Chemical Peel

Indications for chemical peel include wrinkled, sun-damaged, blemished or unevenly pigmented skin. A chemical peel involves the application of a solution containing either alphahydroxy acids (AHAs), trichloroacetic acid (TCA) or phenol to remove the top layers of skin. The AHA peel is the mildest, removing the fewest layers of skin; phenol solutions achieve the deepest peel. The formulas for each type of peel can be adjusted for individual cases.

A chemical peel may be performed in conjunction with a face-lift, but it is not a substitute since it does not achieve the same effects. Chemical peels do not retard the effects of aging.

The AHA peel smooths rough, dry skin and improves the texture of sun-damaged skin. It may also help to improve mild acne. The AHA solution can be mixed with a bleaching agent to correct or improve pigmentation problems. Sometimes the AHA peel is used as a pretreatment to prepare the face for a TCA peel or for laser resurfacing.

An AHA peel may cause mild stinging, but no anesthetic is required. Several treatments may be needed to achieve the desired effects, but once this point is reached, the patient can maintain improved skin texture by using a low-concentration of an AHA, such as a glycolic or fruit acid, mixed with a facial cream or wash as part of a daily at-home skin care program.

The TCA peel is a medium peel that can be administered in various strengths to adjust the depth of the peel. The TCA peel is appropriate to smooth fine surface wrinkles, remove superficial blemishes and correct pigmentation problems. Unlike the other peels, the TCA peel may be used on the neck as well as the face, and this is the preferred peel for darker-skinned individuals.

To achieve the best effects, the skin is sometimes pretreated with Retin-A or AHA. A full-face TCA peel may take from 30 to 60 minutes. The peel does not require anesthesia, but the patient may be sedated to make him/her more comfortable. Repeat treatment may be necessary to maintain the desired effects.

The phenol peel is the deepest peel, achieving the most dramatic effects. A phenol peel can correct blotches caused by sun exposure, birth control pills and aging. It smooths coarse wrinkles, and is sometimes used to remove precancerous growths. The phenol peel is appropriate for use on the face only, as scarring can result on other parts of the body. Because of the depth of the phenol peel, it is not suitable for dark-skinned individuals. The best candidates for phenol peel are people with fair, thin skin and superficial wrinkles.

The duration of a phenol-peel procedure varies with the extent of the peel. A full-face peel may take up to two hours to perform. The phenol peel does not require anesthesia, but the patient usually receives sedation for greater comfort. He or she will probably also undergo precautionary cardiac (EKG) monitoring during the procedure. Although an outpatient facility is the usual setting for a phenol peel, selected patients may require a one or two day inpatient stay. A single treatment with phenol usually achieves the desired results.

Temporary side-effects and recovery time vary with the type and depth of chemical peel. After an AHA peel, the patient is likely to experience flaking, scaling, redness, dry skin and possibly minor crusting, but these conditions are transient and should not interfere with prompt resumption of normal activities. The patient should use a sunblock every day to protect the skin, however.

After a TCA peel, the patient may experience tingling or throbbing sufficient to require a mild pain medication, and there may be significant swelling, especially if a strong formula has been used. Swelling generally subsides within a week. Crusts or scabs that form on the treated areas begin to slough off in a week to 10 days. At this time, the patient can return to normal activities except for sun exposure, which should be avoided until complete healing has occurred. Then the patient should apply sunblock daily for protection.

The after-effects are most severe with a phenol peel. The patient's face may be quite swollen, even to the extent that the eyes are swollen shut for a day or two. The patient may be limited to a liquid diet for several days, and talking will be difficult. New, very red skin will begin to form in seven to ten days; the color will gradually fade to normal over a period of weeks to months. The skin may be acutely sensitive to the sun during this period, so it is important that the patient use a sunblock to prevent permanently blotchy skin. Going to work and other normal activities-including the wearing of makeup-can be resumed about two weeks after the peel.

Risks vary with the type and depth of the peel, but all peels carry a small risk of infection and/or scarring. Patients with allergies could experience a flare-up of skin allergies. Fever blisters and/or cold sores may also develop. The phenol peel also carries a risk of permanent abnormal skin-color changes, and while very rare, a patient may develop heart irregularities while undergoing treatment.

Results of an AHA peel are neither dramatic nor long-lasting. Improvements must be maintained by periodic treatments. The effects of a TCA peel are more noticeable and slightly more enduring, but they are not permanent. The results of a phenol peel are both dramatic and permanent, but new wrinkles will still develop with age. Patients considering a phenol peel should be aware that their facial skin will be permanently lightened and that this skin will never tan. Also, people who have had phenol peels must always wear sunblock.

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Retin-A® Treatment

Patients with fine facial wrinkles and/or blotchy pigmented areas can achieve brighter, fresher-looking skin with at-home treatments of prescription Retin-A® gel or cream formulations. To achieve the desired effect, the product is applied topically every night before going to bed for a period of eight months to one year. After that, two to three applications per week are sufficient to maintain the desired result.

Until the skin adjusts to the treatment, the patient may experience temporary redness, itching, irritation, stinging and/or dry skin. Some patients may need to limit Retin-A® usage to once every two or three days until their skin adjusts to the formula. There are no serious medical risks, but the patient may have to discontinue use of some cosmetic products if they cause irritation. The patient should apply moisturizer twice daily and wear sunblock when outdoors. Results will be maintained as long as treatment is continued, but will be lost when Retin-A® treatment is discontinued. Deeper wrinkles may form with aging.

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Glycolic Acid Treatments

Glycolic acid is another home treatment that may be prescribed for skin improvement. In a cream or facial-wash formulation, glycolic acid can smooth rough, sun-damaged skin. With the addition of bleaching agents, glycolic acid also works to correct or improve uneven pigmentation. The cream or wash is applied twice daily for as long as the patient desires. Transient redness, irritation, itching, stinging and/or dry skin will disappear as the skin adjusts to the treatment. There are no serious medical risks.

Skin care includes applying moisturizer once or twice daily and wearing sun block when outdoors. Results are permanent as long as treatment is continued, but treatment does not prevent deeper wrinkles from forming with aging.

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Laser Resurfacing (Laser Peel)

Indications for carbon-dioxide (CO2) laser resurfacing include fine lines, facial scars, sun damaged skin and uneven pigmentation. The CO2 laser works by removing areas of damaged or wrinkled skin layer by layer. The most common application is for removal of fine lines, especially around the eyes and mouth, but the procedure can be used on the whole face. It can also be used in conjunction with other procedures, such as rhytidectomy or blepharoplasty. Patients with fair, healthy, non-oily skin are the best candidates for this type of treatment.

Depending upon the area to be resurfaced, operating time ranges from a few minutes to more than an hour. In some cases, the patient may need more than one laser session to achieve the desired result. The patient usually receives treatment under local anesthesia with sedation in an outpatient setting, but for extensive procedures, hospitalization and general anesthesia may be required.

Temporary side effects include swelling and mild discomfort. Laser resurfacing produces little (if any) bleeding and post op discomfort is usually mild but may result in some pain in the early post op period.

Risks include burns and other injuries associated with the heat of the laser, scarring, abnormal pigmentation and infection. Susceptible patients may also experience a flare-up of herpes virus (cold sores).

The new skin generally becomes crust-free about ten days postoperatively, but the patient's skin may remain bright pink for weeks. In some cases, pinkness does not fade entirely for up to six months. The patient should avoid sun exposure until all skin color has returned to normal and should wear sunblock outdoors thereafter. The patient can begin wearing makeup about two weeks after surgery, depending on the sensitivity of their skin.

Results of laser resurfacing are long-lasting, but not permanent. Treatments do not prevent the development of deeper wrinkles with aging.

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Collagen Injections

Indications for collagen injections include wrinkles, furrows, creases and facial hollows, especially in the cheeks. When injected beneath the skin, collagen plumps up and fills in the lines and creases and fills out sunken areas of the face. Injectable collagen can also be used to make thin lips appear fuller. Sometimes collagen injection can make a depressed scar less noticeable by filling it out to the level of the surrounding surface.

Because there is some risk of an allergic reaction to collagen, the patient must undergo an allergy skin test one month before treatment. Redness, itching, swelling or the development of a wheal at the test site are contraindications for collagen injection. Collagen injections are also contraindicated in patients with histories of collagen vascular disease, autoimmune disease, allergies to beef or bovine products and allergies to lidocaine, the anesthetic injected along with the collagen. Pregnant women should wait until after delivery to have collagen treatments.

Depending upon the number of sites to be injected, treatment may last from 15 minutes to one hour per session, and multiple sessions may be required. Since lidocaine is part of the injection formula, the surgeon may provide sedation but no additional anesthetic. Patients who are undergoing other procedures at the same time may require general anesthesia. Unless the patient is undergoing multiple procedures that require hospitalization, collagen injections are administered in an outpatient setting.

Stinging, throbbing, burning, swelling and mild skin redness are common transient effects after collagen injection. Slight puffiness due to overfilling disappears within a few days as the saline carrier is absorbed.

The greatest risk is allergy, but this risk is greatly reduced if the patient undergoes pretreatment allergy testing. Allergic reactions may include hives, swelling, rash and flu-like symptoms. Other risks include infection and lumpiness or other contour irregularities. Collagen injections have been implicated in autoimmune disease and connective-tissue disease, but research studies to date have not borne out this claim.

Patients can resume normal activities immediately after treatment. The duration of effects is brief, but variable. In general, effects will disappear soonest in areas with the greatest muscle movement. For reasons that are not entirely clear, some patients retain effects longer than others, but patients should not expect longevity of results for more than a year and perhaps only for a few months.

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Dermabrasion is a procedure that uses a high-speed rotary wheel to scrape off the top layers of skin. Dermabrasion is appropriate for removing fine wrinkles and softening the edges of scars (including acne) and other surface irregularities to make them less noticeable. Dermabrasion can be performed on selected areas or on the entire face and it can be used in conjunction with other procedures, such as chemical peel or rhytidectomy.

A dermabrasion session may last from a few minutes to more than an hour, depending upon the extent of the treatment, and multiple sessions may be required. The surgeon generally performs the treatment in an outpatient setting, with the patient under local, topical or general anesthesia.

After dermabrasion, the patient may expect to experience temporary tingling, burning, swelling, itching and/or redness. Crusts that form over the treated area will drop off as new skin grows underneath. Some patients develop small whiteheads. New skin in the treated area is likely to be lighter-colored, acutely sensitive to the sun and unable to tan. These effects should gradually disappear within six to twelve months.

Risks include infection, permanent scarring and permanent abnormal skin-color changes. Some patients may develop a flare-up of skin allergies, fever blisters and/or herpes virus (cold sores).

Patients can return to work in two weeks and resume strenuous activity in four to six weeks. Redness may persist for up to three months. Patients should wait for six months to a year to return to sun exposure (with protection). By that time, the new skin will be susceptible to tanning.

The results of dermabrasion are permanent, but the treatment does not keep new wrinkles from forming with aging.

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