Healthier skin through a chemical burn
The history of facial peels is an interesting one that has gone through many convolutions over the years. All peels have the same final aim—to leave the patient’s skin:
- even in color
- with smaller pores
All peels do this to some extent, but some do it much better than others.
The first peels I learned to use were phenolic acid peels while I was in my cosmetic plastic surgery residency in Houston. The patients were older women with deeply sun-damaged, wrinkled skin. The phenol affects the heart as well as the skin, so the heart was monitored closely during the surgery. The phenol would remove both the superficial skin and most of the dermis. Recovery consisted of placing gauze on the skin to keep it clean from the ooze that followed after applying the peel. Patients had a hospital stay of 4-7 days and left with wrinkle-free skin. It worked great, but it also:
- was painful, requiring general anesthesia
- required a long recovery
- took all pigment out of the skin, leaving it white as a sheet—patients had to apply makeup at all times for the rest of their lives
- could be dangerous
I haven’t done one in 20 years.
Trichloroacetic acid peels became common in the 1990s. The acid works on the superficial and part of the deep layers of the skin—the epidermis and dermis.
The Obagi skin care company picked up on this type of acid peel, and by adding a pigment that changed color as the acid did its work, they simplified the procedure and took the guess work out of it; the surgeon no longer had to guess how long to leave the acid on a patient’s face because the color change told him or her it was time to wash it off. Leaving the acid on too long would cause severe burns and scars, while not leaving it on long enough meant no result. Patients had to pre-treat their faces for two weeks with skin bleaching creams such as hydroquinone and Retin A because the TCA could otherwise cause darkening of the skin. The advantages of the TCA, or “Blue peel,” were:
- could be performed in doctor’s office
- less dangerous than phenol
- easier to administer than phenol
- multiple layers could be applied to match patients’ needs
- effective against dark spots
- some wrinkle improvement
TCA peels are the facial peels most commonly used by cosmetic plastic surgeons today. They are applied once or twice a year as needed.
Alpha hydroxy peels are the peels you can buy over the counter at the grocery store. These weak acids are designed to be applied on a more frequent basis—daily or weekly—to improve skin quality. They are by nature not very strong and work only on the top layer of the skin, the epidermis. They will leave the skin cleaner and softer with repeated use, but do not expect any wrinkle improvement or loss of skin blemishes and color unevenness. Many patients today forgo the treatment of wrinkles with peels and prefer to have laser treatments such as Fraxel. I personally believe that Fraxel is a better treatment for wrinkles.
Morad Tavallali, M.D., FACSCosmetic Plastic Surgeon