Surgery Overview

Surgery Overview
In a chemical peel, a chemical solution is applied to the skin and allowed to soak in. Over the next 1 to 14 days, depending on how deeply the chemical penetrated the skin, the skin peels off. This procedure destroys parts of the skin in a controlled way so that new skin can grow in its place. The chemicals used are sometimes called exfoliating or wounding agents.

The types of chemical peels differ based on how deeply the chemical penetrates and what type of chemical solution is used. Factors that may affect the depth of a peel include the acid concentration in the peeling agent, the number of coats that are applied, and the amount of time allowed before the acid is neutralized. Deeper peels result in more dramatic effects as well as higher risks, increased pain, and longer healing time. There are three basic types of peels:

Superficial peels are the mildest type of chemical peel and can be used on all skin types. Superficial peels usually use liquid containing a mild (dilute) acid, most often glycolic acid. Dry ice (solid carbon dioxide) is sometimes used.
Medium peels penetrate the skin more deeply than superficial peels and cause a second-degree burn of the skin. Trichloroacetic acid (TCA) is the main peeling agent used for medium peels, though the peel may also be done in several steps using a different chemical solution followed by TCA.
Deep peels penetrate several layers of skin and cause a second-degree burn of the skin. They are used only on the face. A chemical called phenol is usually used for a deep peel. Deep peels may not be used on darker skin types because they tend to bleach the skin (hypopigmentation). Even in lighter-skinned people, phenol peels—or any type of deep resurfacing—may bleach the skin. A deep peel can be done only once in most cases.
Before the peel
Your doctor can help you decide what depth of peel and what type of chemical solution is most appropriate, based on your skin type, which areas you want peeled, what kind of results you want, how much risk you are willing to take, and other issues. A small “test spot” may be peeled to get a better idea of the results, especially for people with darker skin.

Two to three weeks before the peel, you will need to begin preparing your skin by cleansing it twice a day, applying a special moisturizer or cream once or twice a day, and using sunscreen every day. In some cases, daily use of tretinoin (Retin-A), a topical medication usually used to treat acne, is also recommended and may speed healing. This skin care regimen will help the skin peel more evenly, speed healing after the peel, and may reduce the chance of infection and other complications, especially uneven color changes in the skin.

For medium and deep peels of the face, especially in the areas near the mouth or eyes, you may be given a short course of medication (such as acyclovir) a few days before the peel to prevent viral infection.

How a superficial peel is done
Right before the peel, the skin is cleaned. The chemical (usually a liquid or paste) is then applied to the skin with a small brush, gauze, or cotton-tipped applicators. The chemical is left on the skin for 2 to 7 minutes, depending on the type of chemical used. Water is often used to neutralize the acid and end the chemical reaction, then it is wiped off. You may feel a little burning while the chemical is on your skin. A handheld fan can help cool the skin and relieve any discomfort.

How a medium peel is done
The technique used to do a medium peel is similar to that used for a superficial peel, but the chemical may be left on for a longer period of time. Medium peels are more painful than superficial peels because the chemicals are stronger and they soak deeper into the skin. You may be given a pain reliever and an oral sedative to reduce pain and anxiety during the procedure. Cool compresses and fans can be used to cool the stinging and burning caused by the chemical. The procedure takes about 20 minutes. There is little or no pain once the peel is finished.

How a deep peel is done
Deep peels take the most time and are the most painful type of chemical peel. The procedure for a deep peel using phenol is also more complicated than for other types of peels.

You may be given an oral sedative and pain relievers, usually in the form of a shot. General anesthesia is used less often because it increases the risk of complications and is usually not necessary.
You may be put on a heart monitor and receive intravenous (IV) fluids during the procedure because phenol is toxic when absorbed into the body's systems in large doses. These measures may not be necessary if only a single, small area is being peeled.
After the skin has been thoroughly cleaned, the chemical will be applied and allowed to penetrate. After one area of the face is treated, there will be a 15-minute break before the next area is treated to avoid getting too much phenol in your system.
Tape or ointment may sometimes be applied to the area after the peel to treat deeper problem areas. When tape is used, it is removed after 2 days. Ointment is washed off with water after 24 hours and then reapplied as needed.
Depending on how large an area is being treated, the entire procedure may take 60 to 90 minutes.

What To Expect After Surgery
Recovery time after a chemical peel depends on what kind of peel was done and how deep it was. With all types of peels, proper care of the skin after the peel is very important to speed healing, help results last longer, prevent infection, and avoid color changes in the treated area caused by sun exposure. Proper skin care after a peel is very similar to the care used to prepare for a peel and typically involves:

Cleansing the skin frequently with water.
Changing the dressing or ointment on the wound (for medium and deep peels).
Moisturizing the skin daily.
Avoiding any sun exposure until peeling has stopped and sunscreen can be used. Once peeling has stopped, sunscreen should be used every day. New skin is more susceptible to sun damage.
Some doctors may also recommend using tretinoin cream nightly, usually starting 2 to 3 weeks after the peel.

Superficial peels
Superficial peels are done on an outpatient basis, do not require anesthesia, and cause only slight discomfort afterwards. Most people can return to their normal activities immediately. The skin heals quickly after a superficial peel. The skin may turn pink, and usually only minimal peeling occurs. You can use makeup to hide any redness until it fades.

Medium peels
Medium peels are usually done on an outpatient basis, but you may need to take a few days off work to recover. A medium peel causes a second-degree burn of the skin. The skin takes 5 to 7 days to heal to a point where you can use makeup to hide the redness caused by the peel. There is little or no pain after the peel, but there may be some swelling, especially if the area around the eyes is treated. The skin will turn reddish brown in 2 to 3 days, become crusty, and then flake and peel over the next few days.

Deep peels
A deep peel causes a second-degree burn of the skin. Skin regrowth begins within 10 to 14 days after a deep peel, and the skin remains extremely red and tender for up to 3 weeks. Most people take this time off from work. Complete healing of the skin may take several months.

Oral pain relievers may be given to reduce pain after the peel.
Some people have severe swelling, especially around the eye area. Elevating the head may reduce the swelling to some extent, and corticosteroids may be used for more severe swelling.
You may be given a short course of antiviral and antibiotic medications to prevent infection after the peel.
Proper wound care is extremely important after a deep peel to speed healing and prevent infection of the wound. You may be asked to shower several times a day to reduce crusting, and you may have to return to the doctor's office frequently to have the wound cleaned and checked.
Why It Is Done
Superficial peels are used to improve the appearance of pigment changes in the skin, acne scars, mild sun damage, or fine wrinkles in all skin types. They can be done on the face and on other parts of the body. A superficial peel may also be used to prepare the skin for a deeper peel.
Medium peels are used to treat mild to moderate wrinkles, long-term sun damage, pigment changes, and precancerous lesions of the skin (usually caused by sun exposure). Medium peels are used most often on the face.
Deep peels are used to treat severe wrinkles, long-term sun damage, pronounced pigment changes, and lesions and growths of the skin. They are done only on the face. Deep peels are not done on darker skin types because they bleach the skin.
Chemical peels are sometimes done with dermabrasion or laser resurfacing for a more dramatic overall effect.

A chemical peel (except for a superficial peel) may not be done if you have:

Recently used isotretinoin (Accutane, a drug used to treat acne).
Had recent facial surgery or facial radiation therapy. This can make regrowth of the skin more difficult.
An active herpes infection affecting the area to be treated.
An impaired immune system. This can delay healing and increase the risk of infection and skin color changes after the peel.
Known allergies to certain medications.
How Well It Works
The results of a chemical peel depend in part on the depth of the peel. 1

A superficial peel may slightly reduce but does not eliminate sun damage and signs of aging. The results may not appear for some time, and when they do appear, they may be minimal. Repeated peels are often needed to produce the effect the person wants.
A medium peel can be very effective in evening out pigment differences and in reducing fine wrinkles and signs of sun damage. Retreatment is often needed after 3 to 6 months to produce the best effect.
A single deep peel eliminates wrinkles and may tighten the skin. The effects are often dramatic. In general, a person cannot have repeated deep phenol peels.
Your skin type, skin care before and after the peel, the doctor's level of experience, and your lifestyle after the procedure can also affect the results. Some types of skin problems respond better to chemical peeling than others. People with lighter skin who limit their sun exposure after the procedure tend to have better results than those with darker skin and those who continue to spend lots of time in the sun.

Before you decide to have a chemical peel, talk to your doctor about the kind of results you can expect.

Changes in the color and texture of the skin caused by aging and sun exposure may continue to develop after a chemical peel. Chemical peels are not a permanent solution for these problems.

Risks
In general, the deeper the peel, the greater the risk of side effects and complications. 1 Chemical peels can result in:

Redness (erythema). Expect some redness of the skin after a chemical peel. With deeper peels or with certain skin types, redness can be severe. It may fade within a few weeks, or it may last several months.
Color changes in the skin. Treated areas may be darker or lighter than the surrounding skin.
Crusting and scaling.
Swelling (edema), especially around the eyes.
Scarring.
Allergic reaction to the chemical.
Infection. People who have a history of herpes outbreaks are especially prone to infection after a chemical peel.
Increased sensitivity to sunlight.
Special concerns with deep peels
Deep peels using phenol can rarely cause more severe complications during the procedure, including heart, liver, or kidney failure.

What To Think About
Expectations
Chemical peels are designed to wound and remove the upper layers of the skin. You need to prepare yourself for how your skin will look immediately after the peel and throughout the healing process. You also need to be prepared to use cosmetics to blend skin tones between treated and untreated areas, such as between the face and jawline.

It is important that your doctor understand what you hope to achieve and that you understand what results you can realistically expect. Even with realistic expectations, you may not see results for several weeks or months after a chemical peel.

Sun protection
During the early healing period after a chemical peel (before the skin has finished peeling), you will need to avoid sun exposure. Once the early healing period has passed, you will need to wear sunscreen every day and limit sun exposure as much as possible. New skin is more susceptible to damage and discoloration from sunlight.

Options for skin resurfacing
Chemical peel, dermabrasion, and laser resurfacing are the most commonly used techniques for improving the texture and appearance of the skin. Although these techniques use different methods, they have basically the same effect on the skin: They destroy and remove the upper layers of skin to allow for skin regrowth.

No one technique is necessarily better than the others. When performed by an experienced surgeon, laser resurfacing may be slightly more precise than chemical peeling or dermabrasion. However, the choice of technique is based on the site you want to treat, your skin type and condition, the doctor's experience, your preferences, and other factors. Some people may get the best results using a combination of techniques.