The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Dermabrasion

JAMES L. BAKER, JR.
CHAPTER 14

A
ging of the skin is affected by both intrinsic and extrinsic factors. Intrinsic ag-
ing consists of endogenous influences such as genetic sequence, chronologic
aging, skin laxity, and fine wrinkles of the skin not exposed to the sun. Genetic fac-
tors in combination with ultraviolet (UV) radiation exposure can affect the degree
of UV radiation damage. Race, ethnicity, eye and hair color, and freckles all con-
tribute to early onset of skin aging. Extrinsic aging and photodamaged skin are the
result of chronic exposure to UV radiation, one of the major reasons why skin ages.
Other factors leading to extrinsic aging include the type of clothing a person wears,
where a person lives, and his or her occupation, lifestyle, age, and geography.
Photodamage is cumulative, from the first day of exposure until death. Fifty percent
of a person’s exposure to UV radiation occurs before 18 years of age. From the first
moment a baby is taken outdoors, all subsequent outdoor activities will increase his
or her likely radiation exposure. The working environment also influences exposure
potential. Exposure decreases for people who work in an indoor environment. Oc-
cupations that require outdoor exposure will increase the photoaging process, par-
ticularly in unprotected skin. The key to diminishing this damage is education and
the use of sunblocks.
Environmental factors such as heat, wind, humidity, pollutants, cloud cover, season,
time of day, and reflected sunlight from the sand or snow also play a major role in
radiation exposure. UV radiation increases with decreasing latitude and is com-
pounded 4% for every thousand feet above sea level. Therefore skiing on Vail Moun-
tain at 10,000 feet would increase the UV radiation exposure 40% over a visit to
Walt Disney World in Orlando, Florida, which is at sea level.
Evolution of Technique
Removal of the upper layer of the skin for improvement in surface texture probably
began in Egypt in 1500 BC, when a type of sandpaper was used by Egyptian sur-
geons to smooth out scars. In 1905 Kromayer, a German dermatologist, used a mo-
torized dermabrader. This instrument used rotating burrs, which could remove the
skin at various depths. Kromayer noted that ablation of the reticular dermis would
result in healing with no scar. In 1947 Iverson, an American plastic surgeon, applied
sandpaper abrasion for acne scars and traumatic tattoos. This technique was simi-
lar to the one used by Egyptian surgeons. Kurtin in New York, in collaboration with
Robbins, modified power dental equipment for use in dermabrasion. Robbins also
developed the diamond fraise, which is widely used today for dermabrasion. In 1985
Silverman et al advocated the use of prophylactic oral acyclovir for patients at risk
for developing Herpes simplex labialis. Oral antiherpetic prophylactic medication
is now a standard in skin resurfacing. In 1995 Tsai et al proposed using aluminum
oxide crystals in a microdermabrasion instrument for superficial rhytids.
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Part III  Nonsurgical Cosmetic Treatments

The current dermabrasion technique, which has evolved from its inception 3500
years ago, employs a small, handheld electric-powered instrument that rotates a wire
brush or diamond fraise at speeds of 15,000 to 30,000 rpm. Either sedation with lo-
cal anesthetics, topical spray refrigerants, or general anesthesia is necessary; the pro-
cedure is commonly performed as an outpatient procedure. The abrasion can be pre-
cisely controlled and results in an open wound that heals with reepithelialization
after a relatively short period. Preventing infection and achieving rapid healing re-
quires attention to detail for basic wound care. A variety of “artificial skin” materi-
als can be used to diminish the discomfort of the operative site after the procedure
and to promote wound healing. Products such as N-Terface (Winfield Laboratories,
Inc., Richardson, TX), a polyethylene mesh developed as a cover for burn wounds,
have been very useful.
In the past decade, incorporating some of the concepts of traditional dermabrasion,
the new technique of microdermabrasion has been advocated. Microdermabrasion
can improve certain types of scars from aged and sun-damaged skin while avoiding
many of the problems seen with traditional dermabrasion. The technique uses a fine
beam of aluminum oxide microcrystals to precisely and superficially peel the skin
surface. Its advantages are that it is gentle and requires no significant change in the
patient’s normal routine or activities. However, multiple treatment sessions are needed
for optimal improvement.
Despite the initial popularity of skin-resurfacing CO2 lasers over the past decade,
dermabrasion remains a safe, efficacious, and inexpensive method of skin resurfac-
ing with very predictable outcomes. A complete dermabrasion setup will cost less
than $1000, whereas most resurfacing lasers cost in excess of $50,000.
Pretreatment Assessment
When dermabrasion is used as an adjunct to facial rejuvenation, the patient’s moti-
vation is well documented and justified. Perioral rhytids are effectively treated with
dermabrasion, and the results are predictable and satisfactory. For deep rhytids, only
phenol chemical peeling can produce a superior result. However, the hypopigmen-
tation that usually follows phenol peels is undesirable, especially in patients with
Fitzpatrick skin types III or IV.
Because of the surgeon’s ability to control the depth with dermabrasion, hypopig-
mentation is usually avoided. Deep rhytids respond better to dermabrasion than to
CO2 laser resurfacing, with less potential for prolonged recuperation and/or hyper-
pigmentation, hypopigmentation, or scarring.
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Chapter 14  Dermabrasion

When using dermabrasion for improvement of postacne scarring, the surgeon must
evaluate the patient carefully from a psychological standpoint to avoid unrealistic
expectations of what the procedure can accomplish. It is very difficult to make the
patient understand that scarring is permanent, and dermabrasion can only improve
the amount of light and shadow that falls on the craters of the skin. Dermabrasion
will produce a more undulating surface as opposed to a rocky, craggy type of der-
mis. Scars, although they are improved, will not be removed, and the patient should
never expect to have the skin restored to the soft smooth texture of infancy. It should
be stressed that two or three procedures are necessary for maximal improvement,
and it will be an improvement, but not a cure.
Patients to avoid are those who exaggerate a tiny or barely visible defect, such as
a small scar, and those who are unable to describe what they expect from the pro-
cedure (that is, their desired change). If the surgeon has trouble establishing good
rapport with the patient, it is best to decline to treat that person. Surgeons should
also be wary of patients who have had two or three procedures performed by dif-
ferent plastic surgeons and criticize all of their results. These patients come to you
because they have heard that you are “the best.” If you operate on this type of pa-
tient, his or her eventual disillusionment and dissatisfaction following your proce-
dure are predictable.
The extent of the procedure and the areas to be treated should be marked on a face
diagram to ensure that the patient understands exactly what areas will be addressed
with the procedure and where improvement should be expected. Darker areas can
easily be noted with the use of colored marking pens or highlighters. Photographic
documentation is mandatory, despite the difficulty in demonstrating skin pits and
scars with photography. If lines are extremely deep, it is likely that neither laser resur-
facing nor dermabrasion will completely eradicate them, and the possibility of a later
treatment with a tissue filler should be discussed. This type of advance preparation
should help to adequately inform the patient about what to expect and help to pre-
vent patient disappointment. For this reason and to facilitate compliance, it is ex-
tremely important for the patient to understand postoperative care. It normally takes
a week before healing is completed, and the patient’s role in wound care is of the
utmost importance. The treated area needs to be kept clean and moist with a rec-
ommended skin ointment. Sun exposure must be avoided, and the use of sunblocks
is mandatory until normal color returns.
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Chapter 14  Dermabrasion
ANATOMIC FORM
Name_____________________________________________________________ Date_______________
LAST
FIRST
MIDDLE
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Patients taking isotretinoin (Accutane) or those who have recently completed a course
of Accutane therapy should not undergo any skin-resurfacing procedures for at least
6 months after completion of their therapy. Accutane will act as an inhibitor of pi-
losebaceous gland function, which is necessary for reepithelialization. I prefer to wait
at least 1 year, and ideally, 2 years after Accutane therapy to ensure that piloseba-
ceous gland function has returned to normal. Because of the paucity of these glands
below the mandibular rim, dermabrasion of neck rhytids should also be avoided.
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Part III  Nonsurgical Cosmetic Treatments
A complete physical examination is essential, and any health problems should be
carefully evaluated. The patient’s history of cigarette smoking and alcohol intake
should be weighed as to their possible deleterious effects on wound healing. Aller-
gies and medications should also be carefully evaluated.
Fitzpatrick Skin Care Classification
The Fitzpatrick classification system of sun-reactive skin type is a good measure of
ideal candidates for skin-resurfacing procedures. Although those with skin types I to
III are considered the ideal patients for a predictable outcome for dermabrasion and
other resurfacing procedures, those with type IV skin can anticipate a good result
with the use of bleaching creams applied both preoperatively and postoperatively to
diminish melanocytic activity. However, it should be discussed with these patients
that they are more prone to hyperpigmentation problems postoperatively and, of
course, all patients undergoing skin resurfacing should be advised to avoid sun ex-
posure or tanning booths until normal color returns. Sunblocks with an SPF of 35 or
higher are recommended, and patients should be advised not to sit near a swimming
pool or go to the beach because of the reflected UV radiation coming off the water.
The sun’s rays can also attack the skin even when an individual is wearing a wide-
brimmed hat. Boating is also contraindicated during this period for the same reason.
This 52-year-old woman underwent a face lift and
attempted removal of neck rhytids by dermabra-
sion. The result was hypertrophic scarring of all
areas treated on both sides of the neck.
This example illustrates why dermabrasion on the
neck should not be attempted because of the pau-
city of pilosebaceous glands, which are needed for
reepithelialization.

Skin care counseling with the continued use of alpha-hydroxy acid products and sun-
blocks should be a part of the routine discussion and recommended regimen for the
patient to ensure the longevity of the procedure. Perioperative use of systemic an-
tibiotics as well as an antiviral medication (acyclovir) is strongly recommended, even
without a direct history of a “cold sore” that the patient can recall. Many patients
have had inoculation of the herpes simplex labialis virus in childhood and may not
remember having had an attack. When it comes to prophylactic use of acyclovir drugs,
the familiar expression, “An ounce of prevention is worth a pound of cure,” is sound
advice.
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Chapter 14  Dermabrasion
Fitzpatrick’s Classification of Sun-Reactive Skin Types
Skin Type
Color
Reaction to First Summer Exposure
I
White
Always burns, never tans
II
White
Usually burns, tans with difficulty
III
White
Sometimes mild burn, tanning moderate
IV
Moderate brown
Rarely burns, tans with ease
V
Dark brown*
Very rarely burns, tans very easily
VI
Black
No burn, tans very easily
*For example, East Indian, Asian, Hispanic, or light African descent.
This 42-year-old woman underwent perioral dermabrasion for rhytids before pro-
phylactic acyclovir therapy. She gave no history of “cold sores” at any time during
her life. A single lesion of herpes simplex occurred in the central portion of her up-
per lip 5 days after dermabrasion. Her outbreak was treated with acyclovir without
sequelae. It is recommended that all patients, despite a negative history, be placed
on prophylactic acyclovir therapy for any resurfacing procedure.
For patients with skin types V and VI who are contemplating dermabrasion, it is im-
portant to first perform a test spot at the hairline. Although this preliminary test can
give an indication of the expected result, there is no 100% guarantee that the re-
mainder of the facial skin will respond identically, and the patient should be fore-
warned of this.

Healing of the Dermabrasion Wound
Although dermabrasion can be performed to any dermal level by control of the sur-
geon’s hand, most procedures are targeted to a specific level of the dermis. Deeper
rhytids require a greater depth of wounding, and it is not the ablation of the abnor-
mal epidermis that creates the result but rather the stimulation of dermal fibroblasts,
which lay down collagen that creates the improvement. Healing is expected in 7 to
10 days.
Healing of dermabraded areas is similar to that of split-thickness skin graft donor
sites. Initially there is an outpouring of serum, which forms a coagulum that covers
the abraded surface, trapping necrotic and other cell debris. Immediate activity be-
gins in the adnexal cells adjacent to those exposed by the dermabrasion. These ex-
posed cells undergo necrosis, and those below take on several of the attributes of
squamous epithelium. Marginal epithelial cells migrate from the edges of the abraded
areas, and within 3 days new epidermal cells are seen growing across the surface and
extending out from these adnexal components. By the fifth postoperative day, epi-
dermal regeneration is usually complete. It is thin, lacks rete pegs, but exhibits de-
veloping hair follicles and sebaceous glands. These elements not only contribute to
the epithelial resurfacing but are also evidence that functional activity is resuming.
The period required for complete epidermal regeneration is usually between 5 and
7 days. In the newly regenerated dermis, young fibroblasts are seen lying with their
long axis in a horizontal plane and new capillary development is noted. Collagen
is being laid down by the second week. This new collagen shows a horizontal stri-
ation that can last for 3 to 4 years following dermabrasion. It is this new collagen
that fills out the skin, resulting in the youthful rounded appearance frequently wit-
nessed after dermabrasion procedures. Moisturizers are recommended to keep the
new skin hydrated, and sunblock is mandatory to diminish the possibility of hyper -
pigmentation.
In the first month there is little evidence of pigment formation in the basal layers of
the epidermis. After 1 month, however, some return of fine pigment granules can be
noted. With the newly healed postoperative skin, exposure to sunlight intensifies the
potential for hyperpigmentation even in patients with Fitzpatrick skin types I to III.
It can last from 3 months to several years and occasionally can be permanent.
Treatment for the prevention of hyperpigmentation consists of an SPF 30 or higher
sun protection as well as vitamin C tablets (2 g ascorbic acid daily) to inhibit melanin
formation, either topical steroids, or in developing cases of hyperpigmentation,
25 mg of cortisone daily to inhibit the pituitary melanocyte–stimulating hormone.
Hydroquinone is also indicated to inhibit melanin production by the melanocyte.
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Chapter 14  Dermabrasion
Milia are small white-headed cysts arising from the epithelial cells of the hair follicles,
sebaceous gland ducts, and sweat ducts that have been sealed over at the time of sur-
gery and have become isolated under the newly epithelialized surface. They usually ap-
pear within the first month following the procedure. These can be treated with an
exfoliating buffing pad or mild abrasive facial scrubs to unroof the blocked ducts.
This 20-year-old woman underwent full-face dermabrasion for acne scarring. Milia
were noted 8 days after the procedure and were attributed to the epithelial regener-
ation covering the small oil gland ducts. This was successfully treated with gentle
abrasion using a buff puff to unroof the small cysts. Prophylaxis is difficult, but treat-
ment is simple.
Equipment
This is a typical small, self-contained dermabrader. There are several units to choose
from commercially. They are ideal for office use, because they require limited space for
storage or operation and can be easily cleaned with the handpiece being sterilized.
Either wire brush or diamond fraise drums are used. I prefer the diamond fraise, be-

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Part III  Nonsurgical Cosmetic Treatments
cause I am familiar with its operation; I have used it with satisfactory results over
the past 35 years and find that it makes it easier to judge the depth of treatment. The
diamond fraise is available in different surfaces, from fine to extra coarse. For aes-
thetic surgery most surgeons prefer medium to coarse, plus a touchup of the finer
rhytids with a fine diamond fraise.
Although the small hand engine–type dermabraders have a knob to control the speed
of the drum rotation and an on/off switch, this limits the surgeon’s control during the
procedure. I prefer a foot pedal rheostat, which allows me a wide range of speeds un-
der my total control during surgery. For operating room use, an electric dental mo-
tor with a handpiece will provide an unlimited number of years of use with minimal
cost or downtime for repair. These motors are extremely reliable and inexpensive.
For the past 20 years I have used a Foredom Electric Series S-Engine Motor Style
CC with handpiece No. 7D (The Foredom Electric Co., Bethel, CT). The cost is sev-
eral hundred dollars, and the dental handpiece is very easy to hold and control.
A diamond fraise 17 by 10 mm or 17 by 14 mm is used with coarse, regular, or fine
surfaces.
Technique
Preoperative treatment consists a broad-spectrum antibiotic administered intra-
venously just before the procedure, or given orally beginning the day before the pro-
cedure, and continuing for 1 week postoperatively. An acyclovir preparation such as
Valtrex (500 mg twice a day) or Zovirax (400 mg three times a day) is administered
the day before surgery, as well as the morning of surgery, and is continued for 7 to
10 days postoperatively. The skin is cleansed with an antibacterial soap in the oper-
ating room. Either general anesthesia or local anesthesia with nerve block and se-

dation is used. This is a matter of personal choice, and the decision is made by the
surgeon and the patient. Anesthesia equipment should be covered to prevent blood
spray from contaminating the equipment, and precautions should be taken by the
anesthesiologist and the nursing personnel. Magnifying loupes are used not only to
magnify the surface of the skin and the rhytids but also to help protect the surgeon
from blood spray. The surgeon’s eyes should be covered with some protective eye
shields, in any event. If acne scars are being addressed, it is helpful to mark the pit
of the scar with a surgical marker and outline the area of maximal scarring. This
will be helpful in determining the depth to which dermabrasion will be done. It can
also be performed with deep rhytids, placing a line at the base of the depth with a
fine-point marker.
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Chapter 14  Dermabrasion
Because the drum is rotating in a clockwise direction, the drum should always be
moved toward the leading edge of soft tissue. With the drum rotating counterclock-
wise, the hand moves the dermabrading instrument over the cutaneous junction edge
to avoid avulsion of the lip. This is very important, especially when trying to treat
crow’s-feet.
The rotating motion of the drum is used to obtain a smooth surface. Great care must
be taken in holding the sponge in the opposite hand a safe distance from the rotating
drum. Once the gauze is impregnated with blood, it is very easy to have an edge of the
gauze get caught in the fraise or wire brush and torque into the patient’s face. This
could cause severe eye or soft tissue damage from the whiplike effect of the end of
the gauze. The abrader is moved slowly back and forth or in a circular motion across
the surface, abrading through epidermis down to the desired level of the dermis.

The bleeding pattern is a good indicator of depth. The skin should be wiped fre-
quently so this bleeding pattern can be observed. Care must be taken to not angu-
late the fraise or wire brush because the leading edge can cut into the skin surface
and cause undesired pitting, grooving, and/or scarring. It is critical to maintain the
drum parallel to the skin surface.
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Part III  Nonsurgical Cosmetic Treatments
When working around the lips, the speed should be reduced and the drum pulled
softly over the vermilion-cutaneous junction to avoid avulsion of the lip edge. When
nasolabial folds are being dermabraded, the drum should rotate away from the edge
of the nose and toward the soft tissue angle at the bottom of the rhytid. The same
caution is necessary when dermabrading crow’s-feet near the eyelids. The rotation
of the drum should always be toward the leading edge of any soft tissue.
After the desired depth in the dermis has been achieved, the dermabraded areas
should be thoroughly cleansed with saline solution using a soft bristle brush or rough
gauze. This will remove the excess skin debris. To diminish bleeding, a sponge soaked
in saline solution with epinephrine in a 1:1,000,000 dilution is helpful.

The operative site can then be treated open, with the application of antibacterial or
Aquaphor ointment or with a layer of Adaptec or Telfa. For the past 15 years I have
preferred to use N-Terface, which is a polyethylene mesh developed originally for the
treatment of burn patients. Strips of this nylonlike material are cut to fit over the
treated areas, and a layer of Aquaphor ointment is applied. This diminishes the post-
operative discomfort considerably, and the material will separate on its own as reep-
ithelialization occurs, which is usually 5 to 7 days. Patients may shower with the ma-
terial in place and are encouraged to trim loose edges as healing progresses. It will
eventually soak off with gentle soap and water application. For many years, thymol
iodide powder was used to dry the operative site; however, as this dried to a stiff
crust, it was not only uncomfortable but looked unsightly.
Postoperative Care
Bulky dressings over the operative areas are usually discouraged, because they are
normally left in place for at least a week and are extremely uncomfortable in warm
weather. Perspiration and blood that dry under the dressing create an obnoxious
odor and provide an excellent culture medium. The dressings usually have to be
soaked off, which also creates discomfort for the patient. The open technique or a
thin layer of Telfa or N-Terface is much preferred by the patient, the family, and the
surgeon. The patient is reminded of the importance of taking the antibiotic and an-
tiviral therapy until the recommended course has been completed. Normally by the
end of 7 or 8 days the patient can apply makeup and be comfortable going out in
public. It is stressed to the patient that sunblock must be worn as the first applica-
tion on the skin each morning before makeup is applied or before leaving the house.
If the patient has a lot of red in the skin, this redness will persist for a longer period
than in Fitzpatrick type III and IV patients. A green base makeup applied to the red
skin will neutralize the color, and then a light layer of natural makeup can be ap-
plied. The patient must be careful about being exposed to sun, especially when driv-
ing in a car, since glass is made of quartz, not lead, and does not provide any pro-
tection from UV radiation.
After a week or two, topical steroid creams can be used if there is marked redness
or it appears that fibrosis is occurring that could produce scarring. Temovate cream
0.05% (clobetasol propionate), applied twice a day for 2 weeks and discontinued
for a week, can be cycled until normal color returns. The patient must be warned
that this is a potent steroid and should not be used continuously or not on the eye-
lids and only sparingly for the times indicated by the surgeon.
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Chapter 14  Dermabrasion

Problems and Complications
Hyperpigmentation and Hypopigmentation
With proper patient selection, and if the expected level of surgical skill has been ex-
ecuted, the results should be rewarding and predictable. Problems and complications,
however, can occur with any procedure. Many of these have already been reviewed.
Hyperpigmentation of the skin in patients with Fitzpatrick skin types V and VI cer-
tainly can be considered one of the least desirable results. Hypopigmentation can oc-
cur when very deep dermabrasion has been performed causing a decrease in the num-
ber of melanocytes.
Milia
As mentioned previously, approximately one third of the patients who undergo derm-
abrasion will develop milia, which appear as small white cysts over the surface of
the treated area. They normally appear within 2 to 4 weeks after the procedure and
will clear spontaneously in most patients. A buff puff or other mildly abrasive prod-
uct can be applied to unroof these small cysts (see p. 483).
Residual Rhytids
Very deep lines are difficult to eradicate completely, and the patient should be ad-
vised preoperatively that filler materials might be indicated and recommended after
they have completely healed. Attempting to remove every deep rhytid can produce
scarring and surgical judgment is critical in knowing when to stop. This is especially
true with postacne scarring, and it should be stressed to every patient undergoing
treatment for postacne scarring that they may need a minimum of two to three pro-
cedures to achieve maximal improvement. All scars will never be eradicated and some
patients will never be completely satisfied.
Scarring
If linear scarring occurs, this is usually caused by inadvertent angling of the drum
so that it causes skin gouging from the leading edge (see p. 486). If noted at surgery,
several small sutures can be placed and healing will normally occur without notice-
able defects. Hypertrophic scarring is more difficult to address and can be caused by
an abrasion that is too deep or when infection has occurred postoperatively. Steroid
injections may be helpful, especially early in the scar formation.
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Infection
Infection is extremely rare because most patients receive perioperative antibiotics
and antiviral medications (see p. 481). Patients with occlusive dressings can hide a
smoldering infection, and for that reason I do not use them. Hyperpigmentation and
hypopigmentation have been addressed, and the patient should be warned preoper-
atively that these conditions can occur and can be permanent.
Result
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Chapter 14  Dermabrasion
This 62-year-old woman presented with severe sun damage resulting from an active
outdoor lifestyle. She requested improvement of the deep rhytids in the perioral area.
She did not request any other corrections. A photograph 6 months after dermabrasion
shows smooth skin with normal color. The patient was counseled regarding future
sun exposure.
Concluding Thoughts
For a technique first described about 1500 BC, dermabrasion is still valid as an ex-
cellent ancillary treatment for facial rejuvenation. Most important changes have oc-
curred within the past five decades. Dermabrasion is a safe and effective technique
that produces predictable results when performed properly. Careful patient selection
and a detailed informed consent, which includes the limitations of the procedure,
are essential for achieving optimal results and ensuring patient satisfaction.

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Part III  Nonsurgical Cosmetic Treatments
Clinical Caveats
 The drum should always be moved toward the leading edge of the soft tissue.
 The drum should not be angled and should be kept parallel to the skin to avoid
skin gouging.
 Antiviral and antibiotic coverage is required.
 Patients should be instructed to avoid sun exposure following dermabrasion un-
til normal skin color returns.
 Patients with acne scars and deep wrinkles should be advised that a repeat derm -
abrasion procedure may be needed.
Annotated Bibliography
Iverson PC. Surgical removal of traumatic tattoos of the face. Plast Reconstr Surg 2:427, 1947.
This is an excellent evaluation of the problem of herpes simplex infection following
deepithelialization procedures. The beginning of the use of acyclovir drugs for treatment
and prevention of this problem is also discussed.
Kromayer E. Cosmetic Treatment of Skin Complaints. New York: Oxford University Press,
1930 (English translation of the second German edition, 1929).
The author discusses development of the microdermabrasion technique, which is widely
used today by many aestheticians and plastic surgeons on an outpatient basis for re-
moving unwanted epithelium in a simple “lunchtime procedure.”
Kurtin A. Corrective surgical planing of the skin. Arch Dermatol Syph 68:389-397, 1953.
To go back in time and review wound healing as described by one of the giants in plas-
tic surgery is worthwhile, and this article is well worth reading and rereading.
Lawrence N, Mandy S, Yarborough J, et al. History of dermabrasion. Dermatol Surg 26:95-
100, 2000.
The authors present a thorough historical review of dermabrasion from 1500 BC to the
present. Included are all the advances in this technique, and for those who enjoy the his-
tory of procedures, it is one of the best resources and well worth reading.

Suggested Readings
Campbell R. Surgical and chemical planing of the skin. In Converse JM, ed. Reconstructive
Plastic Surgery: Principles and Procedures in Correction, Reconstruction, and Trans-
plantation, vol 1. Philadelphia: WB Saunders, 1964.
Silverman AK, Laing KF, Schuberg DR. Activation of herpes simplex following dermabra-
sion. Report of a patient successfully treated with intravenous acyclovir and brief review
of the literature. J Am Acad Dermatol 13:103-108, 1985.
Tsai R, Wang C, Chan H. Aluminum oxide crystal microdermabrasion. Dermatol Surg
21:534-542, 1995.
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Chemical Peels

RICHARD H. BENSIMON, MICHELLE B. LOCKE,
FOAD NAHAI
CHAPTER 15

T
he process of facial aging can be broadly divided into three categories: struc-
tural or gravitational changes, volume depletion, and textural or qualitative
changes of the skin. Surgeons are experienced in and comfortable dealing with struc-
tural changes by means of a multitude of surgical procedures that receive the ma-
jority of attention in meetings and professional publications. This is understandable,
because as surgeons we know how to perform surgery and it is within our capacity
and experience to read about a new technique and successfully perform it. Correc-
tion of volume loss is a relatively new field, but many surgeons are increasingly be-
coming proficient in the use of alloplastic implants, autologous fat transfers, and in-
jectable dermal fillers; these nonsurgical treatments are now an integral part of many
plastic surgical practices.
The treatment of well-established rhytids, creases, and textural changes of the skin
is altogether another matter. Surgeons are sometimes intimidated by this aspect of
our specialty and tend to surrender their patients to aestheticians or use nonablative
superficial techniques that are minimally invasive but may also be minimally effec-
tive. An all too common tactic is to simply ignore the problem. In doing so, surgeons
are missing the opportunity to provide patients with a more complete rejuvenation
and improve fundamental aspects of aging, such as the quality of the skin. Perioral
rhytids can be more troubling to a patient than jowls or loose skin, and the very best
face-lift results can be marred by deep creases around the mouth or forehead. The
reality is that there must be a wounding into the dermis to improve deep wrinkles
and etching of the skin, and at present this requires a more prolonged recovery period
than that experienced after injectables are used. The goal is to find the best, most
cost-effective approach that yields a result significant enough to warrant the recovery
period and inconvenience to the patient.
Chemical peels represent an effective method for skin resurfacing to treat rhytids and
other skin problems. Today physicians have a number of effective chemical peel op-
tions from which to choose; these offer the dermal wounding that is needed, with
less morbidity and fewer adverse effects than with the agents that were available pre-
viously. Physicians can now plan the depth of peel depending on the patient’s skin
type, age, or clinical need. By choosing the appropriate resurfacing agent, solution
concentration, and peel application, the surgeon can have precise control, thereby
achieving treatment goals and avoiding possible problems with hypopigmentation.
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Evolution of Treatment
Chemical peels were introduced to the United States in the early part of the twenti-
eth century not by doctors, but by lay operators. The origin of the formulas used by
these flamboyant individuals is unknown, but what is clear is that they involved the in-
gredients phenol and croton oil and that the clinical results were quite good. The early
history of chemical peels has been elegantly chronicled by Gregory Hetter, and trac-
ing this history is important to understanding and appreciating where we are today.
These early “lay peelers” used cumbersome “secret” formulas that involved dissolv-
ing phenol crystals and drops of the caustic croton oil. Over the years, as these in-
dividuals gained notoriety, the response of the medical community was to fight them
rather than to learn from them. Eventually plastic surgeons took note, and finally
Thomas Baker published a formula in 1961 that was easily reproduced by anyone.
The ingredients were simple, and it was presumed that phenol was the peeling agent.
In 1962 Dr. Baker altered the volumes of the formula for convenience, while keep-
ing the 3 drops of croton oil unchanged. This effectively elevated the croton oil con-
centration to 2.1%, and thus he inadvertently altered the history of chemical peel-
ing. This formula was very successful in improving severe wrinkles but also had the
significant drawback of causing predictable and severe hypopigmentation. The peel
gave dramatic results, but patients developed an unnatural porcelain or alabaster
look that required them to permanently wear makeup. For older patients with pro-
nounced wrinkling and light skin color this was a reasonable trade-off, but the peel
was not done on younger patients or on darker skin. The peel was considered diffi-
cult to perform, and phenol developed the reputation of having an “all-or-none” phe-
nomenon that was out of the surgeon’s control. The presumption was that phenol
denatured the skin and created a barrier that prevented deeper penetration; a weaker
concentration was thought to be dangerous, because it would peel deeper. It took a
great deal of faith and courage to paint the solution on and hope for the best as the
face densely frosted. Phenol also had the reputation of being cardiotoxic, requiring a
deliberately slow application with strict cardiac monitoring. These beliefs became
dogma, no matter how unsubstantiated, and were passed on from generation to gen-
eration of plastic surgeons. To this day, these presumptions are still mentioned in
professional publications, and “phenol peels” have a negative connotation in lay
books on cosmetic surgery. Although the results were quite remarkable, the factors
discussed and the long and difficult recovery prevented this peel from gaining wide-
spread acceptance.
The next development in chemical skin resurfacing was the popularization of
trichloroacetic acid (TCA) peels by dermatologist Zein Obagi. TCA peels had been
around for some time, but Obagi and Johnson’s work in the 1990s brought them to
the attention of plastic surgeons. They popularized the concept of skin pretreatment,
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as well as documenting and controlling the depth of TCA penetration. Obagi’s role
was controversial at the outset because of unseemly commercialization with “secret
formulas” and very expensive training programs, but his book, Obagi Skin Health
Restoration and Rejuvenation, remains an important contribution, especially for
plastic surgeons less familiar with peels and skin anatomy and physiology.
TCA peels were an important addition in that Obagi showed histologically that dif-
ferent concentrations varied the depth of the peel and that the application technique
was a major determinant of the depth reached. Lighter to medium peels were possi-
ble with a concentration of up to 25%, and medium to deeper peels occurred with
35% and 50% concentration for more pronounced rhytids. TCA therefore largely
overtook phenol as the peeling agent of choice, because of the ability to control the
depth of penetration and tailor the peel to the patient’s skin type. Although higher
concentrations engendered more serious complications, namely scarring, TCA peels
at light- and medium-depth concentrations are viable and popular options when
chemical peels are considered for facial resurfacing.
Another significant advance in peel resurfacing was introduced by Gregory Hetter
in Las Vegas, Nevada. Interestingly, Nevada was a state in which aestheticians could
perform weak phenol peels, and Hetter treated multiple patients who had had such
peels. These patients had not achieved significant improvement, but more important,
had not had any ill effects from the weaker phenol concentrations, directly contra-
dicting what had been believed and taught about phenol peels for decades.
With this in mind, Hetter diluted the Baker formula in half and successfully per-
formed peels on patients without the hypopigmentation that had attended the older
peels. Clearly something different was at play, and Hetter devised a series of experi-
ments to explain this phenomenon. Hetter performed peels on a series of patients
with different combinations of ingredients of the Baker formula; he noted that phe-
nol alone had scant effect and that adding croton oil to phenol at different concen-
trations led to deeper peels that were proportional to the concentration of the cro-
ton oil. An analysis of the classic Baker formula revealed that the concentration of
croton oil was quite high at 2.1%, which was responsible for the results as well as
the familiar drawbacks. Having convincingly shown that croton oil was the critical
peeling agent, Hetter was free to alter the concentration of the ingredients as desired.
He lowered the concentration of phenol and varied the concentration of croton oil,
and in so doing, Hetter ushered in a new era in chemical peeling. The new formulas
had the advantage of being clinically effective, similar to the classic Baker peel, with-
out the troublesome complication of hypopigmentation. Having the freedom to alter
the croton oil concentration as needed is a major advance that allows the peel to be
performed superficially or deep, depending on the circumstance. This versatility makes
the peel applicable to patients of all ages and skin types.
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Having the ability to alter the croton oil concentrations has further ramifications. It
is now possible to use croton oil concentrations weak enough so that the applica-
tion technique becomes one of the important factors in determining the depth
reached. The entire process is slowed down so that the surgeon can observe the skin
changes and have the opportunity to stop at whatever depth is deemed appropriate.
The all-or-none phenomenon seen with the Baker peel was simply that the croton
oil concentration was so high that it immediately resulted in dense frosting. This con-
sistently resulted in a peel deep enough to cause hypopigmentation.
Current peeling agents provide physicians with increased flexibility when treating
wrinkles, creases, and skin pigmentation problems. It is now possible to use chemi-
cal peels to achieve the desired clinical results without reaching a depth that causes
hypopigmentation. Another critical difference is that the surgeon can choose differ-
ent concentrations on different areas of the face, depending on relative skin thick-
ness. Many practitioners of the traditional peel were reluctant to apply a peel to the
eyelids because of the fear of scarring, but now with the choice of a weak concen-
tration of peeling solution, the delicate eyelid skin can be effectively improved with
safety and predictability.
Pharmacology of Chemical Peeling Agents
Jessner’s Solution
Jessner’s solution is a standardized mixture of lactic acid, salicylic acid, and resor-
cinol (14% each) compounded in 95% ethanol. Alone, it causes a superficial epi-
dermal peel. It may be an option for superficial peeling as an adjunctive treatment
for acne. It can also be used as a pretreatment before a TCA peel, to enhance pene-
tration of the TCA solution. It should be noted that salicylate toxicity (known as sal-
icylism) can cause tinnitus, nausea, and headaches.
Trichloroacetic Acid
TCA (also known as trichloroethanoic acid; CCl3COOH) is an analog of acetic acid
in which the three hydrogen atoms of the methyl group have been replaced by chlo-
rine atoms. TCA acts to dissolve keratin and coagulate surface proteins. This pro-
duces a frost as the salts precipitate. It is neutralized by contact with tissue fluids or
topically applied sa line solution for surface TCA. Lower concentrations (10% to 30%
solutions) will pro duce a superficial epidermal peel. Higher concentrations (35% to
50%) penetrate into the superficial dermis, creating a medium-depth peel. Concen-
trations above 50% produce a deep peel, which is usually avoided, because this can
result in scarring.
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Phenol
Phenol, also known as carbolic acid or hydroxybenzene (C6H5OH), is an aromatic
hydrocarbon derived from coal tar. The stock pharmacologic solution of phenol is
known as liquefied phenol USP. This contains 88% phenol, which is the highest con-
centration that will stay in solution at room temperature; 100% phenol is a crys-
talline material at room temperature. Similar to TCA, phenol causes protein coagu-
lation and produces a skin frost almost immediately. Liquefied phenol USP penetrates
into the upper reticular dermis, causing a medium-depth peel. The Baker’s mixture is
the most commonly used and reproducible formula; it is approximately a 50% (w/v)
solution. Notably, less-concentrated solutions such as Baker’s mixture penetrate more
deeply than higher concentrations, presumably because the more dilute mixture
causes less keratocoagulation and more keratolysis, therefore permitting deeper pen-
etration of the phenol.
These ingredients do not combine easily. The liquid soap (Septisol) acts to saponify
the solution. The solution must be stirred vigorously before application to ensure
even mixture of the components.
Croton Oil
Croton oil is an extract of the seed of the plant Croton tiglium. Croton oil is the
source of the organic compound phorbol. Internally, it is a purgative that causes se-
vere diarrhea. Its action on the skin is related to free hydroxyl groups. It produces a
caustic, exfoliating effect on the skin, even in low doses. As mentioned earlier, Het-
ter showed that croton oil was the essential peeling ingredient in the Baker’s mix-
ture. Altering the concentration of croton oil directly alters the depth of the peel.
Commonly used concentrations range from 0.1% to 0.8% croton oil solutions.
Baker’s Phenol Mixture
 Liquefied phenol USP 88%
3 cc
 Distilled or tap water
2 cc
 Croton oil
3 drops
 Septisol soap
8 drops

Indications and Contraindications
As with all aspects of plastic surgery, patient selection for chemical peels is vital to
ensure consistent, reliable outcomes. Chemical peeling agents are ideal for treating
wrinkled skin or skin with blotchy, irregular pigmentation. There is also some evi-
dence to show that peeling the skin of patients with dysplastic epithelium or actinic
keratoses may reduce or prevent the development of skin malignancy. The patient
must understand that there is a difference between chemical resurfacing and face lift-
ing. The chemical peel will improve rhytids and pigmentary changes but does not
treat the gravitational and volumetric effects of aging.
Patient evaluation requires accurate assessment of skin color and type, skin thick-
ness, and the amount of skin damage (such as rhytids, actinic damage, and pigmen-
tary changes). Thicker, more sebaceous skin can tolerate deeper peeling than thin
skin can. However, peeling is not a good treatment for large pores; pore size is rarely
reduced by the peeling process, and in fact, large pores can become more noticeable
and may seem larger after the peel.
Traditionally, the ideal patient has been considered to be one with thin to moderate
skin, a fair complexion, blue eyes, fine to moderate rhytids, and actinically damaged
skin. However, recent experience and increased knowledge have led to the under-
standing that chemical peels can be safely used in a broader spectrum of patients.
Still, not everyone is a suitable candidate. All patients must be fully informed of the
risks of hyperpigmentation and hypopigmentation, as well as the possibility of a line
of demarcation at the margin of the peel. As usual with all plastic surgery, a thor-
ough history, physical examination, and pertinent investigations should be performed
before the procedure. These include a complete blood cell count, an electrolyte as-
say, urinalysis, and a blood urea nitrogen test for renal function.
Fitzpatrick Classification of Skin Type
The Fitzpatrick classification system can be a useful guide for evaluating a patient’s
skin type and response to sun exposure. Generally speaking, patients who burn and
do not tan (type I) have a lower incidence of postpeel hyperpigmentation and are
more prone to hypopigmentation. Conversely, patients with higher skin types (types
V and VI) are more likely to develop postpeel hyperpigmentation. Fitzpatrick types
III and IV tan easily; this implies that melanocyte proliferation (known as rebound)
may occur after peeling. This tendency must be controlled with a prepeel skin care
regimen. Therefore the greater the skin pigmentation, the longer and more intense
the skin pretreatment regimen must be to control this rebound phenomenon.
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Skin type IV
Skin type V
Skin type VI
Skin type I
Skin type II
Skin type III
Fitzpatrick Classification of Skin Type
Type
Color
Tanning Response
I
White
Always burns, never tans
II
White
Usually burns, tans less than average
III
White
Sometimes burns mildly, tans about average
IV
Brown
Rarely burns, tans more than average and with ease
V
Dark brown
Very rarely burns, tans very easily
VI
Black
Never burns, tans very easily

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Chapter 15  Chemical Peels
Glogau Classification of Photoaging
Glogau developed a classification system for photodamage based on the degree of
skin wrinkling. This scale is commonly used to help determine skin type and thus
treatment options.
Patients in Glogau II with moderate aging and pigment spots can be treated with a
medium-depth peel. Medium-depth peels penetrate the papillary dermis and is ef-
fective for fine facial rhytids and pigmentary problems. Patients with Glogau III and
IV skin have deeper rhytids and therefore require deeper peeling agents for effective
results. Deep resurfacing agents such as phenol/croton oil may be more appropriate
for these patients. Deep resurfacing is effective for fine and coarse rhytids, hyper-
pigmentation and epidermal dysplasia.
As discussed earlier, patients with darker skin types are less suitable for resurfacing.
Other relative contraindications include a history of keloid scarring, cardiac abnor-
malities, and diabetes mellitus (unless the disease is well controlled and stable). Sig-
nificant medical comorbidities such as hepatorenal disease or immunosuppression
are contraindications to chemical peeling, as are abnormalities of collagen or elastin,
such as Ehlers-Danlos syndrome, scleroderma, or collagen vascular diseases. As with
Glogau Classification of Photoaging
Typical
Group
Classification
Age
Description
Skin Characteristics
I
Mild
28-35
No wrinkles
Early photoaging: mild pigment
changes, no keratosis, minimal
wrinkles; minimal or no makeup
II
Moderate
35-50
Wrinkles in
Early to moderate photoaging: early
motion
brown spots visible, keratosis pal-
pable but not visible, parallel smile
lines begin to appear; wears some
foundation makeup
III
Advanced
50-65
Wrinkles
Advanced photoaging: obvious discol-
at rest
orations, visible capillaries (telangi-
ectasias), visible keratosis; always
wears heavier foundation makeup
IV
Severe
60-75
Only wrinkles
Severe photoaging: yellow-gray skin
color, prior skin malignancies,
wrinkles throughout, no normal
skin; cannot wear makeup because
it cakes and cracks

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any plastic surgery, emotional or mental instability is a contraindication to chemi-
cal peeling. Peeling should be postponed until at least 1 year and perhaps longer af-
ter any treatment with oral isotretinoin (Roaccutane; Accutane) because of the in-
creased risk of unpredictable scarring and keloid scar formation.
Pertinent Anatomy
Patients who request a chemical peel are commonly middle-aged and older women
with aged or sun-damaged skin. Chronologic aging results from thinning of the epi-
dermis and dermis along with loss of elasticity. Actinic changes are the photochem-
ical effects of solar radiation damage. These changes manifest histologically as de-
generation of the elastic network (elastosis), disorderly arrangement of the epidermis
and collagen fibers, and flattening of the dermal-epidermal junction with loss of the
rete ridges; thus the resulting dermis is more lax and less elastic. Melanocytes tend
to increase in number but are less evenly distributed in the basal layer and contain
variable amounts of melanin. Clinically, chronological and photoaging results in
coarse, dry skin that shows wrinkles and tissue sagging.
Depth of Peeling
The comparative depth of penetration of peeling agents can be seen above. In su-
perficial peels, the wounding extends to the stratum granulosum. Superficial peels
therefore affect the epidermis only. Medium-depth peels extend into the papillary
dermis, and deep peels extend into the mid-reticular dermis.
Superficial
peels
Medium-depth
peels
Deep
peels
Epidermis
Basal layer
Papillary dermis
Reticular dermis
Subcutaneous
tissue

Histologic Changes With Chemical Peels
Biopsies taken 2 days after a Baker peel have shown necrosis of the epidermis. De-
pending on the depth of the peel, this necrosis can extend through the papillary der-
mis. There is a marked inflammatory response. A medium-depth peel, injuring the
epidermis and papillary dermis, improves actinically damaged epidermis as well as
producing neocollagen formation in the upper dermis. The wounded surface starts
to reepithelialize from the follicular and eccrine duct epithelium. While the epider-
mis usually regenerates within 7 days, dermal regeneration is slower. New collagen
formation begins within two weeks and may continue for up to a year. Obagi com-
pared biopsies from 48 hours post–TCA peel with similar biopsies taken 6 weeks af-
ter a peel and found that medium-depth peels show a clearly defined new layer of
fibrillar collagen and delicate elastic fibers in the upper reticular dermis. Deep peels
showed that the neodermis formed almost the full thickness of the reticular layer.
Therefore deeper peeling modalities produce a greater degree of neocollagen forma-
tion, which is spread deeper into the dermis. The neodermis shows horizontal, thin,
compact bundles of collagen and a dense network of fine, elastic fibers. Melanocytes
show fine, even distribution of melanin granules. However, melanin synthesis is im-
paired, and this can result in a generalized bleaching effect.
Prepeel Preparation
Regardless of the chemical peel to be used, adequate preparation of the patient is an
important factor contributing to the success of the treatment. The patient must be
motivated and understand the recovery period required. The reward is a dramatic
long-term improvement in skin texture that is not easily replicated by any other
modality. However, to achieve this, the patient must be prepared for the postpeel
morbidity. The immediate postpeel phase, although not particularly long, can be try-
ing for the patient; therefore it must be described realistically and in considerable de-
tail. Detailed photographs of a representative patient’s day-by-day recovery are shown
to the patient and, if possible, to the patient’s caregiver. Some patients will not tol-
erate the postpeel morbidity associated with medium to deep chemical peels. These
patients can be treated with superficial peels, but they must understand that the clin-
ical improvement will be less dramatic, and regular treatments may be required. Pa-
tients with coarse rhytids requiring deep resurfacing can gain a dramatic improve-
ment but must be prepared for the significant postpeel recovery. It is worthwhile to
have a prospective patient speak or, ideally, meet with patients who have had a sim-
ilar peel. Seeing someone in person who has successfully gone through the process
offers invaluable encouragement that although the recovery is difficult, it will be well
worth it. The peel is well tolerated and the experience will be a positive one if the
patient is well informed and the physician sets the proper tone.
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Preparation of the skin before the peel is a means of preventing such complications
as pigmentary changes. This is done by applying aggressive doses of tretinoin and
hydroquinone 4%, as described below. Some companies offer a complete “set” of
required products and a protocol for their use, such as the complete Obagi Nu-Derm
system (Skin Specialists PC, Omaha, NE), which may be of value to practitioners.
With an appropriate pretreatment regimen, the epidermis is stabilized, the dermis is
stimulated to create more collagen, and the melanocytes are suppressed. The pur-
pose is to regulate cell function and reduce the risk of postoperative pigment change.
The skin is in essence “revved up” for the injury to come.
Preparation begins at least 2 weeks (ideally, 4 to 6 weeks) before the peel with ap-
plications of tretinoin 0.1%. Also known as Retin-A or Renova, this product is an
acid form in vitamin A. It acts to decrease the cohesiveness of epidermal cells, which
results in thinning of the stratum corneum. One inch (1 g) should be applied to the
whole face once per day. The application should include the earlobes, tragus, and
hairline, continue to 1 inch below the mandibular border, and up to 1 to 2 mm be-
low the ciliary edge. The upper lids must be avoided, because application on this tis-
sue could lead to irritation. The neck can be prepared in a similar fashion, less fre-
quently, depending on whether irritation develops.
Hydroquinone 4% or other bleaching creams are used both preoperatively and post-
operatively to reduce the risk of hyperpigmentation. Hydroquinone decreases melanin
formation by inhibiting tyrosinase in melanocytes. Therefore it produces a reversible
suppression and regulation of melanocytes. It is used for 2 weeks preoperatively
(again, the ideal is 4 to 6 weeks), then again after the peel once the skin has resur-
faced. Also, to prevent postinflammatory hyperpigmentation, glycolic acid 8% or
phytic acid 2% is applied once daily to loosen desquamated cells in the stratum
corneum and help accelerate exfoliation.
This process accelerates cellular turnover and results in erythematous, flaky skin; the
patient must be prepared to accept this phase. Retinoid dermatitis is also common
preoperatively. This can be lessened by decreasing the application of tretinoin to every
other day for the first 1 to 2 weeks. The preparation should be stopped 4 or 5 days be-
fore the peel to allow the epidermis to settle.
The patient is instructed not to apply anything on the skin on the morning of the
procedure.
This skin preparation regimen is certainly a nuisance, and there is controversy as to
its absolute necessity. There are practitioners who successfully perform peels or laser
resurfacing without it; greater experience and specific studies will be required before
consensus is reached. Our experience has been that omitting or shortening the prepa-
ration has led to excessively long erythema.
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Part III  Nonsurgical Cosmetic Treatments

Pretreatment Planning
Medications
Antiviral prophylaxis is routinely prescribed to all patients, regardless of whether
they have a history of oral herpes. Valacyclovir hydrochloride 500 mg, 1 tablet two
times a day, or the equivalent dose of acyclovir or famciclovir, is begun 3 days be-
fore the procedure and continued for 7 days after the peel. Although the postpeel
phase is not particularly painful, narcotic pain medication is prescribed along with
ibuprofen 800 mg 3 times daily. Steroids are administered intraoperatively, followed
by a Medrol Dosepak begun the day after the peel. Sleep medication is prescribed
and a mild sedative may be considered to help the patient cope with the inconve -
nience and isolation of the recovery period.
Solution Preparation
TCA
These solutions are generally prepared by a compounding pharmacist using appro-
priate weight-to-volume calculations (w/v) to achieve the correct percentages. As an
example, a 35% TCA solution should be compounded by dissolving 35 g of anhy-
drous TCA crystals in a little distilled water, then more water should be added to
bring the final volume to 100 ml. Dissolving 35 g TCA in 100 ml of distilled water is
incorrect, as this will result in a more dilute solution than expected. The required va-
riety of concentrations should be compounded by the pharmacist and not diluted
from each other by the surgeon. If stored in acid-resistant plastic bottles, the stock
solutions are stable for at least 2 years. Small volumes of each concentration can be
poured from the stock bottles as required.
Using the correct concentration of TCA solution is vitally important. If the physi-
cian does not know a reliable compounding pharmacist, a national distributor can be
used to ensure that the TCA mixture has been accurately prepared.
Croton Oil
Preparation of the acid peeling solutions is a critical step that ideally should be per-
formed by the operating surgeon to ensure accuracy and consistency. The ingredi-
ents, including water, phenol, croton oil, and Septisol, are the same as in the classic
Baker peel formula. They are inexpensive and can be obtained from compounding
pharmacies or from Delasco (Council Bluffs, IA), a dermatologic supply company.
Traditional formulations used drops of croton oil which can be awkward to deal
with and have the potential of dangerous variability especially when dealing with
small volumes. The process is simplified significantly by delivering the croton oil in a
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Chapter 15  Chemical Peels

standardized stock solution consisting of USP phenol 88% 24 ml and croton oil
1 ml. This solution yields a reliably accurate concentration of 0.04 ml croton oil to
1 ml stock solution. This increased volume of ingredients allows easy measurement
with standard syringes. As can be seen in the table below, the volumes of water and
Septisol remain constant, and by varying the relative volumes of phenol and stock
solution, different concentrations of croton oil are possible. As an example, to make
a 0.8% croton oil solution, one would mix water 5.5 ml, Septisol 0.5 ml, and add
USP phenol 88% 2 ml and stock solution 2 ml. The 2 ml of stock solution contains
croton oil 0.08 ml. Because the total volume of the solution is 10 ml, the final con-
centration is 0.08 ml of croton oil in 10 ml total volume, or 0.8%. Weaker solutions
such as 0.1% and 0.05% are very useful; to make these, one first makes 0.4% and
0.2% and these are further diluted, as noted in the table. The final concentration of
phenol in all these formulas is 35% by volume. If a greater concentration of phenol
is desired, the relative volume of the USP phenol 88% is increased and the volume
of the water is decreased. The stock solution, at 4% croton oil, should always be
diluted—never applied full strength.
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Part III  Nonsurgical Cosmetic Treatments
Hetter Peel Formulas With a 35% Phenol Vehicle
0.2%
0.4%
0.8%
1.2%
Water
5.5 ml
5.5 ml
5.5 ml
5.5 ml
Septisol
0.5 ml
0.5 ml
0.5 ml
0.5 ml
USP phenol 88%
3.5 ml
3.0 ml
2.0 ml
1.0 ml
Stock solution containing phenol
0.5 ml
1.0 ml
2.0 ml
3.0 ml
and croton oil (see below)
TOTAL
10 ml
10 ml
10 ml
10 ml
Croton Oil
0.1%  1 ml of 0.4%  1.2 ml phenol  1.8 ml water.
0.05%  1 ml of 0.2%  1.2 ml phenol  1.8 ml water.
Stock solution  24 ml phenol  1 ml croton oil (0.04 ml croton oil/1 ml stock solution or 4% croton oil).
A useful variation is to add olive oil to the solution to allow a smoother, more even
application. For example, to make a 15% olive oil solution from the 10 ml formu-
las, one would include 1.5 ml of olive oil and decrease the water volume to 4 ml. In
the weaker 4 ml total volume formulas, 0.6 ml of olive oil would be added and the
water volume decreased to 1.2 ml.

Pretreatment Routine
Application of the peel is painful; therefore intravenous sedation or general anes-
thesia is usually necessary. Regardless, adequate blocking of pain is important to pre-
vent excessive stimulation and allow the patient a pain-free emergence from anes-
thesia and a comfortable initial postpeel course. If the initial pain cycle is avoided,
the entire recovery and general experience will be better. Some patients report mild
tingling or burning on the first night, but they are usually pain free the following
morning.
After sedation or general anesthesia, complete local sensory facial nerve blocks are
performed with bupivacaine (Marcaine) with epinephrine. These include supraor-
bital, supratrochlear, infratrochlear, zygomaticotemporal, zygomaticofacial, infra-
orbital, dorsonasal, mental, and cervical nerve branches. Subcutaneous infiltration
of dilute plain bupivacaine throughout the entire operative site is very useful. Color
changes of the skin are important indicators of the depth reached; therefore epi-
nephrine is not used in the superficial infiltration to prevent blanching. Intramuscu-
lar ketorolac tromethamine (Toradol) is administered as an adjunct to anesthesia if
a concomitant operative procedure is not being performed. Steroidal agents are given
intraoperatively, and a Medrol Dosepak is begun the next day.
Ophthalmic ointment and corneal protectors can be used during a peel to protect
the eyes, but even when they are used, extreme caution around the eyes is impera-
tive. If excessive ointment is used, any spilled or misplaced chemical may dissolve in
the ointment and prevent immediate flushing out if it becomes necessary. Alterna-
tive measures include avoiding the use of ophthalmic ointment altogether or sutur-
ing the eyes shut.
The fear of cardiac toxicity has been historically associated with phenol peels, but
rare reports of death are anecdotal, and it is impossible to implicate phenol toxicity
rather than complications related to anesthesia. The occurrence of arrhythmias dur-
ing peeling is well documented, and although rare, these are not clinically signifi-
cant. Historically, traditional peels were performed with anesthesia or sedation but
without local blocks. There is speculation that the catecholamine release from the
intense stimulation caused by the high concentration of croton oil may have been
the cause of the arrhythmias. With a lower concentration of phenol (35% versus
49%), a lower concentration of croton oil, and thorough local anesthesia of the face,
cardiac complications have not been seen. Thomas Baker, who popularized the tra-
ditional peel, has stated that in his vast experience he has never encountered cardiac
arrhythmias that required treatment. General recommendations include cardiac mon-
itoring, adequate hydration, and peeling a full face in no less than 45 minutes. Fol-
lowing these precautions, we have encountered no cardiac complications in nearly
10 years of peel procedures.
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Chapter 15  Chemical Peels

TREATMENT
Application Routine
With the patient sedated and the nerves of the face well blocked, the skin is thor-
oughly cleaned and degreased with acetone or alcohol. This step is vital to allow even
penetration of the peeling agent; a splotchy peel can occur as a result of uneven pen-
etration if the skin still has residual oil or stratum corneum. Thereafter, the applica-
tion process should be an orderly and nonintimidating one. The reason for this is
that practitioners can choose an adequately weak concentration to slow down the
process, depending on their preference and experience, to give ample time to judge
the depth achieved. Furthermore, there are a number of factors at the surgeon’s dis-
posal (see below) that can be used to fine-tune the control of the application. In gen-
eral, the different concentrations of solutions are placed in separate, easily identifi-
able bowls or cups. Materials for application are 2  2 gauze (preferably synthetic
fiber, which is less abrasive) and cotton-tipped applicators.
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Eyewash solution should also be kept in reach, in case an ophthalmic washout is re-
quired. For application, the gauze is folded twice, dipped into the solution, and care-
fully wrung out to avoid dripping. The solution is stirred before each application to
ensure even mixing of the ingredients. An assistant helps dry the applying hand to
prevent inadvertent application where it is not wanted. Consistent vigilance in this
respect is imperative, especially in segmental peels, where errors will be obvious.

TCA Peel
Epidermal peels are performed with a 20% TCA solution, whereas medium-depth
peels can be performed with more-concentrated solutions. We generally use a 30% to
35% solution for medium-depth peeling. Deeper peels are produced with 40% to
45% solutions. Concentrations higher than 50% are best avoided; at this high con-
centration, penetration into the dermis occurs rapidly and can be difficult to control.
The wet (not dripping) gauze sponge is used to apply the TCA solution in turn to
each region to be treated. If the patient is awake, holding a fan close to the peeled
area can help decrease the associated burning sensation. As the skin is treated, it de-
velops a whitened color, known as a frost. There is a delay between the application
of the solution and formation of the frost. In appropriately pretreated skin, the delay
is approximately 60 seconds (45 to 120 seconds on average). Therefore, after each
pass with the gauze, the physician should pause to observe the frosting before fur-
ther application to the area. This process requires patience on the part of the physi-
cian but is essential to prevent undesirably deep peeling. Each region of the face is
treated in turn until the desired depth of frosting is achieved, then attention is turned
to the next region. We prefer to peel regions that require deeper penetration first (for
example, the perioral region and the forehead) and regions to be peeled less deeply
(such as the periorbital area) last.
Once the desired depth of peel has been achieved, ice-cold saline-soaked gauzes are
placed on the peeled region. This relieves the burning sensation for the patient and
helps to neutralize any remaining TCA solution on the skin surface to prevent fur-
ther penetration. The gauzes warm up quickly and should be replaced or refreshed
regularly with ice-cold saline solution. Removing the gauzes also allows the physi-
cian to assess the resolution of the frosting. Erythema appears after the frosting re-
solves, when serum in the tissue and vessels neutralizes the TCA and the coagulated
proteins resolve. The time taken for the frosting to resolve and erythema to occur is
directly related to the depth of the peel: frosting resolves more quickly with superfi-
cial peels than with deep peels. According to Obagi, superficial epidermal peels will
resolve in less than 20 minutes. The frosting in medium-depth (papillary dermal)
peels lasts up to 40 minutes. Deeper peels into the reticular dermis take longer to re-
solve, with frosting persisting for up to 60 minutes.
Factors That Influence the Depth of a TCA Peel
Low concentrations of TCA result in a more superficial peel. Higher concentrations
peel more deeply. Peel depth is also related to the amount of acid and the prepara-
tion of the skin. Therefore depth can also be increased by applying more layers of
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solution or by pretreating the skin with either Jessner’s solution or mechanical abra-
sion (for example, with a gauze sponge). This becomes particularly important if the
patient has not completed the routine prepeel skin preparation regimen.
Assessing the Depth of a TCA Peel
Obagi has noted that the ability of the body to defend against the acid depends on the
concentration and volume of acid applied, as well as on the thickness of the skin.
Frost (or skin whitening) occurs as the skin proteins precipitate on application of
TCA. The speed at which the frost develops varies with the concentration of the TCA
used: dilute concentrations take 15 to 60 seconds to produce a frost, whereas higher
concentrations may frost in less than 10 seconds. The precipitated protein disperses
with time and therefore the frost disappears. Frosting of the skin is a helpful clinical
sign to aid the surgeon in deciding when to end the peeling process, as the amount
of frosting is related to the depth of the peel. Obagi grades frosting as level 1 through
3, as shown in the table.
Obagi Level of Frosting
Obagi Level
of Frosting
Clinical Relevance
1
Limited to the epidermal layer; a nonorganized, foggy or cloudy white frost
on a pink (erythematous) background
2
Penetration to the papillary dermis; a regular, white-coated frosting with
erythema still showing through
3
Penetration through the papillary dermis; a solid, intense white to yellow
frosting, with no background erythema
In level 1, the peel penetrates the epidermal layer only and results in a combined pink
and white frost that is disorganized or “cloudy.” Penetration into the papillary der-
mis produces a level 2 frost, which is a more uniform white frost, but with erythema
still showing through. Penetration of the peel into the reticular dermis produces a
solid white frost with no visible erythema; this is level 3. Deeper dermal penetration
of the peel is undesirable; this produces skin with a grayish appearance and is asso-
ciated with long-term scarring.

This patient is shown partway through the peeling process; she has also undergone
an upper blepharoplasty followed by a full facial chemical peel with 30% TCA. Note
the level 2 frosting of the forehead with visible erythema in the base, compared with
dense level 3 frosting of the perioral region, where no erythema can be seen (left).
At the end of the peeling process, there is level 1 irregular frosting of the nasal tip,
regular level 2 frosting of the forehead, cheeks, and mental area, and level 3 frosting
of the perioral regions (right).
Obagi also suggested the epidermal sliding sign to show when a TCA peel has pen-
etrated the papillary dermis. At this level, the epidermis can slide over the firmer, im-
mobile dermis, since the rete ridges have been disrupted. Skin firmness (turgor) can
also be palpated. Untreated skin is soft to the touch, whereas a deeper peel results in
firmer dermis caused by an increased amount of protein precipitation.
Recommendations for TCA Peels
The following are general recommendations of TCA concentrations in specific ar-
eas, but it is important to consider individual variations and to remember that con-
centration choice is only one factor influencing the depth of penetration of the peel.
Regardless of concentration, it is imperative to always judge the depth of the peel as
described in the previous section.
The whole face can be peeled with the same concentration of TCA, with depth var-
ied by increasing the number of layers of solution applied, or by using varied con-
centrations of solution. In general, the author prefers to use a single concentration
of solution, usually 30% to 35% TCA, to peel the entire face.
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In general, the deepest peel should be performed in the perioral region. This is fol-
lowed by the forehead and cheeks, with the lightest peels performed on the eyelids
and earlobes. The perioral region has deeper rhytids and is peeled until a level 3 dense
white frost is achieved.
Application
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The 30% TCA is applied to the perioral region with a cotton-tipped applicator; this
ensures accurate application of the solution into the perioral rhytids. The forehead
and cheeks generally require a medium-depth peel, depending on the patient. Pene-
tration into the papillary dermis is ideal; therefore frosting is carried to level 2. The
solution is usually applied with gauze 2  2 squares to cover a large area evenly.
The solution is applied to the nose with a 2  2 gauze square on the dorsum and
sidewalls, and cotton-tipped applicators are used to ensure penetration into the alar
grooves. Because the eyelids have thin skin, the solution is carefully applied to this
area with a cotton-tipped applicator. This is usually the last area of the face to which
the solution is applied.

If the neck or décolleté region is to be treated, a lower concentration of TCA (such
as 20%) should be used. This is because the skin in this area has fewer adnexal struc-
tures; therefore reepithelialization can be delayed with deeper peels. If the neck is
not to be treated, the facial peel should be blended or feathered just below the
mandibular angle by applying solution to this area very lightly.
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After the peel is applied to the desired depth, iced saline-soaked gauze is placed across
the patient’s face to cool and relieve the burning. This is changed regularly to ensure
the gauze stays cold and that the physician can review the resolution process. Once the
frost starts to resolve, a thin layer of petrolatum-based occlusive ointment is applied
across the peeled surface, and the patient is transferred to the recovery suite. Com-
plete resolution of the frosting depends on the depth of the peel. The patient should
be checked in the recovery suite, and the physician should note how long the reso-
lution process takes. This is a good indication of the depth of the peel and aids the
physician in developing judgment in the art of peeling.
The patient is shown 30 minutes after the peel, with
resolution of the frosting.

Croton Oil Peel
Application
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With the damp gauze in hand, the physician makes multiple passes, observing the
color change of the skin to assess the frost formation. As the application progresses,
the depth is gauged by the degree of frosting, which becomes progressively more
dense and opaque. The speed at which the frost appears depends on the concentra-
tion used and the wetness of the gauze. With the typical concentrations described
and use of a damp (not wet) gauze, the appearance of the frost is gradual and is seen
in about 10 seconds. Unlike TCA peels, with a croton oil peel there is no need to wait
several minutes to see the final depth. Once the acid solution is applied, there is no
neutralizing agent and the effect is irreversible. The only recourse in this respect is
that if a too-wet application is made, quickly blotting it will diminish the depth.
Factors That Influence the Depth of a Croton Oil Peel
The versatility and safety of the peel are based on the fact that there are a number
of variables that determine the depth. Hetter’s invaluable contribution was in demon-
strating that the concentration of the croton oil is a key factor of the depth reached,
and compared with older peels, is the demarcation between an excellent result and hy-
popigmentation. Regardless of the concentration used, the number of coats applied
has an additive effect; therefore a weak concentration applied repeatedly can lead to
deep involvement, even scarring. The safety of a weak concentration is only relative
and should never be taken for granted.
As previously described, the croton oil concentrations are relatively weak, so the
other main factor of the depth reached is the application technique, which is directly
controlled by the surgeon. This is the fundamental difference between the modern
croton oil peel and its predecessors. A damp sponge can be rubbed multiple times,
variable pressures can be used, or the gauze can be wetter and fewer passes made.
Theoretically, the same depth can be reached by using different techniques or even
different concentrations.
1
15-1 Croton oil peel

The location on the face to which the peel solution is applied is significant because
of the relative thickness and recuperative potential of the skin. For example, the peri -
oral skin can sustain a deeper peel than the thinner, more delicate skin of the eyelids.
Assessing the Depth of a Croton Oil Peel
The key to success with these peels, as with any resurfacing technique, is choosing
and safely reaching the appropriate endpoint. This depends on the degree of frost-
ing, which is mainly a visual phenomenon, and therefore subjective and based on
experience. Regardless of these apparent difficulties, photographs and available videos
are very accurate references, and the process is not as daunting as it may initially ap-
pear. Anatomically, a superficial peel wounds all the structures of the epidermis. Such
a peel may have an effect on pigmentary issues and be “refreshing,” but it cannot be
expected to improve real wrinkles. Usually croton oil peels are deeper and affect
change beyond the epidermis. A medium-depth peel goes to the papillary dermis.
Deep peels go to the reticular dermis (upper to mid-dermis), and peeling to the lower
reticular dermis can be problematic, leading to hypopigmentation and possibly scar-
ring. The recovery, of course, is more involved with increased depth, but the harsh
reality remains that to provide real change, there must be injury into the dermis.
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The visual clues are a thin, transparent frost with a pinkish background denoting a
peel to the papillary dermis. The pink hue is caused by the subdermal vascular plexus,
still intact, showing through.
A solid, opaque, organized, even frost signifies that the upper to mid-reticular der-
mis has been reached.

Practitioners familiar with the different degrees of frosting with deeper TCA peels
will have little difficulty transitioning to croton oil peels. The important concept is
that this is a gradual continuum that is slow enough, with the visual changes easily
recognizable and predictable. An experienced practitioner can control the process,
peeling slowly enough to recognize the various stages and is able to stop at the ap-
propriate depth and go no deeper.
Another indicator in evaluating the level of peel is epidermal sliding, which is seen
when the peel reaches the level of the papillary dermis; the epidermis is separated
from the underlying reticular dermis and slides as a thin, independent sheet. This
sliding disappears when the reticular dermis is reached and the epidermis and der-
mis bond together, forming a single protein block. Epidermal sliding is most obvi-
ous in thin-skinned areas such as the eyelids and lateral forehead, as opposed to
around the mouth. Epidermal sliding is a particularly telling indicator in the very
thin eyelid skin, where the margin for error is small.
Defrosting, or loss of the frost, can also be used to assess or confirm the peel depth,
although it is already after the fact.
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Defrosting Times
 Papillary dermis
5-10 min
 Upper to mid-dermis
15-20 min
 Mid- to lower dermis
20-30 min
A thick, gray-white sheet of frost with eventual red-
brown overtones indicates that the mid-dermis has
been reached—as deep as the peel should go. The
red-brown overtones may take 15 minutes or more
to become evident and are a reliable and accurate
sign. Once a dense frost has been achieved, such
as in the perioral area, it is worthwhile to wait to
see whether the red-brown appears before consid-
ering further application.
Recommendations for Croton Oil Peels
The following are general recommendations for croton oil concentrations in specific
areas, but it is important to consider individual variations and to remember that the
choice of concentration is only one factor. Regardless of the concentration, it is im-

perative to always judge the depth of the peel, as described in the previous section.
The perioral area (including the lower nose) is quite resilient and can be peeled with
a strong concentration, such as 0.8%. This is extended beyond the chin onto the
mental crease. Individual rhytids are stretched out to allow even penetration. The
peel can be extended into the vermilion to improve lip wrinkles and gain beneficial
lip eversion. The commissures heal well and can be peeled to a relatively deep level.
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General Peel Recommendations*
Location
Croton Oil Concentration
Forehead, temporal area
0.2%-0.4%. The glabellar area can be peeled deeper than the
lateral forehead and temporal area. Precise deeper peeling of
individual lines is possible with a wetter cotton-tipped applicator
and blotting dry as frost appears.
Perioral area (including
Precise deeper peeling of individual lip lines is useful.
lower nose)
Cheeks, preauricular area
0.2%-0.4%. Deep peeling is rarely needed.
Eyelids
0.1% lower eyelids; 0.1% upper eyelids. Consider 0.05% in
upper lids, especially below the tarsal fold.
Neck
0.1%. This is light peeling for blending of color, not for improve-
ment of wrinkles.
*Predictable problem areas that require careful attention include the temporal area, immediate preauricular area, gen -
iomandibular area, and the medial upper lid where it abuts the nasal skin. These are general recommendations. The key
to the peel is to always judge the depth by the visual clues described, whatever technique or concentration is used.
There is only relative safety in using a weaker concentration, and similar depths can be reached by the use of different
techniques, even different concentrations.
The cheeks and forehead are peeled with 0.4% concentration. The glabellar area and
central forehead are relatively thick and can be peeled to the mid-dermis (solid white
frost). The lateral forehead and temporal area are more delicate and peeling to the
papillary dermis is usually more appropriate (a white frost will appear, with a pink-
ish background). The peel can be safely extended to the hairline and brows to avoid
lines of demarcation. Deep peeling of the cheeks is not often needed. Caution should
be exercised in the preauricular area and geniomandibular groove.

The eyelids are peeled with 0.1%, and 0.05% is a consideration for the upper lids. In
the lower lids, the peel is extended close to the ciliary margin. The peel is applied
with a cotton-tipped applicator, and as in other areas, the relative dampness and
number of passes affect the depth of the peel. The thin eyelid skin responds well and
in a predictable way to these weak concentrations. Epidermal sliding and an even
white frost are easily recognizable and reliable findings that denote the proper depth.
If there is obvious redundancy of skin in the upper lid, the peel can be safely extended
below the tarsal fold, possibly with a concentration of 0.05%.
The peel is extended onto the neck using 0.1% (or weaker) with light, wispy strokes,
because this skin is thin and does not heal as well as the face. The endpoint is a light,
scattered frost that is not at all organized. The neck skin is too thin to withstand a
peel deep enough to improve wrinkles; doing so will result in hypopigmentation and
quite possibly scarring. The purpose of the neck peel is to prevent the obvious de-
marcation that is commonly seen with laser resurfacing and deeper peels.
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Precise deeper peeling of individual rhytids without affecting surrounding areas is a
great advantage, especially in the perioral area and chin. This is done with a wetter
cotton-tipped applicator, painting the individual line and then quickly drying it as
a dense frost appears. This is very useful in troublesome radial lip lines. More pre-
cise application, as in the crow’s-feet, can be done with the splintered wooden end

of the applicator. Focal repeeling of persistent rhytids is easy to do with the patient
under local anesthesia. Repeat peeling either in part or whole has an additive effect.
If peeling appears to be uneven or if there is a sharp demarcation between areas
peeled with different concentrations, a weak concentration such as 0.2% or 0.1%
is used to blend these sections.
The best way to learn these peels is to gain experience, but this must be done safely.
Like any difficult procedure worth performing, whether a deep SMAS dissection or
a TRAM flap, diligent study and attention to details are required. It is always worth-
while to watch another surgeon perform a peel, but this may be impractical. Good
color photographs in publications and available videos are valuable to familiarize
oneself with the visual aspects of the frost. One approach is to purposely plan on a
lighter peel using a maximum concentration of 0.4% with the thought of perform-
ing a repeat peel should it become necessary. Thus the surgeon gains experience mix-
ing and handling the solutions and visualizing the appearance of frost after appli-
cation. It is never wrong to underpeel, and once this threshold is crossed, it is not
difficult to progress to full-fledged peels.
Variation of Chemical Peels
Segmental peels are possible with any resurfacing agent but carry the risk of a mis-
match in coloration; therefore good judgment must be exercised. Skin with wide-
spread solar damage carries a risk of demarcation, so a full-face peel is preferable.
Segmental perioral peels can be done, peeling to a medium depth at most. The color
takes 8 to 10 weeks to blend adequately and the patient can manage color differ-
ences in the meantime with makeup.
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In selected individuals with isolated upper lip lines, peeling of the mustache area can
produce excellent results.

The skin of the lower eyelid responds very well to chemical peeling. When peeled to
the appropriate depth, the thin eyelid skin contained within the borders of the or-
bital rim is very forgiving. Healing is well tolerated and easily camouflaged with
makeup or glasses, making this an excellent location for segmental peeling. How-
ever, we would add a note of caution when treating this area: very low concentra-
tions of peeling agents should be used. With croton oil peels we limit the concen-
tration to 0.1%, and with TCA we limit the concentration to 20% or a very light
pass with 30%.
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Considerable improvement was achieved after a segmental peel in this 42-year-old
man, whose wrinkled lower eyelid skin was incongruent with his otherwise youthful
looks.
A major advantage of the lower eyelid peel is that it can easily be done under local
anesthesia and in a gradual fashion. If a patient requests a procedure with a quicker
recovery, a lighter peel can be done and repeated in the future with additive effect.
In a real sense, the lower eyelid can be peeled to the patient’s satisfaction. Treatment
of the lower lids is a good option for chemical peeling because of its safety and pre-
dictability; it is a good starting point for patients who are reluctant to begin with a
full-face peel. Regardless of the technique chosen, the wise surgeon will avoid seri-
ous problems by accepting that wrinkles cannot be completely removed with a peel
procedure.
A novel use of these procedures is to perform a lighter peel in younger individuals
to improve early imperfections while providing an easier recovery. These peels suc-
cessfully improve early wrinkling and solar damage, restoring a brightness or lu-
cency to the skin that evokes a look of youth. The aim of peels is to keep up with ag-
ing; they can be an excellent adjunct to many facial procedures, except surgeries in
which major skin flaps are elevated.

This 45-year-old woman exhibited generalized elastosis and etching of the chin. Con-
siderable improvement without loss of pigment is seen at 1 year, and her results re-
main stable after 6 years. Other than the original Baker peel, no other modality has
been able to claim this kind of longevity of results.
Posttreatment Care
Once the peel is completed, the patient is observed until all the frosting subsides.
The peeled area is then covered with an occlusive dressing, which acts as a mechan-
ical barrier to enhance the results of the peel. This has been shown to increase the
depth of phenol penetration. Previously, a waterproof mask of adhesive tape was
commonly used for this purpose. However, this has to be removed usually 48 hours
after the peel and is associated with increased patient discomfort, especially during
removal. In addition, the physician is unable to view the peeled surface during the
coverage period. More commonly today, a petrolatum-based occlusive dressing is
used, such as Vaseline or Aquaphor. Alternatively, one tube of Polysporin (Pfizer) and
one tube of lidocaine jelly can be mixed together and briskly beaten into an even
emulsification. This antibiotic/anesthetic cream can then be applied over all the peeled
areas to provide analgesia as well as occlusive coverage. The remainder of the mixture
can be placed in a container and given to the patient for use at home.
The purpose of the petrolatum-based dressing is to moisturize the peeled skin to pre-
vent crusting and provide analgesia. An advantage to this approach is that the wound
is always in view for evaluation, and it is less painful for the patient. This regimen is
inexpensive and effective; with more experience and more practitioners involved,
other, better approaches may be developed.
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Pretreatment
1 year after peel
6 years after peel

The early phase of the recovery lasts 7 to 10 days as the skin gradually reepithelial-
izes from the deeper layers upward. During this period, the wounded skin is moist
and oozes serous fluid. Frequent application of the ointment is necessary to prevent
drying and crusting. The patient is strongly admonished not to pick at or dislodge
any crusts, because this may cause scarring. The surgeon must also exercise restraint
in this respect.
Management of the postpeel phase begins before the peel with adequate informa-
tion. Patients must fully understand what the experience will be like and how they
will look. Showing photographs of the day-by-day recovery is valuable and ensures
that the patient will be a willing participant based on accurate information. The early
recovery can be challenging, but patients do well if they are well prepared.
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Pretreatment
1 day after peel
Depending on the depth of the peel, the appearance on the first day can be impres-
sive, and the patient may be almost unrecognizable. This 49-year-old woman had
advanced wrinkling, sun damage, and smoker’s lines. On day 1 after the peel (with
anesthetic/antibiotic ointment applied), there is serous oozing and some blistering
along the neck. Despite this appearance, most patients are not uncomfortable.