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![Page 1: Chemical Peeling - University of Texas Medical Branch · Chemical Peeling Michael E. Decherd, MD Faculty Advisor: Karen H. Calhoun, MD The University of Texas Medical Branch Department](https://reader031.fdocuments.us/reader031/viewer/2022021805/5baf57a209d3f2b25c8c1ce4/html5/thumbnails/1.jpg)
Chemical Peeling Michael E. Decherd, MD
Faculty Advisor: Karen H. Calhoun, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
November 15, 2000
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“Mislike me not for my complexion,
The shadow’d livery of the burnished sun”
Shakespeare, The Merchant of Venice
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History
• Ancient Egypt: oils, salt, alabaster Sour milk – lactic acid
Sun damage – cultural stigma
• Scripture: emollients, perfumes for wives of
Jewish and Babylonian kings
• Turks: used fire to induce exfoliation
• Indian women: urine and pumice
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History
• Hungarian gypsies: secret generational
formulations
• Madame Pompadour: red wine (tartaric
acid) 18th century France
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History
• Modern use began late 1800s
– Unna 1882 described phenol, TCA, salicylate,
resorcinol
– World War I: phenol
– Lay peelers
– Litton, Baker-Gordon, 1960’s
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• What skin changes occur with aging?
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Skin Architecture
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Aging + Actinic Damage
• Loss of subepidermal collagen
• Decreased volume of dermis
• Thinning epidermis with thick stratum
corneum
• Irregularities of melanocytes
• Irregular elastosis
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Different Causes of Wrinkles
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Fitzpatrick Classi fication
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Glogau Classification
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Glogau Classification
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Peeling
• Creates a controlled wound
• Simulates regrowth of collagen in more
abundance and order – dense, homogenized,
parallel
• Elastin, GAG’s
• Epidermal growth and thickening
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Post-Peel, Immediate
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Post-Peel, 72 hrs
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Post-Peel, Complete
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Classification of Peel Depth
• Very superficial: exfoliates statum corneum
• Superficial: between strata granulosa and
basale
• Medium: papillary or upper reticular
dermis
• Deep: Midreticular dermis
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• 14 years post peel
• Solar elastosis
improved
• Orderly collagen
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• Depth of injury visible histologically
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Factors that Affect Depth
• Agent used
• Method of application and number of layers
• Pre-peel degreasing
• Pretreatment – retinoids or hydroxy acids
• Skin thickness
• Sebaceous gland activity and density
• Anatomic unit
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Which Agent to Use?
• Phenol
• Baker’s peel
• Jessner’s solution
• TCA 10-35%
• Modified Unna’s
resorcin paste
• Jessner’s + TCA
• CO2 + TCA
• Solid carbon dioxide
• Alpha hydroxy acids
• Alpha keto acids
• Tretinion
• 70% Glycolic + TCA
• TCA 50%
• Azelaic acid
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Peel Depths
• Very Superficial
– TCA 10-20% 1-2 layers
– Jessner’s 1-3 layers
– Glycolic acid 20-30% for 1-
2 minutes
• Superficial
– TCA 20-30%
– Jessner’s 4+ layers
– Glycolic acid 40-50% for 2-
20 minutes
• Medium
– TCA 30-40%, or 50%
– TCA Plus
• Jessner’s
• Glycolic acid
• CO2
• Deep
– Phenol
– Baker-Gordon
• Unoccluded
• Occluded
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Superficial Peels
• Indicated for:
– Comedonal acne
– Melasma
– Skin refresher
– Nonfacial peeling
• Repetitive peels may promote collagen stimulation
• Low-risk, rapid recovery
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Indications – Medium & Deep
• Actinic changes and preneoplasia
• Rhytides (fine)
• Pigmentary dyschromias
– Woods lamp helpful
• Superficial scarring
• Radiation dermatitis
• Acne vulgaris and rosacea
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Contraindications
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Structure of Various Compounds
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Pretreatment
• Hydroquinone
– Decreases melanosomes and inhibits tyrosinase
– Useful in Fitzpatrick III and IV to prevent
hyperpigmentation
– Begin 1 mo pre-peel and continue post-peel
• Tretinoin (topically)
• Anti-virals
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Retinoids
• Topical tretinoin has been shown to:
– Correct epidermal atypia
– Thicken atrophic epidermis
– Eliminate microscopic actinic keratoses
– Cause uniform dispersion of melanin granules
– Increase collagen in papillary dermis
– Increase angiogenesis
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Retinoids
• Systemic isotretinoin (Accutane) inhibits
collagenase and decreases the sebaceous
units – Much more likely to scar with
chemical peel
• Recommend waiting 1-2 years before peel
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Other Bleaching Agents
• Hydroquinone
• Kojic Acid
• Azelaic acid
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Jessner’s Solution
• Resorcinol 14 g
• Salicylic acid 14 g
• Lactic acid 85% 14 mL
• Ethanol 95% q.s.ad 100cc
• Also called Coombe Formula or Horvath’s
concoction
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Jessner’s Solution
• Must be stored in dark bottle else discoloration
• Superficial peeling
• Minimizes toxicity
• Advantages
– One solution
– No timing
– No dilution
• Used in combination peels
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Alpha Hydroxy Acids
• Occur naturally
• Superficial peel -- corneolytic
• Time of contact important – must be
washed off with water or bicarb
• Exact mechanism of wrinkle imporovement
unknown
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Alpha Hydroxy Acids
• Glycolic – sugar cane
• Lactic – sour milk
• Malic – apples
• Citric – fruits
• Tartaric – wine
• Pyruvic Acid – alpha keto acid – metabolized to
lactate
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Trichloroacetic Acid (TCA)
• Mix X% solution X gms with distilled H2O
to volume of 100cc
• Stable in clear glass bottles for 6 mo
(dissolves plastic)
• Works by precipitating proteins
• 10-35% superficial peeling
• 50% deep peeling – caution!
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Phenol
• Initially used by Joseph Lister for antisepsis
• More likely to cause pigmentary changes,
usually hypopigmentation
• Full strength is keratocoagulant – self-
blocks penetration
• Lower strength is also keratolytic – breaks
sulfur bridges and penetrates
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Baker-Gordon Solution
• Phenol 88%
• Distilled H2O
• Croton oil
• Septisol
3 cc
2cc
8 gtts
3 gtts
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Baker-Gordon Solution
• Septisol acts to decrease surface tension and
thus increase absorption
• Croton Oil – from the seed of the plant
Croton tiglium, may enhance phenol
absorption and cause inflammation
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Baker-Gordon Solution
• Mix before application
• Must be stirred before application because
solution is not miscible
• Dilutes phenol to approx 50-55%
• Occluded vs. Unoccluded
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Toxicity
• Salicylates: tinnitus, vertigo
• Resorcinol: circulatory collapse,
hypothyroidism, methemoglobinemia
• Phenol: arrhythmias
• TCA: none
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Peel Depth
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Degreasing
• Alcohol, freon, or acetone
• Patient does first, then physician
• Care to be thorough but not too abrasive for
uniform absorption
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Technique -- TCA
• Frosting indicates deeper penetration
• Fan for pt comfort as peel is exothermic
(also useful for alpha hydroxy acids)
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Technique -- Phenol
• Preop Chemistries, CBC, UA, EKG
• IVF
• Sedation / Analgesia
• No more than 25 % at a time with 10-15 minute
pauses between segments
• Area more important than strength for toxicity
• Applied in deep rhytids with pointed wooden stick
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Example
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Phenol Application
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Tape Occlusion
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Post Peel Day 11
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Post Peel Month 6
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Post Peel Month 10
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Post-Peel Care
• Moist salve, dressing
• Frequent cleansings
• Bacitracin – zinc may hasten healing
• Preparation H – live yeast cell factor may
stimulate fibroblasts to increase collagen
• Pain meds usually only for deep peels
• Sunscreen!
• Makeup during recovery, can usu. begin day 7
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Wound Healing, Dry
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Wound Healing, Moist
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TCA vs. Phenol
• Concentrated TCA (>35%) more likely to
scar
• TCA less likely to cause pigmentary
changes
• TCA less toxic
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Other Forms of Skin Resurfacing
• Dermabrasion
• Laser
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Laser Versus Deep Peel
• Patient left is peel, right laser
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Laser Versus Deep Peel
• Postoperative day 1
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Laser Versus Deep Peel
• Two weeks postop
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Laser Versus Deep Peel
• One year later
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Laser Versus Deep Peel
• Authors conclude that peel is equally
effective in thin-skinned areas
• Laser better in thick glandular skin but had
more hypopigmentation, longer discomfort,
longer postop erythema
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Complications
• Pigmentary changes
– Feather application to avoid demarcation line
– Exacerbated by estrogen, sun, certain drugs
• Scarring
– Ectropion
• Infection
– Staph
– Pseudomonas
• Herpetic outbreak
• Persistent erythema
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Scarring
• Perioral
scarring
after TCA
50% peel
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Scarring
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Demarcation
Line
• Avoid by
feathering
peel at edges
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Pseudomonas Infection
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Herpetic Outbreak
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Final Thoughts
• Efficacy of chemical peeling well
established
• Technique and training key to avoiding
complications
• Individualize to patient needs
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History
• Transplantation of animal omentum – 1839
• Autotransplantation of fat 1893
• 1911– Histopathological studies
• 1911– Cosmetic augmentation post-rhinoplasty
• 1929 – Liposuction attempted, d/c’ed after resulted in leg amputation
• 1978 – Modern liposuction
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Cell Biology of Fat
• Mesodermal origin
• Organized in lobules supplied by one arteriole
– <1cm: descends from subdermal plexus
– >1cm: ascends from fasical arteries
• Brown fat – regulates heat
• White fat – lipid storage
• Cervicofacial fat relatively constant in adult
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Fat Cells
• Cells
undergo
hypertrophy,
not
hyperplasia
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Indications
• Improvement of contour via
augmentation/reduction of subdermal tissue
volume
• Removal of localized fat deposits (wattles and
jowls)
• Correction of asymmetries
• Adjunct to face/neck lift
• Enhancement of malar eminences
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Contraindications
• Absolute—generalized obesity, collagen
vascular disease, endocrine disorders,
bleeding disorders
• Relative—inelastic skin, cellulitic or pitting
defects, stretch marks, age > 55,
hypertension, diabetes, fine dermal rhytids
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Workup
• Examine and mark in sitting position
• Take preoperative photographs
• Specific areas to assess
– Submental (wattles)
– Submandibular (jowls)
– Mandibular contour
– Cervicomental angle
– Buccal and parotid areas
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Suction Design
• Mark in
upright
position
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Cannulas
• Blunt tip cannula
good for general
work
• Cobra tip good for
fibrous areas
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Cannulas
• Liposhaver may
be less traumatic
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Example -- Liposhaver
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Cannula Size
• Recommend
4-6 mm
cannulas
with suction
8-10 mm
from end
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Techniques
• “Wet”
– Hypotonic salt solution + lidocaine/epi injected
subdermally
– Decreases bleeding and helps dissection
– Distorts tissues
– Higher incidence post-op edema & ecchymosis
• “Dry”
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Technique
• Direct
approach
• 10-12 times
per tunnel
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Technique
• Indirect
approach
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Technique –
Nasal Aperture
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Technique –
Lower Eyelid
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Liposuction
Approaches
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Technique
• Multiple
tunnels
designed to lay
flat smoothly
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Technique
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Other Uses
• Adjunct to
rhytidectomy
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Other Uses
• May
augment
effect of
chin
implant
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Fat Grafting
• No smaller than 16-18 gauge cannula
• Expect 75-80% volume
• Volume stabilizes by 6-9 months
• Filter harvested fat
• Overcorrect 20-30%
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Technique
• Inject distally
first
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Areas Helped by Fat Grafting
• Glabellar frown line
• Inframalar groove
• Nasolabial fold
• Cheek hollows
• Mentum
• Oral commisures
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Example – Fat
Augmentation
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Complications
• Minor
– Ecchymosis (common)
– Dysesthesia (common)
– Irregularities, bulges, depressions (leave 2mm subdermal fat)
– Pigmentation changes (avoid sun)
• Major
– Neural and vascular injury
– Hematoma/seroma
– Infection
– Skin loss
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Summary
• Liposuction
– Use dry technique with blunt 4- to 6-mm cannula
– Use crisscross method to minimize surface irregularities
– Direct suction aperture away from skin
• Lipoinjection
– Harvest with 18-gauge or larger cannula
– Inject small quantities (usually in 0.1-mL increments) beginning distally
– Overcorrect by about 30%