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Sun Oct 22, 2006 9:43 pm  |
I thought you might be interested in this...it is step by step instructions for a tca peel...
Medium depth peels
Trichloroacetic is the author’s agent of choice for this effective peel modality. It is very controlled, penetrating the basal layer of the epidermis, papillary dermis, and even extending to the upper reticular dermis. The concentration of the peel, the number of coats applied, the pressure during application, and the preparation of the skin will affect the depth and the final result. Concentrations of 10% to 20% function as superficial peels and are recommended as mild exfoliants to treat mild actinic changes or when patients cannot spare any downtime. The neck and hands are areas treated with these lower concentrations. Concentrations of 30% to 40% are considered medium depth peels and will affect the papillary dermis.
Preparation
Patients with a history of herpes simplex should be pretreated with acyclovir, 400 mg four times daily, beginning 24 hours before the peel and continuing after the peel for about a week. When possible, a home care regimen of topical AHAs, retinoids, bleaching agents, and sunscreen should be started at least 2 weeks before the peel.
Steps of application
Cleansing
The skin should be well cleansed with make-up remover, wiped with toner to remove remaining debris, and then degreased with alcohol or acetone. Care should be taken with these aromatic liquids in the periocular area.
Fig. 6. Irregular frosting during a 20% TCA peel for improvement of lower eyelid dyspigmentation and texture. Vaseline limits the borders of the peel.
Patient preparation
Owing to the nature of this peel, a mild analgesic is recommended 30 minutes before the treatment. The patient should wear loose fitting clothing, and a headband should be used to keep the hair away from the face. Tetracaine eye drops are applied, and a petrolatum base lubricant is applied to the skin to delineate the limit of the peel, avoiding dripping of the solution down the neck, into the ear, or in other unwanted areas. The patient’s head remains elevated throughout the procedure.
Application
With a folded 4 by 4 gauze pad or three small cotton-tipped applicators grasped in one hand, application is started on the forehead from the midline to the side, the other side, down the nose, the eyelid (2 mm below the lower lid margin), the cheek, the other eyelid, the other cheek, and, finally, the perioral area. After a few minutes, frosting should become apparent, and one can assess where to apply additional TCA. For the eyelids, a single small cotton tip applicator is used (Figs. 6 and 7A,B).
Pearls about the application
The skin should be stretched tightly to allow the chemical to treat the depth of the wrinkle and to prevent it from staying on the shoulders of the rhytid.
The applied coats of the peel should not be overlapped. One should assess the completeness of the frosting and the length of time for the frost to appear before applying additional coats. The more homogeneous the frosting, the more rapidly the frost appears and the more profound the depth of the peel.
To avoid a demarcation line, the peel should be extended into the hairline and beyond the jawline. If one plans to use two coats of the TCA solution on the face, one coat should be applied 1 cm beyond the jaw for blending purposes.
One should be consistent about the pressure applied during the application of the peel. The peels are very technique dependent.
One should consider the preparation of the skin. Patients who have been using retinoids or who have been prepared with keratolytic solutions should be observed carefully to avoid overtreatment.
Fig. 7. (A) Photographs before and (B)1 week after a laser-assisted lateral canthal plication and lower eyelid 20% TCA peel. A significant improvement in lid level and contour is noted; mild erythema and hyperpigmentation are still evident. This appearance cleared by the second postoperative week.
Depth of the peel
The degree of frosting of the skin reveals the desired level of penetration of a TCA peel. Frosting denotes coagulation of protein. Clues to the depth of penetration as determined by the level of frosting are as follows (see Fig. 3B– D):
No frosting or minimum frosting occurs in a very superficial peel limited to the stratum corneum.
Minimum frosting in a scattered pattern with mild erythema occurs in a superficial epider mal peel.
Mild frosting with erythema showing through occurs in a full epidermal peel.
With total frosting (homogeneous), the peel penetrates from the epidermis to the papillary dermis. If the skin acquires a grayish appear-ance, the peel has penetrated the reticular dermis and can lead to scarring.
To prevent complications or overcoating, the physi-cian should observe the frosting time. The time between the application of the peel and frosting is about 40 to 90 seconds. One should wait until the frosting is completely evident, denoting which level or depth has been achieved, before applying another coat.
Time to change from frosting to erythema
How fast the skin changes from frosting to erythema denotes the depth of the peel:
In a superficial peel to the basal layer of the epidermis, the frosting fades in 15 minutes.
In a medium depth peel to the papillary dermis, the frosting fades in 30 minutes.
In a deeper peel to the reticular dermis, the frosting fades in 60 minutes.
The application of cold compresses immediately following application of the TCA can reduce the symptoms of burning and discomfort but will not neutralize the peel. Moist compresses can dilute any excess TCA that remains on the skin.
Postpeel care
Healing time depends on the depth of the peel. In a superficial peel, the healing time is 1 to 2 days. A gentle cleanser and bland moisturizer are required. A normal skin care routine can be resumed in 4 to 5 days. A medium depth peel requires a longer healing time. The skin will turn from light to dark brown in 72 hours. It will start peeling off around the mouth, eyes, and finally on the forehead. In 5 to 6 days, most of the crusting will have peeled off, and a radiant glowing skin will be apparent. In the early postpeel period, only bland moisturizers such as Aquaphor, Vaseline, or CU3 copper peptide cream should be used. In the early postpeel period, sun avoidance, with use of hats and sunglasses, is of paramount importance. After the first week, patients should begin to use transparent zinc oxide sunscreens.
Complications and management of complications
Hyperpigmentation
Patients with skin types II, III, and IV should be very aware of this transient complication. It can be ameliorated or prevented with extreme sun avoidance. Once it occurs, the use of Retin-A with bleaching agents (hydroquinone, kojic acid) is highly recommended. Care should be taken not to overtreat and create an additional inflammatory response with secondary hyperpigmentation.
Hypopigmentation
The occurrence of hypopigmentation is proportional to the depth of the peel. Once destroyed by the chemical agent, the melanocytes cannot recover.
Herpes simplex
Patients with a previous history are prophylatically treated with antiviral agents starting the day before the peel and continued for 1 week. If there is an active lesion on the face, the peel should not be performed.
Scarring
Scarring is rare. It is secondary to the depth of the peel or to infection or trauma. Patients who have undergone treatment with Accutane within 1 year before the peel are not good candidates for chemical peels because re-epithelialization is compromised.
Patients who undergo chemical peels should be carefully monitored (Fig.  . When early signs of infection, such as persistent crusting and erythema that does not resolve with mild cleansing, or hypertrophic healing are observed, a more aggressive treatment regimen with topical and systemic antibiotics and topical steroids can be instituted.
Chemical peels are a minimally invasive modal ity of skin rejuvenation and an effective addition to the arsenal of skin therapies. The learning curve is not steep, the cost patient satisfaction is low, and is high. |
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