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Peels

Chapter Two Aging Skin Factors That Age the Skin How Skin Ages Hollowing Sagging Wrinkling Vitamin A Acid Cream Nonsurgical Face-lifts Injection Treatments Peels

There is another kind of wrinkling that has little to do with personality, or every heredity, unless you apply those factors to the case of the blond, fine-skinned patient who stubbornly insists on spending a great deal of time in the sun without sunscreen protection. By the time this patient reaches the late-forties, serious sun damage will begin to show in the form of a kind of “spiderweb,” or fine etching, often on the eyelids and cheeks. Happily, we are able to treat this patient with a chemical peel that, in many cases, can remove up to ninety percent of the wrinkling. It is important to remember that a chemical peel is best for wrinkles that affect the texture of the skin, not wrinkles caused by habitual facial expression.

According to a medical text on the subject, published as a guide for facial plastic surgeons by the American Academy of Facial Plastic and Reconstructive Surgery, the chemical peel, or “chemexfoliation” as it is technically known, was invented by an otolaryngologist names Sir Harold Gillies. He used carbolic acid, known as phenol, as a agent to decrease the elasticity of aged eyelid skin. Since then, various other acids, such as trichloroacetic and glycolic acid, have been used in efforts to improve the texture of skin, but phenol has come through as the most effective agent for deeper skin problems.

Chemical peel solution can be divided into three types, depending on the depth to which the peel penetrates. Phenol, the deepest of peels, removes all the epidermis and part of the top of the dermis, working to smooth the skin within the dermis layer. Phenol is good for the treatment of eyelid wrinkling and skin tightening, and it works well on problems associated with over-exposure to the sun.

For epidermal problems such as freckles, liver spots, melasma - dark skin spots that appear during pregnancy - age spots, and post-inflammatory hyperpigmentation, a trichloroacetic acid peel (TCA peel, for short) works best. TCA peels come in various concentrations, but thirty-five percent strength solution will solve most of the problems I’ve mentioned. A deeper TCA peel can be used to treat fine wrinkling.

A fifty percent glycolic acid peel, is the most superficial peel. It generally is used for exfoliation that renews the keratin layer of skin, giving the face a refreshed look. This sort of treatment can be applied regularly, along with glycolic acid cream applied twice daily. Frequent glycolic acid peels fade age spots and improve areas of wrinkling. (With this peel, you can go to a party the same day of the peel - the face has only a hint of pink.)

The deep chemical peel formula, which is applied with a cotton-tip swab, is composed of eighty-eight percent phenol, croton oil, antiseptic soap and distilled water. I’ve given the recipe only to illustrate the delicacy of the technique: essentially, a chemical peel is a controlled acid burn. Croton oil, from the seek of Croton tiglium, is composed of glycosides of several acids, and it is a very toxic material. Croton oil combined with phenol effectively dissolves the epidermis. The liquid soap, such as Septisol, has several functions, like increasing the penetration of the phenol and croton oil into the deeper layers of the skin. It also makes the phenol and water mix with one another. The distilled water produces the correct chemical concentration of the mixture so that penetration can be controlled.

With a full-face chemical peel, the formula is applied more or less the way you’d apply a facial or mud mask. From time to time, I perform full-face peels in the Toronto area where I practice, but doctors who practice in the Sun Belt latitudes of the U.S. would be more likely to do them regularly because of the number of patients who’ve spent a lifetime in the sun. In Southern Ontario, most people are wish enough to use sunscreens; even farmers work in air-conditioned tractors these days. Mose often, I do regional peels, so-called for the eight aesthetic units of the face. For example, I can use a regional chemical peel on the crow’s feet at the corner of a patient’s eye. A peel also works well on the etched wrinkles that sometimes appear on the lower eyelid or on the so-called “lipstick” wrinkles - the wrinkles where lipstick settles into embarrassing vertical lines - of the upper lip.

As effective as it is, there are drawbacks to the phenol chemical peel. For one, it actually lightens the color of the skin. This means it has to be applied with a feathering motion around the edges - for example, at the hairline, around the ears and slightly into the vermilion of the lips - or the patient may end up with an obvious line of demarcation where the paler skin meets the darker. This lightening effect makes it a difficult technique to use with black or olive-skinned people. For a period of time following the peel, patients have a pinkness added to their skin color though the contrast does, eventually, fade. The new skin is smoother with slightly less pigmentation than before. Rock star Michael Jackson is reputed to have had a series of full-face chemical peels to permanently lighten the color of his skin, which, in my opinion, is a questionable use of the phenol chemical-peel technique.

During application of a chemical-peel solution, it’s important that a patient’s tears do not touch the solution. Tears might be caused by the temporary stinging or burning sensation that follows contact with the skin. If the solution tracks into the eye, it will cause severe burns to the eyeball. As the solution acts on the skin, a kind of white frost develops as the chemicals begin to burn. About ten minutes after application, the burning sensation stops and then may return with the next six or seven hours, when some sort of pain-killing medication might be required. Eight hours after application, most of the pain will disappear, though there is a lingering discomfort for some days due to the swelling of the skin in the area peeled.

The day after the operation, the skin becomes gray in color and “edematous”, or pooled with liquid, just like a burn. It will slow the first signs of peeling. On the second day, the skin looks even worse, more liquidy and more swollen. If it has been a regional peel in the area of the eyes, or the lips, it is likely that the eyes might swell nearly shut, or the lips will puff up like a boxer’s. For the next two weeks, a patient may shower daily and then cover the peeled areas with Polysporin ointment.

Somewhere between the seventh and tenth day after application, the crusting and peeling skin is completely shed. This is the stage when the patient must expect to wear a bright red face, or bright red patches if I’ve done regional peels. The new healing skin is very delicate, and the temptation to pick away final little bits of crust must be avoided: essentially, the patient has experienced a second-degree burn, and picking will cause infection that might result in scarring. The showering and lubricating allows the crust to be shed naturally without a great amount of itching or discomfort.

Within the next month, the bright red skin will fade to an intense pink and then lesser shades of pink as the healing process continues. At no time, for six months following the operation, should the skin be exposed to direct sunlight. Even if you plan to travel in a car on a sunny day, your new skin must be covered with a broad spectrum sunscreen that has an SPF of at least 15. The chemical peel is used to correct damage done by overexposure to the sun. Perhaps it is a kind of cruel retribution for past excesses that if a patient exposes the new skin to the sun, it may result in hyperpigmentation - blotchy, brown spots that might require a lighter re-peel.

I have not spared anything in this description of the process and postoperative effects of the chemical peel because it is a gruesome sort of ordeal, and no matter how much I try to prepare patients for it, the sight in the mirror is always a shock to them. It’s important for them to know the steps that must be gone through in order to get a good effect.

It might be some comfort to know that at the end of two weeks, some patients are healed sufficiently to actually apply water-based makeup. This gives women a slight advantage over men in that they can “go public” a little faster. With the less penetrating TCA peels, patients have fewer reactions and are “socially acceptable” in seven days. As noted earlier, with the glycolic acid peels, patients can go out the same day; their faces have an acceptable glow. These days more patients choose the lighter peels for a more youthful appearance without going through the deeper phenol peels.

Despite the ordeal, chemical peel is a dramatically effective technique for dealing with some of the consequences of aging skin. I sometimes think of it as lifting the mask of age to reveal a patient’s more youthful face.

It is a fortunate era for facial cosmetic surgeons like myself to have such nearly magical tools at our fingertips: our patients need look only as old as they want to.

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