By ANIS LACERTE Medical licensed esthetician and skin care manufacturer TCA Localized Peeling (Focal Treatment of Acne Scars With Trichloroacetic Acid) TCA Cross Method TRICHLOROACETIC ACID (TCA) has a particularly long history as an effective agent for rendering histo logic and clinical improvement to the skin and is par ticularly safe when used as a superficial peel or in "combination peels" of medium depth for acne scars.l-4 Application of TCA to the skin causes precipitation of proteins and coagulative necrosis of cells in the epider mis and necrosis of collagen in the papillary to upper reticular dermis.1 Over several days the necrotic layers slough and the skin repithelializes from the adnexal structures that were spared from chemical damage.3 Dermal collagen remodeling after chemical peel may continue for several months.4 Many investigators have observed that the clinical effects of TCA were due to both a reorganization in dermal structural elements and an increase in dermal volume as a result of an increase in collagen content, glycosaminoglycan, and elastin. Recent studies have shown that the reticular dermis heals with scarring. They offer an explanation for some of the increased risk associated with the use of TCA for deeper peels, suggesting that peeling with higher TCA concentrations is very risky and definitely not recommended.8 We also have limited experience and very little information regarding the effects of higher TCA concentrations for acne scars in dark ­complexioned patients, including Koreans, whose skin is known to develop post inflamma tory hyperpigmentation. In order to maximize the effects of TCA and to overcome complications such as scarring, hyperpig­mentation, and hypopigmentation, we suggest a tech nique consisting of the focal application of higher TCA concentrations by pressing hard on the entire de pressed area of atrophic acne scars using a sharpened wooden applicator. Eventually it produces multiple, frosted white spots on each acne scar. This technique is called chemical reconstruction of skin scars (CROSS) by the authors; however, the tech nique itself has not been patented or restricted to pre vent usage. The CROSS method, achieved with 65% or 100% TCA alone, has the advantage of reconstruct ing acne scars by focusing on the dermal thickening and collagen production that increase with high TCA concentrations.7 Healing is more rapid and has a lower complication rate than conventional full-face medium to deep chemical resurfacing, because the adjacent nor mal tissue and adnexal structures are spared. This tech nique And then either 65% TCA or 100% TCA was focally applied by pressing hard on the entire depressed area of atrophic acne scars using a sharpened wooden applicator. The skin was monitored carefully until it reached a "frosted" ap pearance after a single application. The frosted appearance is the result of coagulation of epidermal and dermal proteins and is used mainly to monitor the peel depth. Focal applica­tion of TCA produced even frosted spots on each acne scar within 10 seconds. After CROSS, an ointment­ based antibiotic instead of an occlusive dressing was applied for moisturizing effect, but this application was discontinued after crust formation in order to avoid the risk of detaching the crust. Oral prophylaxis consisting of antibiotics and anti viral medications were not needed after CROSS. One to 2 weeks after CROSS, a moisturizer sunscreen cream consisting of 0.05% tretinoin, 5% hydroquinone, and a hydro base was used in some patients for a minimum of 4 weeks. The appli cation of makeup was allowed after CROSS. CROSS was re peatedly performed every 1-3 months to allow dermal thick ening and collagen production. Recently acne scars have been classified into three types: icepick, rolling, and various treatment modalities are used for reconstructing and improving the appearance of acne scars, including punch excision, punch elevation, subcutaneous incision (subcision), chem ical skin resurfacing, and laser skin resurfacing.16,17 By combining these multiple modalities, it is possible to pro duce dramatic improvement in acne scars. However, procedures that include chemical skin resurfacing have generally been limited to skin types N-VJ.9 So far, no appropriate and effective single treatment modality has been developed for reconstructing and ameliorating the appearance of acne scars. We suggest the CROSS method, which consists of the focal application of higher TCA concentrations, even up to 100%, by pressing hard on the entire de pressed area of atrophic acne scars using a sharpened wooden applicator. This technique, achieved with higher TCA concentrations of 65% or 100% TCA alone, has the great advantage of reconstructing the acne scars by focusing on the dermal thickening and collagen pro duction that increases with high TCA concentrations. Of interest is that rather than being equivalent to the classic full-face chemical resurfacing, this technique can be used on focal chemical scar reconstruction. Moreover, this technique can avoid scarring and re duce the risk of developing hypopigmentation by spar ing the adjacent normal skin and adnexal structures. We found that in using the CROSS method, applica tion with 100% TCA was more effective in treating atrophic acne scars than with 65% TCA. Repeated CROSS application can normalize deep rolling and boxcar scars, and a similar result can be achieved for deep icepick scars with higher TCA con centrations of up to 100%. treatment, this method is effective for the treatment of all deep acne scar types. Furthermore, it can also be utilized for autologous soft tissue augmen tation prior to performing the classic full-face resur facing modalities for deeply pitted areas. Also, we have used this technique successfully for treating di lated pores. Recently we used the CROSS method for reconstructing depressed surgical scars. A history of drugs that depress adnexal glands, such as isotretinoin, is a relative contraindication tomedium to deep chemical resurfacing because of the increased risk of developing hypertrophic scars. We believe that a drug history of isotretinoin is not a rela tive contraindication and does not influence the clini cal results because CROSS may spare the adjacent normal skin. But further study is required to deter mine the effect of isotretinoin in CROSS. Please visit Our EBAY Store: http://stores.ebay.com/Anis-Lacerte-anti-aging-skin-care You can order TCA peel lit at different strength starting at 8% (lunch peel), 12.5%, 25%, 50%, 80% with vitamin & DMAE and 100% TCA peel for cross method.. (C) Copryight 2006. Anais Corporation. All rights reserved. text and pictures. Products made in France and labeled in France.