Chapter 213 :: Chemical Peels and Dermabrasion
:: Gary Monheit & Bailey Tayebi
AT-A-GLANCE
■ Chemexfoliation agents are broadly classified into
superficial, medium, and deep peeling agents
according to their depth of penetration and
histologic injury.
■
Preoperative evaluation of skin type, degree
of photoaging, and underlying skin disorders
is critical in safeguarding against potential
complications.
■ Appropriate patient selection and choice of
procedure are critical to success.
■
Keratocoagulation, evidenced by a white frosting
of the skin, is generally regarded as the desired
clinical end point of chemical peeling with
trichloroacetic acid.
■ Mechanical resurfacing, which includes
microdermabrasion, manual dermasanding, and
motorized dermabrasion, is an effective method for
treatment of scars.
■ Infection, prolonged erythema, pigmentary
alterations, and scarring are potential
complications of resurfacing procedures.
BACKGROUND
Resurfacing procedures, including chemical, mechani-
cal, and laser resurfacing, wound the skin in a con-
trolled and predictable manner so as to promote the
growth of new skin with improved texture and quality.
The art of chemical peeling dates back to ancient Egyp-
tian times when the use of animal oils, salt, and lactic
acid in sour milk were used to cosmetically enhance
the appearance of skin. Mechanical exfoliation was
first described in Greek and Roman literature using
compounds containing mustard, sulfur, and limestone.
In the mid-1800s, Viennese dermatologist Ferdinand
Hebra used various peeling agents to treat pigmentary
abnormalities. These early exfoliative agents included
tinctures of iodine and lead, croton oil, cantharides,
and various acids, including sulfuric, acetic, hydro-
chloric, and nitric acids. Tilbury Fox first introduced
phenol to the topical dermatology arena in 1871. A
decade later, P. G. Unna reported on the use of salicylic
acid, resorcinol, phenol, and trichloroacetic acid (TCA)
as peeling agents. Over the next century, several phy-
sicians worked to modify peeling agent formulations,
combinations, and procedures. In the 1980s, Samuel
Stegman identified the depth of injury associated with
various peeling agents, which enabled later categori-
zation into superficial, medium, and deep chemical
peels. Today, chemexfoliation, or chemical peeling,
Kang_CH213_p3895-3905.indd 3895
31
involves the application of a chemical exfoliant aimed
to wound and subsequently regenerate the epider-
mis and/or dermis to remove superficial skin lesions,
improve pigmentary abnormalities and photodamage,
and address textural concerns (Table 213-1).1
PERIOPERATIVE
Chapter 213 :: Chemical Peels and Dermabrasion
CONSIDERATIONS
The perioperative evaluation is a critical component
of every chemical resurfacing procedure. The physi-
cian should seek a thorough understanding of patient
treatment goals, expectations, and allotted down time
prior to initiation of the procedure. The physician
should also assess the patient’s level of compliance
and need for preprocedural and/or postprocedural
adjuvant treatments.2 Patients should be instructed
to avoid depilatory procedures, such as waxing and
shaving, prior to the procedure, as well as ultraviolet
light exposure before and after the date of the chemical
peel. Lastly, preoperative photographs should be taken
to serve as a benchmark with which to grade clinical
results.
INDICATIONS
Chemexfoliation indications can be classified into pig-
mentary (eg, postinflammatory hyperpigmentation,
melasma), photoinduced (eg, actinic keratoses), and
textural abnormalities (eg, epidermal growths, rhyt-
ides, scarring, acne vulgaris).2
PATIENT SELECTION
The perioperative evaluation should assess the
patient’s skin type, degree of photoaging, and whether
or not the patient has underlying skin disorders. When
evaluating skin type, it is useful to classify patients
according to their Fitzpatrick skin phototype (SPT).
In general, darker skin types (SPT IV to SPT VI) have
an increased risk of pigmentary alterations following
chemical peels. While superficial peels tend to be well
tolerated by all skin types, deep peels are commonly
avoided in patients with SPT IV to SPT VI skin because
of the higher risks of postprocedural pigmentary
change and scarring (Table 213-2).2-4
The patient’s degree of photodamage assists the phy-
sician in electing the appropriate rejuvenation proce-
dure necessary to achieve clinically significant results.
08/12/18 12:03 pm
31 TABLE 213-1
treated with an antiviral agent prior to the procedure.
Common pretreatment regimens include acyclovir 400
Resurfacing Procedures mg thrice daily and valacyclovir 500 mg twice daily
starting on the day of the peel and continued until
PEELING DERMABRASION LASER reepithelialization has occurred (Table 213-3).3,5
Superficial Glycolic Microdermabrasion –
Jessner solution
Salicylic acid
Medium Jessner solution Manual Erbium laser SIDE EFFECTS
depth + 35% dermasanding
trichloroacetic The perioperative consultation is also an appropri-
acid ate time to review the risks and benefits of chemical
Deep Baker phenol Mechanical CO2 laser peeling. Expected intraoperative side effects include
peel dermabrasion stinging, burning, and/or itching. In the immediate
Part 31

postoperative period, erythema, edema, and desqua-

mation may be experienced.2
The Glogau system, which classifies patients into
categories I through IV based on whether the patient
::

has mild, moderate, advanced, or severe photodam-

PERIOPERATIVE
Cosmetic Dermatology

age, is a useful categorization tool for this purpose.

In general, both category I and category II photodam-
age will improve with more superficial peeling agents
(Fig. 213-1). Category III will respond to medium-
depth peels, while category IV will require deep peel-
ing agents possibly in combination with mechanical
and/or laser resurfacing procedures3 (Fig. 213-2).
Lastly, inquiring about a patient’s underlying skin
disorders allows the physician to safeguard against
potentially-devastating complications such as infec-
tion and scarring. The physician should inquire about
a history of atopy, rosacea, isotretinoin therapy, poor
wound healing, connective tissue disease, and hyper-
trophic or keloid scar formation as chemical resur-
facing may be contraindicated in these patients.4
Additionally, a history of recurrent infections, includ-
ing bacterial, fungal, and viral, should be elicited in
the preoperative consultation. A patient with recur-
rent herpes simplex virus should be prophylactically
TABLE 213-2
Fitzpatrick Skin Phototypes and Peel Indications
PEEL
SKIN
PHOTOTYPE SKIN REACTION SUPERFICIAL MEDIUM
I Always burn, + +
never tan
PREPARATIONS
Chemical peeling agents can penetrate to predictable
histologic depths; however, the physician can augment
this depth with the use of certain preoperative prepa-
rations.6-8 Topical pretreatment with retinoic, glycolic,
or lactic acid alone, or in combination, will increase the
absorption of the wounding agent and promote a more
even penetration of the peel. Pretreatment should
begin 2 to 4 weeks before the procedure and be dis-
continued approximately 2 to 3 days prior to the peel
date.2,6 Pretreatment with a topical retinoid may also
speed the healing process (Table 213-4).4
Topical medications such as 2% to 5% hydroquinone
may be applied to the skin preoperatively and post-
operatively to minimize the risk of postinflammatory
hyperpigmentation. Pretreatment should be consid-
ered in patients with SPT III to SPT VI, and in those
treated for problems of hyperpigmentation.6 Applica-
tion of hydroquinone, in addition to a ultraviolet A/
ultraviolet B protective sunscreen (sun protection
factor 30 or higher), should be initiated 2 to 4 weeks
prior to the date of the peel and resumed once reepi-
thelialization has occurred postoperatively. As a rule,
DEEP patients prone to dyschromias should adhere to a pol-
icy of strict sun avoidance in the perioperative period.
−

PROCEDURAL TECHNIQUE
II Always burn, + + −
sometimes
tan
Following informed consent, instruct the patient to
III Sometimes + + −
burn, always
remove any makeup with a gentle facial cleanser. The
tan patient is then placed in the supine position on the
operating table with the head elevated to a 30-degree
IV Never burn, + + ±
always tan
angle.9 This position minimizes the risk of solution
inadvertently dripping toward the eyes and allows the
V Moderate pig- + ± −
physician to visualize the complete treatment area.
mented skin
In general, more superficial chemical peels do not
VI Darkly pig- + ± − require sedation or other forms of anesthesia. Medium
mented skin
3896 and deep peeling agents, however, are associated
−, no; +, yes; ±, either. with significantly more operative discomfort and may

Kang_CH213_p3895-3905.indd 3896 08/12/18 12:03 pm

 31

Chapter 213 :: Chemical Peels and Dermabrasion

Figure 213-1 Glogau photoaging types I and II. Indications for superficial peeling.

3897
Figure 213-2 Glogau photoaging types III and IV. Indications for medium and deep chemical peeling.

Kang_CH213_p3895-3905.indd 3897 08/12/18 12:03 pm

31 TABLE 213-3
Contraindications to Medium and Deep Peels
RELATIVE CONTRAINDICATIONS
Active skin disease
Recent facial surgery
History of facial keloids
History of postinflammatory
hyperpigmentation
Radiation to head and neck
Active skin infection
■ Bacterial
Part 31
ABSOLUTE CONTRAINDICATIONS
Open wounds, excoriations
Isotretinoin within last 6 months
Pregnancy
Unrealistic expectations
Poor patient–physician
relationship
 
This cleansing regimen will remove all oil and debris
and promote even penetration of the wounding agent
while minimizing the risk of a spotty or ineffective
peel.
For medium-depth peeling, an absorbing agent may
be applied to the skin to increase the effectiveness or
penetration depth of the peeling agent. In 1986, Brody
and Hailey applied solid carbon dioxide (CO2) in com-
bination with acetone prior to application of 35% TCA
to disrupt the epidermal barrier and achieve a more
even peel at a greater histologic depth.3 Later, in 1989,
Monheit described a similar technique using Jessner
solution prior to application of 35% TCA. Acting as
an absorbing agent, Jessner solution removes the stra-

tum corneum allowing for deeper penetration of TCA.

■ Viral Coleman similarly demonstrated greater wounding
depths with use of 70% glycolic acid prior to applica-
tion of 35% TCA.3,9 Use of absorbing agents such as
::

require sedative and pain medications and/or local these offers improved safety, minimizes the risk of pig-
nerve blocks. Such blocks commonly include anes-
Cosmetic Dermatology

mentary alterations and scarring, and creates clinical

thetizing the supraorbital, infraorbital, temporal, and
mental nerves.9
Once the patient has been positioned and the appro-
priate level of anesthesia has been undertaken, the
skin is vigorously cleansed and degreased. A vari-
ety of cleansing agents may be used for this purpose
including hexachlorophene, acetone, rubbing alco-
hol, chlorhexidine, or some combination of these
agents.3,6,7,9 An even application can be achieved with
a 4-inch × 4-inch gauze. The skin should then be rinsed
and dried prior to application of the chemexfoliant.
TABLE 213-4
Preoperative and Postoperative Care for
Chemical Peels
Preparation (Weeks to Days Before Peel)
■ Topical pretreatment with a retinoid, glycolic or lactic acid solution
(begin 2 to 4 weeks prior, discontinue 2 to 3 days before peel date)
■ Consider topical 2% to 5% hydroquinone preoperatively and
postoperatively, if postinflammatory hyperpigmentation is a
concern (2 to 4 weeks prior)
■ Sun avoidance, especially in individuals at risk for dyschromias
■ Consider pretreatment with acyclovir 400 mg thrice daily or
valacyclovir 500 mg twice daily on the day of peel and until
reepithelialization
Preprocedural Care (Immediately Prior to Peel)
■ Cleanse skin with gentle facial cleanser
■ Position patient with head up at a 30-degree angle
■ Consider sedative/pain medications or local nerve blocks for
medium to deep peels
■ Degrease skin with acetone, hexachlorophene, rubbing alcohol,
or chlorhexidine
■ Rinse and dry skin prior to application of chemexfoliant
Postprocedural Care
■ Cleanse skin up to 4 times/day
■ Dilute 0.25% acetic acid (1 tbsp vinegar in 1 pint water) as
cleansing agent
■ Pat dry, apply bland emollient
■ Daily sunscreen use
3898
■ Avoidance of excessive sun exposure
results comparable to a deep 50% TCA peel.
The peeling agent is then applied. This is com-
monly done with cotton-tipped applicators or 4-inch ×
4-inch/2-inch × 2-inch gauze. The face is peeled
sequentially by anatomic location starting on the fore-
head, followed by the temples, cheeks, and finally the
lips and eyelids.3 Feathering of the solution into the
hairline, brows, and jawline helps to conceal lines of
demarcation between peeled and nonpeeled areas.9
Alternatively, a superficial peeling agent may be
applied to such areas as neck and décolleté to assist in
blending treated and untreated cosmetic units. Special
care is taken to protect the eyes during a chemical peel.
A semidry applicator should be used to carry the solu-
tion within 2 to 3 mm of the lid margin. Furthermore,
tears are wicked away with a dry cotton-tipped appli-
cator to prevent peel solution from traveling to the
puncta and eye via capillary action.9 Should peel solu-
tion inadvertently enter the eye, initiate aggressive irri-
gation with normal saline flushes immediately.
During the procedure, the physician is able to ensure
even application of the peeling agent by the demon-
stration of even frosting. Frosting is representative of
underlying keratocoagulation, or denaturation of epi-
dermal keratin proteins.9 Although true frosting does
not occur with each and every peeling agent, frosting
is generally regarded as the desired end point. Level I
frosting is defined as erythema with blotchy or spotty
frosting. This is often seen with light chemical peels.
Level II frosting is commonly seen in medium-depth
chemical peels and is achieved when a white coating is
evident with a slight erythematous background show-
ing through. Level III frosting is attained when a solid
white enamel-like frosting is demonstrated on the skin.
This is seen in deeper chemical peels and is indicative
of peel penetration into the papillary dermis.3
Immediately following the procedure, cool saline
compresses are applied for 5 to 10 minutes. This is for
comfort as the reaction is complete after frosting. Only
glycolic acid peels require neutralization. A bland
emollient as well as a broad-spectrum sunscreen are
then gently massaged into the skin.

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 CHEMICAL RESURFACING Superficial chemical peeling chemicals
31
PROCEDURES Phenol Resorcinol Salicylic Acid
OH OH COOH
Chemical peeling involves the application of a chemi-
cal agent that wounds the epidermis and/or dermis OH
and stimulates collagen remodeling and new epider-
mal growth, thus achieving a cosmetic benefit. The OH
degree of penetration, destruction, and inflammation
Trichloracetic Acid
determines the level of peeling.3 Superficial peel- Glycolic Acid C2HCl3 O2
ing agents remove the stratum corneum and wound OH O
the epidermis.8,9 Destruction of the entire epidermis
defines a full superficial peel. Medium-depth peels
penetrate through the papillary dermis to the upper H2C C OH

Chapter 213 :: Chemical Peels and Dermabrasion

reticular dermis.3,8 Deep peeling agents wound a
greater portion of the reticular dermis resulting in
production of new collagen and ground substances
(Fig. 213-3).3,8,9
SUPERFICIAL CHEMICAL
PEELING
Superficial chemical peels are indicated for acne,
particularly comedonal acne, enlarged pores, postin-
flammatory hyperpigmentation, melasma, mild pho-
todamage, and fine textural concerns.2,4,10 Superficial
exfoliants include 10% to 20% TCA (20% to 35% TCA
achieves a complete epidermal peel), Jessner solution
(14% salicylic acid, 14% lactic acid, and 14% resorcinol
in ethanol), resorcinol, salicylic acid, and α-hydroxy
Figure 213-4 Superficial chemical peeling chemicals.
acids such as glycolic acid.2,6 Superficial peeling agents
disrupt corneocyte adhesion and lead to regenera-
tion of a thickened epidermis, normalization of the
basal cell layer, and dispersal of melanin. Superfi-
cial agents may also enact dermal change including
increased dermal collagen and improved quality of
elastic fibers.11,12 Complete recovery is expected in 2 to
4 days (Fig. 213-4).4,6
Salicylic acid is a naturally occurring β-hydroxy acid
derived from the bark of the willow tree. It is regarded
as a safe peel in all skin types for the treatment of acne,
melasma, and postinflammatory hyperpigmentation.
As described by Grimes, salicylic acid exhibits a lipo-
philic nature that allows for effective dissolution of the
stratum corneum as well as comedolysis.13 Therefore,

Depth of peels

Hair Peel depth

Stratum corneum
Stratum
granulosum

Stratum Super-
spinosum ficial
wound
Stratum basale (.06 mm)
Papillary
dermis

Upper Medium
reticular depth
dermis (.45-.60 mm) wound
Apocrine Mid. Deep
gland reticular depth
dermis (.60-.80 mm) wound
Lower
reticular
dermis

Fat (2.0 mm)

3899
Figure 213-3 Depth of peels.

Kang_CH213_p3895-3905.indd 3899 08/12/18 12:03 pm

31
A acid concentrations of 10% to 70% are frequently
Part 31
::
Cosmetic Dermatology
B
C in keratocoagulation, or protein denaturation, and
Figure 213-5 Salicylic acid peel for acne. A, Pretreatment.
B, Perifollicular frosting. C, After 3 treatments.
salicylic acid proves beneficial in the treatment of
comedonal and papular/pustular acne.2,4,13,14 A split-
face study by Meguid and colleagues reported that
treatment of inflammatory acne lesions with the use
of 30% salicylic acid was superior to treatment using
25% TCA, although an improvement in total lesions,
including both comedonal and inflammatory, occurred
3900 in 95% of patients on the salicylic acid–treated side
(Fig. 213-5).14 Salicylic acid peels are also effective in the
Kang_CH213_p3895-3905.indd 3900
treatment of dyschromias. In a pilot study by Grimes,
88% of patients with SPT V and SPT VI demonstrated
improvement in dyschromias, with 4% hydroquinone
pretreatment followed by a graduated series of 20%
and 30% salicylic acid peels.10 Salicylic acid is a pref-
erential peeling agent for dyschromia as it is the least
inflammatory of peeling agents. It has the least risk
of producing postinflammatory hyperpigmentation
(Fig. 213-6).
α-Hydroxy acids include glycolic acid along with
several other naturally, occurring, nontoxic agents
such as lactic, citric, malic, and tartaric acid.2,6 Glycolic
used in the treatment of acne, dyschromias, and mild
signs of photoaging, and are safe in most skin types.
Unlike other superficial peeling agents, the action of
glycolic acid is time dependent and must be neutral-
ized with normal saline, water, or sodium bicarbonate.
α-Hydroxy acids wound the skin via loss of keratino-
cyte cohesion within the epidermis. Peels using 70%
glycolic acid can also result in increased fibroblast
proliferation, collagen and elastic fiber formation, and
melanin dispersion.2,15
MEDIUM-DEPTH
CHEMICAL PEELING
Medium-depth chemical peels are indicated for the
treatment of mild to moderate photoaging, pigmen-
tary disorders, lentigines, epidermal growths, rhyt-
ides, and actinic keratoses.9 Peeling agents include
45% to 60% TCA as well as combination peels such
as Jessner solution with 35% TCA (Monheit peel),
70% glycolic acid with 35% TCA (Coleman peel), and
solid CO2 with 35% TCA (Brody peel).3,6,9 Fifty percent
TCA is not used any longer because of the risk of scar
from deeper penetration of the agent in the dermis.
Combination peels are the preferred medium-depth
peels because of their lower risk of postprocedural
dyschromias and scarring.3,9 Histologically, medium-
depth chemical peels are associated with diminished
solar elastosis, fibroblast proliferation, increased col-
lagen formation, and reorganization of elastic fibers
(see Fig. 213-3; Table 213-5).8,12
TCA is a crystalline inorganic compound that results
resultant cell death, as indicated by a white frosting on
the skin. Effects of this self-neutralizing peeling agent
are cumulative with each application penetrating
deeper than the last. TCA may be relatively quantitated
with utilization of 1 to 4 cotton-tipped applicators.
Loose or wrinkled skin should be stretched to achieve
an even application of the solution and prevent pool-
ing of the solution in folds. A level II to level III frosting
is generally complete within 30 seconds to 2 minutes of
TCA application; however, thicker epidermal growths
may require additional applications.2,9 Moreover, areas
of poor frosting may require careful reapplication of
the peeling agent.3 At the completion of the peel, cool
08/12/18 12:03 pm
 Spectrum of superficial chemical peeling
Inflammatory
Jessner Resorcinol Glycolic
Figure 213-6 Spectrum of superficial chemical peeling. TCA, trichloroacetic acid.
saline compresses are placed on the skin. A bland
emollient and sunscreen are then applied. Expected
side effects include erythema, edema, and desquama-
tion. Edema of the eyelids may be severe enough that it
closes the lids. As the skin heals, erythema intensifies as
desquamation comes to an end within 3 to 4 days. New
skin is evident within 6 to 7 days, and healing is com-
plete within 7 to 10 days. At this point, the erythema
is reminiscent of a sunburn and is expected to resolve
within 3 to 4 weeks.9 TCA should be used cautiously in
SPT IV to SPT VI. One should never “overcoat” TCA
once the frosting is complete as accumulated TCA will
produce a deeper peel (Fig. 213-7).
DEEP CHEMICAL PEELING
Deep chemical peels are indicated for deep rhytides
and severe photoaging (Glogau categories III and IV)
and include peeling agents such as Baker phenol.9 The
phenol is diluted to a concentration of 45% to 55% with
croton oil, hexachlorophene, and water, and is referred
to as the Baker-Gordon phenol peel. Two variations, an
occluded and unoccluded, exist in clinical practice. In
the occluded phenol peel, zinc oxide tape is placed over
the skin after the peeling solution has been applied so
as to increase absorption. The unoccluded method,
described by McCollough, requires application of
higher volumes of peeling solution; however, depth of
penetration is diminished as compared to the occluded
technique. Both variations of the Baker-Gordon phenol
peel possess inherent risks and require monitoring and
IV fluid administration because of potential cardiac,
renal, and hepatic toxicities.3,16,17 Baker-Gordon deep
chemical peeling is a more aggressive procedure with
inherent risks, but is the most permanent skin rejuve-
nation of all resurfacing procedures.
TABLE 213-5
Medium-Depth Wounding
■ Trichloroacetic acid (TCA) 50%
■ Liquified phenol USP (U.S. Pharmacopoeia) 88%
■ Solid carbon dioxide + TCA 35% to 50%
■ Jessner solution + TCA
Kang_CH213_p3895-3905.indd 3901
31
Noninflammatory
TCA Salicylic Acid
High concentrations of TCA are used in the treat-
Chapter 213 :: Chemical Peels and Dermabrasion
ment of atrophic scars in a procedure known as TCA
chemical reconstruction of skin scars (TCA CROSS). In
this procedure, first described by Lee and colleagues,
TCA is applied with a sharp-tipped wooden applicator
pressed firmly against the base of the scar until a white
frost is apparent. Because high concentrations (70% to
100%) of TCA penetrate to the deep dermis, histologic
remodeling also occurs at this level. Such remodeling
consists of dermal expansion with increased collagen
proliferation that results in elevation of depressed,
atrophic scars.18,19 Agarwal and colleagues reported
successful use of 70% TCA applied with standard TCA
CROSS technique in the treatment of boxcar, rolling,
and ice pick scars in SPT IV and SPT V. In this study,
postinflammatory hyperpigmentation was reported
but improved with time and use of “depigmenting”
creams; formation of keloids, persistent erythema, and
reactivation of herpes simplex virus were not seen.19
Medium-depth and deep peeling agents result in
significant inflammation and wounding within the
deep reticular dermis and heal with 4 characteristic
stages, including inflammation, coagulation, reepi-
thelialization, and fibroplasia. Inflammation and
coagulation occur within hours of application of the
peeling agent. Reepithelialization then begins on day
3 and continues through days 10 to 14. Fibroplasia is
the last stage of the healing process and persists for
3 to 4 months. This stage includes neoangiogenesis
and collagen proliferation.3 In a histologic and bio-
chemical analysis by Butler and colleagues, reorgani-
zation of dermal collagen and elastic fiber networks
was prominently seen following 50% TCA and phenol
peels.12 These dermal changes allow for the improve-
ment in rhytides and other signs of photoaging seen
clinically following deep chemical peels.
POSTOPERATIVE CARE
Following a chemical peel, patients are instructed to
cleanse the skin up to 4 times daily to prevent infec-
tion and debride the necrotic exfoliation. Dilute 0.25%
acetic acid (1 tablespoon vinegar in 1 pint water) is a
commonly recommended cleansing agent because of
its antibacterial action against Pseudomonas and other
Gram-negative bacterial organisms.3,5,9 After cleans-
ing, the skin is patted dry and a bland emollient is
3901
applied.
08/12/18 12:03 pm
31 COMPLICATIONS
Complications can occur either intraoperatively or
postoperatively.3 Intraoperative complications include,
but are not limited to, incorrect peel concentrations, use
of expired products, accidental solution misplacement,
and failure to properly neutralize the peel solution.
Such errors may be prevented with care taken to check
concentrations and dates of expiration. As removal of
intact peeling agent crystals from the storage bottle
may lead to higher concentrations placed on the skin,
the physician should pour the peeling solution into a
secondary container prior to initiation of the proce-
dure. Furthermore, solution should never be passed
Part 31

over the face or allowed to actively drip onto the skin.

Neutralizing solutions should be identified properly
(eg, sodium bicarbonate for glycolic acid peels) and
kept at the patient’s bedside for quick placement fol-
::

A
lowing completion of the peel.
Cosmetic Dermatology

Postoperative complications include infection (bac-

terial, viral, fungal), prolonged erythema, pruritus,
pigmentary alterations, contact dermatitis, milia/
acne, exacerbation of an underlying skin disease, and
scarring.3,9 Frequent postoperative visits and early
recognition of complications are critical, especially
for medium and deep chemical peels in which risks of
scarring are inherently higher. Delayed wound heal-
ing and persistent erythema are signs that skin is not
healing normally and are indicative of scarring poten-
tial. Delayed healing is evident with the appearance of
friable, stellate erosions on the skin at the time reepi-
thelialization is expected. As erosions may be indica-
tive of infectious etiologies, all such wounds should
be cultured. Erosions should be treated with artificial
wound dressings and topical or systemic corticoste-
roids.5 Persistent erythema is defined as erythema
lasting longer than 3 to 5 days for a superficial peel,
B
15 to 30 days for a medium-depth peel, and 60 to
90 days for a deep chemical peel.3 Etiologies include
underlying skin disorders such as rosacea and atopy,
contact dermatitis or sensitivity to the peeling agent,
and aggressive peeling techniques.20 Persistent ery-
thema should be treated promptly with topical and/
or systemic corticosteroids (Fig. 213-8).3,5,20
Postinflammatory hyperpigmentation and other
pigmentary dyschromias are more common in
SPT IV to SPT VI with medium and deep chemi-
cal peels presenting a greater risk than superficial
peels. Hyperpigmentation is also more common

Risk of scarring: medium and deep peeling

Intrinsic Operative Postoperative

Skin susceptible Overtreatment Infection
to overinjury with peel Trauma
C

Figure 213-7 Levels of frosting. A, Level I: erythema with Scarring

streaky frosting—superficial epidermal. B, Level II: white
3902 frosting with visible erythema—full-thickness epidermal.
C, Level III: white enamel frosting—epidermal or dermal. Figure 213-8 Risk of scarring: medium and deep peeling.

Kang_CH213_p3895-3905.indd 3902 08/12/18 12:03 pm

 in individuals on hormonal therapies including
oral contraceptive pills and photosensitizing
medications.5 In general, superficial peels should be
elected in individuals with darker skin types. The
physician may recommend treatment with hydroqui-
none, with or without a retinoid, in the perioperative
period to minimize risks of hyperpigmentation.2,4,5
Hypopigmentation, on the other hand, can be a com-
plication associated with phenol peels. The resulting
coloration of the skin is comparable to the natural
appearance of sun-protected sites, such as the axillae
and postauricular skin, and is directly proportional
to the amount of phenol applied.5 Deeper penetra-
tion can efface the papillary dermis creating a much
lighter appearance with an “alabaster” texture.
MECHANICAL
RESURFACING
PROCEDURES
MICRODERMABRASION
Developed by Marini and Lo Brutto in 1985, micro-
dermabrasion is a closed-system mechanical resur-
facing procedure using abrasive aluminum oxide
crystals to ablate the superficial epidermis.21-23
The machine operates by discharging crystals onto
the skin from a compression source. Crystals wound
the superficial epidermis, removing keratinocytes
and sebum, and are then returned to a waste con-
tainer via vacuum suction. The ablative strength of
the procedure is dependent on the strength of the
vacuum and contact time with the skin. Depth of
injury and clinical results are generally comparable
to that of superficial chemical peels. Histologic inves-
tigation by Freedman and colleagues demonstrated
return of a “basket-weave” stratum corneum, thick-
ening of the epidermis and dermis, and increased
collagen and elastic fibers following a series of
microdermabrasion treatments.24
Microdermabrasion is regarded as a safe procedure
in most skin types. The procedure is well tolerated
and does not require anesthesia. Indications include
enlarged pores, fine rhytides, mild photodamage, and
acne scarring. Multiple treatments are usually neces-
sary to achieve appreciable clinical results. Side effects
are minimal and short-lived including erythema,
petechiae/purpura, and tenderness. Complications
such as persistent erythema, telangiectases, and postin-
flammatory hyperpigmentation are uncommon; how-
ever, microdermabrasion is best avoided in patients
with underlying rosacea, and aggressive technique
should be discouraged in patients with SPT V and SPT
VI. Rare complications to the technician involve inha-
lation of the crystals and include pulmonary fibrosis
and foreign-body granuloma, which are a result of the
aluminum oxide crystals used in the procedure. To
minimize such risks, eye protection and masks should
be worn by the operators.23,25
Kang_CH213_p3895-3905.indd 3903
TABLE 213-6
31
Manual vs Motorized Dermabrasion
MANUAL DERMABRASION MOTORIZED DERMABRASION
■ Minimal cost of equipment, ■ High cost of machine; gas
no maintenance, disposable sterilization of burrs and
■ No aerosolization of blood fraises required; face shields,
and infectious particles draping required
■ Difficult to perform in con- ■ Aerosolization of blood and
cavities (alar groove, nasola- infectious particles
bial fold) ■ Specialized burr shapes pro-
■ Longer procedure time vide ease of use in smaller
■ Depending on material used, units or concavities
risk for granuloma formation ■ Shorter procedure time
Chapter 213 :: Chemical Peels and Dermabrasion
if inadequate postprocedural ■ No risk for granuloma
cleaning formation
Data from Gillard M, Wang T, Boyd C. Conventional diamond fraise vs
manual spot dermabrasion with drywall sanding screen for scars from
skin cancer surgery. JAMA Dermatol. 2002;138(8):1035-39.
MANUAL DERMASANDING
Manual dermabrasion (Table 213-6), or dermasand-
ing, uses sterile sandpaper of varying grades to
ablate the epidermis and portions of the dermis.
Two hundred or 400 grit-grade sandpaper wrapped
around gauze or a cotton-tipped applicator is used
to abrade the skin until punctate bleeding is evi-
dent. This cost- and time-effective procedure is fre-
quently elected for the treatment of surgical scars. A
split-scar study by Poulos and colleagues reported
improvement in the appearance of surgical scars,
particularly that of scar color and elevation, follow-
ing manual dermabrasion performed 6 to 8 weeks
postoperatively.26 It is important to rinse the abraded
skin thoroughly to remove the silica-carbide crystals
as they can become imbedded in the skin and create
granulomas or tattoos (Fig. 213-9).
MOTORIZED
DERMABRASION
Motorized dermabrasion (see Table 213-6) is a mechan-
ical resurfacing technique in which handheld devices
using burrs of varying degrees of coarseness are used
to remove layers of the epidermis and/or dermis.25
Biopsies of dermabraded skin demonstrate normaliza-
tion of the rete ridge pattern, increased type I collagen,
and increased elastic fibers.27,28
Motorized dermabrasion is indicated for moderate
to severe photodamage, including textural changes,
rhinophyma, and scar revision. Patients with SPT IV
to SPT VI should be treated cautiously because of the
potential for postprocedural pigmentary alterations.
To minimize such risks, pretreatment and posttreat-
ment with a topical retinoid or hydroquinone may be 3903
elected.
08/12/18 12:03 pm
31 Manual dermasanding used in conjunction with medium-depth chemical peel

Sterile sandpaper dipped in water

×

l
Part 31
::
Cosmetic Dermatology

Figure 213-9 Manual dermasanding can be used in conjunction with medium-depth chemical peel to provide selective
deeper resurfacing.

Prior to the procedure, the treatment area is injected
with local anesthesia. Regional nerve blocks also may be
done to improve patient comfort. For larger treatment
areas, sedative medications and/or general anesthesia
may be required. The physician and assistants should
wear gowns and eye protection because of aerosoliza-
tion of skin particles and blood during the procedure.
The proper burr should then be selected for the
treatment area and desired clinical result. Commonly-
used burrs include diamond fraises and wire brushes.
The physician is able to control the depth of destruc-
tion by means of the amount of pressure applied and
the selected speed of the dermabrader. Punctate bleed-
ing is indicative of wounding to the level of the pap-
illary dermis while more confluent bleeding is seen
with wounding to the level of the reticular dermis. To
minimize the risk of adverse events including scarring,
treatment should never extend below the mid-reticular
dermis (Fig. 213-10).
At the conclusion of the procedure, cool saline-
soaked gauze is applied to the skin followed by appli-
cation of a bland emollient. The patient is instructed
to cleanse the treated skin with 0.25% acetic acid daily
and keep the affected skin moist with a bland emollient
until reepithelialization has occurred at approximately
7 to 10 days. Ultraviolet radiation should be strictly
avoided and broad-spectrum sunscreens should be
applied daily. Healing generally occurs in 2 to 4 weeks
and postprocedural erythema is expected to resolve in
1 to 2 months.25

Surgical landmarks

Papillary dermis/capillary loops

Small red dots-fraise
Corn rows of bleeding-brush
Upper reticular dermis
Large red dots-fraise
White parallel lines in
collagen-brush
Mid-deep reticular dermis
Yellow globules-sebaceous
glands
Frayed collagen bundles

3904
Figure 213-10 Surgical landmarks.

Kang_CH213_p3895-3905.indd 3904 08/12/18 12:04 pm

 CONCLUSIONS
Chemical and mechanical resurfacing procedures
serve as effective treatments for a multitude of pig-
mentary, textural, and photodamage-related concerns.
A vast variety of procedures exist, each targeting a spe-
cific depth of wounding and repair and each with its
own inherent risks and benefits. It is prudent for the
physician to have a broad knowledge base regarding
these procedures so as to ensure treatment success and
safeguard against untoward complications. Likewise,
the proper selection of patients and choice of proce-
dure are critical. With appropriate usage, resurfacing
procedures can be a gratifying part of dermatologic
practice.
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