Skin Peels, Part 2

Dr. Furnas (00:12):
Last time we talked about superficial skin peels and home peels. This week we're taking a dive into deeper peels. Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:25):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:39):
So last time we talked about the light level, home peels, superficial peels. We talked about chemical peels, enzyme peels, and physical peels, and we really focused on the chemical peels, the alpha hydroxy acids, the beta hydroxy acids. I mentioned Jessner's peel, which is a combination of both, but there are deeper peels.

Dr. Korman (01:06):
Well, skin is actually, it's the biggest organ in the body and different thicknesses, but the skin is pretty thick in different places. And on the face you can go below the epidermis, you can go below the superficial dermis and you can go pretty deep. It gets more dicey and you need a medical professional to assist, but you can get more effective results.

Dr. Furnas (01:33):
Well, in fact, Adam from Tempa asks how can a peel address his wrinkles and acne scars.

Dr. Korman (01:43):
But Tempe, Arizona, I think that's in the Sunbelt. So I think probably how you address your acne scarring, you have to remember you're in, you live in a sunny climate. But yeah, this is where you can see great results with the newer technologies and the peels. But remember where you're, what climate is and what time of the year you're going to do it.

Dr. Furnas (02:04):
So yes, and this is where we're going to go beyond alpha hydroxy acid and beta hydroxy acid and enzyme peels and get into something called trichloroacetic acid peels, commonly called TCA peels. And so this is an acid that is stronger than alpha hydroxy and beta hydroxy acids. And so it can penetrate into the dermis. So the dermis is a deeper layer of skin. You've probably heard the kids joke, you know, look out, your epidermis is showing. So your epidermis is just that superficial layer of skin where the dead cells are, the dermis has a blood supply and you can feel and it can bleed. And so the TCA peel will get into the dermis and alter the skin so it can actually tighten a little. It can address moderate wrinkles, sun damage and acne scars.

Dr. Korman (03:08):
Are these peels like one and done? I think one of the things that's important to understand is acne scars. I think part of the, as much as we would all like to have an eraser and just erase any scar we have so many people just say, can you use a laser? Can you use a peel, something to get the scar away? The scars can be pretty deep. And if you take the scar that if you really take the hills, meaning hills and valleys, if you take the hills down to bottom to the level of the scar, the deepest point in the scar, you might not have no skin left, which is why you have to do it sort of multiple times. You have to recognize that you're looking for improvement, significant improvement. But it's not like suddenly an eraser.

Dr. Furnas (03:55):
Exactly. The wrinkles will have actually thinning of the dermis, and so what you're trying to do is bring the shoulders of the wrinkle down so that the low point, the wrinkle itself is less evident. You can shrink the skin, build up collagen and thicken the dermis a little bit. So it's a combination, but really the most effective way of getting a deeper wrinkle to look not as deep is to bring down the shoulders with a chemical peel, as Josh said, the one and done will do a little bit. So you've revved up that collagen production, but you kind of need to touch it again. And so often peels will be done as a series like three to four or up to six based typically about a month, a month and a half apart, four to six weeks apart.

Dr. Korman (04:56):
So the different peels, there's salicylic acid peels, phenol peels, TCA peels, trinitone retinoic acid, which is vitamin A based. How should somebody think about what it is that they need given that there are all these things? Do you go to your medical professional and say, I want a peel. Do you say, I would like a TCA peel of 10%. I would like a phenol peel of 10%. What is a consumer, Joe and Jane consumer, what are we supposed to do?

Dr. Furnas (05:29):
Yeah. And that's where communication really is important. And what you do when you see a professional, you say, these are the wrinkles that bother me, and it's the medical professional, depending on the training of that medical professional, who then determines what's the best peel for you. Now these peels come in different strengths, and there will be some mixtures of peels. Some will have a little bit of TCA, a little bit of phenol, a little salicylic acid, a little retin A, vitamin C. And there'll be a mixture of different things that have different purposes. Now, years ago, phenol peels were used very often in combination with a facelift to address the wrinkles of the upper lip. And they did an amazing job at filling in those lines. But the problem with phenol peels is that they de pigmented these patients, the most commonly women. And having a facelift with a phenol peel and the phenol peel would be applied to the entire upper lip where all the lip lines were. And so patients would heal with this beautiful lineless upper lip or very few lines, but it was all white against their regular skin color. And so we really don't use phenol directly the way that it was once done. TCA is really the single ingredient peel that people will use. However, phenol has a place because it is so effective, but just at a very, very low concentration.

Dr. Korman (07:16):
And generally in lighter skin patients.

Dr. Furnas (07:20):
In lighter skin patients, exactly. Yeah. Josh brings up a good point. In the last episode, we talked about the level of pigmentation with levels one through six with six being the darkest. And so some of these peels will be great for say, skin types one through three, not so much for four, five, or six, because it is possible to pigment with some of these chemicals.

Dr. Korman (07:51):
Okay. So it sounds like TCA peels are common and salicylic acid peels, phenol peels are stronger. So what do we do? There's so many technologies out there that because there's a high demand for eliminating wrinkles, we know about lasers, we know about machines. Are there any machines that do peels?

Dr. Furnas (08:16):
Well, there are the dermabrasion type machines like HydraFacial and other dermabrasion things. So it's more mechanical peel as opposed to a chemical peel. However, some of those machines can infuse generally serums, something that benefit the skin as opposed to an additional peel. So generally when we look at technology, because a peel is really placing a chemical on the skin, and that is just, you don't really need a machine to do that. So the machine really is the laser. And Josh, if I came in with deep lines and said, I want a peel and I've got a lot of sun damage, why would I have a peel? Or why would I have a laser? What would you recommend?

Dr. Korman (09:10):
So one of the things that I think is important to understand about lasers, everybody thinks lasers like the magic wand and can do everything, which it can't. But I think the main thing about lasers is it's controlled. I mean, it's very specifically controlled. And one of the things about peels is it's yes, you can apply the solution, the acid solution to the skin for a certain length of time, but how much the person who's applying it presses it on the skin or how thick it is or for how long it stays on. Those are all quite variable. Where the laser is very specific. Literally a computer determines the depth, the practitioner sets the depth, but wherever you put it, it is going to be that depth. And so what that does is it avoids unevenness. It's quite even in the energy it delivers. Again, these are taking the hills down to get the think hills and valleys.

(10:13)
People often have fillers to lift up the valleys, but this is the taking the hills down, or as Heather said, the shoulders off the wrinkles. What does happen when you have these lasers? They come in two, they come in many versions, but there are fractionated lasers and there are not fractionated lasers. They're ablative lasers. And what the fractionated lasers do is they can go deeper, but they have little skin bridges so that you can have good recovery. So it's all a long a story to say what's happening, but basically you can do superficial and do multiple treatments, or you can go deeper and do one or two treatments. And I think that's the main difference between when you deal with lasers, you can go deeper, it's more controlled, and you have the option to do it multiple times, or you can go fewer times, but it's deeper, therefore longer recovery and a higher chance for pigmentation issues.

Dr. Furnas (11:19):
Yeah, no, if you have a really deep wrinkle or an acne scar, there will be a limit to what peel can do, at least with a concentration that is a safe concentration. So before lasers, people were using TCA peels at 50%. So that's a really strong peel. The results were dramatic, the lines would improve and acne scars, but there was a really high complication rate, a lot of depigmentation. So you could have splotches where the pigment just disappeared. You could have scarring of the face that could really make you look like a burn victim, which is basically what people were. And so nowadays there would be no reason to use a 50% TCA peel to penetrate that deep into the skin. So you use TCA peels up to maybe 30%. That's what we'll use. But once somebody comes in with really deep wrinkles, a lot of sun damage, then that's when I'll say I can control the depth at that deep level precisely with a laser.

(12:36)
But with a TCA peel, I don't have any control on how exactly the depth is. So there was a time when really strong TCA peels were being done less so now that said, a TCA peel still has greater risks, the greater the depth. And so that's why it really depends on whom you go to. At the aesthetician will be able to use maybe 10 to 12% TCA peel but at a greater strength. You're not going to find typically med spa doing a 30% depth. That tends to be something that an MD is going to use. And if it's a full face patient may elect to be sedated or a full topical because it can burn a lot. So there can be a limit to what you can do at the esthetician level, at the RN level, and then you see the MD for the very deep peels.

Dr. Korman (13:44):
I think really what we're talking about is with all these are controlled burns. And it's interesting because people always want to know what's the least invasive. And people always think surgery is the most invasive. I think sometimes these deep peels, even though they somewhat can be construed as a little bit invasive, mostly in terms of recovery. Fortunately these days with these controlled steps and these much more improved treatments for recovery and post peel care and post laser care, it is a lot easier to recover. But it is important for everyone to understand that the more that the skin is being treated, the more significant injury to the face, that then heals. And it's important to understand that this is some version of why people say, well, when's the right time to start treating? Well, I just actually did an upper eyelid operation on a patient who is in her sixties who told me that she's been using eye cream since she was 17 years old.

(14:53)
And people say, oh, that's so early. But I would say there's a short distance from the pimples to the wrinkles and self-care is an important thing. So how much the wrinkles and how many wrinkles really depends on your genetics and your skin type and how much sun damage you've had over the years. These are all things that you and your practitioner can unpack and figure out because ultimately it's designed for patients to be happy and to feel like they got what they thought they were getting and to understand what to do next. So it is important to learn about, but also realize that ultimately it's about a relationship and as Heather said, communication with your medical professional about what is you're trying to do and accomplish.

Dr. Furnas (15:42):
And with that communication we talked about, peels are often best done as a series, particularly if you're really after a condition, you want to improve your lines, you want to improve your hyperpigmentation or your acne or acne scars, whatever it is, you have a set goal as opposed to just looking a little bit refreshed for a party. But once the series is over, the work isn't done. And that's where the home care products are so important because as we've mentioned in other episodes, the products themselves have a place in kicking up the cell turnover and all kinds of growth factors and a lot of things that can target even the cell at the nuclear level to increase that cell turnover, disperse pigment, and make skin look younger. So it all fits together even moisturizer. There's a article that I remember seeing a twin study, and it showed these pairs of twins. One twin had used moisturizer on her chest for years and years, and the other twin hadn't in a series of twins, and the one who had used moisturizer looked so much younger. The skin looked so much younger. It was really dramatic. So you don't think of something as like moisturizers not really doing something. It doesn't burn, but it is effective and it's that daily product that contributes and prolongs the benefit of these peels or lasers or whatever skincare you are or treatment you're getting.

Dr. Korman (17:24):
So let's get to the nitty gritty of cost. How much do all these things actually cost? Because it's nice to think, oh, we should have the peels and then the series of peels and then the post-treatment and it's the maintenance. It's like, okay, I mean it's nice to look young, but come on. How much do these things cost anyway?

Dr. Furnas (17:47):
Like anything, it's going to be an investment. Depends on where you live. If you are in rural Iowa, if you can find a med spa, it's going to be less expensive than in New York or Beverly Hills. But for a light peel, the range is typically 150 to $400. Medium peel will be the 400 to a thousand, and a deep peel is a thousand to 6,000. And if you think about it, the professional who is doing that peel will be at a more highly trained level, the deeper the peel.

Dr. Korman (18:25):
Okay. So now when you say it's like the light peels one 50 to 400, is that per peel or per series?

Dr. Furnas (18:31):
Yeah, that is per peel. And so we mentioned that oftentimes peels are done as a series, and so most places will discount the per peel cost if you do have a series. So on the other hand, you want to go someplace where they're using the best ingredients and have the best, most experienced people. And safety is a real concern because as we've discussed, the deeper the peel, there are risks. And so I wouldn't choose a peel just based on cost. You want really quality ingredients and well-trained professionals applying the peel.

Dr. Korman (19:15):
So that means that if you're doing a deep peel or let's say a laser, and you're saying it could be from a thousand to 6,000, so if someone's going to do three deep peels, that's like 3000 just using the lower end 3000 and the one-time, let's say the one-time laser is 6,000. So how do you decide what you should do? Is it downtime related to do them in multiple times or the one and done? What do you think?

Dr. Furnas (19:49):
This is where the experience of the practitioner is going to be really helpful because they'll have some insight into what's going to quote unquote give you the biggest bang for your buck. As we mentioned, sometimes a laser will give you the result that a peel can't. However, sometimes they'll be equivalent. It's just that the laser can give it after one treatment depending on the type of laser. And so sometimes even though it's more expensive, that may be the better way to go, more expensive for a single treatment. That may be the better way to go to get the equal. It may take you more than the three deep peels to give you the equal result of a laser. Just like if you look at a single peel versus a series, you could say that the single peel is a lot cheaper than the series, but the results you're going to get will be much better after the series. So I would look at both your budget, but also the goal, the result, what are you really trying to achieve? And then go to someone you trust, somebody who has your best interest in mind as opposed to just looking at the profit level frankly.

Dr. Korman (21:06):
So finally, the last question is how long do these last? So if somebody came to you and said, okay, if I do these three treatments or I do the one treatment and I have this result and I like the result, well, how long can I expect it to last?

Dr. Furnas (21:22):
Well, that's a really good question, Josh, we talked about home products, but there are also other things that come into play. Are you dealing with wrinkles that are created by your facial expression muscles? So then Botox or Dysport or one of the neurotoxins are going to be important in minimizing the recurrence of the wrinkles. Similarly, filler can also help. So sometimes other things can prolong the result. It's not just a single treatment solution to a problem. That said, we age. If you don't protect yourself from the sun, you're not going to see the results last as long. And then we vary as far as our genetics. So there are a lot of components with appeal. There's especially one that gets into the dermis. There is change. It's not like a glycolic peel, superficial glycolic peel where you just exfoliate and you're kind of back to where you were with a peel that gets into the dermis or laser. There is change to that dermis. But then as far as a year from now, do you feel like you need another? Well, that remains to be seen as far as a number of factors.

Dr. Korman (22:47):
Yeah, I think it's also what size of your magnifying mirror you're looking at, because the magnifying mirror that only you can see the extent of the wrinkles and everyone else looking at you is different. Is different. So I think ultimately it's important to understand that we need to recognize how long things last as a function of, as you say, our genetics, what we're doing and what we're expecting, and realizing that the earth is still spinning and we're still on this earth and we are still living and aging, and that is what we continue to do, which is why we come here every two weeks to try to help you what to do to make it better.

Dr. Furnas (23:30):
Yeah, I think the happiest people are the ones who are looking to improve and not expecting perfection, not expecting all fine lines or all wrinkles to be gone and accepting that we are human. And as Josh said, yes, the earth continues to spin, and we hope to be spinning with that earth and accepting what we can't change.

Dr. Korman (23:54):
Thank you for listening to this episode of Skintuition. Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Furnas (24:07):
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