels, unless they are very superficial basal cell carcinomas. Nevoid or nevus lesions may become darker or actually stimulated to grow, and port wine stains, hemangiomas, and neurofibromatoses are not effectively treated with chemical peels. Contraindications include the presence of hepatorenal disease or cardiac disease (for phenol peels) unless approved by an appropriate specialist. True documented allergies to an agent are obvious contraindications, and dressings should be latex free in sensitive patients. Patients who are unstable psychologically should not be treated with any resurfacing modality, particularly because the postoperative care may require intense patient involvement, education, and understanding.

Box 23.2

Brody's Contraindications to Chemical Peels

Relative

Darker skin type (Fitzpatrick IV, V, and VI)
Keloid formation by history
History of herpes infections
Cardiac abnormalities
History of previous facial irradiation
Marked quantity of vellus hair present
Unrealistic patient expectations
Physical inability to perform quality postoperative care
Telangiectasias
Anticipation of inadequate photoprotection because of job, vocation, or recreation

Absolute

Significant hepatorenal disease
Human immunodeficiency virus–positive patient
Significant immunosuppression (hypogammaglobulinemia)
Emotional instability or mental illness
Ehlers-Danlos syndrome
Scleroderma or collagen vascular diseases
Isotretinoin treatment within the previous 6–12 months

Chemical Peel Procedure

Patient Selection and Education

Patients who request rejuvenation of aging skin via chemical peels must have a realistic understanding of potential outcomes, limitations, and postoperative care. The preoperative consultation should include a discussion of the patient's expectations and motivation to participate in postoperative care. The patient must have a clear understanding of the postoperative discomfort, appearance, and care that will follow. He or she must understand that preexisting large pores will remain unchanged, and that telangiectasias may appear to be more prominent. Informed consent about the risks and benefits is essential. At the end of the consultation, high-quality photographic documentation is obtained and should be standardized using reproducible measures. Acne scarring is notoriously underdemonstrated or overdemonstrated, depending on the lighting or flash used; therefore the clinician should adjust the setup to accurately reflect the patient's true skin appearance; this is the only objective way that the surgeon can later determine whether satisfactory results have been achieved. Standard preoperative workup and medical clearance are obtained, depending on the patient's preexisting health status. If a phenol chemical peel is to be used, special attention must be given to cardiac, liver, and kidney function in the preoperative medical workup. Any impairment of liver or kidney function could slow the excretion of phenol and has the potential to increase the bloodstream concentration, which can lead to cardiac irregularities or even death.

Prepeel Preparations

Before any resurfacing procedure, steps must be taken to optimize the patient's final aesthetic outcome. The preoperative consultation is used to ensure that the patient is adequately prepared for the day of the chemical peel. Considerations such as a positive history of herpetic outbreaks should warrant appropriate prophylaxis. In all patients who are undergoing a medium or deep peel, with or without a preceding history of fever blisters, we have found that acyclovir at 800 mg 3 times per day starting the day before the peel and continuing until reepithelialization is complete is effective at preventing outbreaks.

To achieve optimal results, patients must adhere to a skin care regimen in both the preoperative and postoperative periods for a minimum of 2 weeks. Patients undergoing medium or deep chemical peels are best pretreated with tretinoin on a nightly basis starting 4 to 6 weeks before the peel, stopping 2 weeks prior to peel or laser. The use of retinoic acid before light or medium chemical peels, dermabrasion, or laser resurfacing speeds epidermal healing and enhances the effects of the procedure. Retinoic acid also increases the depth of a chemical peel by decreasing the thickness of the stratum corneum, and, therefore, it should NOT be used with a Baker peel to prevent complications from increasing depth. Its use is restricted during the postoperative period until reepithelialization is complete and maturation of the skin has occurred. This takes approximately 3 months.

In darker-skinned individuals (Fitzpatrick types IV and V), the use of 4% hydroquinone gel in the preoperative and postoperative periods may reduce the incidence of hyperpigmentation. It is also necessary to use hydroquinone when peeling for the treatment of pigmentary dyschromia (melasma) in patients of any skin type. Hydroquinone blocks the enzyme tyrosinase from developing melanin precursors for the production of new pigment in the epidermis during the healing phase. Ideally it should be used 4 to 6 weeks prior to chemical peel and stopped 1 to 2 weeks prior to chemical peel.

All patients undergoing medium to deep facial resurfacing procedures must minimize sun exposure in the postoperative period. This is even more important in patients taking estrogens and in those with preexisting pigmentary disturbances. Wearing sunblock with a sun protection factor (SPF) of 30 or greater is recommended during the first 9 to 12 months after a peel.

Decision on which type of resurfacing to use depends on each individual patient's degree of photoaging: pigmentary issues versus degree of rhytidosis. Different depths of peels or lasers are demonstrated in Table 23.3 .

TABLE 23.3

Resurfacing Techniques With Depth of Penetration

Classification	Resurfacing Technique	Typical Indications	Depth of Penetration
Medium	Phenol 88%–89%	Eyelids, pigmentary photoaging with mild rhytidosis	Papillary dermis to upper reticular dermis (0.45 mm)
Medium	TCA 35% + Jessner Erbium lasers	Pigmentary photoaging with mild rhytidosis	Papillary dermis to upper reticular dermis (0.45 mm)
Deep	Baker-Gordon Fractionated and ablative CO ₂ laser Dermabrasion	Pigmentary photoaging with moderate to severe rhytidosis	Midreticular dermis (0.6 mm)

TCA , Trichloroacetic acid.

Chemical Peel Agents

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