Facial wrinkles are one of the most striking signs of ageing and are reported to be one of the most common reasons for patients to seek medical help. Medium-depth and deep peels are a valid option in wrinkle reduction, especially when dealing with static (non-dynamic), moderate to deep wrinkles. They can be performed as full-face treatments or applied only to specific areas such as the upper lip. The deeper the peel, the greater the complexity involved in handling the procedure. However, gratifying results can be achieved for both patient and doctor, provided that its actuation process is well known and deeply understood by the practitioner. In this article, the author presents his personal view on the use of chemical peels, particularly for wrinkle reduction, based exclusively on his own experience over 10 years.
A chemical peel consists of inducing a controlled aggression to the skin by applying a substance on the surface to remove layers and promote cutaneous regeneration. Improving the imperfections located in the removed skin layers results in a rejuvenating effect.
Chemical peels have successfully outlived the appearance of a number of sophisticated laser platforms over recent years. They can be performed even in the event of a power failure, they do not have breakdowns, do not require consumables or technical assistance, they are not rapidly made obsolete, and offer a good cost‑to‑benefit ratio.
Peels can be used on almost any part of the body, from the scalp to the feet, including the external genital organs and the hands. They are intended to not only improve the aesthetic appearance of the skin itself, such as in cases of wrinkles, elastosis or melasma, but also to treat a wide range of clinical conditions such as acne, scars, folliculitis, psoriasis, keratosis, and pre-cancerous lesions.
When we talk about wrinkle reduction through peeling, we mainly refer to the treatment of exposed areas like the face, the neck, the decollete, and/or the hands.
Chemical peels are one of the most popular procedures in medical aesthetic practices worldwide, as proven by the wide range of currently available peeling treatments and by the fact that high-profile corporations are now starting to make major investments in chemical peel agents, supporting the development of new products and designing new protocols. These treatments are extremely popular in countries with significant solar exposure (South and Central America and Mediterranean countries), but used much less in countries in which people are less exposed to the sun.
The classic division of chemical peels is based on their aggressiveness and ability to penetrate through tissue. The three categories are:
- Superficial peels — those which only penetrate to the epidermis
- Medium-depth peels — those that penetrate through the whole epidermis and the papillary dermis
- Deep peels — those penetrating to the reticular dermis.
However, other classification systems are based on the chemical characteristics of peels and on their indications for use (acne, wrinkles, elastosis, melasma). For example, a number of molecules capable of carrying out a peel can be used to perform a superficial or a medium peel, depending on its concentration, the application method, and the type and condition of the patient’s skin. The author believes the classification system based on the aggressiveness of the peel is the more practical method to use.
Superficial peels are relatively simple treatments and their procedures are not complex. However, deep and some medium‑depth peels are considerably invasive, even though they do not involve a surgical procedure as such. The learning curve for the medium and deep peels is lengthy, and extensive previous experience with superficial and medium peels is required before one can start performing deep peels.
While approved peeling solutions supplied as ready-to-use ‘off-the-shelf’ packages are usually used to perform superficial and/or medium peels, most formulations used for medium or deep peels are pharmaceutically compounded. This means that any practitioner who is taking the first steps in deep peeling procedures may not find it easy to obtain fully reliable and reproducible formulae, which is certainly one of the key aspects to be taken into account. Given some time and experience, most practitioners develop their own protocols for the use of different peeling agents. The more senior and experienced practitioners often combine different types of substances or different concentrations of a single peel in one procedure. The author believes the ability to combine localised deep peels, such as in the peri-oral area, with medium peels on the rest of the face can help those practitioners not familiar with deep peels gain experience on easier to treat areas before tackling the full face.