Chemical peels are among the most popular cosmetic procedures in facial rejuvenation. In fact, chemical exfoliation is the third most performed non-surgical procedure after botulinum toxin and dermal filler application. Although there has been a shift to laser resurfacing technology in recent years, peeling agents remain an efficient, predictable, and cost-effective way to improve the texture and suppleness of facial skin. When used for the right patient and with the proper technique, peeling agents demonstrate excellent clinical efficacy and consistent results. Therefore, they continue as an indispensable tool in the oculoplastic surgeon’s aesthetic practice.

Anatomy of facial skin and the effects of aging

Our skin consists of three layers: the epidermis, the dermis, and the subcutaneous tissue. Only the two most superficial layers are relevant to our topic. The outermost layer, known as the epidermis, forms the protective, waterproof barrier of the face and contains five layers. The stratum corneum is the outermost layer and is mainly composed of dead cells. These cells eventually slough off, allowing younger cells to take their place. The stratum corneum acts as a natural protective layer and retains moisture for the body; superficial chemical peels exfoliate this layer.

The dermis is the layer under the epidermis made up of an intricate arrangement of collagen and elastin fibers. These skin components are vital in maintaining skin’s firmness and structure. Hair follicles, glands, and blood vessels are also found in the dermis. Collagen and elastin degradation with aging is one of the leading causes of facial aging.

Skin aging can be divided into two causes: genetic and environmental. Caused by the genetic makeup passed down to us from our parent’s genes, genetic or intrinsic aging is considered our natural aging that begins in our mid-20s and continues. Collagen growth becomes sluggish, and elastin fibers do not respond well and are compromised. Since these are the main factors of skin firmness and elasticity, their slow degradation causes:

  • Thinning of the skin 
  • Uneven skin tone 
  • Sallow complexion
  • Loss of skin moisture
  • Fine lines

Exposure to ultraviolet light, stress and smoking are environmental factors that cause external or extrinsic aging. The number one cause of extrinsic aging is sun exposure. The aging and damage caused by the sun are known as “photoaging.” A definite sign of photoaging is the pigmentation of the skin, which is characterized by a blotchy and uneven skin tone and sunspots. Another cause of extrinsic aging is smoking, which is devastating to skin health. Tobacco ages skin very rapidly, and the first signs of this are fine wrinkles and sallow skin lacking luster. 

Our facial expressions and movements, such as squinting, raising the eyebrows, and smiling, also cause extrinsic aging. Over the years, the constant motion of these muscles will carve deep lines into the skin. Application of botulinum toxin relaxes the muscles of facial expression and effectively treats expression lines. 

How do chemical peels revert skin aging?

Chemical peeling is a method of targeted skin exfoliation induced by specific caustic agents that allow for accelerated, predictable, and uniform regeneration of the skin. This procedure aims to improve the clinical appearance of eyelid and facial skin. It is a controlled skin wound that promotes thickening of the epidermis and new collagen and elastin formation in the dermis, producing increased tissue volume and tighter skin.

In other words, chemical peels turn back the clock of aging by addressing wrinkles, laxity, and uneven skin tone and instead produces a vibrant complexion that is firmer, healthier, and younger.

Light vs. deep chemical peels

Chemical peels improve overall skin tone and appearance by removing a predictable, homogenous layer of damaged skin. This controlled wound allows new skin formation and simultaneously treats superficial wrinkles and unwanted pigmentary changes.   

Chemical peels are classified according to the depth of the wound created by the peel and the chemical nature of the caustic agent. The depth of the peel determines the intensity of the exfoliation. The caustic chemical type, its concentration, mode of application, and the number of applications (mono vs. multilayer), among other factors, all dictate peel depth.

The degree of impact of the peel will be in proportion to its depth. Deeper peels stimulate more collagen and elastin formation, thereby improving deeper lines. On the other hand, lighter peels improve only superficial lines and subtle pigmentary changes. Multiple light peels cannot equal the effect of one deep peel. 

Superficial peels only penetrate the epidermis, while medium-depth peels affect the entire epidermis and superficial dermis. Deep peels allow for controlled tissue injury to the deeper layers of the dermis. 

Caustic agents used as chemical peels

The exfoliative nature of a peel depends on its chemical composition. The selection depends on the patient’s needs and expectations for aesthetic improvement, skin type, and ability to tolerate the post-procedural recovery period.

Most caustic agents fall under one of the following three categories: alpha-hydroxy acids, beta hydroxy acids, and trichloroacetic acid. Other peels can be used alone or combined with the previously mentioned agents, although their use is less frequent in Costa Rica. 

Chemical Peels Costa Rica

What is the application method for chemical peels?

As mentioned earlier, the type of chemical agent selected corresponds to the skin type, degree of aging, and the patient’s goals for treatment. Nearly all chemical peels can produce excellent clinical improvements in facial skin tone and texture when used for the right patient, in the correct setting, and with the proper technique. 

Before applying the caustic agent, skin must be cleansed and degreased. This step is especially important for water-soluble peels such as glycolic acid; however, it must be followed for all peels since superficial oils and dirt will prevent the peel from reaching the epidermal layer. 

Superficial peels

Superficial peels can be done in an office setting while the patient is awake. After cleansing the skin, the first pass of the chemical agent is applied with extreme care to distribute the agent uniformly over the entire treated area. Since the peel will cause burning, patients are given a fan to provide comfort during the application. After the first coat, patients are asked to grade the level of burning. One to two more coats of the chemical agent can be applied according to the patient’s pain tolerance or until sufficient skin frosting is achieved.  

Medium-depth and deep peels

Medium-depth and deep peels are performed with mild sedation and intravenous anti-inflammatory medication since they induce higher pain levels. NSAIDs help reduce swelling and pain and are often given before the procedure to relieve postoperative symptoms. Patients undergoing deep peels should be closely monitored since these agents can have toxic effects on the heart, liver, and kidneys.  

Chemical peels post-operative care

After a chemical peel, it is normal to experience swelling, redness, and desquamation. The deeper the peel, the more pronounced and prolonged these symptoms will be, thus requiring a more extended downtime. In cases where the peel is applied to the eyelids, cheeks, and around the eyebrows, swelling can be very pronounced and may even result in the eyes shutting closed for the first 24 hours. 

NSAIDs such as Advil and Aleve are typically effective in relieving post-procedure pain and swelling. Patients are instructed to soak the skin with diluted vinegar and apply cool compresses with ice packs. A bland emollient such as baby Vaseline or Aquaphor should be applied to the treated areas of skin at least two times a day until healing is complete.  

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Skin preparation protocol before Chemexfoliation

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