Dr Evgeniya (Jane) Ranneva explains how to treat the sensitive eye area using chemical peels
Ageing of the periorbital area is a common concern amongst many patients.
Rejuvenation of the upper and/or lower eyelids using chemical peels is a relatively simple and quick rejuvenation procedure. It is commonly referred to as ‘chemical blepharoplasty’, despite the fact that it is non-surgical.
The results are inadequate for treating fat pads, but are excellent in all resurfacing indications. However, the practitioner must be experienced in performing deep chemical peels on other areas of the face, and peels of this depth should not be performed by novice or inexperienced practitioners.
In practice, I have found that applying chemical peels to the eyelids can treat wrinkles and fine lines, dyschromia, keratoses and sagging eyelids successfully. However, the results of a ‘chemical blepharoplasty’ may be inadequate if there is a large amount of excess skin on the lower eyelid. In these cases, surgical blepharoplasty is indicated.
When peeling the eye area, practitioners need to consider a type of peel that is safe and will create a lifting effect. I have found that alpha hydroxy acid (AHA) and trichloroacetic acid (TCA) peels are ineffective for non-surgical ‘chemical blepharoplasty’ because they are unable to reach the reticular dermis and modify it.1
I therefore choose to use a phenol peel, and if treating in limited areas using small quantities, there is a very low risk of danger related to its toxicity.1-7 There are many different levels of phenol formulations, but for optimum effectiveness and patient safety, I use a phenol oil formula because it has a good depth of penetration in the thin eyelid skin.
Before treatment, practitioners should be aware of the complications (explained below) and contraindications for phenol, some of which include active herpes, keloid history, history of radiotherapy, surgical intervention in the same area and the recent use of retinoids.7,8
Prior to the ‘chemical blepharoplasty’, to avoid any reactional hyperpigmentation, the patient should apply a bleaching cream containing tyrosinase inhibitors and antioxidants twice a day for two to three weeks.
Practitioners should consider botulinum toxin injections in the musculus orbicularis oculi one to eight days before the application of the peeling solution as it keeps the muscles paralysed during the skin regeneration phase and, in my experience, allows a better and longer lasting result. If the patient has a history of herpes, prevention is necessary for four days before and up to four days after the peel (valacyclovir 500mg twice a day).
Immediately before the chemical peel treatment (30 minutes), give the patient an analgesic. The skin should always be degreased and disinfected; you can use a mixture of 50% alcohol and 50% acetone before application. Place one drop of petroleum jelly-based ophthalmic ointment in the eyes immediately before starting the procedure and once finished to prevent post-peel ocular irritation.
The practitioner should perform nerve blocks if the patient displays any pain or if they do not tolerate pain well.
In the absence of nerve blocks, applying a chemical peel may trigger a strong burning sensation for approximately 15 seconds, after which the skin will become numb for about 15 minutes. After 15 minutes, the patient will experience a gradual, unpleasant, warm, pulsatile inflammatory sensation. This can last until the middle of the first night due to the effects of the sympathetic nervous system.1
Practitioners should consider their applicator choice; I find that a single cotton bud is ideal for the eye area as it is light, precise and simple. An assistant should be present throughout the whole procedure to clear any tears as soon as they appear to prevent any diluted phenol from dripping onto the face or going up into the conjunctivae by capillarity. This will avoid eye injuries in the form of corneal damage.
It is extremely important that a fresh cotton pad is used for each tear. Using a 1cm3 syringe, 0.2cm3 of the peel solution should be drawn up from the bottle, and the cotton bud soaked by ‘injecting’ 0.10-0.14cm3 of the solution directly onto it. After disinfecting the area and carefully degreasing, the peel solution should be applied carefully onto one of the lower lids with the cotton bud.
The tarsus of the upper eyelid is not usually treated because it can induce severe oedema,9,10 which is very uncomfortable for the patient and will not significantly improve results. Distinct frosting – when the skin turns white during a peel – usually occurs immediately and marks the end of the phenol application.
To treat the second eyelid, three drops of product should be ‘injected’ onto the end of the same cotton bud and applied to the eyelid. The same quantity of solution and the same procedure is needed to treat the upper eyelids.
Following the ‘chemical blepharoplasty’, an evening-out peel is necessary to prevent demarcation lines.
To do this, a milder peel can be applied, such as a superficial-medium depth peel based on TCA. It should be applied on the rest of the face when the periorbital application has finished and before any dressing is applied.1 The practitioner can apply a thick coat of an anti-inflammatory, anti-erythema, antioxidant rich, post-peel mask immediately before applying bismuth subgallate powder.
The powder will stick perfectly on the post-peel mask and form a protective barrier. It will stay on the skin for six to eight days by forming a crust-like protection. This is an excellent antiseptic, preventing scarring as it allows for skin regeneration under the powder.11,12
The patient should not sleep with the treated skin pressing against any surface, including a pillow, the night after the treatment as the treated area might stick to the surface and result in infection, scarring, prolonged erythema or other complications.13-15
Practitioners should arrange to see the patient on the first, third and sixth day following the peel to monitor their progress and ensure that there is no infection. ln the case of infection, prescribe the patient antibiotics (usually orally).
On the third day, apply sterile, white petroleum jelly on the edge of the treated areas. On the sixth day, apply it on the entire treated area as this will help unstick the bismuth subgallate. The patient can then wear makeup beginning on the eighth day, so long as the skin has fully recovered.
Severe eyelid oedema, which usually lasts seven days at the most, will appear immediately after the solution has been applied. It usually peaks on the morning of the first and second day and goes down during the day, when the patient is no longer lying down.
It spreads to the upper cheek on the second day, the lower cheek on the third day, the lower jaw on the fourth day and, on the fifth day, it is barely noticeable. It is not uncommon for the patient to be unable to open his or her eyelids on the morning of the first day. If the oedema lasts longer than seven days, it is not normal.7,16
This is not very common, and if it does happen, the practitioner should proceed with thorough medical history and if there is infection, which can be the cause of the oedema, medical follow-up is necessary.
Erythema will develop just a few minutes after the peel has been applied and will peak during the first few weeks. The erythema takes longer to fade on lighter, more transparent skin, and is easily covered up with makeup. The bismuth subgallate powder comes away from the skin automatically due to the petroleum jelly, which prevents transepidermal water loss (TEWL) evaporation.16,17
The increased depth of action of the phenol sometimes translates into a persistent moist scab in the inside corner of the upper eyelid, where the phenol has macerated more intensely. Applying an antibiotic cream or ointment remedies the problem, and it should resolve before the fifteenth day. There are no sequelae from this slow healing. If the scab persists for more than two weeks, the practitioner should closely monitor the patient.1,7
The practitioner must be prepared for any reactional hyperpigmentation, even though it is generally accepted that phenol has more of a depigmenting, than a hyper-pigmenting, effect.
If the skin that is being treated is a very melanin-reactive phototype such as Fitzpatrick IV or above, or has been identified in the consultation as the potential to have a severe inflammatory reaction, the melanocytes should be sedated with tyrosinase inhibitors and antioxidants before and after the peel.18 This needs to be used on the areas being treated and the surrounding areas.
Bleaching cream should be applied as soon as possible after the peel. The skin can usually tolerate the cream up to the tenth day after the peel. Inhibition of melanocytes should be continued for a minimum of six weeks.17
If the peel is being performed on a skin Fitzpatrick I-III, and if the patient follows advice to keep out of the sun and use sun protection, there should be no post-inflammatory hyperpigmentation.
However, there is an increased risk of prolonged erythema on lighter skin types. Patients should completely avoid the sun and use effective sun protection (SPF 50+) for up to three to six months, followed by gradual exposure to UV light thereafter.1,7
As mentioned, there is a risk of a demarcation line on the skin that has severe dyschromia or sun damage, wrinkles, freckles, keratoses or lentigines, as the skin treated will look rejuvenated and stand out clearly from the surrounding damaged skin. It is especially important to combine the peel with a superficial-medium TCA-based peel to minimise the demarcation line if the skin phototype has been properly selected.1,7
I have found that ‘chemical blepharoplasty’ using an adapted phenol oil formula for this sensitive area is a good alternative to surgical blepharoplasty when there is not an excess amount of skin. It is easy to apply and patients usually recover within several days. Practitioners must ensure they are experienced in chemical peeling before attempting this procedure.
Disclosure: Dr Jane Ranneva is a medical advisor for Skin Tech Pharma Group.