Medium-Depth Peels and Trichloroacetic Acid Blue Peel

Introduction

Medium-depth chemical peels remain very important and highly versatile tools for skin resurfacing and rejuvenation. Although newer laser technology has added to the arsenal of tools for skin resurfacing, these lasers are either cost-prohibitive for certain patients, not advisable for certain skin types, or, most importantly, not as flexible for the physicians who like to tailor their skin-resurfacing approach for each patient. When performed correctly, chemical peels can play an important role in cosmetic surgery and can be tailored to address most skin issues. Advanced chemical peel techniques can be used in combination with laser resurfacing, nonablative lasers, and surgical procedures to enhance the overall outcome for patients.

Indications for Medium-Depth Chemical Peels

Indications for light and deep peels will be covered in other chapters in this textbook. This chapter will focus on medium-depth peels. Knowledge of skin anatomy and where in the skin a particular skin pathology (wrinkles, lentigines, melasma, scars, actinic keratosis) exists is crucial to performing a safe and effective resurfacing procedure ( Table 5.1 ). If one resurfaces too superficially, the patient’s chief complaint may be missed. Conversely, resurfacing deeper than is required only increases the risk of complications and prolongs the recovery time.

Aging Skin (Intrinsic and Extrinsic)

Many complex changes are occurring in the skin that reflect both intrinsic and extrinsic aging. Starting around the age of 18 years, there is a natural decline in fibroblast function resulting in decreased collagen and elastin production, which is referred to as “intrinsic aging.” This reduction is on the order of approximately 1% per year starting at the age of 18 years. External factors such as ultraviolet radiation (UVR), high-energy visible light, and infrared light act on the skin to accelerate the aging process and is known as “extrinsic aging.” At the epidermal level, the normal cycling of the keratinocytes slows with age, but with extrinsic aging, the epidermis begins to show roughness, dyschromia, and keratinocyte atypia.

Patient Evaluation

Chapter 2 of this textbook covers patient evaluation in more depth. Some points worth reiterating are mentioned here. Of utmost importance is the proper selection of the resurfacing modality for the patient and the patient’s concerns and the proper preparation of the patient’s skin before and after skin resurfacing (see Chapter 3 ). Be sure to evaluate the patient for skin flaws and scars and to document skin imperfections at the time of consultation and to take high-quality before-and-after photographs for each procedure. Similarly, showing patients high-quality before-and-after photographs is extremely useful and allows the patient to gauge whether this treatment is giving the amount of improvement they seek. Showing photographs also helps the physician to identify patients with unrealistic expectations.

Patient evaluation should include a thorough medical, social, and family history to identify any possible contraindication to skin resurfacing ( Table 5.2 ). Patients should be examined with no makeup on in a well-lit room. Acne scar patients should be examined with indirect overhead light to allow shadows to be cast on the skin to better delineate scar morphology. Skin conditions that can Koebnerize to areas that are resurfaced should be identified as well (i.e., flat warts, vitiligo, psoriasis) ( Fig. 5.1 ).

Patients being treated for melasma should be questioned about the use of hormone intrauterine devices (IUDs), hormone cervical rings, or oral contraceptives. The use of hormone contraceptives will continue to stimulate the melasma and may lead to treatment failure or worsening of the condition.

Considerations in Medium-Depth Skin Resurfacing

Chapter 2 offers a more detailed discussion on contraindications for skin resurfacing. The beauty of a properly performed chemical peel is that with the correct patient skin preparation and proper peel depth penetration, patients of most skin types can be treated. Furthermore, areas that are usually not amenable to laser resurfacing can be safely peeled with the proper chemical peel ( Table 5.3 ), allowing for safe combination resurfacing in one sitting to give overall rejuvenation with no lines of demarcation. Similarly, with the proper skin preconditioning, patients of most ethnicities can be treated. Patients with darker complexions still remain at higher risk for temporary postinflammatory hyperpigmentation (PIH) with any peel and permanent hypopigmentation with peels that reach the reticular dermis. The risk of PIH in a darker-skinned patient can be reduced by extending the length of skin preconditioning to 3 months rather than the usual 6 weeks. Thus, although the risk of PIH is not a contraindication to resurfacing, it should be anticipated and addressed before resurfacing.

Medium-depth and deep peels require a healthy nutritional status and well-functioning immune system for uneventful wound healing. Patients who have undergone bariatric surgery often are deficient in vital nutrients, iron, and protein. Blood laboratory tests can help identify issues. Transplant patients or those on medications for autoimmune diseases are functionally immunologically impaired, putting them at risk for infection. These patients may require coverage with an oral antibiotic during the healing period (penicillin, cephalosporin, or trimethoprim/sulfamethoxazole).

Recent oral retinoid use was once considered an absolute contraindication for skin resurfacing due to concerns of increased hypertrophic scar formation in these patients. Many recent studies and case series have shown that this concern may not be valid. Patients having laser hair removal, laser skin resurfacing, or medium-depth peels in these studies did not demonstrate increased adverse outcomes. Although these studies may be small, they do show the complexities associated with keloid formation, and they challenge the conventional thinking that isotretinoin impairs wound healing. As described in Chapter 12 , the author uses isotretinoin during the recovery phase if indicated to control oiliness and inflammation, but the same author does wait 6 months out from isotretinoin treatment before performing a deep peel. For medium-depth peels, it may be prudent to stop isotretinoin 3 to 4 months before the peel. If a patient has an inflammatory condition such as acne or rosacea, oral antiinflammatory antibiotics (doxycycline) can be used temporarily.

The timing of skin resurfacing with surgical procedures is important, because patients like the idea of maximizing their treatments and reducing the amount of time they have to take off from work or daily activities. Studies have shown the safety of skin resurfacing with browlifts, blepharoplasties, and rhytidectomies. Care has to be taken to minimize the depth of resurfacing over flaps (basal layer or papillary dermis level peel) and kept away from incisions, whereas the peel or laser resurfacing can be deeper over the central face (nonundermined skin).

As with any elective procedure, the absolute contraindications to resurfacing include pregnancy, active infection at the treatment site, significant tendency to develop keloids, and the inability to adhere to postoperative instructions.

Medium-Depth Skin Resurfacing