Facial Peels

The American Academy of Cosmetic Surgeons reports that 72 percent of people who consult cosmetic surgeons do so because they're interested in facial work. The reason is simple — the face is the most visible part of the body. Whether we like it or not, we're judged by first impressions, and our faces tell the stories of our lives. In 1996, over half a million individuals had some kind of facial cosmetic surgery, some involving a hospital stay and many using general anesthesia.

Facial laser peeling, by contrast, can be done in an afternoon in a doctor's office. Local anesthesia can be used if the doctor is an expert in the use of tumescent anesthesia (see chapter 13 for more information on tumescent anesthesia). The recovery is quite manageable, though a bit aggravating. Patients desire facial peels for a variety of reasons: most often for wrinkles, discoloration, and other skin imperfections. It is not usually very effective for acne scarring. Some have work done only around the eyes or the mouth. Others will treat the entire face. Either way, if done skillfully, laser peeling can produce remarkable improvements. A light “TCA” peel of the face combined with a laser peel around eyes and mouth is often a well-tolerated and acceptable procedure that, in most cases, blends the result without lines between the treated areas.

Deeper “dermabrasion” and deep “chemical” or “acid” peeling are still used, but they produce more frequent complications, including scarring and/or permanent changes in skin color. Superficial peels, both chemical and laser, are safer. There's a trade-off between depth of any peel and quality of results and risks, of course.

Dermabrasion involves using a tiny electric sander which revolves at a very high speed, and literally “sands” the surface of the skin. A good surgeon can “rub out” wrinkles or acne scars to an even plane, but it requires a lot more skill than the laser, and scarring or uneven results are more common. Dermabrasion also produces a lot of bleeding. It's been said in some medical texts that 50 percent of dermabrasion patients wish they'd never had the procedure.

Acid peeling is the chemical version of the same idea. Rather than sanding the skin surface, acid — phenol or trichloracetic (TCA), for example — is applied to produce a deep, hopefully even, injury to the old skin. Phenol usually produces beautiful wrinkle shrinkage, but also produces permanent color loss in most cases. Patients often end up with a white cast to their faces, which will need to be covered up with makeup. This is acceptable only in certain elderly patients. When enough TCA (40 to 50 percent strength) is applied to produce significant wrinkle shrinkage and deep penetration, there may be a three to five percent chance of scarring (the lighter TCA peels use 15 to 25 percent strength). It's difficult to accurately predict how the more concentrated TCA will penetrate the skin. In my opinion, this makes deep TCA peeling unacceptable.

Superficial TCA peeling, however, is an excellent technique. When 20 percent TCA is placed on the face, skin changes are produced during the application process. These changes are obvious, and different from those resulting from the deep TCA peel. This is good for texture improvement, though deep wrinkles are not improved. Recovery time for this lighter peel may only be four to five days. Fruit acid, such as 40 to 70 percent Glycolic acid, is also being used in a similar fashion as the light (20 to 25 percent) TCA peeling.

The heavily advertised “lunch-time peel” irritates the deep skin in order to produce improvement but does not cause peeling. It is popular because each session is inexpensive and requires no “down time,” or time off usual activities. The procedure is performed with new machines which produce light that may not be a single-frequency band like a laser. This peel is similar to very minimal aesthetician peels performed with low acid strength. It is not very effective and requires repeat procedures over time — sometimes as many as 10 to 20. Added up, these sessions may be more expensive than the invasive peels.

Prior to facial laser surgery, patients may be asked to treat their faces with Retin A, Renova, and/or skin bleaches or creams for two to four weeks. Because dark skinned people can sometimes darken further after the procedure, they are frequently advised to treat their skin before surgery to prevent this or not to have the procedure at all. We require our patients to take an anti-viral medication such as Valtrex® or Acyclovir® to prevent cold sores, which can be stimulated by the treatment. Cold sores can spread all over the face and may cause scarring if they occur after treatment when the skin is raw. Also due to its effects on healing skin, Accutane® cannot be taken for one year prior to facial laser or dermabrasion surgeries. You also don't want to undergo a surgical procedure if you are ill or if you have unstable medical problems. Your doctor will counsel you about any limitations.

I believe that preparing for your recovery is the most important element to consider when it comes to facial laser peeling. Patients should be given an accurate picture of what to expect during this period, because frankly, a newly peeled face is not a pretty sight. Most patients may stay in the house for a week after the procedure, as their faces are either bandaged, or if exposed, raw and swollen. Recovery from deep peels is, on average, the toughest of any procedure we do. The dressings are claustrophobic for some people. So plan to take adequate time off from work, and don't book any important social engagements until at least two weeks after your deep peel. Let your family and friends know what to expect.

When you arrive at your doctor's office, you'll be given a sedative. I usually give my patients a light anesthetic drip to allow them to sleep. While you're relaxing, the doctor may draw on your face to mark the areas to be treated. Your face will then be washed with an antiseptic solution and the tumescent solution, if used, is injected with a tiny needle to numb the face. If the doctor is not using tumescent, he may alternatively have an anesthesiologist put you in a heavy sleep. For lighter peels, some patients can tolerate the discomfort without anesthetic.

By the time the doctor begins working with the laser tool, you shouldn't feel anything at all. The laser “zaps” small areas on the face as the doctor moves carefully from one area to the next, treating each in turn, using his skill to blend everything evenly.

In theory, the laser doesn't actually burn the skin because there's very little heat transfer involved. Instead, it vaporizes the skin surface by making the water boil inside the skin. During the process, the treated skin changes in a way that allows the doctor to wipe off the top layers with a wet gauze pad. With each zap of the laser, the doctor can see new, fresh skin appear. Very little bleeding occurs. Each laser zap lasts a fraction of a second, and if you're awake (but sleepy) during the procedure, you'll hear it working — zip, zip, zip — and you may hear the doctor and staff talking and working around you. The whole process usually lasts about half an hour.

When the procedure is finished, you may be feeling drugged, and you'll need someone to drive you home. When you get there, you may want to sleep for a few hours until the drugs work their way out of your system. The next morning you will likely feel more normal.

You'll often leave the doctor's office with a dressing on your face or sometimes a layer of Vaseline® or other ointment on your skin. There are many different schools of thought about dressings, and doctors are continually learning more about which are most effective. I believe that dressings are important for recovery from a peel deep enough to remove wrinkles effectively. We currently like a dressing that looks like clear food wrap, but is much more expensive and lets air penetrate to the skin to a certain degree. For lighter peels, ointment may be used. In some cases, tap water splashes every hour while awake are sufficient, or no treatment at all. For very deep peels, it's helpful to leave dressings in place for about two to three days. A clear benefit is that most patients have virtually no pain when modern full-face dressings are used for several days. They describe their dressings as annoying but not painful. For lighter peels used to treat minor facial problems, a dressing may be removed sooner or may not be needed at all.

Our deep-peel patients leave the office with their faces wrapped like a mummy or “the invisible woman.” The eyes and lips are exposed, and may swell, and they look very strange at first. One patient's four-year-old son became very frightened when his mom returned home with her face bandaged. He wouldn't let her near him until her face normalized. He even had nightmares. Depending on the depth of your laser peel, you might want to make arrangements to have very young children stay at Grandma's for a few days, or prepare them well for the event.

Again, pain isn't a big issue with most laser peel recoveries when the full face dressing is used. Some people have a burning sensation. If you are having much pain, see the doctor right away — you may be having a cold sore outbreak which can cause scarring. Others have itching, and special creams may be used to relieve this. The most irritating thing is the night-and-day facial wrap and the strange feeling of your swollen face. For the first day or two, it will help to ice your face several times a day for ten to twenty minutes with a washcloth (or the dressing) between the skin and the ice.

You may also find that the swelling (and sometimes the dressing) makes it difficult to move your mouth comfortably for the first couple of days. Some people lose a little weight because they don't eat much. When the dressing is removed, your face will be red and still swollen. Your skin will feel dry and tight, and you should keep it lubricated with whatever cream your doctor recommends.

Depending on the depth of your peel, you can expect to look presentable with makeup in one to two weeks. During the second and third weeks, the swelling decreases, but redness remains. Don't expect to lose all the redness for up to several months. You may also experience some temporary darkening, which can be treated with bleaching creams and should disappear in time. Remember, the depth of the treatment is proportional to the risk, the recovery and the results.

There are a number of possible complications associated with laser resurfacing, chemical peels, and dermabrasion. These include, but are not limited to, redness during recovery, hyperpigmentation (dark spots), hypopigmentation (light spots), thinning of the skin (which will expose underlying structures such as pimples, vessels, etc.), scarring, visual disturbances, itching, tingling, pain, and environmental sensitivity (to sun or bright light, dust, makeup, soap, clothing, etc.). Some of these can be permanent. In order to make a well-informed decision as to whether or not you wish to undergo one of these procedures, you should discuss the risks with your doctor.

Just as in your recovery, your results are related to the depth of the peel. It's not safe to go too deep in one session, so for some very wrinkled faces or deep acne scars, patients may require a second procedure to get the best results. People who smoke tend to have deeper lines around their lips and may require a deeper peel. Sometimes there are fine details which aren't noticeable until after healing is complete, and these patients may return for an additional treatment. Small areas can be “touched up.”

Your skin should look softer, younger and smoother. Wrinkle removal can be very dramatic. With deeper peels, the new skin will somewhat “shrink to fit” your face. Healing of human injuries is accomplished by shrinkage of the tissue, and what the laser does is provide a careful “injury” to the skin. Brown spots generally disappear. Patients are usually asked to use light moisturizers for at least a month. Occasionally, acne breakouts can occur, but this can be treated by decreasing the lubricants and possibly prescribing antibiotics.