Medium-depth peels combinations

Epidermal growths such as actinic keratosis, lentigines or thin seborrheic keratoses can all be treated effectively with 25-35% TCA peels. Thicker epidermal growths or growths involving the dermis will be more resistant to treatment such as hypertrophic actinic keratoses and thicker seborrheic keratoses and may even be resistant to a medium-depth peel. Resistant lesions many times are best treated with a combination of a medium-depth chemical peel and other modalities such as manual dermasanding or CO, laser. 

Jessner s solution contains 14% resorcinol, 14% salicylic acid and 14% lactic acid. Jessner s solution has been used alone for superficial peeling, or in combination with TCA 35% to achieve a medium-depth peel. Increasing the number of coats applied to the treated area increases the depth and reaction induced by the Jessner s peel. These peels are well tolerated with minimal side effects in the author s practice. As with glycolic acid and salicylic acid peels, Jessner s peels are most commonly used as adjimctive therapy for moderate to severe facial dyschromias, acne, oily skin, texturally rough skin, fine wrinkles, and pseudofolliculitis barbae. 

Trichloroacetic acid and phenol peels (see peel sections) have been used extensively to treat photodamage [60, 61]. However, TCA peels in concentrations above 35% are unpredictable. Albeit efficacious for severe photodamage, phenol peels are associated with myriad side effects [61]. Hence, combination medium-depth peeling agents have become increasingly popu-... 

Ayres achieved a medium-depth peel by combining phenol and trichloroacetic acid (TCA). These two formulas are no longer used today, as there are many other modern peel solutions that provide effective medium-depth peels using other molecules, such as TCA, that are not potentially toxic. 

Monheit GD (1996) Combination medium-depth peeling the Jessner s+TCA peel. Facial Plast Surg 12(2) 117-124... 

In patients with Fitzpatrick skin types IV to VI, the use of salicylic acid as a very light chemical peeling agent seems to result in a much lower incidence of PIH Combination peels have replaced 50% TCA as the gold standard for medium-depth peels... 

Figure 7.1 (A), Patient with generalized dyschromia and actinic damage prior to a medium-depth peel. (B), Patient 2 weeks following a medium-depth peel (Jessner s solution with 35% trichloroacetic acid (TCA) combination). Note significant improvement of dyschromia and fine lines...

As in the superficial peel, medium-depth peel solution is compounded using a weight/volume method. A concentration of 35% should be prepared as described above (see Making up the solution). Combination peels are those using solid CO2 ice plus 35% TCA (Brody combination), Jessner s solution plus 35% TCA (Monheit combination), or 70% glycolic acid and 35% TCA (Coleman combination). These peels will be discussed in greater detail later. 

Jessner s solution contains 14% resorcinol, 14% salicylic acid and 14% lactic acid. It has been used alone for superficial peeling, or in combination with TCA 35% for medium-depth peeling. 

While medium-depth peels on the face can be considered one-stage procedures, this is often not the case on the body. Due to increased potential for adverse events such as scarring off the face, similar peels are done in a series and at lower concentrations. Results are seen after a few sessions and should be accompanied by a regular topical maintenance program to prolong the benefits. Additionally, for specific indications, body peels can be combined with other minimally invasive procedures including lasers, light sources, electrodessication, cryosur-... 

Glycolic acid creams, cleansers, and exfoliating preparations are used to boost epidermal exfoliation, reduce stratum corneum thickness and augment the peel penetration, thus enhancing the uniformity of the light chemical peel. Pretreatment is also essential for combination medium-depth peels. 

Figure 14.6 (A) Combination procedure utilizing perioral-periotbital CO2 laser resurfacing with Jessner s + 35% TCA peel over remaining face. The peel will blend color and texture of the laser treated areas. Preoperative the eyelids and lips need deeper resurfacing than cheeks, which require only medium depth injury. (B-F) Combinations laser resurfacing to eyelids, perioral area medium-depth peel to face, light peel to neck. Preoperative the peel is performed first postoperative laser and peel postoperative 4 day postoperative 4 months...

Laser areas need local anesthesia performed with periorbital and perioral nerve blocks. The peel areas do not need full anesthesia, making this a simpler procedure than full-face laser resurfacing. Combining medium depth peeling, laser resurfacing, and dermal sanding makes the combined procedure a simpler and better procedure because it results in ... 

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