Patient Selection

Proper patient selection and assessment of each individual’s skin condition is crucial prior to determining if a chemical resurfacing procedure is indicated. The preoperative consultation is important in identifying at-risk patients who are best avoided or who necessitate an extra-cautious approach, as well as selecting patients who are ideal candidates for the resurfacing procedure. At the time of initial consultation, the dermatologist must evaluate the patient for relative contraindications; discuss the indications of the procedure; and assess the patient’s goals, expectations, anticipated results, and limitations as well as the potential risks of the procedure. It is crucial that the patient’s goals and expectations are realistic prior to selecting the patient for the procedure. The patient must fully understand the potential benefits, limitations, and risks, and an informed consent must be signed prior to performing the surgical procedure.

Several different factors must be assessed to determine if the patient is an appropriate candidate for skin resurfacing. A thorough history and physical examination must be taken during the initial evaluation. The patient’s skin type should be evaluated using Fitzpatrick’s classification (Table 4.3) measuring pigmentary responsiveness of the skin to ultraviolet (UV) light, which is most often based on the ethnic background. Skin types I–III are ideal for peeling. Ethnic skin types IV–VI can also be peeled, but the risk of unwanted pigmentary change in the form of hypopigmentation and hyperpigmentation is greater. Regarding skin types IV–VI, it is best to limit peels to superficial and medium-depth and to avoid deep peels in order to reduce the risk for potential side effects. In addition, Glogau’s classification of photoaging (Table 4.4) is helpful in assessing sun damage. Superficial peels are indicated for patients with early to moderate photodamage. Past (within the last 6 months) or present use of systemic isotretinoin must be ascertained, since retinoids are known to be associated with a greater risk of scarring after peeling [5]. Patients should be asked about prior resurfacing procedures or cosmetic procedures such as rhytidectomy, coronal brow lift, or blepharoplasty as these procedures can increase the risk of complications following medium-depth and deep resurfacing [6].An interval of 4–12 weeks is recommended between peeling and procedures involving undermining [7]. Individuals with prior radiation exposure (e.g., history of superficial X-ray treatment for acne) should be examined carefully to evaluate for presence of vellus hairs in order to ensure that there are enough adnexal structures to promote re-epithelialization [8]. Patients, irrespective of their history of recurrent herpes simplex, should be give prophylactic acyclovir, valacyclovir, or famciclovir beginning the day of the procedure and continuing for 3–5 days postprocedure whereas previously, treatment was continued for 10–14 days [9]. Patients with active inflammation as seen in seborrheic, atopic dermatitis, irritant or allergic dermatitis, rosacea, psoriasis, or vitiligo, may be at an increases risk for postoperative complications secondary to alterations in the skin’s normal barrier function. Thus, these conditions should be controlled before receiving a superficial peel [10].Any history of abnormal scar formation, either hypertrophic scar or keloids, creates a greater risk to scar with deep as opposed to medium-depth peeling. In addition, the patient’s pregnancy history and medications should be considered, especially postmenopausal women on estrogens and women on oral contraceptives, which may sensitize the skin to the sun or produce postinflammatory splotching.Most importantly, the physician must understand the patient’s philosophy regarding sun exposure, as patients are expected to avoid sun exposure and must use sunscreens postprocedure to prevent continuing sun damage. Patients infected with HIV may experience delayed healing or be at risk for secondary infection after peeling. The general health and nutritional status of the patient is also an important consideration, especially for medium-depth and deep chemical peels. Of note, superficial peels are tolerated with little risk in all patients of all skin types regardless of their general state of health.

Table 4.3. Fitzpatrick classification   Skin type Color Skin characteristics   I White Always burns, never tans   II White Usually burns, tans less than average   III White Sometimes mild burn, tans about average   IV White Rarely burns, tans more than average   V Brown Rarely burns, tans profusely   VI Black Never burns, deeply pigmented

Table 4.4. Glogau’s classification of photoaging   Glogau photoaging classification Skin features   Type I “No wrinkles” Early photoaging,minimal wrinkles Mild pigmentary changes, no keratoses Younger patient, 20s–30s Minimal or no makeup   Type II “Wrinkles in motion” Early to moderate photoaging Early senile lentigines visible Keratoses palpable but not visible Parallel smile lines beginning to appear Patient age late 30s or 40s Usually wears some foundation   Type III “Wrinkles at rest” Advanced photoaging Obvious dyschromia, telangiectasia Visible keratoses Wrinkles even when not moving Always wears heavy foundation   Type IV “Only wrinkles” Severe photoaging Yellow-gray color of skin Prior skin malignancies Wrinkles throughout, no normal skin Patient age 60s or 70s Can’t wear makeup; “cakes and cracks”

It is worth mentioning that a postauricular test peel may be useful in select patients to assess their suitability for chemical resurfacing and may be especially helpful in identifying patients at increased risk of postoperative pigmentary dyschromias [11].Although a favorable test post is reassuring, it does not guarantee a positive outcome following full-face resurfacing.