Skin Rejuvenation: Microdermabrasion and Chemical Peels

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IAPAM Reports on Skin Rejuvenation Treatments:  Medical Microdermabrasion, Dermabrasion and Medical-Grade Chemical Peels

The IAPAM’s Aesthetic Medicine Symposiums represent the most comprehensive minimally invasive modality training for physicians new to the aesthetic medicine field.  The IAPAM’s multi-day Aesthetic Medicine Symposium program focuses on the top 5 minimally-invasive treatments:  botox, dermal fillers, medical microdermabrasion, medical grade chemical peels and laser and light procedures.

The use of exfoliating agents to peel the epidermis and superficial dermis date back to ancient Egypt.  Sour milk baths were used to soothe the skin.  Salt and brimstone were used to exfoliate and produce a more elegant appearance.  Today, deeper dermal injury is used to improve deformities due to photoaging and acne.  Chemabrasion and mechanical abrasion (dermabrasion) are used to resurface skin to achieve a more youthful appearance (Source:  Photoaging, Rigel, Weiss and Lim, 2004).

The IAPAM focuses on training physicians and their medical staff in the best practices for two of the most popular skin rejuvenation procedures: medical-grade chemical peels and medical microdermabrasion.  For a comprehensive overview of the other core skin resurfacing treatment:  lasers and light therapies, see the IAPAM’s newly updated Resouces page – http://iapam.com/aesthetic-resources/lasers-and-light-based-devices .

For more detailed information on medical microdermabrasion and chemical peel “best practices”, along with more information on providing the other core minimally-invasive treatments to your patients, please visit the IAPAM’s Aesthetic Medicine Symposium, (http://www.aestheticmedicinesymposium.com) or contact the IAPAM at 1-800-219-5108 x704.

See also  Microdermabrasion” by Genisis Biosystems and an overview of Genesis Biosystems 3-1 Combination Therapy – AccelaFuze (TM)

Medical Microdermabrasion

Since its introduction in the US in 1996, microdermabrasion offers a simple, relatively inexpensive treatment for photoaging, with rapid recovery time.

It is one of the most popular procedures in the US (ASPAS reported 621,943 microdermabrasion procedures in 2009).

It requires no anesthesia, and can be used on all Fitzpatrick skin types, and has minimal risk for dyschromia, infection or scarring.

Source:  Photoaging, Rigel, Weiss and Lim, 2004.

Medical microdermabrasion is a resurfacing procedure with an abrasive instrument that mechanically sands the skin to remove some of the top skin layer (epidermis) and stimulate new skin growth.  By removing the outer skin layers and smoothing the treated skin the physician can achieve a rejuvenated appearance. Using micro-particles, or a diamond-tipped wand, the plastic surgeon uses a device, like a fine sandblaster, to spray tiny crystals across the face, mixing gentle abrasion with suction to remove the dead, outer layer of skin. As with other skin rejuvenation techniques, more than one treatment may be needed to reduce or remove fine wrinkles and unwanted pigmentation.

This technique is used to treat substantial scarring, discoloration, and sun damage, as well as:

  • reduce wrinkles
  • tighten loose skin
  • improve skin tone and color
  • remove blotchiness
  • eliminate damaged blood vessels

Source: http://www.aad.org/public/publications/pamphlets/cosmetic_facial.html

According to the American Academy of Dermatology (AAD), medical microdermabrasion treatments are often needed and should be spaced two to three weeks apart.

Complications

There are virtually no known side effects associated with microdermabrasion. The AAD advises that microdermabrasion does not require an anesthetic and involves little or no recovery time or downtime.

Cost

Patients can expect to pay more for medical microdermabrasion in major cities and in dermatologists’ offices. Average prices range from $125 to $180 in major urban centre and $65-125 elsewhere.

Equipment costs for adding medical microderm typically costs around $200-500/month.

Source:  http://www.ehow.com/facts_5760543_cost-medical-microdermabrasion_.html

New Advances in Microdermabrasion Treatments

The Accelafuze System by Genesis Biosystems offers a new 3-1 combination therapy for medical microdermabrasion pateints.

Accelafuze™ delivers three clinically effective treatments without pain or downtime. These three separate, yet uniquely necessary, skin treatments in one system.

First, a gentle, crystal-free peel of the stratum cornium is performed.

After the aged cells of the skin are removed, an infusion of scientifically formulated topical serums is given specifically for the skin condition being treated. The infusion process is cool, soothing and extremely effective as the newly peeled surface of the skin drinks in the nutrients that are professionally applied through the Accelafuze™ process.

The final stage is LED Light Therapy. It is applied to the treatment area, providing multiple benefits to complete the treatment regimen.

For more information on Genisis Biosystems’ Accelafuze (TM), see http://www.genesisbiosystems.com/product/accelafuze-systems.html

Dermabrasion and Dermaplaning

A more invasive form of skin resurfacing is dermabrasion (and dermaplanning).

Dermabrasion and dermaplaning help to “refinish” the skin’s top layers through a method of controlled surgical scraping. The treatments soften the sharp edges of surface irregularities, giving the skin a smoother appearance.

Dermabrasion is most often used to improve the look of facial skin left scarred by accidents or previous surgery, or to smooth out fine facial wrinkles, such as those around the mouth. It’s also sometimes used to remove the pre-cancerous growths called keratoses. Dermaplaning is commonly used to treat deep acne scars.

Both dermabrasion and dermaplaning can be performed on small areas of skin or on the entire face. They can be used alone, or in conjunction with other procedures such as facelift, scar removal or revision, or chemical peel.

Source: http://www.plasticsurgery.org/Patients_and_Consumers/Procedures/Cosmetic_Procedures/Dermabrasion.html

Chemical Peels

Chemical peels are the acceleration of exfoliation using a chemical agent.  Very light peeling agents induce a faster sloughing of the cells in the stratum corneum, whereas deeper peeling agents create necrosis and inflammation in the epidermis, papillary dermis or reticular dermis. A chemical peel uses a chemical solution to improve and smooth the texture of the facial skin by removing its damaged outer layers. This is helpful for individuals who suffer from facial blemishes, wrinkles and uneven skin pigmentation. A chemical peel is most commonly performed to enhance appearance. Chemical peels may also remove pre-cancerous skin growths, soften acne scarring and control acne. In certain cases, health insurance may cover the peel procedure.

Peeling Agents:

  • Alpha Hydroxy Acids (AHA)
  • Trichloroacetic Acid (TCA)
  • Phenol
  • Salicylic Acid
  • Jessner’s Solution
  • Retinoids (Retinoic acid, retinol, retinyl palmitate, retinaldehyde)
  • Resorcinol
  • Alpha Keto Acids (Pyruvic Acid)

The precise formula used may be adjusted to meet each patient’s needs. Peeling agents are classified as follows

Very Superficial

  • Glycolic acid 30% to 50% applied briefly for 1-2 minutes
  • Jessner’s solution applied in 1 to 3 coats
  • Low-concentration resorcinol 2-% to 30% applied briefly (5 to 10 minutes)
  • TCA 10% applied in 1 coat

Superficial

  • Glycolic acid 50% to 70% applied for a variable time (2 to 20 minutes)
  • Jessner’s solution applied in 4 to 10 coats
  • Resorcinol 40% to 50% applied for 30 to 60 minutes
  • TCA 10% to 30%

Medium Depth

  • Glycolic acid 70% applied for a variable time (3 to 30 minutes)
  • TCA 35% to 50%
  • Augmented TCA (CO2 plus TCA 35%; Jessner’s solution plus TCA 35%; glycolic acid 70% plus TCA 35%)

Deep

  • Phenol 88%
  • Baker Gordon Phenol Formula

Source:  Manual of Chemical Peels, Mark Rubin, 1995.

Alpha hydroxy acids (AHA)

Alpha hydroxy acids are a group of water-soluble carboxylic acids. They work to release the desmosomes that hold skin cells together. This action allows for easier exfoliation and increased cell turnover. AHA are also thought to stimulate fibroblasts to produce collagen and elastin to strengthen the matrix and firm the skin. AHA, include glycolic acid, malic acid, tartaric acid, mandelic acid, lactic acid, or citric acid. These types of peels can provide smoother, brighter-looking skin for people who can’t spare the time to recover from a phenol or deeper TCA peel. AHA peels may be used to treat fine lines and wrinkles, areas of dryness, uneven pigmentation and acne. Various concentrations of an AHA may be applied according to the skin condition being treated.

Uses:

  • Smoothes rough, dry skin
  • Improves texture of sun-damaged skin
  • Aids in control of acne
  • Can be mixed with bleaching agent to correct pigmentation

Considerations:

  • A series of peels may be needed
  • As with most peel treatments, a full spectrum UVA/UVB sun block is recommended

Trichloroacetic acid (TCA)

TCA is a very safe peeling agent that has been used for over 50 years. It does not absorb into the bloodstream. This acid is typically used at higher percentages by physicians for traditional chemical resurfacing procedure. When used as a single acid at high percentages, it is best for textural concerns such as scarring and moderate to deeper wrinkling because of its action as a cauterant (breaking down living tissue). It is typically more aggressive when used as a single acid, but can be safely applied as a superficial peel, even on higher Fitzpatrick and sensitive skin, when used in a blended formulation.

Uses:

  • Smoothes out fine lines and surface wrinkles
  • Aids in control of acne
  • Corrects pigment problems

Considerations:

  • Can be used on neck or other body areas
  • May require pre-treatment with Retin-A or AHA creams
  • Treatment takes only 10-15 minutes
  • Peel depth can be adjusted
  • Repeat treatment may be needed to maintain results
  • A full spectrum UVA/UVB sunscreen must be used for several months
  • Healing is usually much quicker than with a phenol peel
  • TCA peels that are blended with additional ingredients produce less downtime and increased benefits

Phenol Peel

Phenol is the strongest of the chemical solutions. It is used mainly to treat patients with coarse facial wrinkles, damaged skin caused by sun exposure, or pre-cancerous growths. Since phenol sometimes lightens the treated areas, your skin color may be a determining factor as to whether or not this is an appropriate treatment for you. Phenol is primarily used on the face; scarring may result if it’s applied to the neck or other body areas.
Uses:

  • Corrects uneven pigmentation caused by sun exposure, birth-control pills, aging, etc.
  • Smoothes out coarse wrinkles
  • Removes pre-cancerous growths

Considerations:

  • Used on the face only
  • Not recommended for higher Fitzpatricks
  • Procedure may pose risk for patients with heart problems
  • Full-face treatment may take one hour or more
  • Recovery may be slow – Complete healing may take several months
  • May permanently remove facial freckles
  • A full spectrum UVA/UVB sun block must be used at all times
  • Results are dramatic and long-lasting
  • Permanent skin lightening and lines of demarcation may occur

With a phenol peel, the new skin frequently loses its ability to make pigment (that is, tan). This means that not only will the skin be lighter in color, but protection from the sun will always be necessary. Phenol may pose a special risk for patients with a history of heart disease. It’s important that you make your surgeon aware of any heart problems when your medical history is taken. It is also possible that phenol will cause some undesired cosmetic results, such as uneven pigment changes. Certain modified phenol peels are gentler and may be preferred in some circumstances.

Source: 

Beta Hydroxy (and Salicylic Acid) Peels

The only beta hydroxy acid typically used in skin care is salicylic acid. Salicylic acid is lipophilic and has the ability to penetrate into oil-filled follicles and breakdown impaction. It also functions to normalize the excess inter-follicular cell shedding that contributes to the formation of microcomedones. Salicylic acid has a keratolytic action the works to break down surface impaction, leaving the skin smooth. Because of this, salicylic acid typically produces little to no post-treatment exfoliation.

Jessner’s Peel

Jessner’s peel solution, formerly known as the Coombe’s formula, was pioneered by Dr. Max Jessner, a German-American dermatologist. Dr. Jessner combined 14% salicylic acid, lactic acid and resorcinol in an ethanol base. It is thought to break intracellular bridges between keratinocytes. It is very difficult to “overpeel” the skin due to the mild percentages associated with the acid combination.  The Jessner’s Peel is ideal for dull, slightly wrinkled, sensitive and dark skins and treatment for chronological aging and/or acne and acne scarring.

Uses:

  • Corrects uneven pigmentation caused by sun exposure, birth-control pills, aging, etc.
  • Smoothes out fine lines and wrinkles
  • Aids in controlling acne and over productive sebaceous glands

Considerations:

  • Used on the face, can be used on the body
  • Can be used on darker Fitzpatricks
  • Full-face treatment takes 20-30 minutes
  • Recovery is typically quick; 7-10 days
  • A full spectrum UVA/UVB sunscreen is highly recommended

Modified and Enhanced Jessner’s Solution

The Modified and Enhanced Jessner Solution was coined 20 years ago by PCA SKIN’s founder Margaret Ancira.  The original modified Jessner solution is enhanced with additional citric acid, kojic acid and hydroquinone for increased benefits.

Uses:

  • Provides all of the benefits of the traditional Jessner’s Solution plus accelerated evening of
  • discolorations.
  • Assists in the clearance of acne, hyperpigmentation, asphyxiated skin and sun damaged skin.
  • Can be used on darker Fitzpatricks

Considerations:

  • Full face treatment takes only 20-30 minutes
  • Added ingredients significantly reduce the risk of complications and discolorations
  • No down time or recovery is required
  • A full spectrum UVA/UVB sunscreen is highly recommended

Retinoids

Retinoic acid is derived from retinoids; which is denatured vitamin A. It is chemically similar to Retin-A.
Retinoids, which are vitamin A derivatives, have many benefits for the skin. They are ingredients that have many normalizing benefits. They work to increase cell turnover and, at high percentages, act to increase post-treatment exfoliation. This is particularly important for lifting pigmentation, reducing impaction in acne patients and when treating aging skin that has a naturally slowed cell turnover cycle. Additionally, retinoids act as melanogenesis inhibitors by preventing the production and distribution of pigment.
Retinoic acid can be irritating to some skin types, although it may be necessary in more severe skin conditions. Retinol is a gentler vitamin A derivative that is effective, yet non-irritating. Retinol is converted to retinoic acid in the skin.

Uses:

  • Used to treat acne, aging skin, hyperpigmentation and sun damaged skin
  • Best indicated for Fitzpatrick I-VI

Considerations:

  • Full face treatment takes only 20-30 minutes
  • The use of retinoids may increase visible flaking following treatment
  • A full spectrum UVA/UVB sunscreen is highly recommended

Blended Peeling Solutions

Certain chemical peels use blends of well-tolerated, safe and effective peeling ingredients. Alpha hydroxy acids (AHA), beta hydroxy acids (BHA), trichloroacetic acid (TCA) and retinoids are used in strategic combinations to address a wide variety of skin concerns. These ingredients work to break down surface build-up and loosen the desmosome bonds holding the keratinocytes together. Ancillary ingredients that nourish, strengthen and protect the skin are incorporated into the formulas so the skin is flooded with these beneficial actives during treatment.

Blended peels are unique in that they typically do not require neutralization.  They are not timed and removed from the skin. Instead, they are self-neutralizing and are left on the skin, with the exception of the masks, which are removed with moist cotton. Unlike straight acid alpha hydroxy acid peels that can potentially collect in the upper portions of the skin and cause surface irritation or burns, blended peels can be formulated to be naturally neutralized by constituents of the skin and its water content. The strength and depth of the treatment is controlled by the professional based on the number of layers applied during treatment. After peel application, nutritive topicals and calming moisturizers with SPF are recommended and the patient leaves with a glowing, healthy complexion. This makes the experience much more relaxed and pleasant for both the clinician and patient.

Chemical Peel Complications

  • The 2 main causes of complications are incorrect peel pharmacology and accidental solution misplacement.
  • It is best to pour the solution in a secondary container rather than apply the solution spun around the neck of the bottle.  Intact crystals may give the solution a higher concentration, if taken directly from its container.
  • Saline and bicarbonate of soda should always be available for neutralization of acids.Source:  Photoaging, Rigel, Weiss and Lim, 2004
  • The use of blended chemical peels significantly reduces post-treatment downtime and the risk of complications.

Costs


  1. Start Up Costs are Low:  Chemical Peel start up costs are very low ($2,000, assuming you have a treatment room and table)
  2. Margin is high: the cost to provide a chemical peel treatment is $25 ($20 labor, $5 products) and the retail is typically around $125, so the profit is $100.
  3. Patients repeat the treatment often:  For success in chemical resurfacing, the patient needs to come back once a month, so with a chemical peel patient, one can make $1,200/yr.
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