MEDIUM-DEPTH CHEMICAL PEELS 2001

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FUNDAMENTALS OF COSMETIC SURGERY 0733-8635/01 $15.00 + .OO 
MEDIUM-DEPTH CHEMICAL PEELS 
Gary D. Monheit, MD 
Chemical peeling involves the application 
of a chemical exfoliant to wound the epider- 
mis and dermis to remove superficial lesions 
and improve the texture of skin. Various 
acidic and basic chemical agents are used to 
produce the varying effects of light to me- 
dium to deep chemical peels through differ- 
ences in their ability to destroy skin. The level 
of penetration, the nature of destruction, and 
the inflammatory response determine the 
level of the peel. The stimulation of epidermal 
growth through the removal of the stratum 
corneum without necrosis consists of light su- 
perficial peel. Through exfoliation, it thickens 
the epidermis with qualitative regenerative 
changes. Destruction of the epidermis defines 
a full superficial chemical peel inducing the 
regeneration of the epidermis. Further de- 
struction of the epidermis and induction of 
inflammation within the papillary dermis 
constitutes a medium-depth peel. Finally, fur- 
ther inflammatory response in the deeper 
reticular dermis induces new collagen pro- 
duction and ground substances, which consti- 
tutes a deep chemical peel.14 These have now 
been well classified, and usage has been cate- 
gorized for various degenerative conditions 
associated with photoaging skin based on lev- 
els of penetration. The physician thus has 
tools capable of solving photoaging skin 
problems that may be mild, moderate, or se- 
vere with agents that are very superficial, su- 
perficial, medium-depth, and deep-peeling 
chemicals. The physician must choose the 
right agent for each patient and condition. 
Medium-depth peeling is defined as the 
use of a chemical agent to wound skin 
through papillary dermis. It is most useful for 
the removal of epidermal or superficial le- 
sions and the improvement of skin texture in 
moderate photodamaged skin (grade I1 Glo- 
gau photoaging skin).3 Medium-depth peel- 
ing agents create changes through necrosis of 
the epidermis and part or all of the papillary 
dermis with an inflammatory reaction in the 
upper reticular dermis. The procedure is per- 
formed to remove actinic keratoses, repair 
mild photoaging of the skin including rhy- 
tides, treat pigmentary dyschromias, and im- 
prove depressed scars8 (List 1). 
List 1. INDICATIONS FOR MEDIUM 
DEPTH CHEMICAL PEELING 
1. Epidermal growths 
2. Moderate photoaging skin-Glogau I1 
3. Pigmentary dyschromias 
4. Mild to moderate acne scars 
5. Blending photoaging skin with laser re- 
surfacing and deep chemical peeling 
Trichloracetic acid (TCA) has been the gold 
standard in quantitating chemical peel 
strength and depth. Ten percent to 30% has 
been quantitated as superficial wounding, 
and above 50% is deep-chemical peeling. The 
From the Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama 
DERMATOLOGIC CLINICS 
VOLUME 19 NUMBER 3 JULY 2001 413 
414 MONHEIT 
level 35%-50% TCA is the spectrum of me- 
dium-depth peeling. It is standard to think of 
45% or 50% TCA corresponding to a wound- 
ing level of mid to deep reticular dermis. 
This concentration of TCA, though, has been 
found unreliable and associated with a higher 
incidence of pigmentary dyschromia, textural 
change, and even scarring.2 In an attempt to 
reduce the morbidity of higher-concentration 
TCA, a combination of products has been 
devised that improves the absorption of the 
lower concentration of trichloracetic acid 
without the associated complications.8 The 
combination peels include the following: 
1. Solid CO, freezing with trichloracetic 
2. Jessner’s solution + 35% TCA 
3. Glycolic acid. 70% plus 35% TCA 
The combinations produce a more even 
peel with deeper penetration of the wounding 
agent without the associated complications 
of higher-concentration TCA. This article will 
review the scope of medium-depth peeling, 
the patients and conditions most commonly 
treated, the techruques of application, wound 
healing, and complications. 
acid 35% 
TCA 
TCA has become the gold standard of 
chemical peeling agents for its long history of 
usage, its versatility in peeling, and its chemi- 
cal stability. It has been useful in many con- 
centrations because it has no systemic toxicity 
and can be used to create superficial, me- 
dium, or even deep wounds in the skin. TCA 
is naturally found in crystalline form and is 
mixed weight-by-volume with distilled water. 
It is not light sensitive, does not need refriger- 
ation, and is stable on the shelf for more than 
6 months. The standard concentrations of 
TCA should be mixed weight-by-volume to 
accurately assess the concentration. That is, 
30 g TCA crystals mixed with 100 mL dis- 
tilled water will give an accurate 30% concen- 
tration, weight-by-volume. Any other dilu- 
tional system, volume dilutions and weight 
by weight, are inaccurate in that they do not 
reflect the accepted weight-by-volume mea- 
surements. 
Because TCA itself is an agent more likely 
to be fraught with complications, especially 
scarring, in strengths of 50% or higher, the 
higher concentration has fallen out of favor.* 
It is for this reason that the combination prod- 
ucts along with a 35% TCA formula have 
been found equally effective in producing this 
level of control damage without the risk of 
side effects. 
Brody first developed the use of solid CO, 
applied with acetone to the skin as a freezing 
technique before the application of 35% TCA. 
The preliminary freezing appears to break the 
epidermal barrier for a more even and com- 
plete penetration of the 35% TCA.l 
Monheit then demonstrated the use of Jess- 
ner ’s solution before the application of 35% 
TCA. The Jessner’s solution was found effec- 
tive in destroying the epidermal barrier by 
breaking up individual epidermal cells. This 
also allows a deeper penetration of the 35% 
TCA and a more even application of the peel- 
ing so l~ t ion .~ Similarly, Coleman has demon- 
strated the use of 70% glycolic acid before the 
application of 35% TCA. Its effect has been 
very similar to that of Jessner’s solutionza (Ta- 
ble 1). 
All three combinations have proven to be 
as effective as the use of 50% TCA with a 
greater safety margin. The application of acid 
and resultant frosting are better controlled 
with the combination so that the ”hot spots” 
with higher concentrations of TCA can be 
controlled, creating an even peel with less 
incidence of dyschromias and scarring. The 
combination peel produces an even, uniform 
peel. The Monheit version of the Jessner’s 
solution, 35% TCA peel, is a relatively simple 
and safe combination. The technique is used 
Table 1. AGENTS FOR MEDIUM-DEPTH 
CHEMICAL PEEL 
Agent Comment 
TCA-50% 
Combination-35% TCA- 
Combination-35% TCA- 
Combination-35% TCA- 
89% Phenol 
solid C02 (Brody) 
Jessners (Monheit) 
70% Glycolic (Coleman) 
Not recommended because 
of risk of scarring 
The most potent 
combination 
The most popular 
combination 
An effective combination 
Rarely used 
MEDIUM-DEPTH CHEMICAL PEELS 415 
Table 2. ADJUNCTIVE AGENTS IN CHEMICAL PEELING 
____ ___ 
Agent Formula Mechanism Treatment Program 
Tretinoin Retin-A, retinoic acid Decrease comeocyte adhesion, Begin a QHS dosage 6 weeks 
.05%-0.1% decrease stratum comeurn before peeling and continue 
thickness, increase epidermal after reepithelialization 
growth kinetic, affect new 
collagen production 
stimulation, decrease UV thereafter 
damage allowing the skin to 
rest before the peel 
Sunscreens UVA and UVB block Decrease pigmentation, darkening Begin 3 months and continue 
Bleach H ydroquinone Blocks production of new Begin 6 weeks before resurfacing 
4%-8% melanin and continue after 
reepithelialization 
Exfoliation Abrasive scrubs for Disrupts the stratum corneum to Epidermabrasion begun 6 weeks 
sloughing, stratum stimulate new epidermal before peeling, moisturization 
comeum-glycolic growth. Decreased corneocytewith glycolic acid lotions 6 
acid, lactic acid, adhesion weeks before peel 
tartaric acid 
for mild-to-moderate photoaging, including 
pigmentary changes, lentigines, epidermal 
growths, dyschromias, and rhytids. It is a sin- 
gle procedure with a healing time of 7 to 10 
days. It is useful also to remove diffuse actinic 
keratoses as an alternative to chemical exfoli- 
ation with topical 5-fluorouracil chemother- 
apy. Topical chemotherapy is applied for 3 
weeks, creating erythema, scabs, and crusts 
for up to 6 weeks.7 The combination peel will 
produce similar therapeutic benefits within 10 
days of healing. It thus reduces the morbidity 
significantly and gives the cosmetic benefits 
of improved photoaging skin. 
Skin preparation is of vital importance to 
encourage correct healing and avoid compli- 
cations. Agents used before the peel to pre- 
pare the skin correctly (Table 2) include’l the 
following: 
1. Sunscreen 
2. Exfoliations-abrasive cleansers, 5%- 
10% glycolic acid lotion 
3. Tretinoin .05% used 6 weeks to 3 months 
before the peel 
4. Bleaching products-hydroquinone 
4%-8% used in patients with pigmentary 
dyschromias and those with type III-VI 
Fitzpatrick skin pigmentation 
5. Anti-viral agents in selected patients 
with history of facial HSV I infections 
that the peeling agent will sting and bum 
temporarily, and aspirin is given before the 
peel and continued through the first 24 hours 
if the patient can tolerate the medication. Its 
inflammatory effect is especially helpful in re- 
ducing swelling and relieving pain. If given 
before surgery, it may be all the patient re- 
quires during the postoperative phase. For 
full-face peels, though, it is useful to give pre- 
operative sedation (diazepam 5-10 mg orally) 
and mild analgesia, meperidine 25-50 mg (De- 
merol, Winthrop, New York), and hydroxyzine 
hydrochloride 25 mg intramuscularly (Vistaril, 
Lorec, New York). The discomfort from this 
peel is not long lasting, so short-acting seda- 
tives and analgesics are all that are necessary.’O 
Vigorous cleaning and degreasing are nec- 
essary for even penetration of the solution. 
The face is scrubbed gently with Ingasam 
(Septisol, Vestal Laboratories, St. Louis, Mis- 
souri) 4-inch by 4-inch gauze pads and water, 
then rinsed and dried. Next, an acetone prep- 
aration is applied to remove residual oils and 
debris. The skin is essentially debrided of 
stratum corneum and excessive scale. A thor- 
ough degreasing is necessary for an even pen- 
etrant peel. The physician should feel the dry, 
clean skin to check the thoroughness of de- 
greasing. If oil is felt, degreasing should be 
repeated. A splotchy peel is usually the result 
of uneven penetration of peel solution be- 
The procedure is usually performed with 
mild preoperative sedation and nonsteroidal 
anti-inflammatory agents. The patient is told 
cause of residual oil or stratum corneum and 
a result of inadequate degreasing. 
After thorough cleaning, the Jessner’s solu- 
416 MONHEIT 
tion is applied with either cotton-tip applica- 
tors or 2-inch by 2-inch gauze. (List 2) The 
Jessner’s solution is applied evenly with usu- 
ally one or two coats to achieve a light but 
even frosting. The frosting achieved with Jes- 
sner’s solution is much lighter than that pro- 
duced by TCA, and the patient is usually 
comfortable, feeling only heat. A mild ery- 
thema appears with a faint tinge of splotchy 
frosting over the face. Even strokes are used 
to apply the solution to the unit area, covering 
the forehead to the cheeks to the nose and 
chin. The eyelids are treated last, creating the 
same erythema with blotchy frosting (Fig. 1). 
The application of Jessner’s solution alone is 
equal to a superficial or light chemical pee1.l 
List 2. THE JESSNERS SOLUTION 
FORMULA 
Resorcinol 14 g 
Salicylic acid 14 g 
Lactic acid 14 mL 
Ethanol (qs) 100 mL 
After the Jessner’s solution has dried, the 
TCA is applied. The TCA is painted evenly 
with one to four cotton-tipped applicators 
that can be applied over different areas with 
light or heavier doses of the acid. Four cotton- 
tipped applicators are applied in broad 
strokes over the forehead and also on the 
medial cheeks. Two mildly soaked cotton- 
tipped applicators can be used across the lips 
and chin, and one damp cotton-tipped appli- 
cator on the eyelids. Thus, the dosage of ap- 
plication is technique dependent on the 
amount used and the number of cotton- 
tipped applicators applied. The cotton-tipped 
applicator is useful in quantitating the 
amount of peel solution to be applied. Care 
must be taken to ensure the acid is not 
dripped inadvertently over unwanted areas 
such as the neck or eyes. 
The white frost from the TCA application 
appears complete on the treated area within 
30 seconds to 2 minutes. Even application 
should eliminate the need to go over areas 
a second or a third time, but if frosting is 
incomplete or uneven, the solution should 
be reapplied. Thirty-five percent TCA takes 
longer to frost than Baker’s formula or 
straight phenol, but a shorter period of time 
than the superficial peeling agents do. The 
surgeon should wait at least 3 to 4 minutes 
after the application of TCA to ensure the 
frosting has reached its peak. He or she then 
can document the completeness of a frosted 
cosmetic unit and touch up the area as 
needed. Areas of poor frosting should be re- 
treated carefully with a thin application of 
TCA. The physician should achieve a level I1 
to level I11 frosting. Level I frosting is ery- 
thema with a stringy or blotchy frosting, seen 
with light chemical peels. Level I1 frosting is 
defined as white-coated frosting with ery- 
thema showing through. A level I11 frosting, 
which is associated with penetration through 
the papillary dermis, is a solid white enamel 
frosting with little or no background of ery- 
thema.13 A deeper level I11 frosting should be 
restricted only to areas of heavy actinic dam- 
Figure 1. Jessner’s solution applied with 2 x 2 gauze sponges. 
MEDIUM-DEPTH CHEMICAL PEELS 417 
Figure 2. The intensity of the frost correlates to the level of peel penetration. A, Level 
I-Splotchy frosting with erythema-superficial penetration. 13, Level Il-Uniform white frost- 
ing with erythema-full epidermal penetration. C, Level Ill-Opaque white 
frosting-extension to papillary dermis. 
age and thicker skin. Most medium-depth 
chemical peels use a level I1 frosting, and this 
is especially true over eyelids and areas of 
sensitive skin. Those areas with a greater ten- 
dency to scar formation, such as the zygo- 
matic arch, the bony prominences of the jaw- 
line, and chin, should only receive up to a 
level I1 frosting. Overcoating TCA will in- 
crease its penetration so that a second or third 
application will drive the acid further into the 
dermis, creating a deeper peel. One must be 
careful in overcoating only areas in which the 
take up was not adequate or the skin is much 
thicker (Fig. 2). 
Anatomic areas of the face are peeled se- 
quentially from forehead to temple to cheeks 
and finally to the lips and eyelids. The white 
frosting indicates keratocoagulation or pro- 
tein denaturation of keratin, and at that point 
the reaction is complete. Careful feathering of 
the solution into the hairline and around the 
rim of the jaw and brow conceals the line 
demarcation between peeled and non-peeled 
skin. The perioral area has rhytids that re- 
418 MONHEIT 
quire a complete and even application of so- 
lution over the lip skin to the vermillion. This 
is accomplished best with the help of an assis- 
tant who stretches and fixates the upper and 
lower lips while the peel solution is applied. 
Certain areas and skin lesions require spe- 
cial attention. Thicker keratoses do not frost 
evenly and thus do not pick up peel solution. 
Additional applications rubbed vigorously 
into the lesion may be needed for peel-solu- 
tion penetration. Wrinkled skin should be 
stretched to allow an evencoating of solution 
into the folds and troughs. Oral rhytides re- 
quire peel solution to be applied with the 
wood portion of a cotton-tipped applicator 
and extended into the vermilion of the lip. 
Deeper furrows such as expression lines will 
not be eradicated by peel solution and thus 
should be treated like the remaining skin. 
Eyelid skin must be treated delicately and 
carefully. A semidry applicator should be 
used to carry the solution within 2-3 mm of 
the lid margin. The patient should be posi- 
tioned with the head elevated at 30 degrees 
and the eyelids closed. Excess peel solution 
on the cotton tip should be drained gently on 
the bottom before application. The applicator 
is then rolled gently on the lids and perior- 
bital skin. Never leave excess peel solution on 
the lids, because the solution can roll into 
the eyes. Dry the tears with a cotton-tipped 
applicator during peeling because they may 
pull peel solution to the puncta and eye by 
capillary attraction (Fig. 3). The solution 
should be diluted immediately with cool sa- 
line compresses at the conclusion of the peel. 
The Jessner’s-TCA peel procedure is as fol- 
lows: 
1. The skin should be cleaned thoroughly 
with Septisol to remove oils. 
2. Acetone or acetone alcohol is used to 
further debride oil and scale from the 
surface of the skin. 
3. Jessner ’s solution is applied. 
4. Thirty-five percent TCA is applied until 
5. Cool saline compresses are applied to 
6. The peel will heal with 0.25% acetic acid 
a light frost appears. 
dilute the solution. 
soaks and a mild emollient cream. 
There is an immediate burning sensation as 
the peel solution is applied, but this subsides 
as frosting is completed. Cool saline com- 
presses offer symptomatic relief for a peeled 
area as the solution is applied to other areas. 
The peel reaction is not neutralized by saline 
solution, as the reaction is completed when 
frosting OCCUIS.~ The compresses are placed 
over the face for 5 to 6 minutes after the peel 
until the patient is comfortable. The burning 
subsides fully by the time the patient is ready 
to be discharged. At that time, most of the 
frosting has faded and a brawny desquama- 
tion is beginning. 
Postoperatively, edema, erythema, and des- 
quamation are expected. With periorbital 
peels and even forehead peels, eyelid edema 
can occur and may be enough to close the 
lids. For the first 24 hours, the patient is in- 
structed to soak four times a day with a 0.25% 
acetic acid compress made of 1 tablespoon 
white vinegar in 1 pint of warm water. A 
bland emollient is applied to the desquamat- 
ing areas after soaks. After 24 hours, the pa- 
tient can shower and clean gently with a mild 
nondetergent cleanser. The erythema intensi- 
fies as desquamation becomes complete 
within 4 to 5 days. Thus, healing is completed 
within 1 week to 10 days. At the end of 1 
week, the bright red color has faded to pink 
and has the appearance of a sunburn. This 
can be covered by cosmetics and will fade 
fully within 2 to 3 weeks. 
The medium-depth peel is dependent on 
three components for therapeutic effect: de- 
greasing, Jessner ’s solution, and 35% TCA. 
The amount of each agent applied creates the 
intensity and thus the effectiveness of this 
peel. The variables can be adjusted according 
to the patient’s skin type and the areas of 
the face being treated. It is the workhorse of 
peeling and resurfacing in the author’s prac- 
tice because it can be individuated for most 
patients seen. 
The medium-depth chemical peel has five 
major indications: destruction of epidermal 
lesions-actinic keratoses, resurfacing the 
level I1 or I11 moderate photoaging skin, pig- 
mentary dyschromias, mild acne scars, and 
blending photoaging skin with laser resurfac- 
ing and deep chemical peeling. 
MEDIUM-DEPTH CHEMICAL PEELS 419 
1. 
Figure 3. A, Perioral rhagades are stretched, and peel solution is 
applied with a cotton-tip applicator. B, Dry cotton-tip applicators are 
used around the eyes to prevent tearing. 
Actinic keratoses-This procedure is 
well suited for the patient with epider- 
mal lesions such as actinic keratoses that 
have required repeated removal with ei- 
ther cryosurgery or chemoexfoliation (5- 
fluorouracil). The entire face can be 
treated as a unit or subfacial cosmetic 
unit, such as forehead, temples, and 
cheeks, and can be treated indepen- 
dently. Active lesions can be removed, 
and incipient growths as yet undetected 
will be removed as the epidermis is 
sloughed. Advantages for the patient 
2. 
with photodamaged skin include a lim- 
ited recovery period-7 to 10 days- 
with little postoperative erythema after 
healing5 There is little risk of pigmen- 
tary changes, either hypopigmentation 
or hyperpigmentation; thus, the patient 
can return to work after the skin has 
healed (Fig. 4). 
Moderate photoaging skin-Glogau 
level I1 or I11 damage responds well to 
this peeling combination with removal 
of the epidermal lesions and dermal 
changes that will freshen photoaging 
MONHEIT 420 
3. 
4. 
characterized as sallow, atrophic skin 
with fine rhytides. This peel is favored 
over deeper resurfacing procedures such 
as CO, laser and deep peel in that it will 
heal in 10 days with minimal risk of 
textural or color complications. It is, 
however, only designed for medium- 
depth damage (Fig. 5). 
Pigmentary dyschromias-Though color 
change can be treated with repetitive 
chemical peeling, the medium-depth 
peel will be a single treatment preceded 
and followed by the use of bleaching 
agents and retinoic acid.’l In most cases, 
the pigmentary problems are resolved 
with this single peel as an adjunct to the 
skin care program. 
Blending other resurfacing procedures- 
In a patient in whom there is advanced 
photoaging changes such as Crow’s feet 
and rhytides in the periorbital and/or 
perioral area with medium-depth 
changes on the remaining face, a me- 
dium-depth peel can be used to integrate 
these procedures. That is, laser resurfac- 
ing or deep chemical peeling can be per- 
formed over the periorbital and perioral 
areas that have more advanced pho- 
toaging changes, while the medium- 
depth chemical peel is used for the rest 
of the face. This will blend the facial skin 
as a unit so that the textural and color 
changes will not be restricted to one 
area. Patients requiring laser resurfacing 
in a localized cosmetic unit will have the 
remaining areas of their faces blended 
with this medium-depth chemical peel. 
Patients having laser resurfacing or deep 
peeling to the perioral or periorbital ar- 
eas alone develop a pseudohypopigmen- 
tation that is a noticeable deformity. The 
alternative-a full-face deep peel or laser 
resurfacing-has an increased morbidity, 
longer healing, and risk of scarring over 
areas such as the lateral jaw .line, malar 
eminences, and forehead. If deep resur- 
facing is needed only over localized ar- 
eas such as perioral or periorbital face, a 
blending medium-depth peel does re- 
duce morbidity and healing time12 (Fig. 
Figure 4. A, Preoperative patient undergoing a Jess- 
ner’s-35% TCA peel for the removal of actinic keratoses. 
B, Appearance after Jessner’s solution. 
Illustration continued on opposite page 
RESULTS 
This medium-depth peel will produce su- 
perior results for the conditions listed (Table 
2). Removal of actinic keratoses, both present 
and incipient, affords the patient a single pro- 
cedure with healing time within 1 week to 10 
days as a preventive therapeutic modality for 
the removal of precancerous growths over the 
face (Fig. 4). A comparison study of the effi- 
cacy of Jessner’s solution plus 35% TCA with 
5-fluorouracil documented superior effective- 
ness of this single procedure with a signifi- 
cant reduction in m~rbidity.~ It is an effective, 
6) . safe, and simple single procedure that can be 
MEDIUM-DEPTH CHEMICAL PEELS 421 
Figure 4 (Continued). C, Frosting after TCA. 0, Three 
days postoperative. 
used to removeactinic keratoses and epider- 
mal growths as both a therapeutic and cos- 
metic procedure. 
Glogau grade I1 photoaging skin can be 
effectively treated for improvement in tex- 
ture, color change, and epidermal growths 
with a medium-depth Jessner’s TCA peel. Of 
equal importance to the procedure is choos- 
ing the correct patient for the procedure. Pa- 
tients with superficial textural changes and 
those with epidermal growths seem to re- 
spond best to this peel. Fine wrinkles, cross- 
hatched lines, and sallow color changes of 
photoaging, along with a crinkly appearance, 
are the textural changes that will respond to 
this peel. Additionally, epidermal growths 
such as freckles, lentigenes, actinic keratoses, 
and seborrheic keratoses will also respond 
well (Fig. 5). The more advanced changes 
seen with’ deeper grooves and wrinkles, peb- 
bly appearance of the skin, and more pro- 
nounced gravitational changes of Glogau I11 
and IV photoaging skin require either deep 
chemical peeling or laser resurfacing. Using 
TCA or any of its combinations as a deep 
chemical peel for these more advanced indi- 
cations will only risk potential side effects 
and complications. 
Pigmentary dyschromias such as melasma, 
blotchy hyperpigmentation, and pigmentary 
growths do respond well to medium-depth 
chemical peeling. This is especially suited to 
those problems that have not resolved well 
with medical treatment or repeated light 
chemical peeling. Epidermal pigment seems 
to respond the best, and this can be identified 
with Wood’s light examination. Dermal pig- 
ment will show some response but is not as 
effective as epidermal pigment. This combi- 
nation peel is effective in that it will fully 
remove the epidermis and have an effect on 
melanocytes in the pilar apparatus during re- 
epithelialization. It is important that these pa- 
tients be prepared correctly with 4%-8% hy- 
droquinone, tretinoin, and sunscreen begun 
at least 6 weeks before the peeling procedure. 
The bleaching agent is reinstituted after reepi- 
thelialization and tretinoin 6 weeks later. It 
should be continued for up to 3 months after 
the chemical peel, and sunscreen should be 
used for longer period of time to ensure the 
dyschromia does not return. There are many 
bleaching agents on the market today that 
have some lightening effect, but hydroqui- 
none is the most effective. 
When localized areas of the face have ad- 
vanced or severe photoaging such as deeper 
wrinkles around the eyelids and rhagades on 
the lips, the combination Jessner’s TCA peel 
can be used to blend the remaining areas of 
the face if they have only moderate pho- 
toaging of the skin. Thus, eyelids and lips can 
be resurfaced with a pulsed CO, laser and 
the remainder of the face treated with the 
Jessner’s TCA peel. In this instance, the peel 
should be performed first in the manner de- 
scribed above, and then appropriate anesthe- 
sia, eye protection, and preparation be used 
to laser the designated areas. Healing will 
occur in the usual manner for either laser or 
peel, with soaks and occlusive ointments. 
This is an effective method of reducing mor- 
bidity with deeper agents to areas that don’t 
need them. It will also blend the photoaging 
skin, texture, color, and appearance to that of 
the laser-treated skin (Fig. 6). 
422 MONHEIT 
Figure 5. Jessner’s TCA peel for moderate photoaging 
skin, Glogau level I I . A, Preoperative view demonstrating 
rhytides, lentigenes, keratoses, and sallow skin. B, Jess- 
ner’s solution applied to face. C, Full application 35% TCA 
with a level 111 frosting. 
Illustration continued on opposite page 
POSTOPERATIVE CARE AND 
COMPLICATIONS 
3. Reepithelialization 
4. Fibroplasia 
At the conclusion of the chemical peel, the 
inflammatory phase has already begun with 
during the first 12 hours. With the medium- 
depth peels, the epidermis will begin to sepa- 
rate, creating a leathery, dry, cracking appear- 
The four stages Of wound are ap- 
parent after a medium-depth a brawny, dusky erythema that will progress 
They include the following: 
l . Inflammation 
2. Coagulation 
MEDIUM-DEPTH CHEMICAL PEELS 423 
Figure 5 (Continued). 0, Four days after chemical peel. €, Six months after 
chemical peel. 
ance to the epidermis. This is an accentuation 
of pigmented lesions on the skin as the coagu- 
lation phase separates the epidermis, produc- 
ing serum exudation, crusting, and pyo- 
derma. It is during this phase that it is 
important to use debrident soaks and com- 
presses as well as occlusive salves. These will 
remove the sloughed necrotic epidermis and 
prevent the serum exudate from hardening as 
crust and scab. The author prefers the use of 
1/4% acetic acid soaks found in the vinegar- 
water preparation (1 teaspoon white vinegar, 
1 pint warm water) because it is antibacterial, 
especially against pseudomonas and gram- 
negative bacteria. In addition, the mildly 
acidic nature of the solution is physiologic for 
the healing granulation tissue and mildly 
debrident because it will dissolve and cleanse 
the necrotic material and serum. Occlusive 
dressings including bland emollients and 
salves and biosynthetic membranes. For me- 
dium-depth peeling, the author prefers the 
occlusive salves because these can be moni- 
tored carefully day by day for potential com- 
plications. 
Reepithelialization begins on day 3 and 
continues until day 7 to 10. Occlusive salves 
promote faster reepithelialization and less 
tendency toward delayed healing6 The final 
stage of fibroplasia continues well beyond the 
initial closure of the peeled wound and con- 
tinues with neoangiogenesis and new collagen 
formation for 3 or 4 months. Prolonged ery- 
thema may last 2 to 4 months in unusual cases 
of sensitive skin or with contact dermatitis. 
New collagen formation can continue to im- 
prove texture and rhytides for a period up to 
4 months during this last phase of fibroplasia. 
Many of the complications seen in peeling 
can be recognized early during healing 
stages. The cosmetic surgeon should be well 
acquainted with the normal appearance of a 
healing wound in its time frame for medium- 
depth peeling. Prolongation of the granula- 
tion tissue phase beyond 1 week may indicate 
delayed wound healing. This could be the 
result of viral, bacterial, or fungal infection; 
contact irritants interfering with wound heal- 
ing; or other systemic factors. A red flag 
should alert the physician that careful investi- 
gation and prompt treatment should be insti- 
tuted to forestall potential irreparable damage 
that may result in scarring. Thus, it is vitally 
important to understand the stages of wound 
healing in reference to medium-depth peel- 
ing. The physician then can avoid, recognize, 
and treat any and all complications at an 
early stage. Specific complications are dis- 
cussed in the appropriate article. 
Long-term care of peeled skin includes sun- 
424 MONHEiT 
Figure 6. Combination laser resurfacing and Jessner's +35% TCA peel. A, Preoperative areas for 
laser (perioral and periorbital) and peel over the remainder of the face. 6, Immediate postoperative. 
C, Three months postoperative. 
screen protection for up to 6 months along 
with reinstitution of medical treatment such 
as low-strength hydroxy acid lotions and tret- 
inoin. Re-peeling areas should not be per- 
formed for 6 months from the previous peel. 
If any erythema or edema persists, the peel 
should not be performed because the re-in- 
jury may create complications. This peel 
should not be performed on undermined skin 
such as occurs with facelift or flap surgery 
performed up to 6 months before the peel.7 
The evolution of medium-depth chemical 
peeling has changed the face of cosmetic sur- 
gery. It has introduced new techniques into 
the armamaterium of the cosmetic surgeon to 
treat problems that previously were ap- 
proached with tools inadequate to obtain the 
results for moderate photoaging skin or with 
overly aggressivetreatment using deep peel- 
ing agents. The combination peels have pro- 
vided some of the more popular tools needed 
to approach a burgeoning population with 
photoaging skin. 
References 
1. Brody HJ: Chemical Peeling and Resurfacing. St. 
Louis, Mosby, 1997, pp 109-110 
2. Brody HJ: Variations and comparisons in medium 
depth chemical peeling. J Dermatol Surg Oncol 
2a. Coleman WP, Futrell JM: The glycolic acid trichloro- 
15:953-963, 1989 
MEDIUM-DEPTH CHEMICAL PEELS 425 
acetic acid peel. J Dermatol Surg Oncol 20:76-80, 
1994 
3. Glogau RG: Chemical peeling and aging skin. J Ger- 
atr Dermatol 230-35, 1994 
4. Goslen JB: Wound healing after cosmetic surgery. In 
Coleman WP, Hanke CW, Alt TH, et a1 (eds): Cos- 
metic Surgery of the Skin. Philadelphia, B C Decker, 
1991, pp 47-63 
5. Lawrence N, Cox SE, Cockerel1 CJ, et al: A compari- 
son of efficacy and safety of Jessner’s solution and 
35% trichloracetic acid vs. 5% fluorouracil in the 
treatment of widespread facial actinic keratoses. Arch 
Dermatol 131:176-181, 1995 
6. Maibach HF, Rovec DT Epidermal wound healing. 
St. Louis, Mosby, 1972, pp 72-95 
7. Monheit GD: Advances in chemical peeling. Facial 
Plast Surg Clin North Am 2:5-9, 1994 
8. Monheit GD. The Jessner’s + TCA peel A medium 
depth chemical peel. J Dermatol Surg Oncol 15:945- 
950, 1989 
9. Monheit GD: The Jessner’s-TCA peel. Facial Plast 
Surg Clin North Am 221-22, 1994 
10. Monheit GD: The Jessner ‘s-trichloracetic acid peel. 
Dermatol Clin 13977-283, 1995 
11. Monheit GD: Skin preparation: An essential step be- 
fore chemical peeling or laser resurfacing. Cosmet 
Dermatol 9:9-14, 1996 
12. Monheit GD, Zeitouni NC: Skin resurfacing for pho- 
toaging: Laser resurfacing versus chemical peeling. 
Cosmet Dermatol 1O:ll-22, 1997 
13. Rubin M: Manual of Chemical Peels. Philadelphia, 
Lippincott, 1995, pp 120-121 
14. Stegman SJ: A comparative histologic study of the 
effects of three peeling agents and dermabrasion on 
normal and sundamaged skin. Aesthetic Plast Surg 
6~123-135, 1982 
Address reprint requests to 
Gary D. Monheit, MD 
2100 16th Avenue South, Suite 202 
Birmingham, AL 35205