Monday, November 18, 2013
THE LOST ART OF ABLATIVE CHEMICAL PEELS
Since the days of ancient Egypt, people have been using chemical exfoliation methods, also known as chemical peeling, to rejuvenate skin. The original chemexfoliant was lactic acid, an active ingredient of sour milk that was used topically by the nobles as part of an ancient skin rejuvenation regimen. In the Middle Ages, old wine with tartaric acid as its active ingredient was used for the same purpose. Today, these historical chemexfoliants are known to contain alpha hydroxy acids, which are the active ingredients responsible for the skin exfoliation. Modern day chemical peeling originally was promoted by dermatologists, such as P.G. Unna, who first described the properties of salicylic acid, resorcinol, phenol, and trichloroacetic acid (TCA).
Slowly, the early practitioners of chemical peels began to develop other peeling agents for varying depths of penetration. In the 1960s, Baker and Gordon developed a deep peeling agent, which was able to smooth deeper furrows, especially around the mouth. I first met Dr. Tom Baker as a medical student and pharmacist attending medical school at the University of Miami. For the next 20 years, Dr. Baker was one of my mentors in plastic surgery. In 1982, Dr. Baker and I co-authored a chapter entitled “Chemical Peeling and Dermabrasion” in Dr. Barnard Barrett’s plastic surgery book entitled “Patient Care in Plastic Surgery”.
facelift and phenol peel performed on first day of my practice
From the 1980's to the present, an explosion has occurred in the mass of research on this subject, with the elucidation of many different types of peels, each for a specific range of problems. Unfortunately, with the advent of skin resurfacing lasers, the last two generations of plastic surgeons are beginning to lose their expertise with ablative chemical peels. I am perhaps the last bastion of this valuable tool from Dr. Baker’s very first peel in the 1960’s. Although the majority of my patients are candidates for our Icon™ 1540 fractional laser hand piece, there is still a large population of patients who are better treated with a single and less expensive chemical peel.
Phenol was almost entirely replaced with the use of 35% TCA which avoids the skin bleaching effect of phenol and ablative lasers. The best time of year for these treatments is between October and March because of sun exposure restrictions. Recovery occurs usually within one week at which time make up and concealers may be used. Facial peels are usually pain free after treatment and almost any area of the body may be treated with TCA peels. The back of the hands responds well to TCA peeling and are generally treated with the face. Below are images of patients I have treated in the past.
Although the above example include an older age group, TCA peels may be performed in younger patients with solar (sun) damage and sun spots or freckles.
Fractional laser skin resurfacing is still used for most patients both for total and partial facial treatments and usually requires 2 to 4 treatments.
Total facial TCA chemical peels only requires one treatment with oral Valium and or/Percocet. As with laser resurfacing, synthetic or natural fillers may be used at the same time. It is not unusual to treat patients with SlimLipo neck tightening, Adivive stem cell fat grafting and TCA chemical peeling during a single session.