Chemical peeling

The flash of interest of some cosmetic surgeons to chemical peelings and laser polishing coincided with people's desire for a younger appearance by repairing sun damaged skin. Public interest was stimulated by advertising of cosmetics, over-the-counter chemicals and curative programs that entered the market of products intended for skin rejuvenation and elimination of the effects of sun and age.

Before consulting a dermatologist, most of these over-the-counter do-it-yourself programs have already been tested by patients, and therefore they are ready for more intense exposure by chemical peeling or laser resurfacing. The doctor's task is to analyze the skin type of the patient, the degree of its light damage and recommend the right method of rejuvenation, which will give the best result with the least risk and number of complications. Dermatologists must disclose to the patients the full range of possibilities of drug therapy, cosmetics, dermabrasion, chemical peeling and laser treatment for selective destruction of the skin and restoration of its surface. Each of these methods should find its place in the arsenal of cosmetic surgeons.

Chemical peeling involves applying a chemical that eliminates surface damage and improves the texture of the skin by destroying the epidermis and dermis. To achieve a superficial, medium or deep chemical skin covering, various acids and alkalis are used, differing in the degree of destructive effect on the skin. The degree of penetration, destruction and inflammation determines the level of peeling. A light superficial peeling is to stimulate the growth of the epidermis by removing the stratum corneum without necrosis. By slimming, peeling stimulates the epidermis to qualitative regenerative changes. The destruction of the epidermis is a complete surface chemical peel, followed by the regeneration of the epidermis. Further destruction of the epidermis and provocation of inflammation in the papillary layer of the dermis means peeling of medium depth. In this case, a further inflammatory response in the reticular layer of the dermis causes the formation of a new collagen and interstitial substance, which is characteristic of deep peeling. At present, all these effects are based on the level of penetration for various conditions associated with insolation and age-related changes. Thus, doctors have a means of eliminating skin changes that can be very superficial, moderate or severe, by applying substances that affect different depths. For each patient and the condition of the skin, the physician must choose the correct substance.

[1], [2]

Indications for chemical peeling

When analyzing patients with insolation and age-related skin changes, account should be taken of its color and type, as well as the severity of the changes. There are different classifications, but I will present a combination of the three systems that help the physician find it easier to determine the correct individual curative program. The skin classification system by Fitzpatrick describes the degree of pigmentation and the ability to sunbathe. Divided to the extent of I to VI, it predicts photosensitivity of the skin, its exposure to phototrauma and the ability for additional melanogenesis (innate ability to tan). This system also divides the skin by the risk factors for chemical peel complications. Fitzpatrick distinguishes six types of skin, taking into account both its color and its response to the sun. The first and second types are pale and freckled skin, with a high risk of sunburn. Skin of the third and fourth types can burn in the sun, but usually tans from olive to brown. The fifth and sixth types are dark brown or black skin, which rarely burns and usually does not require protection from the sun. Patients with skin type I and II and a significant degree of photodamage need constant protection from the sun before and after the procedure. However, the risk of developing hypopigmentation or reactive hyperpigmentation after chemical peeling in these individuals is quite low. Patients with type III and IV skin after chemical peeling are more at risk of pigmentary dyschromia, hyper- or hypopigmentation, and may need a preliminary and subsequent application of not only a sunscreen but also a bleaching agent to prevent these complications. The risk of pigmentation is not too great after very superficial or superficial peeling, but this can be a significant problem after a medium or deep chemical peel. In some areas, such as lips and eyelids, pigment disorders can occur much more often after exposure to a pulsed laser that significantly changes color in these cosmetic units. In some areas, after a deep chemical peel, there may be changes that have an "alabaster appearance". The doctor should inform the patient about these possible problems (especially if there is a type III or IV skin type), explain the advantages and dangers of the procedure and suggest an appropriate method for preventing unwanted changes in skin color.

The substance for peeling is a corrosive chemical compound, which has a damaging therapeutic effect on the skin. It is important that the doctor understands the condition of the patient's skin and its ability to withstand such damage. Certain types of skin resist chemical damage better than others, and some skin changes tend to potentiate the side effects and complications of chemical peeling. In patients with significant photodamage, a deeper peeling and repeated use of medium-depth peeling solutions may be required to obtain a curative result. In patients with skin conditions such as atopic dermatitis, seborrheic dermatitis, psoriasis and contact dermatitis, exacerbation or even delayed healing, as well as post-erythematous syndrome or contact sensitivity, may occur after peeling. Rosacea is a vessel-motor instability of the skin, which can be accompanied by an excessive inflammatory response to substances for peeling. Other important anamnestic factors include radiation therapy courses, since chronic radiation dermatitis is accompanied by a decrease in the ability to properly heal. In all cases, the hair should be examined in the area of irradiation; their intactness indicates the presence of sufficient amount of sebaceous-hair units for a full-fledged skin healing after an average and even deep chemical peeling. However, there is no direct dependence, so it is also necessary to find out the time of radiotherapy and the doses used for each session. Some of our patients with severe radiation dermatitis received treatment for acne dermatitis in the mid-fifties of the last century, and over time, significant degenerative changes developed in the skin.

Problems in the postoperative period can cause a herpes simplex virus. Suspicious of this infection to patients, to prevent the activation of herpes, you need to prescribe a preventive course of an antiviral drug, such as acyclovir or valciclovir. These patients need to be identified in the initial consultation and prescribe appropriate therapy for them. All antiviral drugs suppress the replication of viruses in intact epidermal cells. It is important that after peeling the re-epithelization is completed before the full manifestation of the action of the drug. Therefore, antiviral therapy should continue with deep chemical peeling 2 full weeks, and when peeling medium depth - at least 10 days. The authors rarely use antiviral drugs for surface chemical peeling, since the degree of damage with it is usually not enough to activate the virus.

The main indications for chemical peeling are associated with the correction of actinic changes, such as photodamage, wrinkles, actinic growths, pigmentary dyschromia and post-acne scars. A physician can use classification systems to quantify and quantify the level of photodamage, and to justify the use of a suitable combination of chemical peelings.

Superficial chemical peeling

Surface chemical peeling is the mopping of the stratum corneum or the entire epidermis to stimulate the regeneration of less damaged skin and achieve a younger appearance. For maximum results, several peeling sessions are usually required. The drugs are divided into those that produce very superficial chemical peels, removing only the stratum corneum, and those that produce a superficial peeling that removes the stratum corneum and the damaged epidermis. It should be noted that the effect of surface peeling on age-altered and insolation-treated skin is negligible, and the procedure does not have a prolonged or very noticeable effect on wrinkles and folds. For surface peeling, trichloroacetic acid (TCA) is used in 10-20% Jessner solution, 40-70% glycolic acid, salicylic acid and tretinoin. Each of these compounds has special characteristics and methodological requirements, so the physician should be fully aware of these substances, their methods of application and the nature of the healing. Usually the healing time is 1-4 days, depending on the substance and its concentration. Very light substances for peeling include glycolic acid in low concentrations and salicylic acid.

10-20% TCA gives a light whitening or freezing effect, removing the upper half or third of the epidermis. Preparation of facial skin for peeling consists in thorough washing, removal of surface fat and excess horny scales with acetone. THC is evenly applied with a gauze cloth or sable brush; for the formation of frost, usually it is enough from 15 to 45 seconds. The appearance of erythema and superficial streaks of frost can be regarded as a freezing of the I level. Freezing of II and III levels is observed when peeling medium depth and deep peeling. During the procedure, patients experience tingling and some burning sensation, but these sensations very quickly subside and patients can return to their normal activities. Erythema and the following sluschivanie lasts 1-3 days. With this superficial peeling, sunscreen and light moisturizers are acceptable, with minimal care.

The Jessner solution is a combination of caustic acids, which has been used for over 10 0 years to treat hyperkeratotic skin diseases. This solution was used for the treatment of acne to remove comedones and signs of inflammation. When surface peeling, it acts as an intensive keratolytic agent. It is applied in the same way as ТХК, moist gauze, sponge or sable brush, causing erythema and mottled frost deposits. Trial applications are made every other week, with coating levels of Jessner solution increasing with repeated application. The visual end result is predictable: the epidermis slides and grows. This usually occurs within 2-4 days, and then apply soft cleansers, moisturizing lotions and sunscreens.

Alpha hydroxyl acids

Alpha hydroxyl acids, especially glycolic acid, in the early 90s of the last century became wonderful medicines that promised skin rejuvenation when applied locally at home. Hydroxy acids have been found in food products (for example, glycolic acid is naturally present in sugarcane, lactic acid in curdled milk, malic acid in apples, citric acid in citrus, and tartaric acid in grapes). Milk and glycolic acids are widely available and can be purchased for medical use. For chemical peeling glycolic acid is produced in unbuffered form at 50-70% concentration. When wrinkles 40-70% solution of glycolic acid is applied to the skin with a cotton swab, sable brush or a wet napkin weekly or a week later. For glycolic acid, the exposure time is important - it should be washed off with water or neutralized with a 5% soda solution after 2-4 minutes. Within an hour, mild erythema with tingling and minimal flaking may be present. It is reported that repeated use of this solution removes benign keratosis and reduces the number of wrinkles.

Surface chemical peeling can be used for comedones, after inflammatory erythema and for correction of pigmentation disorders after acne, for the treatment of aging of the skin associated with insolation, and also for an excess of black pigment in the skin (melasma).

To effectively treat melasma, the skin should be treated before and after the procedure with sunscreen, 4-8% hydroquinone and retinoic acid. Hydroquinone is a pharmacological preparation that blocks the effect of tyrosinase on melanin precursors and thus prevents the formation of a new pigment. Its use prevents the formation of a new melanin during the restoration of the epidermis after chemical peeling. Therefore, it is necessary for peeling for pigmentary dyshromias, as well as for chemical skin peeling of type III-VI skin according to Fitzpatrick (skin most prone to pigmentation disorders).

When carrying out a surface chemical peel, the doctor should understand that repeated exposures do not add up to medium or deep peeling. A peeling that does not affect the dermis will have very little effect on the texture changes associated with dermal damage. In order not to be disappointed in the results, the patient must understand this before surgery. On the other hand, to achieve the maximum effect of superficial peeling, repeated procedures are necessary. The procedures are repeated every week, in a total of six to eight, and are backed up with appropriate therapeutic cosmetic products.

[3]

Chemical peeling of medium depth

Chemical peeling of medium depth is a one-stage controlled damage to the papillary layer of the dermis with a chemical substance, leading to specific changes. Currently used drugs are complex compounds - Jessner solution, 70% glycolic acid and solid carbon dioxide with 35% TCA. The defining component of this level peeling is 50% TCA. It has traditionally allowed to achieve acceptable results with smoothing of fine wrinkles, actinic changes and premalignant conditions. However, since TCA, in concentrations of 50% or higher, causes many complications, especially scarring, it has ceased to be used as a mono drug for chemical peeling. Therefore, for peeling, a combination of several substances with 35% TCA, which just as effectively causes controlled damage, but does not give side effects, was used.

Brody suggested treating the skin with acetone and dry ice to freeze before applying 35% TCA. This allows a 35% solution of TCA to overcome the epidermal barrier more effectively and completely through it.

Monheit used Jessner's solution before applying a 35% solution of TCA. The Jessner solution destroys the epidermal barrier by damaging individual epithelial cells. This makes possible a more even exposure to the peeling solution and a deeper penetration of 35% TCA. That Coleman effect was demonstrated with respect to 70% glycolic acid before using 35% TCA. Its effect is very similar to the action of Jessner's solution. It has been proven that all three of these combinations are more effective and safer than 50% TCA. Using these combinations, the uniformity of blending and frost formation is more predictable, so that "hot spots" that can cause dyschromia and scarring, characteristic of high concentrations of TCA, do not cause serious problems when a lower concentration is included in the combined solution. The modified Monheit Jessner-35% TCA solution is a relatively simple and reliable combination. This technique is used for small or moderate photodamage of the skin, including pigment changes, freckles, epidermal overgrowth, dyschromia and wrinkles. It is applied once, with a 7-10-day period of healing and is useful for removing manifestations of diffuse actinic keratosis as an alternative to chemical slushing with chemotherapy with 5-fluorouracil. This peeling significantly reduces the number of complications and cosmetically improves the aging skin.

The procedure is usually performed under a previously created light sedation with non-steroidal anti-inflammatory drugs. The patient is warned that the peeling preparation will be pinched and burned for some time; To reduce these symptoms before peeling and within 24 hours after it is prescribed aspirin, if the patient tolerates it. The anti-inflammatory effect of aspirin especially helps to reduce swelling and relieve pain. If you take aspirin before the procedure, then this can be all that is needed in the postoperative period. However, sedation before sedation is desirable (diazepam 5-10 mg orally) and mild analgesia [meperidine 25 mg (dimedrol) and hydroxyzine hydrochloride 25 mg intramuscularly (vitaril)]. Discomfort from such a peel is not long, so you need sedative and analgesic drugs of short action.

To achieve an even penetration of the solution, strong cleaning and degreasing is necessary. The face is gently handled with an inhalation (Septisol) (10 x 10 cm napkins), washed with water and dried. To remove residual fats and contaminants, a preparation of mazetol is used. For the success of peeling, deep skin degreasing is necessary. The result of uneven penetration of the solution for peeling, due to the presence of residual fat or horny deposits after defective degreasing, is spotted peeling.

After degreasing and cleaning on the skin with cotton swabs or 5 x 5 cm napkins, a Jessner solution is applied. The amount of frost formed under the influence of Jessner's solution is much less than that of TCA, and patients usually do not feel uncomfortable. Under frost there is a weak uniform shade of moderate erythema.

Then with 1-4 cotton buds, TCA is uniformly applied, the doses of which in various areas can vary from low to high. With broad strokes of four cotton buds, the acid is applied to the forehead and the medial part of the cheeks. One slightly moistened cotton swab goes to the processing of the lips, chin and eyelids. Thus, the dose of TCA is proportional to the amount used, the number of cotton buds used and the technique of the doctor. Cotton buds for peeling are convenient for dispensing the amount of the applied solution.

White frost from THC appears on the treated surface after a few minutes. Uniform application eliminates the need to treat individual areas a second or third time, but if the freezing is incomplete or uneven, the solution should be applied again. Hoarfrost from TCA is formed longer than from the composition of Baker or pure phenol, but faster than from substances for surface peeling. To ensure that the freezing has reached its maximum, the surgeon should wait at least 3-4 minutes after applying TCA. Then he can evaluate the completeness of the effect on this or that cosmetic area and, if necessary, something to correct. Areas with incomplete freezing should again be carefully treated with a thin layer of TCA. The doctor must achieve an impact level II. Level II is defined as a layer of white frost with erythema radiating through it. III level, meaning penetration into the dermis, is a dense white enamel layer without an erythematous background. With most chemical peels of medium depth, the II level of freezing is achieved, especially when exposed to eyelids and sensitive skin areas. In areas with a greater tendency to scarring, such as zygomatic arches, bony protuberances of the lower jaw and chin, peeling should not exceed level II. The application of an additional layer of TCA enhances its penetration, so that the second or third application will further dry the acid, causing more damage. Therefore, an additional layer of acid can be applied only to areas where the effect was not sufficient or the skin is much thicker.

Peeling anatomical areas of the face is carried out consistently, from the forehead to the temples, cheeks and, finally, to the lips and eyelids. White frost means coagulation of keratin and suggests that the reaction is complete. Careful framing with a solution of the hair growth borders, the edge of the lower jaw and eyebrows hides the demarcation line between the areas that have been exposed and not subjected to peeling. In the perioral area there are wrinkles that require a full and even closure of the skin with a solution of the skin of the lips to the red border. This is best done with the help of an assistant who stretches and fixes the upper and lower lips while applying the peeling solution.

Some areas and pathological formations require special attention. Thick keratoses are not impregnated with the peeling solution evenly. To penetrate the solution, it may require additional application, even intensive rubbing. The wrinkled skin should be stretched to achieve a uniform coverage with a solution of wrinkles. In the perioral folds, up to the red border of the lips, the peeling solution should be applied with the wooden part of the cotton applicator. Deeper folds, such as mimic lines, can not be corrected with peeling, so they need to be treated like the entire skin.

The skin of the eyelids should be treated with caution and neat. For application of the solution, 2-3 mm from the edges of the eyelids, a semi-dry applicator should be used. The patient should be located with a head raised to 30 ° with closed eyes. Before applying, the excess solution for peeling on the cotton swab should be pressed against the wall of the container. Then, the applicator is neatly rolled over the eyelids and near-orbital skin. Never leave excess solution on the eyelids, as it can get into the eyes. During the peeling, tears need to be dried with a cotton swab, as they can hold a solution for exfoliation in okolaglaznye tissues and eyes by capillary attraction.

The procedure for peeling with Jessner-TXK solution is as follows:

• The skin is thoroughly cleansed by Septisol.
• Acetone or acetone alcohol is used to remove sebum, contaminants and deceased horny epidermis.
• Apply Jessner's solution.
• Thirty-five percent THC is applied until light frost appears.
• To neutralize the solution, compresses with cold saline solution are applied.
• Healing is facilitated by wetting with 0.25% acetic acid and applying a softening cream.

When applying the solution for peeling immediately there is a burning sensation, but it passes after the end of freezing. Symptomatic relief in the field of peeling is achieved by applying cold compresses with saline solution to other areas. After the peeling is completed, compresses are applied to the entire face for a few minutes, until the patient feels comfortable. Burning completely passes by the time the patient leaves the clinic. By this time, the frost gradually disappears, giving way to pronounced peeling.

After the procedure, there will be swelling, redness and flaking. With periorbital peeling and even exfoliation of the forehead, the eyelid edema can be so pronounced that the eyes will be closed. In the first 24 hours patients are recommended to apply lotions with 0.25% acetic acid (4 times a day), made from 1 tablespoon white table vinegar and 0.5 liters of warm water. After the lotions on the area of peeling, an emollient is applied. After 24 hours, patients can take a shower and gently cleanse the skin with a gentle cleanser without detergent. After completing the mopping (after 4-5 days), erythema becomes more noticeable. The healing is completed in 7-10 days. By the end of the first week, the bright red color of the skin changes to pink, like a sunburn. This can be hidden by cosmetic means after 2-3 weeks.

The therapeutic effect of medium-depth peeling is based on three factors:

• degreasing,
• solution of Jessner and
• 35% of THC.

The effectiveness and intensity of peeling is determined by the amount of the drug applied. Differences in results may be related to the type of skin of the patients and the peculiarity of the areas treated. In practice, medium-depth peeling is used most often and is planned individually for almost every patient.

The middle depth peeling has five main indications:

1. destruction of epidermal skin formations - actinic keratosis;
2. treatment and restoration of the surface moderately damaged by the sun exposure of the skin to level II,
3. correction of pigmentary dyschromia,
4. removal of small superficial scars after acne; and
5. Combined with laser polishing and deep chemical peeling treatment of sun-damaged skin.

[4], [5], [6]

Deep chemical peeling

Photo damage of the III level requires deep chemical peeling. This implies the use of TCA at a concentration of more than 50% or phenol peeling by Gordon-Baker. Laser damage can also be used to correct damage to this level. TCA more concentrated 45% is considered unreliable, as it often causes scarring and complications. For this reason, concentrated TCA is not included in the list of standard products for deep chemical peeling. For deep chemical peeling for more than 4 0 years the phenolic composition of Baker-Gordon has been successfully used.

Deep chemical peeling is a time-consuming procedure, which should be treated as seriously as any large surgical procedure. Patients require preoperative intravenous sedation and hydration. Typically, a liter of fluid is injected into the drip before surgery and a further liter - during the operation. Phenol is cardiotoxic, hepatotoxic and nephrotoxic. Therefore, attention should be paid to the serum concentration of phenol during its absorption through the skin. The methods of limiting this are as follows:

• Intravenous hydration before and during the procedure for elution of phenolic compounds from blood serum.
• Stretching the application time for the whole face peeling for more than 1 hour. Before applying the solution to the skin of each next cosmetic unit, the interval is 15 minutes. Thus, the treatment of the forehead, cheeks, chin, lips and eyelids gives a total of 60-90 min.
• Observation of the patient. If any electrocardiographic changes occur (for example, premature contraction of the ventricles or atria), the procedure is discontinued, and the patient is carefully observed to identify other signs of intoxication.
• Oxygen therapy. Many doctors believe that oxygen therapy during the procedure can help prevent rhythm disturbances.
• Correct selection of patients. All patients with an anamnesis of cardiac arrhythmias, failure of kidney or liver function, or taking drugs predisposing to arrhythmia should refuse to conduct a phenol peeling on Baker-Gordon.

Patients going for deep chemical peeling should be aware of the significant risk, the large number of possible complications of this procedure, so that the possible benefits should be weighed against specific risk factors. In the hands of those who perform this operation on a regular basis, it is a reliable and safe way to rejuvenate the skin with heavy photodamage, deep perioral wrinkles, periocular wrinkles and crow's feet, lines and folds on the forehead, as well as other textural and morphological changes associated with heavy process with the skin's melting under the influence of insolation.

There are two methods of deep chemical pilling: occlusive and non-occlusive peeling with phenolic composition Baker. Occlusion is done by applying a waterproof tape with zinc oxide, such as a 1.25 centimeter tape Curity. The tape is applied directly after phenol treatment with each cosmetic unit. Occlusion with tape increases the penetration of phenol solution Baker and is especially good for deeply stratified "weather-beaten" skin. Occlusal phenol peeling creates the deepest damage in the middle part of the mesh layer of the dermis, and this form of chemical peeling should be performed only by the most knowledgeable and experienced cosmetic surgeons who understand the dangers of unduly penetrating and damaging the mesh layer of the dermis. Its complications are oneself in hyper- and hypopigmentation, textural changes, such as "alabaster skin", and scarring.

Non-occlusive technique, in the McCollough modification, means more skin cleansing and applying more solution for peeling. In general, this technique does not give such deep sloughing as the occlusal method.

The composition of Baker-Gordon for this peeling was first described in 1961 and has been successfully used for more than forty years. This compound penetrates the dermis deeper than undiluted phenol, as the latter is thought to cause immediate coagulation of the epidermal keratin proteins, thereby blocking its own penetration. Dilution of up to about 50-55% in Baker-Gordon solution causes keratolysis and keratocoagulation, which promote a deeper penetration of the solution. Liquid soap Hibiclens is a surface active substance that reduces the surface tension of the skin and provides a more even penetration of the drug for peeling. Croton oil - an epidermal antimicrobial agent that improves the absorption of phenol. Freshly prepared compound is not miscible, so it must be shaken in a medical glass container from clear glass immediately before application to the patient's skin. Although the composition can be stored for a short time in a bottle of darkened glass, this is usually not required. Preferably, each time a fresh formulation is prepared.

[7], [8]

The chemical peeling method

Before performing anesthesia, the patient sits down and marks the face, with the designation of such landmarks as the angle of the lower jaw, chin, anterior notch, edge of the orbit and forehead. This is done in order to perform peeling strictly to the borders of the face and slightly beyond the edge of the lower jaw, creating an imperceptible transition of skin color. This peeling necessarily requires sedation. For this, the anesthetist is administered intravenously, for example, a combination of fentanyl citrate (Sublimaze) and midazolam (Versed) and observes the patient for m. It is useful to make a conductor anesthetic of the supraorbital nerve, the infraorbital nerve and the chin nerve with bupivacaine hydrochloride (Marcape), which should provide local anesthesia for about 4 hours. Then the whole face is cleaned and degreased with a keratolytic substance such as hexochlorophene with alcohol (Septisol), with particular care in such sebaceous areas as the nose, the border of hair growth and the middle part of the cheeks.

Then the chemical compound is successively applied to the skin of six aesthetic units: the frontal, perioral, right and left buccal, nasal and peri-ocular areas. Treatment of each cosmetic area takes 15 minutes, which in total is 60-90 minutes for the entire procedure. For the application, cotton swabs are used, in the same way as described in the section on middle-weight peeling with Jessner-35% TCA solution. However, the drug is applied in a smaller amount, since the freezing occurs much faster. The immediate burning sensation is present for 15-20 seconds, and then passes; however, the pain returns after 20 minutes and disturbs from 6 to 8 hours. The last area of the peeling is the circumorbital skin, on which the solution is applied only with moistened cotton buds. In no case should it be allowed to contact drops of the solution for peeling with the eyes and tear fluid, since the tear-mixed solution can penetrate the eye by capillary attraction. It is important to remember that dilution of the composition for peeling in water may increase its absorption; therefore, if the chemical has got into the eye, it should be washed with mineral oil, not with water.

After applying the solution, frost appears on all areas and an occlusal peeling tape can be applied. At the end of the peeling, bubbles with ice can be used to increase comfort; and, if the peeling is non-occlusive, Vaseline is used. For the first 24 hours, a biosynthetic dressing, such as Vigilon or Flexzan, is applied. The first postoperative visit of patients is appointed after 24 hours to remove the tape or biosynthetic dressing, as well as to monitor the progress of healing. At this time, patients are explained how to apply compresses and occlusive dressings or ointments. It is important not to allow the formation of a scab on the skin.

After a deep chemical peel, four stages of wound healing are determined. These include (1) inflammation, (2) coagulation, (3) re-epithelialization, and (4) fibroplasia. Immediately after the chemical peel is completed, an inflammatory phase develops, beginning with severe dark erythema, progressing during the first 12 hours. Pigmented foci on the skin become more emphasized as the epidermis separates into the coagulation phase, serum exudation occurs and pyoderma develops. During this phase it is important to use cleansing lotions and compresses, as well as occlusive soothing ointments. This will remove the sloughing necrotic epidermis and prevent the drying of the serum exudate to form crusts and a scab. The authors prefer to use lotions with 0.25% acetic acid (1 teaspoon white table vinegar, 500 ml warm water), since they have antibacterial action, especially with regard to Pseudomonas aeruginosa and other gram-negative microorganisms. In addition, the slightly acidic reaction of the solution is a physiological environment for the healing granulation tissue and gently launches the wound, dissolving and washing the necrotic material and serum. With a daily skin examination to identify complications, we prefer to use emollients and soothing agents, such as Vaseline, Eucerin or Aquaphor.

Re-epithelization begins on the 3rd day and lasts until the 10th-14th day. Occlusive bandages contribute to faster healing. The last stage of fibro-lasia lasts long enough after the initial closure of the wound and consists in neoangiogenesis and the formation of a new collagen for another 3-4 months. Erythema can persist for 2 to 4 months. Long-term retention of erythema is usually not observed and is associated with individual skin sensitivity or contact dermatitis. The formation of new collagen during the phase of fibroplasia can continue to improve the skin texture up to 4 months.

Complications of chemical peeling

Many of the complications of peeling can be recognized in the early stages of healing. The cosmetic surgeon should be well acquainted with the normal kind of healing wound at different times after the peeling of different depths. Renewal of the granulation stage for more than 7-10 days can speak of delayed wound healing. This can be the result of a viral, bacterial or fungal infection; contact dermatitis interfering with healing; or other system factors. The "red flag" (granulation) should encourage the surgeon to carefully examine and prescribe the appropriate treatment to prevent irreparable damage that can cause scarring.

Causes of complications can be both intraoperative and postoperative. Two characteristic errors leading to intraoperative complications are (1) improper selection or use of the drug and (2) accidental drug exposure to undesirable sites. The doctor is responsible for the correct application of the solution to the desired concentration. The volume-weight concentration of TCA should be determined, as this is a measure of the depth of the peeling. The expiration date of glycolic and lactic acid, as well as the Jessner solution, should be checked, since their effect is weakened as they are stored. Alcohol or water may undesirably increase the effect, so it is necessary to clarify the preparation time of the solution. The solution for peeling should be applied with applicators with cotton tips. With medium and deep peeling, it is best to pour the solution into a free container, and not take it from the bottle in which it was stored, squeezing the cotton buds against the walls of its neck, since the crystals dropped on the walls can increase the concentration of the solution. It is necessary to apply the solution to the appropriate places and not to carry a wet applicator over the central parts of the face, where the drops can accidentally fall on sensitive areas, for example, the eyes. To dilute TCA or neutralize glycolic acid, in cases of their incorrect application, physiological saline and sodium bicarbonate solution should be at hand in the operating room. Also, with phenol peeling on Baker you need to have mineral oil. Postoperative complications are most often associated with local infection and contact dermatitis. The best way to curb local infection is using lotions to remove crusts and necrotic material. Under thick occlusive dressings, streptococcal or staphylococcal infection may develop. The use of lotions with 0.25% acetic acid and reasonable removal of the ointment upon their application inhibit the development of infection. Infections caused by Staphylococcus, Escherichia coli and even Pseudomonas may result from improper care of the healing wound and should be treated with the corresponding oral antibiotic.

Early detection of bacterial infection requires frequent patient visits to the doctor. It can manifest itself by delayed healing, ulceration, the formation of necrotic material in the form of excess films and crusts, purulent detachable and odor. Earlier recognition allows the treatment of the skin and prevent the spread of infection and scarring.

Viral infection is the result of the reactivation of the herpes simplex virus in the skin of the face and especially in the perioral area. Anamnesis of herpetic infection requires a prophylactic oral intake of an antiviral drug. Such patients can be treated with 400 mg of acyclovir three times a day for 7-14 days, depending on the depth of the procedure, starting from the day of peeling. The mechanism of action of acyclovir is to suppress the replication of viruses in unchanged epithelial cells. This means that the drug will not have an inhibitory effect until re-epithelialization of the skin occurs, that is, until the 7th-10th day after the middle or deep peeling. Previously, the antiviral agent was canceled after 5 days, and the clinical infection manifested itself on the 7-10th day.

Active herpetic infection is easily treated with antiviral drugs. At an early start of treatment, scarring usually does not happen.

Slow wound healing and prolonged erythema are signs that normal tissue repair after peeling does not occur. To recognize inadequate healing, a cosmetic surgeon must know the normal duration of each stage of this process. Delayed wound healing can be accelerated by treating the wound, with infection, with corticosteroids and eliminating the dermatitis-causing substance that supports allergic reactions and irritation, as well as protection with a biosynthetic membrane such as Flexzan or Vigilon. When the diagnosis is made, the patient should be observed daily, changing the bandage and observing the changes in the healing skin.

Persistent erythema is a syndrome in which the skin remains erythematous for longer than it is considered normal for a particular type of peeling. After a superficial peel of erythema passes through 15-30 days, after a peeling of average depth - within 60 days, and at deep chemical peeling - within 90 days. Erythema and / or itching, which lasts longer than this time, are considered as a deviation and indicate this syndrome. It can be contact dermatitis, contact sensitization, exacerbation of a pre-existing skin disease or a genetic tendency to erythema, but this situation can also mean possible scarring. Erythema is the result of the action of angiogenic factors that stimulate vasodilation, which also occurs in the phase of fibroplasia, stimulated for a long time. Therefore, it can result in thickening of the skin and scarring. Such a condition should immediately begin to be treated with adequate doses of steroids, both topically and systemically, as well as skin protection against irritating and allergenic factors. If thickening and scarring become apparent, it is useful to apply a daily silicone protective coating and a pulsating dye laser to influence the vascular factors. With proper intervention, scarring is often reversible.

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