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INTRODUCTION
Chemical peeling is a procedure used for the cosmetic improvement of skin or for the treatment of some skin disorders. Chemical exfoliating agent is applied to the skin to destruct portions of epidermis and/or dermis with subsequent regeneration and rejuvenation of the tissues. In the periorbital area, it results in improvement of the skin quality, shrinkage of redundant skin and lightening of the pigmentation.
The periorbital area is a barometer of facial aging, since it is affected by intrinsic and extrinsic factors of aging. In addition, the skin in this area is tightly attached to the underlying orbicularis oculi muscle and therefore is under constant muscular movements, induced by mimetic expressions. Moreover, the periorbital skin has the thinnest epidermis and dermis. It has been shown that type I collagen content diminishes with aging in the eyelid skin due to a decrease in its synthesis. All these factors contribute to the fact that the periorbital area is the first to show the signs of facial aging.
Chemical peels can be performed on the lower lid exclusively or on the whole periorbital skin. They can be a part of the full-face peeling procedure or can be performed as isolated chemical blepharoplasty. Eyelid peeling can be combined with simultaneous surgical blepharoplasty or with non-surgical procedures, such as botulinum toxin injection or tear trough deformity correction by dermal fillers.
INDICATIONS AND CONTRAINDICATIONS
Lower eyelid wrinkles and redundant eyelid skin are challenging for treatment. As long as the skin in this area is tight and elastic, eyelid wrinkles can be improved by infraorbital injection of small doses of botulinum toxin. If flaccid, additional relaxation will worsen the skin appearance and cause suborbital swelling. Furthermore, the lower portion of the lateral orbicularis oculi assists in elevation of the upper cheek. When it is totally paralyzed in older patients, an extra roll of skin becomes apparent at the junction of the lower eyelid and cheek skin when smiling.
Lateral crow’s feet in young patients are treated successfully by botulinum toxin injection. Our experience shows, however, that if these lines are not significantly worsened during animation, as happens in older individuals, the effect of muscle paralysis would not be sufficiently effective. The option of botulinum toxin injection in sub- and periorbital areas is therefore preserved for relatively young patients with tight skin. Chemical peels significantly improve this area. Periorbital skin rejuvenation using medium and deep peels is achieved due to stimulation of the production of new dermal collagen and elastic tissues, with a desired overall refreshed and tightened appearance, reduction of fine wrinkles and skin tightening.
Lower eyelid wrinkles are minimally helped by standard surgical blepharoplasty, in particular when a transconjunctival approach is used for fat removal or fat transposition. They are therefore commonly neglected during this procedure. A combination of eyelid surgery with lower eyelid peeling has been suggested as an effective and safe procedure that improves the final result of lower blepharoplasty.
For upper eyelid blepharochalasis, surgical blepharoplasty is indicated in most cases. The results are generally good, natural and long lasting. Nevertheless, if a patient is reluctant to have surgical intervention or if full-face chemabrasion is scheduled, the periorbital procedure can be surprisingly effective on the upper eyelid as well ( Fig. 4.1 ).
Periorbital pigmentation is prevalent in 9–38% of American women under the age of 30 years. This manifestation worsens with age. Histological examination of infraorbital darkening suggests that it is caused by multiple etiologic factors, including acquired dermal melanocytosis, ethnic or age-related dermal melanin deposition, postinflammatory hyperpigmentation secondary to atopic or allergic contact dermatitis, periorbital edema, skin photoaging, superficial location of the vasculature, and tear trough depression.
Chemical peels are highly effective for the removal of melanin depositions secondary to ethnic dark circles and postinflammatory hyperpigmentation, and in skin photoaging.
Our experience shows that in ethnic dark circles, deep peels create definitive results ( Fig. 4.2 ).
A novel use of periorbital peels is to treat younger patients who show only textural changes and who are not necessarily contemplating surgery. This approach not only opens up treatment to a much larger patient population but is also a means of keeping up with aging. The inherent improvement and tightening of the anterior lamella caused by the peel may bring enough improvement in younger patients with mild fat protrusion who may not be ready to consider surgery ( Figs 4.3 and 4.4 ).
There are no absolute contraindications for periorbital peeling. Ectropion secondary to chemical peeling is a remote possibility and its existence is debatable. Nevertheless, pre-existing ectropion or moderate-to-severe lower lid laxity is a relative contraindication for lower eyelid peeling, unless each is corrected surgically prior to the chemical peel.
PREOPERATIVE HISTORY AND CONSIDERATIONS
When evaluating the patient before the peel, an extensive history should be taken. The patient has to be questioned about general health status, medications such as oral isotretinoin, smoking, previous cosmetic procedures such as surgical lifts or fluid silicone injections, recurrent herpetic outbreaks, keloid formation, etc.
Skin type should be determined, based on Fitzpatrick’s skin type scale. Skin preparation with bleaching creams and early reintroduction of these products in the immediate post-peel period are crucial to avoid postinflammatory hyperpigmentation in dark phenotypes.
The message of ‘the deeper the peel, the more the inconvenience, the more significant the results’ should be clearly conveyed and discussed with the patient.
The patient should be aware of the need to regularly apply sunscreen in the immediate post-peel period and of the possibility of using makeup to conceal post-peel redness, and advised to resume normal daily activities immediately after the procedure.
Of paramount importance is to have the patients photographed and sign the term of consent prior to the procedure.
OPERATIVE APPROACH
Chemical peels are an extremely versatile tool and are divided into three categories, depending on the depth of the wound created. Superficial peels penetrate the epidermis only, medium-depth peels damage the entire epidermis and papillary dermis, while deep peels create a wound to the level of the mid-reticular dermis.
The depth of the peel is dictated by a number of factors: the chemicals that have been applied, their concentration and mode of application, and skin type and its condition. In general, the depth of the peel determines patient’s inconvenience during and after the procedure, healing time, the rate of the potential side effects and the results.
PRE-PEEL SKIN PREPARATION
Skin can be pretreated with topical tretinoin 0.025–0.05% for 2–6 weeks, but its efficacy in periorbital skin priming is controversial. Immediately before applying the chemical, the skin is thoroughly cleaned and degreased with acetone. The treatment area, particularly in the lower eyelid, is marked while the patient is in the sitting position. If an occluded deep-peel procedure is scheduled, the authors mark the area to be occluded and a marginal area in which to perform a non-occluded peel ( Fig. 4.5 ).
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