Jon D. Perenack¹ and Brian W. Kelley²

¹Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA

²Private Practice, Carolinas Center for Oral and Maxillofacial Surgery, Charlotte, North Carolina, USA

The use of a chemical exfoliant to injure specific tissue layers to lessen fine facial rhytids, decrease dispigmentation and actinic changes, and rejuvenate damaged areas in a minimally invasive manner.

Indications

1. Photo dyspigmentation
2. Superficial rhytids
3. Melasma
4. Acne vulgaris
5. Ephelides

Contraindications

1. Active cutaneous infection (i.e., herpes)
2. Ice-pick or deep atrophic acne scars
3. Allergy to agent
4. Extreme sunburn
5. Open wounds (open acne wounds will propagate peel depth)
6. Unrealistic patient expectations
7. Patient is unable or unwilling to perform postoperative management
8. Caution with patients using skin sensitizers (e.g., Retin-A, Retinol, and Accutane)

Anatomy

• Epidermis: Layers from superficial to deep: stratum corneum, stratum granulosum, stratum spinosum, and stratum basale
• Dermis: Layers from superficial to deep: papillary dermis and reticular dermis

Pretreatment Protocol for Chemical Peel Patients

1. Commercially prepared skin systems that contain tretinoin 0.05–0.1% and 4% hydroquinone, such as Obagi Nu-Derm (Skin Specialists PC, Omaha, NE, USA), are available and are recommended for 4–6 weeks prior to the application of a peel in order to allow for a more uniform depth of peel and to minimize complications associated with melasma and postinflammatory pigmentation.
2. Valacyclovir (Valtrex) is recommended beginning the day prior to the peel and for 7–14 days post peel.

Procedure: Medium-Depth Chemical Peel

1. All patient consents are reviewed and signed, and all patient questions are answered. All patient makeup is removed, and the maxillofacial skeleton is prepped with alcohol from the hairline to a point several inches below the inferior border of the mandible.
2. For medium-depth and deep peels, intravenous sedation is performed.
3. The patient is positioned supine on the surgical table. The skin is degreased with acetone, and standard nerve blocks are performed with long-acting a local anesthetic within the areas of the anticipated peel.

4. A pre-peel is performed with Jessner’s solution to include the forehead, the periorbital region (the upper lids and thin tissue below the lower lid lash lines are avoided), the nasal bridge, the perioral region, and the lower face to the inferior border of the mandible (Figure 37.2). After the Jessner’s solution has dried and a thin layer of frosting has occurred, 25–35% trichloracetic acid (TCA) is applied to the above-mentioned regions with 4 × 4 gauze (Figure 37.3).

5. When using TCA solution, it is important to wait several minutes after the application of the solution in order to allow for frosting of the tissue to assess the depth of the peel. The peel is typically carried into the hairline in order to minimize any demarcations of the peel. Areas such as the central forehead, glabellar region, and peri-oral region contain thicker tissue and are resilient to peels. Additional solution may be applied to these areas. The use of a cotton-tipped applicator may be used to rub the solution into areas such as deep peri-oral and glabellar rhytids. The upper eyelids are avoided in medium to deep peels, and the ciliary margin is the upper extent of the lower lids’ involvement. The solution is feathered as the inferior border of the mandible is reached in order to prevent a line of demarcation to the thinner and more vulnerable cervical tissue. Additional layers of TCA may be applied until the desired amount of frosting is observed (Figure 37.4) and the desired depth of penetration is reached.
6. Once the desired depth of the peel has been reached, a facial moisturizing cream is applied to the facial skeleton. In the immediate recovery period, the use of cool compresses and/or a fan will aid in minimizing immediate postoperative discomfort.

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