Phenol Peels

Phenol represents the most common deep chemical peeling agent. It leads to dramatic results by producing a controlled chemical burn to the level of the upper reticular dermis. As healing occurs, new stratified collagen is laid down, resulting in younger-appearing skin. Phenol is an extremely effective agent for reversing facial wrinkling and irregular pigmentary changes related to sun exposure and the natural aging process.

The most commonly used phenol preparation is the BakerGordon formula, which contains 3 mL USP liquid phenol, 2 mL tap water, 8 drops liquid soap, and 3 drops groton oil. Although this formula remains popular, other buffered phenol solutions exist that are reported to cause less postpeel hypopigmentation. By varying the concentration of phenol, the depth of the peel will change. The lower the phenol concentration, the more deeply it penetrates. In addition, the use of croton oil appears to be especially important in enhancing or limiting phenol penetration. When the solution contains lower concentrations of croton oil, less phenol penetration is observed, limiting postpeel hypopig-mentation. Although the risk of hypopigmentation decreases when the formula is varied (i.e., 88% phenol solution), the improvement of coarse facial rhytids and the degree of neocollagen formation may also be reduced. For this reason, patients who are at greater risk of developing postpeel hypopigmentation, those with Fitzpatrick type III-VI skin, should consider other skin resurfacing modalities, such as laser resurfacing.

Indications

Phenol is extremely successful in eradicating coarse wrinkles and pigmentary changes caused by chronic solar exposure, birth control pills, or pregnancy. Because of its effectiveness, the best candidates for phenol chemical peeling are those with Fitzpatrick type I skin and those with little prior sun exposure. In these patients, regional peeling can be performed more successfully because an obvious line of demarcation will not result. In Fitzpatrick type II or greater skin types, and in those patients with significant actinic damage, results are improved if the entire face is peeled. Phenol peeling is not the best option for Fitzpatrick type IV, V, or VI skin types. They may exhibit blotchy hyper- and hypopigmentary changes.

The best candidates for phenol peeling are those patients who demonstrate moderate to severe facial rhytids and those with moderate to significant pigmentary changes. Coarse facial rhytids in the perioral and periorbital regions are treated extremely well with this agent. However, unlike the medium-depth peels, additional morbidity is associated with phenol peeling. The potential toxicity of the agent itself, extended healing times, and increased postoperative sequelae mandate that the treating physician fully understand the nature of phenol peeling.

Mechanism of Action

Unlike other agents, phenol is a keratocoagulant that creates an all-or-none response. As stated above, varying the concentration of the phenol agent inversely varies the depth of the peel. This means that a more effective peel is not obtained by increasing the concentration. By contrast, a lower concentration of phenol yields a deeper peel because keratocoagulation is slowed, allowing the phenol to penetrate more deeply. A higher concentration will only increase the chances of systemic toxicity.

A potential side effect of phenol peeling is the toxicity of the agent itself. Phenol is absorbed through the facial skin and then carried through the bloodstream to the liver, where it is detoxified. The metabolic products are then excreted through the kidney. Therefore, a toxic dose of phenol that is absorbed systemically can injure both the liver and kidney. Phenol may also depress the respiratory system and the myocardium. The risk of producing cardiac dysrhythmias is lessened when phenol is applied systematically, to smaller regions of the face over time. When doing a full face peel, if it is applied sequentially over the various aesthetic units over a 1- to 2-h period, the risk of myocardial irritability and electrocardiographic (ECG) changes is rare. However, because the potential risk exists even when following these guidelines, patients undergoing phenol chemical peeling should be monitored electrocardiographically and should have an intravenous (IV) line placed. Adequate IV hydration before and during the peeling process will lower the risk of cardiotoxicity.

Preparation

Phenol is used as an 88% concentration. We use the standard Baker-Gordon formula in most cases. This consists of 3 mL USP liquid phenol (88% concentration), 2 mL water, 8 drops surgical soap (Septisol), and 3 drops of croton oil. The soap is used to help saponify the mixture. Although we use Septisol, any liquid soap should be effective. Croton oil, extracted from the seeds of Croton tiglium, serves as a vesicant. Croton oil enhances the mixture's keratolytic action and therefore permits deeper penetration of the solution. This formula is prepared fresh for each patient. When using this formula, it must be mixed well just before its application because chemically it does not readily combine.

Technique

Before entering the operating room, patients are instructed to wash their face well with an astringent, which helps remove the stratum corneum. Upon entering the operating room, the patient is first placed in a sitting position, and the submandibu-lar region is marked to delineate the limit of the peel in this region. If the patient is marked while supine, the gravitational effects will not be accounted for, and peeling will not be carried into the shadow beneath the mandibular border. Failure to peel into this region will result in an obvious line of demarcation. The patient is then placed supine, as IV sedation or general anesthesia is administered by an anesthesiologist. When IV sedation is used, additional subcutaneous local infiltration of a mixture of 2% lidocaine without epinephrine and 0.5% marcaine without epinephrine in equal amounts is also used. The rate of intravenous D5LR or NS are increased at this time so that patients receive at least 1000 to 1500 mL of fluid during the peripeel period. Epinephrine must never be used in the infilter-ation of local anesthetic because it can deepen the penetration of the peel solution and lead to scarring.

An acetone-soaked 4 x 4-in. gauze sponge is used to thoroughly cleanse oils from the patient's face. The mechanical action of vigorous cleansing also helps remove other debris and desquamated epithelium to allow deeper and more consistent penetration of the peeling solution. At this time, the patient's head is placed at an approximately 35-degree angle, where it remains until the procedure is completed. By using the broken end of a cotton-tipped applicator, individual rhytids are first treated with the phenol solution. Coarse rhytids extending into the vermilion are similarly treated by this method. Next, the facial subunits are treated sequentially, using a dampened cotton-tipped applicator. The aesthetic subunits include the forehead and glabella, perioral, nasal, cheek, and periorbital regions. When full face peeling is performed, we begin with the application of the peeling solution to the forehead. As the formula is applied, the skin begins to turn a frosty gray-white. As phenol does not affect hair follicles, the peeling agent may be feathered into the frontal and temporal hairline. After the application of the phenol solution to each aesthetic subunit, 20 min is permitted before applying the solution to the next subunit. Using this method, we have never had a cardiac dysrhythmia that required treatment. When treating subsequent subunits, erythema will be observed at the border of the previously treated region. The area of reactive erythema will require the application of the solution, as it is not an area that was adequately treated by the previous application.

Postpeel Care

All patients are monitored with an ECG for at least 2 h postpeel. After the peel is complete and the frost has disappeared, a wet dressing is applied over all the peeled areas. Eucerin cream is our current choice of an emollient and is applied approximately 1 h after the peel. Other agents that can be used include A&D ointment, Crisco, Elta, or other antibiotic ointments. We avoid ointments containing neomycin, as this may pose additional risk to patients who develop a dermatologic reaction to this agent. Other occlusive techniques, including taping the face, have been used in the past but have been abandoned by most. Although both techniques work well, we believe that our technique affords greater patient comfort and allows us to evaluate the peeled areas more easily. Despite giving a parenteral dose of steroids (Decadron 8 mg) before the peel, moderate to severe facial edema often occurs during the postpeel period. Patients are instructed to reapply Eucerin cream every 3 to 4 h for approximately 5 days. They are also instructed to shower twice daily during this time. During postoperative days 5 to 8, an antibiotic ointment is substituted for the Eucerin cream. Patients should be instructed not to pick or remove any eschar, as this may result in unwanted scarring. Generally, reepithelial-ization will occur 10 days after the peel. At this time, patients begin using Eucerin lotion liberally, and a 2.5% hydrocortisone cream two to three times daily. Patients are also allowed to begin wearing makeup to camouflage the peeled areas that now appear pink. As with all skin resurfacing techniques, patients should avoid exposure to the sun for at least 6 weeks postpeel. Patients should also be instructed to always wear a sunscreen of SPF 30 or higher when outdoors.

Complications

Toxicity Phenol has the potential to cause cardiac, renal, and pulmonary toxicity. The best management of these complications is to avoid them. If the phenol solution is applied to facial subunits sequentially, as suggested, the risk of developing any of these problems is minimal. Patients should be monitored carefully and appropriate treatment instituted should these complications develop. The use of phenol warrants extreme caution in the periorbital region, to avoid burning the eye. Extreme care must be employed when peeling these areas. An assistant should always have a clean, dry, cotton-tipped applicator in her hand. It should be used to absorb tears that may drip down onto the face or into the temporal area, which would otherwise cause deeper, unwanted penetration of the solution.

Milia Milia are tiny superficial epidermal inclusion cysts that often appear during the first few weeks of recovery. They present in small numbers or may be present diffusely all over the treated areas. Milia often resolve spontaneously with normal cleansing of the face, although at times it is necessary to uncap the persistent milia with an 18-gauge needle tip. Although annoying when present, milia are never a permanent problem.

Erythema The erythema present after phenol peeling is not a complication, but an expected result. Camouflage makeup can be worn as needed starting at approximately 10 days. Slight erythema may persist for 10 to 12 weeks but gradually subsides. Although a topical steroid cream (2.5% hydrocortisone) is used routinely, it may not diminish the erythema rapidly. At times the erythema can be severe, lasting up to 6 to 9 months. Occasionally, it may be necessary to use a short course of systemic steroids to counteract severe postpeel inflammatory response.

Hyperpigmentation Postinflammatory hyperpigmentation is a very common postoperative complication, especially in Fitzpatrick type III-VI skin types. It also occurs commonly in those who receive sun exposure too early. When it appears, a bleaching formula (described previously) is used with great success. Retin-A, glycolic acid products, lighter TCA peels, and other hydroquinone preparations may be necessary to alleviate persistent hyperpigmentation.

Undesirable Alteration of Skin Texture Several changes may occur in the skin of some patients after a Baker-Gordon peel. Although there is no scientific evidence to explain this, some patients may complain that their skin pores appear to be enlarged. Patients with telangiectias may notice a worsening of them after phenol peeling. These are easily treated with one of the vascular lasers. Nevi may appear darker after the peel. The skin may acquire a fine reticular pattern in some areas that does not represent a scar and in cases in which epithelialization occurred within a normal period of time. These patients can be treated with a fairly potent nonfluorinated topical steroid such as Elocon 0.1%, for 2 to 3 weeks with good resolution.

Infection In spite of prophylactic use of antiviral agents, patients may develop an outbreak of herpes simplex infection. This can be treated with acyclovir 800 mg 4 times per day, along with careful treatment of ulcers with emollients. Our patients are routinely placed on a prophylactic dose of Famvir or Valtrex 2 days preoperatively and are maintained for 5 days postoperatively. Although a herpes outbreak during the peripeel stage may be disconcerting, it responds rapidly to treatment and rarely causes residual scarring. A herpetic outbreak may delay complete epithelialization and cause prolonged erythema at the herpetic sites.

Scleral Show or Ectropion of the Lower Eyelid Older patients with senile lid laxity, patients who have undergone a prior trans-cutaneous lower blepharoplasty, and patients with extremely thin skin are predisposed to this complication after a BakerGordon phenol peel. When ectropion does occur, the first line of treatment is conservative care, such as massaging of lower lid skin, taping of the eyelid, especially at night, and adequate protection of the globe using Natural Tears and Lacrilube. In most cases, this is a self-limiting process that corrects spontaneously or with conservative care. Intralesional steroids or surgical repair are only considered for rare persistent cases with severe ectropion.

Skin Depigmentation Clinically and histologically, patients undergoing phenol chemical peeling may exhibit a bleaching effect. After phenol peeling, melanocytes reorganize themselves along the basement membrane. Although still present, these melanocytes lose their ability to produce melanin. Clinically, this results in a bleached appearance. This may be desired and beneficial for those patients seeking treatment of certain pigmentary problems. However, in patients undergoing regional facial peeling, this bleaching effect may become noticeable and problematic. It is often most noticeable in the jaw-neck region, where untreated skin in the neck appears more obvious as it abuts the newly rejuvenated cheek or periorbital skin.

Scarring Although rare, scarring from phenol peeling may be very disturbing to both the patient and the surgeon. The perioral area, specifically the upper lip, and the region over the mandible are the most common areas in which scars develop. Scarring may occur as a result of poor postpeel wound care. For this reason, our patients are evaluated every 2 weeks for the first 2 months to avoid preventable complications. Infections and self-inflicted wounds that result in excoriated areas should be addressed immediately to prevent scarring. Scarring may also result from poor patient selection, particularly those patients with microvascular disease resulting from underlying diabetes or as a result of smoking. Scars may also develop when the peeling agent has penetrated too deeply. When it does occur, scarring is best managed with the use of intralesional steroids. We routinely use a 20% Kenalog solution injected into the scar every 2 to 3 weeks as needed. If the surgeon is overzealous with the use of intralesional steroids, however, dermal atrophy and telangiectasia will develop. Phenol peeling in the neck is not recommended, as it can produce severe scarring.

Summary

Phenol chemical peeling produces a dramatic improvement in the treatment of coarse facial rhytids. The longevity of its results have been established. We continue to use phenol as the agent of choice for deep chemical peeling. However, we also recognize that potential pigmentary disturbances may occur; therefore, proper patient selection, proper technique, and proper postoperative care are critical to a successful outcome. For Fitzpatrick III-V skin types, we prefer phenol 88% rather than the Baker-Gordon formula. This has proved successful for the treatment of deep facial rhytids in these patients, while minimizing pigmentary disturbances. In the future, phenol may be supplanted by laser resurfacing or by newer resurfacing techniques as they are developed. For the present, phenol remains the most effective deep skin resurfacing tool.

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