Technique

The learning curve is very long and each practitioner must carefully assess whether the number of eligible candidates for this treatment is enough to justify adding this technique to his/her therapeutic portfolio. Only after a significant number of procedures may any medical professional acquire the experience level required to comfortably handle a deep peel. This procedure should be performed in the operating room, involves general anaesthesia or intravenous sedation, and an anaesthetist must be present throughout the procedure to continuously monitor the patient.

Step 1: This step comprises cleaning, removing make-up, and degreasing the skin (by removing the protective lipidic layer) in order to allow the products to penetrate uniformly and with no interference. No hair can be in contact with the face.

Step 2: The peeling is applied to the skin using solution‑soaked cotton-tipped applicators, layer by layer, applying pressure and rubbing according to the skin depth to be reached. The end-point is an ivory-white, solid and opaque frosting, with the skin surface gradually acquiring a grey-like opaque tone. Application is by cosmetic (anatomic) units at intervals, allowing for the systemically absorbed phenol to be eliminated from the system, preventing any systemic overload. Application should begin at the frontal and temporal regions, followed by the periocular and malar areas, and then the rest of the face, ending at the mandibular and perioral regions. Around the lips, the procedure must be applied 1–2 mm into the vermilion border. The eyelids must be treated last, as they are particularly delicate areas.

This treatment is not indicated for the neck; therefore, the transition line, approximately 1–2 cm below the jaw line, must be carefully defined. The peeling solution must be applied slightly into the hairline (a few millimetres) to prevent the formation of a demarcation line.

Step 3: Once the intended end-point has been reached, non-permeable tape is applied to the face. Its application is extremely important. No areas are to be left uncovered and no air pockets should be allowed to form. During the first day, the patient will experience some discomfort as the face bloats, and adequate oral pain medication must be prescribed. After 24 hours, the tape mask is removed and the adhering epidermis and part of the dermis are then eliminated.

Step 4: The next step comprises covering the face with bismuth subgallate antiseptic powder for approximately 7 days — the time required to complete full re-epithelisation. When the bismuth mask is removed by the physician, the skin finally appears renewed and rejuvenated, with no wrinkles. Seven to 10 days of social downtime are required and the patient may gradually resume his/her normal life, and use make-up from 10–12 days.

Post-procedure

In the following months, the skin will tend to blush. Adequate cosmetic care must be taken and caution is advised solar exposure, which should be avoided until a few months after the procedure. This is owing to the risk of hyperpigmentation and because the skin is very sensitive. The avoidance of UV radiation is one of the most important factors in preventing hyperpigmentation. The patient must be psychologically stable in order to reliably adhere to the entire process, for which good family support is desirable, especially during the first week after the intervention.

The benefits of the deep peel do not cease with skin renewal; improvements will extend over the following months. Penetrating all the way to the mid-reticular dermis, this kind of peel strongly induces the production of high-quality collagen and triggers a good tensor effect. The improvement in facial flaccidity can be so dramatic that the procedure is often referred to as ‘chemical lifting’.

Figure 3 Patient (A) before and (B) 8 weeks after one deep peel

Figure 3 Patient (A) before and (B) 8 weeks after one deep peel

The ideal candidate for a full-face deep peel is someone with a low phototype, moderate to deep wrinkles scattered over the entire face, and with mild to moderate flaccidity (Figure 3).

The deep peel can also be used for wrinkle reduction in a specific problem area. The author does not recommend its isolated application on the periocular area owing to the resulting demarcation line, which is often hard to disguise or attenuate. However, the author does frequently use the procedure for the reduction of lip and/or chin wrinkles. In most cases, a medium peel is simultaneously performed on the whole face to obtain a more homogeneous look to the skin (Figure 4).

In the case of the upper lip alone, a deep peel can be safely performed at the practitioner’s office owing to the low quantity required (approximately 0.05 ml). In the author’s clinical practice, he often performs a localised deep peel in the perioral area, in conjunction with cervicofacial lifting or a blepharoplasty during the same operating time.

Figure 4 Patient (A) before,  (B) 15 days post-treatment, and (C) 1 year after a deep peel to the upper perioral area

Figure 4 Patient (A) before,
(B) 15 days post-treatment, and (C) 1 year after a deep peel to the upper perioral area

It should be noted that the dramatic wrinkle improvement powered by this type of peel calls for extreme care to be taken when performing localised applications. There is the risk of an undesirable contrast between an over-rejuvenated area and the remainder of the aged face.