M e s o t h e r a p y,

M i c ro n e e d l i n g , a n d
Chemical Peels
Johnson C. Lee, MDa,*, Mark A. Daniels, MDb,
Malcolm Z. Roth, MDb

KEYWORDS
 Mesotherapy  Microneedling  Chemical peels  Percutaneous collagen induction

KEY POINTS
 Mesotherapy, microneedling, and chemical peels are three minimally invasive techniques used
today to combat facial aging.
 Chemical peels can be used in various combinations, strengths, and application techniques to opti-
mize outcome while minimizing complications.
 Mesotherapy most commonly involves multiple injections of bioactive substances for facial con-
touring through lipolysis.
 Microneedling utilizes controlled needle penetration of the skin to stimulate the wound healing
cascade and induce regeneration of skin components.
 A thorough understanding of the indications and limitations of these techniques will allow the plastic
surgeon to maximize their patient’s outcome.

INTRODUCTION method of skin resurfacing obviating laser abla-

Mesotherapy, microneedling, and chemical peels
are 3 very different techniques used today for the
common goal of facial rejuvenation. Mesotherapy,
from the Greek words mesos (middle) and therapeia
(to treat medically), uses multiple subcutaneous
or intradermal injections of pharmaceutical and
homeopathic medications, plant extracts, vitamins,
and other bioactive substances into the dermis
and/or subcutaneous fat.1,2 Proposed indications
include vascular and lymphatic disorders, pain, alo-
pecia, and psoriasis. Although first reported in the
1950s, mesotherapy has only recently gained popu-
larity in the United States as a nonsurgical method of
rejuvenation, particularly for fat reduction.3–6
Microneedling, also known as percutaneous
collagen induction (PCI) or collagen induction ther-
tion.7–9 Rather than the injection of substances
used in mesotherapy, microneedling uses the
physical trauma of needle penetration to promote
regeneration. PCI does not ablate the epidermis
nor create open wounds, thereby requiring little
downtime and a shorter healing phase compared
with ablative modalities, such as laser or derm-
abrasion. By leaving an intact stratum corneum
and basement membrane, microneedling can be
used on all skin types with reduced risk of photo-
sensitivity, infection, and pigmentation changes.
In contrast to both mesotherapy and micronee-
dling, chemical peeling is a topical modality in
which application of chemicals creates injury to
the skin. Purposeful injury to the epidermis and
dermis stimulates growth and exfoliation to
reverse skin degeneration from time, trauma,
plasticsurgery.theclinics.com

apy, was first described in the 1990s as a novel

Disclosure: None of the authors has any affiliation or conflicts of interest with any products or companies listed
in the article.
a
Private Practice, Enhance Medical Center, 462 North Linden Drive, Suite 333, Beverly Hills, CA 90212, USA;
b
Division of Plastic Surgery, Albany Medical Center, 50 New Scotland Avenue, MC-190, Albany, NY 12208, USA
* Corresponding author.
E-mail address: Johnsonlee1@gmail.com

Clin Plastic Surg 43 (2016) 583–595

http://dx.doi.org/10.1016/j.cps.2016.03.004
0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
584 Lee et al
disease, ultraviolet, and environmental exposures.
Its immense versatility comes from the number of
chemicals available as well as the technique
used. Chemical peeling is a tried-and-true proce-
dure for skin resurfacing and rejuvenation used
for thousands of years and continues to be a
cornerstone in the treatment of facial aging.
Today, nonsurgical aesthetic procedures have
become increasingly popular and varied from
energy-based modalities to physical methods,
including injectables, PCI, and chemical peeling.
With appropriate understanding of various non-
surgical modalities for facial rejuvenation, plas-
tic surgeons are able to better implement a
treatment plant to maximize efficacy and minimize
complications.
MESOTHERAPY
In the 1950s, Dr Michel Pistor3 injected intravenous
procaine in an unsuccessful attempt to treat an
acute asthma attack in a partially deaf patient.
Although it was a failure as an asthmatic therapy,
intravenous procaine injection temporarily restored
hearing and the concept of mesotherapy was
born.3,4 Since then, a variety of solutions have
been used to treat a multitude of conditions.
Although popular in Europe and South America,
mesotherapy has met resistance in the United
States due to a lack of clinical and scientific evi-
dence. In 2005, no substantial clinical scientific
studies on the workings of mesotherapy had been
published. It was conjectured to work by increasing
blood flow as well as lymphatic flow in the meso-
derm, resulting in shrinkage of fat cells, which ulti-
mately dissolve and are excreted.6 Comparatively,
the past decade has shown significant advance-
ments in the basic science research of mesother-
apy and injection lipolysis, in particular.
Classic Mesotherapy
Injections of vitamins, minerals, homeopathic rem-
edies, and proteins have been the mainstay of mes-
otherapy. The terms, mesolift and mesoglow, have
been developed to describe the result of toning and
facial rejuvenation with mesotherapy. Reduction of
facial rhytids, increased elasticity, and improved
pigmentation have been suggested but never
proved. In a 2006 skin rejuvenation study, subjects
receiving injections of a multivitamin mixed in hyal-
uronic acid (HA) demonstrated no significant
changes in epidermal thickness, vessel size and
density, solar elastosis, and elastin content. Elec-
tron microscopy revealed smaller collagen fibers,
suggestive of new collagen synthesis, but at
6 months, no clinical change was appreciated.10
In a similar study, 6 patients underwent injections
of a multivitamin solution mixed with a non–cross-
linked, high-viscosity HA to the periocular region.
Two subjects showed mild changes with increased
glowing of the skin, but none reported improvement
in skin tightening or wrinkles after 3 months. No
difference was seen in epidermal thickness and
an insignificant increase in type III collagen was
seen, along with a decrease in total elastin.11
HA is often chosen for mesotherapy due to its
ability to increase hydration and fibroblast activa-
tion. HA stimulates fibroblasts to express collagen
type I, matrix metalloproteinase-1 (MMP-1), and
tissue inhibitor of MMP-1 (TIMP-1).12 In 2011,
Jager and colleagues13 used fibroblasts from skin
biopsies maintained in 5 distinct formulas to help
further elucidate molecular and cellular mecha-
nisms. HA and various vitamin cocktails applied
to human fibroblasts maintained cell proliferation
and enhanced mRNA expression of collagen type
I, MMP-1, and TIMP-1 for at least 11 days. Two
other solutions, thought to work by stimulating
repair mechanisms, led to proapoptotic processes
and necrosis. Savoia and colleagues14 used 2
other HA formulations, 1 with vitamins, amino acids
minerals, coenzymes and antioxidants, and the
other with idebenone, and reported improved
epidermal texture and increased elasticity and
brightness of skin. Clinical evaluation with the
Global Aesthetic Improvement Scale score and
Wrinkle Severity Rating Scale revealed statistically
significant results at 2 months although biopsies
failed to show any significant difference at the level
of the epithelium and of the dermis. Immunohisto-
chemistry revealed a decrease in interleukin 1b,
interleukin-6, and MMP-1 and increased collagen
type I at 6 weeks after treatment.14
Injection Lipolysis
Although HA is considered a key component in
mesotherapy for facial rejuvenation, other agents
are used when targeting unwanted adiposity for in-
jection lipolysis. Since a 2001 report by Rittes15
described injecting phosphatidylcholine (PC) to
improve lower eyelid bulging, numerous studies
have contributed to the understanding of injection
lipolysis with 2 agents: PC and deoxycholic acid
(DC).15–26 DC acts as a detergent, disintegrating
the fat cell membrane.27 This results in cellular
oncosis, a process characterized by swelling and
formation of blebs, resulting in increased perme-
ability. Lysosomes eventually leak hydrolase, which
damages the cell membrane, resulting in cell lysis.26
DC has been shown nonspecific in its toxic
behavior, affecting adipocytes, skeletal muscle
cells, keratinocytes and fibroblasts. It is thought
that protein binding in nonadipose tissue may
 Mesotherapy, Microneedling, and Chemical Peels
neutralize its effects to these other key structures.
Furthermore, PC has been shown to have a buff-
ering effect, leading to a reduction in inflammation
and tissue damage.26 This is ideal for larger areas
to be treated, such as hips and thighs. When treat-
ing the face or neck, however, isolated DC is most
beneficial in focal areas, such as submental
fullness.
Several companies have conducted clinical tri-
als involving various lipolysis products. On April
29, 2015, the US Food and Drug Administration
approved ATX-101 (Kybella) (Allergan, Irvine, CA)
for improvement in the appearance of moderate
to severe convexity or fullness associated with
submental fat in adults.28 More than 20 clinical
trials with more than 2600 patients were carried
out by a global clinical development program.
Phase I trials demonstrated that ATX-101 is rela-
tively safe, with a transient increase of plasma
DC, which normalizes after 24 hours. Adverse
events included edema/swelling (87%), hema-
toma/bruising (72%), pain (70%), and numbness
(66%).29 Two phase 3 trials where patients
received ATX-101, 1 mg/cm2 and 2 mg/cm2, or
placebo, were conducted in Europe and their
pooled results are as follows: 58.8% and 63.8%,
of those receiving 1 mg/cm2 and 2 mg/cm2,
respectively, had improvements in clinician re-
ported measures versus 28.6% in those receiving
placebo. Treatment did not lead to worsening of
skin laxity.30–32 Five cases of injection site nerve
injury occurred and all spontaneously resolved.
Similar results have been found in the US phase
3 trials, with 68.2% of patients having at least a
1-point increase in clinician-reported and
patient-reported submental fat rating scales. The
manufacturer recommends a maximum of 50 in-
jections, 0.2 mL each (up to 10 mL), spaced 1
cm apart. Using this method, up to 6 single treat-
ments may be administered at intervals no less
than 1 month apart.33 Another agent undergoing
clinical trial is salmeterol xinafoate (Lipo-202)
(Neothetics, San Diego, CA). This injectable
formulation of a long-acting ß2-adrenergic recep-
tor agonist may achieve lipolysis by triggering the
metabolism of triglycerides stored in the fat cells
and causing shrinkage.34 It is used specifically
for abdominal bulging, but given its different
mechanism of action, there are theoretically fewer
side effects and less inflammation. An upcoming
agent, Aqualyx (Marllor International, Marignano,
Italy) is a DC-based solution with a lactose-
based delivery system. It has received the
European Conformity mark for localized fat reduc-
tion, and shows promising and significant results
in multiple areas of the body when performed by
fully trained practitioners.35
585
Complications
Although mesotherapy is relatively new in the liter-
ature, complications have been reported, with
infection the most commonly reported. More
than 198 separate cases of associated infections
have been documented, all of which were caused
by atypical mycobacteria.36 Late consequences
of injecting DC include necrobiosis of the reticular
dermis and death of adnexal glands, blood
vessels, and nerves in the deep dermal layer.19
Most mesotherapy patients experience minor
side effects postinjection, including erythema,
edema, and ecchymosis. Despite this, patient
satisfaction has been reported at more than
85% for those receiving treatment in the orbital
fat compartments, neck, submental, and jowl fat
areas.37
MICRONEEDLING
In contrast to mesotherapy, microneedling uses
direct mechanical trauma to modify tissues. Tradi-
tional ablative techniques injure tissue beyond the
epidermal-dermal junction, effectively disrupting
the basement membrane and causing fibroblast
deposition of collagen in a parallel orientation
inherent in visible scars.38–41 PCI is believed to
induce more regenerative effects by inducing the
normal wound healing cascade of inflammation,
proliferation, and remodeling within normal skin
architecture.42–44 Microneedling devices applied
to the skin create a controlled depth of microchan-
nels, which close within minutes, during which
time topical substances can be delivered and
captured.45 Shortly after the microneedles pene-
trate the skin, platelets release chemotactic
factors causing invasion of other platelets, neutro-
phils, and fibroblasts. The neutrophils are replaced
and monocytes change into macrophages within
the first 48 hours. Macrophages release numerous
growth factors, including platelet-derived growth
factor (PDGF), fibroblast growth factor (FGF), and
transforming growth factor (TGF)-a and TGF-b,
which stimulate the migration and proliferation of
fibroblasts. In particular TGF-b1, TGF-b2, and
TGF-b3 are involved in promoting scar collagen
production and regeneration of normal collagen
lattice structure and scarless healing.46,47
Keratinocyte-fibroblast interactions enhance the
production of laminin and collagen types IV and
VII at the level of an intact basement membrane.
In the final stage of remodeling, fibroblasts
continue to form and break down collagen in
the upper dermis. Patients undergoing PCI can,
therefore, expect continued improvement in over-
all skin quality, thickness, and obliteration of
586 Lee et al

Fig. 1. (A) A 61-year-old patient after local flap reconstruction of left nasal Mohs defect. Two microneedling ses-
sions were spaced 3 weeks apart. (B) Results are shown at 1 month. (Courtesy of Mark Codner, MD, Atlanta, GA.)

superficial wrinkles over several months in
contrast to the more dramatic short-term results
achieved by ablative laser resurfacing. Histologi-
cally, hematoxylin-eosin studies of treated skin
have shown a significant increase in collagen
deposition at 6 months as well as a 40% increase
of the epidermis and normal rete ridges at 1 year
after treatment48–50 (Fig. 1).
In addition to dermal rejuvenation, PCI has been
reported as a successful treatment modality for
several skin conditions. Patients with postacne
atrophic scars were shown to have increased
collagen types I, III, and VII, resulting in significant
improvement of scar appearance, skin tightness,
and overall skin texture after 2 to 6 sessions of
PCI over 1 to 3 months51 (Fig. 2). Hair density in
patients with androgenic alopecia and alopecia
areata were also increased, presumably from
increased vascularization and follicular and fibro-
blastic activity through multiple growth factors,
including vascular endothelial growth factor,
PDGF, and FGF-7.52,53 There is also potential to
help patients with stretch marks by increasing
elastin fiber density with microneedling treatments
and theoretically reducing the striae gap distance
to improve overall appearance.45 In the rat
model, by pretreating skin with microneedling,
subsequent fat grafts placed in those areas had
greater integrity, vascularity, and overall survival
compared with controls.54

Fig. 2. (A) A 49-year-old patient with a history of acne scarring of the cheek. A single full-face microneedling ses-
sion was performed. (B) Results are shown at 5 months. (Courtesy of Mark Codner, MD, Atlanta, GA.)
 Mesotherapy, Microneedling, and Chemical Peels 587

More recently, microneedling technology has Topical anesthetic is applied and left on the skin
been augmented with additional modalities. Bipo- for 20 minutes prior to removal with rubbing
lar radiofrequency devices have been used to treat alcohol. Areas that are sensitive or require aggres-
acne vulgaris and oily skin by inhibition of seba- sive treatment, such as the upper lip, may benefit
ceous gland through heat production; however, from local nerve blocks. A topical hyaluronic-
the distance between electrodes limits the pene- based gel is then layered on the skin as a lubricant,
tration of standard bipolar radiofrequency.55–57 with the added benefit of being an active ingredient
Fractionated radiofrequency microneedling over- that is microinjected into the skin through micro-
comes this limitation by applying direct thermal needling action. Depending on the device used,
injury to the dermis between paired microneedles appropriate needle length and speed are chosen
to precisely administer bipolar radiofrequency at for the planned treatment area. Areas of thin skin
specific depths. This has resulted in overall clinical overlying bony surfaces, such as the forehead,
improvement of acne scar and acne vulgaris and nasal, periocular, and upper lip area, require
related erythema.58,59 When used in conjunction shorter needle lengths ranging from 0.25 mm to
with platelet-rich plasma, PCI increased survival 0.5 mm. Patients with thicker skin or scarring can
rates in skin flaps created in rat models.60 tolerate deeper needle lengths from 0.5 mm to
2 mm. Areas of thick skin, such as the face, chest,
Equipment and trunk or with significant scarring, can be
treated with depths up to 2.5 mm. Increasing
There is a significant range of equipment available
speeds are used with longer needle lengths to
for PCI techniques. Standard tattoo devices require
help minimize discomfort. The method of needle
accurate control of depth by the user at all times and
application is user-dependent with the common
are, therefore, unlikely to provide a consistent depth
endpoint of mild swelling, evenly spread erythema,
of needling for larger areas. Stamp devices allow
and transient punctate bleeding (Fig. 3). This is
spot treatment of smaller areas and localized scars.
achieved by applying appropriate pressure, speed,
Electronic stamp devices allow the user to select
and needle depth for the skin quality and thickness
both penetration speed and needle depth,
of the area being treated. Multiple passes over the
decreasing patient discomfort and allowing the
same area in different vectors are recommended to
same instrument to be used on various areas of
avoid track marks from repeat needle insertions
skin. Tip cartridges on stamping devices are dispos-
into the same microchannel. This creates
able. Drum-shaped rollers have great variation in
needle material (gold, titanium, and so forth), length,
diameter, and overall surface density, depending on
the manufacturer. Rollers are 1-time-use devices
best for open flat surfaces, such as the cheek, but
are more challenging in narrow channels, such as
the perioral or scalp area, where hair can become
entangled. Medical needle depths range from
0.5 mm to 3 mm although home-care devices with
needles less than 0.3 mm are available for self-
treatment. In addition to varied design styles, fea-
tures, such as vibration, light-emitting diodes, and
radiofrequency, are dependent on the manufac-
turer. Regardless of the type of equipment, a quality
build is essential for minimal risk of needle breakage
into the skin, ease of use, and maximum results.

Technique
Prior to treatment, patients should avoid prolonged
sun exposure or sunburns for at least 24 hours to
avoid excessive inflammation and injury. Topical
products are discontinued 12 hours prior and the
skin must be clean and free from cosmetic prod-
ucts. Any patient with active or resolving infection Fig. 3. The goal endpoint of microneedling should be
should have treatment delayed until resolution. mild swelling, evenly spread erythema, and transient
When preparing a patient, the skin is first cleaned punctate bleeding. (Courtesy of Mark Codner, MD,
with a gentle cleanser with or without exfoliation. Atlanta, GA.)
588 Lee et al
unintentionally larger wounds and undesirable
cicatricial healing. On completion, the skin is
washed with sterile water to remove residual serum
and debris. At this point, transdermal delivery of
substances, such as topical vitamins, peptides,
growth factors, and other active ingredients, can
be immediately applied while microchannels are
still patent. An additional layer of petrolatum-
based skin protectant can be applied. Multiple
sessions are spaced at 1-month intervals to allow
sufficient epidermal and dermal proliferation and
to achieve the desired clinical effect. Other tech-
niques, such as subcision or punch elevation, may
be combined for optimal results for difficult skin
conditions, such as deep acne scars.
Postprocedural Care
There may be the feeling of a sunburn-like discom-
fort for the first few hours post-treatment that can
be treated with over-the-counter analgesics or
an HA-based hydrating serum. Sunscreen and
cosmetic products are to be avoided for at least
12 hours. The patient can return to work the next
day although swelling may persist into the second
or third day. Erythema and mild desquamation can
last up to 5 days after which regular skin care,
including tretinoin, can be restarted. By 1 week,
patients can expect to be free of postprocedural
side effects although they should avoid any
alcohol, acid-based toners, and direct sun expo-
sure for 2 weeks. Antiviral medication is indicated
to prevent herpes simplex outbreak.
Complications
There are a few reports of complications in the
microneedling literature given its minimally inva-
sive, superficial mechanism of action.45,61 Multiple
treatment sessions using a 1.5-mm needle depth
have shown to initiate collagen synthesis with no
interference of the patient normal lifestyle.51
Increasing needle depth to greater depths (up to
3 mm) has demonstrated improved results but
with longer downtime and greater swelling,
bruising, and bleeding.48 Careful cleansing and
preparation of the skin is important to avoid intro-
ducing immunogenic particles into the dermis,
which may initiate local or systemic hypersensitiv-
ity reactions. Soltani-Arabshahi and colleagues62
described 3 cases of foreign body–type facial
granuloma formation due to intradermal tattooing
of topical moisturizer during microneedle therapy.
Two of these patients also had positive patch test
reactions to vitamin C serum. Steroid therapy was
ineffective with only partial improvement after
doxycycline hydrochloride and minocycline hydro-
chloride treatment.62 In a case report by Pahwa
and colleagues,63 a female patient formed tram
track scars; multiple lines of pigmented punctate
hypertrophic scars were formed in the direction
of microneedle roller application predominantly
over the bony prominences of the zygoma, fore-
head, and temporal area. Slight improvement
occurred after topical silicone gel treatment. Spe-
cial considerations should be given to patients
with a history of keloid or hypertrophic formation,
particularly if treatment is planned over bony
prominences. In these patients, setting a more su-
perficial needle depth and avoiding repetitive
passes over the same areas can reduce trauma.
CHEMICAL PEELS
Skin peeling through the use of chemical agents
has evolved for thousands of years from natural
products of milk and honey to more caustic
methods, including mustards, sulfur, limestone,
and even fire.64 Modern peels became a common
method of facial rejuvenation in the early twentieth
century, with Hollywood stars undergoing the
procedures by nonphysicians. In the 1950s and
1960s, physicians began to understand and
methodically improve on existing chemical solu-
tions to standardize techniques and formulations
for more controlled outcomes.65 As the number
of products and basic understanding of the
peeling process advanced, peels became not
only a method of reversing skin damage and aging
but also an approach to treating a variety of
dermatologic conditions.
Chemical peels are most commonly categorized
by their depth of skin penetration. Superficial peels
mainly affect the epidermis, resulting in partial
or total necrosis. Occasionally, with varying
strengths and augmentation with other acids or pre-
treatment regimens, these peels may reach the
papillary dermis. Superficial peels may be further
divided to very light and light.66 Very light
peels induce exfoliation and include low-strength
a-hydroxy acids (AHAs), salicylic acid, 10% to
20% trichloroacetic acid (TCA), and retinoic acid.
Light peels extend their effects to the basal layer
of the epidermis, resulting in regeneration of new
epithelium. Examples include 40% to 70% glycolic
acid (GA), 25% to 30% TCA, and Jessner solution.
Superficial peels may be used to treat acne and
postinflammatory erythema, mild photoaging,
actinic keratosis, solar lentigines, and pigmentary
dyschromias.67 Medium-depth peels include 30%
TCA peels and 80% phenol peels. These penetrate
further into the superficial dermis where they effec-
tively treat superficial rhytids and photoaging. Deep
peels, such as phenol-croton oil solutions or 50%
TCA peels, penetrate into the midreticular dermis
 Mesotherapy, Microneedling, and Chemical Peels
to improve severe dyschromias and deep rhytids.
Although it is convenient to categorize peels by
depth of peeling, chemicals may vary their depth
and fall into multiple categories, depending on con-
centration, skin conditions, application method,
duration of application, and formulation.
All patients require a thorough history and ex-
amination of skin properties, including prior skin
treatments and subsequent reactions. Patients’
skin type (Fitzpatrick classification scale) and de-
gree of photodamage (Glogau classification)
should be assessed. Superficial peels can be
used safely in patients with all Fitzpatrick skin
types. In Fitzpatrick types IV to VI patients, postin-
flammatory hyperpigmentation is a limiting factor to
medium and deep chemical peeling, and these pa-
tients should receive spot testing in a hidden area
prior to attempting treatment of larger exposed
areas.68,69 All patients should be given pretreat-
ment with tretinoin and other desquamating agents
to enhance even penetration of peeling agents prior
to medium and deep peeling. Hydroquinone can
also be added to minimize risk of postpeel hyper-
pigmentation.69,70 Pretreatment should cease 3 to
4 days prior to the date of the peel and may be
resumed 1 week after the peel. A history of herpes
simplex requires prophylactic treatment with antivi-
rals to reduce the chances of recurrence. Consider-
ation should be given to those with cardiac,
hepatic, or renal dysfunction, particularly for deep
peeling due to a greater risk of systemic toxicity.
Patients who have recently undergone isotretinoin
treatment (<12 months) should not undergo facial
peeling or resurfacing.67 Other contraindications
to receiving a chemical peel include factors result-
ing in poor wound healing, such as poor nutrition,
nicotine use, and immunosuppression.71
a-Hydroxy Acids and b-Hydroxy Acids
AHAs include lactic, glycolic, citric, malic, mandelic,
and tartaric acids. Glycolic acid, derived from sug-
arcane, is the most commonly used, ranging in
concentration from 20% to 70%. GA produces
exfoliation by decreasing the cohesion of corneo-
cytes, and increases both collagen type I and HA
deposition.72–74 It provides the additional benefit
of degreasing and works well on oily skin.75 Through
these mechanisms, GA is effective at improving
signs of photoaging, superficial rhytids, texture,
acne, melasma, hyperpigmentation, and warts. Af-
ter cleansing the skin, acid is applied with cotton or
a soft brush to the face. Once applied, total treat-
ment time may range from 1 to 15 minutes. The pri-
mary endpoint is an erythematous appearance of
the skin. GA is then neutralized with a basic solution,
such as sodium bicarbonate or ammonium salts,
589
due to its time-dependent mechanism of action.76
Lower acid concentrations (20%) should be trialed
prior to using higher-concentration peels and
spaced at least 2 weeks apart to measure tolerance.
Minor side effects include erythema, stinging/
burning sensation, and postinflammatory hyperpig-
mentation. Rarely, hypopigmentation and persis-
tent erythema can occur.
Lactic acid, which is derived from sour milk, is
another commonly used AHA. By acting as a hu-
mectant, lactic acid causes absorption of water
and is best for those with dry or dehydrated
skin.75 Its larger molecule size compared with GA
allows for slower penetration of the epidermal
layers with less overall inflammation.
Salicylic acid is a b-hydroxy acid. It may be used
at concentrations of 20% to 30% for treatment
of acne, rosacea, melasma, hyperpigmentation,
mild photoaging, and rough skin.67 By acting as
a lipophilic keratolytic agent, it produces exfolia-
tion and dissolves follicular impactions, resulting
in a reduction of acne lesions. Additional benefits
of salicylic acid are antiinflammatory and antimi-
crobial properties. When applied, the acid crystal-
lizes and may be visible after the first minute. After
3 to 5 minutes, the face is gently cleansed with tap
water. Salicylic acid peels can potentially result in
systemic toxicity, with the presence of nausea,
hearing loss, tinnitus, and central nervous system
dysfunction.67
Jessner Solution, Retinoids, and Blended Peels
Jessner solution, the first blended peel formula-
tion, is composed of resorcinol (14 g), salicylic
acid (14 g), and 85% lactic acid (14 g) in 95%
ethanol.77 It is commonly used to treat acne and
hyperpigmentation through its exfoliative and ker-
atolytic properties (Fig. 4). Jessner solution is
applied layer by layer with erythema as the
endpoint. Mild rhytids may be improved when
the papillary dermis is reached through the use
of additional layers of application secondary to
stimulation of collagen production.78
Retinoids are forms of vitamin A, with retinoic
acid, or the tretinoin peel, the most commonly
used. These peels are best used for acne, photo-
aging, lentigines, and rhytids. Tretinoin is typically
mixed in a propylene glycol solvent and regulates
abnormal desquamation by shedding the stratum
corneum and promoting cellular turnover. Reti-
noids inhibit melanogenesis and thicken the skin
by production of collagen. Overall, the peels may
be less irritating than other superficial agents.67,75
As combinations of lower concentrations of
multiple superficial products, blended peels
have become increasingly popular and
590 Lee et al

Fig. 4. Before (left) and after (right): Jessner peel for acne and hyperpigmentation of the cheek at 2 months.
(Courtesy of Mark Codner, MD, Atlanta, GA.)

commercially available over the past decade. In Trichloroacetic Acid

theory, blended peels are able to maximize out-
TCA peels are the most common medium-depth
comes while minimizing concentrations and
peels used to remodel skin and provide improved
resulting side effects.79
skin texture, firmness, pigmentation, and scar
appearance (Fig. 5). TCA is diluted by glycerin

Fig. 5. Before (left) and after (right): full-face 30% TCA peel with upper blepharoplasties at 7 weeks. (Courtesy of
Mark Codner, MD, Atlanta, GA.)
 Mesotherapy, Microneedling, and Chemical Peels
polysorbate and causes a coagulative necrosis
within the upper dermis depending on the strength
of the solution (eg, 25%, 35%, or 50%). Strengths
of 50% are considered deep peels capable of pro-
ducing full-thickness burns with an associated
high incidence of scarring. Lower-strength peels
of 15% TCA have shown equal efficacy to
superficial GA peels, ranging from 35% to 70% in
treating dyschromias.80–83 Generally, 35% TCA is
considered safe to use on normal facial skin
whereas 25% is better suited for the thin skin of
the neck or décolletage. Application is performed
under sedation and analgesia for full-face or larger
applications to minimize discomfort. Skin is first
cleaned and degreased with rubbing alcohol or
acetone. TCA solution is then applied to the
skin in single-layer applications until frosting, or
visible blanching, of the skin is achieved.84 With
appropriate selection of TCA strength, 1 to 3 passes
are usually sufficient to achieve a frosting endpoint.
The TCA is self-neutralized within the dermis and
antibiotic ointment is used as topical dressing.
Blanching should resolve shortly after the comple-
tion of application and is replaced by edema and er-
ythema. Areas of excessive penetration may remain
blanched and are more prone to complications.
TCA peels can be used in a complementary
fashion with other peels. Simultaneous use with
superficial GA peels enhances dermal penetration
and lowers the necessary TCA concentration.85
A Monheit peel combines both Jessner and
TCA repeated once to twice a year.68 Jessner
solution uniformly prepares the skin for lower-
concentration TCA peeling and decreases the
risk of irregular peeling, permanent pigmentary
changes, or scarring.86
General complications include hyperpigmenta-
tion, sun sensitivity, hypertrophic scarring, milia,
and infection. Systemic absorption or toxicity is un-
likely due to limited dermal penetration. Care must
be taken to avoid contact with the eyes to prevent
significant keratitis and corneal burn.87 Other com-
plications include dissatisfaction with a single peel,
with greater satisfactory results reported by pa-
tients who receive multiple treatments.88
Phenol-Croton Oil
Phenol was one of the earliest components of
chemical peels and has been commonly used to
treat acne scarring and gunpowder staining since
World War I.64 Early studies in the 1960s showed
histologic evidence of subdermal collagen
proliferation after phenol application.89 When used
alone, 80% phenol acts as a medium-depth peel
penetrating to the upper reticular dermis.69
The Baker-Gordon peel, described in 1961, is
591
comprised of 3 mL of phenol 88% (United States
Pharmacopeia), 3 drops of croton oil, 8 drops of
Septisol, and 2 mL of tap water. This deep peel so-
lution has been considered the benchmark for
phenol-croton oil peels, with which consistent and
long-lasting results can be achieved for up to
20 years.90–93 Multiple variations have since been
described, including a buffered phenol peel, use of
glycerin instead of hexachlorophene, and variations
in the amount of phenol and croton oil used.91–93 In
particular, Stone91 described a modified formulation
of phenol peel after demonstrating that the croton oil
is responsible for the depth of injury and depigmen-
tation. He, therefore, used less croton oil to reduce
pain, risk of hypopigmentation, and the depth of
peeling.91 Hetter94 further elucidated the role of
croton oil as the true active ingredient in creating tis-
sue injury. His modifications to the original Baker-
Gordon formula vary the proportions of croton oil
to phenol to allow a better-tolerated peel without
the risk of cardiac toxicity from phenol while main-
taining effectiveness in its ability to treat moderate
and severe facial rhytids.94–97
Phenol peel solutions penetrate into the midretic-
ular dermis in an all-or-nothing fashion, creating a
consistent level of partial-thickness chemical burn
for patients with moderate to deep rhytids, photo-
damage, and minimal to moderate skin laxity.98 Pa-
tients are placed under sedation and analgesia,
cardiac monitoring, and intravenous hydration.
Even strokes are used in a systematic order—
beginning at the forehead and followed by the peri-
orbital and nasal areas, the middle third of the face,
and then the lower third of the face. Each area can
be taped to create a vapor barrier for deeper pene-
tration until the full face is treated. Edges of the peel
are feathered 1 cm to 2 cm into surrounding skin,
particularly at the mandibular border to prevent a
line of demarcation from pigmentary changes.
There is prolonged recovery from facial erythema,
transudate, crusting, and edema similar to a
partial-thickness burn. Patients are dressed with
bland emollients and occlusive salves until skin re-
epitheliazation occurs after 7 to 10 days. Erythema
may last for several months whereas dermal regen-
eration continues to occur over 3 months.
Phenol peels require prolonged recovery with
the risk of significant hypopigmentary changes,
thereby making them best suited for Fitzpatrick
types I and II patients. Phenol is absorbed through
the skin, detoxified in the liver, and excreted by
the kidneys. Toxicities include respiratory depres-
sion and cardiac arrhythmias and patients require
cardiac monitoring and adequate hydration
throughout the procedure.99 Cardiac arrhythmias
can be further prevented by evenly spreading out
treatment time and facial areas over the period of
592 Lee et al
an hour.100,101 Other complications include milia
and hypertrophic or keloid scar formation.102
SUMMARY
Noninvasive facial rejuvenation has become in-
creasingly popular over the past decade. Whereas
chemical peels have become time-tested treat-
ments, methods, such as mesotherapy and micro-
needling, have emerged relatively recently in the
literature. As with most new modalities, nonstan-
dardized formulations and protocols and lack of
long-term follow-up have made mesotherapy and
microneedling controversial yet evolving topics.
Mesotherapy studies are shedding light on what
benefit, if any, can be gained as reports of clinical
improvements far outweigh studies demonstrating
histologic changes. Similarly, the growing number
of indications and benefits of PCI outpace
the available research into long-term outcomes.
Even so, the obsession for noninvasive methods
to combat facial aging has existed for thousands
of years and undoubtedly will fuel further research
and evolution of these promising tools in skin care
and other facets of plastic surgery. Together, mes-
otherapy, microneedling, and chemical peels offer
plastic surgeons a large number of modalities to
combat facial aging and pathology. A thorough
evaluation of patients as well as understanding
the indications, risks, and limitations of each avail-
able technology is essential for safe and effective
treatment.
ACKNOWLEDGMENTS
The authors thank Julie Krochonis, RN, BSN,
and Rena L. McConville, LPN, for providing patient
materials and technical assistance.
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