CUTANEOUS REJUVENATION part 2

Comprehensive Facial Rejuvenation: CHAPTER NINE: CUTANEOUS REJUVENATION part two

Hypopigmentation
Unlike post-inflammatory hyperpigmentation, which is reversible, hypopigmentation proves to be a more recalcitrant entity. Hyperpigmentation usually results from injury of the melanocytes superficially that leads to melanin stimulation, whereas hypopigmentation is a product of a deeper level of dermal injury in which the melanocytes are ablated. Hyperpigmentation typically occurs several weeks after resurfacing, whereas hypopigmentation arises after several months to even years post procedure. Hypopigmentation rarely occurs after a medium-depth chemical peel, such as with the authors’ choice of Jessner’s solution followed by 35% TCA. However, phenol peels may be more prone to develop hypopigmentation (the so-called “porcelain-mask” appearance), particularly if the croton-oil component is increased., Ablative laser resurfacing may also lead to hypopigmentary changes that become more evident as time advances. This is particularly noticeable at the jawline and may be progressive in nature. Due to this fact laser resurfacing has been limited to discrete areas of the face that, in the authors’ experience, tend to tolerate laser resurfacing better such as the lower-lid, glabellar, and perioral regions.
Hypopigmentation must be carefully delineated from frank depigmentation. Hypopigmentation may resolve, but true depigmentation is not easily managed. If complete depigmentation occurs, all the underlying melanocytes have been destroyed and therefore may not repopulate. Hypopigmentation, on the other hand, involves a reduction in melanocyte number and consequent melanin production. To regain pigmentation, the hypopigmented patient must be subjected to the arduous undertaking of repeated application of psoralen agents exposed to ultraviolet light – which has been successfully used to treat vitiligo for over fifty years. The authors confess lack of experience with this corrective formula and would refer interested (and motivated) patients to their dermatological colleagues for further evaluation and management.

Erythema
Erythema is a known sequela of resurfacing and may persist for several months in the laser-treated patient but usually resolves within 1 to 2 weeks for the chemically treated patient. The thermal injury imparted by the laser may contribute to this longer recovery period. Although erythema may last for a protracted period of time, longstanding erythema may predispose toward dermatitis or scarring. The continuum of erythema, dermatitis and scarring must be carefully understood by the physician so that aggressive management may be employed to abort this chain of events (vide infra). The erythematous skin is still sensitive to sun exposure, irritative topical agents, and other noxious stimuli. Therefore, it should be managed to minimize exposure to substances that may stimulate dermatitis. If erythema persists for longer than the typical timeframe delineated above, then active treatment should be initiated as if a dermatitis were present. Topical or oral steroids should be considered to treat the erythema so as to abort the development of dermatitis, which can in turn transform into scarring. Any signs that the erythema has changed in nature, usually turning a more inflamed red, may be suggestive of an incipient dermatitis.

Dermatitis
Dermatitis usually occurs between 10 to 30 days post-resurfacing and is manifest by a constellation of signs and symptoms, including significantly increased erythema, raised or irregular contour to the affected skin, and associated pruritus (Figure 5, 6). In the authors’ experience, dermatitis has been more prevalent in laser- than chemically treated skin, which may be a product of the prolonged erythema associated with laser-resurfaced skin. As previously mentioned, this erythema predisposes the patient to dermatitis and must be carefully followed. Dermatitis has been noted to occur principally in the lower eyelid and perioral region, as the authors have chosen to confine laser treatment to these specific areas to avoid the morbidity of full-face laser resurfacing, e.g., prolonged erythema, hypopigmentation at the jawline, etc. In the past, when the authors treated patients with full-face laser resurfacing, patients exhibited broader areas of dermatitis. Therefore, in the authors’ experience, physicians should be more attentive to laser-treated areas for signs and symptoms of developing dermatitis.
The main objective in treating dermatitis is early identification and removal of the offending agent that is causing the dermatitis. One should interview the patient to determine what agent may have been introduced to engender the dermatitis flare-up. The importance of early recognition and treatment cannot be overemphasized. Dermatitis that smolders for a protracted period of time may be more difficult to break, as this vicious cycle becomes more tenacious as time progresses. Pathophysiologically, dermatitis stimulates fibroblast activity and collagen synthesis, which directly serves as constituent elements for scar formation. Over time, the temporary dermatitis may transform into more permanent scarring if not addressed early.
Treatment should begin with flurandrenolide tape (Cordran tape, Oclassen Pharmaceuticals, Corona, CA), which contains a potent corticosteroid and which has been observed to be quite impressive in reversing dermatitis. Cordran tape should be applied only to intact, dry skin and works well in discrete areas of dermatitis. It should be applied at night and left in place until the following morning when it can be gently removed by allowing shower water to loosen its adhesive qualities. For more generalized areas, desonide cream (DesOwen, Galderma) – which contains topical corticosteroid to combat dermatitis – is favored. As mentioned, if dermatitis is allowed to persist, the chance of scarring also rises. Therefore, if the above methods fail to rid the dermatitis, then intralesional or systemic steroids should be entertained. Intralesional steroid injection may be administered in discrete areas afflicted with dermatitis: triamcinalone acetonide (Kenalog) 10mg/ml strength dosed at 1 mg per kg is preferred. Alternatively or concurrently, a medrol dose pack or oral-prednisone equivalent regimen may be started. In addition, pulse-dye laser therapy has proven very effective as an adjunctive measure in the authors’ experience.

Scarring
Fortunately, scarring remains a rare complication of cutaneous resurfacing. However, if erythema or dermatitis persists, some scarring may develop from the chronic irritation to the skin. If such an outcome arises, then treatment should be directed at minimizing the scarring through aggressive and diligent attention to the situation. Similar to management of dermatitis, corticosteroid application (topical, intralesional, systemic) may be administered in a stepwise fashion until a favorable response is evident. Further, early and frequent pulse-dye laser treatment (about every 3 to 4 weeks) may also control and hopefully eliminate scar formation. Patients who develop scars should be followed weekly until resolution of their complication.

Basic Skin Care
Many physicians who provide aesthetic services relegate knowledge of basic skin care to their aestheticians. Although, aestheticians have oftentimes received extensive training in skin care and cosmetic camouflage, the facial plastic surgeon should not rest on his/her laurels about proper understanding of basic skin care. The surgeon should fully comprehend if the patient’s skin-care regimen may adversely affect the healing of the resurfaced skin, detect topical agents that may be contributing to dermatitis, and recommend basic products that would promote healing without irritation. Further, the physician should advise the patient on products that will maintain the longevity of the peel or educate the patient on alternative, non-invasive, topical therapy other than ablative resurfacing.
This section will not endeavor to undertake an exhaustive review of all products that are currently on the market, which would otherwise be confusing, unnecessary and outdated by press time. After reading this section, the physician should understand basic concepts in daily skin care and answer straightforward questions that patients may pose. Perhaps the simplest method of understanding proper skin care is through the requisite products that the patient should use to ensure healthy and vital skin, i.e., daily skin-care products: cleansers, toners, moisturizers, sunscreens/blocks, and night creams; and rejuvenative agents: tretinoin and alpha hydroxy acids.

Daily Skin-Care Products
Cleansers
Cleansers are the first step toward healthy skin. Unfortunately, most individuals are accustomed to harsh, drying soaps that are counterproductive to good skin care, especially for the post-resurfaced skin. Traditional soaps are alkaline by nature and strip essential oils and protective lipids from the skin, leaving it dry and raw. The “antibacterial” soaps may be safely used on the body but are too astringent and alkaline on the more sensitive facial skin and furthermore unnecessary for proper cleaning. Abrasive components, like pumice, only serve to irritate the skin and may exacerbate conditions such as acne or otherwise sensitive skin. Unlike conventional soaps (pH 8-9), cleansers are pH balanced to the skin (pH 5.5) and maintain the acid mantle, which is particularly critical for oilier skin types. Alkaline soaps will excessively remove oil and stimulate increased oil production, leaving the skin even oilier.
Cleansers may be divided into two principal types: creamy and foaming. The former type is particularly suited for dry skin, as it maintains greater moisture than the foaming type. Creamy cleansers work well with the post-resurfaced skin or in older patients who tend to have more dessicated skin. In addition, creamy cleansers are better at removal of cosmetics than foaming cleansers. However, foaming cleansers offer the patient the visual appeal of lather like traditional soap products and may more effectively clean oilier skin than creamy cleansers are capable.
Cleansers should really only be used once daily, preferably at night, especially if used to remove cosmetics. Twice daily is unnecessary and potentially drying and irritating to the skin. After the face is rinsed, a washcloth may be used to pat dry the skin. If the skin should require additional cleansing during the day, water alone will suffice unless an unusual amount of dirt or debris is accumulated.

Toners
Toners are designed to balance the pH (if an alkaline cleanser is used) and remove any residual debris (e.g., lingering make-up) after use of a cleanser. Toners that contain salicylic acid may benefit the acne-prone skin but may at times promote acne flare-up. However, quality, pH-balanced cleansers have effectively made toners in most cases superfluous. If a toner is used, one should avoid a product that contains alcohol or acetone, both of which are detrimental to the skin due to the caustic nature of these agents.

Moisturizers
After any kind of cleansing (and/or toning) of the skin, no matter how gentle, the skin is left somewhat dehydrated and requires effective moisturization. Even oily skin that appears to need no moisturization benefits from a good moisturizer. In fact, a moisturizer will assist in keeping the oil production in check, especially after a cleanser has stripped some of the native oils away.
In general, moisturizers may be either water- or oil-based. The former is better for acne-prone or oily skin, whereas the latter is better designed for drier skin types. Combination skin (oily skin distributed along the central T zone of the face) should be treated with a water-based product. However, during the winter months when the air may be quite dry, then a water-based product may be used in combination with an oil-based product for areas that remain dry despite water-based moisturization.
A moisturizer should be used once in the morning and once at night. The morning moisturizer may contain an SPF (Sun Protection Factor), which is a critical element to healthy skin. The lip should also be protected with a moisturizing balm that contains an effective SPF. Prolonged, direct sun exposure, particularly between 10 am and 4 pm during the height of direct rays, should be avoided as much as possible. Sun protection may consist of a physical blocking agent, e.g., titanium dioxide or zinc oxide, or a chemical block, e.g., octyl methoxycinnamate A combination of a physical and a chemical block will work together synergistically to achieve the best protection, while minimizing the chemical load that would be imparted by a pure chemical blocking agent. Generally speaking, an SPF 15 is all that is required for indirect, daily sun exposure with only a nominal gain with higher SPF strengths. However, if one should elect to be outdoors for greater than one hour, then an SPF 30 should be used, with a higher percentage of a physical block again to minimize chemical irritation. Conversely, the body can tolerate much higher chemical and physical blocks than can the face. All patients that have undergone ablative resurfacing should avoid any product with a chemical block for the first 30 days to reduce the likelihood of irritation and dermatitis.
A different moisturizer should be used at night that contains no SPF but instead has a higher lipid content, which acts to nourish and replenish the skin. The skin undergoes its maximal replenishment during the nighttime hours of rest, and therefore nightly moisturization with proper lipid-based ingredients is critical to ensuring healthy skin. As part of any moisturizing program, the patient should drink plenty of water during the day. Water spray mists to the face add little benefit but may instead dry the skin further when evaporated.

Rejuvenative Agents
In addition to a strict daily regimen of skin care, certain topical agents may serve a medicinal purpose to rejuvenate aging skin. The two types that will be discussed are alpha hydroxy acids and vitamin A derivatives.

Alpha hydroxy acids
Alpha hydroxy acids (AHA) are antioxidants that also act to reduce the signs of aging by gently peeling the outer part of the epidermis. Glycolic acid is a type of AHA derived from sugarcane, whereas lactic acid represents another AHA, which is a constituent of milk. AHAs may come packaged in high-end moisturizers or anti-aging creams, or alternatively as a separate product. Usually 8-12% AHA may act as an effective exfoliant and may be used up to twice daily after cleansing and before application of a moisturizer. Higher strengths of AHAs exist (70%) that act as a physician-strength chemical peel, which violates the full expanse of the epidermis. However, TCA peels may offer the physician more control and efficacy than these higher potency AHA solutions. AHAs are particularly useful for the younger face, which exhibits early signs of aging, or may be used as an alternative to the more irritating vitamin A derivatives, e.g., tretinoin (Retin-A). Alternatively, AHAs may be used for a couple of months, as a transition before engaging in a full program of Retin-A in order to prime the skin and minimize unwanted irritation.
Vitamin A Derivatives
Tretinoin, which is a Vitamin A derivative, comes in different forms, e.g., Retin-A, Retin-A Micro, and Renova. The effect that these agents have on ridding the face of the stigmata of aging is much more pronounced than that of AHAs. However, tretinoin products are quite harsh and drying on most types of skin. Actually, some erythematous irritation is desired as an endpoint, which signals that the skin is responding appropriately to the product. Retin-A comes in different strengths (0.025%, 0.05%, 0.1%) with the latter two concentrations more suited to facial rejuvenation as well as different formulations (cream and gel) with the former better for facial rejuvenation and the latter appropriate for oily, acne-prone skin. Retin-A Micro reportedly offers a more sustained release of the active ingredient over the 24-hour period and may be used instead. Renova has had great success as an alternative to Retin-A and has been considered less irritating to the skin, as the creamier base relieves the drying effect engendered by the medicine.
The method of application is as critical to success as compliance and may considerably influence the level of compliance if done properly. The authors usually recommend that patients start slowly on tretinoin-based products, perhaps every third day and advancing to every other day and finally to every day as the skin tolerates it. Retin-A or Renova is applied only at night after the face is gently cleansed. At least 10 minutes (preferably 30 minutes) are allowed to transpire before application of the medicine because a moist skin may accelerate the absorption leading to undesired sensitivity. Only a pea-size of the cream is placed on the index finger and equally distributed at four points on the face: the central forehead, each cheek, and the chin. Then this modest aliquot is spread evenly over those four quadrants. A night moisturizer may then be immediately applied. It is very important that the patient remain out of direct sunlight during use of the product, as it causes photosensitivity. Therefore, a good sunblock should always be used in conjunction with Retin-A or Renova. The patient will only observe the benefit of the medicine after several weeks to months of consistent usage. Unfortunately, the beneficial effects may be erased if the product is discontinued. Patients are recommended to begin Retin-A or Renova after all the erythema has subsided after a peel or other resurfacing in order to maintain longevity of the procedure.

Conclusions
The non-dermatologically oriented surgeon may refuse to hassle with the time- and labor-intensive process involved during the post-resurfacing period. However, traditional lifting procedures are oftentimes not indicated or fall short of the intended effect. As part of the armamentarium, resurfacing offers the facial plastic surgeon the most comprehensive capacity to rejuvenate the aging face.

Clinical Presentations: A Synthesis of Approach

This is a 40-year-old State officer who presented for improvement of his skin texture and complexion. He stated that he has had acne his entire life but no serious episodes since his 20’s. In the wake of his prior severe cystic form of acne, he has been left with an extremely disfigured malar region. In particular, he exhibited multiple, deep “ice-pick” scars in the setting of an irregular and uneven cutaneous topography. He was also noted to have very thick skin and moderate to marked sebaceous activity. The patient possessed brown eyes and a Fitzpatrick III classification of skin. To achieve the optimal aesthetic result, the patient was advised that a staged treatment protocol would be warranted. First, the deep ice-pick scars would be excised and closed followed later by a combined resurfacing approach that involved CO2 laser resurfacing, chemical peeling, and wire-brush dermabrasion. He was informed that only 50% improvement would most likely occur despite the most aggressive treatment strategy because of the recalcitrant nature of acne scarring. Also, the patient was told that subsequent sessions might be required for further refinement if so desired.
Surgical Procedure:
Surgical excision of multiple “ice-pick” scars (a total of 9) and wound approximation followed by a combined resurfacing technique with Jessner’s/35% TCA peel to the entire face, wire-brush dermabrasion to the cheek regions, and CO2 laser over the dermabraded areas six weeks later. The patient initially underwent excision of nine separate, large ice-pick type scars, which was carried out with a No. 11 blade in the orientation of relaxed skin tension lines and repaired with good apposition of the wound edges and closure using After a period of six weeks, a combined resurfacing technique using laser, peel, and dermabrasion was undertaken to achieve an improved contour to the remaining malar skin. First, the patient underwent full-face Jessner’s/35% TCA chemical peel until a uniformly opaque frost was observed. A chemical peel was enlisted first to improve his overall skin texture, to eradicatemoderate photodamage and to ensure an imperceptible transition between treated and untreated dermabraded areas. Once the chemical peel was completed, wire-brush dermabrasion was undertaken to address the principal cutaneous pathology, i.e., the uneven texture. CO2 laser was then used to achieve hemostasis in the dermabraded-treated areas and to effect further collagen tightening in these areas. Aquaphor ointment was applied, and the patient subscribed to the intensive postoperative regimen for the resurfaced patient.
Discussion:

This patient demonstrates the two principal types of acne scarring that are possible: “ice-pick” scarring and cystic acne scarring. As evident, the treatment strategy is divergent in that discrete ice-pick depressions must be excised and closed, whereas cystic acne must be resurfaced using combined techniques. A staged procedure provides the best solution to the problem in which the ice-pick scars are addressed first. Combining three resurfacing techniques permits the advantage that each modality provides: the chemical peel facilitates even transitions between treated and untreated dermabraded areas; the dermabrader provides maximal improvement to the areas of acne scarring; and the CO2 laser adds the benefit of hemostasis and further tissue contraction in dermabraded-treated areas. The reader is reminded that a chemical peel must always be completed first in intact skin before either laser or dermabrasion is attempted. For darker complected patients, the depth of dermabrasion should be more conservative and the chemical peel used more extensively to achieve a uniform result. Additional treatment sessions may be required for patients with higher Fitzpatrick scores due to the conservatism advocated for each session. Prophylactic treatment with 4% hydroquinone 2 to 3 weeks after resurfacing may preclude the onset of unfavorable post-inflammatory hyperpigmentation in these patients. Above all else, the patient should be fully cognizant of the limited benefit (no greater than 70%) that resurfacing will achieve for acne scarring.

This is a 55-year-old business owner who presented for facial rejuvenation. She acknowledged that her life-long sun exposure had contributed significantly to her present aged appearance. Different resurfacing modalities were discussed with the patient including full-face Jessner’s/35% TCA peel alone, full-face CO2 laser resurfacing, or a combination of both modalities. Given the patient’s extensive photodamage – namely deep rhytids and coarse, leathery skin – it was felt that full-face CO2 laser resurfacing would be justifiable in this patient’s particular case to achieve the maximal aesthetic benefit. The protracted recovery period and the potential for post-resurfacing pigmentary problems concomitant with this treatment modality were carefully elaborated to the patient so that she could render a reasonable decision which resurfacing method she would be more willing to endure. Given the risks, benefits, and alternatives, the patient elected to proceed with full-face CO2 laser resurfacing.
Surgical Procedure:
Full-face CO2 laser resurfacing. The patient underwent resurfacing with Sharplan’s CO2 laser outfitted with the silk-touch hand piece using the manufacturer’s recommended start-safe parameters. Under general anesthesia, the patient was subjected to three full passes of the CO2 laser in a systematic fashion progressing from facial subunit to subunit. Only one pass was executed along the jawline to provide a gentle transition to the untreated neck. The thinner periorbital area was resurfaced including the upper eyelids but excluding the pretarsal skin using only two passes of the laser. At the conclusion of the procedure, the patient was dressed with Aquaphor ointment and N-terface occlusive dressing for the first 48 hours. The patient subscribed to the intensive post-peel regimen and was followed in the office on a daily basis.
Discussion:
Although the Jessner’s/35% TCA chemical-peel combination has become the workhorse of facial rejuvenation in the authors’ practices for cutaneous rejuvenation of the Caucasian face, the CO2 laser has proven its value in select facial areas that are more recalcitrant to treatment by the Jessner’s/35% TCA peel, namely, the peri-oral and glabellar regions. In the past, the senior author used CO2 laser more widely but has retreated from this staunch position due to the extended recovery period and the risk of progressive hypopigmentation that becomes particularly notable along the jawline (see principal text). Nevertheless, certain circumstances justify this more aggressive modality for the entire face. Although this patient was managed during the era of liberal CO2 resurfacing, the patient would have been treated likewise today given her entrenched, cutaneous pathology. For very coarse, leathery skin and deeply etched, widespread rhytidosis, CO2 laser remains the mainstay of therapy. Clearly, phenol chemical exfoliation is a suitable alternative but has not represented a significant part of the authors’ practices and therefore cannot be authoritatively discussed.

This is a 74-year-old patient referred by her dermatologist to evaluate her candidacy for cosmetic rejuvenation of her skin.. The patient admitted to chronic sun exposure but denied any history of prior skin cancer in herself or her immediate family. The referring dermatologist had been treating her for numerous pre-cancerous lesions using flurouracil-based topical therapies but with limited success. The patient was motivated to seek treatment because she desired more global rejuvenation that could restore her skin to a more youthful state. On examination, she was noted to have fair skin and blue eyes. In addition, she had numerous hyperkeratotic lesions consistent with actinic keratoses but without any frank evidence of malignancy. Overall, the skin appeared to be desiccated, uneven, and leathery in texture consistent with significant photodamage, particularly in the perioral and pericular regions. The patient was counseled on the benefits and limitations of CO2 laser resurfacing versus TCA peel or combined treatment modality using both laser and peel. Although the patient would have been an excellent beneficiary of full-face or partial-face CO2 laser therapy from an aesthetic perspective, she was a less than ideal candidate given her advanced age and hesitant disposition. Instead, full-face TCA peel was elected for optimal rejuvenation given the above-enumerated constraints. Surgical Procedure:
A full-face 35% tricholoroacetic acid peel after pre-treatment with Jessner’s solution. The patient underwent shave excision of her hyperkeratotic and actinic-keratotic lesions using a No.10 blade prior to the application of the peel solution. Care was taken to maintain a full layer of epidermis below the level of each shave excision.
Discussion:
Given the patient’s significant photodamage, CO2 laser therapy would have been an ideal choice for at least partial ablation of the more severely affected areas, such as the perioral and periocular regions. Nevertheless, the patient expressed some trepidation over the proposed recovery period that would potentially last several weeks to months. In addition, the senior author’s experience has revealed that mature patients poorly tolerate a protracted postoperative course that accompanies laser resurfacing. Even in younger patients the CO2 laser can often be an overwhelming experience and has now been mostly relegated to select facial zones that tend to require its higher ablative efficacy, e.g., the glabellar, periocular, and perioral regions. Except for these more recalcitrant areas, the TCA peel provides exceptional rejuvenation without the concomitant downtime of laser rejuvenation and has become the mainstay of cutaneous resurfacing in the authors’ practices.

This is a 39-year-old consultant who presented to the office to discuss various options for facial rejuvenation. The patient stated that she was not interested in any kind of surgical intervention but was primarily bothered by the uneven pigmentation of her skin. She commented that she had been on oral contraceptives periodically over the pastseveral years. She also admitted to a moderate amount of sun exposure and felt that her complexion made her face “look dirty”. Clinical examination revealed some mild to moderate horizontal rhytidosis of the forehead but only minimal wrinkling in the remaining facial skin. She is classified as a Fitzpatrick II skin type.

Procedure:
Full face 35% TCA chemical peel following pre-treatment with Jessner’s solution.

Discussion:
The 35%tricholoroacetic-acid chemical peel has become the workhorse in the authors’ practices for the patient with fair skin, minimal rhytidosis, and extensive facial dyschromia. At times it is warranted to reduce the concentration of the tricholoroacetic acid to 20-25% in a patient with primarily uneven pigmentation and only minimal rhytids. Similarly, a lighter peel can be used for areas that require less rejuvenation, and the full 35%, reserved for facial subunits that manifest greater photoaging. However, the reader is reminded that any concentration of TCA can be used aggressively (i.e., repeated application and prolonged contact time of the peeling agent before water dilution) in order to achieve the intended result. Therefore, all peels should be used judiciously and systematically to avoid an unintended result. The technical details of chemical-peel application that are elaborated in the principal text will not be reiterated herein. However, it is worth emphasizing that consistent, reproducible, and safe results are dependent upon correct patient selection and compliance with proper technique.
Patients with darker complexion may be better served with a lighter peel, e.g., Jessner’s/20% TCA peel rather than the more potent 35% concentration. Aggressive peeling of discrete facial zones in Fitzpatrick IV-V patients may result in visible lines of demarcation between peeled and unpeeled areas. Fitzpatrick VI patients are generally unsafe to resurface, whereas Fitzpatrick V patients must be very cautiously approached. Serial peel application using Jessner’s alone at 2-week intervals for 4 treatment sessions may also be a suitable alternative treatment strategy for darker skin types. Diligent application of topical 4% hydroquinone after complete epithelialization in these types of patients can also abort the rise of post-resurfacing hyperpigmentation. However, use of this noxious product should only be used after a minimum of two weeks post-resurfacing and be carefully followed for the risk of dermatitis due to its irritating effects. As the preceding text has suggested, not only is the cutaneous pathology (mild to moderate rhytids and related photodamage) a critical aspect to selection of treatment modality but also the patient’s overall Fitzpatrick scale to determine how that individual will tolerate the effects of the peel and how vigorous a peel can be attempted.

Figure: Spider vein dude
These photographs show a 40-year-old patient who suffers from acne scarring along both malar regions. He exhibits both ice-pick scarring and cystic acne scarring. He underwent direct excision and closure of his ice-pick scars, followed 6 weeks later by combined resurfacing which involved a full-face Jessner’s/35% TCA chemical peel, bilateral wire-brush dermabrasion to his malar region, and CO2 laser resurfacing over the dermabraded areas.
. These photographs show a 55-year-old patient who exhibits significant photodamage with deeply etched rhytids and coarse, leathery skin. She underwent full-face CO2 laser resurfacing with a total of 3 passes except only 1 pass along the jawline for better feathering and transition to the untreated cervical skin and 2 passes along the thinner periorbital region excluding the sensitive pretarsal skin altogether. She is shown approximately 1 year after laser resurfacing with notable cutaneous improvement.
These photographs show a 74-year-old lady who was referred by her dermatologist for cutaneous rejuvenation of her skin. She had been treated with fluorouracil-based topical therapies without notable improvement to her multiple hyperkeratotic lesions. The patient was desirous of cosmetic improvement of her overall photodamaged skin rather than continued medical management of discrete keratotic lesions. Although CO2 laser therapy would have been beneficial at least to provide maximal rejuvenation in the periocular and perioral regions, the patient’s advanced age and hesitant disposition precluded use of this modality. Instead, full-face chemical peel with Jessner’s and 35% TCA was used after shave excision of her numerous hyperkeratotic lesions. She is shown 1 year after a one-time chemical peel that has brought about significant improvement in her photodamaged skin.
These photographs show a 39-year old lady who suffers from a significant bronzed appearance to her skin due to prior oral contraceptive use and chronic sun exposure. She also has some mild horizontal rhytidosis across her forehead with finer wrinkles in the remaining facial skin. The patient underwent a Jessner’s preparation followed by a 35% TCA peel to her entire face and is shown 15 months after resurfacing. After the peel, she exhibits a more even complexion free of sun-induced dyschromias and a tighter appearance to her overall skin.