Postoperative Regimen
for Chemical Peeling:
A Clinical Approach
Wallace K. Dyer II, M.D., F.A.C.S.
To develop an effective postoperative treatment
regimen for chemical peels, it is necessary to under-
stand general wound healing principals, the perti-
nent anatomy and physiology of skin, and the depth
of injury that is being treated. Chemical peeling de-
scribes a wide range of wounding agents that, de-
pending on the desired result, will damage the skin
from the stratum corneum to the midreticular der-
mis. This depth of injury may also be extended by
postoperative complications such as infections. Ulti-
mately, the depth of the injury determines the post-
operative care regimen.
CUTANEOUS ANATOMY
After a chemical peel, the epidermis and dermis
both actively contribute to wound healing. Because
the basal layer remains intact, partial thickness
wounding, even to the level of the midreticular
dermis, generally heals without visible scarring.
However, since melanocytes are found in the epi-
dermis, deep chemical peel injuries may result in
pigmentary abnormalities. The epidermis contains
no collagen fibers but has impressive growth poten-
tial, enabling epithelial cell migration often to cover
wide wounds within a few days when given the
appropriate conditions. Collagen is extensively cross-
linked in the dermis and provides intrinsic strength
to this layer.1 The process of laying down dermal
collagen matrix after superficial wounding requires
Department of Surgery, Otolaryngology—Head and Neck Surgery, Emory University
Atlanta, Georgia
Reprint requests: Dr. Dyer II, 1218 W. Paces Ferry Rd., Suite 108, Atlanta, GA 30327
Copyright ©1995 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
much more time than epithelialization, and ulti-
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mately the strength of the skin depends on the thick-
ness of the dermis.
WOUND HEALING
Controlled wounding with chemical peel agents
produces a partial thickness wound that heals by
secondary intention. Golsen2 defines wound healing
as "the interaction of a series of complex events that
leads to the resurfacing, reconstitution, and propor-
tionate restoration of tensile strength of wounded
skin. Partial-thickness wounds penetrate partially
but not completely into the dermis. These defects
heal by reepithelialization from residual adnexal
epithelium or epithelium derived from adjacent un-
injured skin. Healing is rapid and scarring is clini-
cally imperceptible since contraction does not gener-
ally occur."
Wound healing is accomplished in multiple phases
that overlap over time (Fig. I).3 On injury, an imme-
diate vascular and inflammatory response occurs.
The complex cellular response activated by the in-
jury mediates the inflammatory phase, which nor-
mally persists for at least 1 week. Granulation tissue
begins to form, providing a temporary matrix over
which epithelial cells and fibroblasts may proliferate
within the wound. Polymorphonuclear leukocytes
stimulated by the cellular response remove bacteria
from the wound. In a contaminated wound, poly-
47
FACIAL PLASTIC SURGERY Volume 11, Number 1 January 1995

vasoeoAarmc~lon INFUMMAToRY PHASE

C.IIuIar Response
...............................
PROLIFERATIVE PHASE

I MATURATION I REMODELING PHASE

I I I I I I I I I I I I
P
$ $'
P ,f &?
. **
3
8
3
8'
,s,
*$
4
' . ha'
Figure 1. Phases of wound healing.
8

morphonuclear leukocytes persist and prolong the Bio-occlusive dressing

inflammatory phase. This extended inflammation
Moist exudate

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may account for more severe cellular damage, in-
creasing the original wound depth and resultant
scarring. Thus, it is important to minimize contam-
---- Wound surface

ination and inflammation to maximize the rate of

epithelialization. Macrophages also migrate to the
wound and are essential for phagocytosis and tissue
\ Migrating epithelial cells
debridement.4 During the proliferative phase of Figure 2. Epidermal migration beneath a moist wound.
wound healing, epithelial regeneration is maxi- (With permission of Dr. Jim English.)
mized. Fibroplasia, collagen formation, and neo-
vascularization also occur within this phase. Wound
contraction is often minimal in superficial injuries, the early postoperative period to enhance reepithe-
but may account for the tightening of skin demon- lialization. Numerous semiocclusive or occlusive
strated in medium to deep chemical peels. Epithe- dressings have been developed. Numerous types of
lialization begins within 24 hours of injury by migra- bio-occlusive dressings are delineated in Table
tion of epithelial cells from the surrounding wound Occlusive dressings not only encourage epithelial-
margins or from the deeper adnexal structures, such ization, but have the added advantage of promoting
as hair follicles or sebaceous glands.5 The rapidly fibroblast proliferation." However, bacteria also have
advancing front of epithelial cells continues until it the opportunity to proliferate under such dressings.
comes in contact with other epithelial cells. Simul- Contaminated states may lead to local bacterial
taneously, basal cells within the wound begin mitotic wound infection, and wound healing will be pro-
activities, thus thickening the new epithelial layer. It longed. Bacteria delay the normal healing phases by
has been shown that the rate of postoperative epi- directly damaging cells of wound repair, by pro-
thelialization may be increased by preoperative longing the inflammatory phase, and by competing
treatment of the skin with tretinoin 0.1% (Retin-A)in for oxygen and nutrients within the wound.12J3
a double-blind placebo study.6
It has been demonstrated by Maibach and Rovee7
that in a moist environment, wounds will heal ap-
proximately 40% faster than those that undergo dei-
iccation.819 If a wound is kept moist, particularly
with an occlusive dressing, epithelial migration pro-
ceeds more directly and efficiently. Conversely,wound
desiccation sipficantly impairs normal wound heal-
ing? When a desiccated crust forms over wounded
skin, the migrating epidermis takes a longer, less
I Normal scab

efficient route, thus delaying epithelialization (Figs.

2,3). Accordingly, most surgeons prefer to maintain Figure 3. Epidermal migration beneath a dry wound.
a moist environment for chemically peeled skin in (With permission of Dr. Jim English.)
 REGIMEN FOR CHEMICAL PEELING-Dyer

Table 1. Bio-Occlusive Dressings* --

~e~meabilit~
Name Types of Composition Transparent Adherent Absorbent Gas Fluid Clinical Uses
Ob-Slte Polyurethane Yes Yes No Yes No Sutured wounds, cutaneous
ulcers, skln-graft sltes,
laser wounds
Tegaderm Polyurethane Yes Yes No Yes No Same as for Ob-Slte
B~oclus~ve Polyurethane Yes Yes No Yes No Same as for Ob-Slte
Ensure Polyurethane Yes Yes No Yes No Same as for Ob-Slte
Vlgllon Polyurethane ox~de/water Part~ally No Yes Yest Yest Dermabras~ons,laser
wounds
Spenco Second Polyurethane ox~de/water Part~ally No Yes Yest Yest Dermabras~ons,laser
Skln wounds, frlctlon bl~sters
Duoderm Hydrocollo~d No Yes Yes No No Cutaneous ulcers, sutured
wounds, dermabraslons,
frlctlon bllsters
Comfeel Ulcus Hydrocollord No Yes Yes No No Same as for Duoderm
Blobrane S~l~cone/nylon
wlth No No No Yes Yes Thermal burns,
collagen peptldes dermabras~ons
N-terface Monof~lamentplastic No No No Yes Yes Skln grafts, dermabraslons
*Modified from Wheeland.19
+Permeability of gas and fluid depends on the removal of one or both of the supportive polyethylene sheets.

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Therefore, it is imperative to change the dressings
and cleanse the area beneath the dressing at least
every other day.
It has been shown that certain topical agents may
affect epidermal migration (Table 214). All of the
agents noted within Table 2 promote hydration by
covering the peeled areas and reducing desiccation.
Those containing antibacterial properties tend to in-
crease the relative healing rate and those without
similar antibacterial properties tend to decrease the
healing rate. Providing a sterile environment along
with hydration will help promote epithelialization.
Short-acting corticosteroids are often used to mini-
mize edema and inflammation within the immedi-
ate postpeel period, but this would not be recom-
mended without the simultaneous use of antibiotic
prophylaxis. Clinical morbidity is decreased with
low to moderate doses of corticosteroids, but high-
dose corticosteroids are contraindicated due to a
direct inhibitory effect on early wound healing that
has been reported in the rat model.l5
Systemic disease, genetic or acquired, can ad-
versely affect wound healing. The more common
genetic disorders include Ehlers-Danlos syndrome,
cutis laxa, progeria, pseudoxanthoma elasticum,
among others. Some diseases have both a genetic
and acquired basis, such as metabolic disorders, vas-
cular disorders, keloid/hypertrophic scars, and im-
mune deficiencies.12J6 Infections represent an ac-
quired cause for poor wound healing. Infectious
etiologies with chemical peels include bacterial (most
commonly Staphylococcus aureus and Pseudornonas
species), viral17 (most commonly herpes simplex),
and fungal (most commonly Candida). Iatrogenic
causes of impaired cutaneous wound healing in-
clude radiation therapy and 13 cis-retonoic acid (Ac-
cutane). The use of 13 cis-retonoic acid has been
shown to impair wound reepithelialization and
should be avoided 6 to 12 months prior to chemical
peeling or dermabrasion.18
A N APPROACH T O POSTOPERATIVE
CHEMICAL PEEL CARE

Table 2. Topical Agents By understanding the phases of wound repair,

That Affect Eaidermal Mieration* and the effects of medications, dressings, and sys-
Relative Healing temic agents on the skin, we are able to optimize the
Agent Ratet (%)
local environment for wound healing. Our approach
Neosporin ointment* +25 to postoperative chemical peel wound care and its
Silvadene creams f38
Eucerin cream +5 rationale are discussed (Table 3).
Petrolatum, USP -8 Preoperative patient selection for chemical peel-
Triamcinolone acetonide oiuntment, 0.l0/0 - 34
ing is very important, but, in all patients, preopera-
*Adapted from Geronemus et tive conditions that may optimize the cutaneous re-
+Guinea pig skin. sponse to wounding are considered. The patient's
*Contains neomycin sulfate, polymyxin B sulfate, and bacitracin
zinc. perioperative nutritional status is important, and
§Contains 1% sulfadiazine silver. they are encouraged to eat a well-balanced diet with
FACIAL PLASTIC SURGERY Volume 11, Number 1 January 1995

Table 3. An Approach to Chemical Peel Care

Preoperative Postoperative
2 Weeks 1 Day 24 Hours 2-7 Days 7-14 Days Extended Treatment
Medication
Vitamins x x x x As needed
Prophylactic acyclovir x x x x
Prophylactic antibiotics x x x x
Tretinoin cream x As needed
Lidocaine ointment x
Methylprednisolone x x As needed
Cortisone cream As needed As needed
Hydroquinone cream As needed As needed
Petrolatum ointment x As needed
Sunblock a30 SPF* x
Treatment
High protein diet x x x x x As needed
Oral hydration x x x x As needed
Occlusive ointment x x
Bio-occlusive dressing x
Wound debridement x As needed
*SPF: sun protection factor.

an emphasis on extra protein. Preoperatively, multi- for four different time frames: the first 24 hours, 2

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vitamins are begun to ensure that trace elements and
enzymatic cofactors are adequate for protein syn-
thesis. We believe that a high protein diet and vita-
mins are important from 1 week preoperatively to l
month postoperatively. Oral antibacterial and anti-
viral agents (cefaclor 250 mg three times daily and
acyclovir 800 mg three times daily) are used pro-
phylactically beginning 1 day preoperatively and
continuing until the completion of epithelialization.
The skin is prepared preoperatively with a 2-week
treatment of 0.05 to 0.1% tretinoin to enhance the
postoperative wound healing. This regimen is dis-
continued 1day prior to chemical peeling. Preopera-
tive hydration is also important, and patients are
encouraged to drink at least 1quart of liquid (prefer-
ably Gatorade) the evening before surgery.
Postoperatively, wound treatment differs slightly
to 7 days, 7 to 14 days, and from 2 weeks on.
Immediately after the chemical peel procedure is
complete and during the first 12 to 24 hours, a thin
layer of lidocaine ointment 5% is applied to the
wound as needed to decrease pain, provide wound
occlusion, and hydration. It is occasionally mixed
with petrolatum for better hydration. Oral methyl-
prednisolone in a tapering dosage (Medrol Dose-
pac) is used to limit the inflammatory response.
During days 2 to 7, the wound care is directed
toward removing the debris of the superficial skin
slough. Patients are directed to wash the area every
4 to 6 hours with water (shower) and gently mas-
sage the skin with their fingertips. The use of cotton
balls, tissue paper, and washcloths to remove debris
is discouraged because cotton and wood fibers may
easily be incorporated into the new epithelium, pro-

Figure 4. There is incomplete epi-

thelialization at 7 days postoperatively.

. Figure 5. Appearance with Duo-
derm bio-occlusive dressing applied.
Figure 6. At 48 hours after Duo-
derrn application, epithelialization i s
complete.
longing the inflammatory phase. Hydration of the
skin is maintained with a thick covering of pe-
trolatum. During the first 2 weeks, if a dramatic
increase in pain is noted, herpes simplex virus infec-
tion is the likely cause. Acyclovir is increased to
double the prophylactic dosage, and symptoms usu-
ally subside over 24 hours. At 7 days, most deep
peels are approximately 80% epithelialized, and
most medium peels are completely resurfaced.
Between 7 and 14 days postoperatively, bio-occlu-
sive dressings (our choice is Duoderm; Figs. 4-6) are
utilized to cover any areas yet to be epithelialized
completely. If there appears to be a persistent in-
flammatory response, a second course of methyl-
prednisolone is given. Until the wound area is fully
epithelialized, the patient is maintained on systemic
antibiotics and acyclovir. Hytone cream may also be
added to the regimen to help treat the inflammatory
response. Any early hyperpigmentation may be
treated with hydroquinone (2%).
REGIMEN FOR CHEMICAL PEELING-Dyer
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CONCLUSION
In treatment of the aging face, chemical peeling is
one of the most useful modalities available to com-
plement incisional surgery. A requirement for pre-
dictable results is a sound knowledge of the skin's
reaction to the peeling agents and a logical approach
to postoperative wound treatment. Appropriate pa-
tient selection and avoidance of complications by
adequate patient follow-up are necessary to obtain
the best outcome. These principles should allow fa-
cial plastic surgeons to incorporate chemical peeling
into their armamentarium and provide consistent,
predictable results.
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