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BLEPHAROPLASTY 101
"A little here. A little there.
A little more. Everywhere."

Topic 22 - 1
Eyelid Skin Rejuvenation:
Chemical Peel, Laser Resurfacing,
and Non-Ablative Devices
fat injections and fillers   eyelid laser chemical peel


"I can honestly say I love getting older. Then again, I never put my glasses on before looking in the mirror."
--Cherir Lunghi


Other names: Ablative (that is, superficially destructive) procedures include chemical peel, laser resurfacing, and dermabrasion (not used on the eyelids), each available in a variety of forms. Non-ablative devices may employ mid-infrared laser, intense pulsed light, LED, or radiofrequency energy.

Primary goal: Blunting of wrinkles by tightening within the dermal layer of the skin

Secondary goals: Improvement of skin texture, generation of new collagen, bleaching of solar pigmetation and blotching

Special anatomy: The outermost layer of the skin is called the "epidermis", below which is located the "dermis".

Anesthesia: From none to mild oral sedation to nerve block by injection

Operative technique: Skin resurfacing is a non-surgical (although destructive) technique. It may performed as a stand-alone procedure and performed immediately after blepharoplasty.

Chemical Peel: Following skin preparation and cleansing, the selected chemical is applied using Q-tips. Most typically, 35% TCA (trichloroacetic acid) solution is used on the eyelids.

Laser resurfacing: The beam of the laser is directed over the tissue to be treated in one or a series of "passes".

Transconjunctival fat removal with
lower eyelid TCA 35% chemical peel




Variations:

Chemical Peel: Different chemicals may be used alone or in combination. The more destructive the chemical, the deeper the level of wounding and the more pronounced the final effect. Superficial chemical peeling may be accomplished using alpha-hydroxy acids or weak trichloroacetic acid (TCA) solutions (such as the Obagi Blue Peel) and must be repeated often (for instance, once a month for four to six months) to have much effect. Medium-depth peels usually require only a single treatment. Deep chemical peels are accomplished with phenol-based mixtures, which are quite toxic. Since the depth of peeling with the more potent chemicals is not fully predictable, some practitioners tout their use of the laser, in which the delivery of energy is said to be more controlled. Any real advantage, however, seems to be over-emphasized by advertisers and laser manufacturers; using a laser does not guarantee a superior result.

Laser resurfacing: Either the carbon dioxide (stronger) or erbium:YAG (weaker) lasers may be used, or the two may be used in combination. The doctor may "dial in" the amount of energy and depth of penetration by setting different laser beam parameters on the machine. Newer and less destructive (non-ablative) lasers cause less tissue damage but also less effect.

• Either localized areas (skin around the eyes, around the mouth, etc.) or the full face may be treated.

Advantages: Blepharoplasty surgery is designed to remove extra tissue and strengthen weakened structure. While canthal tendon reinforcement may blunt the appearance of wrinkling in the lower eyelid, skin creasing is due to damage within the skin rather than excess tissue and is thus not helped by "cutting surgery." Resurfacing procedures are designed to create a relatively controlled "injury" into the dermis of the skin, which, in the process of healing, leads to a reduction in wrinkling. It is reasonable to expect about a 50-70% reduction in the depth of most deep wrinkles.

Limitations: If blepharoplasty is indicated in a patient for the removal of more than tiny amounts of excess eyelid skin and/or fat, attempting to avoid true surgery by using heavy-handed laser resurfacing or chemical peeling (phenol-based solutions) to shrink the skin risks scarring and will not often yield a satisfactory result.

Care and recovery: With deeper treatments (carbon dioxide laser, phenol chemical peels), the face may appear truly "hideous" for several weeks and bad for many months more. Redness and blotchy skin pigmentation may resolve only gradually and create a cosmetic problem for 6-18 months. On the other hand, TCA 35% chemical peels add little time to the healing of a blepharoplasty. After treatment, unprotected exposure to the outdoors should be avoided for at least several months if not indefinitely.

Risks and complications: Complications of laser, phenol, and TCA peels include prolonged and extreme skin redness and tenderness, hyperpigmentation, permanent blotchy pigmentation, worsening of pre-existing acne, herpes and other types of infection, hypopigmentation, and eyelid scarring. More aggressive techniques (laser, phenol) may leave the "texture" of the skin with a somewhat waxy look. The phenol used in deep chemical peels is highly toxic. If the skin of the lower eyelid is excessively tightened by deep resurfacing, ectropion (eversion) or retraction (pulling down) of the lid may occur. While rare, severe injury to the cornea has been reported.

Non-Ablative Skin Resurfacing Devices are designed to deliver energy to the deeper layer of the skin (dermis) while avoiding surface (epidermis) damage, thus greatly decreasing or even eliminating the healing time needed for recovery. Such devices may use mid-infrared laser, intense pulsed light, LED, or radiofrequency energy, etc. Do they live up to their claims? Are they a equal substitute for the ablative therapies such as chemical peel or the laser?

For a substantial number patients after multiple treatments, the answer is a disappointing "no." But do they at least help a little? Some do seem to improve skin color and texture. While more convenient and less risky than the ablative procedures mentined above, the results are simply not comparable, especially on the eyelids and adjacent skin.

Comments: Resurfacing techniques tend to benefit "static" wrinkles rather than "dynamic" wrinkling caused by underlying muscular pull (for example, crowsfeet).

As with any "artistic" discipline, to obtain consistent results with skin resurfacing requires a good deal of doctor knowledge and experience.

Be aware that some eyelid specialists have now abandoned the laser in favor of TCA chemical peeling; treatment is easier, less painful, and less expensive. While carbon dioxide laser resurfacing and deeper phenol chemical peeling may work wonders on severely sun-damaged or aged skin, younger patients with more modest changes should carefully consider the downside of such aggressive treatments. Scarring may occur with any type of resurfacing treatment but is more common with laser and phenol-based peels.

Next: TCA Eyelid Chemical Peel


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