As mentioned before, deep peels (e.g. the classic phenol peel, 35% TCA) should be avoided because of the destruction of the epidermis. Medium-depth peels (e.g. 15% TCA, Jessner's peel) that do not destroy the basal layer of the epidermis are much safer, though one treatment will not give the smoothening that people demand from a peel, but the recovery might be almost as great as that for a deep peel. On the other hand, serial light peels done once a month in conjunction with daily applications of vitamin A, vitamin C and other active ingredients will give results at 6 months that match those of one heavy peel.
Low concentrations of TCA, as low as 2.5%, have been used with gratifying results. This form of peel is safe to use repeatedly on the upper eyelids (Fig. 62.6). The advantage of peeling in these types of cases is that one can smooth out the fine wrinkles of the upper-eyelid skin that can spoil even the best blepharoplasty. Sometimes the improvement is so great that it mimics an upper blepharoplasty as in the case shown.
Repetitive peeling allows the patient to continue with their daily lives with minimal telltale signs, and as the skin becomes refined, the need for continuing the peels disappears. Patients with thick rough skins should be treated to a peel at the beginning of their skin care programme so that the vitamin A can express its beneficial effects. One advantage of serial light peels in conjunction with vitamin A based cosmeceutics is that the patient will get a better result than expected. Less invasive
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