Chemical Peel (Deep,

M e d i u m , Li g h t )
Sidney J. Starkman, MDa, Devinder S. Mangat, MDb,*

KEYWORDS
 Chemical peel  Chemoexfoliation  Phenol-croton oil peel  Skin resurfacing

KEY POINTS
 Chemical peels offer an excellent option for skin resurfacing for rhytids and dyschromias.
 Phenol-croton oil peels have been modernized dependent on croton oil concentration to minimize
risks.
 Complications associated with chemical peels are uncommon with proper technique and postop-
erative management.

INTRODUCTION laypeelers of the 1920s. In Hollywood, laypeelers

would cater to the movie stars who wished to
With modern medicine increasing both the maintain youthful skin and facial features. Some
average life span and quality of life, there has of the foundational laypeelers of the twentieth cen-
been a greater demand for treatment of age- tury were Jean DeDesly and Antoinette LaGasse.
related skin changes. This has led to a boon in The physicians began to incorporate chemical
skin care products, and medical devices. As peeling into their practices in the 1950s and
many new options in skin resurfacing are devel- 1960s. There is a 4-part series by Gregory Hetter
oped annually, it is chemical peeling that has with- that details the transition of chemical peeling
stood the trials of time and scrutiny. Ever since from the hands of the laypeelers to the plastic
1550 BC when keratolytic formulas were surgeons.
mentioned in the Ebers Papyrus, and more As chemoexfoliation entered the realm of medi-
recently with the laypeelers of the twentieth cen- cal practice and literature, the experiences of the
tury, chemoexfoliation has been the standard by many plastic surgeons became publicly
which other methods of skin resurfacing are described. Some writings were more scientific,
measured. and other publications were more anecdotal in na-
The different variations of chemoexfoliation ture. In some cases, dogma was written and fol-
have been used for rhytids, actinic damage, lenti- lowed for decades.
gos, and dyschromias. The goal of this article
was to describe the most recent knowledge about
chemical peeling, and to expose the previously PATIENT SELECTION
accepted yet incorrect dogmas. Chemical peeling,
when practiced with knowledge and good tech- A critical portion of practicing chemical peeling is
nique, can yield excellent results in skin the identification of the suitable patient. The pa-
rejuvenation. tient must both be a physical candidate for a
chemical peel, and also have appropriate expecta-
HISTORY tions for their postpeel results. Skin-related
changes, such as rhytids and photodamage,
facialplastic.theclinics.com

Before becoming common practice of plastic sur- must be distinguished from other changes like vol-
geons, chemical peeling was modernized via the ume loss or jowling. Ideally, a chemical peel

a
Facial Plastic Surgeon, Mangat Plastic Surgery, 56 Edwards Village Boulevard, Suite 226, Edwards, CO 81632,
USA; b Starkman Facial Plastic Surgery, 8560 E Shea Boulevard, Suite 110, Scottsdale, AZ 85260, USA
* Corresponding author. 133 Barnwood Drive, Edgewood, KY.
E-mail address: [email protected]

Facial Plast Surg Clin N Am 28 (2020) 45–57

https://doi.org/10.1016/j.fsc.2019.09.004
1064-7406/20/Ó 2019 Elsevier Inc. All rights reserved.
46 Starkman & Mangat

patient will have blue eyes, fair skin, and shallow this reepithelialization for healing. The most cur-
rhytids. However, most chemical peel patients rent recommendations are to stop isotretinoin for
will not fit this exact description. Most commonly, 12 to 24 months before the peel.
the Fitzpatrick scale is used to help define a pa- Finally, the patient and the practitioner must
tient’s skin type (Table 1). have agreed on the reasonable expectations of
Patients also can be rated by their skin type, the peel. The patient’s axillary skin can represent
texture, complexion, and photoaging, using cate- the final result of the chemical peel, as long as
gorizing schemes such as the one by Glogau this region has not previously received excessive
(Table 2). sun damage.2
The medical history of the patient must be
reviewed before any chemical peeling occurs.
PREPARATION
Relative contraindications for any resurfacing pro-
cedure include smoking, diabetes, active or After the patient selection and planning are
frequent herpes simplex virus (HSV) infections, completed, adequate skin preparation must
cutaneous radiation history, hypertrophic scarring, begin before the peel. Sunscreens should be
or keloid history. Photosensitizing drugs, exoge- started 3 months beforehand to prevent prepeel
nous estrogen, and birth control pills should be tanning or sunburns. Part of the purpose of this
avoided because of the increased risk of hyperpig- is to decrease the melanocyte activity before
mentation. Patients also should be warned not to the peel. Topical tretinoin (Retin-A) is recommen-
have plans to become pregnant within 6 months ded for 6 to 12 weeks before the peel. The
after chemical peeling, because of elevated estro- topical tretinoin has been shown to have a syner-
gen levels of pregnancy.1 gistic effect with trichloroacetic acid (TCA) peels,
Smoking and sun exposure always should be and can sustain the effects of these peels.3–5
addressed in the planning stages. Chemical peels Tretinoin leads to exfoliation of stratum corneum
on the faces of chronic smokers can lead to poor tis- and increased melanin distribution, and aids in
sue healing, because of the microvascular damage proper penetration of the peel solution. The
from smoking. It is recommended that smokers tretinoin contributes to a thickened and uniform
stop 1 month before the peel and continue absti- epidermis, which aids in uniform application of
nence for at least 6 months afterward. Likewise, it the peeling agent.
should be recommended to patients that prolonged Nighttime tretinoin treatments can begin
sun exposure should be avoided for 3 months after 6 weeks before the peel, and continue until the
the peel. If this is unacceptable to the patient, other postpeel reepithelialization is completed. The
options besides chemical peeling should be dosing ranges from 0.025% to 0.1%; however,
explored. no literature has shown improved results with the
An absolute contraindication to chemical higher dosing. Patients should be counseled of
peeling, or any facial resurfacing, is recent use of the possible side effects of tretinoin, such as ery-
isotretinoin (Accutane). Isotretinoin prevents reepi- thema, flakiness, or skin irritation. If this was to
thelialization from hair follicles and sebaceous occur, the dose can be reduced or the medication
glands, and chemical peeling relies primarily on can be discontinued entirely.

Table 1
Fitzpatrick skin type scale

Skin
Type Skin Color Characteristics
I White; very fair; red or blond hair; blue Always burns; never tans
eyes; freckles
II White; fair; red or blond hair; blue, hazel, Usually burns, tans with difficulty
or green eyes
III Cream white; fair with any eye or hair Sometimes mild burn, gradually tans
color; very common
IV Brown; typical Mediterranean Rarely burns, tans with ease
white skin
V Dark brown; Middle Eastern skin types Very rarely burns, tans very easily
VI Black Nevers burns, tans very easily
 Chemical Peel (Deep, Medium, Light) 47

Table 2
Glogau skin classification scale

Group I Group II Group III Group IV

(Mild) (Moderate) (Advanced) (Severe)
No Early actinic Actinic keratoses-obvious Actinic keratoses and skin
keratoses keratoses-slight yellow skin cancers have occurred
yellow skin discoloration with
discoloration telangiectasias
Little Early wrinkling-parallel Wrinkling present at Wrinkling: much cutis laxa of
wrinkling skin lines rest actinic, gravitational, and
dynamic origin
No scarring Mild scarring Moderate acne scarring Severe acne scarring
Little or no Little makeup Wears makeup always Wears makeup that cakes on
makeup

Another beneficial drug in the preparation of continues it for 7 days in the postoperative period.
chemical peel patients is hydroquinone. Hydro- In patients who are B-lactam sensitive, erythro-
quinone is used mostly in patients with dyschro- mycin 250 mg 4 times a day can be used. To main-
mias or lentigos, or in patients with Fitzpatrick III, tain uniform depth of the peeling agent, it is
IV, V, and VI skin types, because of the elevated advisable to recommend avoiding microdermab-
risks of postpeel postinflammatory hyperpig- rasion, waxing, or electrolysis for 3 to 4 weeks
mentation. The mechanism of hydroquinone is before peeling.
to block the conversion of tyrosine to L-Dopa
by tyrosinase, thereby decreasing melanin pro- DEFINING DEPTH OF PEEL
duction. In applicable patients, hydroquinone in
a concentration of 4% to 8% should be started The depth of a chemical peel is characterized by
4 to 6 weeks before chemical peeling. Recom- the amount of penetration, amount of destruction
mended formula for prepeel skin preparation is of the epidermis and dermis, and inflammatory
the following: hydroquinone 8%, hydrocortisone response. A superficial chemical peel is an
1%, and Retin-A 0.05% in a moisturizing cream appropriate option for patients with superficial
base. Similar to tretinoin, hydroquinone should lentigos, mild actinic damage, and fine rhytids.
be restarted after the peel once the patient’s This has a much greater safety and fewer com-
skin is ready to tolerate it. All patients should plications than deep chemical peels. The super-
be warned of the possibility of HSV outbreaks, ficial peel penetrates through the entire
even if they deny any history of herpetic vesicle epidermis and causes epidermal sloughing. It
breakouts. It is possible to harbor latent infec- will also cause an inflammatory response in the
tions even without any apparent clinical history. upper portion of the papillary dermis. For pa-
Recommended practice is to start any patient tients with Glogau types III or IV classification
with a negative history on a prophylactic dose and Fitzpatrick type I and II, a deep peel such
of antivirals, acyclovir 400 mg 3 times a day, as the classic Baker formulation can be used in
3 days before and continued for at least 7 days the perioral area. Deep peels cause sloughing
after the peel. For patients who do have a history of the epidermis and papillary dermis, and
of herpetic breakouts, a therapeutic dose of inflammation of the reticular dermis. The deep
antivirals should be used, such as valacyclovir peel is most effective in erasing deep rhytids,
1 g 3 times a day for the aforementioned time but it also carries the highest risk of complica-
period. tions, such as scarring with the 50% TCA peel
The first line of resistance to bacterial infection is or hypopigmentation with the classic Baker for-
the skin, and resurfacing procedures can reduce mula. With superficial and deep peels
this barrier. This can lead to infections by cuta- comprising 2 ends of the spectrum of chemical
neous bacterial flora, such as staphylococcal or peeling, the medium-depth peel balances excel-
streptococcal species. Appropriate antibacterial lent results with low risks. The medium-depth
coverage should begin before the peel as prophy- peel effectively treats moderate photoaging
laxis. The senior author (DSM) uses cephalexin, skin (Glogau II), dyschromias, and mild-to-
250 mg 4 times a day, 1 day before the peel and moderate acne scars.
48 Starkman & Mangat

SUPERFICIAL PEELS some popularity as TCA peels and CO2 laser

surfacing rose into the field. The Baker-Gordon
The workhorse peel for plastic surgeons, derma- peel did offer arguably unparalleled treatment for
tologists, and aestheticians has been the alpha- deep facial rhytids, but the irreversible hypopig-
hydroxy acids (AHAs). Various AHAs of differing mentation risk and the cardiac/renal toxicity
types and strengths have made their way into limited its applicability.
over-the-counter skincare products. However, Another option for deep peels is the 50% TCA
this wide application still requires that providers peel; however, a significant percentage of patients
know the clinical characteristics and safety profile develop scarring with this formulation. This cata-
of these chemicals. strophic complication halted the application of
AHAs are natural fruit, carboxylic acids, with the this strength of TCA solution.
most common AHA being glycolic acid or Notwithstanding the risks of the Baker-Gordon
2-hydroxyethanoic acid. Glycolic acid is derived peel, it does have a role in the correct scenario.
from sugar cane and is generally used in a concen- In patients with deepened rhytids in distinct facial
tration of 20% to 70%. Other common AHAs are subunits with Fitzpatrick I and II skin types, this
citric acid (2-hydroxyl 1,2,3 propanetricarboxylic is a very effective peeling option. Nonetheless, a
acid), found in citrus fruit, and lactic acid (2-hydrox- high level of technique and caution must be used
ypropanoic acid), found in sour milk and tomato to avoid excessively deep peeling with this solu-
juice.6 Salicylic acid, in concentrations of 20% to tion. A uniform application of peeling solution
30%, is also used in superficial chemical peels. with mindfulness of the developing frost will help
AHAs penetrate through the epidermis and the to prevent potential complications.
most superficial layer of the dermis. They work
by diminishing the cohesion between the keratino-
cytes of the stratum granulosum. This leads to the MEDIUM-DEPTH PEELS
sloughing of the abnormal cells and thins the stra- Current discussion and development of modern-
tum corneum. These benefits generally last for 2 to day chemical peel centers around the
3 weeks. medium-depth peeling agents. Medium-depth
Although superficial chemical peels do have a peels penetrate through the epidermis and the
high safety profile, a false sense of security should papillary dermis and cause some inflammation in
be avoided with AHAs. Without neutralization, gly- the upper reticular dermis. The standard medium
colic acid can have persistent effects and pene- peel has been the 35% TCA peel. It does not
trate deeply. Its action should be neutralized with have systemic toxicities, and it is very easy to
water. If glycolic acid remains un-neutralized, the store, as it does not require refrigeration in its crys-
deeper penetration can lead to healing problems, talline form. However, the risk of scarring with TCA
crusting, and scarring. The anticipated endpoint is much higher than with phenol-based peeling so-
of a glycolic acid peel should be erythema and lutions. TCA solution concentrations are measured
light peeling of the epidermis.7 strictly on weight by volume (grams per 100 mL
Jessner solution (14 g salicylic acid, 14 g lactic distilled water). Any miscommunication between
acid, and 14 g resorcinol in 100 mL of ethanol) is the provider and the pharmacy in the manner of
a superficial peeling agent with a high safety pro- mixing the TCA solution would be catastrophic.
file. The depth of penetration depends on the num- TCA concentrations of 50% or more greatly in-
ber of coats applied. If 1 to 3 coats are applied, crease the possibility of scarring.9 There have
exfoliation of the stratum corneum occurs. If 5 to been no additional techniques that have proven
10 coats are applied, the depth of penetration con- beneficial in reducing this risk of scarring.10
tinues down to the basal layer. To achieve medium-depth peels without the
risks of scarring, providers have been combining
DEEP PEELS 35% TCA solutions with other less potent agents.
The additional solution is applied first as an epider-
The peel relies on injury down to the reticular molytic, and this enhances the depth of penetra-
dermis to treat the deep rhytids of the lateral can- tion of the 35% TCA peel solution. This
thal and perioral regions. Although the papillary technique was first described by Brody, using
dermis is thought to heal via reorganization, the CO2 ice and acetone to create epidermal break
reticular dermis is thought to heal via scarring.8 for the TCA solution that follows.11
With deep chemical peeling, additional recovery Another combination peel is Jessner solution
time is necessary, and the risk of scarring is higher. followed by 35% TCA, described by Monheit.12
The workhorse deep chemical peel agent was Jessner solution plays the role of penetrating the
the Baker-Gordon formulation; however, this lost epidermis, and TCA is then applied once the
 Chemical Peel (Deep, Medium, Light) 49

Jessner solution has dried.12 Unlike with phenol Spies17 discovered that croton oil was soluble in
peels, frosting does not occur immediately, and ethanol and benzene, but poorly soluble in a
3 to 4 minutes must be allowed for the full frost 50:50 mixture of phenol to water. Hetter15 theo-
to form. Once this has happened, additional coats rized that this may be why septisol is needed as
can be applied to reach the desired depth of peel. a surfactant in the Baker formula.
Care is taken with additional applications of TCA, Hetter15 investigated the role of croton oil and
as this has a cumulative effect and leads to a phenol in chemoexfoliation by experimenting on
deeper peel, thus increasing the changes of hypo- a volunteer with multiple formulations of varying
pigmentation and scarring. concentrations of phenol and croton oil. These
Coleman and Futrell13 experimented with experiments refuted the previously described
creating a combination peel out of glycolic acid dogmas of the mid-twentieth century. A solution
and 35% TCA. Their histologic examinations of 18% phenol without croton oil demonstrated
demonstrated that it penetrated slightly deeper minimal postpeel effect. With a 35% phenol solu-
than Jessner/TCA combination peels.13 tion, mild keratolysis occurred with no dermal ef-
Investigations by Brody11 into the complications fect. It was only with an 88% phenol solution that
of these 3 combination peels found that their risks a papillary dermal effect took place. When croton
of scarring were less than 1%. This scarring risk oil was added to the phenol solution, more sub-
placed them on par with other skin resurfacing mo- stantial postpeel effects were noticed. In addi-
dalities, such as phenol-croton oil peels or CO2 tion, varying croton oil concentrations had
laser resurfacing. different results. A 0.7% croton oil concentration
solution required a 7-day recovery period,
MODIFIED PHENOL-CROTON OIL PEELS whereas a 2.1% croton oil concentration required
an 11-day recovery period. Hetter15 thus postu-
TCA peel solutions have taken a prominent role in lated that higher concentrations of phenol (88%)
modern-day chemical peel practices, due to the without septisol would peel more deeply than
all-or-none qualities of the Baker-Gordon phenol- lower concentrations (50% and 35%). He also
croton oil peel. Decades-worth of anecdotal expe- remarked that phenol formulations result in
riences regarding phenol-croton oil peels made deeper peels with increasing concentrations of
their way into the literature. The descriptions croton oil.
began in the 1950s and 1960s when plastic sur- Hetter’s subsequent studies allowed him to
geons first adopted the phenol-croton oil solu- form scientific generalizations in regard to
tions. Litton14 was the first to present these phenol-croton oil chemical peels. He realized
formulas to the American Society of Plastic and that by diluting the concentration of croton oil in
Reconstructive Surgery in the late 1950s. Soon af- these formulas, the healing times would be short-
terward, the classic formula was credited to Baker ened, signifying a shallower depth of penetration.
in the early 1960s.15 He took these assertions further by stating that
Around this time in the 1960s, Adolph Brown16 the concentration of phenol in fact had little to
wrote extensively about phenol-croton oil peels. do with the depth of penetration. Obagi18 was
He presented 3 doctrines of phenol peeling. First, the first to suggest that different concentrations
increasing the concentration of phenol (80% to of these formulas should be applied to the
90%) would work to prevent further penetration discrete subunits of the face (Fig. 1). Hetter
by creating an immediate keratocoagulation. Sec- used this postulation to apply varying concentra-
ond, adding a saponin to the solution would in- tions of croton oil to the facial subunits. He found
crease the depth of penetration. Third, the role of that the lower nose could tolerate croton oil con-
croton oil was merely to buffer the solution. These centrations up to 1.2%; the cheeks and forehead
writings were accepted as standards, and addi- only tolerated concentrations up to 0.8%; and the
tionally felt that phenol was the sole active ingre- upper nose, temple, and lateral brow could only
dient within the Baker formula. This resulted in withstand concentrations up to 0.4% before the
the belief that phenol in lower concentrations risk of complications rose. Last, Hetter felt 1%
was more dangerous because of deeper penetra- croton oil solutions were the upper threshold for
tion and that croton oil had no role in the depth of safe use to avoid serious risk of
peel. These beliefs lasted until the 1990s, when hypopigmentation.
they were questioned by Gregory Hetter.15 Hetter first created his formulations using
Croton oil is pressed from the seeds of Croton phenol at 33% to carry croton oil at 1-drop
tiglium, a small shrub found in India and Ceylon. (0.35%), 2-drop (0.7%), and 3-drop (1.1%) con-
Croton oil comprises mostly oleic, myristic, arach- centrations. However, he soon switched to a
idonic, and linoleic acids. In 1935, Joseph R. more standardized system of measurement, rather
50 Starkman & Mangat

upright position. This serves to avoid noticeable

delineation between the peeled and unpeeled
areas of the neck. The patient is then placed in
the supine position.
After appropriate sedation has been reached,
supraorbital, infraorbital, and mental nerve blocks
are performed with a 50:50 mixture of 2% lido-
caine and 0.5% bupivacaine. Local anesthetic is
also applied via a field block over the areas to be
peeled. Epinephrine is avoided, as this will slow
the clearance of the phenol. The face is meticu-
lously degreased with an acetone-soaked gauze.
Residual skin oil on the patient’s face will impair
Fig. 1. Varying areas of skin texture, quality, and the uniform application of the peeling agent. Other
thickness marking the concentration of peeling agent investigators, such as Hetter and Obagi, suggest
to be used. using a wrung-out 2-inch  2-inch gauze for the
application of the peeling agent; however, the se-
than relying on a dropper, which is naturally unre- nior author feels that using a wide cotton-tipped
liable. He converted 1 drop into 1 cubic centi- applicator allows for superior control of
meter, and used this conversion to make a stock application.
solution of 0.04 mL of croton oil per 1 mL of A benefit of phenol-based chemical peels is the
phenol. From this, he could make different croton frosting occurs almost immediately, as opposed to
oil formulations of 0.4%, 0.8%, 1.2%, and 1.6% TCA where the frost can take 3 to 4 minutes to
in a constant phenol concentration (Table 3). occur. This means that the quality and uniformity
of depth, and need for reapplication, is almost
TECHNIQUE immediately clear to the provider in a phenol-
based peel. Medium-depth peels should result in
Before application of the peeling solution, the a level II to level III frost (Fig. 2).19,20
skin must be sufficiently prepared. This starts
with a vigorous cleaning with septisol or acne Level I: erythema with stringy or blotchy frosting
wash the evening before and the morning of Level II: white-coat with erythema showing
the chemical peel. Preoperative oral sedation, through (should be used for eyelids and areas
10 mg diazepam and 100 mg dimenhydrinate of bony prominences, that is, zygomatic arch,
(Dramamine), help to relieve patient anxiety. malar, chin. higher rate of scarring)
The antihistamine serves to reduce oral secre-
tions and protect the patient’s airway during
the sedation. Intravenous fluids should be
started before bringing the patient to the proced-
ure room, as the patient will have had nothing to
drink since the previous night.
Preoperative marking consists of marking the
patient’s submandibular shadow while in the

Table 3
Hetter peel formulations (stock
solution 5 24 mL D 1 mL croton oil [4% croton
oil])

Croton oil, % 0.2 0.4 0.8 1.2 1.6

Distilled water, mL 5.5 5.5 5.5 5.5 5.5
Septisol, mL 0.5 0.5 0.5 0.5 0.5
USP Phenol 88%, mL 3.5 3.0 2.0 1.0 0
Stock solution 0.5 1.0 2.0 3.0 4.0
containing phenol
and croton oil, mL
Fig. 2. A level 3 frost obtained during phenol-croton
Total, mL 10 10 10 10 10
oil peeling in the perioral region.
 Chemical Peel (Deep, Medium, Light) 51

Level III: solid white frost with little or no back- 15 to 30 seconds. The burning sensation can then
ground erythema return approximately 30 minutes later and can
last for the remainder of the procedure day. The
The facial subunits are divided by the severity of bupivacaine in the local anesthetic blocks should
rhytids, photodamage, and lentigos, as well as provide anesthesia for hours following the peel.
skin thickness. The senior author uses 0.8% This is part of the reason why it is critical to apply
croton oil Hetter solution in areas of thicker skin comprehensive local anesthetic blocks to the
and deeper rhytids (Glogau III and IV), such as peeled areas.
the glabella and perioral regions. Intermediate
areas (Glogau II and III) are treated with 0.4%
croton oil Hetter solution. An 89% phenol solution POSTOPERATIVE PERIOD
is used for feathering along the borders of the The postoperative period begins immediately after
peeled areas to achieve an even postpeel result. the final subunit of the face is peeled. Once the last
A classic Baker formula can be used in patients area of frosting dissipates and only erythema re-
who are Fitzpatrick types I or II, and have severe mains, a thick coat of emollient is applied to all
Glogau IV rhytids in the upper lip. of the peeled skin areas. The senior author prefers
Ten to 15 minutes are allowed between each to use Eucerin cream, but Elta or Bacitracin oint-
subunit peeled for adequate clearance of the ment are other acceptable alternatives. These
phenol. Less clearance time is needed with the emollients are not occlusive and therefore do not
Hetter solution because of lower phenol compared affect the depth of the peel. The patient is
with the Baker-Gordon peel. The entire face can instructed to maintain a steady coat of this emol-
be peeled over 30 to 60 minutes. In the case that lient over the entire peeled region by reapplying
a minor supraventricular arrhythmia occurs, the 4 to 5 times per day, or as often as needed. This
peel should be paused until the patient returns to is continued for the duration of the postpeel period
normal sinus rhythm. until the area has fully peeled, and fresh skin is
When applying the peeling solution to the fore- visible.
head and temporal regions, the peel should The provider and staff should adequately
continue up to and even into the hairline. Phenol explain the expectations for the immediate post-
and croton oil will not affect the pigment of the peel period to the patient. The patient’s preopera-
hair follicles. In addition, in the perioral area, the tive understanding of the expected burning
peel should continue just over the vermilion sensation in the immediate postpeel will help
border. This is because the margin of each peeled with his or her tolerance. The patient also should
region will have a distinct line of reactive hyper- be prescribed an oral narcotic. In addition, the pa-
emia. While peeling adjacent facial subunits, tient should be prepared for the expected ery-
these lines of hyperemia should be included and thema, edema, and gradual desquamation over
peeled to prevent any resultant lines of demarca- the first week after the peel.
tion. For deep wrinkles of the perioral region, the The healing process consists of 4 stages. The
skin can be stretched taut to evenly apply the peel first stage occurs over the first 12 hours and con-
to these rhytids. Phenol-croton oil peels do not sists of facial inflammation. The epidermis be-
need to be neutralized, like glycolic acid peels, comes leathery and begins to separate from
due to the completed reaction, as demonstrated the dermis. The underlying treated dermal layer
by the frost. will become necrotic and being to slough. The
An area to exercise caution is in the lower eyelid applied emollient helps with removing this
region. The phenol-croton oil peel should be necrotic skin from the underlying tissues. The
applied to within 3 mm of the lower eyelid margin second stage is desquamation, which occurs
and then stopped. The sedated patient can over the next 3 to 7 days (Figs. 3–9). This ex-
develop tearing during the peeling procedure, poses the underlying erythematous dermis. The
and these tears should be wiped away to prevent third stage is reepithelialization, which partially
the peeling solution from tracking up along the coincides with desquamation and occurs be-
tear into the eye. The peel solution is not applied tween days 2 through 10 following the peel. Ree-
to the upper eyelid skin, as this area lacks the pithelialization will be demonstrated by the
sebaceous glands that are necessary for reepithe- changes in dermal color from bright red to a ligh-
lialization after a peel. ter shade of pink. The final stage is fibroplasia
If there were any areas of inadequate local and occurs toward the end of the first week
anesthesia, the patient can experience an imme- and continues for 12 to 16 weeks after the
diate burning sensation on application of the peel. This final period is when the full benefits
peeling solution, which will last for approximately of the chemical peel become apparent. During
52 Starkman & Mangat

this time, the skin will undergo new collagen for-

mation, reorganization of the collagen, and
neoangiogenesis.
For 12 weeks following the peel, the patient is
instructed to avoid any direct, prolonged sun
exposure. During this period, the skin is vulnerable
to UV light exposure and is at risk for resultant hy-
perpigmentation. The senior author also recom-
mends avoidance of sunscreens for the first
6 weeks. Many chemical sunscreens include the
ingredient, para-aminobenzoic acid, which can
cause erythema, irritation, and induration of the
healing skin. It is also recommended that women
avoid birth control pills during this same period,
as the increased estrogens can lead to
hyperpigmentation.

COMPLICATIONS
Even with careful technique and appropriate pa-
tient selection, it is still possible to encounter a
host of potential complications following chemical
facial resurfacing. Therefore, it is critical for any
practitioner offering chemical peels to be cogni-
Fig. 3. A patient 5 days post phenol-croton oil peel, in zant of any potential complications, as well as
the midst of re-epithelialization. the appropriate treatments. This knowledge aids
in remedying any undesired effects, and still as-
sists in achieving the desired results.

Fig. 4. A woman treated with a phenol croton oil peel, improving her fine and course rhytids and skin pigment.
 Chemical Peel (Deep, Medium, Light) 53

Fig. 5. Three months post-phenol croton oil peel, with improvement in skin tone and fine rhytids.

Cardiac Arrhythmias have been properly selected and adequately hy-

drated before their chemical peel, a reversible
The most commonly cautioned and feared intra-
cardiac arrhythmia can possibly occur. This is
operative complication of phenol-croton oil peels
especially true in a patient with an undiagnosed
is cardiac arrhythmias. Even in patients who

Fig. 6. Marked improvement in perioral rhytids following application of a 1.6% Hetter phenol-croton oil peel.
54 Starkman & Mangat

Fig. 7. Five months post-peel result with improvements in fine facial rhytids.

heart condition. The common presentation is a area of the face that does not fully reepithelialize
supraventricular tachycardia that occurs within within 10 days should be considered prolonged.
30 minutes of starting the peel, and can evolve This phenomenon is more common with deeper
into paroxysmal ventricular contractions, parox- phenol peels (Baker formula) and TCA peels. It is
ysmal atrial tachycardia, ventricular tachycardia, important to not merely dismiss prolonged healing
and possibly, atrial fibrillations. The best way to times as coincidentally, and to rule out the pres-
manage any of these listed progressive arrhyth- ence of underlying infections or contact irritants.
mias is to prevent them from occurring in the first These areas should be checked daily and treated
place. As soon as a supraventricular tachy- accordingly, or else the risk of scarring can rise
cardia, or other irregular rhythm, is noted, the precipitously.
peel should be immediately paused and
adequate hydration should continue. At this Scarring
point, the rhythm should eventually return to
If any facial scarring begins to develop, it is most
normal sinus rhythm as the phenol is cleared.
likely to occur in the area of the upper lip or over
Once the rhythm has returned to normal, the
areas with prominent underlying bone structure
phenol peel may proceed carefully with
such as the mandible. Scarring most commonly
attention to the rhythm monitor. In the rare
is due to an overly deep peel, or from inattentive
instance that the rhythm does not naturally
postoperative care. Again, the risk of scarring is
return to a normal rhythm, proper medical
significantly elevated in isotretinoin users. Once
procedures should be undertaken for that aber-
the patient has stopped isotretinoin, the practi-
rant rhythm.
tioner should check to confirm that the patient
is clearly producing skin oils. Once developing,
Delayed Reepithelialization
the scars can be treated with silicone
A more common complication following a deep sheeting coverings and intralesional corticoste-
chemical peel is prolonged recovery times. Any roids injections (Kenalog 20 mg/mL) every 2 to
 Chemical Peel (Deep, Medium, Light) 55

Fig. 8. Results of a facelift for a middle-aged woman with excessive submental soft tissue, and moderate jowling.

3 weeks. It is recommended to exercise caution Infections

in the injections of steroids, as overinjection can
Bacterial infections can irritate normal wound
lead to atrophy and skin depressions. As most
healing and lead to scar formation. In the case of
scars will be erythematous, a flash-lamp
a patient presenting with signs of cellulitis or infec-
pulsed dye laser is helpful over multiple
tion, an appropriate antibiotic regimen should be
treatments.
immediately started and continued for a 7-day to
56 Starkman & Mangat

Fig. 9. A woman with moderate jowling and neck skin crepiness being treated with an SMAS facelift.

10-day course. Similarly, herpetic viral infections Postoperative Erythema

can be problematic for a patient’s natural recov-
Postoperative erythema after a peel is common in
ery. In the case of a herpetic outbreak despite
all peel patients and it is not unusual for it to last
appropriate prophylactic dosing of antivirals, a
longer than predicted. In patients with contact
course of valacyclovir 1 g 3 times a day for
dermatitis or sensitive skin, hydrocortisone
10 days, should be used.
(2.5%) lotion is commonly prescribed to aid in
 Chemical Peel (Deep, Medium, Light) 57

the resolution of this erythema. As this erythema is 2. Brody HJ. Complications of chemical resurfacing.
eventually subsiding in the weeks following the Dermatol Clin 2001;19:427–38.
peel, some patients will develop postinflammatory 3. Kim IH, Kim HK, Kye YC. Effects of tretinoin pretreat-
hyperpigmentation. The typical scenario for this is ment on TCA chemical peel in guinea pig skin.
in a patient with excessive sun exposure following J Korean Med Sci 1996;11:335–41.
the peel, or with Fitzpatrick III-VI skin types. This 4. Popp C, Kligman AM, Stoudemayer TJ. Pretreat-
can be managed with a combination of 0.05% ret- ment of photoaged forearm skin with topical tretinoin
inoic acid, 2.5% hydrocortisone cream, and 4% accelerates healing of full-thickness wounds. Br J
hydroquinone cream. Dermatol 1995;132:46–53.
5. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates
Hypopigmentation healing after trichloroacetic acid chemical peel.
A more severe complication of chemical peeling is Arch Dermatol 1986;15:848.
hypopigmentation. This is likely due to phenol’s 6. Yu RJ, Van Scott EJ. Alpha-hydroxy acids: science
ability to eliminate melanocyte’s ability to produce and therapeutic use. J Cosmet Dermatol 1994;
melanin. Hypopigmentation is far more noticeable 1(Suppl 1):12.
when single facial subunits are peeled, rather than 7. Van Scott EJ, Yu RJ. Alpha-hydroxy acids: proced-
the whole face. This complication was more com- ures for use in clinical practice. Cutis 1989;43:222.
mon in the past when deeper peels such as the 8. Hayes DK, Berkland ME, Stambough KI. Dermal
classic Baker formulation were used, along with healing after local skin flaps and chemical peels.
postoperative occlusive dressing applications. Arch Otolaryngol Head Neck Surg 1990;116:794.
Hypopigmentation is unfortunately irreversible, 9. Brody HJ. Variations and comparisons in medium
and all patients who experience some level of depth chemical peeling. J Dermatol Surg Oncol
this should be advised about the potential need 1989;15:953.
for makeup usage. 10. Dinner MI, Artz JS. Chemical peel: what’s in the for-
mula? Plast Reconstr Surg 1994;94:406.
SUMMARY 11. Brody HJ. Chemical peeling and resurfacing. St
Louis (MO): Mosby; 1997. p. 109–10.
With the relatively recent arrival of CO2 laser 12. Monheit GD. Advances in chemical peeling. Facial
resurfacing and Erbium:YAG laser resurfacing, Plast Surg Clin North Am 1994;2:5–9.
chemical peeling was disregarded by many as an 13. Coleman WP, Futrell JM. The glycolic acid trichloro-
out-of-date procedure. In addition, phenol-croton acetic acid peel. J Dermatol Surg Oncol 1994;20:
oil peels were considered by many to have unpre- 76–80.
dictable and possibly dangerous results 14. Litton C. Chemical face lifting. Plast Reconstr Surg
compared with the more recent modalities. Much 1954;13(3):240–5.
like the disproven phenol peel dogmas of the 15. Hetter GP. An examination of the phenol-crotol oil
twentieth century, these beliefs are far from reality. peel: part III. The plastic surgeon’s role. Plast Re-
Phenol-croton oil peeling has withstood the test of constr Surg 2000;105:752–63.
time and is still considered the standard against 16. Brown AM, Kaplan LM, Brown ME. Phenol-induced
which other facial resurfacing procedures are histological skin changes: hazards, technique, and
judged. In addition, the widely expanded knowl- uses. British Journal of Plastic Surgery 1960;13:
edge of croton oil, and its various concentrations, 158–69.
has yielded many options for specializing treat- 17. Hetter GP. An examination of the phenol-croton oil
ment for different facial subunits, skin types, thick- peel: part I. Dissecting the formula. Plast Reconstr
nesses, and so on. A strong familiarity with the Surg 2000;105:227–39. discussion 249–251.
fundamentals and techniques of chemical peeling 18. Johnson JB, Ichinose H, Obagi ZE, et al. Obagi’s
can result in predictable and excellent results. modified trichloroacetic acid (TCA)-controlled vari-
able-depth peel: a study of clinical signs correlating
DISCLOSURE with histological findings. Ann Plast Surg 1996;36:
225–37.
The authors have nothing to disclose.
19. Monheit GD. Medium-depth chemical peels. Derma-
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