Essentials of Aesthetic Surgery

222
Part V Noninvasive and Minimally Invasive Therapy
17. Manuskiatti W, Fitzpatrick RE, Goldman MP, et al. Prophylactic antibiotics in patients undergo-
ing laser resurfacing of the skin. J Am Acad Dermatol 40:77, 1999.

abrasion. J Am Acad Dermatol 46:399, 2002.

dioxide laser resurfacing for phyotoaged facial skin. J Am Acad Dermatol 40:401, 1999.
20. DiBernardo BE, Pozner JN, Codner MA, eds. Techniques in Aesthetic Plastic Surgery Series:


22. Wanitphakdeedecha R, Phuardchantuk R, Manuskiatti W. The use of sunscreen starting on the

23. Ratner D, Tse Y, Marchell N, et al. Cutaneous laser resurfacing. J Am Acad Dermatol 41:365,
1999.
24. Nanni CA, Alster TS, Complications of carbon dioxide laser resurfacing. An evaluation of 500
patients. Dermatol Surg 24:315, 1998.
25. Nanni CA, Alster TS. Complications of cutaneous laser surgery. A review. Dermatol Surg 24:209,
1998.
26. Sriprachya-Anunt S, Fitzpatrick RE, Goldman MP, et al. Infections complicating pulsed carbon
dioxide laser resurfacing for photoaged facial skin. Dermatol Surg 23:527, 1997.


dioxide laser. Plast Reconstr Surg 115:1731, 2005.

kits in the treatment of facial hyperpigmentation and photo-aging. J Drugs Dermatol 11:964,
2012.
-


Plast Surg 10:238, 2008.



the treatment of rhinophyma. J Dermatol Surg Oncol 13:172, 1987.



Electrotechnical Commission, 2007.

223
EQUIPMENT
Two types of nonablative lasers, and two additional modalities, are commonly used in
nonablative resurfacing.
MIDINFRARED LASERS
and

Target

ND:YAG LASER

One of the earliest lasers used for nonablative resurfacing
• Early applications did not include a cooling device, and this resulted in a high rate of
scarring, hyperpigmentation, and pain.
Newer models include a cryogenic cooling spray, which keeps the epidermis
temperature around 40°-48° C, while the dermis is heated to 60°-70° C.1,2
3,4
WITCHED ND:YAG LASER

Coupled with a cryogenic cooling device
5
SENIOR AUTHOR TIP: This laser does not see “brown pigment” well so it is an excellent
choice for treating tattoos in darker skin types.
DIODE LASER

6
7
ERBIUM OPED FRACTIONAL LASER
Fraxel (Solta Medical)

The and has such as
dyschromia,8,9 8,9 acne scars,10 burn scars,8,9,11 striae distensae12

lasers13,14

224
Part V Noninvasive and Minimally Invasive Therapy

13,14
Requires three to six treatments, spaced at 2- to 4-week minimum intervals

15
SENIOR AUTHOR TIP: Currently our most frequently used laser is actually a dual


quicker healing time and greater dermal change.
VISIBLE LIGHT LASERS




• Shown to increase the quantity of collagen and elastin in the dermis
16

photosensitizer, such 17

of vascular lesions, and pulse width durations are longer than those used to treat
port-wine stains to minimize purpura.
• Best used for signs of and

INTENSE PULSED LIGHT
Intense polychromatic light including from 500-
1200 nm.18

chromophores.

Excellent in the treatment of such as and 19
• Very good in the treatment of dyspigmentation, such as solar lentigines13

transcription to a more youthful genomic expression with multiple frequent
treatments at least three times per year for several years
20

photosensitizer, such as 5-aminolevulinic acid.21
RADIOFREQUENCY
ThermaCool (Solta Medical)
• Radiofrequency waves cause collagen denaturation when heated to 55°-62° C, and
the amount of collagen in the skin increases over time.
22
• Amount of tissue heating and the placement of that heating zone can be controlled

cryogenic cooling spray.

2) for short pulses (<2.3 seconds) (
heating).

225
Chapter 18
• Because radiofrequency does not target melanin, it

• Used in patients with
• Does not address underlying structural ptosis

measurable improvement in skin laxity.

12,23
24,25
• Can be painful to the patient

from heat damage to adipose tissue early in the treatment’s evolution.
26 Current
treatment protocols greatly minimize or eliminate this risk.
TECHNIQUE
ANESTHESIA
Nonablative lasers are as ablative lasers in general, but can vary
depending on the depth; i.e., a deep, nonablative laser treatment could possibly cause



It must be applied at least 1 hour before treatment, covered with an occlusive dressing,

SAFETY
Medical lasers are all class IV devices.


• A warning sign must be placed on each entrance, with extra goggles hanging
outside the door.
Corneal eye shields are placed, with ophthalmic ointment lubrication.
If patient is under general anesthesia, a laser-safe ET tube must be used if treating
around the mouth, and the lowest possible FiO2 should be given.
• Wet towels should be applied around the treatment area to absorb heat energy.
If treating viral warts, live viral particles can be transmitted into personnel’s airway.
• Therefore appropriate masks and ventilation systems must be in place.
TECHNIQUE


beyond a novice level of experience.
• Clinical endpoints for nonablative lasers are usually based on guidelines determined
by experts and depend on the treatment goal. There is usually no visual endpoint for
nonablative lasers used for the treatment of rhytids.



observed with prior treatments.
Multiple passes may be needed before the clinical endpoint is observed.

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Part V Noninvasive and Minimally Invasive Therapy
Most authors recommend a between treatment zones because of

APPLICATIONS


rhytids.

27


and unfavorable, hypertrophic surgical scars, but require multiple treatments.

for scar pliability, texture28
• PDL for erythema and irritation of immature scar29,30,31,32
• IPL for chronic folliculitis, scar dyschromia33
SENIOR AUTHOR TIP:
fractionally treated scar to enhance results.






Best response is usually obtained with PDL and IPL


normal guidelines.

Pigment is embedded in the dermis as large particles.
• The goal of laser therapy is to

Ideal laser but are ideal tattoo
removal devices.
absorbs a wide range of lasers: 694 nm Q-switched ruby, Q-switched
1064 nm Nd:YAG, Q-switched alexandrite
Q-switched alexandrite
34
Up to 10-15 treatments may be needed.34

Chromophore is
to destroy the follicle.

227
Chapter 18
Typical lasers used are the 810 nm diode, 755 nm alexandrite, 1064 nm ND:YAG, and
694 nm ruby.
Wavelengths in the visible light spectrum have a higher risk of complications with
darker skin types.
The ruby laser has the highest incidence of hyperpigmentation, hypopigmentation, and
blistering in darker skin types and tanned individuals.35
Up to 6-8 treatments may be needed.
TIP:
POSTOPERATIVE CARE
Because nonablative modalities do not leave an open wound,

If blistering occurs, triple antibiotic ointment is applied until the area heals.
Sun avoidance and the use of sunscreen with SPF 30+ are extremely important.
Ice packs as needed for swelling.

COMPLICATIONS


moderate to severe rhytids.
TIP: Up to eight treatments may be needed to achieve the desired clinical result.
36
• Thought to be caused by melanocyte destruction by heat energy
• Usually transient and self-limiting
• Rarely, delayed hypopigmentation can develop 6-12 months after treatment.
• Skin type is not a predictor.
SENIOR AUTHOR TIP: This complication is extremely rare in nonablative treatments
and is more common in aggressive CO2 resurfacing.

• Usually mild and self-limiting
• Petrolatum ointment used until healed
—very rare

• Reported with the monopolar radiofrequency device
• Frequency unclear
SIDE EFFECTS
NOTE:

228
Part V Noninvasive and Minimally Invasive Therapy
13
• Usually lasts for 24-48 hours
• Self-limiting
13
• Usually lasts 24-48 hours
• Self-limiting
• Ice pack used as needed

• Thought to be caused by
• Patients with are at much higher risk.


37

and/or lasers with longer pulse durations.
• Risk is higher if sun avoidance and sunscreen use are not practiced, i.e., tan is
present.
• Pretreatment and posttreatment with hydroquinone and tretinoin recommended
5
is started: Hydroquinone/

• When treating solar lentigines, lesions typically darken for 1 week before improving.
• Self-limiting



37
• Most common in patients with a prior history of herpes simplex virus outbreak
SENIOR AUTHOR TIP: I am often asked, “If you could only buy one machine, which
one would you buy?” This is impossible to answer, because it depends on the patient

device. (NOTE: Currently, many platform options allow physicians to purchase one
device and add to it as their knowledge and practice grow. This is a very reasonable
approach to building a laser- and light-based practice.
TOP TAKEAWAYS

When treating with visible-light wavelengths, patients with unrecognized tans
have the highest rate of complications.

Patients treated with nonablative lasers should be informed that their result
is directly related to the response of their immune system and genetic factors
beyond their control or the surgeon’s control. They are paying for minimal
downtime but accepting the risk of variability of result. The time spent

issues if it is documented well.



youthful skin is the rule.

229
Chapter 18
REFERENCES

treatment of facial rhytides. Arch Dermatol 135:691, 1999.




laser: retrospective study. Dermatol Surg 31:1218, 2005.
4. Rogachefsky AS, Hussain M, Goldberg DJ. Atrophic and a mixed pattern of acne scars improved
with a 1320-nm Nd:YAG laser. Dermatol Surg 29:904, 2003.

Med 26:196, 2000.


37:14, 2005.

treatment of atrophic facial scars: a prospective clinical and histologic study. Dermatol Surg
30:152, 2004.

a split-face comparative study. J Drugs Dermatol 12:175, 2013.
9. Collawn SS. Fraxel skin resurfacing. Ann Plast Surg 58:237, 2007.
10. Ong MW, Bashir SJ. Fractional laser resurfacing for acne scars: a review. Br J Dermatol 166:1160,
2012.
-
mented scars: a pilot study. Dermatol Surg 33:289, 2007.
12. Guimarães P, Hadad A, Sabino Neto M, et al. Striae distensae after breast augmentation:
treatment using the nonablative fractionated 1550-nm erbium glass laser. Plast Reconst Surg
131:636, 2013.
-
ence. Plast Reconstr Surg 113:1789, 2004.

glass laser: a clinical and histologic analysis. Dermatol Surg 28:833, 2002.
15. Weiss RA, Gold M, Bene N, et al. Prospective clinical evaluation of 1440-nm laser delivered by
microarray for treatment of photoaging and scars. J Drugs Dermatol 5:740, 2006.

Surg Med 25:229, 1999.

18. Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed
light treatments. Dermatol Surg 26:835, 2000.
19. Sadick NS, Schecter AK. A preliminary study of utilization of the 1320-nm Nd:YAG laser for the
treatment of acne scarring. Dermatol Surg 30:995, 2004.

skin by broadband light treatment: a pilot study. J Invest Dermatol 133:394, 2013.
21. Dover JS, Bhatia AC, Stewart B, et al. Topical 5-aminolevulinic acid combined with intense
pulsed light in the treatment of photoaging. Arch Dermatol 141:1247, 2005.

230
Part V Noninvasive and Minimally Invasive Therapy
23. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of noninvasive radiofrequency


radiofrequency system. J Drugs Dermatol 8:259, 2009.
25. Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower
face and neck. Semin Cutan Med Surg 22:115, 2003.
26. Youn A. Nonsurgical face lift. Plast Reconstr Surg 119:1951, 2007.
27. Cohen SR, Henssler C, Johnston J. Fractional photothermolysis for skin rejuvenation. Plast Re-
constr Surg 124:281, 2009.
28. Haedersdal M, Moreau KE, Beyer DM, et al. Fractional nonablative 1540 nm laser resurfacing

29. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions.
Burns 36:443, 2010.
30. Allison KP, Kiernan MN, Water RA, et al. Pulsed dye laser treatment of burn scars. Alleviation
or irritation? Burns 29:207, 2003.

the alternative to excision. Ann Plast Surg 60:480, 2008.

of laser therapy on hypertrophic burn scars. Ann Plast Surg 70:521, 2013.
33. Erol OO, Gurlek A, Agaoglu G, et al. Treatment of hypertrophic scars and keloids using intense

34. Alster TS. Q-switched alexandrite laser treatment (755nm) of professional and amateur tattoos.
J Am Acad Dermatol 33:69, 1995.

2003.
36. Handley JM. Adverse events associated with nonablative cutaneous visible and infrared laser
treatment. J Am Acad Dermatol 55:482, 2006.
-
molysis: experience with 961 treatments. Dermatol Surg 34:301, 2008.

231
PREOPERATIVE EVALUATION
Consultation with the patient to establish realistic goals and expectations
Does the patient have an indication for chemical resurfacing?

• Preneoplastic or neoplastic lesions such as actinic keratoses and lentigines
• Underlying skin disease such as acne
• Pigmentary dyschromias
• Demarcation lines secondary to other resurfacing procedures
Any contraindications (Box 19-1)?
Box CONTRAINDICATIONS FOR CHEMICAL PEELS

• Poor physician-patient relationship

• Unrealistic expectations
• Poor general health and nutritional status
• Isotretinoin therapy within the last 6 months*
• Complete absence of intact pilosebaceous units on the face
• Active infection or open wounds (such as herpes, excoriations, or open acne cysts)

• Medium-depth or deep resurfacing procedure within the last 3-12 months*
• Recent facial surgery involving extensive undermining, such as a facelift*
• History of abnormal scar formation or delayed wound healing
• History of therapeutic radiation exposure
• History of particular skin diseases (such as rosacea, seborrheic dermatitis, atopic
dermatitis, psoriasis, and vitiligo) or active retinoid dermatitis
• Fitzpatrick skin types IV, V, and VI*
*These contraindications are for medium- and deep-depth peels and do not apply to touchups.
Comprehensive medical and surgical history and physical examination
• Bleeding complications/risks from prescription and herbal medicine
Is the patient taking isotretinoin, birth control pills, or immunosuppressants?
• Is the patient pregnant?
• Patients having a history of cold sores require herpes simplex prophylaxis.
•
• Does the patient have a history of hypertrophic or keloid scars?

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Part V Noninvasive and Minimally Invasive Therapy
• Does the patient have a history or risk of hepatitis or HIV?
• Does the patient have certain cutaneous diseases in the operative site?
TIP: Patients with rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, or
vitiligo may be at increased risk for postoperative complications, including disease
exacerbation, prolonged erythema, contact hypersensitivity, or delayed healing.
Patients with rosacea have a vasomotor instability and may develop an exaggerated

• What skin regimens have been used and what were the results?
• If patient has history of skin rejuvenation, what type of rejuvenation was done, what
were results, and did problems occur?
• Identify dyschromias and determine the best depth of peel (Box 19-2).
• Determine depth of pigmentation using a Wood lamp.



Deep dermal hyperpigmentation is not seen or is less pronounced.
TIP: The worse the patient looks under a Wood lamp, the more superficial the
pigmentation.
Box PEEL RESULTS FOR DIFFERENT DYSCHROMIAS


Excellent Results
Excellent Results
Ephelides
Ephelides
Epidermal hyperpigmentation
Epidermal melasma





hyperpigmentation





Senile lentigines
Variable Results
Variable Results




melasma
hyperpigmentation


hyperpigmentation
Senile lentigines
Poor Results
Poor Results
Dermal melasma
Nevi


hyperpigmentation
Junctional nevi
Seborrheic keratoses

233
Chapter 19 Chemical Peels
• Determine and document patient’s skin type (using the Fitzpatrick skin type
1 and photoaging grouping (Tables 19-1 and 19-2), degree of actinic
damage, sebaceous gland density, dyschromias, suspicious lesions, and scarring.
• Point out any skin excess and gravitational changes that will be corrected by
chemical peels.
Standard preoperative photographs for surgical planning (see Chapter 3)

Analysis and operative planning based on patient’s desires, clinical examination, and
photographs.




I
Pale white, freckles, blue eyes, blond or
red hair
Always burns, never tans
II
Fair white, blue/green/hazel eyes, blond
or red hair
Usually burns, minimally tans
III
Cream white, any hair or eye color
Sometimes burns, tans uniformly
IV
Moderate brown (Mediterranean)
Rarely burns, always tans well
V
Dark brown (Middle Eastern)
Rarely burns, tans easily
VI
Dark brown to black
Never burns, tans easily
Glogau Photoaging Scale
Type


I (mild)
Wrinkles not present or
minimal
Early photoaging
No keratoses, pigmentary changes
Patient generally wears minimal or no makeup
Typical age range: 20s-30s
II (moderate)
Wrinkles present only
when skin is in motion
Early to moderate photoaging
Early actinic keratoses
Sallow color
Smile lines begin
Patient generally wears some makeup

III (advanced)
Wrinkles present when
skin is at rest
Advanced photoaging
Dyschromias, telangiectasias
Actinic keratoses
Persistent wrinkling
Patient always wears makeup
Typical age range: 50s or older
IV (severe)
Only wrinkles
Severe photoaging
Yellow-gray skin
Dynamic/gravitational wrinkling throughout
Actinic keratoses ± skin malignancies
No normal skin
Patient wears makeup, but coverage is poor (it cakes or
cracks)
Typical age range: 60s or older

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Part V Noninvasive and Minimally Invasive Therapy
NONFACIAL PEELING
INDICATIONS

• To remove sunburn freckles across the shoulders and upper back
• To improve acne scars
•

•
and sunburn freckles
• To improve acne scars, especially in areas of hypopigmented scars and
hyperpigmented actinic damage
•
•

• To improve hyperpigmented macules (age spots)
•
• To improve rough texture
SOME KEY POINTS2
It usually takes areas to heal than the face. Patients need
to be sure they have time to undergo this type of therapy before having it done.
Dermal peels on the arms, hands, neck, and chest are more prone to scarring or
abnormal textural changes. It is safer to perform in these areas.
Dermal hyperpigmentation and most types of scars on nonfacial areas should not be



patients their best results. Nonfacial peels are usually repeated several times to achieve
the best response.
Most nonfacial peels are performed on large areas of skin (a larger surface area than
the face). If a peeling agent with potential toxicity is used, there is a greater risk of
developing a systemic reaction.

patients to care for it, and the greater the chance of a complication, particularly
premature peeling or infections.
INFORMED CONSENT

No warranties, guarantees, or special contracts about the success and longevity of the
procedure
Review of the healing process and how the patient will look and for how long
Possible need for additional surgeries/procedures
Complications, especially pigment changes (hyperpigmentation and
hypopigmentation), scarring (including keloids, hypertrophic scarring), fever blisters
(herpes simplex) activation, infection, milia, and “pink areas” (erythema)
Review (with the patient) the things chemical peels can and cannot do (Box 19-3).

235
Chapter 19 Chemical Peels
Box THINGS CHEMICAL PEELS CAN AND CANNOT DO


Correct sun damage (actinic degeneration)
Decrease pore size—chemical peels might
Flatten mild scarring
increase pore size
Remove rhytids
Improve skin laxity
Improve irregular hyperpigmentation
Improve deep scarring


Totally remove hyperpigmentation in


dark-skinned whites, Asians, and blacks


Remove vascular lesions
PEEL PREPARATION

(epidermal injury)

• Deep (mid-dermal injury to the reticular dermis).
is dependent on:
• Chemical agent used
• Concentration
• Time of application before neutralization
• Number of coats and the amount of peeling agent placed with each application (i.e.,
degree of wetness of the applicator)

used are summarized in the section Common Chemical Peel Agents.
Epidermis
Papillary
dermis
Upper reticular
dermis
Upper to mid-
reticular dermis
Deep peel
Shallow peel
Skin anatomy and chemical peel depth.
COMMON CHEMICAL PEEL AGENTS
GLYCOLIC ACID4

• Not light sensitive: Does not need to be stored in a dark bottle

• Deliquescent (absorbs moisture): Must be kept in a tightly capped bottle

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Part V Noninvasive and Minimally Invasive Therapy

• Most practitioners use 30%-70% glycolic acid and neutralize the skin with a
bicarbonate solution or rinse with water at the onset of erythema.
• Caution must be used, because uneven peeling and dermal wounding can occur.

• Moy et al
5 found a protocol of 10%-15% glycolic acid applied twice daily and


6 using a similar protocol for 10
months, reduced wrinkles in 21 of 27 patients.

• Piacquadio
7 concluded that retinoids, light TCA peels, and glycolic lotion represent a
better consumer value than glycolic acid peels.
TIP: Glycolic acid is an alpha-hydroxy acid (AHA) made from sugar cane. Other AHAs
include lactic acid (from sour milk), malic acid (from apples), citric acid (various fruits)
and tartaric (from grape wine).
JESSNER SOLUTION4
Formulated by Dr. Max Jessner. The combination allows decreasing the concentration and
toxicity of each ingredient.

• Contains and
• Retains strength for up to 2 years if container is opened for only 5 minutes per
month
• Light and air sensitive! May develop a salmon-colored tone on exposure to light and
air—store in a dark amber bottle with a tight cap

• It creates a uniform-depth peel that results in an excellent exfoliation.
• It is useful in treating hyperpigmentation by increasing epidermal turnover and
yielding a decrease in the number of melanin-containing keratinocytes.
• Complications are rare because of the limited penetration.
• Use is limited to the face because of the potential for salicylate (tinnitus, headache,
nausea) or resorcinol (methemoglobinemia and hypothyroidism with prolonged
use) toxicity.
• It is thought to break the intracellular bridges between keratinocytes and has the
capacity to remove the epidermis.

• Depth is controlled by
• No neutralization is needed.
• It can be combined with TCA for a medium peel.


exfoliation is seen for 8-10 days when a frost is achieved; however, no weeping or
crusting is seen, because it remains an intraepidermal peel.

237
Chapter 19 Chemical Peels
TRICHLOROACETIC ACID

light sensitive
• Refrigeration needed
• Stable for at least 23 weeks in an opened container
• 20%-100% TCA stored in an unopened TCA-resistant clear plastic container for
2 years—TCA concentration within 3% of the labeled strength
• Colorless and clear
• Free of precipitate

• TCA is commonly used in concentration for medium-depth peeling
penetrating into the upper reticular dermis.
• The concentration, skin preparation, pretreatment skin type, and method of
application contribute to the peel depth obtained.
• An intraepidermal, epidermal, or papillary dermal peel can be successfully obtained

porcine model at 24 hours using 20% TCA; however, no change in the number of

8
• Dolezal9
Has no frost, and the skin looks slick and shiny, which represents
removal of the stratum corneum.
Has an irregular, light frost with some erythema; this is an

Has a pink-white frost, which suggests a full-thickness epidermal peel,
and heals in about 5 days.

retinacular dermis. Johnson et al
10 described an additional sign of “epidermal
sliding” for a papillary dermal peel.
CROTON OIL PEEL

• Initially utilized by “lay peelers.” The formula was obtained by Tom Baker in the early
1960s. The original Baker Gordon formula utilized high concentrations of phenol
and croton oil (50% phenol, 2.1%-2.4% croton oil). Although excellent results could
be obtained, long-term hypopigmentation became a problem and croton oil peeling
fell into disfavor.
• Phenol-croton oil peeling regained popularity in the early 2000s due to the work
of Hetter
11-14 and later Stone and colleagues.15-16 Hetter refuted a number of
the concepts espoused by Baker (phenol-croton oil peeling is an “all or none
phenomenon,” and decreasing concentrations of phenol led to deeper injury).
But most importantly both Hetter and Stone demonstrated by reducing the

while the results could be maintained.

• Stone suggested that the depth of peeling is dependent on the concentration of
both the phenol and croton oil, whereas Hetter suggested that croton oil is the
critical agent determining peel depth.
• Ozturk et al
17 stated that a concentration of 33% phenol and 1.1% croton oil is

the perioral area.

238
Part V Noninvasive and Minimally Invasive Therapy
• Gatti et al18 stated that treatment of the lower lids with phenol 22% and 1.1% croton







and testing of kidney, liver, cardiac function

concentrations of phenol and croton oil.

PHENOL ROTON OIL AND TCA PEELS
Although traditionally TCA was considered a medium-depth peeling agent and phenol-
croton oil a deep peeling agent, this has clearly been disproven by Hetter and Stone.

(epidermal), intermediate (papillary dermal), or deep (mid-reticular dermal) levels
depending on:
1. Concentration of agents used
2. Number of applications
3. Wetness of the applicator
Most critical to the level of the peel is the
• frost suggests injury to the papillary dermis; dense white frost suggests
suggests mid-reticular dermal
injury.
Therefore, TCA and croton oil peels should not be thought of as intermediate or deep

increases their respective versatility.
SALICYLIC ACID

• Made into a paste and spread over the skin using a tongue depressor
• Formula: Salicylic acid powder USP, 50%; methyl salicylate, 16 drops; Aquaphor, 112 g




arms. Patients will need to have their hands/arms wrapped in plastic wrap and gauze
for 48 hours.
• In concentrations of 3%-5% it is keratolytic and enhances topical penetration of other
agents.
• It has mild potency as a fungicide.

dizziness, and/or headache several hours after the peel. Increased water intake and
removal of the bandage may improve mild salicylism.

239
Chapter 19 Chemical Peels
• Application of salicylic acid will cause mild stinging for 1-3 minutes followed by

washed with water.
• Peeling starts around days 3-5 and continues until day 10.
BETA IPOHYDROXY ACID

• Eight-carbon fatty chain linked to a benzene ring (derivative of salicylic acid)
• Available in formulations of 5% and 10%


neutralization is not required.
• It reduces melanosome clustering and epidermal pigmentation and is used for
treatment of photoaged skin and acne.
• It increases the skin’s resistance of UV-induced damage.

• The corneosome-corneocyte interface is targeted to cleanly detach individual
corneosomes, preventing desquamation in clumps and resulting in skin smoothness.
KEY POINTS FOR ETHNIC SKIN
Ethnic skin may respond unpredictably to chemical peels regardless of phenotype.
and
and chemical peels should only be approached
with caution in this patient population. Prolonged pretreatment suppression with
4% hydroguinone is critical.
Consider modifying the peel technique: Spot treat lesions instead of treating the entire face.
Indications
• Dyschromia
• Acne
• Scarring

• Melasma
• Pseudofolliculitis barbae
Chemical peel formulations considered safe to use in ethnic skin include:
• Beta-lipohydroxy acid: 5%-10%
• TCA: 10%-20%
• Glycolic acid: 20%-70%
• Salicylic acid: 20%-30%

• Jessner solution

Preparation of patients may include oral antibiotics and antivirals, facial cleansing, and

require no preprocedure prophylaxis, whereas deeper peels may place susceptible
patients at higher risk of herpetic outbreaks and should be covered with an appropriate
antiviral agent. Skin preparation may include vigorous cleansing with an exfoliant to
remove oils and debris.

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Part V Noninvasive and Minimally Invasive Therapy
Patients should be instructed to start a vitamin A (retinoic
acid 0.1% cream daily for a minimum of 2 weeks before the peel) and glycolic acid
skin conditioning program for 6 to 8 weeks before the procedure. Preconditioning the
skin causes treated skin to heal faster by 3-4 days by increasing its metabolism—from
accelerated cellular division and new collagen formation.
20-22
TIP: All-trans-retinoic acid (tretinoin) will speed epidermal healing and enhance the
22
Patients undergoing a peel to improve hyperpigmentation
(any depth) need to use before

hyperpigmentation (determined by history—does the patient’s scar turn dark?). In
addition to tretinoin, two other products are available, hydroquinone and kojic acid, in
the following preparations:
23-24
• 4% Hydroquinone preparation
• 2% Hydroquinone with 10% glycolic acid gel
• 2% Hydroquinone with 2% kojic acid and 6% AHA gel base
TIP: 4% Hydroquinone is prescription strength, and 2% is not. However, 2%
hydroquinone combined with 10% glycolic acid is equally effective. Kojic acid is
an alternative bleaching agent that can be used on patients who do not tolerate
hydroquinone.
TECHNIQUES
SAFETY CHECK BEFORE PEELING
Always check the label on the bottle of any chemical to be applied to a patient’s skin.
Accidental application of the wrong acid can create serious problems.
Never pass an open container of acid (or an applicator wet with acid) over a patient’s
face. Acid could accidentally spill onto the skin.

head at least 30-45 degrees. Failure to elevate the head increases the chances of acid
collecting around the eye.

Watch for tears with all peels. A tear running down the cheek onto the neck can create
an area of peeling on the neck.

solution), always know whether the preparation is made by the same weight-to-volume
measurement. With glycolic acid, note whether the pH of the new solution is the same
as the pH of the previous one.
Before peels, always ask patients whether they:
• Recently had a facial waxing
• Recently used a facial depilatory
• Recently had electrolysis
• Recently had head or neck surgery

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Chapter 19 Chemical Peels
• Have taken isotretinoin (13-cis-retinoic acid [Accutane]) within the past 1-2 years
• Are currently using retinoic acid (Retin A) or AHAs

a peel.

starting 2 days before and until healing is complete.

broad-spectrum sunscreen daily.
ANESTHESIA: OFFICE ASED1,2
: Anesthesia is generally not needed. Explain to patients they will feel
a warm stinging-burning discomfort that will last for 15-30 minutes. If there are no
contraindications, patients can take over-the-counter NSAIDs before the procedure to
help with discomfort.

pain is intense and lasts for 2-3 minutes. Strategies to address the pain include:
• Patients can take NSAIDs an hour before the procedure.
• Use a fan to cool patients during the peel.
• Perform the peel in anatomic units to allow one section to cool before performing
the next.
• Narcotics: Intramuscular meperidine and hydroxyzine, or intravenous midazolam or
fentanyl, or oral diazepam is given before the procedure.
• Nerve blocks: The entire face can be adequately anesthetized with 12 injections (Fig.
19-2). Patients must decide if 12 injections is a fair trade for 3 minutes of burning pain.

depth of a TCA peel.
SENIOR AUTHOR TIP: With topical anesthetics, apply a lower strength of TCA than
originally planned, because unrecognized vasoconstriction will lead to a deeper peel.
SO
ST
IO
AE
IT
M
Transcutaneous
Intraoral

nerve block and mapping of nerve distribution. The

on each side and two centrally). Usually, only 1 ml
of lidocaine is needed at each site. The infraorbital
nerve can be blocked by intraoral needle placed
cephalad between the bicuspid teeth above the
periosteum in the midpupillary line. Alternatively,
an injection can be performed just cephalad and
lateral to the nasolabial fold. The mental nerve
is reached by inserting the needle between the

point down the mandible. The remaining sites are
anesthetized with a direct, transcutaneous approach.
( External branch of the anterior ethmoidal nerve;
infratrochlear nerve [V2]; SO, supraorbital nerve
[V1]; supratrochlear nerve [V1].)

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Part V Noninvasive and Minimally Invasive Therapy
DEGREASING THE SKIN
Before a chemical peel, the skin must be adequately prepared with a degreasing agent
to remove debris and allow a uniform penetration. Proper degreasing allows deeper
penetration of the agent.
•

(povidone-iodine or chlorhexidine) and then self-scrubs with acetone on gauze
for 3 to 5 minutes. Patients will almost always underscrub themselves. The
physician or nurse should wipe the skin again with isopropyl alcohol and then
vigorously scrub it with acetone for 2 minutes to strip the stratum corneum. A
handheld fan can be used to disperse acetone fumes.
•

2 minutes.

23 Acetone has the

ambulatory surgery centers. Rubbing alcohol is a mixture of isopropyl alcohol, acetone,
methyl isobutyl ketone, and water. Hibiclens is a detergent and surfactant, nontoxic,
and has a pH of 5-6.5. It has the disadvantage of the additional step of rinsing the skin
thoroughly and drying it to eliminate surface residue.
CHOICE OF APPLICATOR AND MODE OF APPLICATION
Pouring the wounding agent into a glass cup before application will eliminate
contamination of the master bottle, prevent cotton-tipped applicator disintegration,
and conserve product.
: Cotton balls are a reservoir for product and are best used for quickly
applying a lotion of glycolic acid.
One moist cotton-tipped applicator rubbed on the surface
with moderate pressure will deliver more solution than a single, lightly applied, slightly
damp applicator. Rubbing the surface with two cotton-tipped applicators with hard
pressure will deliver more product than a single applicator.
- A 4 × 4 gauze sponge wrung out, damp or wet, can deliver
more wounding agent to a larger area.
A 1-inch sable brush used with Jessner solution delivers more agent than a
4 × 4 gauze sponge.
A large cotton-tipped applicator is a reservoir for the agent and can
deliver product over a large area. The large surface area prevents streaking with uneven
application, but it will waste a lot of product. These swabs should not be used with phenol

TIP: Sable brushes are available in art supply stores and can be cleaned with povidone-
iodine solutions.
DILUTION
Once frosting appears, penetration of the agent has already occurred—adding water to

concentration and reproducibility of the peel.

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Chapter 19 Chemical Peels
TCA peels do not need to be “neutralized” or diluted.
AHAs (i.e., glycolic acid) do not frost in the same manner as TCA peels and are
dependent on with the skin. Washing them from the skin after a given
time is important. A 10% sodium bicarbonate solution can also be used.
OCCLUSION
Taping after phenol-croton oil peeling is thought to increase the depth of injury.24

occlusive ointment for absorption and penetration of phenol.
Tape can applied to selected problem areas, and taping the entire face is not
imperative.
Clinically, the results can be the same with or without taping.
SUGGESTED ORDER OF AREAS TO BE PEELED UPERFICIAL AND
MEDIUM EPTH

and still (before the inevitable squirming that will occur once frosting starts).


PERIORBITAL PEELING TECHNIQUE
Photograph demonstrating preprocedure markings and planned phenol/croton oil

and croton oil will peel deeper than lower concentrations, given similar application process (i.e.,
number of swipes). For this patient an upper lip and cheek peel with phenol 33%/croton oil 1.1%
and periorbital peel with phenol 27%/croton oil 0.105%. B, Photograph immediately following
phenol 27%/croton oil 0.105% peel. Note the indicative of controlled injury at the
depth of the papillary dermis.
A
B
The cotton-tipped applicator should be and to prevent dripping of
product into the eyes.
Generally, except for the crow’s-feet area, the entire periorbital complex is thin skinned,
and one applicator should be used for better control.
The applicator must not be passed over the eye. A syringe or bulb of saline solution

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Part V Noninvasive and Minimally Invasive Therapy

1. The head is elevated to 30-45 degrees.
2. Tears are wiped away during the peeling process with a cotton-tipped applicator at
the medial and lateral canthus while the eye is held open to prevent capillary action
from wicking product into it.
3. For the lower eyelid, the eye is opened and the patient looking up. Product is applied
within millimeters of the eyelash margin by moving from the lateral crow’s-feet to
the medial canthal area.
4. For the upper eyelid, the eye is closed. Application proceeds from the lateral to
inner canthal area. Product is not applied below the superior tarsal plate to prevent
edema. However, if sun damage is severe enough to warrant peeling within

TCA is used.
5. Ice pack application over the eye will help with postpeeling swelling—5-10 minutes
for TCA peel and 6 to 8 hours after phenol application.
If performing periorbital peel only: Always peel to the orbital rims to prevent a line of

blending the demarcated areas.
TIP: Some physicians advocate using protective ophthalmic ointment petrolatum.
The ointment may promote excessive tearing and blinking and is unnecessary if the
cotton-tipped applicator is well wrung out.
PERIORAL PEELING TECHNIQUE
Peeling agent should be applied 3 mm onto the vermilion border.
Manually stretching the skin will allow deeper and more even penetration.
The wooden end of a cotton-tipped applicator can be used to apply agent to an
individual rhytid, especially on a repeat peel.
For especially deep, severely damaged actinic skin damage, aggressive pre-peel
defatting of the area with heavy application of the agent seems to work well. Another
method is to use selective occlusion.
If peeling the perioral area only, agent is applied to at least immediately beyond the

prevent lines of demarcation.
TECHNICAL TIPS
GLYCOLIC ACID
The skin is cleaned with a gentle wipe of acetone or alcohol. Excessive defatting before
a 70% glycolic acid peel may cause undesirable erythema or pigmentation.
The agent is applied rapidly, covering the entire face within 20 seconds. Glycolic acid
comes as a liquid or lotion. A large cotton applicator or cotton balls are used to apply
the product. To create an even peel, the product must have the same contact time
throughout the face. See Table 19-3 for recommended glycolic acid concentrations and


with water-soaked gauze, or the patient can go to the sink and splash water over the
face. Ensuring the entire product is diluted is critical.

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Chapter 19 Chemical Peels
TIP:
have NO advantage over tap water. Ensuring that water-soaked gauzes or a 10% sodium
bicarbonate solution is available before applying the agent is essential.




Acne

50-70

1-3
Melasma

50-70

2-4
Actinic keratoses

70

5-7
Fine wrinkles

70

4-8
Solar lentigines

70

4-6
Back or chest—any indication

70

5-10
TIP: Glycolic acid can create dermal wounds. Never tell patients it is a “risk-free” peel.
Glycolic acid peels usually need to be repeated several times for best results.
Some patients will have amazing results from glycolic acid peels and others will not.
Stress to the patient that results
Glycolic acid peels The longer
the peel is left on the skin, the deeper it will penetrate.
Glycolic acid peels can induce postinflammatory hyperpigmentation and create

JESSNER SOLUTION
Jessner solution is excellent for use in acne patients, because resorcinol is a well-known

resorcinol and salicylic acid, it should not be used over large surface areas of the body.
• Clean skin with a gentle wipe of acetone or alcohol.
• Apply Jessner solution in a uniform layer. Any of the applicators mentioned
previously can be used. Most advocate using a sable brush.

the method used for patients with thick, sebaceous skin.

applicator: sable brush, cotton-tipped applicators, or cotton balls.
• Observe for skin changes based on the level of peel. Each deeper level requires
additional coats of Jessner solution, and each coat takes 4-6 minutes for the full skin
reaction to occur.

erythema and light, powdery-looking whitening on the face (not to be confused

ball.
Requires two or three coats. With deeper penetration, erythema
becomes more pronounced, turning bright red. Some smaller areas of white frost

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Part V Noninvasive and Minimally Invasive Therapy
stinging for 15-30 minutes. The next 1-3 days will develop persistent, mild red-
brown coloration. For 2-3 days, patients may feel like cellophane is on their face,
and for the next 2-4 days their face exfoliates (appearing windburned instead of
actually peeling).

exfoliation may take as long as 8-10 days. Some actual peeling may occur.
• Dilution or neutralization is needed.
TRICHLOROACETIC ACID

The head should be elevated 45 degrees—patients are more comfortable and there is
less chance of acid pooling around the eyes.
The head should be stabilized with one hand so the other hand can press fairly hard
with a gauze applicator as the acid is applied.
When applying the TCA below the eyes and in the crow’s-feet area, the surrounding
skin is pulled tight so that the acid gets to the bottom of the wrinkles and prevents acid
from wicking into the eye along the wrinkle.
Overlapping coats of TCA will increase the depth of the peel. When using low strengths
(<25% TCA), this is not much of a problem, but with higher concentrations, an area of
accidental overlap can be a problem. This is prevented by always following the same
pattern of application.

TCA is a chemical cauterant, which coagulates proteins in the skin. This is the basis for
the formation of the white frost seen when TCA is applied to the skin. The deeper the
peel performed with TCA, the more intensely white the frost. Again, the nature and
density of the frosting is the critical factor determining the depth of injury as espoused
by Obagi.
10,25

The patient is seated at 45 degrees.
TCA is applied with folded 2 × 2 gauze sponges to allow the TCA to be rubbed into the
skin. The sponge should be wet enough to allow a few drops to escape if squeezed.
TCA is applied in a systematic fashion (Fig. 19-4).

PAUSE



proceeding.

• An alternative application procedure has the advantage of applying TCA to the

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Chapter 19 Chemical Peels
Sequence for a TCA peel. After step 5, the physician pauses to observe the results and
to allow the patient’s skin to cool. After step 8, the physician pauses again to observe results of
steps 6 through 8.















upper eyelid

Right forehead/
upper eyelid
Step 5
Nose
Pause and
observe


eyelid/cheek
Step 8
Perioral area
(left to right)
Pause and
observe

Right lower
eyelid/cheek






















TIP:
dermal), gray-white (mid-reticular dermal).

A second coat of acid is applied over the area that has already frosted. (It is safest to
decrease the strength of TCA in the second coat by 5%-10% to prevent too deep a peel.)
When applying the TCA to the next (previously untreated) area on the face:
• A gauze sponge that is wetter is used. It will allow application of a greater quantity
of acid, which will create a deeper peel.
• The acid-soaked gauze is rubbed more aggressively into the skin, in an attempt to
overlap areas of application.
Once the appropriate frost has been achieved, rinsing the patient’s face with room

Some physicians advocate applying ice packs to the skin after the peel to cool the skin
and to decrease residual burning. Many patients are hypersensitive immediately after
the peel, and ice packs may be too uncomfortable for them.
TIP: If water or ice compresses are applied to the skin after a TCA peel, the stratum
corneum will be hydrated and more TCA cannot be reapplied, because the acid will be
rapidly diluted by the water trapped in the stratum corneum.

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Part V Noninvasive and Minimally Invasive Therapy
COMBINATION PEELS
Combination peels allow deeper penetration at lower concentrations. The following are
common combinations.
JESSNER SOLUTION AND TRICHLOROACETIC ACID
Skin is cleaned in the normal fashion.
One to four layers of Jessner solution is applied to the face with the endpoint of fairly
uniform erythema with areas of little frost. Wait 5 minutes between applications.
TCA 35% is applied in the usual manner. This penetrates more rapidly and uniformly
than when it is applied to untreated skin.
In patients with thick, sebaceous skin, several coats of Jessner solution may be needed.
Patients with thin or dry skin generally do not need this combination treatment.
TIP:
be created. Jessner solution stings and burns—after it is applied, patients will be more
sensitive and uncomfortable when TCA is applied. Applying coats of Jessner solution
will add an additional 15-30 minutes to the procedure.
GLYCOLIC ACID AND TRICHLOROACETIC ACID
Patients are primed as usual, but the skin is not cleaned.

TCA 35% is applied in the normal fashion.


one.
Applying water to dilute a glycolic acid peel will hydrate the stratum corneum and may
dilute TCA when applied.
Dots are placed along the mandibular ramus as a reminder to use the peel caudal
to this line.


Cardiac monitoring equipment is placed, a pulse oximeter and blood pressure monitor.
Sedation and analgesia are given. A facial nerve block is performed, longer-acting
anesthetics—bupivacaine, ropivacaine, or etidocaine may be used.
The face should have been thoroughly washed the night before and morning of surgery.
Patients should have NO makeup on.
The skin is cleaned using Septisol (hexachlorophene with alcohol) or acetone.

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Chapter 19 Chemical Peels
The phenol wounding agent should be applied with moist but not very wet cotton-
tipped applicators or 2 × 2. Deep rhytids can be individually addressed before the rest
of the cosmetic unit.
The wound agent should be applied to each cosmetic unit in this order:
• Forehead

• Right cheek
• Perioral area
• Nose
• Periorbital area

To minimize the risk of renal and cardiac toxicity, 10-15 minutes should elapse between
applications to cosmetic units before a new coat is applied. Thus the peel is completed
in 60-120 minutes.
TIP:
TAPING NCREASES DEPTH OF INJURY OR PETROLATUM LLOWS
WOUND OBSERVATION
Tape is applied to each segment as the peel progresses or, if using the croton oil peel,
after the peel is completed.
Tape is precut into 1.5-4 cm strips.
The tape is applied along the inferior border of the mandible in a sawtooth pattern.
This pattern will produce an irregular line that is less noticeable. Tape placement is
expanded out from there by applying the tape 1-2 cm parallel to the inferior border of
the mandible.
Stuzin et al24 found that application of petrolatum (Vaseline) immediately after the peel
is an alternative to taping. It will provide a vapor barrier to prevent phenol evaporation
and increased maceration and penetration.
SENIOR AUTHOR TIP: Petrolatum (Vaseline) should be applied as a thick layer
immediately after a region of the face has been treated with the wounding agent. THE

injury of the peel.
Tape removal
• The mask is removed in 48 hours when the exudate has lifted the tape. The mask
should be removed as a single unit, not as individual strips of tape.
TIP: Repeat peeling can be performed in 12-18 months if necessary. Individual rhytids
or spot areas can be retouched in 6 months.

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Part V Noninvasive and Minimally Invasive Therapy
POSTPEEL CARE AND INSTRUCTIONS TO PATIENTS
ALPHA YDROXY ACID PEELS LYCOLIC ACID
Do not expect to really “peel.” Most patients have a little redness for 12-24 hours.

area of crusting may develop. If this occurs, apply an antibiotic ointment to the area

Apply a bland moisturizer to the skin as often as needed. Do not apply any medications
or glycolic acid products during this time—it will irritate the skin.
Do not expect to see much reaction to this peel. Most patients look normal the day

until about 2-3 weeks after the peel.
JESSNER PEELS
The face may appear slightly redder than usual for 7 days. In general, the peeled area
will appear mildly or moderately sunburned.
Peeling usually occurs from day 2-5 after treatment. The skin will become very dry, and
small cracks may develop.
Skin should be cleaned with a nondrying cleanser such as Dove, Neutrogena, or

Aquaphor should be applied.
Makeup may be applied as usual.

Topical medications such as retinoic acid (Retin A) and glycolic acid should not be
applied for several days after the peel.
TRICHLOROACETIC ACID PEELS
Blistering, crusting, and peeling skin can occur for about a week.
Treated skin should not be picked or rubbed.
When washing hair, the head is tilted backward in the shower or in the sink. Too much
water will cause premature peeling and leave red, sore areas that may lead to scarring
or the need to be treated again.

scissors.
Avoid the sauna, Jacuzzi or strenuous exercise. Sweating will sting and cause premature
peeling.
Minimize facial expressions for a week after the peel. Excessive facial movements will
cause the skin to crack prematurely.
The face should be washed gently for 20-30 seconds twice a day using a mild, quality
liquid soap (Dove, Neutrogena, or Cetaphil). The soap is lathered in the hands and
gently patted onto the face. Rinse with a splash of lukewarm water. Dry by patting
gently with a clean towel.
A petrolatum-containing ointment (Aquaphor, Vaseline) or Preparation H should be
used after washing. A tube is more sterile than a jar.
Do not let the skin dry out. Ointment can be applied 10 times a day to prevent the skin
from drying. A well-moisturized face will reduce tightness and will enhance comfort.
Exercise by walking in the early morning or late evening when the sun
is barely out.

251
Chapter 19 Chemical Peels


will resolve on its own. Sleeping with an extra pillow to elevate the head may help to
decrease swelling.
Ice packs or cold compresses should NOT be applied to the face to decrease the
swelling. The moisture from these may cause the skin to peel prematurely.
Sleep on the back to prevent rubbing the peeling skin against the pillow. This could
create an area of prematurely peeled skin.
Sunscreen must always be worn when outside.
Makeup may be worn 1-2 days after peeling is complete.
CAUTION:

CROTON OIL PEEL

until the bandages are removed (if present). Cool ice packs may be applied to the
outside of the bandages.
If no bandages are in place, those areas should be kept moist consistently with
ointment.
Swelling will be considerable, and drainage may appear underneath the tape after the

Sleep with the head elevated on several pillows.
Minimize talking or biting/chewing after peeling; sipping liquids through a straw is
helpful.
After the tape is removed, wash in the shower with a mixture of Betadine Skin Cleanser

Do not use a washcloth or other exfoliating aides. After each washing, a moisturizing
ointment should be applied as a thick coat. If no tape is present, wash in the shower
after 48 hours.
Swelling begins to subside after day 5, and the peel is usually healed by day 14.
DO NOT PICK AT THE CRUST.
Avoid prolonged constrictive use of caps, shower caps, eyeglasses, or visors in peeled
areas until the skin has healed over.
If pain or fever blisters develop anytime during the peel process, have the patient call

Itching 7-14 days after healing is common. Excessive redness and itching may be
caused by allergy to the ointment. If this happens, switching to Vaseline or Crisco is
appropriate.
Most patients can return to work as soon as day 14. Makeup and sunscreen can be
applied on any area that has healed.

may result in microhemorrhages and red blotching.

selected deep wrinkles.
Complete avoidance of the sun is critical. Exposure to sunlight, getting pregnant, or
taking birth control pills before the redness has disappeared may cause blotchiness or

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Part V Noninvasive and Minimally Invasive Therapy
The redness from deep peeling is usually resolved 90-180 days after peeling.
Occasionally, localized areas may persist as long as 18 months.
In lighter-skinned individuals (Fitzpatrick I), redness is more persistent and may last for
months.
SIMULTANEOUS FACELIFT AND CHEMICAL PEEL

simultaneously with a chemical peel.29-31
Fulton31
facelift.
A deep, full-face phenol peel should NOT be done simultaneously over undermined

healing. However, croton oil peeling can be performed at the same time as a facelift
in areas not undermined. Therefore, perioral and periorbital peeling at the time of
facelifting is safe.
17
All preoperative considerations for a face peel should be followed for the facelift.
Patients can expect the skin to begin peeling around day 3 or 4 after the peel. The
duration of exfoliation is directly related to the depth of the peeling.
Skin hydration with a petrolatum-based moisturizer is paramount.
EXPECTED RESULTS
Photograph during chemical peel
of the face. In the region of the cheek note
the abating dense white frost in the cheek.
The concentration in the cheek was phenol
33%/croton oil 1.1%.
A
B
Preprocedure photograph. B, Postprocedure photograph 3 years after full-face

perioral rhytids with minimal hypopigmentation of the skin.

253
Chapter 19 Chemical Peels
A
B
Preprocedure photograph. B, Postprocedure photograph 3 years after facelift, fat

improvement of perioral rhytids with minimal hypopigmentation of the skin.
A
B
Preprocedure photograph demonstrating periorbital hyperpigmentation. B, Post-

improvement in hyperpigmentation.
COMPLICATIONS
Complications can be divided into three categories: during procedure, early
postprocedure, and late postprocedure.
DURING PROCEDURE COMPLICATIONS
Usually a result of errors in technique

• Tears can drip down the cheek and dilute the acid. This will result in a strip of skin

• Tears can drip down the cheek and neck, bringing acid with them. The path of
an acidic tear can burn the skin, easily scarring the neck (especially if the acid
concentration is high).
SENIOR AUTHOR TIP: Someone should watch the patient and blot any tears
immediately with cotton-tipped applicators. If a tear should reach the neck, the area
should be washed with water to dilute the acid.

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Part V Noninvasive and Minimally Invasive Therapy

• This is usually caused by inadequate degreasing with acetone.
• This can also be caused by overlapping of peeled areas.


• May occur with phenol-based peels
• Usually premature atrial and ventricular contractions
• Cardiac monitoring necessary with phenol-based peels
• Most arrhythmias reversed with hydration, supplemental oxygen, and stopping
the peel. Whether phenol-croton oil peel is causative with regard to arrhythmias is,
however, debatable.
EARLY POSTPROCEDURE COMPLICATIONS

and species are the most common.
species, mycobacteria, and fungi.
• Bacterial and fungal infections are rare in the absence of prolonged occlusive taping
methods.

• Early detection and aggressive treatment can prevent long-term and disastrous
sequelae.
TIP:
and generally mild. Sudden deterioration of the peeled area is suggestive of infection

The necrotic skin created by the peel functions as a protective


are common signs of premature peeling:
• A sharply demarcated area of bright erythema
• A peel that is completed within 1-2 days of the expected halfway point of the peel.
• No evidence of old peeling skin can be found. (Usually compliant patients will have
small areas of peeling skin in the hairline.)
TIP: Patients with signs or symptoms of premature peeling should be confronted
about the possibility of them picking at the scab. This should be documented in the
medical record and the patient counseled about the possible complications.

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Chapter 19 Chemical Peels
LATE POSTPROCEDURE COMPLICATIONS

bumps
• Usually occurs 3 weeks after procedure
• Found most often around the periorbital area
• Responds well to topical vitamin A derivatives, which prevents future outbreaks with
continued use
• Can also be physically extracted
Tender erythematous follicular papules. Caused by follicular
occlusion from emollients or ointments.
• Treatment: Topical antibiotic therapy with clindamycin or erythromycin or systemic
therapy with tetracycline and erythromycin
• Typically clear in 5-10 days

• Can occur as early as 10-14 days, but most cases occur 4 weeks postoperatively.



spontaneously.




can resolve the problem completely

added.

treatment to diminish pigment.
(pink areas)
• This is almost completely self-limiting within 6 months (most within 3 months)
• Patient will need reassurance.
• Topical steroid treatment will resolve the erythema for very anxious patients.

• This results from excessively deep penetration.

• Treatment of the scar with serial intralesional triamcinolone injections often resolves
the problem.
• Resistant scars may need dermabrasion or laser resurfacing followed by silicone
sheet therapy.

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Part V Noninvasive and Minimally Invasive Therapy
TOP TAKEAWAYS



The goal of chemical peeling is to produce a controlled partial-thickness skin
injury, mitigating pigmentary disorders, solar damage, and aging.

Pretreatment (priming) with Retin-A and hydroquinone is helpful to minimize
posttreatment hyperpigmentation, especially in darker-skinned patients.

Pretreatment with Retin-A and AHAs can smooth skin texture, optimizing the
peeling outcome. Moisturizers and sun-blocking agents further enhance the
result.

The propensity for complications and untoward reactions is directly related to
the depth of peeling.


concept. Phenol-croton oil and trichloroacetic acid (TCA), formerly considered
deep and intermediate peeling agents respectively, can instead be used as

by reducing the concentration of agents used, reducing the number of
applications, or the wetness of the applicator.

Critical to predicting the depth of injury is assessing the nature and intensity of
frosting: pink-white suggests injury to the level of the papillary dermis; dense



inappropriate concentrations, or even with aggressive skin preparation.

Secondary alteration of skin pigmentation is the most common complication.

Damage to the melanocytes at the epidermal-dermal junction leads to
hypopigmentation. This is more common in fair-skinned patients, and especially
after phenol peeling.


melanocyte overstimulation. Darker-skinned patients are more prone to this
complication, especially with premature sun exposure.

Scarring, the most serious, although rare, complication, is usually secondary to
extension of damage to the deep reticular dermis. It is most often encountered
in the perioral and mandibular areas. Heralded by persistent erythema, it usually
begins as an area of induration. It should be aggressively treated with dilute
Kenalog injection (3 mg/ml) on a weekly (not monthly) basis until it is resolved.
Surgical revision may be required.

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Chapter 19 Chemical Peels
REFERENCES
1. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Der-
matol 124:869, 1988.
2. Collins PS. Trichloroacetic acid peels revisited. J Dermatol Surg Oncol 15:933, 1989.


Surg 104:854, discussion 865, 1999.

Dermatol Surg Oncol 19:243, 1993.
6. Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis 43:222,
1989.
7. Piacquadio D, Dobry M, Hunt S, et al. Short contact 70% glycolic acid peels as a treatment for
photodamaged skin. A pilot study. Dermatol Surg 22:449, 1996.
8. Roenigk RK, Brodland DG. A primer of facial chemical peel. Dermatol Clin 11:349, 1993.
9. Dolezal J. Trichloroacetic acid solutions and basic pharmacy. In Rubin MG, ed. Manual of Chemi-



Surg 36:225, 1996.

concentrations of phenol and croton oil. Plast Reconstr Surg 105:1061; discussion 1084, 2000.
12. Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeons’ role.
Plast Reconstr Surg 105:752, 2000.
13. Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their croton
oil formulas. Plast Reconstr Surg 105:240; discussion 249, 2000.
14. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast
Reconstr Surg 105:227; discussion 249, 2000.


technique. Clin Plast Surg 9:351, 2001.
-
tion face lift and perioral phenol-croton oil peel. Plast Reconstr Surg 132:743e, 2013.
18. Gatti JE. Eyelid phenol peel: an important adjunct to blepharoplasty. Ann Plast Surg 60:14,
2008.

and photoactivity. Clin Cosmet Investig Dermatol 3:135, 2010.
20. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after trichloroacetic acid chemical
peel. Arch Dermatol 127:678, 1991.

258
Part V Noninvasive and Minimally Invasive Therapy
21. Nemeth AJ, Eaglstein WH, Falanga V, et al. Methods to speed healing after skin biopsy or
trichloroacetic acid chemical peel. Prog Clin Biol Res 365:267, 1991.
22. Mandy SH. Tretinoin in the preoperative and postoperative management of dermabrasion. J
Am Acad Dermatol 15:878, 1986.

trichloroacetic acid peels. J Dermatol Surg Oncol 20:724, 1994.

1989.
-

26. Monheit GD. The Jessner’s-trichloroacetic acid peel. An enhanced medium-depth chemical
peel. Dermatol Clin 13:277, 1995.
27. Coleman WP III, Futrell JM. The glycolic acid trichloroacetic acid peel. J Dermatol Surg Oncol
20:76, 1994.

29. Baker TJ. Chemical face peeling and rhytidectomy. A combined approach for facial rejuvenation.
Plast Reconstr Surg Transplant Bull 29:199e, 1962.

31. Fulton JE. Simultaneous face lifting and skin resurfacing. Plast Reconstr Surg 102:2480, 1998.
32. Roy D. Ablative facial resurfacing. Dermatol Clin 23:549, 2005.

259
PREOPERATIVE EVALUATION
Consultation with the patient to establish (see Chapter 4)
Comprehensive medical and surgical history and physical examination. Some medical
conditions are contraindications to dermabrasion (see Box 20-2).
• Bleeding complications/risks from prescription and herbal medicine

• Is the patient pregnant?
• History of cold sores requires herpes simplex prophylaxis
• History of hypertrophic or keloid scars?
• History or risk of hepatitis or HIV?
TIP: Dermabrasion results in aerosolization of tissue and blood. Physicians and their
assistants (including the anesthesiologist) must take appropriate measures to protect
themselves. This involves wearing a gown, face shield, face mask, and gloves.
• History of connective tissue disorders, cold intolerance, or Raynaud phenomenon?
(These patients may not be candidates if a refrigerant is used.)
• Current and past skin regimens and their results?
• Prior history of skin rejuvenation? When and what kind? Results/problems from
those treatments?
• Tanning history: Does the patient have hyperpigmentation or hypopigmentation?

20-1) and photoaging grouping (Table 20-2), degree of actinic damage, sebaceous
gland density, dyschromias, suspicious lesions, and scarring.
• Skin excess and gravitational changes that will be corrected by dermabrasion
are pointed out.




I
Pale white, freckles, blue eyes, blond or red hair
Always burns, never tans
II
Fair white, blue/green/hazel eyes, blond or red hair
Usually burns, minimally tans
III
Cream white, any hair or eye color
Sometimes burns, tans uniformly
IV
Moderate brown (Mediterranean)
Rarely burns, always tans well
V
Dark brown (Middle Eastern)
Rarely burns, tans easily
VI
Dark brown to black
Never burns, tans easily
SENIOR AUTHOR TIP: Skin types I through III will have a uniform blended skin color
postoperatively. Types IV proceed with caution and best to not dermabrade types V and
VI due to hyperpigmentation postoperatively.

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Part V Noninvasive and Minimally Invasive Therapy
Standard preoperative photographs for surgical planning
• Patients evaluated for facial rejuvenation or scar improvement are asked to provide
photographs of themselves (in repose) when they were younger.
• Preoperative and postoperative photographs are helpful for those who had prior
surgery on their face.

Analysis and operative planning based on patient desires, clinical examination, and
photographs
Patients are given an antibacterial cleanser to wash and shampoo with the night before
and the morning of surgery and prescriptions for cephalexin 500 mg twice per day
for 5-7 days, acyclovir 1 g once per day (twice per day for patients with history of oral
herpes, start the day before the procedure) for 5-7 days, diazepam (or similar relaxant),
and narcotic pain medication.
Test spot close to the area to be treated should be considered. This allows the patient
to experience the procedure in a limited fashion and provides some information about
expected results. Usually a 1 cm area is abraded with the patient under local anesthesia.
TIP: The test spot should be placed close to the area to be treated but in an obscured area

for patients who will have facial or neck dermabrasion, the spot can be made behind the ear.
Stressing that the test spot is not predictive of the overall outcome is critical.
Glogau Photoaging Scale
Type


I (mild)
Wrinkles not present or
minimal
Early photoaging
No keratoses, pigmentary changes
Patient generally wears minimal or no makeup
Typical age range: 20s-30s
II (moderate)
Wrinkles present only
when skin is in motion
Early to moderate photoaging
Early actinic keratoses
Sallow color
Smile lines begin
Patient generally wears some makeup

III (advanced)
Wrinkles present when
skin is at rest
Advanced photoaging
Dyschromias, telangiectasias
Actinic keratoses
Persistent wrinkling
Patient always wears makeup
Typical age range: 50s or older
IV (severe)
Only wrinkles
Severe photoaging
Yellow-gray skin
Dynamic/gravitational wrinkling throughout
Actinic keratoses ± skin malignancies
No normal skin
Patient wears makeup, but coverage is poor (it cakes
or cracks)
Typical age range: 60s or older

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Chapter 20 Dermabrasion
INDICATIONS AND CONTRAINDICATIONS
Box CONDITIONS TREATABLE WITH DERMABRASION
Acne rosacea
Actinically damaged skin
Active acne
Adenoma sebaceum


Blast tattoos (gunpowder)
Chloasma
Chronic radiation dermatitis (mild)
Congenital pigmented nevi
Darier’s disease
Dermatisis papillaris capillitii
Early operative scars
Facial rhytids
Favre-Racouchot syndrome
Fox-Fordyce disease
Freckles
Hair transplantation (elevated recipient
sites)
Hemangiomas
Hypertrophic scars
Keratoacanthomas




Discoid lupus erythematosus
Mibelli porokeratosis
Multiple pigmented nevi
Multiple seborrheic keratoses
Multiple trichoepitheliomas
Neurotic excoriations
Postacne scars
Pseudofolliculitis barbae
Rhinophyma
Scleromyxedema
Smallpox or chickenpox scars
Striae distensae
Syringomas
Syringocystadenoma papilliferum
Tattoos (decorative and traumatic)
Telangiectasias
Traumatic scars
Verrucous nevus
Vitiligo


Box CONTRAINDICATIONS TO DERMABRASION

Isotretinoin therapy within the last
6-12 months*
Congenital ectodermal defects
Radiodermatitis (only if severe)
Pyoderma
Psychosis
Active herpes labialis

History of hypertrophic scars
History of keloids
Burns—deep thermal or chemical
Fitzpatrick skin types IV, V, VI (test patch

History of hepatitis or HIV†
*Seven patients with atrophic acne scars on the face taking oral isotretinoin to treat facial acne had
manual dermabrasion on an area approximately 1 cm.2 At the 6-month follow-up, all patients had
normal cicatrization, and the atrophic acne scar revision was deemed excellent.5 In another study,
10 patients treated with oral isotretinoin for acne had a medium-depth chemical peel applied to the
entire face and manual sandpaper dermabrasion (until the appearance of a blood dew) 1-3 months after
the isotretinoin therapy was concluded. At the 6-month follow-up, all patients had normal cicatrization,
and no hypertrophic scars or keloids were observed. Depressed acne scar revision was satisfactory.6
†Personal decision of the surgeon.

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Part V Noninvasive and Minimally Invasive Therapy
PHYSICAL EXAMINATION
Thorough inspection of the type or condition to be treated. Dermabrasion has been
used for numerous traumatic and medical conditions. (Box 20-1 contains a partial list.)
Characterization of the scar. Deep, wide, or ice-pick scars may not be appreciably
helped by dermabrasion and may require multiple procedures.
Evaluation of the patient’s scar for potential of dyspigmentation
INFORMED CONSENT1,2
Recommended items to be included in the informed consent:



the location where dermabrasion will be done.”
No warranties, guarantees, or special contracts about the success and longevity of the
procedure
The possible need for additional surgeries/procedures
Scarring, catastrophic intraoperative disaster (avulsion of soft tissue
such as lips and eyelids), dyspigmentation, and failure of the procedure to adequately
improve the treated area
A complete understanding from the patient that some skin conditions have malignant
potential, and that any recurrence or new growth at the treated areas requires
immediate evaluation
EQUIPMENT AND PREPARATION
Standard equipment includes personal protective gear for everyone in the operating room,
a dermabrader, a standard surgical tray, a cryogenic spray or local anesthetic, and a choice
of planing tips—diamond fraises, serrated wheels, and wire brushes.
Dermabraders can be electrical or gas powered. The choice of dermabrader is
dependent on the physician’s level of comfort with the device’s rotational speed and
torque.
• Compressed-gas–powered units generate greater torque and higher rotational
speed.
• Electrical-powered dermabraders are more convenient but have slower rotational
speeds and torque. Some units have foot pedal control and can achieve a variable
speed ranging from 400-40,000 rpm.
TIP: The rotations per minute of devices with high torque will not decrease in response
to friction caused by the downward pressure of the planing tip onto the skin.
Abrading tips are available in a wide range of sizes (width, length, and coarseness), with
three basic types:
Stainless steel wheels with industrial-grade diamonds bonded
to them. They are graded according to barrel width, shape, and coarseness.
The coarser the diamond surface and the faster the cutting speed, the greater
penetration into the tissue.

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Chapter 20 Dermabrasion
TIP:
greatest margin of safety.

or straight. Great care is required with this planing device, because it can easily


TIP:
blood, and tissue.
. A circular wheel with small surface spikes. The spikes are widely
spaced on a barrel-type tip and can easily cause tissue gouging. This tip is not used
much and should be employed by experienced surgeons because of its greater
potential to cause tissue damage.
8 Manual spot dermabrasion involves abrading devices
for dermabrasion, including wire brush, diamond fraise, sandpaper, Bovie scratch pads,
abrasive cloth, and drywall or plaster sanding screen. These instruments are used
manually in a back-and-forth or circular motion.
SENIOR AUTHOR TIP: Wrapping a sheet of sanding screen paper around the barrel
of a 3 ml syringe provides a controlled and easy-to-use method of spot dermabrasion.
A variety of microdermabraders are available on the market.
Common to all systems is a pump that generates a high-pressure stream of aluminum
oxide or salt crystals, a connecting tube that delivers the crystals to the handpiece,
a handpiece, and a vacuum to remove the crystals and exfoliated skin. The crystals
are discarded and cannot be recycled. Handpieces can be reusable or disposable. The
reusable handpieces must be resterilized after each use.
TECHNIQUES
DERMABRASION




Antibiotics are started the day before the procedure if taken orally or just before the
procedure if given intravenously. Oral postoperative antibiotics should be continued for
a week after the procedure, or until complete reepithelialization.
Patients with a history of cold sores are treated with antiviral agent (acyclovir or
valacyclovir) on the day before the procedure, the morning of the procedure, and for
approximately 7 days after the procedure.
The skin is cleaned with antibacterial soap. Patients should not apply makeup on the
day of the procedure, and all of it should be removed before arriving for the procedure.
Anesthesia is required. A general anesthetic or sedation with a nerve block is used.
The surgeon and everyone else in the room MUST wear protective eyeglasses to shield

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Part V Noninvasive and Minimally Invasive Therapy
The valley of deep rhytids and acne pits should be marked with a surgical marker to
help determine the depth of treatment.
TIP:
with an outline around the area of maximum scarring will help to identify the depth and
extent of dermabrasion needed.

When working around tissues with free edges, the rotation should always be toward
the leading edge, and the dermabrasion drum should always be moved toward the
direction of rotation (Fig. 20-1).
Direction of
handpiece movement
Drum rotation
(clockwise)
Free edge
Free edge
Wrong way
Correct way
Correct way to move the handpiece of a dermabrader. When the handpiece is moved
in the direction of rotation (correct way), the tissue is swept away from the rotating drum. When
the handpiece is moved in the direction opposite the drum’s rotation, the abrasive tip will clutch
the tissue; the rotating drum, in combination with the moving handpiece, will “dig into” the tissue
and cause the upcoming tissue to be forcefully and rapidly pulled toward the rotating drum. A free
edge would be dragged up and over the drum. This can forcefully avulse tissues with free edges
(lips and eyelids).
For treatment around the lips, the and the
drum should be swept over the vermilion-cutaneous border to prevent lip avulsion.
For treatment of nasolabial lines and crow’s-feet, the movement of the handpiece
and the direction of rotation should be AWAY from the nose and AWAY from the eye,
respectively.
If it is caught, it will be
ripped from the physician’s hand and whipped around, possibly injuring the eye or soft
tissue.
The abraded surface needs to be wiped frequently with a gauze to observe the bleeding
pattern.
The fraise or brush is held If the drum is angulated, the leading
edge will cut into the skin.
After dermabrasion treatment, the skin is cleaned using a saline solution rinse and a
soft bristle brush or rough gauze to remove excess skin debris.
TIP:
the open wounds can decrease bleeding.

265
Chapter 20 Dermabrasion

Treated areas can be left uncovered, and the patient can apply antibacterial or white
petrolatum ointment.
Ointment can be generously applied and nonadherent dressings or petrolatum gauze
placed on the treated areas.

Patients are reminded to complete their full course of oral antibiotic and antiviral
therapy.
The importance of wearing sunblock EVERY day—regardless of the season and whether
the patient works inside or outside—must be stressed.
Persistent redness can be treated with topical steroid cream (Temovate [clobetasol
propionate] 0.05%) applied twice per day for 2 weeks. This regimen is repeated until
normal skin color returns. Patients are counseled against using it continuously and not

TIP: A green-base makeup applied to the red skin will neutralize the color, and a light
layer of natural makeup can be applied over it.
MICRODERMABRASION
Microdermabrasion works by blasting aluminum oxide crystals at high speeds toward the

in the epidermis. A vacuum is used to remove the abrasive crystals, sloughed skin, and
debris.


wrinkles and scars. Indications for performing microdermabrasion include treatment for


with minimal risk and rapid recovery.

The most commonly treated area is the face; however, the neck, hands, and chest can
be treated.
The depth of the treatment depends on:

• The rate of movement of the handpiece against the skin
• The number of passes over the treatment area

and performing more passes will result in a deeper abrasion. Two passes will exfoliate to

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Part V Noninvasive and Minimally Invasive Therapy
Box ADVANTAGES AND DISADVANTAGES OF MICRODERMABRASION

Does not require anesthesia
Painless
Can be repeated within short intervals
Simple and quick to perform

dermabrasion
Consistent depth of tissue loss (adjustable)

dermabrasion
Risks of hyperpigmentation/
hypopigmentation and scarring low
Rapid recovery—erythema resolves after
24 hours
Can be performed by a physician, nurse, or
licensed aesthetician

Multiple treatments needed

patients

Premedication is usually not necessary.
Skin is cleaned of all makeup and oil.
Topical or local anesthetic is usually not necessary.
Contact lenses must be removed, and eye protection is worn to prevent injury from
stray crystals.

The for successful microdermabrasion is to
by placing the skin under tension. This is achieved by stretching the
treatment area with the nondominant hand and using the dominant hand to guide the
handpiece. When the neck is treated, it is placed in extension to ensure the most skin
tension.
Treatment sessions generally last 30-40 minutes for the face and 20 minutes for the neck.
TIP:
skin is tensed with the nondominant hand while using the dominant hand to control
the handpiece.

The handpiece is moved over the treatment area in a single, smooth stroke.
A foot pedal controls the pressure of the crystal stream. Pressure is decreased when
treating the thinner skin of the lower eyelids and upper cheek.
Thicker skin, such as that on the forehead, chin, and nose, can be treated aggressively.
All strokes are vertically oriented for treating the neck.

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Chapter 20 Dermabrasion

Between treatments, the face is cleaned of residual crystals.

The endpoint is

individually treated with additional passes.

The treated area is cleaned with a wet cloth to remove any residual crystals.
A moisturizer or ointment is applied. The use of a moisturizer or ointment is continued
postoperatively until the erythema resolves, because exfoliation may occur.
Patients may have a mild sunburnlike sensation for a couple of days.
Sunscreen should be used liberally.
SENIOR AUTHOR TIP: Patients must avoid direct sun exposure, even with sunblock,



Usually are needed, although more may be warranted in heavily
scarred/damaged areas.

treatments are performed monthly to biannually.
COMPLICATIONS
HYPERPIGMENTATION AND HYPOPIGMENTATION
is the best treatment of these complications.
occurs from dermabrasion that is too deep. Time will usually
correct this problem.
occurs most commonly in patients with type III or IV skin and in
those who have not used sunblock. Hyperpigmentation can be minimized with

epidermis and treatable with topical applications of Retin-A, hydroquinone, and glycolic
acids. If pigmentation persists after several months of adequate skin care treatment, a
medium-depth trichloracetic acid chemical peel will usually be necessary.
MILIA
Milia are small white cysts over the surface of the treated area. One third of patients will
develop them.
They typically appear within 2-4 weeks after treatment and will clear spontaneously in
most patients.

RESIDUAL RHYTIDS AND SCARS
BEFORE the procedure, physicians should emphasize that deep rhytids and all scars will

achieve the aesthetic goal.

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Part V Noninvasive and Minimally Invasive Therapy
SCARRING
are usually caused by gouging from an inadvertent angling of the
dermabrasion drum. If recognized at the time of the procedure, the defect should be

Dermabrasion that was too deep and postprocedure infection can cause hypertrophic
scarring. Early steroid injection helps to minimize it.
INFECTION
Infection after dermabrasion should be rare. Occlusive dressings can hide an infection
and should be used with caution.
Patients with an oral herpes history are pretreated with an antiviral agent. If a lesion
appears, it should be very aggressively treated.
SENIOR AUTHOR TIP: It is a good practice to place all dermabrasion patients on an
antiviral drug as prophylaxis.
TOP TAKEAWAYS

The dermabrasion drum should always be moved toward the leading edge of
soft tissue.

The drum should always be positioned parallel to the skin to prevent gouging
that can occur if it is angled.

Antibiotic and antiviral coverage is required (in patients with a history of oral
herpes and/or fever blisters).

Postprocedure sun protection is essential.

Patients with deep rhytids and/or acne scars should be counseled about the
probable need for multiple treatments.
REFERENCES

New York: Thieme Publishers, 2005.

3. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 9:267, 2001.
4. Coleman S, ed. Structural Fat Grafting. New York: Thieme Publishers, 2004.

treatment with oral isotretinoin. Dermatol Surg 36:483, 2010.
6. Picosse FR, Yarak S, Cabral NC, et al. Early chemabrasion for acne scars after treatment with oral
isotretinoin. Dermatol Surg 38:1521, 2012.
7. Holck DE, Ng JD. Facial skin rejuvenation. Curr Opin Ophthalmol 14:246, 2003.
8. Dubina M, Tung R. Management of complications of microdermabrasion and dermabrasion.
In Tosti A, Beer K, De Padova MP, eds. Management of Complications of Cosmetic Procedures:
Handling Problems and More Uncommon Problems. Berlin, Heidelberg: Springer, 2012.

269
DEFINITION
is a neurotoxin that is produced by a gram-positive
anaerobic bacterium.
HISTORY AND PHYSIOLOGY1,2
BOTULISM

Foodborne botulism occurs from the ingestion of the neurotoxin and rarely occurs in
the modern era, except in home-canned goods or rare instances.
occurs when the bacteria colonize a wound and produce the toxin,
causing progressive weakness.
the most common in the United States (100 infants/year)—results
from the ingestion of clostridial spores, colonization of the gut with the bacteria, and
production of toxin.
TOXINS
produces eight toxins, of which seven have paralytic properties:
serotypes A through G.

4

• The neurotoxin acts at presynaptic nerve terminals to
producing a chemodenervation.
• The protein consists of a heavy and light chain. The heavy chain irreversibly binds
to the nerve terminal, and the toxin is internalized through endocytosis, where it
renders the nerve terminal nonfunctional and blocks the release of acetylcholine
into the neuromuscular junction.
4
• It targets the
(type B toxin).
• Recovery is through

postsynaptic target.
Phase 2: After 28 days, the main axon teminal begins slow recovery of its
acetylcholine release ability. At appromately recovery is complete.
4

and then

• Carruthers and Carruthers
5
treatment of glabellar frown lines in 1992.

270
Part V Noninvasive and Minimally Invasive Therapy
for clinical use.
• Type A is approved for multiple clinical uses, including the cosmetic improvement of
glabellar rhytids and crow’s-feet in patients 65 years or younger.

• Type B is approved for cervical dystonia.
Three preparations of type A are available for facial cosmetic use (Table 21-1).
Preparations of Type A Botulinum Toxin







Xeomin:





2002 for treatment of
glabellar rhytids
2013 for the treatment of
crow’s-feet
2009 for treatment of
glabellar rhytids and
cervical dystonia
2010 for treatment of
cervical dystonia and
blepharoptosis 2011
for glabellar rhytids
7

50 and 100 U vials
300 U vials
50 and 100 U vials

Vacuum-dried
Freeze-dried



concentration of
2.5-4 U/0.1 ml
Typically, diluted to a

10-30 U/0.1 ml
8-10
Typically, diluted to a

2.5-4 U/0.1 ml







11-12


and Xeomin in

8-10
In study comparing
1:1 dosage between

Botox found to be
stronger
7




and spread compared
with Botox
12
Does NOT require
refrigeration
INDICATIONS AND CONTRAINDICATIONS
INDICATIONS
facial rhytids
CONTRAINDICATIONS
at the proposed injection site
Known to any ingredient in the formulation, including albumin
PRECAUTIONS

• Patients with

• Coadministration with or other agents that interfere