Reticular dermis peel

Continued application of acid wiU result in vasospasm of the capillary loops in the papillary dermis. Blood flow to the area will cease, and the pink sign will disappear. The frost will appear as a solid white sheet (absence of the pink sign Fig. ii.i). This is the endpoint for a superficial reticular dermis peel. The loss of the pink sign implies that the entire papillary dermis is involved and the upper reticular dermis has been reached but not penetrated. In darker-skinned individuals, the pink sign may be difficult to visualized, thereby epidermal sliding must be used instead to gauge depth. 

The fact that in most cases they cannot use camouflage make-up makes it difticult to carry out a local or full phenol peel. Moreover, phenol peels produce less spectacular results on thick skins than on thin skins. Shaving does not pose a problem, as a peel to the basal layer of the epidermis does not rule out shaving, even with a blade. For a peel to the papillary or reticular dermis, it is best not to shave while the skin is flaking. It is usually possible to shave after the 8th day. Alcohol-based aftershaves should be avoided, and a hydrating, anti-oxidant or firming cream should be used instead, followed by effective sun protection. 

Patients often ask about make-up. The general principle is that it is possible to wear make-up, even when the skin is flaking, after an epidermal peel or a peel to the basal layer, but it is unlikely to look good. After a peel to the papillary or reticular dermis, make-up is usually allowed, and even recommended, on the 8th day. Patients who do not like wearing make-up should be warned of the likelihood of post-peel erythema, depending on the depth of the treatment. Some patients are thus ruled out, as their professional lives do not allow any visible erythema or they cannot stand the idea of wearing make-up. In these cases, it is recommended to repeat an Easy TCA peel four times rather than use Unideep . ... 

Solar or senile lentigines respond partially to peels to the Grenz zone and the papillary dermis. They sometimes require a peel to the reticular dermis to get rid of them completely. This deep peeling can be local. 

Comedonal acne (Figure 5.5) can be treated with an intraepidermal peel or a peel to the basal layer. A trichloroacetic acid (TCA) peel to the papillary or reticular dermis could be considered, but such a deep treatment would be pointless for this type of disorder, which can be treated with a lighter peel and, in any case, requires longterm maintenance treatment. 

With a TCA-SAS peel to the papillary or reticular dermis the patient s skin needs to be properly cleansed, cleaned of make-up, disinfected (with alcohol) and degreased (with acetone). The doctor must disinfect his hands properly and the patient must be kept away from any potentially infectious staff. The TCA-SAS cannot penetrate the skin properly through grease and make-up, and the skin must be disinfected to limit the risk of post-peel secondary infection. 

The basic protocol for ETCA is intended to reach the basal layer of the epidermis or the Grenz zone. There are (many) other deeper protocols but they are not as straightforward as ETCA and the risk of complications is relatively much higher. ETCA is not necessarily a light peel it can be used to reach all depths, from the basal layer of the epidermis to the reticular dermis, depending on the protocol used. The relatively superficial action of the ETCA solution (basic protocol) strongly stimulates the skin regeneration... 

Awareness of this problem led to the rapid development of new TCA peel formulas between 1990 and 2000. One of the first solutions put forward was the New Peel combination of TCA and Mikuda complex. The soft Peel formulation used asiaticosides and ginsenoids, glycerol, urea (carbamide), sorbitan monolaurate and methyldibromo-glutaronitrile, among other ingredients. Easy TCA , Unideep and Only Touch Peel (OTP) provided another answer to the problem these stabilized solutions consist of a base solution to which a determined quantity of 50% m/m TCA is added. There are no complicated calculations to be performed, the directions for use state precisely what volume of 50% m/m TCA solution should be added to the base solution to make up the Easy TCA , Unideep and OTP solutions, which provide peels to the basal layer, the papillary dermis and the reticular dermis, respectively. 

A peel to the basal layer lightens the freckles, sometimes only temporarily. A peel to the Grenz zone removes many freckles and lightens others. A peel to the papillary or reticular dermis gets rid of freckles altogether (Figure 13.11). 

Gray frosting and/or yellowish patches (phenol) deep reticular dermis TCA should no longer be used for peels to the deep reticular dermis... 

Pure white frosting from a peel to the reticular dermis. 

The cosmetic problems dealt with in this chapter, however, do not respond well to chemical peels, even when they reach the papillary dermis. In an attempt to achieve better results, deeper peel procedures were tried that went as far as the reticular dermis. The peels were in fact dangerous at this depth the reasons for this are discussed in Chapter 37. 

Only Touch (OT) (Figure 22.1) consists of a saponified and stabilized solution, adjuvanted with alpha hydroxy acids (AHAs), vitamins and antioxidants. Once the doctor has reconstituted OT by adding trichloroacetic acid (TCA), it provides a solution that can be used to treat the skin locally to the reticular dermis in the treatment of small benign lesions less than 1 cm in diameter. Its pH is lower than 1 and the solution s final concentration in TCA is approximately 45% m/m. It is therefore a very strong peel, to be used only for limited indications. 

Treatment of AKs and SLs with a full-face peel to the papillary or reticular dermis... 

Dermal lymphocyte infiltration associated with photoaging is reduced after a phenol peel. On the other hand, there is significant lymphocyte infiltration in the reticular dermis 2-5 days after a phenol peel. 

Another study on animals came to the conclusion that raising a skin flap causes changes in the tissue of the reticular dermis and the underlying tissue, which makes it more sensitive to any subsequent injury. The risk of compromising the viability of a raised skin flap is therefore too high to opt for a simultaneous face-lift and deep peel. 

I am talking here of a TCA peel to the reticular dermis. A TCA peel to the papillary dermis (e.g. Unideep ) is, on the contrary, applied immediately after a surgical hft. 

Only Touch is an adjuvanted, stabilized and concentrated TCA peel, used to reach the reticular dermis locally. It should be applied in strict accordance with the recommendations for use (see Chapter 22). 

Local erythema is inevitable after a peel to the reticular dermis. Pulling off scabs must be avoided at aU costs. Only Touch can be combined with Easy TCA to reduce erythema and hyperpigmentation. The maximum frequency for repeating the peel is when the erythema has completely disappeared. Effective sun protection is essential. 

Phenol is the ideal agent for a peel to the reticular dermis. The following signs indicate that the peel has reached the reticular dermis even, pure white or gray-white frosting. 

Skin repair after a peel to the reticular dermis is slower, as all the basal layer keratinocytes have been destroyed and the skin can only rely on the differentiated keratinocytes of the pilosebaceous units and the intradermal excretory ducts of the sweat glands. To repair the dermis, the sebocytes in the pilosebaceous units must dedifferentiate, and horizontal growth is required to close the skin quickly. Next comes a phase of vertical growth whose purpose is to regenerate a physiologically sound epidermis that will maintain homeostasis and restore the vital barrier function after the keratinocytes have differentiated into corneocytes. 

Special care should be taken with patients who have extremely thin, dry or sun-damaged skin, as the acids penetrate this very permeable skin more quickly and more deeply and the skin can sometimes overreact. Careful anamnesis will reveal any personal or family history of keloids or any tendency to scar hypertrophy. Insulin-dependent diabetics should be ruled out from a peel to the reticular dermis (because of the increased risk of scarring and infection), whereas diabetic patients (type 2, noninsulin-dependent) who are stabilized on oral antidiabetic drugs can have a deep peel on condition that they are monitored more closely than usual. 

Skin that has just been treated with a peeT is more prone to all types of infection, as it can no longer rely on its different defense mechanisms being intact. The risk mainly depends on the depth of the peel and how carefully it is applied. However, other factors come into play. Secondary infections rarely cause major problems, and do not really leave scars if treatment is started in time. Infections are most often local, but can become generalized in some serious cases or after a peel to the reticular dermis. 

Peel to the reticular dermis very significant risk... 

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