12. Upper blepharoplasty without skin incisions, by means of mixed peeling 0.5
KEYWORDS: eyelids chemical peeling, chemical upper blepharoplasty, ocular peeling complications, trichloroacetic acid peeling, mixed peeling 0.5, upper blepharoplasty without skin incisions, resorcinol, timedsurgery
A recent physical-chemical mixed peeling procedure enables us to rejuvenate the skin of the upper eyelids, without skin incisions and without risk.
Rejuvenating the eyelids means eliminating wrinkles and making the skin firmer, more supple and thicker. Thickening the skin makes any adipose pouches less visible. Rejuvenating the skin of the eyelids is an important part of rejuvenating the overall appearance of the face.
Mixed peeling 0.5 is also used after surgical blepharoplasty if the skin appears to be old, or if the two upper eyelids need to be made symmetrical.
It is well known that physical treatments are not very efficacious. Even if the patient undergoes several treatment sessions, the desired result is unlikely to be achieved.
The average chemical peeling procedures, for example with 35% trichloroacetic acid, require numerous sessions in order to obtain modest results. Moreover, as is known, peeling of the eyelids has to be carried out in depth if it is to be effective.
Most practitioners in the English-speaking world use 50% trichloroacetic acid or phenol. However, these two peeling procedures cannot be standardized, carry a risk of scarring, require a long period of convalescence, and may give rise to hyperpigmentation or hypopigmentation.
To overcome these problems, we designed mixed peeling procedures that use pulsed timedsurgical de-epithelialization, followed by the application of a saturated solution of resorcin; these are used to treat roughness of the lower eyelid and to eliminate lip wrinkles and dermal/epidermal blemishes.
Mixed peeling by means of de-epithelialization is specific to the lower eyelid. To treat the upper eyelids, we use the above-mentioned recent technique: mixed peeling 0.5, which involves rendering the epidermis permeable and then applying a saturated solution of resorcin. This technique is also used to treat fine wrinkles and skin blemishes of the face of patients with an irregular complexion.
Until today, there have been no standardized methods with this degree of safety and efficacy.
Mixed peeling 0.5 uses a 50 Watt or 38 Watts current, emitted half a hundredth of a second. This emission generates a micro-arc, which renders the epidermis permeable without drying the dermis. Resorcin has no effect on intact skin, but is efficacious once the skin has been made permeable by the timedsurgical current.
Mixed peeling 0.5 is as powerful as peeling by means of phenol, but does not carry the risks of aggressive peeling procedures. The characteristics of mixed peeling 0.5 also make it suitable for use in patients who have already undergone blepharoplasty who present roughness of the eyelids.
If the skin has an aged appearance, the result of a perfectly performed blepharoplasty procedure may be ruined. In a fair number of cases, mixed peeling 0.5 can achieve upper blepharoplasty without any skin incisions, thereby replacing the surgical procedure. One advantage of mixed peeling 0.5 is that there is no loss of eyelid volume. Following the reorganization of the connective fibers and the consequent reduction of the skin surface, the palpebral fold is no longer thin; rather, it acquires the thickness and rotundity typical of the youthful eye. Further advantages of mixed peeling 0.5 are the simplicity of the procedure and the rapid recovery. Even residual redness is minimal in comparison with procedures that use phenol or trichloroacetic acid (TCA).
An anesthetic made up of 2% mepivacaine with epinephrine is injected into the entire surface of the upper eyelid.
On completion of anesthesia, the Timed apparatus (Korpo – Genova – Italy) is programmed to Direct Pulsed 0.5/24.5 hundredths of a second – Coag – 50 Watt or 38 Watt – EM 15. The micro-arc renders the epidermis permeable to the subsequently applied saturated solution of resorcin. Micro-vaporizations are carried out over the entire surface of the upper eyelid, from the eyebrow to 1 mm from the eyelashes. The electrode is repeatedly cleaned with sterile glass-paper. Although mixed peeling 0.5 can also be applied to “crows’ feet”, it is less effective in this area than timedsurgical de-epithelialization followed by the application of the saturated solution of resorcin.
The treatment must not extend to the skin of the nose.
A saturated solution of resorcin is then applied.
The saturated solution of resorcin is prepared before the procedure. A small quantity of resorcin powder is poured into a container and ½ cc of twice-distilled water is added. The resorcin powder will dissolve within about 15 minutes; a few grains of undissolved powder must remain on the bottom of the container. This means that the solution is saturated.
The saturated solution of resorcin in water acts only on skin that has been rendered permeable by the current; it has no effect on intact skin. The resorcin solution causes immediate frosting; this frosting must be uniform over the entire surface of the eyelid.
Where frosting is not evident, the micro-vaporizations will need to be repeated while the resorcin remains on the skin. The micro-arc is triggered when the 1.5 mm diameter EM 15 electrode is not in contact with the skin. The high power of the current (50 Watt or 38 Watt) ionizes the air, making it conductive. The arc forms in the plasma or in the conductive air, driving the resorcin into the dermis.
The resorcin solution is left on the skin for about 4 minutes, before being washed off with physiological solution. Within a few hours, a crust forms.
Within a week, 80% of the crust will drop off; the remaining 20% will drop off within about 10 days. Once the crust has dropped off, some modest redness will remain.
After a few weeks, the upper eyelids have a rejuvenated appearance and are free from artefacts. The surface of the skin has clearly been reduced. The palpebral fold is rounded. The skin is thicker.
A year later, a second session of mixed peeling 0.5 can be carried out, if the patient’s condition requires it. In this second procedure, the operator can limit the intervention to those areas that he wishes to retract further.
Capurro S. (2017): Upper blepharoplasty without skin incisions, by means of mixed peeling 0.5. CRPUB Medical Video Journal. Timedsurgery section. www.crpub.org
What are the indications for mixed peeling 0.5?
Mixed peeling 0.5 is particularly indicated for patients whose palpebral skin is aged, thin and drooping; for patients with asymmetrical eyelids; for young women with a slight defect of the eyelid; for those whose eyelids lack volume; for patients with aged skin who have already undergone surgical blepharoplasty; for those who do not want to risk having an artificial appearance after surgical blepharoplasty, and for those who do not wish to undergo a surgical procedure. Mixed peeling 0.5 is also indicated for upper blepharoplasty in patients with large or medium-sized orbits. If these patients have already undergone traditional surgical blepharoplasty, the shape of the eyelids will have changed, taking on a "withered", sunken and too sharply outlined appearance. If the patient had a palpebral fold when young, our aim is to restore the youthful shape of the eyelids without giving them a sunken appearance, as happens when skin is removed. It should be borne in mind that sunken eyelids, if they are not familial, are characteristic of aged eyes and always appear artificial. As a general rule, I recommend surgical blepharoplasty when the orbits are small; in medium-sized/large orbits, mixed timedsurgical peeling 0.5 certainly yields more natural results.
When is mixed peeling contraindicated?
Mixed peeling 0.5 can always be carried out in the above-mentioned conditions. It must be borne in mind that mixed peeling 0.5 is an esthetic treatment. Surgical blepharoplasty, in addition to improving the esthetic appearance, is also a functional operation; when adipose pouches are removed, the eyelids can be opened more easily and the eye appears larger. Of course, surgical blepharoplasty does not rejuvenate aged skin. The two techniques, however, can be joined. For instance, adipose pouches can be removed without removing any skin, and mixed peeling 0.5 can be carried out later; alternatively, this order can be reversed.
What do you need to be particularly careful about in mixed peeling 0.5?
You have to perform local anesthesia with a 2% anesthetic solution. You have to be careful to remain within the palpebral area and not touch the skin of the nose. Frosting must be intense and uniform. The entire surface of the eyelid must be treated. It is advisable to keep a distance of 1 mm from the eyelashes. For what concerns “crows’ feet”, mixed peeling 0.5 is not as effective in this area as mixed peeling with de-epithelialization; unless the patient expressly asks otherwise, it is preferable to limit the area of action to the eyelids. In this way, the patient can soon return to her normal activities.
What happens if the saturated solution of resorcin comes into contact with the eyes?
We wash it out with a little physiological solution. Brief contact does not damage the tissues of the eye.
What happens in the post-operative period?
After treatment, the patient dries the area several times with a paper tissue. Edema will persist for two or three days. The patient cleans the eyelashes with chamomile and uses decongestant eyedrops. Subsequently, she can apply a non-cortisone anti-inflammatory cream. After 10-12 days, only slight redness will remain. A protective sun-cream should be used in the first few months.
How is the epidermis made permeable?
To make the epidermis permeable, we have to apply a high power (50 Watt or 38 Watt) while in the coagulation function. Emission of the current is extremely short (0.5 hundredths of a second) and powerful, creating an arc that renders the epidermis permeable to the resorcin solution. The brevity of the pulsed emission prevents the arc from reaching the dermis, as this would cause dehydration and desiccation. If the dermis were subjected to vaporization, as would happen if the emissions were more prolonged, it would no longer be able to absorb the saturated solution of resorcin. The operator’s technique also plays a role; the electrode must approach the surface through vertical movements until the arc is triggered. It is important to keep the EM 15 electromaniple clean. The return electrode must remain in contact with the skin of the chest, as close as possible to the face. If there are problems of conductivity, this area can be slightly moistened.
Why must frosting be complete?
Frosting must be complete because the rejuvenating action is exerted exclusively by chemical means – in this case, by the saturated solution of resorcin. Physical treatments are not efficacious and are also risky. To improve the action of retraction and reorganization of the connective fibers of the palpebral skin, the physical-chemical action must be exerted over the entire surface of the eyelid, from the eyebrow to a millimeter from the eyelashes.
Given that timedsurgical de-epithelialization works so well on the lower eyelid, why don’t you use it on the upper eyelid, too?
Because the upper eyelid is much more mobile, the skin is difficult to de-epithelialize. Moreover, we do not want to exert the same action at all points of the surface of the skin of the upper eyelid. For this reason, frosting is made to occur through the epidermis, which has been rendered permeable by the micro-arc. This mixed peeling is powerful (up to 4 minutes of application!), but absorption of the solution is not uniform. This ensures rapid healing and the absence of problems.
We also use mixed peeling 0.5 to remove skin blemishes – even deep ones – in patients with an irregular complexion. While pulsed timedsurgical de-epithelialization, followed by the application of a saturated solution of resorcin for 20 seconds, is able to remove a dermal-epidermal patch in a single session, mixed peeling 0.5 often requires two sessions. However, following mixed peeling carried out by means of de-epithelialization, the skin presents no blemishes and not even slight redness. In a non-homogeneous complexion, this is likely to be noticeable, which is not desirable.
What do you think of those physical methods that create a series of punctiform burns on the palpebral skin?
I think the best apparatus that can create punctiform lesions of uniform depth at stepped power settings is the Timed, which is, by the way, the only apparatus designed to be programmable. However, as I have already said, I believe that physics alone is much less efficacious than physics and chemistry combined. This is why I created these mixed peeling procedures. The result seen in this video was achieved by means of a single treatment session.
You cite power levels of 50 Watt or 38 Watt. What criterion do you use in order to choose one or the other of these two power values?
When performing permeablization of the epidermis, it is always preferable to use the lower power setting. Contrary to what one might think, this enables mixed peeling to be more efficacious. Emissions of 38 Watt for 0.5 hundredths of a second permeabilize the epidermis without drying the dermis. This allows better absorption of the saturated resorcin solution, making mixed peeling more effective. If the skin of the eyelids is particularly aged, it can be useful to apply a urea cream on the days before the peeling procedure, in order to improve the conductivity of the skin. Pulsed emissions at 38 Watt require good conductivity of the skin, a light hand and a magnifying lens. If the operator experiences any difficulty, the 50 Watt setting can be used.
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