Deep Phenol Chemical Peels

In the early 1960s, Baker and Gordon [1, 2] reported their experience with phenol chemical face peeling. Their initial technique involved “taping” or occluding the skin after phenol application, to prevent evaporation and increase the penetration of phenol. In 1985, Beeson and McCollough [3] reported their technique without taping. Almost half a decade later the debate continues. Regardless of the technique used, phenol chemical peeling continues to offer a method of achieving spectacular results for skin rejuvenation. When performed properly and with appropriate patient selection, the complication rate remains low. As with any method of skin resurfacing, the goal involves the production of a controlled and predictable, partial thickness chemical injury. In the case of phenol, penetration is to the superficial dermis, without ablation of the pilo-sebaceous unit.

M. Siegel

Facial Center for Plastic Surgery, 902 Frostwood, Suite 168, Houston, TX 77024, USA and

7700 San Felipe #420, Houston, TX 77063, USA e-mail: drsiegel@houstonfaces.com

B.A. Bassichis ( )

Department of Otolaryngology – Head and Neck Surgery, University of Texas – Southwestern Medical Center,

5323 Harry Hines Boulevard, Dallas, TX 75235, USA and Advanced Facial Plastic Surgery Center, 14755 Preston Road, Suite 110, Dallas, TX 75254, USA

e-mail: drbassichis@advancedfacialplastic.com

The most important factor in achieving a good result with phenol chemical peeling is the selection of the proper patient. Because of the depth of penetration with phenol, some degree of injury to the pigment producing cells will occur, resulting in hypopigmentation or depigmentation of the skin. In order to camouflage this appearance, patients with lighter skin will have a better result. It is not who is a good candidate but who should not undergo phenol chemical peeling. Patients with Fitzpatrick skin type V and VI are very poor candidates, as any hypopigmentation will be obvious. Also red haired freckled Fitzpatrick type I patients are poor candidates. Due to the freckling, hypopigmentation in this category of patients will be more obvious as a freckled and “nonfreckled” zone is created. Asian patients, notorious for pigmentary problems are poor candidates for phenol resurfacing. Male patients with their thicker and oilier skin are less than ideal candidates. Patients with a long history of sun exposure will make poor candidates, as a line of demarcation may be obvious after peeling due to their mottled skin appearance of the non-peeled areas. Having excluded these categories of patients, the more ideal patients are non-freckled Fitzpatrick types I and II. Type III and IV can be cautiously done as long as the patient understand the possible risks of depigmentation.

17.3 Technique

Phenol chemical peeling can be either done as a regional peel, periorbital and/or perioral, or as a fullface peel. Regional peels are done in the office after

Reprinted with permission of Springer.

the patient’s medical history has been reviewed and they are deemed good candidates for phenol peeling. Either topical anesthetic cream placed 30 min prior to the procedure to the region to be peeled, or a local block with 1% xylocaine with 1:100,000 of epinephrine are satisfactory for performing the procedure in the office.

Full-face peeling must be performed in an accredited facility where intravenous (IV) access is available, the patient can be sedated, the cardiac status of the patient can be continuously monitored, and immediate intervention is accessible if needed.

Skin preparation is the most important step regardless of the area to be treated. The skin must be thoroughly washed with soap to remove any traces of makeup and dirt. This is followed by skin degreasing with 100% medical grade acetone soaked gauze. It is extremely important to remove all skin oils to ensure even penetration during the peel. Once the skin has been degreased, the peeling is performed with a freshly made mixture of the phenol. The traditional Baker– Gordon mixture (Table 17.1) yields an 88% phenol solution. The solution is made by the physician in the office prior to each procedure to prevent changes in concentration from evaporation and mixed multiple times during the procedure to prevent settling.

The mixture is applied with dampened cotton tip applicators using a rolling motion into the skin, ensuring to paint the area evenly and to use each applicator only once. One pass per area is performed, allowing the skin to become frosty white, a sign of mid-dermal penetration. After waiting approximately 30 s, any areas with signs of poor penetration will be self-evi- dent, and a limited second pass to these areas is undertaken.

The limits of perioral peeling are as follows: laterally to the nasolabial folds, inferiorly feathering 2 cm below the border of the mentum, and feathering at the vermillion border of the lips.

For periorbital peeling, the orbital subunits are marked and the patient is placed at a 45% angle

Table 17.1 Baker–Gordon phenol mixture 3 ml USP liquid phenol

2 ml tap water

8 drops of Septisol liquid soap

3 drops of croton oil

position. Cotton tip applicators placed at the medial and lateral canthus to prevent tears from running down and possibly mixing with the phenol producing a stronger concentration. Along the upper lid no phenol is placed along the tarsus. When peeling the lower lids the patient is instructed to fix their eyes on a superior point at the ceiling to increase the taughtness of the skin. The lid border is marked to 3 mm. Any time a periorbital peel is performed the sedation is kept to a minimum so the patient is cooperative and awake enough to complain of pain in case phenol contacts the cornea. Cool saline is kept on hand in case ocular irrigation becomes necessary. Because of the anesthetic properties of phenol, discomfort during the initial application is self-limited and no further medication is given to the patient.

To avoid the possibility of cardiac arrhythmias from full-face peeling the patient’s cardiac status is continuously monitored and the procedure is lengthened approximately 2 h by peeling the face as subunits. Each subunit is peeled separately with a 20 min interval between subunits to prevent rapid absorption of the phenol solution. Because of the renal clearance of phenol, normal renal function is essential thus blood urea nitrogen (BUN) and creatinine are obtained prior to the procedure. The patient also receives about 2 l of IV fluids to enhance renal excretion of phenol during the peel procedure. Full-face peeling is recommended in the following order: forehead, periorbital, cheeks, perioral area, and nose. Because the action of this peel is of coagulation, no neutralization of the acid is required. At the conclusion of the procedure, Vaseline is placed along the peeled areas, providing a “semiocclusive” dressing. However, nonocclusive phenol peeling can be achieved by avoiding any petroleumbased ointments after the procedure.

Patients undergoing full-face phenol peeling are started on anti-herpetic medication 3 days prior to the peel and are given antibiotics after the procedure. Patients undergoing regional peeling will be given antiviral drugs only with a history of cold sores.

Some patients will experience a severe burning sensation after the procedure, lasting 6–7 h. For regional peeled patients, pain and antianxiety medications will give some relief. For full-face peeled patients, IV pain management is preferred. The pain and burning associated with this procedure usually subsides after 8 h.

During the first 7–10 days after the peel the patient is instructed to wash their face three to four times a day

with vinegar, followed by application of a petroleumbased ointment. The vinegar mixture decreases the risk of fungal infection. After reepithelialization, usually after the seventh to tenth day, the patient is permitted to wash their face with a noncomedogenic, nonperfumed soap followed by application of a skin moisturizer and sunscreen. It is imperative that patients are counseled on avoiding sun exposure to prevent developing dyschromias. Any itching may be controlled with antihistamines.

Patients are followed very closely for erythema persisting after 12 weeks. Any signs of prolonged erythema are treated with a 3-week course of 2.5% hydrocortisone applied to the face twice per day.

17.4 Complications

With proper patient selection and diligent technique the complication rate with phenol chemical peeling should be low. It is important to differentiate between true complications and transient post-peel reactions. Because of the depth of penetration of phenol there will invariably be injury to the pigment producing cells. Because recovery of these cells is unpredictable, proper patient selection is imperative.

Poor feathering of the peel will result in a suboptimal cosmetic result due to an obvious demarcation line. Feathering too low in the neck will not only cause this, but also an increased risk of scarring because of the paucity of adnexal structures below the jaw line.

It is important to counsel patients before a phenol peel about the length of erythema associated with this procedure. It is not uncommon for patients to experience erythema from 4 to 12 weeks post peel. Make up may be applied after 2 weeks to conceal redness, but patients should be followed closely to treat persistent erythema with topical steroids.

The use of sunscreen for a minimum of 6 months after a peel is vital to prevent hyperpigmentation from sun exposure. Patients need to be educated that their postpeel skin is highly sun sensitive, thus suntanning and excess sun exposure after a phenol peel is not advised.

The most common problem after a phenol peel is transient hyperpigmentation. The darker the patient, the more likely this may occur. Hyperpigmentation is usually seen around the third to fourth week post peel. The most important step in preventing this is avoiding

sun exposure. The first signs will be marked by erythema followed by the appearance of blotchy skin spots. A treatment regimen of Retin-A and hydroquinone is started and patients are seen at intervals of 2 weeks. Patients not responding to this regimen are offered a TCA peel.

The most feared complication of a phenol peel is post-peel hypertrophic scarring (HS). HS results from violation of tissues deep to the reticular dermis. It may be the result of a treated herpes simplex virus (HSV) infection, peeling of tissues with poor adnexal structures, like the neck, or performing multiple passes on the face with phenol solution. Fortunately, HSV leading to hypertrophic scarring is rare as this infection responds well to antiviral therapy. The best treatment though is prevention. Patients with a history of cold sores, or patients undergoing full-face phenol chemical peeling should be treated prophylactic ally with antiviral therapy. Hypertrophic scarring, once diagnosed should be aggressively treated with intralesional and topical steroids.

Patients should be monitored for signs of infection in the post-peel period. Bacterial infections are usually a result of poor facial hygiene. Anti-staphylococcal oral antibiotics will usually resolve this problem. Fungal infections are rare as the patient keeps the pH of the skin in the acidic range using daily vinegar treatments.

Patients with a history of cold sores or undergoing full-face peeling should be started on prophylactic therapy to prevent HSV breakouts. If the patient develops an HSV outbreak post peel, the oral dose of antiviral medication is doubled.

Milia formation is a sequelae rather than a complication. They represent small superficial inclusion cysts, usually lasting days to weeks. Most will spontaneously resolve, but the larger ones can be “unroofed” with an 18-gauge needle.

One should be careful to perform this type of peel on patients with previous history of blepharoplasty, or patients with lower lid laxity as these patients may develop an ectropion. Most will resolve, but corrective surgery may be needed in some instances.

17.5 Conclusions

Phenol chemical peeling has been safely performed for almost half a century. Phenol chemical peeling is a means of providing a controlled and predictable

chemical injury to the skin (Fig. 17.1). Microscopically, phenol induces new collagen and elastins formation as well as the reorganization of melanocytes within the basement membrane. Clinically, the results of phenol chemical peeling are significant and long lasting.

Proper patient selection and counseling regarding the length of recovery is the key to excellent results and happy patients. Because of the properties of phenol, it is imperative that the patient be in good health prior to the procedure. Phenol is absorbed through the skin, detoxified in the liver, and excreted by the kidneys. Poor renal or hepatic function will result in toxic levels of phenol producing cardiac arrhythmias. Thus, patients with poor renal function, liver problems, or heart conditions may not be the best candidates for this resurfacing modality. The safety of the patient remains the number one priority. Healthy patients undergoing full-face chemical peeling should have their cardiac function continuously monitored, and application of phenol should be performed in increments of facial subunits with rest in between applications to prevent cardiac problems.

There are certain conditions because of which phenol chemical peeling produces poor to minimal results,

and patients with these conditions are not offered phenol peeling as an option. These include: capillary hemangiomas, facial telangiectasia, port wine stains, thermal burns, deep-pitted acne scars, and hypertrophic scars. Phenol peeling is not performed on Fitzpatrick types V and VI, or type I with freckles, due to the abnormal hypopigmentation with severe demarcation changes. Phenol should not be applied to areas with minimal to none adnexal structures, like the neck, chest, and hands due to the high risk of hypertrophic scarring.

With the proper technique, patient selection, and counseling about the recovery time, phenol chemical peeling remains a safe and effective means of skin resurfacing.

References

1.Baker TJ, Gordon HL. The ablation of rhytides by chemical means. A preliminary report. J Florida Med Assoc. 1961; 48:451–4.

2.Baker TJ, Gordon HL, Seckinger DL. A second look at chemical face peeling. Plast Reconstr Surg. 1966;37(6): 487–93.

3.Beeson WH, McCollough EG. Chemical face peeling without taping. J Dermatol Surg Oncol. 1985;11(10):985–90.