As the face is the most exposed area, it shows initially when the signs of aging appear. Aging skin signs like wrinkles and flaccidity are usually present in the elderly population. Sunlight exposure abbreviates skin aging and causes worsening of wrinkles, laxity, and changes in skin pigmentation like freckles, solar lentigo, and melasma. Also neoplastic growth as solar keratosis, basal cell carcinoma, or epidermoid carcinoma are present mostly in skin exposed areas. All these together, skin laxity, wrinkles, pigment disorders, and leather texture contribute to the loss of beauty and attractiveness and can cause aesthetic and psychological problems.

Among several rejuvenating technologies Exoderm buffered deep peel has shown to be a fantastic tool for dermatologists as well as for plastic and cosmetic surgeons. This peel was developed 25 years ago by Fintsi. Exoderm is the result of medical research over many years and is composed of 12 components, including phenol, resorcin, citric acid, and a variety of natural oils. More than a decade of experience in more than 20,000 patients and 35 countries has shown that this method is safe and minimizes any systemic side effects or permanent damage. The results are impressive and cause a high degree of patient satisfaction and longlasting results (Fig. 60.1). It is not a substitute for surgery, but in several cases, it can be done instead of surgery or it can be complementary after facial surgery has been performed.

C. Santos

Dermatology in Private Practice, Department of Dermatology, Avenida Brasil, 583 Jardim Europa, CEP 01431-000 São Paulo, Brazil

e-mail: clara_santos@terra.com.br

It is interesting to have skin preparation as it is in any other chemical peel. This is especially important if skin is thicker, in darker skin type, and when hyperpigmentation disorder is present.

When the patient decides to have Exoderm done, basic blood analysis and cardiac evaluation should be done as the procedure is under intravenous (IV) sedation.

The procedure is easy to perform. Patients feel comfortable as IV sedation prevents pain. A point to be taken into careful attention is related to postpeeling edema. Facial swelling is a normal and expected reaction, but as it is important, patients and family must know about it in advance in order to avoid misunderstandings. Also temporary (from 8 to 12 weeks) postpeeling redness has to be fully understood and accepted as it is normal in post peel evolution (Fig. 60.2). Patients must know they are allowed to make up to blend this erythema after the eighth day.

60.3 Instructions

60.3.1 Day of Treatment

1.Patients must wash the face completely with water and a neutral soap.

2.The anesthetist must see the patient in advance and make the prescription of the preoperative medication as well as take care of the monitoring and IV sedation during the procedure. Scrub carefully the entire face with 100% acetone to degrease the skin thoroughly. To achieve a proper scrub, use two 4 × 4 gauzes and apply it with little pressure. Be sure to

go to the eye lids only when the gauzes are dry, but over the lids no pressure is necessary. If correctly done, the facial skin will present a homogeneous erythematic aspect. Ask the patient to sit down and then mark a line 1–2 cm below the mandible ridges as the endpoint for application.

3.Tie the hair behind and use a plastic cap to cover it.

4.Stir (shake) the bottle well before using it. Soak a cotton Q-tip (Fig. 60.3) with the Exoderm solution and squeeze the Q-tip against the bottleneck several times to remove excess solution.

5.Start by applying with a rolling motion with slight pressure into the frontal hairline and forehead until you get an even frosting (Fig. 60.3). Have a dry

cotton ball and clean the Exoderm solution excess right after the frost appears. Apply solution a few millimeters into the hairline in all areas. Gradually cover the entire forehead and then continue on to the temples, eyebrows, eyelids, cheeks, nose, chin, perioral region, etc.

6.Apply the Exoderm solution with a longer Q-tip. Use a cotton ball to clean the Exoderm solution excess right after the frost appears. Gradually cover the entire forehead and then continue working following the anatomical units.

7.Apply 1 mm to the lower vermilion border on the lips (Fig. 60.4). A little more pressure may be used in deep perioral lines. After having done this area, a tiny

wood stick should be applied into each wrinkle line over the lips. This is useful because peribuccal wrinkles are hard to treat. There will be some cases where next day abrasion may be necessary. But it is useful to comment to patient that applying the Exoderm solution and abrading the lips may have a potential risk of hypochromia. Most patients avoid this possibility and understand that most heavy peribuccal

wrinkles will clear but maybe there will still be some lines. Patients understand this easily and they do not get disappointed if they know it in advance. We always work going into the vermilion border and this does not cause any special discomfort to patients at all. It is imperative to know if patient has a positive past history for simplex herpes. In this case, antiviral drugs should be started 2 days in advance.

8.The eyelids will be the most sensitive area for application and should be treated in the moment the patient is sleeping deeper. No pressure is necessary to apply the Exoderm solution on eyelids (Fig. 60.5).

9.On the eyebrows, the application should be in the opposite direction of the hair growth to be certain all the skin is treated.

10.On the eyelids make sure that the Q-tip is nearly dry and apply right to the eyelash margin on the upper and lower lids. When applying to the eyelids, the application should be in the direction away from the eyelid margin. Always have a dry gauze ready to absorb any tears prior to or during the application of the solution.

11.The first application should take about 50–55 min. After the full face is done, start a second coat. This time you can do faster. A third application will be done only over the more damaged area

(s)as on wrinkles and scars using little more pressure.

12.Be sure to treat into the hairline all around and in the sideburns and upper preauricular area.

13.Dry the skin before applying the tape. Use medium size Micropore tape to cover the entire face except the upper eyelids and eyebrows in an overlapping manner. Several layers will be necessary in order to get a perfect occlusion. You must apply the tape overlapping many times, that you won’t be able to

see the skin through its transparency. The Micropore mask will be completed when a white color like “snow” is achieved. Stretch the wrinkles and crow’s feet before applying the white color tape to reduce the chances of air pockets developing.

14.Tape the shower cap down to the frontal scalp and along the temporal hairline.

15.Feather the edges of the tape like a stepladder below the mandible. Leave 0.5–1 cm free at the bottom.

16.Once the tape mask is in place, press firmly down on the face to eliminate any possible air pockets and secure it on the face.

60.3.2Second Day: Micropore Tape Mask Removal and Application of Subgalatic Mask

17.A complete set of pictures of all Exoderm steps, (Fig. 60.6).

18.Remove the tape mask after 24 h. Start releasing it kindly, from the top at the hairline pulling downward.

19.The old skin mostly presents liquefied. Clean off all the liquefied skin with a Q-tip soaked in normal saline.

20.If there is crusting present in any areas, apply saline-soaked gauze to help their removal. It may

Fig. 60.6 Typical case Exoderm evolution. (a) Pretreatment. (b) End of the procedure, patient with Micropore mask. (c) One day after treatment with Micropore mask removal and cleaning

skin liquefaction. (d) Subgalatic bismuth mask (7 days). (e) Eight months posttreatment

be necessary to use mild gauze soaked in normal saline for a light abrasion in these areas. But do it kindly. If it is difficult to remove, leave it. These darker areas represent dead skin and will peel off anyhow together with the bismuth subgalatic mask.

21.Apply Exoderm to the areas of the deepest wrinkles, pigmented area, and scars once more using your pretreatment drawing. If you are treating

acne scarring, use gauze abrasion over the edges of the scars or the Exoderm Chemo Abrasion, according to the proper technique.

22.Apply the bismuth subgalatic powder evenly with a rolling motion of a Q-tip to the entire face except the upper eyelids. If the powder does not stick in an area, use mild gauze abrasion and sterile saline and then try to reapply the powder.