8 Deep Chemical Peels



10.1055/b-0034-92270

8 Deep Chemical Peels

E. Gaylon McCollough

Key Concepts




  • New is not necessarily better.



  • A tool is just that … a tool.



  • If the only “tool” one knows how to use is a hammer, everything begins to resemble a nail.



  • The nature of machines is to malfunction… at the worst possible time.



  • The more complex the machine, the more apt it is to malfunction.



Introduction


Often referred to in nonphysician circles as a “non-surgical facelift,” chemical exfoliation remains the gold standard for treating advanced wrinkling and solar elastosis of the face. Creative ways to apply peeling solutions and modifications in formulations and concentrations do not change the fact that the materials cause a separation of the upper layer of skin, which peels or sheds within a few days. The amount of peeling or shedding is directly related to the depth of injury, a factor that is dependent on the kinds—and caustic nature—of chemicals used.


Although other methods of exfoliation are effective in removing superficial signs of aging and sun-damaged skin, in the author′s experience, level II and III peeling with the original Baker-Gordon peel formula ( Table 8.1 ) has proven to stand the test of time; therefore, the author has seen no reason to modify the formula. It has also been the author′s experience that the depth of injury depends upon several factors, only one of which is related to the chemicals chosen and the formulation of such chemicals with other agents. Penetration can also be affected by adjusting the mechanical act of degreasing the skin that is to be peeled, the number of times that a peeling solution is applied to the treated area, the amount of solution applied with each application, and how well a patient complies with good wound healing principles and instructions following the procedure. Using the same formulation (Baker-Gordon formula), it is possible to do a level II or level III peel on the same patient; it all depends on the factors mentioned in the preceding sentence.


In short, chemical peeling is both an art and a science. There is no one-size-fits-all formulation or application method for all skin types. The treatment plan for each patient must be individualized. Even on the same face, skin thickness varies, requiring more—or less—aggressive treatment. In this regard, the outcomes of treatment are very much determined by the skills and experience of the surgeon as well as patient compliance.






















Chemical peeling, Baker-Gordon solution

Phenol 88% USP


3 mL


Croton oil


3 guttaeb


Septisola


8 guttae


Distilled water


2 mL


Source: Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuvenation. Plast Reconstr Surg Transplant Bull 1962;29:199–207. Used with permission.


Abbreviation: USP, United States Pharmacopeia.


Note: A proven formula for more than 30 years.


aSteris, Mentor, OH.


b27 guttae = 1 mL.



Background: Basic Science of Procedure


With all peels, dermabrasion, and laser resurfacing techniques, outer layers of the skin are removed. However, only with more penetrating (levels II and III) procedures are new collagen and elastic fibers produced in the deeper layers of the skin. As a result, some tightening of facial tissues occurs (more with level III peels than with level II peels), but, in either case, not to the extent that can be achieved with conventional facelifting and eyelid-lifting techniques.


As a rule, light (level I) peels do not produce long-term improvement in the quality and texture of the skin but may be used as adjuncts to the methods herein described for continued maintenance.


Neither a facelift, eyelid surgery (blepharoplasty), nor a brow lift will remove wrinkles that have been etched into weather-beaten skin, transverse creases of the forehead, “crow′s feet” around the eyes, or vertical wrinkles of the upper and lower lips. A good principle to remember is: surgery improves sags and bulges, whereas resurfacing improves wrinkles. And, with respect to skin resurfacing techniques, it has been the author′s experience that dermabrasion is the treatment of choice for acne scarring or for the second and third stages of surgical scar revisions that required excision and wound resuturing. The author has had extensive experience in laser skin resurfacing and has found it to be helpful but not as effective in treating deeper facial rhytids with chemical peeling, nor in treating acne scarring as with wire brush dermabrasion.


To assist the profession in clearing some of the confusion regarding depth of treatment, the author developed a classification system (based on depth of injury) that applies to peels, dermabrasion, and laser resurfacing:




  • Level I—Superficial (Spa peels, commercially available topicals such as glycolic and salicylic acid peels, etc.). Level I peels are temporary skin polishers and do not effectively rejuvenate wrinkled, scarred, or cancer-prone skin, no matter how often they are repeated.



  • Level II—Medium Depth (TCA-based or modified phenol-based peels). Level II peels are more effective than level I peels in that more layers of damaged and wrinkled skin are removed. Healing time generally requires about a week. Level II procedures are generally recommended for patients less than 50 years old or those with minimal to moderate sun damage and wrinkling.



  • Level III—Deep (Wire brush abrasion and Baker-Gordon phenol-based, croton oil peels). Level III peels are the most effective methods of removing severely sun damaged, blotchy skin and deeper wrinkles. Healing time is longer—generally 2 weeks or more. However, results are long-lasting and often dramatic.



Patient Selection


As mentioned in a previous paragraph, different areas of the face require different types of treatment. In full-face resurfacing, the author often combines level II and level III peeling. Level II peeling is effective in treating eyelid rhytids and in blending from treated into nontreated regions (i.e., from the skin overlying the mandible into the shadow line below or into the hairline). And, using the Baker-Gordon formula, it is not necessary to change formulations from one region to the other. Simply modifying the technique of application provides transition from level II to level III. An experienced surgeon will know how to vary the depth of the treatment to meet the patient′s specific needs.


The author′s Facial Rejuvenation Classification System allows surgeons to quantify the condition of each patient′s skin, eyelids, and face ( Tables 8.2 ; Table 8.3 ).1 Abbreviations have been assigned to each of the regions and structures of the face. A score of 0 through 5 is then assigned to each abbreviation, with 0 being the ideal and 5 being the most advanced signs of aging. Once the condition of each region is determined, it is a matter of choosing the most appropriate technique of either surgery and skin resurfacing or both and performing the procedure(s) in a precise and reliable manner. Fig. 8.1a–d demonstrates how the McCollough Facial Rejuvenation Classification was applied in one patient′s total facial rejuvenation.


Anyone performing facial exfoliation must understand and remind patients—in advance of treatment—of the length of time required for healing, especially for level II and III resurfacing procedures. Regardless of the source of injury (peeling, dermabrasion, laser), unless it takes a minimum of 2 weeks to heal, results will generally fall short of the doctor′s and patient′s expectations. In that regard, “no downtime equals no long-term improvement.”


Relative contraindications for phenol-based chemexfoliation include active herpes infections, unrealistic expectations, unreliable patient, the skin of the neck, and diseased state of any organ system that breaks down—or is sensitive to—phenol (liver, kidney, and heart). In the end, the decision to perform chemical peeling lies with the surgeon, who must weigh the potential risks against the benefits of any procedure.

























The McCollough Facial Rejuvenation Classification System

Stage I: The Less than Thirty Facelift


For the younger individual who has little or no loose skin and may require only liposuction to remove unwanted fat and bulges


Stage II: The Thirty-Something Facelift


For the patient who is beginning to notice sagging of the brows and cheeks, but not the neck. Whenever sagging tissues are present, facial muscles and fat must be repositioned into their more youthful relationships. In such cases, a small amount of loose skin is removed.


Stage III: The Forty-Something Facelift


For the patient who exhibits sagging brows, cheeks, and neck. Some of these patients may or may not need liposuction for contouring jowls and fullness under the chin. All, however, require suspension techniques to muscles and fat.


Stage IV: The Fifty-Something Facelift


For the patient with generalized facial and neck sagging, with or without jowls and wrinkles around the mouth. With more obvious muscle, fat, and skin laxity, more suspension of these structures is required.


Stage V: The Sixty-Plus Facelift


For the patient with advanced aging, coupled with sagging of all facial areas, including the forehead, brows, cheeks, and neck. At this stage in the aging process, deep folds develop in the groove between the nose and face, jowls droop below the jaw line, and the muscles of the neck often produce string-like bands that run vertically from the chin to the upper chest. Many of these patients are also beginning to exhibit wrinkles and blemishes over most of the face.


Source: McCollough EG. The McCollough Facial Rejuvenation System: a condition-specific classification algorithm. Facial Plast Surg 2011;27(1):112–123. Used with permission.


“Facelift” is the term commonly used to describe a surgical procedure better known in medical circles as rhytidectomy (removal of loose, wrinkled skin of the face and neck). The procedure is designed to re-create the firmer, smoother face of youth. However, not all facelifts are the same—nor should they be! Not all faces are the same. And at different ages the same face is a different face. Dr. McCollough′s system consists of five general treatment plans, or stages.


























































































The language of surgical rejuvenation

Facelifting


SQ


Skin quality


T


Temple


PL


Platysmal banding


V


Facial volume status


CH


Cheek


ML


Melolabial groove


FH


Forehead


Ne


Neck


MAR


Marionette grooves


Skin resurfacing


WR


Wrinkling/rhytids


PORB


Complete periorbital resurfacing


UPORL


Upper perioral


FH


Forehead


UEL


Upper eyelids


LPORL


Lower perioral


No


Nose


LEL


Lower eyelids


FF


Full-face skin resurfacing


CH


Cheeks


PORL


Complete perioral resurfacing

   

Eyelid and periorbital region


R


Right


LEL


Lower eyelids


NFP


Nasal fat pad


L


Left


B


Bilateral


MFP


Middle fat pad


UEL


Upper eyelids


FX


Fat excess


OFP


Orbital fat pad


Source: McCollough EG. The McCollough Facial Rejuvenation System: a condition-specific classification algorithm. Facial Plast Surg 2011;27(1):112–123. Used with permission.


Note: A number from 0 to 5 should be assigned to each of the above criteria with 0 being the ideal and 5 indicating advanced aging.

(a–d) This patient exhibits many of the signs of aging that the McCollough Condition-Specific Facial Rejuvenation System is designed to address. Using the previously described criteria, her preoperative code would be: SQ-4, V-2, FH-2, T-2, CH-3, ML-2, MAR-0, Ne-4, PL-4, FX-2, WR-5 (FF), BUEL-2, BLEL-4. (See Table 8.3 .)

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Jun 21, 2020 | Posted by in Craniofacial surgery | Comments Off on 8 Deep Chemical Peels
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