JetPeel TM a New Technology for Facial Rejuvenation
Jacob Golan, M.D. and Noam Hai, M.D.
Department of Plastic Surgery,
Shaare Zedek Medical Center, Jerusalem, Israel

This article in the PDF Format with case pictures.

ABSTRACT:
JetPeelTM is a new device for cosmetic resurfacing of the facial skin. It
uses a new technology of a two-phase stream that creates a jet comprised
of gas (oxygen) and micro droplets of fluid (saline) accelerated to
supersonic velocities. This jet impacts the skin causing gentle and
accurate cosmetic peeling.
Our preclinical and clinical experience with the JetPeelTM for rejuvenation
of the face is presented. In a group of 50 patients we found the JetPeel TM
technology to be a safe and effective new tool for the usual indications
for facial peeling. It was most useful and effective for perioral peel.
JetPeelTMcan be used in combination with other resurfacing modalities
such as chemical peeling or laser.
Further investigation is needed to explore other applications of this
technology, such as using different combinations of gases and fluids,
and transdermal transfer of medication dissolved in the peeling jet.
INTRODUCTION:
The desire to rejuvenate the skin by resurfacing it is very old and dates
back to the era of ancient Egypt. The oldest record of cosmetic therapies
performed by physicians is the Ebers papyrus (1560 B.C) [1]. Early
resurfacing techniques involved direct application of minerals, plant
extracts, sulphur, mustard or limestone. Renewed interest for facial skin
resurfacing was noted among physicians and surgeons in the early
twentieth century. McKee (1903) was the first to report his experience
with liquid phenol in the treatment of acne scars [2]. Kromayer (1905)
is considered the first to apply mechanical dermabrasion techniques
using rotating wheels and rasps for the treatment of acne scars, keratoses
and pigmentation disorders [3]. After World War II lay peelers rather
than physicians and surgeons developed new techniques and proclaimed
to find the fountain of youth for their patients. Skepticism of the medical
society gradually resolved in the 1960s with data from numerous studies
showing the clinical effectiveness and histological changes in the skin
associated with chemical peeling [4-9].
Traditionally peeling techniques are either chemical or mechanical. In
chemical peeling the chemical solution applied to the face is designed
to cause controlled peeling of the superficial layers of the skin.
In dermabrasion a mechanical device is used to resurface the skin by
removing the same layers. A variety of abrading techniques are available,
the most popular one being a small rotating abrasive wheel applied to
the skin.
Since the early 1990s various types of lasers have been used to resurface
photo aged skin. CO2 Laser was first introduced in a nation-wide
presentation by Roberts in 1995 [10]. Since then, technologies have
been changing and the clinical use has expanded rapidly throughout the
world. Many proponents of Laser resurfacing attest to its accuracy and
predictability of the clinical results obtained by experienced operators.
The various types of peeling techniques share a common denominator:
they all produce a partial thickness injury to the skin. Following the
controlled injury to the skin, wound healing processes ensue regenerating
the epidermis, replacing and reorienting the fibres in the dermis. The
effectiveness of the resurfacing technique is directly related to the depth
of the controlled injury to the skin. The physiologic basis of healing
following either technique rests upon the ability of the skin to regenerate
its epidermal cover by epithelialization through the skin appendages,
primarily the pilosebaceous unit. The result is an improved, more youthful
appearance and texture of the skin.
This article introduces a novel method for skin resurfacing. The JetPeel TM
device is based on a new technology derived from the world of aviation.
A mixture of sterile saline and oxygen passes through an open convergingdiverging
venturi channel, designed to produce supersonic flow
accelerating the solution droplets to approximately 200 m/sec and exitsthrough specialized nozzles as a powerful jet directly onto the desired
area of skin. This high-energy micro droplet spray gently exfoliates
the skin. After removing the epidermal layer additional layers of the
upper papillary dermis can be removed accurately to reach the desired
end point depth as set by the operator.
STUDY OBJECTIVES:
To determine the safety and the efficacy of the JetPeel TM system as
a peeling modality in a preclinical setting and to determine the clinical
results and patient satisfaction with the procedure.
MATERIALS AND METHODS:
1. THE TECHNOLOGY
The idea behind the JetPeelTM is derived from the world of aviation
using supersonic flow in nozzles. Liquid medium is propelled by
sub-atmospheric pressure caused by the rapid flow through a parallel
capillary tube. The mixture of liquid and gas is accelerated in an open
converging-diverging venturi channel to reach high velocity using a
two-phase stream and emits through a specially designed nozzle unit.
The jet spray impacts on the skin causing shearing forces strong
enough to peel the epidermal and dermal layers of skin as necessary.
2. THE DEVICE
The device used in this study is the JetPeel TM system manufactured
by TavTech Ltd., (Yehud, Israel). The JetPeelTM system is a portable
device, which produces a spray of liquid mixed with gas under a
predetermined pressure of 7 atmospheres. The jet spray consists of
liquid droplets, 5-200 m in diameter, emitted at a speed of up to 200
m/sec.
The JetPeel TMdevice consists of a control unit, a hand piece, a
footswitch and tubing line accessories. A source of pressurized oxygen
(or any other gas, e.g. nitrogen) is connected to the control unit set
to yield a pressure of 7 atmospheres. A disposable solution bag
supplies the sterile liquid medium needed. The mixture of gas and
fluid occurs inside a sterile, disposable hand piece. A separate suction
hand piece removes gas and debris.
3. PEELING TECHNIQUE
The hand piece is held by the operator at a 45o-90o angle to the skin
surface and at a distance of 2-5 mm from the skin. When the footswitch
is pressed the jet is released from the nozzles. Care is taken to avoid
the eyes and the eyelids. When the jet is applied to the skin a blanching
effect is noticed representing a momentary withdrawal of blood from
the treated skin segment. This serves as an indicator for proper
application of the jet. Gradually the abrasive droplet attack creates
enough mechanical energy for peeling of the epidermis. Slow scanning
advancement of the jet stream is then begun along a line in a forward
direction, exploiting the momentum of power, creating a “front” of
peeling and achieving a uniform depth of removal. Areas for which
the operator wishes to increase the depth of peeling are retreated in
the same manner (for example: along the wrinkle creases in the
perioral area). Punctate bleeding and its intensity after discontinuing
the jet serve as an indicator for the peeling depth.
4. PRECLINICAL STUDY DESIGN:
Since the porcine model is the most closely analogous to human skin,
it was used as the preliminary in vivo model. The porcine model has
been well established in the scientific literature [11].
Four porcine (sus scrofa) of a local strain of Landrace x Large Whites,
aged less than 2 years and weighing about 15 kg, were used as the
experimental model.
After proper acclimatization, fasting and sedation, general anesthesia was
initiated. The back and flank of the anesthetized pigs were clipped, taking
care not to cause injury to the skin, and then scrubbed according to
standard aseptic practices for preparation of skin (Iodine surgical scrub
and Alcohol rinse). A template was used to mark the experimental windows
on each side of the back and flank of the swine.
Skin peeling technique was performed using the JetPeelTM system.
Full thickness 8 mm punch biopsies were taken both immediately prior
to the procedure and at 7 and 14 post treatment days during the healing
phase.
Evaluation was based on gross and microscopic examinations of the
biopsies. The parameters examined included peeling depth, dermal
inflammation and re-epithelalization.
5. CLINICAL STUDY DESIGN:
The study group consisted of 50 healthy adult volunteers who agreed to
participate in our study. The study was conducted in accordance with the
Helsinki committee regulations for human experiments.
The indications for treatment were: sun damaged skin, facial rhytids,
pigmentation disorders and post-acne facial scarring.
Periocular skin and eyelids were excluded from treatment.
For partial facial procedures the treatment area was anesthetized locally
using 5% EMLA cream in all cases. Facial blocks using 2% Lidocaine
with 1:200,000 Adrenaline were used as necessary. Full-face procedures
were done under general anesthesia or IV sedation.
The skin was aseptically prepared and draped using a Betadine solution
mixed with normal saline at a ratio of 1:1.
The procedure was continued until the end result as desired by the operator
was reached, judged clinically by direct vision and the intensity of punctate
bleeding.
At the end of the procedure petroleum jelly (Vaseline) was evenly applied
to cover the entire treatment area. An open treatment regime was used
postoperatively and the patients were instructed to cleanse the treated
area with warm tap water and mild soap twice daily and then to apply a
fresh thin layer of Vaseline.
All the patients were given oral Acyclovir 200 mg 5 times daily from a
day prior to the procedure until healing was complete.
RESULTS:
PRECLINICAL:
Biopsies taken from the treated skin showed the effects of removing the
epidermis and the upper dermis. Healing was uneventful, occurring from
7 to 14 days post treatment. There were no wound healing complications
(e.g. infection, delayed healing, etc.). Clinical and histological examinations
proved that the JetPeelTM achieved the desired peeling effect.
CLINICAL:
The study group consisted of 50 healthy adult volunteers, 40 females and
10 males (age 19-62; mean 38)
The indications for treatment were: sun damaged skin, facial rhytids, skin
pigmentation and post-acne facial scarring.
Treatment areas were: concealed retro auricular skin in the preliminary
10 cases, partial facial areas (especially perioral) in 32 and full-face
peeling in 8.
Healing course was smooth and uneventful. Re-epithelialization occurred
within 7 to 9 days depending on the depth and location of the area treated.
Regular follow-up visits were scheduled at predetermined intervals, the
longest follow up to date being 24 months.
The overall length of treatment ranged 5-70 minutes.
The healing phase was very smooth and easy. Erythema was noted during
the first 2-4 weeks post peeling. All the patients were instructed to abstain
from the sun as much as possible and to use sunscreens with SPF >= 30
whenever sun exposure was inevitable.
The aesthetic results as judged both by the patients and by the medical
staff were good to excellent and patient satisfaction was high.
COMPLICATIONS:
We noted only a few cases of complications, all of which were minor:
One case of Herpes Simplex Virus (HSV) infection was noted in a 40
year old female with post-acne scarring after a full-face jet peeling
procedure despite preventive treatment with Acyclovir. The patient
was noticed to have pain, erythema and some small vesicles on her
face. The dose of Acyclovir was increased to a therapeutic level given
intravenously and an antibiotic treatment was added. Healing was
complete with excellent results and no scarring.
Three cases of hyper pigmentation, presumably related to sun exposure,
were treated conservatively with Hydroquinone and Isotretinoin based
products with satisfactory improvement.
One case of subcutaneous emphysema of the lower eyelid was
encountered when the treatment was too close to the periocular area.
The emphysema, although troublesome both to the surgeon and to the
patient, subsided in 2-3 hours without any sequelae.
This unique complication is due to subcutaneous penetration and
dissection of the jet stream in a very loose and thin type of skin. The
best way to avoid it is to exclude areas of thin skin (usually the eyelids)
from treatment, and to use eye-blocking goggles as a means of protection
from inadvertent passage of the jet to emphysematous prone areas.
DISCUSSION:
Whenever a new technology, method or technique is introduced it must
prove itself to be superior or at least as good as older “traditional”
methods. It is commonly said that a new technology is not necessarily
good or better, but every good and useful technology was once new.
The most appealing parameters about the JetPeelTM are its simplicity,
efficacy and safety.
The results show that the JetPeelTM system is a safe and effective device
that achieves mechanical peeling through natural resources such as
saline and oxygen. It avoids potentially harmful processes like burns
and does not create an eschar of dead tissue.
It appears to be less bloody and cumbersome as compared with
traditional dermabrasion devices. The device is quite easy to operate
and mandates only minimal dexterity from the operator with a short
learning curve as noted by ourselves.
The resources needed for applying the JetPeel TMtechnology (saline
and pressurized gas) aside from the JetPeel TM device itself are readily
available in most medical facilities. It is an accurate tool that can be
applied to the desired area without any significant collateral damage.
It is a versatile tool which allows for “fine tuning” of the peeling depth
by controlling gas pressure and number of passes, thus meeting the
requirements of different areas of skin simultaneously. Since the skin
is actually peeled off it is not left to become necrotic and slough later.
It is our clinical impression that healing is somewhat smoother and
swifter as compared to other peeling modalities.
We find the JetPeel TMespecially efficient in treating the perioral region.
The ability to achieve different depths of penetration in this area is of
significant importance.
The JetPeelTM technology can be used in combination with other peeling
techniques, for example combining the accuracy of the JetPeel TM in the
perioral area with the speed of a chemical peel in the rest of the face.
We believe that further applications of the JetPeel TMtechnology should
be carefully examined. One example is the use of various combinations
of liquids with gases that may prove to be superior to others. Another
example is the potential transdermal transfer of medications, passing
the skin barrier. This type of transdermal transfer deserves serious
investigation and might be a useful vector for introduction of various
medications, from vitamins to growth factors, for various therapeutic
purposes.
It is possible that tissue oxygenation during the treatment with the
JetPeelTM device contributes to the accelerated wound healing that was
noticeable in this study.
Another application is already in use: a very superficial peeling is
performed by para-medical staff for indications like post rhinoplasty
intense skin treatment or post Laser eschar removal.

CONCLUSIONS:
These are the first published results from an ongoing study.
We find several advantages for the use of the JetPeel TM
technology as a peeling technique: it is safe, accurate and
versatile. Perioral rhytids, which are numerous creeks
compacted closely together, best demonstrate the advantage
of JetPeel TM technology as it has the added ability to treat each
wrinkle separately. The healing process was noticed to be very
smooth and easy. Our patients were very satisfied with the
treatment and the results.
The KISS principle (Keep It Safe and Simple) strongly applies
to the JetPeel TM system. Further applications of this technology
should be investigated.
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