HISTOPATHOLOGIC CHANGES OF THE EYELID SKIN FOLLOWING TRICHLOROACETIC-ACID CHEMICAL PEEL

The use of trichloroacetic acid (TCA) as a periorbital and eyelid peel for skin rejuvenation is gaining significant acceptance among oculopl astic surgeons, dermatologists, and other surgery groups. In spite of the current enthusiasm, there remain potentially serious complications resulting from any periorbital peel. Cases of cicatricial ectropion h ave been reported in phenol-peeled patients, and lower eyelid ectropio n has reportedly occurred in patients undergoing deep eyelid peel in c onjunction with a blepharoplasty (1,2). To avoid this complication, it is necessary to better understand the depth of the wound produced by different strengths and combinations of peeling agents applied to livi ng eyelid tissue and, more important, to determine the concentrations of TCA that are likely to lead to cicatricial ectropion when applied i n a consistent fashion. We chose upper-eyelid skin because it is easie r to obtain for histopathologic study than lower-eyelid skin and, in o ur experience, is more sensitive to hypertrophic changes after chemica l peeling or carbon dioxide laser resurfacing. We applied TCA to the p reseptal skin of 10 patients 48 h before standard upper-eyelid blephar oplasty. The acid was applied to produce a ''frost,'' using varying co ncentrations of acid, ranging from 20 to 50%. The treated skin removed at the time of blepharoplasty was reviewed in a masked fashion by a d ermatopathologist to determine the depth of necrosis. We found that su perficial peels with necrosis involving 30% of the epidermis were prod uced by the lowest-concentration combination of TCA applied (20% follo wed by 0%). As the strength increased, so did the depth of peel. The c ombination of 50% followed by a second application of 50% produced the deepest peel, with necrosis into the papillary dermis. This finding w ould indicate that the chance of developing cicatricial ectropion with any of the tested combinations of TCA should be very remote.