Superficial depth chemical peels are the mildest of all chemical peels and are indicated for all skin types. They are generally well tolerated and safe with rare complications. These peels create an inflammatory response from the epidermis to the stratum granulosum, or upper papillary dermis. Patients with pigmentary dyschromias, minimal photodamage, and the mildest of rhytids will benefit from superficial peels.

Alpha hydroxy acids (AHA) are extracts from fruits and vegetables and are common agents in superficial peels. Examples include glycolic acid from sugar cane, citric acid from citrus, and lactic acid from milk. The beta hydroxy acids (BHA), salicylic acid and lipo-hydroxy acid, are also agonized as superficial peels, although less commonly used. The AHA and BHA are manufactured in varying strengths and are commonly found incorporated in the many of the cosmetics and in skin maintenance cosmeceutical regimens today. Glycolic acids are one of the most frequently used alpha hydroxy acids, and in the delicate periorbital area, concentrations up to 70 % may be used with careful observation [4]. Caution should be taken when working with glycolic acid, its application is time-dependent, and a neutralizing solution such as water is used to counteract the action. These peels are extensively used today in both physician offices and by trained aestheticians.

The concentration of trichloroacetic acid (TCA) may be adjusted to create a superficial, medium, or deep peel. Low concentrations of 10–25 % generate superficial peels. Trichloroacetic acid at these concentrations produces superficial coagulation of skin proteins and destruction of the epidermis and upper papillary dermis, followed by dermal rejuvenation with new collagen deposition and normalization of elastic tissue [5]. For lower eyelid dyschromias and mild rhytidosis, 20 % TCA is an effective superficial peeling agent. Clinical indication of the depth of penetration of a TCA peel is judged by the intensity of the skin frost, with superficial peels exhibiting erythema or erythema with a light frost.

Used alone, Jessner’s solution (Table 3.2) is a superficial peeling agent which acts as a keratolytic, by targeting the intracellular bridges between keratinocytes. It is depth-dependent, and the penetration used to achieve exfoliation is generally achieved using one to three chemical coats. The first clinical response after if application is mild erythema followed by a light powdery frost of the skin.

Medium-depth peels create a skin injury depth from the epidermis to the upper portions of the papillary dermis. These peels are a widespread peel of choice in the periocular region due to its uniform penetration, consistent results, and favorable risk/benefit ratio. Patients that present with crosshatched skin in the lower lid area, crow’s feet, superficial rhytids, and moderate amount of sun damage often benefit from medium-depth peels (Figs. 3.1, 3.2, and 3.3).

The spectrum of medium-depth TCA concentrations starts from 30 % and generally does not exceed 50 % [6]. Concentrations of 50 % or greater have lost favor, as the results are unreliable and have been shown to greatly increase the risk of postoperative scarring [7]. Variables such as the concentration, time of application, and application technique influence the outcome of a TCA peel and are therefore vastly operator-dependent.

Over time, practitioners began combining the lower concentrations of TCA with other agents. The combination produced a deeper penetration of the wounding agent without the associated complications of higher concentrations of TCA [8]. Combinations of TCA with other agents have been described by Monheit with Jessner’s solution [9], Brody and Haily [10] with solid carbon dioxide [10], and by Coleman with 70 % glycolic acid [11, 12]. The authors discovered that these combinations obtain deeper penetration of the wounding agent and have proven to be equal as the use of 50 % TCA but without its associated complications.

The combination peel described by Monheit begins with the application of Jessner’s solution and then sequentially follows with the 35 % TCA. The Jessner’s peel functions as an exfoliant and superficial peel, removing the stratum corneum and penetrating down to the basal layer of the epidermis, allowing for a deeper penetration of the 35 % TCA and a more even application of the peeling solution [13]. This combination Jessner’s/35 % TCA peel has been shown to produce predicable results with a measured decrease in complications. Patients generally develop a light crusting in 3–5 days and will exfoliate completely in 7–10 days. Patients may return back to work in 7 days, using light makeup to cover the pink and erythematous color of the freshly peeled skin. This combination medium-depth peel is the author’s peel of choice in the periorbital area and will be described in detail in this chapter.

TCA solutions are prepared commercially or in the office from crystals mixed with distilled water and compounded in a weight-to-volume preparation. Clear communication with those preparing the solution is paramount, bringing attention to the fact that the dilution is weight to volume, assuring a standardized concentration. The solution should be carefully mixed before usage due to potential settling of crystals. It is stable at room temperature and not light-sensitive, but care must be taken to make sure the bottles are closed securely, as evaporation will increase the concentration of the solution.

Deep chemical peels use chemoexfoliants that penetrate from the epidermis to the mid reticular dermis. They effectively resurface deeper periocular rhytids, crepey appearance, crow’s feet, and severe actinic keratosis (Fig. 3.4). The Baker–Gordon formula (Table 3.3) is the often referenced classic deep peel and has given rise to various authors developing modifications of the phenol–croton oil-based formula. The reaction following application of the phenol is characterized by keratocoagulative necrosis of the epidermis extending into the papillary dermis and by a marked inflammatory reaction [14]. The healing process takes place over 8–14 days with post-peel redness continuing up to 2 months [15]. The lasting and restorative effects make phenol peeling ideal for patients seeking improvement of deeper rhytids and creases in the periorbital area.

Because of the depth of the wounding of the skin, these peels have a prolonged healing time and higher risk of complications such as hypopigmentation and scarring. Discretion should be used in patients with a history of hepatic, cardiac, and renal disease, as it can affect hepatic and renal function and has reportedly caused suppression of pulmonary function and cardiac activity [16]. Phenol is directly toxic to the myocardium, necessitating the need for full cardiopulmonary monitoring. To minimize these complications, the solution is applied slowly and systematically to individual aesthetic units over a prescribed period of time, while monitoring carefully for cardiac arrhythmias before proceeding to the next subunit. These peels have a considerable learning curve and should be reserved for physicians with a comprehensive understanding of complexity of peels and considerable level of experience with the procedure.