several of the manufacturers has led to a proliferation of devices placed in the hands of those least educated about the potential for harm that may ensue from their use. Scarring, hyperpigmentation, hypopigmentation, and a host of other complications that may occur under the best of circumstances have become more frequent as the treatment of photoaging has been moved (to a large degree) from the dermatologist’s office to the mall. Regulations to govern the use of these devices including the need for supervision will, at some point, catch up with the technology and marketing, and this will hopefully bring the situation back into a balance that favors patient safety. Likewise, seminars that train nonspecialists may eventually become liable for the damages that these practitioners cause. This may have a chilling effect on the seminars that exchange official looking certificates designed to confer credibility for the price of the course.

15.5 Conclusions

Non-ablative photorejuvenation is here to stay because it is safe and effective. Enhancements to the technology will continue to improve the ability of the devices to treat the signs of aging. Improvements in technique, including the use of double-stacked pulses and the adjunctive uses of other procedures and medications, will increase the efficacy of the devices used. Regulations and public awareness campaigns will serve to decrease the complications associated with usage by nonphysicians and nonspecialists.

The use of these devices has transformed cosmetic dermatology by providing a safe and effective means to renovate the surface of the skin. Outcomes associated with these devices will continue to improve with refinements in training, techniques, and technology.

References

1.Marmur E, Goldberg D. Nonablative skin resurfacing. In: Dover J, Alam M, Goldberg D, editors. Procedures in cosmetic dermatology: lasers and lights, vol. 2. Philadelphia: Elsevier; 2005. p. 29–30.

2.Goldman M, Weiss R, Weiss M. Intense pulsed light as a nonablative approach to photoaging. Dermatol Surg. 2005; 31(9 Pt 2):1179–87.

3.Mark K, Sparacia R, Voight A, Marenus K, Sarnoff D. Objective and quantitative improvement of rosacea associated erythema after intense pulsed light treatment. Dermatol Surg. 2003;29(6):600–4.

4.Gold MH. The evolving role of aminolevulinic acid hydrochloride with photodynamic therapy in photoaging. Cutis. 2002;69(6 Suppl):8–13.

5.Hernandez-Perez E, Ibiett EV. Gross and microscopic findings in patients submitted to nonablative full face

resurfacing using intense pulsed light. Dermatol Surg. 2002; 28(8):651–5.

6.Zelickson B, Kist D. Pulsed dye laser and photoderm treatment stimulate production of type I collagen and collagenase transcripts in papillary dermis fibroblasts, (abstract). Lasers Surg Med Suppl. 2001;13:33.

7.Goldberg DJ, Cutler KB. Nonablative treatment of rhytids with intense pulsed light. Lasers Surg Med. 2000;26(2): 196–200.

8.Kligman D, Zhen Y. Intense pulsed light treatment of photoaged skin. Dermatol Surg. 2004;30(8):1085–90.

9.Carruthers J, Carruthers A. The effect of full face broadband light treatments alone and in combination with bilateral crow’s feet botulinum toxin type A chemodenervation. J Dermatol Surg. 2004;30(3):355–66.

10.Sperber B, Walling H, Arpey C, Whitaker D. Vesiculobullous eruption from intense pulsed light treatment. Dermatol Surg. 2005;31(3):345–8.

16.1 Introduction

Chemical peeling of facial skin has become an integral part of the armamentarium for resurfacing aging, sundamaged, and diseased skin. The desire to reverse the aging process has generated tremendous interest throughout history. Ancient texts describe the application of substances to the skin in an attempt to rejuvenate the appearance. More recently, many factors have contributed to the explosion of popularity of skin resurfacing procedures including the excess ultraviolet exposure both naturally and via tanning booths, the aging baby boomer cohort, youth-centric culture, smoking, ozone layer depletion, and the prevalence of both hot and cold weather outdoor recreations, which have all had a significant effect on people’s skin health and premature wrinkling.

The modern body of knowledge regarding chemical agents began with the description of a variety of agents still in use today by Unna [1], including salicylic acid, resorcinol, phenol, and trichloroacetic acid (TCA). Over the ensuing century, peeling became popularized by nonmedical practitioners and cosmeticians who attracted increasing attention because of the rejuvenating results they achieved. Subsequent scientific studies of chemical peels by the medical community have further delineated the indications and limitations of these procedures and improved safety and efficacy. We are currently in an era of rapid development of new

B.A. Bassichis

Department of Otolaryngology – Head and Neck Surgery, University of Texas – Southwestern Medical Center,

5323 Harry Hines Boulevard, Dallas, TX 75235, USA and Advanced Facial Plastic Surgery Center, 14755 Preston Road, Suite 110, Dallas, TX 75254, USA

e-mail: drbassichis@advancedfacialplastic.com

techniques for skin enhancement and rehabilitation, some of which offer the possibilities of dramatic results, with minimized discomfort and diminished downtime [2].

There are many products currently available for chemical resurfacing of the skin, from over-the-counter superficial peeling agents to deep peeling chemicals that should only be applied by a physician in a controlled setting [3]. Many of these products and procedures have proven very successful in improving the quality and appearance of facial skin. The goal of chemical peeling is to remove a controlled uniform thickness of damaged skin to improve and smooth the texture of the facial skin by removing the superficial layers and stimulate a wound healing response. In response to the chemical injury, fibroblasts in the papillary dermis increase production of collagen and growth factors. The collagen increase in turns thickens the dermis, which enhances the tensile strength of the skin and yields the clinical appearance of rejuvenation.

16.2 Skin Anatomy

The approach to chemical resurfacing of the skin necessitates a thorough knowledge of skin anatomy and normal wound healing. The skin is composed of two mutually dependent layers, the epidermis and dermis, which reside on a layer of subcutaneous adipose tissue. The epidermis is the most superficial layer of the skin and provides a critical barrier of protection. The epidermis is composed of keratinocytes in four layers: the stratum corneum, stratum granulosum, stratum spinosum, and stratum basale.

Reprinted with Permission of Springer, Berlin