Historic Background

The desire to restore facial skin and improve one’s appearance is nothing new. The oldest recorded report of a peel to remove wrinkles is in the Ebers Papyrus written around 1560 BC, which documents a physician using soured milk, oils, and abrasives to resurface and beautify the face and body.¹ In 1892, Edmund Saalfeld published a report that phenol was used to remove freckles, and later, in 1903, New York dermatologist George MacKee reported the use of phenol to treat acne scars.^1,2 Then in 1927, Herbert Otto Bames wrote the first article explaining the use of phenol as the essential element in cosmetic chemical peeling; and Chicago, Illinois, plastic surgeon Joseph Urkov, in 1946, published a 15-year experience treating 2,000 patients using croton oil.^1,2 These were the earliest practitioners experimenting with deep chemical peels in the early 20th century.

But the most colorful and truly innovative techniques in peeling came from the lay peelers of the time. These peelers were cloaked in mystery with French-sounding pseudonyms and “secret ingredients.” One of the first lay peelers to gain prominence was Jean DeDesley, whose formula was the absolute standard by which all other peels were judged.³ Other very well-known peelers in the Hollywood, California, community received their training and formulas from her. These included Arthur Gradé, Venner Kelson, Antoinette LaGassé, Maryanne Coppersmith, and Miriam Maschek during the 1940s to the 1960s.³ All of their formulas were based on phenol crystals and the presence of croton oil.

The first plastic surgeon to acquire the lay peeler’s secret was Adolph Brown, MD. He was an otolaryngology instructor in Chicago, and then moved to southern California. The secret was croton oil. He not only published but, also in 1959, patented the formula that contained water, phenol, croton oil, sesame oil, and cresol.² Drs. Litton, Truppman, and Baker were three plastic surgeons in Florida who were in contact with the lay peelers Coopersmith and Maschek.^2,4 They were able to develop peel formulas from them that contained phenol and croton oil as ingredients, but in different concentrations (▶ Table 24.1).

In 1961, Thomas Baker published the first article that provided a simple recipe to make the formula and described the peel regime that he received from the lay peelers. This included a tape mask, removal of the mask, and the use of thymol iodine powder.⁵ Then in 1962 Dr. Baker changed the formula by decreasing the volume from 9 to 5 mL, therefore almost doubling the concentration of the croton oil from 1.2 to 2.1%, which created the classic Baker-Gordon formula we all recognize.^1,2,5,6

The belief during this time was that it was the phenol that was the active agent creating the burn, and that the croton oil was only a mild irritant and might not even be necessary to the peel. This thinking persisted until 1998 when Phillip Stone showed the critical importance of patient selection, skin preparation, vigor and length of rubbing, volume of the peel solution, concentration of croton oil, and that the method and type of occlusion and that all are responsible for the depth of peel.^4,7 Then in 2000, Gregory Hetter published a four-part series in the journal Plastic and Reconstructive Surgery examining the roles of phenol and croton oil and their concentrations in deep chemical peeling.^2,3,6,8 Hetter presented proof that augmenting the concentrations of croton oil increased the depth of peel, and that the phenol was used mainly as a vehicle to deliver the croton oil. With the work of Hetter, all the previous ideas and dogmas of the past 50 to 60 years surrounding the roles and actions of phenol and croton oil have been proven either inaccurate and/or obsolete.

24.3 The Classic Baker-Gordon Peel

When the phrase “deep chemical peel” is discussed or the use of phenol and croton oil are mentioned, the Baker-Gordon peel comes to mind. It is still referred to as the gold standard in peeling and resurfacing techniques. The peel is based on a formula with ingredients that were easy for the surgeon to obtain and create. The classic (1962) formula consists of:

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  3 mL United States Pharmacopeia (USP) liquid phenol (88%)

  
  
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  2 mL tap water

  
  
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  8 drops liquid soap (Septisol, Sandent Co., Murfreesboro, Tennessee)

  
  
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  3 drops croton oil

Note that in the original article, Baker states that if the croton oil is unavailable, it can be eliminated.^1,5 The croton oil was considered an “enhancement” to the formula’s keratolytic and penetrating action.

The indications stressed the importance of patient selection due to the bleaching effect of the phenol.^1,5 It was recommended that fair complexions are better suited to the peel and that darker and olive skin will produce a distinct demarcation line. Baker also stated that red-haired, freckled patients, men, and persons of Asian or African descent were all poor candidates for phenol peels. The major indications were the treatment of facial wrinkles, dyschromias, pigmentation irregularities, and actinic and precancerous lesions.

The original articles all recommended that the peel be done under anesthesia, and that the patient needed to be monitored for 1 to 2 days by experienced personnel.^1,5 The patient was degreased of all oils and makeup with ether or acetone. The peeling mixture was painted evenly to cover the entire face and obtain an immediate grayish-white frost. It was applied slowly to minimize the burning sensation and avoid rapid phenol absorption that could result in toxic reactions. The toxicity was most likely due to the large amount of solution that was used and the immediate occlusive dressing that increased absorption. The peel was applied to one region at a time. After each region of the face had been covered with the peeling solution, an occlusive dressing was applied. The dressing of choice was waterproof adhesive tape or a Vaseline occlusive dressing. This was to increase the depth of peel, and produce a longer lasting result. The disadvantages of taping were increased patient discomfort, painful removal process, and the inability of the surgeon to evaluate the peel wound. Application was completed over a 1- to 2-hour period. An assistant watched the eyes for tearing, and carefully blotted any forming tear before it dripped. The tears were thought to deepen the penetration of the burn. The tape was usually removed about 48 hours following the peel. After the tape mask was removed, the peeled area of skin was dusted with thymol iodide. This was to dry the area and forms an eschar. Re-epithelialization usually begins to occur at around 7 to 10 days following the peel, at which point the patient is instructed to use Crisco or cocoa butter. Depending on the individual patient’s rate of healing, makeup and sunscreen can be used at about 10 to 15 days. Erythema may persist for up to 3 to 6 months.¹

Serious complications with the Baker-Gordon peel were described as rare, adding, “However some undesirable results are to be expected.” These included hypopigmentation (bleaching effect), which was described as “unavoidable,” prolonged erythema, sensitivity to sunlight, scarring, ectropion of the lower eyelid, postpeel hyperpigmentation, infections (more often than not, herpes virus), and milia.^1,5

24.4 Dispelling the Myths

Phenol and croton oil have been the basis for deep peels beginning with the lay peelers. Then in1962 when the Baker formula was published, it became the formula used by plastic surgeons and dermatologists. During this period no one questioned the classic formula or the roles of phenol concentrations or of croton oil in chemical peeling. A set of absolute dogmas developed that persisted for more than 40 years.^6,8 These unchallenged beliefs or “truths” were:

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  Phenol is the active ingredient, and there is an “all-or-none” effect.

  
  
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  Phenol peels deeper in lower concentrations. Highly concentrated phenol prevents deeper penetration of the dermis by denaturing keratin, whereas lower concentrations would penetrate deeper.

  
  
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  Lower concentrations of phenol are more dangerous.

  
  
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  The loss of pigmentation or the “porcelain mask” is the result of phenol.

  
  
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  Phenol has an uncontrollable toxicity.

  
  
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  Addition of soap lowers the surface tension, thus increasing penetration of the phenol.

  
  
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  Croton oil is only an irritant.

  
  
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  Adding an oil “buffers” the solution.

For years the Baker-Gordon peel has been used with varied results, in large part due to the steep learning curve in the “art” of peeling. Controlling the many variables takes much experience. In the late 1990s Stone^4,7 and Hetter^2,3,6,8 published articles describing the role of croton oil and phenol concentrations in chemical peeling. By doing actual studies, the old ideas and dogmas of the past changed, dispelling previous beliefs. In his comprehensive and elegant four-part article in Plastic and Reconstructive Surgery, Hetter showed:

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  Phenol greater than 50% peels deeper with increasing concentration to a maximum with 88% USP phenol.

  
  
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  Unoccluded phenol less than 35% does not peel the skin.

  
  
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  Unoccluded 88% USP phenol without croton oil produces only a light-to-mild peel.

  
  
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  Phenol does not have an all-or-none effect.

  
  
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  Croton oil contains a powerful cytotoxic resin

  
  
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  Minute amounts of croton resin will cause skin burns.

  
  
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  Small amounts of croton oil added to phenol will cause peeling or skin burns.

  
  
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  Peel depth increases with augmented concentrations of croton oil.

  
  
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  Phenol acts as the carrier for the croton oil.

  
  
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  The depth of the peel is increased by tape occlusion, petroleum-based ointments, and multiple applications of croton oil in phenol.

With this knowledge about the actions and interactions of phenol and croton oil, we can formulate a protocol for deep peeling. Hetter has described in detail the use of serial dilutions of croton oil in phenol, creating solutions with a range of depth of penetrations that can easily be made from stock solutions. (See Chapter ▶ 25.)

24.5 Technique for the Deep Chemical Peel: Croton Oil–Phenol

Using the combined knowledge of Baker and his formula and Hetter’s studies of croton oil and phenol, the following chemical peel technique has been developed. In addition, the work done by Stone in 1998 showed the critical importance of patient selection, skin preparation, vigor and length of rubbing, volume of the peel solution, concentration of croton oil―and method and type of occlusion―are all responsible for the depth of peel. Since 2001, this author has used this technique⁹ with superior results and a lack of complications. The peeling procedure involves the prepeel and postpeel care, as well as the formula preparation and actual peeling itself. The peel is based on the original Baker-Gordon formula, with multiple solutions being made varying the amount of croton oil in each; however, an occlusive dressing is never used, and the peeled skin is kept moist throughout the peeling process.

24.5.1 Prepeel

As in all other surgical procedures, patient selection is critical in obtaining the optimum results.⁹ Patients with fair or lighter complexions are usually the best candidates. Those patients with olive or darker complexions, marked solar damage, and those with freckles all require full-facial peeling and are not good candidates for regional peels. They do very well with the full-face peels. Regional peels in these patients will leave obvious lines of demarcation and create a noticeable color disparity. Persons of Asian or African descent are not good candidates due to the increased risk of irregular complexion with areas of hypopigmentation and hyperpigmentation occurring.

The consultation preoperatively includes a frank discussion of the principles of resurfacing and the procedure itself. Before and after photos including pictures of the healing process are reviewed with the patient. The healing process is explained in detail to the patient including swelling, discomfort, weeping of the skin, keeping the skin moist, and postpeel erythema. Risks and complications are reviewed in detail and questions are answered. Prescriptions are given at the preoperative visit for cefadroxil monohydrate 500 mg for 7 to 10 days, methylprednisolone dose pack, hydrocodone bitartrate with acetaminophen 7.5/500 mg, or ketorolac tromethamine (Toradol, Roche Pharmaceuticals, Nutley, New Jersey) as needed for discomfort, and valacyclovir HCL 500 to 1,000 mg every 12 hours beginning 2 days prior to the procedure and ending 10 to 12 days postpeel. The patient is instructed to purchase Eucerin cream (Beiersdorf Inc., Wilton, Connecticut) and Aquaphor. A complete written postpeel manual of care with restrictions, do’s, and don’ts is reviewed and given to the patient. We do not recommend the use of any exfoliating agents such as retinoids or hydroquinone for 1 month prior to the peel. Any patient-applied pretreatments can vary from patient to patient, and we do not want to change the epidermal kinetics.⁹

Preoperatively, a complete and thorough history and physical examination are required. Evaluation of cardiac, hepatic, and renal function as well as any disorder that affects healing such as diabetes, collagen-vascular disease, history of radiation treatments, medications such as isotretinoin (Accutane, Roche, Nutley, New Jersey), and a history of herpes outbreaks should be well documented. A current electrocardiogram (EKG), complete blood count (CBC), and basic chemistry profile (including electrolytes, blood urea nitrogen [BUN], and liver function tests) are obtained. Standard photos are taken.

Be aware that deep chemical peels should be limited to the face and not extend down to the neck. Peeling the neck will result in hypertrophic scarring.⁹

24.5.2 Deep Peel Formula

Formula preparation used and recommended by this author is based on the Baker-Gordon formula with varying amounts of croton oil used (▶ Table 24.2). The idea behind this formulation is supported by the work of Hetter,^6,8 who has shown that 33% phenol can produce a medium-light, medium-heavy, heavy, or very heavy peel if the concentration of croton oil is changed from 0.35 to 0.7% to 1.1 to 2.1%, respectively. It is to be noted that the depth of the peel from 88% phenol has been shown to be less than that produced by 62.5% phenol, which was less than that produced by 48.5% phenol (Baker-Gordon formula).

The formula consists of liquid phenol in a concentration of approximately 88% USP. Croton oil is a powerful cytotoxic resin that increases the depth of peel with boosted concentrations. Distilled water is used as a diluent. Liquid soap Septisol is used as a saponifying agent.

These mixtures are prepared as a fresh batch for each case. It is strongly recommended that each surgeon mixes his own formula and does not entrust this job to a pharmacist, nurse, or other personnel. The formulas are compounded in individual 30-mL, amber glass bottles that are labeled with the patient’s name, the date, and the concentration.⁹

24.5.3 The Peeling Procedure

The procedure is performed under conscious sedation anesthesia monitoring with EKG and pulse oximeter. The face is cleansed with Septisol and then degreased with acetone. Removing the oils from the skin allows for even penetration and is a key step in the peeling procedure (▶ Fig. 24.1). Nerve blocks are used to aid in postpeel comfort. Bupivacaine 0.75% is used to block the supraorbital, infraorbital, and mental nerves (▶ Fig. 24.2).