Cosmetic Facial Surgery

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
483
FIGURE 11-94.  Unfavorable earlobe scars can be improved by laser resurfacing. Several passes of high-fluence/high-density
laser are performed.
A
B
C
FIGURE 11-95.  A prereduction photo (A), an unfavorable scar (B), and the same lobe after laser resurfacing (C).
A
B
C
FIGURE 11-96.  A prereduction photo (A), an unfavorable scar (B), and the same lobe after laser resurfacing (C).

484
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-97.  Patient’s lobe has been reduced by inferior resection.
Figures 11-97 to 11-102 illustrate before-and-after cases of
earlobe reduction by the aforementioned techniques.
Repair of Torn Earlobes
Torn earlobes are a very common presentation in the cosmetic
surgery practice. This can result from gradual stretching from
heavy earrings or from trauma by tearing the lobe. Accidental
earring hole tears can occur from catching the earring on sweat-
ers, hair brushes, towels, and phone cords. Another category
that is working its way into the fabric of our society is body
piercing and deformation (Figure 11-103). This will be a very
commonly requested repair that older practitioners have not
experienced. Other traumatic tears include children pulling on
the earring or assault. Earlobe tears can be partial, complete,
and multiple (Figure 11-104). They may present immediately
after the trauma or more commonly, years later. Regardless of
the cause of the tear, the treatment is consistent and includes
excising the scar with primary closure. Many techniques include
direct suturing, Z-plasty techniques, and purse-string sutur-
ing.37-40 I most commonly utilize a simple scar excision and
primary closure technique.
Earlobe repair is performed with local anesthesia and takes
about 15 minutes per tear. For incomplete tears that are in the
middle two-thirds of the lobe, simple excision of the fistula and
primary closure is performed. The scar is excised by means of
an elliptical incision on both surfaces of the lobe. Securing the
inferior lobe with a skin hook will stabilize the mobile lobe and
provide skin tension for easier incision (Figure 11-105).
The earlobe is a fleshy appendage and can be difficult to
incise with a scalpel. For this reason, a pressureless incision
modality such as radiowave microneedle or laser can be useful.
When using a scalpel, the ear can be stabilized with a chalazion
clamp, which also will provide compression hemostasis (Figure
11-106).
The anterior and posterior surfaces of the fistula are incised
and the scar excised. Pinching the lobe will raise the fistula,
making it easier to excise (Figure 11-107). The scar can also be
removed by using a round or elliptical biopsy punch. Placing a
tongue blade on the posterior surface of the lobe will stabilize
the lobe when using the punch (Figure 11-108).
A caveat of closing the excision site is to not elongate the
lobe. This is especially problematic if a round punch or excision
pattern is used. When a round hole is closed, it can produce
elongation and thus a cosmetic deformity of the lobe, as pic-
tured in Figure 11-109.
Even an elliptical incision can cause lengthening of the lobe,
and this symmetry must be kept in mind. When the lobe is
approximated, the surgeon must make sure that it is not elon-
gated. By offsetting the sutures during closure, the lobe length
can be controlled (Figures 11-110 and 11-111). Figure 11-112
shows the final closures.
In planning excision of an incomplete tear, its size and posi-
tion must be considered. If the elongated hole sits in the upper
two-thirds of the lobe, it can be primarily excised without
deforming the lobe. If the elongated hole lies on the inferior
third of the lobe, it is preferable to convert the hole to a full
cleft by violating the inferior border of the lobe (Figure 11-113).
Complete lobe tears are also very common and are similarly
repaired by excising the V-shaped region of scar between the
tear. The scar tissue can be excised with a scalpel (Figure 11-114)
or radiowave microneedle (Figure 11-115).
One of the most important steps is to make sure that the
incision at the inferior border of the lobe is perfectly straight
and not rounded or jagged. If the incision is not straight and
flat, obvious deformities can exist. Insuring two flat surfaces that
meet edge to edge will assist in a smooth and contiguous inferior
border. The inferior border of the earlobe can contract during
Text continued on page 492.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
485
A
B
FIGURE 11-98.  Patient was treated with earlobe reduction by triangular excision and closure.
A
B
FIGURE 11-99.  Patient was treated for earlobe excess (megalobe) with triangular wedge excision.

486
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
D
FIGURE 11-100.  Patient was treated for megalobe with inferior border excision.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
487
A
B
FIGURE 11-101.  Patient with lobe excess was treated with triangular wedge excision.
A
B
FIGURE 11-102.  Patient with significant megalobe was treated with a large triangular wedge excision.

FIGURE 11-103.  Body piercing, dilation, and deformation procedures are presenting unique reconstruction conundrums for
contemporary surgeons.
A
B
C
D
FIGURE 11-104.  Common earlobe tears. A, An incomplete tear. B, A near complete tear. C, A single complete tear. D, Multiple
complete tears.
488

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
489
A
B
FIGURE 11-105.  Incision of the mobile earlobe is facilitated by securing the inferior border with a skin hook. This also places
tension on the skin, making incision easier.
FIGURE 11-106.  A chalazion clamp conveniently stabilizes the mobile lobe
and assists in hemostasis.
FIGURE 11-107.  Pinching the lobe after making both incisions will elevate
the scar tissue, facilitating removal.

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
FIGURE 11-108.  A round or elliptical biopsy punch is an alternate means of excising the scar for incomplete lobe tears. A, The
elongated hole. B, An elliptical punch removing the scar. C, The sutured incision.
FIGURE 11-109.  How closing a round hole in the earlobe can elongate the lobe.
A
B
FIGURE 11-110.  A, An elliptical repair that would elongate if closed. B, Offset marks to control the lobe shape by lifting the
inferior portion of the incision, thus rounding the lobe.

A
B
FIGURE 11-111.  A, The first key suture to reposition the incision superiorly. B, The final closure. (Although the lobe still looks
somewhat elongated, this will resolve by healing contraction.)
A
B
FIGURE 11-112.  Anterior and posterior incision closure with 6-0 fast-absorbing gut suture.
A
B
C
FIGURE 11-113.  A low partial lobe tear that is too low to repair without violating the inferior lobe border. To attempt to treat
without excising the lobe border would distort the lobe. A, The low-positioned partial tear. B, The partial tear converted to a
full cleft. C, The repair with excised scar tissue shown.

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-114.  Scar tissue of a torn earlobe being excised with a scalpel.
A
B
C
FIGURE 11-115.  A typical earlobe repair using a radiowave microneedle. A, The incision. B, Lobe with the scar excised. C, The
repair.
healing and leave a noticeable notch; proper alignment can
prevent notching. Slightly everting the inferior lobe border can
also help prevent notching and using a single horizontal mat-
tress suture at the base of the lobe can enable wound eversion.
It is also important to incorporate enough of the normal lobe
to obtain accurate approximation. Failure to do this can affect
the shape of the lobe (Figures 11-116 and 11-117).
After the scar is excised, the radiowave ball electrode is used
to cauterize any active bleeding, and one or two subcutaneous
sutures are placed to strengthen the wound and prevent dead
space (Figure 11-118).
It is important to precisely align the inferior border in a
similar manner as repairing a lip laceration where the vermilion
must be aligned. The inferior incision edges are carefully aligned
with a “key” suture and inspected for proper alignment (Figure
11-119). If the alignment is not satisfactory, the suture is
removed and replaced. Remember that the incision will never
look any better than when it is closed, so proper alignment is a
requisite. Some surgeons prefer to make a geometric “tongue-
and-groove” configuration to ensure alignment, but I have
found this unnecessary.
The final suturing is completed with interrupted 6-0 nylon
or fast-absorbing gut suture. Either running or interrupted
sutures can be used, but I prefer interrupted sutures because
tension and position can be more easily adjusted. Figure 11-120
shows a congenital earlobe cleft repaired in the described manner.
With the increased popularity of body piercing, multiple
earlobe tears are common. Because of the vascularity of the lobe,
several tears can generally be repaired simultaneously. In cases
where multiple tears exist with very thin islands of normal skin,

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
493
A
B
FIGURE 11-116.  The yellow lines indicate the absolute straight-line incisions that must be made to ensure proper shape of the
lobe. A rounded edge or uneven border will prevent proper approximation.
A
B
C
FIGURE 11-117.  A, Earlobe tear was repaired and sutured, but the inferior lobe was misshapen. B, By removing additional tissue
(yellow lines) to ensure a flat and even interface, the lobe was restored to a normal shape and border (C).
the procedure can be staged to preserve tissue vitality. Figures
11-121 to 11-124 illustrate cases of multiple earlobe tears with
simultaneous repair.
Simultaneous Earlobe Repair
and Piercing
Earrings are habitual and loved by many patients to the point
where they do not want to be without them. Offering the option
of immediate ear piercing with repair is very popular with
patients.37,38 Basically, this is a very simple task and involves
placing an ear-piercing stud through the incision between
stitches. A piercing stud is used because it is pointed, longer, is
usually hypoallergenic, and has smooth surfaces (Figure 11-125).
Although I have used the patient’s own earrings, sometimes the
post is too short to accommodate postoperative edema, and
pressure necrosis can ensue. A potential negative aspect of
simultaneous repair and piercing is that it is more difficult to
choose the most desirable point of placement for the earring.
The repair proceeds as previously described, and at the end
of the procedure, a specialized piercing earring is placed through
the ear between the sutures. One caveat is to make sure the shaft
of the earring is perpendicular to the long axis of the earlobe
and not slanted or tilted (Figure 11-126). If the earring is
slanted, future earrings will not sit correctly.
For delayed ear piercing, the patient is allowed to heal for 1
month, at which time the repair is strong enough to be pierced
and support light earrings. The patient is handed a mirror and
decides the exact position of the new earring holes. These can
be measured with a caliper to confirm symmetry. Local anesthe-
sia is injected into the lobe with a 32-gauge needle, and an
18-gauge needle is used to pierce the earlobe (Figure 11-127).
The earrings are then placed after coating the stem with
Text continued on page 497.

494
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
FIGURE 11-118.  Subcutaneous 5-0 gut sutures strengthen the repair and prevent dead space.
A
B
FIGURE 11-119.  A “key” suture is placed on the inferior lobe margin and serves to align the incision edges. Failure to properly
align the most inferior margin can significantly affect the result.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
495
A
B
FIGURE 11-120.  Patient with a congenital earlobe cleft that was treated in the same manner as a torn earlobe.
A
B
FIGURE 11-121.  A, An earlobe with two tears. B, The first scar incision with a radiowave microneedle.
A
B
C
FIGURE 11-122.  The incisions (A), the excisions (B), and the final 6-0 fast-absorbing gut suture (C).

A
B
C
D
FIGURE 11-123.  Patient is shown before and after dual ear lobe tears. The procedure was staged where the outside tears were
repaired first (A–B) and on a second appointment, the final tear was closed and the lobe immediately pierced (C–D).
A
B
FIGURE 11-124.  Patient treated for two tears on the earlobe.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
497
FIGURE 11-125.  A specialized piercing stud is placed between the sutures
to allow the patient to heal with an earring in place.
A
B
FIGURE 11-126.  Correct horizontal placement is imperative for earring aes-
thetics. A, A slanted immediate piercing will prevent proper earring posture
when healed. B, Proper placement of the immediate piercing, which is
horizontal to the long axis of the lobe. Placing an everting horizontal mat-
tress suture at the lobe base can prevent or reduce notching in many
cases.
FIGURE 11-127.  Local anesthesia and an 18-gauge needle placed at true
horizontal is used for delayed ear piercing.
triple-antibiotic ointment. Piercing studs are preferable, but
conventional earrings are frequently used as well. The patient is
instructed to twist the earring several times a day to encourage
fistulization. After 1 month, the earrings can be removed and
normal earring wear resumed.
Simple, inexpensive, and expedient automated piercing
devices are available (Delasco Inc., Council Bluffs, IA) (Figure
11-128). Figures 11-129 and 11-130 show a case of immediate
earlobe repair and piercing.
Complications
Complications with earlobe repair are infrequent and are usually
present as a suboptimal aesthetic result. Hematoma, wound
dehiscence, inferior notching, and electrosurgery char tattoo are
problems I have personally witnessed over the past 20 years of
treating torn lobes.
One common problem that can occur with earlobe repair is
inferior notching. Close detail to tissue alignment can reduce
this, but the area is notorious for notching. Placing an everting
horizontal mattress suture at the lobe base can prevent or reduce
notching in many cases. When this does occur, the prominence
can be reduced with a radiowave ball electrode or CO2 laser.
Figure 11-131 shows a notched earlobe recontoured with a
radiowave ball electrode and Figure 11-132 shows a before-and-
after image of the procedure.
Although rare, wound dehiscence can occur (Figure 11-133).
This is usually from overactivity on the part of the patient, such
as sleeping on the repaired side, pullover clothes, helmets, and
the like. In the case of wound opening, the area is kept clean
and reclosed after healing. In some cases, the use of dissolvable
sutures can lead to dehiscence, so some surgeons prefer nylon
sutures.
The earlobe is extremely vascular, and if attention is not paid
to intraoperative hemostasis, the ear can bleed for an extended
period of time. The patient in Figure 11-134 presented on the
second postoperative day with a history of bleeding since the
surgery. The sutures were removed, and the source was
cauterized.

498
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-128.  Single-use ear-piercing devices are simple and cost effective and facilitate delayed ear piercing.
A
B
C
FIGURE 11-129.  Patient underwent immediate earlobe repair and simultaneous piercing.
A
B
C
FIGURE 11-130.  Another case of immediate earlobe repair and immediate piercing.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
499
A
B
C
FIGURE 11-131.  This earlobe healed with a visible notch, which was smoothed by reducing the prominence with a radiowave
ball electrode.
A
B
FIGURE 11-132.  Patient sustained a notched lobe after repair (A) and is shown after radiowave recontouring to decrease the
notch (B).
FIGURE 11-133.  Patient developed wound dehiscence 6 days after the
procedure. The wound was cleaned with hydrogen peroxide and triple-
antibiotic ointment and reclosed at a later date with permanent suture.
FIGURE 11-134.  Attention to hemostasis is imperative on the vascular
earlobe to prevent bleeding and hematoma.

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
Postoperative infection is extremely rare; I have only ever
seen a single case (Figure 11-135). Incision and drainage with
systemic antibiotics will clear up these small infections.
As mentioned earlier, one of the reasons dedicated piercing
posts are used with simultaneous repair and piercing is that they
are longer, and the earring won’t cause pressure necrosis second-
ary to edema (Figure 11-136). In addition, piercing posts are
pointed to easily pass through tissue and have smooth surface
areas to promote healing.
Clinical Results
Figures 11-137 to 11-148 illustrate before-and-after cases of
earlobe repair.
Treatment of Earlobe Keloids
Any trauma to the earlobes can cause keloids of the earlobes:
earring piercing, sebaceous cysts, surgical procedures, and burns,
to name a few. These benign tumors are bothersome from aes-
thetic, social, and functional standpoints and have a high recur-
rence rate.
Historically, earlobe keloids have been treated with numer-
ous surgical and nonsurgical modalities, including direct exci-
sion, laser reduction, injection of steroids and chemotherapeutic
agents, pressure, and therapeutic radiation.41-59 The biggest
conundrum for the surgeon is the high rate of recurrence and
the fact that any interventional therapy has the potential to
make the condition worse.
Keloids are different from hypertrophic scars. In the case of
a hypertrophic scar, the lesion does not exceed the boundaries
of the original. Keloid scars, on the other hand, can proliferate
well outside the boundaries of the original scar or lesion to the
point of gross disfigurement. Hypertrophic scars usually develop
about 30 days after insult, whereas keloids appear around 90
days but can be delayed for years. In addition to their physical
unattractiveness, they are socially embarrassing and also can be
painful, itch, and become secondarily infected. Hypertrophic
scars and keloids exclusively develop in humans, with the same
prevalence in males and females and the highest incidence in
the second decade. The keloid is seen in individuals of all races,
A
B
FIGURE 11-135.  Patient presented at 1 week after lobe repair with a purulent infection. The lobe was incised and drained and
the patient placed on cephalosporin, with fast healing.
FIGURE 11-136.  Patient insisted on using her normal earrings for immediate
piercing and sustained pressure necrosis secondary to postoperative
edema.
Text continued on page 506.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
501
A
B
C
FIGURE 11-137.  Partial lobe tear (A) was treated with direct scalpel excision (B) and is shown 90 days postoperatively (C).
A
B
FIGURE 11-138.  Partial lobe tear is shown before (A) and 90 days after repair (B).
A
B
FIGURE 11-139.  Low partial tear (A) was converted to a complete cleft and is shown 90 days post repair (B).

502
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-140.  Low partial tear (A) was converted to a complete cleft and is shown 90 days post repair (B).
A
B
FIGURE 11-141.  Full lobe tear was treated by scar excision and is shown before (A) and after (B) repair with delayed piercing.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
503
A
B
FIGURE 11-142.  Full-thickness earlobe tear before (A) and 4 months after (B) primary repair.
A
B
FIGURE 11-143.  Full-thickness earlobe tear before (A) and 3 months after (B) primary repair.

A
B
C
FIGURE 11-144.  Full-thickness earlobe tear shown before (A) and 3 months after (B) primary repair. C, A small notch is present
postoperatively, but the patient did not desire correction.
A
B
FIGURE 11-145.  Full-thickness earlobe tear shown before (A) and 3 months after (B) primary repair. The scar is slightly depressed
and was treated later with silicone oil injection to plump the lobe.
A
B
FIGURE 11-146.  Full-thickness earlobe tear shown before (A) and 3 months after (B) primary repair.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
505
A
B
FIGURE 11-147.  Full-thickness earlobe tear before (A) and 3 months after (B) primary repair. There is a slight scar present, but
the patient was satisfied and declined laser resurfacing to improve it.
A
B
FIGURE 11-148.  Full-thickness dual tear before (A) and 4 months after (B) excision and repair.

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
but black, Hispanic, and Asian people have proved to be more
susceptible. The anterior chest, shoulders, earlobes, upper arms,
and cheeks have a higher predilection for keloid formation,
whereas eyelids, genitals, and even the umbilical cord are less
affected.41
Surgical excision carries a 60% chance of recurrence and
appears not to differ between laser or cold steel. Combination
therapies such as excision and radiation or excision and intral-
esional injection have lower recurrence rates.41
Treatment Options
The most common presentation of keloids in my practice
is earlobes. Some of these patients have never been treated,
but a good percentage of them have undergone multiple
procedures.
My first line of therapy is intralesional triamcinolone 40 mg/
mL injection (Figure 11-149). Since this can be painful, the
keloid is first injected with local anesthesia, and then the entire
lesion is injected with up to 1 mL of the steroid per side. It is
important to deposit the steroid deep into the lesion and
attempt to treat all involved keloid tissue. These patients are
injected at 1-month intervals. For smaller keloids, I have been
successful in their resolution with this method alone. For resis-
tant patients, 0.1 mL of triamcinolone 40 mg/mL is mixed with
0.9% of 5 fluorouracil (5-FU) 50 mg/mL (see Figure 11-149).
This is injected in the same manner at monthly intervals and
has proven effective in lesions resistant to steroid alone. Although
some practitioners recommend pure 5-FU59 without steroid,
this has proven less successful for me. The 5-FU can cause local
tissue necrosis, and the patient must be aware of this. The lesions
will gradually shrink and become dark like a raisin (Figure
11-150). Since the steroid is particulate, I use a 12-inch 25-gauge
needle (smaller needles will clog). It is also important to thor-
oughly shake the solution before injecting, because the particles
will separate out and encourage needle clogging.
After 3 to 4 months of injections, if there is no significant
resolution of keloid size, I will consider surgical options. My
most successful regimen has been surgical excision followed by
an immediate single dose of radiation (Figure 11-151). The
radiation dose is 10 Gy in a single fraction with high energy
electrons. The surrounding skin is protected with lead shielding
covered with dental wax on the surface of the lead to prevent
scatter (Figure 11-152). Although my treatment numbers are
small (10 or 12 patients) only a single patient has had any recur-
rence. This patient had a 3-mm nodule return, which responded
well to intralesional injection and reduction with radiowave
surgery loop electrode.
Although the excision/radiation protocol has been successful,
this is beyond some patients without insurance coverage for
radiation fees or those who fear treatment with radiation. For
these patients, I perform the usual triamcinolone injections for
A
B
FIGURE 11-149.  A combination of 5 FU and Triamcinolone is used to reduce keloids (A). The mixture is injected into the keloid
with a 25-gauge needle (B).
FIGURE 11-150.  A postinjection keloid (A) is shown after several injection
sessions of 5 FU and Triamcinolone (B).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
507
A
B
C
D
FIGURE 11-151.  The keloid (A) and the initial skin incision (B). The keloid being undermined with dissection scissors (C) and
the shelled out lesion (D).
Continued

508
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
E
F
G
H
I
J
The excised keloid (E) and the postexcision surgical field (F).The excision of the involved anterior skin
(G) and the final closure with 6-0 nylon suture (H). The intraoperative steroid injection (I) and the anterior skin closure (J).
FIGURE 11-151, cont’d

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
509
A
B
FIGURE 11-152.  A, An immediate postsurgical keloid patient in the radiation suite with the device in position. B, A view looking
down through the treatment device to the radiation field shows the protective lead shield in place to protect the nonradiated
regions.
A
B
FIGURE 11-153.  Pedunculated lesions (A) are simpler to remove; the stalk is severed and remnant keloid tissue is excised at
the base (B).
3 to 4 months and then perform surgical excision. Steroid is
injected immediately after closure and monthly for several
months. Although I don’t have statistical backing, anecdotally
this has also been successful.
For pedunculated lesions, the stalk of the lesion is, severed
and any remnant keloid tissue is excised (Figure 11-153).
For broad-based lesions, surgical treatment is performed
similarly with local anesthesia, and the lesion is degloved, with
the goal of removing as much abnormal tissue as possible and
leaving as much normal skin as possible (Figure 11-154). Some
keloids “shell out” of the skin, but most are very locally invasive,
and it is sometimes impossible to remove all involved tissue.
Skin closure is also very important. Any source of inflammation
can trigger keloid growth. For this reason, it is important to not
close the wounds under tension and not use dissolvable sutures,
which require an inflammatory response to dissolve. At the end
of closure, a needle is inserted beneath the sutures, and the
surgical wound is irrigated with 1 mL of triamcinolone 40 mg/
mL. These patients are then seen monthly for several months
for continued injections.
Although not an earlobe keloid, Figure 11-155 shows
a case of large facial keloids secondary to a previous procedure

A
B
C
D
F
E
510

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
511
FIGURE 11-154.  A, A large broad-based keloid that involves both surfaces of the lobe. B, Lesion being shelled out with a
curette. C, Keloid mass being undermined with scissors. D, Surgical specimen on a 4 × 4 gauze pad. E, Intraoperative steroid
injection. F, Final closure.
A
B
C
E
F
G
D
FIGURE 11-155.  Patient before (A and C) and 1 year after (B and D) bilateral facial keloid excision with immediate radiation.
E, The direct excision. F, The undermining of the wound margins. G, Skin hooks aligning the wound for closure.
Continued


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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
H
I
J
A
B
C
FIGURE 11-156.  Patient experienced wound breakdown after keloid excision with immediate radiation. A, Operative site imme-
diately after surgery. B, The wound 14 days later. C, 6 weeks after wound care.
H, The final closure. I, The immediate steroid lavage. J, Steri-Strip reinforcement of the wound to
decrease tension during healing. The patient proceeded directly to the hospital radiation facility single fraction treatment.
FIGURE 11-155, cont’d
at another office. The patient was treated with excision
and immediate radiation and has been keloid free for over
a year.
Postradiation problems have been rare. I have experienced a
single case of wound breakdown. The exact cause remains
unknown and could have been from a combination of a thin
skin flap and concomitant radiation (Figure 11-156).
Figures 11-157 to 11-162 show before-and-after cases
of keloid removal with various modalities, including steroid
injection only, excision only, and excision with radiation.
Conclusion
There are diverse means of correcting protruding ears, and I
have discussed two techniques that have proven safe, predict-
able, and stable in my practice and many others. This is by no
means the only way to correct these problems; numerous prac-
titioners utilize a plethora of surgical options to achieve accept-
able results. Otoplasty remains a procedure fueled by a
combination of art and science and can be very rewarding for
both surgeon and patient. Like any procedure, surgeons should

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
513
A
B
FIGURE 11-158.  Patient was treated with four intralesional injections of 0.1 mL triamcinolone 40 mg/mL mixed with 0.9 mL of
5-FU.
A
B
C
FIGURE 11-157.  Patient was treated with intralesional steroid injection and no surgery. A, Original keloid that resulted from a
high ear piercing. B, The lesion after one injection. C, Lesion almost resolved after the third injection.

514
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-159.  Keloid before (A) and after (B) several treatments of intralesional steroid injection.
B
A
FIGURE 11-160.  The very large earlobe keloid is shown before (A) and 1 year after direct excision followed by immediate
radiation (B).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
515
A
B
C
D
FIGURE 11-162.  A, Large keloid nodules from multiple
ear piercings. B, Lesions were excised without radia-
tion. The patient was followed for 4 months, with
monthly intralesional injection into the surgical scar.
This patient moved and was lost to follow-up; no long-
term result is available. C–D, Posterior view.
A
B
FIGURE 11-161.  Patient before (A) and after (B) direct excision with immediate postexcision radiation.

516
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
employ techniques that provide the best longevity with the most
sensible surgical approaches.
The sections on earlobe repair and keloid excision highlight
the need for cosmetic facial surgeons to be able to treat other
common cosmetic ear problems that routinely present to the
cosmetic-oriented practice.
References
  1. (accessed 4-6-09).
  2. Deiffenbach JF: Die operative chirurgie. Leipzig (FA): Brockhaus; 1845.
Cited by Tanzer RC. Deformities of the auricle. In Converse JM, editor:
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  3. Ely ET: An operation for prominence of the auricles. Arch Ophthalmol
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  4. Mustardé JC: The correction of prominent ears using simple mattress
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  7. Mustardé JC: The correction of different types of prominent ears. Aesthetic
Plast Surg 7(3):163–168, 1983.
  8. Furnas DW: Correction of prominent ears by concha-mastoid sutures. Plast
Reconstr Surg 42:189–193, 1968.
  9. Converse SM, Wood-Smith D: Corrective and reconstructive surgery in
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10. Tanzer RC: Congenital deformities. In Converse J, editor: Reconstructive
plastic surgery. Vol 4. 2nd ed. Philadelphia (PA), 1977, WB Saunders.
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neck. New York (NY), 1987, Churchill Livingston.
13. Davis JE: Aesthetics and reconstructive otoplasty. New York (NY), 1987,
Springer-Verlag, pp 77–87.
14. Owsley TG: Otoplastic surgery for the protruding ear. In Fonseca
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15. Janis JE, Rohrich RJ, Gutowski KA: Otoplasty. Plast Reconstr Surg
115(4):60e–72e, 2005 Apr.
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of surgical correction of prominent ear. Plast Reconstr Surg 123(3):889–
896, 2009 Mar.
17. Petersson RS, Friedman O: Current trends in otoplasty. Curr Opin
Otolaryngol Head Neck Surg 16(4):352–358, 2008 Aug.
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19. Qureshi TR, Hurren JS, Gourlay T: Can bipolar diathermy enhance scoring
in otoplasty? An ex vivo study. Plast Reconstr Surg 121(3):132e–133e,
2008 Mar.
20. Perez-Macias JM: The correction of concha-mastoid angle in otoplasty.
J Plast Reconstr Aesthet Surg 61(2):229, 2008.
21. Salgarello M, Gasperoni C, Montagnese A, Farallo E: Otoplasty for promi-
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22. (accessed 4-9-09)
23. www2.uchc.edu/~otomain/Powerpoint%20Presentations/Anatomy
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Embryology of the Ear. (accessed 4-9-09).
24. Wood-Jones F, I-Chuan W: Development of the external ear. J Anat
68:525, 1934.
25. Matsuo K, Hayashi R, Kiyono M, Hirose T, Netsu Y: Nonsurgical
correction of congenital auricular deformities. Clin Plast Surg 17:383,
1990.
26. Adamson JE, Horton CE, Crawford HH: The growth pattern of the exter-
nal ear. Plast Reconstr Surg 36:466, 1965.
27. Adamson PA, Strecker HD: Otoplasty techniques. Facial Plast Surg 11:284,
1995.
28. Farkas LG, Posnick JC, Hreczko TM: Anthropometric growth study of the
ear. Cleft Palate Craniofac J 29:324, 1992.
29. Balogh B, Millesi H: Are growth alterations a consequence of surgery for
prominent ears? Plast Reconstr Surg 89:623, 1992.
30. Gasques JA, Pereira de Godoy JM, Cruz EM: Psychosocial effects of oto-
plasty in children with prominent ears. Aesthetic Plast Surg 32(6):910–914,
2008 Nov.
31. Cooper-Hobson G, Jaffe W: The benefits of otoplasty for children: further
evidence to satisfy the modern NHS. J Plast Reconstr Aesthet Surg
62(2):190–194, 2009 Feb.
32. Gosain AK, Recinos RF: Otoplasty in children less than four years of age:
surgical technique. J Craniofac Surg 13(4):505–509, 2002 Jul.
33. Purcell EM, O’Neill AC, Regan PJ: A different type of ‘glue ear’: report of
an unusual case of prominent ears. Ear Nose Throat J 82(9):702–703, 2003
Sep.
34. Goals McDowell AJ: Goals in otoplasty for protruding ears. Plast Reconstr
Surg 41:17, 1968.
35. Tan ST, Abramson DL, MacDonald DM, Mulliken JB: Molding therapy
for infants with deformational auricular anomalies. Ann Plast Surg 38:263,
1997.
36. Tan ST, Shibu M, Gault DT: A splint for correction of congenital ear
deformities. Br J Plast Surg 47:575, 1994.
37. Niamtu J, 3rd: Eleven pearls for cosmetic earlobe repair. Dermatol Surg
28(2):180–185, 2002 Feb.
38. Niamtu J, 3rd: Surgical repair of the cleft earlobe. J Oral Maxillofac Surg
55(8):886–890, 1997 Aug.
39. Vujevich J, Goldberg LH, Obagi S: Repair of partial and complete
earlobe clefts: a review of 21 methods. J Drugs Dermatol 6(7):695–699,
2007 Jul.
40. Vujevich J, Obagi S: Repair of partial earlobe cleft using a “purse-string”
repair. Dermatol Surg 32(7):969–971, 2006 Jul.
41. Kim DY, Kim ES, Eo SR, Kim KS, Lee SY, Cho BH: A surgical approach
for earlobe keloid: keloid fillet flap. Plast Reconstr Surg 113(6):1668–1674,
2004 May.
42. Savion Y, Sela M, Sharon-Buller A: Pressure earring as an adjunct to surgical
removal of earlobe keloids. Dermatol Surg 35(3):490–492, 2009 Mar.
Epub 2009 Feb 22.
43. Hamrick M, Boswell W, Carney D: Successful treatment of earlobe keloids
in the pediatric population. J Pediatr Surg 44(1):286–288, 2009 Jan.
44. Akaishi S, Ogawa R, Hyakusoku H: Treatment of recurrent earlobe keloids
with surgery and high-dose-rate brachytherapy. Plast Reconstr Surg
123(1):424–425, 2009 Jan; author reply 425–426.
45. Morosolli AR, De Oliveira Moura Cardoso G, Murilo-Santos L, Niccoli-
Filho W: Surgical treatment of earlobe keloid with CO2 laser radiation: case
report and clinical standpoints. J Cosmet Laser Ther 10(4):226–230, 2008
Dec.
46. Savion Y, Sela M: Prefabricated pressure earring for earlobe keloids.
J Prosthet Dent 99(5):406–407, 2008 May.
47. Theopold C, Pritchard S, McGrouther DA, Bayat A: Keloid scar harbour-
ing malignant blue naevus emphasizes the need for excision biopsy and
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Epub 2008 Jan 9.
48. Arneja JS, Singh GB, Dolynchuk KN, Murray KA, Rozzelle AA, Jones KD:
Treatment of recurrent earlobe keloids with surgery and high-dose-rate
brachytherapy. Plast Reconstr Surg 121(1):95–99, 2008 Jan. No abstract
available.
49. Ogawa R, Miyashita T, Hyakusoku H, Akaishi S, Kuribayashi S, Tateno A:
Postoperative radiation protocol for keloids and hypertrophic scars: statisti-
cal analysis of 370 sites followed for over 18 months. Ann Plast Surg
59(6):688–691, 2007 Dec.
50. Ogawa R, Hyakusoku H, Akaishi S, Nomoto S, Ono S: Intraoperative
repiercing for earlobe keloid. Ann Plast Surg 59(3):354–355, 2007 Sep.
51. Narkwong L, Thirakhupt P: Postoperative radiotherapy with high dose rate
iridium 192 mould for prevention of earlobe keloids. J Med Assoc Thai
89(4):428–433, 2006 Apr.
52. Stashower ME: Successful treatment of earlobe keloids with imiquimod
after tangential shave excision. Dermatol Surg 32(3):380–386, 2006 Mar.
53. Yencha MW, Oberman JP: Combined therapy in the treatment of auricular
keloids. Ear Nose Throat J 85(2):93–94, 96–97, 2006 Feb.
54. Martin-García RF, Busquets AC: Postsurgical use of imiquimod 5% cream
in the prevention of earlobe keloid recurrences: results of an open-label,
pilot study. Dermatol Surg 31(11 Pt 1):1394–1398, 2005 Nov.
55. Meltzer DI: Complications of body piercing. Am Fam Physician
72(10):2029–2034, 2005 Nov 15. Review.
56. Fikrle T, Pizinger K: Cryosurgery in the treatment of earlobe keloids: report
of seven cases. Dermatol Surg 31(12):1728–1731, 2005 Dec.
57. Chang CH, Song JY, Park JH, Seo SW: The efficacy of magnetic disks for
the treatment of earlobe hypertrophic scar. Ann Plast Surg 54(5):566–569,
2005 May.
58. Vachiramon A, Bamber MA: A U-loop pressure clip for earlobe keloid.
J Prosthet Dent 92(4):389–391, 2004 Oct.
59. Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane A: Efficacy
of intralesional 5-fluorouracil and triamcinolone in the treatment of
keloids. Aesthet Surg J 29(1):40–46, 2009 Jan–Feb.

517
12 
Skin Resurfacing
C
osmetic facial surgery is a fast-moving profession, and
every once in a while, a technology enters the arena and
causes a paradigm shift. Laser resurfacing is one of
those technologies; it truly changed all the rules. Before laser
technology, skin resurfacing was limited to chemical peel and
dermabrasion. Dermabrasion has all but disappeared from cos-
metic surgery for several reasons. It is more an art than a science
and very technically sensitive. Also, it sprays a cloud of tissue
and blood around the operating suite, and with the increase of
bloodborne communicable diseases, it lost popularity.
Since I purchased my first laser in 1998, much has changed,
and many more choices and types of lasers are available. Unfor-
tunately, many of these technologies and devices have had
expectations that exceeded results. Fractional laser technology is
the current rage and like all laser technology promises increased
results with decreased recovery. To date, I have not been
impressed with any new technology displacing conventional
CO2 laser skin resurfacing. Although CO2 laser treatment
requires close to a 2-week recovery, one treatment erases decades
of aging. Naysayers make a 2-week recovery seem like a sin to
be avoided when fractional laser offers 4-day recovery, but frac-
tional laser requires repeating 4 to 5 times to obtain comparable
results. Not much of a “bargain” when compared to traditional
CO2 in my book. Extended erythema and the low possibility of
hypopigmentation are often cited as reasons not to use CO2
laser technology. These can be mitigated by not débriding
between laser passes and contemporary wound care.
Chemical peels have been employed for centuries in some
form, and the treatment which once was relegated to the lay
world has become a refined, scientifically based procedure. Like
laser treatment, chemical peels can be tailored from ultralight
to very aggressive. Although laserlike results can be obtained
from very aggressive deep phenol peels, these procedures are
very technically sensitive, and porcelain hypopigmentation and
significant medical problems (including death) can occur when
using phenol. Much more predictable and safer medium-depth
trichloroacetic acid peels have become popular and present a
viable treatment option for any skin type or color. Pigmentary
problems are reduced compared to laser skin resurfacing.
There can be no doubt that both laser technology and
chemical peels are useful and popular adjuncts in the contem-
porary cosmetic facial surgery practice. No single resurfacing
modality will suit all patients in all situations; peeling and laser
resurfacing are a powerful duo. When the skin is injured—
whether from a chemical agent, a light source, or an abrasive
instrument—the mechanism of wounding and healing are
similar, and many of the same tenets and techniques apply to
both peel and laser.
The Art of the Peel
Indications for a chemical peel include treating generalized skin
aging, fine lines and wrinkles, and dyschromias. Actinic kerato-
ses, solar lentigines, ephelides (freckles), shallow scars, and pre-
malignant lesions are common indications for chemical peel.
As with all procedures, it is important to not overpromote
the effects and to give the patient realistic expectations. The
peels discussed in this chapter will be light and medium depth.
Deep peels, although effective, carry too much liability and
unpredictability and should be reserved for practitioners with
expertise in that area.
Patient Selection
As with any cosmetic procedure, proper patient selection is the
key to obtaining ideal results. Lighter skin types have the poten-
tial for more predictable skin resurfacing and fewer problems
with hyper- and hypopigmentation. Although many skin clas-
sification systems exist, the Fitzpatrick system (Table 12-1) is
the most widely used. This system is derived from skin response
to sunlight.
Fair-skinned redheads are good representatives of a Fitzpat-
rick class 1; blue-eyed blondes, class 2; dark-haired, brown-eyed
patients, class 3; Asians, Hispanics, and light-skinned African
Americans, class 4; brown-skinned African Americans, class 5;
and very dark-skinned African Americans, class 6. There are very
few distinct boundaries, and overlap is frequent. Any skin
classification system offers broad commonalities, not sole
determinants.
Whereas the Fitzpatrick system is relatively straightforward,
looking at the larger picture of who we are and where we came
from intensifies our understanding of skin types. The Fanous
classification of skin type is based on racial origins (Figure 12-1)
and puts a logical understanding behind numbers.
In treating various skin types, novice surgeons should keep
in mind that the darker a patient’s skin is, the more potential
problems can exist with peel or laser, especially hyper- or
hypopigmentation (Figure 12-2). The very light skin types and
the darkest skin types are the most stable; the mixed browns are
the most problematic. Referred to as global skin, this type should
always be approached with caution when using peels and lasers.
The best patients for the novice resurfacing surgeon are Fitzpat-
rick 1 and 2 skin types. Type 3 and above should be reserved
for more experienced surgeons.
Author’s Note: I purposely chose to combine chemical peeling and laser resurfacing in the
same chapter, even though there is enough material to warrant two separate chapters. The
modalities are different, but much of the pretreatment, intraoperative, and posttreatment
parameters are similar, and combining them prevents duplication of much of the material
presented at the beginning of this chapter.

518
Chapter 12  •  Skin Resurfacing
epidermal cells migrate from the base of the pilosebaceous unit,
progress up the hair shaft, then spread laterally on the injured
skin surface (Figure 12-3). It stands to reason that areas of the
body that are heavily populated with pilosebaceous units have
a better chance of more rapid epithelialization. The face has 30
times the pilosebaceous units as the neck or chest and 40 times
the number on the dorsal arms and hands. For this reason,
deeper peeling and laser treatment can be performed on the face,
whereas the same treatment on the neck or extremities can lead
to disastrous scarring (Figure 12-4). In low hair-bearing areas,
the epithelial cells simply have too far to go, but areas heavily
populated with hair follicles heal faster.
My most sincere words to surgeons just beginning skin resur-
facing is to always, always respect the neck, and never treat it
in an aggressive manner, regardless of what others say, do, or
publish. I have served as an expert defense witness for several
surgeons who caused significant scarring by peeling or lasering
the neck. I have also had my own misadventures in this region
but luckily learned to respect the neck early on in my
experience.
Knowing the importance of pilosebaceous units and healing,
any procedure or medication that reduces or suppresses the
pilosebaceous units could affect the result and cause scarring.
Systemic retinoids such as isotretinoin (Accutane) work by
Resurfacing Contraindications
Numerous contraindications exist for both peel and laser resur-
facing. History of hypertrophic or keloid scar, poor healing, and
active conditions such as severe rosacea or acne may prohibit
skin resurfacing. Some skin diseases can spread to traumatized
skin (Koebner’s phenomenon): vitiligo, lichen planus, psoriasis,
and verrucae. Peel or laser resurfacing can induce this problem.
After the epithelium is destroyed by chemical agents or light
sources, it must regenerate, or a full-thickness burn scar can
result. Reepithelialization occurs from the base of the piloseba-
ceous units, and the presence of the hair/sebaceous gland unit
is directly related to how much and how quickly the new epi-
thelium regenerates. In a process known as epiboly, the pilose-
baceous units serve as the progenitors of new epithelium. New
Table 12-1  Fitzpatrick Skin Classification
Skin Type
Skin Color and Characteristics
1.  Ivory white
Always burns, never tans
2.  White
Usually burns, tans minimally
3.  White
Burns moderately, tans moderately
4.  Beige/light brown
Burns minimally, tans easily
N
E
M
I.P
AS
A
FIGURE 12-1.  Examining racial or ethnic origins best explains
skin color, eye color, hair color, and response to sun.  
A, African; AS, Asian; E, European; IP, Indo/Pakistani;
M, Mediterranean; N, Nordic.
A
B
FIGURE 12-2.  A, Asian patient with permanent hyperpigmentation from a burn. B, African American patient with permanent
hyperpigmented areas from acne scars. The possibility of permanent hyperpigmentation or hypopigmentation exists in global
skin.

Chapter 12  •  Skin Resurfacing
519
speeds healing, reduces postpeel pigmentation problems, and
improves treatment results.2 A solid prepeel skin conditioning
program also makes the patient take ownership of their care and
outcome. A motivated patient will be very compliant with
prepeel conditioning, and poorly motivated patients will be
weeded out. Patients who cannot tolerate the chapping, peeling,
and redness from Retin-A will not likely do well with a chemical
peel. Most important, however, is that prepeel conditioning
or “priming” will improve their experience and outcome. In
reality, all the patients in a cosmetic practice should be on
“eternal skin care” as it will make them younger, there is science
behind that.
Aging skin has decreased collagen in the dermis, increased
keratinocyte atypia, roughness, and dyspigmentation. The goal
of prepeel priming is to restore the skin to as normal as possible
before wounding it.3 Epidermal actions of Retin-A (tretinoin)
0.05% to 0.1% reverse many of these aging changes by normal-
izing keratinization, creating a thin and compact stratum
corneum, and improving epidermal dyspigmentation.3 In the
dermis, Retin-A will also increase collagen production (fibro-
blasts), increase glycosaminoglycans, and reduce solar elastosis.
Retin-A has better results when used at a higher percentage on
a nightly basis but is not a user-friendly drug. The inflamma-
tory stage of redness, burning, and chapping begins quickly
and peaks at 2 to 3 weeks, then slowly subsides. Patients typi-
cally will begin a regimen then quit when the inflammation
begins. They must understand that this is not only normal and
expected, it means positive things are occurring. When patients
complain of Retin-A dermatitis, I congratulate them and
tell them it is working. Many patients will start and stop and
never get through the inflammatory stage. It only works if
you use it. The epidermal and dermal changes from Retin-A
allow the chemical peel agent to penetrate deeper and more
homogenously.
Another critical drug for prepeel conditioning is hydroqui-
none 4%. This common bleaching agent inhibits melanocytic
production of melanin and can reduce postpeel hyperpigmenta-
tion problems. Hydroquinone is used twice a day in conjunc-
tion with Retin-A.
suppressing the pilosebaceous units, which would obviously
affect reepithelialization after skin resurfacing by peel or laser.
Most authorities recommend waiting at least 1 year after Accu-
tane therapy before resurfacing. Obagi1 has shown that a
6-month waiting period after Accutane therapy before chemical
peel is safe. Radiation therapy can also destroy pilosebaceous
units, and patients who have received therapeutic radiation can
be problematic healers.
Preresurfacing Skin Conditioning
Chemical peeling is not a procedure that someone just shows
up and does. It has been shown that prepeel skin conditioning
A
B
FIGURE 12-3.  Representation of the mechanism of reepithelialization. A, In
the midst of plentiful pilosebaceous units, epithelial cells don’t have to
travel far because numerous other follicles are regenerating new epithe-
lium. B, The opposite situation in which the scarcity of pilosebaceous units
makes reepithelialization more challenging.
A
B
C
FIGURE 12-4.  Areas of dense pilosebaceous units can be resurfaced. The neck in a heavily bearded male is much more forgiv-
ing because of the high density of pilosebaceous units. A, Male acne patient before resurfacing. B, Bearded neck, safely
treated and improved. C, Scarring and contracture in a female with low density of pilosebaceous units in the neck.

520
Chapter 12  •  Skin Resurfacing
in the epidermis and will respond well to medium-depth or even
superficial-depth chemical peels. If there are visible spots that
do not enhance under ultraviolet light, they reside in the deeper
dermis and are less likely to improve with a single medium-
depth peel.
Commercially available ultraviolet skin scanners are available
from most dermatologic suppliers. These devices have multiple
ultraviolet bulbs and a mirror for the patient to view the pig-
mentation (Figure 12-5). The other end of the device has a
viewing port for the observer (Figure 12-6). I have described a
means of using a common digital camera and imaging software
to reproduce the ultraviolet view for printout and viewing by
the patient4 (Figure 12-7). This not only serves as motivation
for the patient to begin skin care or have a peel, it also gives the
surgeon an idea about the depth of the pigment and the response
of the proposed peel. By making pretreatment and postpeel
For patients who cannot or will not tolerate the typical
Retin-A/hydroquinone regimen, Triluma (Gladerma Laborato-
ries, Fort Worth, TX) is a combination medication containing
tretinoin 0.05%, hydroquinone 4%, and a mild pediatric
steroid, fluocinolone acetonide 0.01%. The steroid reduces
inflammation and although not as clinically effective as straight
Retin-A/hydroquinone, this agent is superior to no prepeel
conditioning.
The third component of prepeel priming is judicious use of
sunscreen, which helps limit production of melanin.
The optimal time for prepeel conditioning is 4 to 6 weeks,
the duration of an epidermal skin cycle where the keratinocyte
matures from the basal layer up through the stratum corneum.
Patients must understand that it takes several skin cycles to see
clinically significant results (smoother skin and lightening of
dyschromias) when used as a skincare regimen. Although prepeel
conditioning is important for all resurfacing patients, it is espe-
cially critical for the darker Fitzpatrick skin types, in whom
postpeel hyperpigmentation problems are much more common.
When planning chemical peeling on Asian, Hispanic, and
African American skin, I prefer a conditioning time of 8 to
12 weeks.
It is important for patients to understand what their chemi-
cal peel will and will not do. The safest and most predictable
type of peel is a medium-depth chemical peel that will wound
the skin (depending upon concentration and technique) to the
level of the papillary dermis or upper reticular dermis. Although
many types of peeling agents are commonly used, I prefer tri-
chloroacetic acid (TCA). In Caucasian patients, I use 30%
TCA, and in darker skin types, I use 15% to 20% and fre-
quently the Obagi Blue Peel proprietary system (Obagi Medical,
Long Beach, California). These techniques will be discussed in
detail later in the chapter.
In my experience, a medium-depth chemical peel will
improve fine lines, wrinkles, and minor scars, tighten the skin,
smooth the skin texture, and improve epidermal and superficial
dermal dyschromias. The degree of skin tightening is minor to
moderate and does not rival that of deep peels (complicated and
more unpredictable procedures) or aggressive laser skin resurfac-
ing. Patients who expect facelift or laser-quality skin tightening
or wrinkle and scar reduction will be disappointed with a
medium-depth chemical peel. Having said this, peels can be
repeated in 90 days, and the cumulative improvement can be
significant. All patients are good medium-depth TCA peel can-
didates. The rapid wounding and turnover of skin reduces the
buildup of aged skin and pigment, but the depth of the pigment
and the peel are directly related to the outcome. Superficial
epidermal pigment is likely to significantly improve with
medium-depth TCA peels, whereas deeper dermal pigment is
more resistant or sometimes impossible to eradicate. A simple
and very effective means of determining the estimated depth of
pigment is the use of ultraviolet light.4 Whether using a common
Wood’s lamp, ultraviolet lamps available at party stores, or a
dedicated skin scanner, the surgeon and patient can visualize the
degree and depth of facial skin pigmentation. Ultraviolet light
enhances epidermal melanin. If a patient has visible dyschro-
mias (lentigines), commonly called age spots, sun spots, or liver
spots, and these enhance under ultraviolet light, they are usually
A
B
C
FIGURE 12-5.  Commercial UV skin scanners are available and work by
allowing patients to view their skin in a magnified mirror surrounded by
numerous UV light bulbs.
FIGURE 12-6.  These skin scanners also allow the observer to view the
patient, comment on his or her condition, and photograph the UV picture.
This is done with the flash turned off.

Chapter 12  •  Skin Resurfacing
521
motivated to begin skin care and have a skin peel procedure.
Images can also be used to show the effect of the procedure
(Figure 12-10).
Prepeel Pharmacologic Concerns
Although controversy exists about the need for prepeel or laser
antibiotic and viral prophylaxis, the standard of care in most
communities is probably consistent with their use. The chance
of activation of herpes simplex and its replication can cause
devastating complications in terms of scarring. Patients with a
images, the surgeon and patient can evaluate the efficacy of the
procedure. Images might also be used (with permission) for
procedure marketing (Figure 12-8).
Newer technology has simplified this process. The Reveal
Imager system (Canfield Imaging Systems, Scientific, Fairfield,
NJ) is a convenient and portable system that gives an immediate
computer image of the patient in normal light and has filters
that enhance vascular and pigment abnormalities (Figure 12-9).
These devices are well worth the investment. Patients are always
surprised at the amount of skin damage they have and are
A
B
C
D
FIGURE 12-7.  The digital UV image will be blue and must be processed with image-editing software. A, Normal flash picture.
B, Unprocessed image taken through the scanner. C, The image is converted to grayscale with software that removes the
blue. D, Finally, the dark image is lightened with software, and the final picture is done.
A
B
FIGURE 12-8.  Patient before (A) and after (B) a resurfacing procedure. The image was made with the procedure described
above using a UV skin scanner and digital imaging processing.

522
Chapter 12  •  Skin Resurfacing
Preoperative Consultation
As with any procedure, comprehensive presurgical communica-
tion is paramount. The patient must understand how the pro-
cedure is performed, how it works, what makes it work it better
or worse, and how to care for it. Patients must also understand
what they will look like as the peeling and healing progresses.
All medium-depth chemical peels are done with IV sedation,
and patients are told that when the awake, they will feel like
they have a sunburn. Over the next 48 hours, the changes are
generally minimal (although some patients swell), and the skin
becomes brown and thicker. At about day 3 to 5, the patient
will begin to peel in the areas of greatest movement, usually the
perioral and periorbital regions. Patients are asked not to pick
at the peeling skin but allow it to naturally exfoliate. Total
exfoliation and reepithelialization usually occurs by day 7, and
then makeup can be applied. The importance of sun avoidance
for the first 30 days is stressed. The patient is further informed
that they will once again start their prepeel skin regimen as soon
as they can tolerate it, generally 2 to 3 weeks.
Medium-Depth Chemical Peel Procedure
Confusion and controversy exist over the terminology and
descriptions of various chemical peels. When a patient is pre-
sented with the option of a peel they may say, “Oh, I had that
done before, and it did not do anything.” Further questioning
often reveals that the peel was done at their beauty shop. Appre-
ciating the numerous types of skin peel agents and the variability
of peel depth is imperative to understanding and communicat-
ing what to expect from chemical peels.
To clarify and quantify types of peels, a consideration of
tissue damage and healing time is the most accurate means of
classification. A very superficial chemical peel wounds all or part
of the stratum corneum and heals in 2 to 3 days. A superficial
peel wounds all or part of the epidermis to a depth of approxi-
mately 0.06 mm and heals in 4 to 6 days; Retin-A is an example
of this type of peel. A medium-depth chemical peel destroys all
or part of the papillary dermis to an approximate depth of
0.45 mm and heals in 7 to 8 days; TCA and glycolic acid are
examples of medium-depth peel agents. Deep peels destroy the
epidermis, the papillary dermis, and extend into the reticular
dermis to an approximate depth of 0.6 mm; 10 to 12 days are
required for reepithelialization. Phenol or high concentrations
of TCA are examples of deep peel agents. Boxes 12-1 and 12-2
summarize chemical peels.
Figure 12-11 shows two patients 7 days after aggressive laser
and medium-depth chemical peel, illustrating the differences in
wounding and healing.
history of oral herpes simplex are more prone to post-resurfacing
viral outbreaks, although patients without a previous history are
also susceptible. I treat all peel patients with antiviral prophy-
laxis beginning 48 hours before the procedure. I prescribe vala-
cyclovir 500 mg every 12 hours and continue this dose for 5 to
7 days post peel. All peel patients are also treated with Cepha-
lexin 500 mg every 6 hours beginning the day before the peel
and for 5 to 7 days post peel. I use the same regimen for aggres-
sive laser procedures. The only time I deviate from these two
medications is for superficial peels and laser resurfacing. Finally,
appropriate analgesics are prescribed for ultralight laser resurfac-
ing. Having personally had a medium-depth chemical peel, I
can attest that most patients do not need narcotic analgesics
after chemical peel, but patient variability may dictate their use
in sensitive patients.
FIGURE 12-9.  Technologically advanced skin scanners enable fast and
impressive documentation of photodamage, which is very motivating for
patients.
A
D
B
E
C
F
FIGURE 12-10.  Using before-and-after scans can assist the surgeon and
patient in appreciating the effects of resurfacing treatments. With the
ReVeal system, the patient is shown in normal digital photography (A), the
vascular view (B), and the pigment view (C). Looking at the before and
after pigment views (C–F), the postpeel pigment reduction is evident.
Box 12-1  Summary of Peeling-Depth Classifications
Very superficial – destruction of the stratum corneum
Superficial peel – destruction of all or part of the epidermis; depth
0.06 mm (alpha hydroxy acid cosmetics, Retin-A)
Medium peel – destruction of all or part of the papillary dermis; depth
0.45 mm (trichloroacetic acid, glycolic acid)
Deep peel – destruction of the epidermis, the papillary dermis extending
into the reticular dermis; depth 0.6 mm (phenol)

Chapter 12  •  Skin Resurfacing
523
keratoses, and superficial scars. They must understand that
medium-depth chemical peels will not significantly affect deep
lines, wrinkles, and folds or tighten facial skin to the degree of
aggressive laser or facelift techniques but can be repeated at
90-day intervals with good results.
Peeling Agents
Numerous chemical agents exist for performing chemical face
peels and are used by themselves or in combination with other
agents. Simple creams such as Retin-A or fluorouracil (5-FU)
can be used for at-home superficial peels and can be started and
stopped as necessary by the patient. The more traditional “pro-
cedural” peels are most often performed with liquid acid solu-
tions (Box 12-3) and are applied at various concentrations with
or without supplemental anesthesia. Some peeling agents such
as alpha hydroxy acid (AHA) can be halted during the proce-
dure with a neutralizing agent, but other agents such as TCA
or phenol cannot be slowed down, stopped, or reversed. Once
they are applied, the damage is done.
Mechanism of Action
Peeling agents are commonly classified by their mechanism of
action on tissue. Keratolytic agents include glycolic acid, lactic
acid, citric acid, malic acid, tartaric acid, and salicylic acid.4
These lighter-peel agents interrupt the adhesion of keratinocytes
and are used for exfoliation but do not have a significant effect
on deeper wrinkles or scars. They are mainly used for improve-
ment of skin roughness, very fine lines, acne control, and mild
pigmentation disorders. They are typically performed without
anesthesia and are repeated numerous times to obtain a result.
Other peeling agents denature and coagulate proteins in the
skin. TCA and phenol peels are examples of protein denatur-
ants. TCA in various percentages is a common peeling agent
with a wide safety margin. Phenol, on the other hand, can be
toxic to the heart, kidneys, and liver, and phenol-peel patients
require electrocardiograph monitoring during treatment.
Because phenol peels can be very deep and have a high propen-
sity for inducing permanent hypopigmentation, they have fallen
out of favor with multiple specialties that perform chemical face
peeling. The efficacy of a properly performed phenol peel can
be dramatic and similar to laser resurfacing, but the trade­offs of
extensive hypopigmentation and health risks limit their safety.
Some clinicians use multiple agents for chemical face peeling.
For instance, the keratolytic effects of a Jessner’s peel can enhance
the skin penetration of TCA. I prefer to keep face and neck
peeling simple and use only TCA. The remainder of this discus-
sion will deal with TCA chemical peeling of the face and neck.
The medium-depth chemical peel is my most common peel
technique. These procedures will extend from the papillary
dermis to the upper reticular dermis depending upon technique.
Patients should expect a medium-depth peel to be effective for
such common epidermal or upper dermal cutaneous disorders
as dyschromias, fine to moderate lines and wrinkles, freckles,
FIGURE 12-11.  These two patients are shown 1 week after laser and peel.
The patient on the left underwent multipass, high-fluence, high-density
CO2 laser resurfacing, and the patient on the right underwent medium-
depth trichloroacetic acid (TCA) chemical peel.
Box 12-3  Common Peeling Agents
• Retinoic acid (Retin-A)
• Fluorouracil (5-FU)
• Jessner’s solution (resorcinol, salicylic acid, lactic acid)
• Trichloroacetic acid (TCA) 30%
• Can’t be neutralized
• Alpha hydroxy acid (AHA) 70%
• Can be neutralized
• Phenol
Box 12-2  Healing Time of Various Peels
A. Stratum corneum exfoliation: 2–3 days healing time
B. Basal layer exfoliation: 4–6 days healing time
C. Papillary dermis: 7–8 days healing time
D. Mid-dermis: 10–12 days healing time
a
b
c
d
(Image from Waugh A, Grant A: Ross and Wilson Anatomy and physiology in health and illness,
ed 10, Edinburgh, 2006, Churchill Livingstone.)

524
Chapter 12  •  Skin Resurfacing
the surgeon can see the daily progress as well as photograph it
for future patient education and marketing.
Ultralight Tca Peel
For the novice peeler, performing simple single-coat, low-con-
centration (e.g., 15%) peels on awake patients is a good begin-
ning. To make a 15% concentration of TCA, use 2 mL of 30%
TCA diluted with 2 mL of water, and apply a single coat after
acetone or alcohol degreasing (Figure 12-12). The entire face
can be treated, but some surgeons do not treat eyelids with these
conservative peels. The patient will have a tolerable burning
sensation and probably not manifest any significant skin frost-
ing. Over the next week, there may be very slight flaking. A peel
of this nature can be repeated every 2 weeks for cumulative
improvement.
Once comfortable performing ultralight peel, the surgeon
can treat the next patient with two coats of the same concentra-
tion, still easily tolerated by the average person. A handheld fan
can ease the burning sensation (Figure 12-13). The skin may
very slightly frost in some areas, and the skin will flake or pos-
sibly peel to a small extent over the next 3 to 4 days.
Although a topical anesthetic may sound like a good idea for
pain control, the compound can actually impede the healing
agent. In some cases, the topical anesthetic can hydrate the skin
and affect acid permeability. For these reasons, topical prepara-
tions are not used with chemical peeling.
As the surgeon becomes comfortable with the technique and
follow up, a patient can be treated with three to four coats of
15% TCA. Although many doctors perform multiple-coat 15%
TCA peels without anesthesia, I personally do not, preferring
Safety Precautions
The acids used in cosmetic surgery are dangerous substances and
can cause full-thickness burns and corneal damage. Both
patients and staff must be continually protected. Injury and
legal proceedings have resulted from improper use of TCA,
including using an improper mixture. Although some surgeons
use concentrations of TCA as high as 70%, in my opinion, there
is no reason to ever use concentrations above 30%. The differ-
ence between therapeutic and caustic quickly rises as the acid
concentration increases. A 30% concentration is very conve-
nient and can be used full strength by experienced peelers or
easily diluted to 15% or 20% for use by beginners or on patients
with darker skin. The most predictable means of ordering TCA
is from well-established dermatologic suppliers (e.g., Delasco
Inc., Council Bluffs, IA), where these products are compounded
and standardized by experienced personnel. Due to the liability
of product use, some of these companies will not sell TCA to a
doctor unless he or she can provide proof of training or mal-
practice coverage. TCA can also be safely mixed by local repu-
table compounding pharmacies, but it is imperative that both
pharmacist and surgeon appreciate the various ways TCA can
be compounded. The most common technique is by weight/
volume (W/V), and if a surgeon uses a pharmacy to compound
TCA, it must be communicated that a W/V mixture is requested.
A 30% W/V solution is made by mixing 30 grams of TCA
crystals in 100 mL of water. Other compounding techniques
must not be confused with W/V, or the result of similar amounts
of acid will not be the same.
Safety must be the prime concern throughout the entire peel
procedure. All vials, bottles, or bowls must be labeled as to
content and concentration so as not to confuse liquids. A large
volume of tap water should be at hand in the event of inadver-
tent spill or eye contact. As the acid is applied to the face and
neck by the operator, assistants must be protecting nontreated
areas from drips of unintentional contact.
Chemical Peel Procedure
A chemical peel performed at a beauty shop or spa is quite dif-
ferent from one performed by a cosmetic surgeon using a more
concentrated acid and IV sedation. Many variables can affect
the depth and related result of a chemical peel.5 These include:
• The amount of prepeel conditioning performed
• The actual type of acid used
• The concentration of the acid
• The number of coats applied
• The duration the acid is in contact with the skin
• The thickness of the skin (e.g., eyelids versus forehead)
• The degree of sebaceous activity of the skin (oily versus dry)
• How the skin is “degreased”
Even with consideration of all such variables, some patients
are simply more sensitive to the same technique and concentra-
tion than others. Controlling the variables increases the safety
margin but does not guarantee complication-free procedures.
The best means of learning chemical peels is to begin with very
conservative peels on patients with predictable skin types (Fitz-
patrick 1 and 2) who can be seen daily to appreciate and evalu-
ate the results. By performing such procedures on staff members,
FIGURE 12-12.  A single-coat application of trichloroacetic acid (TCA; in
this case Obagi Blue Peel) is a good way for the novice practitioner to
learn the effects of light chemical peel and progress to more aggressive
treatments. The patient shown was treated with a single coat of 15%  
TCA. This was made by mixing 2 mL of 30% TCA with 2 mL of the Blue
Peel base.

Chapter 12  •  Skin Resurfacing
525
medium-depth peel. Fine lines and wrinkles that are amelio-
rated by gentle stretching of the skin will improve with a
medium-depth peel. Chemical peels can be repeated at 6- to
12-week intervals (depending on the depth) for cumulative
effects. If a patient is promised more than can be delivered, the
negative aspects will impede the reputation of the surgeon and
will eventually affect the business. All surgeons have the ethical
requirement to be truthful and accurate about anticipated
results.
As stated earlier, the medium-depth 30% TCA peel patient
is started on prepeel skin conditioning 2 to 4 weeks before the
procedure and prescribed antivirals and antibiotics. They are
instructed to not apply makeup, creams, or moisturizers the day
before or the day of the peel. I only perform medium-depth
peels under IV sedation, so patients arrive at the office NPO for
8 hours. Although I prefer IV sedation, many practitioners do
the procedure with oral sedation and facial nerve blocks. I have
had a medium-depth chemical peel without sedation, and I can
verify that the pain is similar to sticking one’s face in a beehive.
I would not recommend having this done without some form
of pain control. In this day and age of sedation and local anes-
thetic techniques, there is no need to subject patients to a very
uncomfortable experience.
The face is degreased with acetone or alcohol by rubbing
vigorously with gauze pads (Figure 12-14). Adequately degreased
skin will appear dry and without shine. The inferior border of
the mandible is marked with a surgical marker unless the neck
or décolletage is to be treated. Any specific scars or areas of
deeper pigmentation are also marked. Instrumentation is
minimal for chemical peel and is shown in Figure 12-15.
At this point, the patient is sedated and the procedure begun.
The head is elevated slightly so that any dripping will not flow
toward the eyes. A small amount (2 to 4 mL) of 30% TCA is
placed in a small basin then applied evenly to the entire face
with a sponge applicator, cotton-tipped applicators, or gloved
IV sedation for these cases. Otherwise, patients can be treated
with oral analgesics and anxiolytics in conjunction with local
anesthetic blocks.
Multiple-Coat, Medium-Depth TCA Peels
The workhorse peel in my practice for light-skinned patients is
a 30% TCA medium-depth peel. Although this can also be
performed on dark skin types, I usually use the Obagi Blue Peel
for darker skin types, and this will be discussed later in the
chapter.
Medium-depth chemical peeling will generally injure some
or all of the papillary dermis and can involve the upper reticular
dermis. The true depth of any procedure is a histologic deter-
mination, and these terms are used as generalities for average
results. The numerous aforementioned variables can affect the
actual depth of injury. Since the medium-depth peel heals in 7
to 8 days, it is safe to assume that the depth of injury is well
into the papillary dermis.
It is explained to the patient that a medium-depth TCA peel
will be very effective for most pigmentation disorders, with
the exception of deeper dermal pigmentation. I explain that
although the degree of pigmentation improvement is usually
dramatic, I cannot guarantee that a single treatment will eradi-
cate all dyschromias, and further peels may be necessary. Com-
municating a realistic expectation of skin tightening and wrinkle
and scar improvement is extremely important. A medium-depth
chemical peel will tighten the skin. The level of tightness is
initially dramatic due to skin edema, but some of this tightness
resolves with healing. The same can be said about wrinkles and
scars. A single medium-depth chemical peel will improve fine
lines and wrinkles, especially in thinner skin such as the lower
eyelids. It is important for the patient to realize that deep
wrinkles, scars, and folds will not be improved with a single
FIGURE 12-13.  A battery-operated handheld fan can ease the transient
discomfort of chemical peeling, or as shown in this picture, can be used
postpeel for pain control. Cold compresses are also effective.
FIGURE 12-14.  The face is degreased by rubbing with acetone- or alcohol-
soaked gauze pads.

526
Chapter 12  •  Skin Resurfacing
and lower eyelids. The first coat of TCA is applied evenly to the
entire face in a systematic fashion (Figure 12-17, A). To treat
the entire face equally and not inadvertently “double treat”
regions, it makes sense to use the same application pattern in
all cases, beginning with one area and moving to another,
working around the entire face or area to be treated. Some
surgeons use a clock-face pattern and begin in the right fore-
head, progress to the right temple and cheek, then to the right
lower cheek, then cross the midline and proceed up the left side
of the face.
The second (and possibly final coat) of TCA is applied after
several minutes. Again, several minutes are allowed to elapse to
evaluate signs of peel depth (see Figure 12-17, B). Skin frosting
is indicative of epidermal and dermal skin protein coagulation
and begins almost immediately. Areas of thinner skin will frost
fingers. A folded gauze pad is also effective because the acid can
be rubbed into the skin. It is of utmost importance to protect
the patient from spilled or misapplied acid. The basin is never
passed over the patient’s face but rather is held by the assistant
to the patient’s side (Figure 12-16).
As the acid is applied in an even coat, the assistant is ready
with a moist gauze ready to absorb any drips or inadvertent
application. Should too much acid be applied or inadvertently
spill, the area is flushed with water. This will not neutralize the
acid (it is already an aqueous solution) but will dilute it and
lessen the penetration.
Generally the 2 to 4 mL of 30% TCA will cover the entire
face for a single coat. I generally also treat the earlobes and upper
A
B
FIGURE 12-15.  Minimal setup is required for trichloroacetic acid (TCA)
peels. A, Required tray for a plain TCA peel. B, Setup for an Obagi Blue
Peel.
FIGURE 12-16.  The container with acid is never held near or passed over
the patient’s face. Inadvertent spill into the eyes or face can cause severe
burns.
A
B
FIGURE 12-17.  A, The first coat of 30% trichloroacetic acid (TCA) is applied to the face in an orderly fashion so as not to “double
treat” any area. The surgeon should wait several minutes to observe the frosting and skin signs before placing the successive
coat of acid. B, Five minutes after the second coat of 30% TCA application. The increased degree of frosting as compared
to the first coat is evident.

Chapter 12  •  Skin Resurfacing
527
in the capillary loops of the papillary dermis. This reaction
causes blood flow in this area to cease and the pink background
to disappear. The frost appears as a solid white sheet. A peel
that reaches this level implies that the whole papillary dermis
is involved, and the upper reticular dermis has been reached
but not penetrated, which is the endpoint of a medium-depth
chemical peel.3 This is also referred to as the intermediate reticu-
lar dermis (IRD) by some authors.3 Lighter peels end at the
IRD, and deeper peels extend below the IRD. A grey frost can
indicate overtreatment and impending burn. Judging the end-
point and related frosting requires significant experience, so the
novice peeler should work their way from light to medium to
deeper peels. This should be done over a significant period of
time, with close observation of each patient during and after
the peel. Photographic documentation of successive cases serves
as an excellent learning aid.
Although the presence and absence of pink skin is helpful in
endpoint judgment, it is more difficult to visualize in darker
skin types. Another means of evaluating when the papillary
dermis has been reached is epidermal sliding (Figure 12-20).
This is exaggerated wrinkling of the skin when pinched. Prior
to complete precipitation and coagulation of papillary dermal
proteins, papillary dermal edema and disruption of anchoring
fibrils allows the epidermis to move more freely, resulting in
FIGURE 12-18.  The broken end of a wooden cotton-tipped applicator is
used to grind the acid deep into acne scars for more through treatment.
A trichloroacetic acid (TCA) Obagi Blue Peel technique is shown.
Box 12-4  Peel Depth by Frost Color
• Sparse disorganized patchy frost
• Epidermis
• Light with frost with pink background
• Into papillary dermis
• Solid white frost (no pink background)
• Entire papillary dermis is penetrated
• Upper reticular dermis has been reached but not penetrated
• This is the endpoint of a medium-depth peel
upon contact, whereas the more sebaceous and thicker skin will
require several coats to frost. When applying the acid to areas
of wrinkled skin such as the lower lids, corners of the mouth,
or lateral canthal regions, the skin is stretched to allow the acid
to penetrate the wrinkles. Using the sharp end of a broken
cotton-tipped applicator stick or tongue blade to “grind” the
acid into acne scars is effective6 (Figure 12-18).
The goal of a medium-depth 30% TCA peel is to produce
a homogenous frost commensurate with the desired depth of
penetration (Box 12-4; Figure 12-19). A sparse, irregular
patchy frost signifies epidermal penetration, and the nature of
the frost changes as the acid progresses deeper. As the acid
progresses to the papillary dermis, a light white frost with a
pink background is seen; blood vessels of the papillary dermis
are still patent. Progression of the acid deeper into the papillary
dermis but not into the reticular dermis results in vasospasm
A
B
C
FIGURE 12-19.  A, A light frost with a pink background, indicating penetration into the papillary dermis. B, Another patient with
a similar frost but more aggressive treatment, still with a pink background. C, Another patient with a solid white frost indicative
of total penetration of the papillary dermis into the upper level of the reticular dermis.

528
Chapter 12  •  Skin Resurfacing
three coats of 15% or two coats of 20% (Figure 12-24). To
concoct 15% TCA, 2 mL of 30% of TCA are mixed with
2 mL of water. To make a 20% mixture, 4 mL of 30% TCA are
mixed with 2 mL of water. The novice peeler should treat the
neck to half the level they think necessary. It is important to
keep in mind that multiple peels can be performed at 90-day
intervals, and it is better to treat safely over several peels than
create scarring from an overly aggressive peel.
I do not treat to a solid white frost on the neck, but rather
a much lighter frost with a pink background (Figure 12-25).
Patients must understand that they will have much less result
on their neck than their face with both peel and laser. The
décolletage (upper chest) can also be treated with the same
conservative tenets as the neck. Patients often want lower and
lower treatment, but they must realize there will always be a
exaggerated wrinkling when the skin is pushed or pinched.1 Put
simply, when epidermal sliding begins, the acid is entering the
papillary dermis. When it disappears, the acid is in the papillary
dermis. This transient sign disappears as the peel progresses and
may not be apparent in thicker-skinned individuals.3
To reiterate, 2 to 4 mL of TCA will generally cover the entire
face, and the frost will intensify during the second coat. If a
white frost with a pink background is the endpoint, the second
coat of 30% TCA will frequently produce this level.
The acid is rubbed into the hairline so no visible demarcation
line exists (Figure 12-21). TCA will not harm the hair. The
eyelids are treated last. One or two coats of 30% TCA can be
very effective in treating lower-lid dermatochalasis (Figure
12-22). This is very thin skin and frosts quickly (Figure 12-23),
so to prevent overtreatment, adequate time should elapse before
the second pass. Novice peelers should be very conservative in
this area. A cotton-tipped applicator provides precision applica-
tion near the eye. A water source should be readily available in
the case of acid entering the eye. The upper eyelid can also be
treated but does not require aggressive treatment. TCA is NOT
toxic to the cornea, but if it enters the eye and is flushed imme-
diately, healing is usually uneventful, although the patient will
feel irritation for several days. Significant eye contact would
warrant an ophthalmology consult.
A third coat of 30% TCA can be performed but will be
overtreatment for many patients and should only be performed
by experienced clinicians. It is important to realize that the
“cookbook” number of coats is not a reliable and predictable
technique. The endpoint of the frost is the true indicator of
injury depth. In some patients, it may be achieved in one coat;
in others, two or three. Understanding the process and the slow
progressive signs that occur during the peel are paramount for
safe and effective results.
If the neck or décolletage is to be treated, the entire process
must be reconsidered in light of the decreased number of pilo-
sebaceous units in the nonbearded neck. Severe scarring and
disfigurement can and has occurred with chemical peels and
lasers. I never use 30% TCA on the neck, but I will use up to
FIGURE 12-20.  Epidermal sliding is shown as an exaggerated wrinkling of
the skin when the acid (in this case an Obagi Blue Peel) reaches the
papillary dermis.
FIGURE 12-21.  To lessen demarcation lines and transition zones, the acid
is rubbed well into the hairline.
FIGURE 12-22.  The eyelids must be treated with precision to prevent acid
from entering the eye. A cotton-tipped applicator is convenient for this.
Although the lower lids can benefit from several carefully placed coats of
acid, the upper lids are less aggressively treated in most patients and
some forgo upper-lid treatment altogether.

Chapter 12  •  Skin Resurfacing
529
described earlier, over the next several days, the skin will become
thickened and brown and begin to peel first in areas of increased
movement (perioral and periorbital regions) between day 3 and
5. It is human nature to want to pick at the peeling skin, but
this can leave scarring, so patients should be encouraged to let
the skin peel naturally. Some patients will actually have sheets
of skin peel off; others will notice the dead skin emulsify and
exfoliate when washing the face. For medium-depth peels, most
of the peeling is complete by day 7, and most female patients
are back in makeup by day 7 to 8 (Figure 12-28). Figure 12-29
shows the author before and throughout the week after medium-
depth TCA peel. Sequelae and complications will be discussed
later in this chapter.
Obagi Blue Peel
Over the years, numerous proprietary chemical peels have come
and gone, but the Obagi Blue Peel (OBP) has maintained a
niche for reliable and safe chemical peeling. Although some
doctors feel there is no advantage to using the OBP over con-
ventional TCA, I almost always use it when peeling pigmented
demarcation line, so the face and neck are generally my desired
treatment regions.
Postpeel Care
Immediately after the peel, the entire treated area is covered with
petroleum jelly or Aquaphor (Belersdorf Inc., Wilton, CT), and
if the patient is uncomfortable, cold compresses are placed on
the treated areas (Figure 12-26). Transient burning is common
but quickly dissipates. Immediate swelling may be evident
(Figure 12-27). Wound care throughout the healing process is
very simple. Patients wash the treated area with a hypoallergenic
cleanser and keep petroleum jelly or Aquaphor on the areas
continually for 1 week. Most patients do not need analgesics.
In the rare event of severe swelling, oral steroids can be used.
Antibiotics and antivirals are continued through the fifth to
seventh day or until epithelialization is complete. Some sur-
geons no longer advocate antibiotics with chemical peeling,6 but
the standard of care in the local community should dictate this.
Patients should understand that for the first 48 hours, not
much change will be apparent other than skin tightness. As
A
B
FIGURE 12-23.  Frosting of the lower eyelids after application of two coats of 30% trichloroacetic acid (TCA).
A
B
FIGURE 12-24.  The neck is never peeled as aggressively as the face. A, After three coats of 15% trichloroacetic acid (TCA).
B, One week later.

530
Chapter 12  •  Skin Resurfacing
and a nonionic blue color base. A reduction of the surface
tension of the TCA, water, and glycerin occurs, which results in
a homogenous TCA-oil-water solution that slows the penetra-
tion and release of TCA in the skin. This results in a more even
coating, allows the skin proteins to neutralize the penetrating
acid between applications, and produces slower frost formation
as compared to straight TCA peels. This gives the surgeon extra
time to evaluate the evolving depth (frost) signs and stop at the
desired depth for a wider margin of safety.3 Finally, the color
prevents inadvertent double treatment on an area (common
with clear TCA), because the blue dye shows what areas have
been covered.
The OBP procedure is much the same as the previously
described TCA peels. The same patient selection criteria and
skin conditioning regimens are used. The face is degreased with
acetone or alcohol and the blue peel component mixed with the
TCA (Figure 12-31). The OBP component is contained in
2-mL tubes. If one tube is mixed with 2 mL of 30% TCA, a
15% solution of TCA will result. For a more aggressive peel, 1
tube of blue base (2 mL) is mixed with 4 mL of 30% TCA (final
concentration 20%). The 15% TCA/blue base is used for novice
peelers and superficial treatment. A single coat of 15% TCA will
exfoliate the stratum corneum. Three to four coats of 15% TCA
(on normal skin) will peel to the level of the papillary dermis.
The 15% mixture is also better tolerated on awake patients. The
20% mixture is more aggressive and should not be used by
inexperienced peelers. In normal skin, a single coat of 20% will
penetrate the stratum corneum but above the basal layer. A
second coat of 20% will reach the papillary dermis. Patients
with thicker skin may take more coats of either concentration,
and those with thin skin may take less. Experience has a lot to
do with the judgment of peel depth and healing. Again, begin
with conservative peels and progress to more advanced tech-
niques over time. In chemical peeling, the art is as important as
the science.
Once the TCA and blue base is mixed, the entire contents
are applied to the face using the preferred method of application
(Figure 12-32). Dilutions are designed to require the entire
mixture to treat the face or similar 5% of body surface area. The
first coat is applied evenly around the entire face with care not
(global) skin (Figure 12-30). I have done over 100 of these peels
on Fitzpatrick 4 to 6 skin types, and they proved safe and effec-
tive. My experience is purely anecdotal, but sometimes in clini-
cal practice, whatever works, works! I can also verify after
teaching hundreds of doctors chemical peeling techniques that
the OBP is a great way to learn the art and a safe and effective
means of treating darker skin types. I believe the ingredients of
the OBP make the peel process slower so the novice surgeon
can better observe the impending depth signs, making the
process safer.
Although one could use the OBP on any skin type, I choose
to treat Fitzpatrick 1 to 3 skin types with pure 30% TCA and
treat the darker skin types with one to three coats of 20% TCA
in the OBP. The contents of the OBP include glycerin, saponins,
FIGURE 12-25.  The décolletage region can be simultaneously treated with
the face, with the same cautions as the neck. Patient is shown immediately
after a three-coat 20% Obagi Blue face peel and three coats of 15% TCA
to the neck and décolletage.
A
B
FIGURE 12-26.  The face is coated with a generous application of petroleum jelly or Aquaphor immediately after the peel is
performed.

Chapter 12  •  Skin Resurfacing
531
A
C
B
FIGURE 12-27.  Transient postpeel burning is common, and some patients exhibit immediate swelling after the peel. Patient
before peel (A), during peak frosting of medium-depth trichloroacetic acid (TCA) peel (B), and 15 minutes after the peel, with
visible facial edema (C).
A
B
C
FIGURE 12-28.  Patient is shown 7 days after a medium-depth 30% trichloroacetic acid (TCA) chemical peel to the depth of the
intermediate reticular dermis.
to overlap passes. I prefer to leave the eyelids last to concentrate
on safety without distraction. After the entire 4 or 6 mL
(depending upon the concentration) is applied, at least 2
minutes are allowed to elapse before applying the next coat. For
medium-depth chemical peels, most patients can tolerate three
to four coats of 15% or two to three coats of 20%. In both
instances, the skin will generally heal in 7 to 8 days.
Light frosting will be noticeable with the first coat of blue
peel but will be sparse and patchy. The second coat will acceler-
ate the frosting (and the discomfort). After the second coat, at
least 2 minutes must again be allowed to elapse before the next
coat. White frost with a pink background will generally appear
after the third or fourth coat of 15% or the second or third coat
of 20%. This indicates the papillary dermal level, which is
adequate for noticeable results in most patients (Figure 12-33).
The experienced peeler can proceed with additional application
to a dense white frost without pink background, indicating the
IRD has been reached. When in doubt, use less!
When treating the neck, I never use more than three coats
of OBP 15% or two coats of OBP 20% for reasons noted earlier
under TCA application without the OBP.
At the end of the peel, the frost will generally persist 10 to
15 minutes then dissipate. Patients must understand that their
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