Centrofacial Rejuvenation

• The Art and Science of Croton Oil Peeling
mentary changes. Black skin, with its greater melanin composition, demonstrates
a remarkable resilience and does not seem to age.
Gender is also a factor; males exhibit less wrinkling in the middle and lower face,
possibly because of thicker skin and factors relating to the beard and frequent


An assessment is made of obvious dynamic lines that occur perpendicular to the

include the horizontal forehead lines caused by frontalis contraction, vertical gla-
bellar lines from the corrugator supercilii, horizontal lines from the procerus, and
radial crow’s feet lines from the orbicularis oculi. The procerus lines commonly
extend onto the dorsum of the nose. The lateral brow can also exhibit passive
oblique rhytids described as “sleep lines.”
The lower eyelid deserves special attention when considering peeling. The lower
eyelid skin is very thin, with the thinnest dermis in the body and a lack of sup-
portive subcutaneous fat. The lid itself is suspended by its m edial and lateral
tendinous connection to bone, leaving the central portion dependent. With fre-
quent contracture of the orbicularis muscle and prominent exposure to the sun,

crisscrossing, and, as a late change, skin redundancy. Therefore the main inter-
vention to be considered should be resurfacing rather than skin excision unless


subcutaneous tissue and the lid is physically supported by the eyeball. The result
is that textural issues are less important, m aking upper blepharoplasty a good

the upper lid.
Recent anatomic studies by Bryan Mendelson have led to greater understanding
of the process of facial aging and by extension to the changes of the skin of the
middle face. Mendelson described that the tissues overlying the parotid gland are
densely attached by a multitude of ligaments anchoring all layers and preventing
m otion over the years. Exam ination of the skin in this region reveals relatively
little wrinkling, and this needs to be kept in mind when peeling. Anterior to the


This change in ligamentous support has repercussions on the skin as the cheek
skin medial to the parotid shows stippling and crosshatching that does not fol-
low a pattern of dynamic movement.
The nasolabial fold is a crease, not a w rinkle, and therefore is not necessarily

• The Technical Use of Croton Oil Peels
when the cheek substance is gently retracted laterally, this can be improved
with peeling.
The soft tissues overlying the oral cavity, m uch like those over the orbits, lack
underlying support and are suspended only from the periphery of the cavity to

is the common and troublesome perioral lines caused by the contracture of the
orbicularis oris muscle.
The oral com m issures are complicated areas that lose fatty support w ith age,
-
sor anguli oris muscle.
The chin area is more anchored but is subject to complex movement by the orbi-
cularis oris, mentalis, and depressor muscles. The result is the transverse men-
tal crease and irregular peau d’orange, which, although stubborn, can be greatly
improved with peeling.
The earlobes age by general involution, thinning of the derm is, creasing, and
elongation. Interestingly, they exhibit all three aspects of aging, and although

very well to peeling.
Aging changes of the neck are best treated with surgery. The neck skin does not
have the recuperative qualities of facial skin and cannot be peeled to improve
wrinkles. Peeling of the neck is extremely light and should be used only to pre-
vent a demarcation line at the mandible.
The relative thickness of the skin in the various areas should also be assessed.
The perioral area bordered by the nasolabial and melolabial folds has the thickest
skin of the face and can be deeply peeled, to the upper or midreticular dermis.
The forehead area changes from medial to lateral. The glabellar area, including
the upper nose, is thicker and can be peeled to the upper reticular derm is. The
lateral forehead is thinner, and peeling to the papillary derm is is m ore appro-
priate. Also, this area rarely has deep wrinkles (other than the transverse lines).
-

correlates with the correct depth of peeling. The temporal area is thin and del-
icate and should be peeled w ith caution. Conveniently, this area rarely needs
deep peeling.
The im m ediate preauricular area is very stable and tends not to w rinkle. This
is also a delicate area, and caution is warranted. Pinching the skin as described
will show that the skin is bound down and adherent over the tragus and preau-
ricular area. Advancing medially, the skin thickens, is more mobile, and contains

• The Art and Science of Croton Oil Peeling
more subcutaneous tissue. This is clearly seen in the “cheek proper,” where af-
fectionate pinching is done. The dividing line between the anterior and posterior
face begins from the lateral canthus, curving posteriorly and then crossing the
juncture of the body of the zygom a and arch, and extending to the geniom an-
dibular border. The anterior portion of the face, being more mobile, often shows

crow’s feet, and occasional sleep lines. This area is thinner than the perioral and
glabellar area; therefore the papillary derm is or upper reticular derm is is usu-
ally the limit for peels.
The lower nose is thick like the perioral area, and if needed can be peeled to a
similar depth. The eyelids are an interesting area because of the thinness of the
dermis but can be safely and predictably peeled with dilute solutions. The eyes
are the focus of the face, and the lower eyelids are com m only the m ain sign of
aging, especially in younger patients. Fortunately m odern croton oil peels are
-
feriorly to the infraorbital rim will demonstrate the change in thickness. This is
also a convenient time to test for excessive laxity of the lower lid.
PREOPERATIVE PLANNING AND PREPARATION
A chem ical peel is, at its core, a controlled chem ical burn done in the hope of

collagen and elastin in an orderly fashion. The more advanced the wrinkling and
solar damage, the deeper the peel must go without causing most feared sequelae,
hypopigmentation and scarring.

recovery. Adequate preparation of the skin and the patient are important factors
in the ultim ate success. The patient m ust be m otivated and counseled to have
a long-term perspective. The reward is a dram atic and lasting improvem ent in
skin texture, which is not easily replicated by any other modality.
The immediate postpeel phase, although not particularly long, can be trying for
the patient; therefore the surgeon must describe it realistically and accurately.
Detailed photographs of the day-to-day recovery are shown to the patient and,
if possible, to any caregiver who will be present. The prospective patient should
speak or ideally m eet with patients who have had a similar peel. Seeing some-
one in person who has successfully gone through the process is an invaluable
-
all the peel is well tolerated and the experience is a positive one if the patient is
well informed and the proper tone is set.
Preparation of the skin before the peel is a m eans of preventing complications
such as pigmentary changes, namely hypopigmentation and hyperpigmentation.
This involves applying tretinoin and hydroquinone 4%. The epiderm is is stabi-

• The Technical Use of Croton Oil Peels
lized, the dermis is stimulated to increase collagen content, and the melanocytes
are suppressed.
On a cellular level, the stratum corneum of the epiderm is is compacted, the
m elanocytes are suppressed, and a m ore even blending of pigm ent deposition
-
creases the circulation in the dermis. In essence, the skin is “revved up” for the
injury to come.
The preparation begins 4 to 6 weeks before peeling with tretinoin 0.05% or 0.1%,
1 inch (approximately 1 gram) applied to the whole face. The application includes
the earlobes, tragus, and hairline and continues to 1 inch below the mandibular
border and 1 to 2 mm below the ciliary edge. Application should avoid the upper
lids to prevent possible irritation. The neck can be prepared in a similar fashion,
decreasing the frequency depending on irritation.

In countries where hydroquinone is regulated or banned, kojic acid is a possible
substitute.
These preparatory treatments accelerate cellular turnover and result in erythem-

bothered by the reaction and wants to stop, he or she should be counseled to de-

is allowed, a weaker tretinoin concentration (0.05%) can be mixed with hydro-
quinone 4% in an emollient cream and used twice a day. This has resulted in less
irritation and greater patient compliance. An exfoliating agent (glycolic acid 8%
or phytic acid 2%) may be used to help remove the desquamated cells in the stra-
tum corneum. The preparation should be stopped 4 to 5 days before the peel to
allow the epidermis to normalize. The preoperative clinical photographs should

This skin preparation is certainly a nuisance, and its absolute necessity is con-
troversial. Som e practitioners successfully peel or laser resurface without it; a
consensus w ill require greater cum ulative experience and controlled studies.
My experience has been that om itting or shortening the preparation leads to

hydroquinone can be omitted.

The surgeon must be aware of any previous episode of abnormal scarring. Recent
use of isotretinoin (Accutane) is potentially problematic because of the inhibition
of collagenase, which can lead to excessive scar form ation. A 6-m onth waiting
period is usually cited, but a true safe interim is not known. A history of herpes
simplex is notable, although all patients are placed on antiviral prophylaxis.

• The Art and Science of Croton Oil Peeling

Antiviral prophylaxis is routinely prescribed to all patients. Valacyclovir hydro-
chloride, 500 mg two tim es per day, is begun 3 days before the procedure and
continued for 7 days after peeling. Although the post-peel phase is not particu-
larly painful, narcotic pain m edication is prescribed along with ibuprofen, 800
mg three tim es daily. Sleep m edication is prescribed, and a m ild sedative is a
consideration to help cope with the inconvenience and isolation of the recovery.
TECHNIQUE

The use of general anesthesia, intravenous sedation, and sensory nerve blocks has
been the standard for many years, because the caustic nature of croton oil is very
stimulating. Several observations, however, are notable and worth considering.
There is no record of lay peelers using any particular form of anesthesia, local or
general, because they were not physicians, but they nonetheless carried out sig-

concentrations are not typically painful in the days after the procedure. The most



Some clues are available by examining phenol’s other uses. Comm on over-the-
counter sore throat sprays and cold sore solutions contain phenol at a concentra-

otorhinolaryngologists very comm only apply 20% to 25% phenol directly to the
eardrum as an anesthetic to perform minor procedures in an outpatient setting.

the hand, I experimented with various dilutions of phenol on my own hand. The
application of 60% phenol on spots caused m inor stinging that promptly sub-
sided, after which a frost appeared. The skin then darkened and remained dark
for som e weeks until it was shed, w ith improvem ent or disappearance of the

skin touched by the phenol was completely anesthetized, even when pricked by
a needle to the point of bleeding. The biochem ical explanation is that the free
hydroxyl of phenol interacts with the myelin surrounding axons, resulting in a

-
trations of 35%, 50%, and even 88% have been applied to the face safely.

applying a single pass of 60% phenol to one segment of skin (such as one half of
the forehead). The patient experiences mild to moderate predictable stinging for
10 to 15 seconds, after which the pain disappears completely. Once the stinging
subsides, the area treated with phenol is completely num b and can be peeled,
even deeply, without discomfort.

• The Technical Use of Croton Oil Peels

anesthesia and then peeled. The stinging sensation is tolerable (less stimulating
than a 20% to 25% trichloroacetic acid [TCA] peel, which is commonly performed
without anesthesia), but the overall experience is improved if oral sedation is in-
corporated. The degree of oral sedation depends on the surgeon’s comfort level,

to require oxygen supplementation, and if appropriately planned and executed
patients tend not to remember the act of peeling.
The standard routine for a full-face peel involves greeting the patient, having the
patient change into a hospital gown, and giving the oral sedation. The typical
regimen includes lorazepam, 0.2 mg, and triazolam, 0.5 mg. Triazolam was once
a common benzodiazepine sleep medication that eventually lost favor because
-
son, and it was at the suggestion of a dental colleague that I include it. Patients
m ay fall asleep or becom e sleepy. They are responsive, quite com fortable, and
do not require oxygen. The only inconvenience of the sedation is that it requires
som eone to drive the patient hom e. A narcotic such as hydrom orphone, 4 to 8
mg, or other com m on analgesic can be used depending on surgeon preference
and patient tolerance. Celecoxib, 400 mg the day prior and 200 mg on the morn-
ing of the peel, is useful.
The operating table or exam chair is made up like a bed with a comfortable blan-
ket and pillow. The cardiac rhythm , oxygen saturation, and blood pressure are
monitored. Pleasant, calming music is played; although the patient is watched,
he or she is left undisturbed to relax or fall asleep. After an appropriate waiting
period (approxim ately 20 to 30 m inutes), the skin is degreased w ith acetone,

patiently, concentrating on small areas at a time and waiting for the stinging to
go away before proceeding to the next area. All areas to be peeled are treated in
this way. The eyelids are treated last, because they are more sensitive. Once the
entire face (or areas to be peeled) have been treated in this manner, and after the
initial frosting has subsided, the surgeon can proceed with the peel, observing
the patient for discomfort. If an area is particularly sensitive, local anesthesia can
be injected, but it is rarely needed. The use of a cryocooler (an apparatus that
blows cold air, used in laser treatments) or similar m achines can be a soothing
adjunct. Distraction with a vibrating device touched to the vicinity of the area
being treated is also useful.
Early experience showed that at the end of the peel, a 1-hour period of discom-
fort and burning was com m on that required use of an oral narcotic. After this,
patients typically have no pain. A way to manage the immediate discomfort af-
ter the peel is to apply a thin coat of a standard compounded topical anesthetic
cream (“BLT,” benzocaine 20%, lidocaine 8%, tetracaine 4%). Due to the lack of an
-

• The Art and Science of Croton Oil Peeling
This technique can also be used if the peel is done under anesthesia. The nerve
blocks are thus avoided and the patient emerges from anesthesia comfortable.
Further experience with these approaches has shown that using weaker phenol


The implem entation of peeling w ithout form al anesthesia has been transfor-

procedure and avoids the expense (and potential risk) of anesthesia. The abil-
ity to control the environm ent m akes these peels m ore user-friendly and less
intimidating. As a consequence, the surgeon can perform more peels in a more

This approach also has a conceptual safety factor, especially for novice surgeons.
Because the ingredients of the peel have negligible cost and operating room ex-
penses can be avoided, the pressure on the surgeon to obtain an ultimate result
at the outset is greatly reduced. In the event of an incomplete peel, planned or

remaining wrinkle with the croton oil solution. The recovery from this is much
simpler, and sedation is not needed. This approach is ideal for correcting stub-
born radial lines on the lip and texturing of the lower eyelid, where the margin


doctor-patient relationship.

Phenol concentrations other than 88% are not typically available, but they are
easily made with simple computations. In 10 ml of 88% phenol, there are 8.8 ml
of phenol and 1.2 ml of water: 8.8/10 = .88, or 88%. To make 60% phenol, the com -
pounder must use this equation to determine how much water must be added
to 10 ml of 88% phenol to dilute it to 60%: 8.8/x = 0.6; x = 8.8/0.6, or 14.66. Thus
to the 10 ml of 88% phenol, approximately 4.7 ml of water must be added to re-
sult in a total of 14.7 ml of solution containing 60% phenol. For 50% phenol, the
computation would be x = 8.8/0.5, or 17.6; therefore 7.6 m l of water is added
to the 10 ml of 88% phenol. For 40% phenol, the equation is x = 8.8/0.4, or 22, so
12 ml of water are added to the 10 ml of 88% phenol. Using these formulas, any
concentration of phenol is possible.
10 m l 88% phenol + 4.7 ml water = 14.7 m l 60% phenol
10 m l 88% phenol + 7.6 ml water = 17.6 m l 50% phenol
10 ml 88% phenol + 12 ml water = 22.0 ml 40% phenol

• The Technical Use of Croton Oil Peels
The preparation of the acid peeling solutions is a critical step that should be
perform ed by the operating surgeon or entrusted only to another individual
who is intim ately acquainted w ith the process. The ingredients are the sam e
as in the Baker peel and include water, phenol, croton oil, and Septisol.1 Phenol,
also known as carbolic acid, is an aromatic organic compound with the molecu-

water. The need to work with crystals to create liquid phenol possibly deterred

88% or 89% phenol are now readily available from m any pharm acies and der-
matologic suppliers.


An interesting historical anecdote is that in the early days of Listerian sterile

(described as weak), because surgeons operated with bare hands. When William
-
nol exposure, he was despondent and sought the aid of the Goodyear brothers,
who developed a practical rubber surgical glove. Soon thereafter, sterile surgical

Croton oil is a natural oil extracted from the seeds of Croton tiglium, a small tree
native to the Indian subcontinent and Malaysia. It is used as a veterinary purga-
tive and has been m entioned in American literature as a poison. During World
War II, croton oil was added to the alcohol propellant of torpedoes to discourage
sailors from drinking the fuel (although the sailors found a way to separate the
alcohol from the croton oil in makeshift stills).
Croton oil is highly caustic and if applied full strength on skin will create a pain-
ful full-thickness ulcer. When correctly diluted and appropriately applied, how-
ever, croton oil can create dram atic aesthetic results. Surgical soap consisting
of hexachlorophene in a liquid form (such as Septisol) is used as a surfactant to
make the aqueous components and the oil components more miscible. Ordinary
tap water is used for preparation of the solutions.
These ingredients are relatively inexpensive and can be obtained from com -
pounding pharm acies or derm atologic suppliers. Delasco is a reliable supplier
in the United States and can ship internationally. Shipping croton oil overseas
can be problem atic because of local regulations, so inquiries to each country’s
customs department should be made.
The preparation of the solutions is logical and straightforward, yet experience
during lectures and live surgery workshops has shown that participants are very
intimidated by the prospect of mixing the solutions and inquire about purchas-

• The Art and Science of Croton Oil Peeling

surgeon to prepare the solution. In addition, the form ulas can be altered and

Preparation of the solution requires a comfortable workspace on a surface that is

of small glass bowls are ideal for mixing. Standard syringes in various volumes
(1, 3, 5, and 10 cc), a small glass or metal funnel, surgical gloves, and containers
to store the various solutions may also be helpful. Various sizes of opaque glass
containers are inexpensive and available from commercial providers, including
bottles with phenolic-cone–lined leak-proof caps.
The environment must allow the preparer to devote undivided attention during
the mixing process. The ingredients are arranged in glass bowls in the order they
will be added; this arrangement should be repeated every time to prevent confu-
sion. Surgical gloves must be worn for protection from the caustic acids. (In my
early experience, I always “double-gloved,” but with time I became more cavalier

Once prepared, the acids can be stored in the opaque containers with leak-proof
caps for extended periods of time, but variation in concentrations my occur from
evaporation if stored more than 6 months.

be awkward to use, especially w ith sm all volum es and w ith the considerable

-
ter toward simplifying the process was to create a standard phenol-croton oil
solution using larger volumes that would then be further diluted with the other
ingredients (Table 13-1). This standard solution, or “stock solution,” is made by
mixing 24 ml of 88% phenol and 1 ml of croton oil. Standard 89% phenol can be
used as well with no practical consequence. By using larger volumes of the ingre-
dients, they are easily measured with accuracy and consistency using standard
syringes. Phenol has a tendency to corrode the rubber in the syringes; therefore
the syringes may need to be changed if the plunger is no longer moving easily. If
the plunger begins to stick, it should not be forced; this may result in splashing.


-
mate phenol concentration when using these formulas is 35% unless otherwise
noted. The surgeon can simply follow the recipes for a standard concentration or

• The Technical Use of Croton Oil Peels
In the croton oil concentrations of 0.2%, 0.4%, and 0.8% listed in Table 13-1, the
volumes of water and Septisol remain constant at 5.5 ml and 0.5 ml, respectively.
The values that change are the relative volum es of phenol and stock solution
(which contains phenol and croton oil). The sum of the volumes of the 88% phe-
nol and the stock solution is 4 ml in each of the formulas.
The stock solution consists of 24 m l of phenol and 1 m l of croton oil. Each m l
of stock solution has 0.04 ml of croton oil, m aking this a 4% croton oil solution.
For example, looking at the form ula for 0.8% croton oil, it is m ade up of 5.5 m l
of water, 0.5 m l of Septisol, 2.0 m l of phenol, and 2.0 m l of stock solution. The
2.0 ml of stock solution contains 0.08 ml of croton oil (2 × 0.04 ml). Because the

m l croton oil in 10 m l total volum e, or 0.8%. Thus by comparing the volum e of
stock solution in any of the form ulas w ith the known content of croton oil in

Notably, the croton oil concentration in the stock solution is extrem ely high at
4% and should never be directly applied to the skin without further dilution. For
instance, the Baker formula had a croton oil concentration of 2.1%.

and these are further diluted by using the formulas indicated in Table 13-1. The

Table 13-1 Croton Oil Solutions
. This solution yields 0.04 ml croton oil per 1 ml of stock solution,
or a 4% croton oil solution. The stock solution is further diluted as follows:







Water
5.5 ml
5.5 ml
5.5 ml
Septisol
0.5 ml
0.5 ml
0.5 m l
Phenol 88%
3.5 m l
3.0 ml
2.0 ml
Stock solution (4% croton oil
solution)
0.5 ml
1.0 ml
2.0 ml


0.1%: 1 ml 0.4% croton oil solution + 1.2 ml phenol + 1.8 ml water
0.05%: 1 ml 0.2% croton oil solution + 1.2 ml phenol + 1.8 ml water
1 4 x%: 1 ml x% croton oil solution + 1.2 ml phenol + 1.8 ml water

In 10 m l formulas (0.2%, 0.4%, 0.8%), use 4.5 ml of water and 1 ml of olive oil.
In 4 ml form ulas (0.1%, 0.05%, or less), use 1.4 ml of water and add 0.4 ml of olive oil.

• The Art and Science of Croton Oil Peeling
kept at 35%. Ultimately, whatever starting concentration is used with this dilut-
ing formula will be diluted by one fourth, because 1 ml of x% croton oil solution
+ 1.2 m l phenol + 1.8 m l water will yield a 1 4x% solution. If larger volum es are
desired, all of the values in the formula can be multiplied by the same factor to
retain the concentration.

total volume of phenol present. Using the formula for 0.4% croton oil as an exam -
ple, 3.0 ml of phenol and 1.0 ml of stock solution are used. Because the phenol is
not pure but is 88% phenol, the 3.0 ml are multiplied by .88, yielding 2.64 ml. The
stock solution is 24 25 phenol, or 96%. Multiplying the 1.0 ml stock solution by .96
yields 0.96 ml. This 0.96 ml is 88% phenol, and therefore is multiplied by .88 to
yield 0.84 ml. Thus the total volume of phenol is 2.64 ml + 0.84 ml, or 3.48 ml. In
a total volume of 10 ml, the phenol concentration is 34.8%. Each of the formulas
vary slightly, but for convenience, they are considered 35%.


more even distribution of the solution. In 10 ml formulas, this concentration is
achieved by changing the water volume to 4.5 ml and adding 1.0 ml of olive oil.
In the weaker croton oil solutions, such as 0.1%, in which the total volum e is 4
ml, the water volume added is 1.4 ml, and the olive oil volume is 0.4 ml.

concentration of phenol was not necessary to result in a good peel.2 It is possible
to alter the formulas to obtain a lower concentration, potentially for a lighter peel
(although the croton oil concentration is the primary determinant). Another op-
tion is to prepare a solution with a higher concentration of phenol, such as 60%,
with a weak concentration of croton oil, such as 0.1%, 0.05%, or even weaker to
use in instances where pigmentation is more of an issue than wrinkles. To change
the phenol concentration to 60% in the 0.1% croton oil 4 m l form ula, the total
volume of phenol needed (x) is determined by x/4 ml = .60; thus x = 2.4 ml. Be-
cause 0.35 ml of phenol comes from the 1 ml of 0.4% croton oil solution (which
is a 35% phenol solution), this leaves 2.05 ml of phenol lacking. The equation .88x
= 2.05 represents the volum e (x) of 88% phenol needed for this am ount, in this
case 2.33 ml. In the formula, the volume of phenol and the volume of water add
up to 3 m l; substituting 2.33 m l of phenol and 0.67 m l of water in the form ula
results in a 60% phenol solution. This formula concept can be used to customize


Traditionally, the Baker peel and the more recent iteration have been done under
general anesthesia or intravenous sedation because of the considerable pain of
the chem ical burn. Regardless of which approach is chosen, adequate blocking

• The Technical Use of Croton Oil Peels
of pain is important to prevent excessive stim ulation and to allow a pain-free
emergence from anesthesia. If the patient wakes up comfortable, the entire re-
covery and general experience is better. Som e patients report m ild tingling or

After induction of anesthesia, complete local sensory nerve blocks are performed
with bupivacaine with epinephrine. These include the supraorbital, supratroch-
lear, infratrochlear, zygom atico-temporal, zygom atico-facial, infraorbital, dor-
sonasal, mental, and cervical branches. An excellent discussion of this topic can
be found in the journal Cosm etic Derm atology authored by Joseph Niamtu III.3-6
-
erative site is very useful. Color changes of the skin are important indicators of

to prevent blanching. Intram uscular ketorolac trom etham ine, 30 to 60 mg, is
administered as an adjunct to anesthesia.
These anesthetic techniques are the common; I have used them successfully for
more than a decade. An innovative alternative approach that allows the surgeon
to com fortably perform even deep peels with oral sedation and no local anes-
thesia is described in detail later in the chapter.
Ophthalmic ointment and corneal protectors are not used, because the phenol

Extreme caution around the eyes is imperative.
The fear of cardiac toxicity has been historically associated with phenol peels,
but rare reports of death are anecdotal and it is impossible to implicate phenol
toxicity rather than anesthesia complications. Traditional peels were performed
with general anesthesia or sedation but without local blocks. There is specula-
tion that the catecholamine release caused by the intense stimulation of the high
concentration of croton oil may have been the cause of the arrhythmias. With a
lower concentration of phenol (35% versus 49%), lower concentrations of croton
oil, and thorough local anesthesia of the face (or the newer technique discussed
later), cardiac complications have not been seen. Thomas Baker,1 who popular-
ized the traditional peel, has stated that in his many years of experience, he never
encountered cardiac arrhythmias that required treatment. Recent studies show
that when peeling is perform ed under anesthesia but without blocks, arrhyth-
mias are not uncomm on, but they are benign in nature. General recommenda-
tions include cardiac monitoring, adequate hydration, and peeling a full face in
no less than 45 minutes. Following these guidelines, I have not seen any cardiac
complications in nearly 17 years of peeling.
The patient is instructed not to apply anything on the skin on the morning of the
procedure; before peeling the skin is thoroughly degreased with acetone. If op-
erating room regulations forbid the use of acetone, it can be applied in the pre-
operative area and the skin again degreased with alcohol in the operating room.

• The Art and Science of Croton Oil Peeling
The process of peeling should be orderly and system atic. Of prim ary impor-
tance is safety, particularly in protecting the eyes, preventing inadvertent peel-
ing where not desired, and preventing splashing of the acids. As previously ex-
plained, corneal protectors and ophthalmic ointment are not used, so great care

prevent acid rolling into the eyes, never using an applying sponge so wet that it
can drip, and never crossing over the eyes with an applying sponge in hand. The
operating surgeon’s hands must be free of acid to prevent application where not
desired. The hands can be wiped dry by an assistant or a surgical towel or other
cloth can be clipped to the surgeon’s scrub shirt shoulder and then draped over
the front for wiping the hands. The acids need to be placed in clearly labeled glass
bowls and arranged in a consistent manner to prevent confusion. The surgeon’s
dem eanor is particularly important: It should never be hurried or brusque, al-
ways focused, deliberate, and free of distractions.

which is less abrasive), large cotton-tipped applicators, and small cotton-tipped
applicators (both the sponged and wooden ends). Toothpicks and aesthetician
sticks (such as those used for applying wax) are also useful. The gauze is folded
twice to decrease the surface area of contact and ensure greater accuracy. It is
then dipped in the solution and carefully wrung out. The solution is stirred be-
fore each application to ensure even mixing of the oil and aqueous components.
The gauze should be m oist, but not so saturated that it could drip. The gauze
should be set in a safe place and the hands dried to prevent the application of
acid where it is not wanted. This is particularly important in segm ental peels,
in which errors are obvious. Again, the surgeon should never cross over the eyes
with the wet gauze (or applicator) in hand.
Once the gauze is passed over the skin, the action of the acid is evident in 10
to 15 seconds, depending on the wetness of the gauze and the concentration of
the croton oil solution. When it com es in contact with the skin, the acid coag-
ulates and precipitates the protein, form ing a frost (varying degrees of a white
appearance to the treated area). As the application progresses, multiple passes
are made, and the depth of the skin reached is gauged by the degree and quality
of the white appearance. The frosting appearance becomes progressively more


juncture between the epiderm is and the derm is). As the peel passes from the
papillary dermis into the upper and midreticular dermis, the frosting becomes


Once the acid solution is applied, there is no “going back”; no neutralizing agent
-
tion is too wet (and has the potential to go deeper than intended), quickly blot-
ting it will diminish the depth. As explained later in this chapter, this technique
can be very useful on deep wrinkles.

• The Technical Use of Croton Oil Peels

The versatility and safety of the peel is based on a number of variables that deter-

was demonstrating that the concentration of croton oil was a primary factor in
the depth reached; compared with older peels, this is the dividing line between
an excellent result and hypopigmentation.7 The fundamental concept is that the
croton oil concentration does not determine the depth, but rather, the appropri-
ate concentration gives the surgeon the tool, assuming the proper technique, to
achieve the desired result. Regardless of the concentration used, the number of

applied can lead to deep involvem ent, even scarring. The safety of a weak con-
centration is only relative and should not be taken for granted.
As previously described, the croton oil concentrations are relatively weak (for
instance, Baker’s was 2.1%, versus the maximal concentration presented here of
0.8%), so the other main factor of the depth reached is the application technique,

between the modern croton oil peel and its predecessors. With a particular con-
centration, a damp sponge can be rubbed multiple times, variable pressure can
be used, or the gauze can be wetter and fewer passes made. In reality, the same
-
tions.
-
ing potential of the skin. For example, the perioral skin can sustain a stronger
concentration than the thinner m ore delicate skin of the eyelids. Interestingly,
as disparate as these areas are, they both can be peeled safely and reliably. The

various parts of the face serves as a useful guide to help plan the peel.

The key to success with these peels, as with any resurfacing technique, is choos-
ing and safely reaching the appropriate endpoint. Any practitioner performing
resurfacing should have a working knowledge of skin anatomy to understand

the epidermis, the dermis, and the subdermis. The epidermis, the outer layer, is
the epithelium. Its basic function is to provide a barrier to the outer world. The
juncture of the epidermis and dermis is undulated with the downward projec-
tion of the epidermal pegs and the interlocking dermal projection, called dermal
papillae. The origin of the epiderm is is at the exact junction of the derm is and
epiderm is, called the basem ent m em brane or stratum basale. On the basem ent


surrounding network called a cytoskeleton. Keratinocytes are connected to each

• The Art and Science of Croton Oil Peeling
other and to the basem ent m em brane by complex proteins called hem idesm o-
som es.
As stem cells, keratinocytes can divide into two stem cells to replenish the supply

breaks down and the new cells m ove up in the epiderm is away from the basal
layer. These new cells now form m any bonds between each other by proteins
called desm osom es. These m any bonds give this new cell layer a spiny appear-
ance; this layer is the stratum spinosum. The cells of the stratum spinosum have
storage containers called lam ellar bodies that hold phospholipids and catabolic
enzym es.



a new layer called the stratum granulosum (because of the m ultiple granules

move toward the surface, they acquire more keratin, becoming harder and scaly.
The released catabolic enzymes act on the phospholipids, creating hydrophobic

of fat that prevent the passage of water into the skin.


layers with fatty layers in between, form ing a barrier to water. The outer cells
are eventually shed, or exfoliated.
On the deep side of the basem ent m em brane lies the derm is. As previously
stated, the juncture of the derm is and epiderm is is undulated, creating m uch
more surface area between the layers. Like interlocking egg-crate foam or hook-

and resistance to shearing. The upper portion of the derm is, surrounding the
upward-projecting dermal papillae, is called the papillary derm is. In the papil-




hence the name reticular derm is for this layer.

m oldability. Fibroblasts are cells in the derm is that produce the collagen, elas-

the spaces between the cells. These polysaccharides have a great capacity to
bind water and are responsible for providing hydration to the skin. The dermis
has ample blood supply in the form of a hearty deep derm al plexus and an in-

• The Technical Use of Croton Oil Peels
terconnecting sm aller network in the papillary derm is. The epiderm is has no

undulating interface between epiderm is and derm is is important in providing
adequate surface area for this process.
Coursing from the deep derm is to the surface are the hair follicles and sweat
glands. Epithelial cells on the surface invaginate and line the hair follicle and
sweat gland, in essence bringing epithelial cells into the deepest parts of the der-
mis. This is clinically important because when an injury into the dermis occurs,
as in a deep peel, it is the epithelial cells in the hair follicles and sweat glands
that regenerate and migrate to reline the surface and therefore reepithelialize the
skin. If the injury (or peel) is too deep or there are inadequate dermal append-

Epidermis that lines the dermal appendages
greatly increases the total amount of cells
available for reepithelialization.
Dermal appendages
(sweat glands, hair follicles)
Epidermis
Dermis
Subcutaneous fat
Deep peel
Shallow peel
Epidermis
Papillary
dermis
Upper reticular
dermis
Upper to mid-
reticular dermis
Fig. 13-1 Layers of the skin and how they apply to depth of peel.

• The Art and Science of Croton Oil Peeling

-

salicylic acid, retinoic acid, Jessner, weak TCA, and even phenol peels without
-
derm is. A m edium -depth peel goes to the papillary derm is and is the dividing
line between an aesthetician peel and one performed by a physician. Deep peels
go to the reticular derm is (upper to m iddle), and it is this layer that m ust be

depth reached, and these deep peels require a longer time for reepithelialization
and resolution. Peeling to the lower reticular dermis can be problematic and re-
sult in unnatural hypopigmentation or scarring.
As the peel begins and progresses, the appearance and quality of the frost is con-
stantly assessed to gauge the depth. The qualities the surgeon should look for are
color hue and “thickness,” or degree of opacity. A thin, transparent frost with a
pinkish background means that the acid has passed from the epidermis into the
papillary dermis. A quality of translucence allows visualization of the horizontal
strata of vessels within the dermis, giving the pink color. This is an appropriate
endpoint in some areas. With further application, the acid passes into the upper
to middle dermis, forming a solid, opaque, evenly colored frost. The denaturing


gone. If the peel is stopped at this point, the next stage is the gradual loss of the
frost, or “defrosting.” This defrosting m ay take approxim ately 15 m inutes and
gives way to red-brown overtones (Fig. 13-2). This is a reliable and accurate sign
Fig. 13-2 A red-brown appearance after defrosting indicates the peel has reached the reticular

• The Technical Use of Croton Oil Peels
that the upper to m idreticular derm is has been reached. If the peel continues
after the solid white frost, the color becomes gray-white, which indicates having
reached the lower reticular dermis. Peeling to this level is not advised.
With the recommended technique and using appropriate solutions, this progres-

and therefore can be controlled. The key to the peel is that it is a gradual contin-
uum w ith visual changes that are easily recognizable and predictable. An experi-
enced practitioner can control the process by peeling slow enough to recognize the
various stages and stop at the appropriate depth and go no deeper. Practitioners
-
culty transitioning to croton oil peels.
Another way to assess the depth of the peel is the phenom enon of epiderm al
sliding. Epiderm al sliding occurs when the peel reaches the papillary derm is
and the tight bond between the epiderm is and derm is is broken. This allows
the epidermis to slide as a thin independent sheet. This sliding disappears when
the reticular dermis is reached and the epidermis and dermis bond together as a
single block. Epidermal sliding is most obvious and useful in thin-skinned areas
such as the eyelids and lateral forehead as opposed to the m outh and glabellar
area. Epidermal sliding is a helpful marker when peeling thin eyelid skin where
the margin of error is small and the other visual signs are not as evident.
Prolonged defrosting tim e can alert the surgeon that an area m ay have been
peeled too deeply and warrants careful observation during the healing. The de-
frosting time for papillary dermis is 3 to 10 minutes; the upper to middle dermis
takes 10 to 15 minutes. A time longer than 20 minutes is potentially problematic.

Relevant technical pearls for executing croton oil peels are listed at the end of
the chapter.
A small handheld fan is useful to dissipate the fumes and soothe the patient. The
head should be stabilized for easy positioning with a cradle or other apparatus;
alternatively two hand towels (one on top of the other) can be folded with one
corner turned down to the long border. The towels are rolled along this oblique
line to create a thick center and two tapered ends, which are folded over each

• The Art and Science of Croton Oil Peeling
other to form a circle with an adjustable diameter that can cradle the head (Fig.
13-3). Surgical towels and drapes can be easily clipped to the towels, completing
an ideal setup for facial surgery.

eyes) and the skin is degreased with acetone. The eyes must be protected from
acetone drips or irritation from the fumes. As mentioned, ophthalmic ointment
and corneal protectors are not used. Standard surgical gloves are m ore protec-
tive than thinner, nonsterile ones. A surgical towel or other cloth is attached to
the shoulder of the scrub shirt and draped over the front.
The solutions to be used should be prepared beforehand and clearly labeled;
they should be arranged in small glass bowls on a back table or Mayo stand with
the original bottle adjacent in a standard order, such as in ascending strength.
Surgeons should ideally adopt a routine sequence of peeling to be used every
time to prevent confusion. I prefer to begin in the perioral region, proceed to the
forehead, then treat the cheeks and central face. Nose and periorbital areas are
next, and special attention is given to the deepest wrinkles. A very light peel of

Although various solution concentrations are discussed here, croton oil concen-
-

reached. A surgeon must make intricate mental computations and analyses when
deciding how much pressure to apply to a scalpel when making a particular in-

Fig. 13-3 Preparation. A, A head roll m ade with two towels to cradle the head. B, Arrangem ent
of labeled solutions.
B
A

• The Technical Use of Croton Oil Peels
The bottle of the solution to be used is gently shaken to evenly m ix the ingre-
dients and several milliliters are poured into its corresponding bowl. The gauze
square is folded twice and dipped into the bowl, then wrung out until damp but
not dripping. The gauze is set in a safe place and the hands wiped on the clipped
towel, then the gauze is retrieved for peeling.
Starting on the upper lip, a pass is made and the skin is examined. A light frost ap-
pears in about 10 to 15 seconds, and as further passes are made, the frost becomes
a denser, more concentrated shade of white. When the frost is still translucent
with a pink background, the papillary dermis has been reached. The thick skin
around the mouth does not exhibit epidermal sliding. As more passes are made,
with the surgeon redipping the gauze as necessary, the frost becomes denser,
whiter, and progressively more opaque, losing the pink color as the upper reticu-
Fig. 13-4 Relative depth of peeling in various areas of the face.
Medial forehead,
glabellar area, upper nose
Lateral forehead
Lower nose
Perioral area
Nasolabial fold
Melolabial fold
Thin skin
(shallow peel)
Temporal area
Lateral
canthus
Zygoma
Posterior face
Anterior face
Thick skin
(deep peel)
Danger areas

• The Art and Science of Croton Oil Peeling
lar dermis is reached. The contents of the solution bowl must be stirred with an
aesthetician stick or the wooden end of an applicator before redipping to keep the
components well mixed. This process is slow, predictable, and therefore control-
lable. The surgeon can stop at any point if a lesser peel is desired. The expected
depth is planned beforehand based on clinical need and other factors, and the peel

using a wetter gauze, rubbing harder and faster, or using a higher concentration
of croton oil. This degree of control is both empowering and reassuring.
If wrinkles are present, as is usually the case, the skin is stretched to allow even
application of the acid. Likew ise, the com m issures are stretched and can be
peeled relatively deeply. The verm ilion are typically peeled with a 0.2% or 0.4%
croton oil solution, using a cotton-tipped applicator to improve the radial lines.
The peel continues onto the submental-submandibular border or inferior border
of the m andible and chin. In this area a lighter peel is used to prevent dem ar-
cation. Once an opaque, solid white frost is reached in the m ain perioral area,
indicative of the upper to m idreticular derm is, the peel progresses to another
area. The surgeon should continue to observe the perioral area for defrosting,
which can take 15 to 20 minutes, watching for the tan, red-brown overtones that

appear or if it is too faint, the area can be readdressed. With experience, the re-
ticular dermis can be reached quickly using croton oil concentrations of 0.4% or
0.8%, but novice practitioners can use weaker concentrations with more, slower
passes to allow more time for observation (Fig. 13-5).
The next area to be peeled is the forehead, including the glabellar area and upper

the thickest, and the skin thins out laterally; the temporal area is especially thin
and delicate. The glabellar area can have deeply etched lines and can be peeled
to the reticular dermis. The rest of the forehead is usually devoid of generalized
wrinkles other than the transverse lines and, occasionally, oblique sleep lines
laterally. A reasonable tactic is to peel the forehead with 0.2% concentration to
the papillary derm is and then peel the central area w ith 0.4% to the reticular
dermis (dense frost). Outside of the central area, peeling to the reticular dermis
is generally not advised, because it is rarely needed and extra caution m ust be
exercised in the temporal area. The deeper transverse lines and the glabellar
lines can be peeled deeper (discussed in more detail later). As with the perioral
region, red-brown overtones are the ultimate goal if peeling to the reticular der-
mis is desired (glabellar area). Peeling should continue into the hairline and just

the peel. Treating the frontalis, corrugator, procerus, and lateral orbicularis oculi
m uscles with botulinum toxin 2 weeks before the peel will provide decreased
mobility during the healing (Fig. 13-6).

• The Technical Use of Croton Oil Peels
Fig. 13-5 As multiple passes are made, the frost becomes more dense and opaque. This patient’s

oil peels. Aesthet Surg J 28:33-45, 2008.)
Fig. 13-6 The frost on the lateral forehead is transparent with a pink background; this represents
peeling to the papillary dermis. The frost in the glabella is more opaque and organized, indicative

• The Art and Science of Croton Oil Peeling
The posterior and anterior face between the eyes and m outh are peeled next.
The skin anterior to the ear overlying the parotid gland is strongly anchored by
num erous ligam ents and is less m obile and therefore does not wrinkle m uch.
Anterior to the parotid area, the ligam entous attachm ents are m ore sparse, al-
lowing the intricate motion of the face. Along with more mobility, this area is the

deep etching can be seen. The preauricular area is delicate and should be peeled
lightly, perhaps w ith a light application of 0.2% croton oil solution. Peeling of
the posterior area should continue into the sideburn, the tragus, and the earlobe
(Fig. 13-7). At the mandible, the peel should continue to the underside for about
1 cm . In the anterior portion, ending on the nasolabial fold, the peel should be
to the papillary dermis with individual wrinkles targeted as necessary. Epider-
mal sliding may be seen in the central face. The region of the geniom andibular
groove is particularly delicate and requires a light touch. In fact, the entire cor-
ridor encompassing the mandibular border between the mandibular angle and
the geniomandibular groove is rarely wrinkled and should be peeled with care.
Fig. 13-7 Cheek peeling to the papillary dermis.

• The Technical Use of Croton Oil Peels
The eyelids are a particularly good area for peeling, especially the lower eye-
lids, because they can show remarkable improvement and despite their innate
thinness are rarely problem atic. By using a weak croton oil concentration such
-
ment. The solution is applied with a cotton-tipped applicator by dipping it into
the bottle after it has been shaken. The wet tip is touched to a gauze or cloth

gradually working up to the vicinity of the ciliary margin (Fig. 13-8). Similar to
other areas, the relative dampness of the applicator and the num ber of passes

stretch out the skin and expose the wrinkles and folds. As the peel progresses,
the motion of the applicator will begin to demonstrate epidermal sliding as the
frost assumes an even white color. Releasing the cheek will allow the lid skin to
m ove superiorly, and the degree of epiderm al sliding can be gauged. Once the
epiderm is appears loose and a uniform white frost appears, the peel proceeds
to the opposite lid. With experience, the surgeon then can return to the original
lid and assess whether further peeling is needed, usually at m idheight on the
lid to target a prom inent wrinkle or redundancy, usually with 0.05% croton oil

precipitating an ectropion always exists, so testing for laxity preoperatively is
-
rhaphy stitch can be performed or a lighter peel performed with an intention to
repeel at a later date. The lower lids may be tight after peeling, but they respond
well to m assage. Further discussion of lower lid peeling as it relates to blepha-
roplasty is addressed later.
Fig. 13-8 The lower eyelids are peeled w ith 0.1% croton oil solution. A concentration of 0.05%
m ay be used for the upper lids depending on the laxity. Although these are weak solutions, the

28:33-45, 2008.)

• The Art and Science of Croton Oil Peeling
The upper lids are delicate, and peeling with 0.05% croton oil solution is a consid-
eration, although lax skin can be peeled with 0.1%. If creating a tight upper lid is a
concern, the peel should be stopped at the tarsal fold. If obvious laxity exists below

is shrinkage of skin, at times resembling an upper blepharoplasty. One negative
repercussion of peeling the upper lid is that the eyes may be swollen nearly shut
for a short period (1 day or less). A potential trouble spot is the medial upper lid,

The skin of the lower nose is thick, similar to the perioral area, and can be peeled
accordingly. The skin of the upper nose is an extension of the glabella with similar
thickness and often shows the transverse lines from the contracture of the proce-
rus. This area should be peeled at the same time as the glabella. Pooling of the solu-
tion in the inner canthus must be prevented; it can cause serious complications. At
all times a dry gauze should be available to immediately dry up any errant drops.
The peel is extended onto the neck with a dilute solution, 0.05% or weaker. This
peel is done with light, wispy strokes, leaving minimal frosting that is scattered
and disorganized. The neck skin is too thin and lacks the healing potential to
withstand a peel deep enough to improve wrinkles; attempting to do so will re-
sult in hypopigmentation and possibly scarring. Less is better than more. Peel-
ing the neck with TCA is also a possibility if the surgeon prefers. The purpose of
peeling the neck is to prevent the visible line of demarcation that has been seen
with laser resurfacing and deeper peels.
Once the face has been peeled, the areas for which the intention was to reach
the midreticular dermis should be reassessed, looking for light red-brown color-
ation. If it is not present or is too indistinct, the surgeon should peel more. This

occur (see Fig. 13-2). The surgeon should also check for uneven blending of areas

should repeel with a dilute solution (0.1%).

• The Technical Use of Croton Oil Peels

is a very valuable tool, especially in the perioral area, chin, glabella, and forehead.
This is accomplished with a wetter cotton-tipped applicator, painting the indi-
vidual line and then quickly drying it as a dense frost appears. This is repeated

An alternative approach is to saturate a toothpick or an aesthetician stick and

drying it. This technique works well in transverse forehead lines (although they
are stubborn, especially on men), glabellar lines, and transverse nasal lines. More
precise application, as in the crow’s-feet, can be done with a splintered wooden
end of an applicator (Fig. 13-9).
-
dating for an inexperienced peeler. Like any new procedure, it requires diligent
preparation and attention to detail. Much of the nuance of the peel is visual,
-
-
lications and videos are useful to familiarize oneself with the appearance of the
frost (Videos 13-1 and 13-2).
Fig. 13-9 Precise deeper peeling of more pronounced rhytids is feasible with a wetter applicator

• The Art and Science of Croton Oil Peeling
One approach in the early peeling experience is to purposely plan on a lighter
frost using only one concentration, such as 0.2% (except for the eyelids and neck),
with the intention of repeeling if necessary. Using mainly one concentration is

this manner, the surgeon can gain experience safely. Once the mixing and han-
dling of the solutions is practiced and visualizing of the frost is understood, it is

Another approach is to systematize the peel by precisely mapping the face into
distinct zones (Fig. 13-10 and Table 13-2) and use the prescribed concentrations,
which are generally one strength weaker than may eventually be used.
-

opacity of the frost.
Zones
1 Perioral
2 Forehead central

(includes glabella and upper 1 3 of nose)
3 Posterior central face (includes mandibular

corridor extending from the angle to

geniomandibular border)
4 Anterior central face
5 Periorbital

In lower eyelid, peel close to ciliary border;

in upper eyelid, peel to tarsal fold unless

obvious laxity exists.
6 Lower nose
7 Neck

This is a very light peel resulting in a thin,

wispy, barely visible frost.
Individual lines

Perioral 0.2% to 0.4%

Deep crow’s-feet 0.1% to 0.2%

Forehead lines 0.2% to 0.4%
2
5
5
6
4
3
4
1
7
0.05%
(upper eyelid)
0.1%
(lower eyelid)
0.2-0.4%
0.2%
(vermilion)
0.1-0.2%
(lateral)
0.2%
0.1-0.2%
(lateral)
0.4%
0.2-0.4%
0.2%
0.1%
0.025% or weaker,
or 15% TCA
0.1%
(temporal)
0.2%
(earlobe)
Fig. 13-10 Operative plan using weaker concentrations than m ay be ultim ately needed. (TCA,
Trichloroacetic acid.)

• The Technical Use of Croton Oil Peels
POSTOPERATIVE CARE
The peel creates an open wound, and the aftercare is essentially wound care to
provide the best environm ent for reepithelialization in the shortest tim e and
-
pect in the peeling process and requires hands-on involvement and attention to
details. Many approaches and topical applications exist for treating peeled and
lasered skin without an obvious best choice. This section outlines the traditional
-
tive. The ointment described works well but also can cause problems; therefore
newer alternatives are also discussed.
After the peel is completed and all frosting subsides, one tube of Polysporin or
triple-antibiotic ointment and one tube of 2% lidocaine jelly are mixed in a bowl

is applied over all the peeled areas. In the upper lid area, application should stop
just below the brow, because applying lower can cause seepage into the eye. The
rem ainder of the m ixture is placed in a container and given to the patient to
use at home. The patient is instructed not to use any other cream on the face to
control the environm ent for wound healing. Severe derm atitis can result from
over-the-counter products with fragrances and other irritating ingredients on
recently wounded skin. Typically, patients em erge from anesthesia in relative
com fort, then m ay experience m ild to m oderate burning that predictably lasts
about 1 hour and may require oral analgesics. The remainder of the recovery is
m ore one of inconvenience than discom fort. The phases of recovery are illus-
trated in Fig. 13-11.
Table 13-2 Peel Zones



Zone 1
Perioral area: 0.2%-0.4%, with 0.2% for the vermilion
Zone 2
Central forehead (including glabella and upper third of nose): 0.2% upper central and 0.4%
glabella and upper nose
Lateral forehead: 0.1%-0.2%
Temporal area: 0.1% (light peel)
Zone 3
Posterior central face (including mandibular corridor extending from the angle to the genio-
mandibular border): 0.1%
Earlobes: 0.2%
Zone 4
Anterior central face: 0.2% (Zone 3 and Zone 4 may overlap)
Zone 5
Periorbital area:
Lower eyelid: 0.1% (peel is close to ciliary border)
Upper eyelid: 0.05% (peel is to the tarsal fold unless obvious laxity exists)
Zone 6
Lower nose: 0.2%-0.4%
Zone 7
Neck: 0.025%, or 15% trichloroacetic acid (TCA) (very light peel resulting in a thin, wispy,
barely visible frost)
Individual lines
Perioral: 0.2%-0.4%
Deep crow’s-feet: 0.1%-0.2%
Forehead lines: 0.2%-0.4%

• The Art and Science of Croton Oil Peeling
B
A
D
C
F
E
Fig. 13-11 A and B, This 49-year-old
wom an had advanced wrinkling, etching,
and smoker’s lines. She had pronounced
sun damage w ith elastosis and brittle skin.
C, Day 1 postpeel with ointment applied.
Considerable swelling and serous oozing
are present. The eyes are slitted (mainly
from upper lid peeling) but not completely
closed. Despite being “unrecognizable,”
patients are usually not uncom fortable.
D, Day 3 postpeel. A m arked decrease in
swelling with gradual reepithelializa-
tion are evident. E, Day 5 postpeel. F, Day
7 postpeel. Reepithelialization is nearly
complete. Most patients reepithelialize
between 7 and 10 days postoperatively.
The skin is erythematous but, when dry,
makeup may be applied. (From Bensimon

28:33-45, 2008.)

• The Technical Use of Croton Oil Peels
H
G
I
Fig. 13-11, cont’d G, At 4 weeks postpeel. The skin rem ains erythem atous but is beginning to
H, At 8 weeks postpeel. I, At 14 weeks postpeel.
The erythema has completely abated. Erythema lasts between 6 and 12 weeks depending on skin

Continued

• The Art and Science of Croton Oil Peeling
K
J
M
L
O
N
Fig. 13-11, cont’d J, Pretreatm ent and, K, posttreatm ent at 8 m onths. She had considerable im -
provem ent in the quality of the skin and notable abatem ent in the perioral and forehead area.
L, Pretreatm ent and,
M, posttreatment views of the perioral area at 1 year. Subtle shortening of the upper lip and cor-
rection of stubborn radial lip lines are evident. N, Pretreatment and, O, posttreatment views of the

• The Technical Use of Croton Oil Peels

The early phase of recovery lasts 7 to 10 days, occasionally a few days more, as
the skin gradually reepithelializes. During this period the skin is moist and oozes

out and crusting. Refrigerating the ointment and applying it cold is very sooth-
ing. The patient is strongly admonished not to pick at or dislodge any crusts to
prevent scar form ation. Patients should be seen for follow-up as frequently as
needed, even daily until they stabilize and are com fortable w ith the routine.

components of the early recovery.
Day One
-
ing. Depending on the depth of the peel, the patient may be considerably swollen
and generally unrecognizable. If the upper lids have not been peeled, the eyes
are usually not closed. Especially for novice peelers, follow-up with the patient
the next day is important to see the process of healing and gain greater under-
standing.
The surgeon should gently cleanse the skin with saline-soaked gauze to remove

by rolling cotton-tipped applicators across the skin, but any material that is at-
tached is left in place.
Instead of saline, a particularly good option is to use poloxamer 188 (Shur-Clens).
Poloxamers are complex synthetic compounds described as amphiphilic surface
copolym ers. On a practical level, they are synthetic surfactants used m edically
as wound cleansers; m any plastic surgeons are fam iliar with the use of polox-
amer 188 to remove free silicone from breast tissue when explanting a ruptured
implant. This important molecule has antimicrobial action, improves capillary

peeled skin it is very soothing and cleansing. On subsequent days, if the skin is
crusted or irritated, gauze soaks with poloxam er 188 are very helpful and can
be provided to the patient to use at home.
On day 1, the surgeon can spot peel any area that appears undertreated with a
cotton-tipped applicator. As mentioned, phenol renders the skin anesthetic, an

not to pick, and the ointment is applied as often as needed to prevent crusting.
Despite the dramatic appearance, most patients are not uncomfortable. The sur-
geon should be aware that the healing is from the depth up and the inner layers
need time to shed the outer damaged skin.

• The Art and Science of Croton Oil Peeling
Day Two
The patient may begin gentle showering on day 2. This involves a weak stream

trickle onto the face. After the shower, the face is gently patted dry with a clean
towel and the ointment is applied. Because many individuals are silent carriers
of genital herpes, the hands must be washed before any application of ointment.
Some patients may prefer waiting one or more days before showering.
Day Three
On day 3 the patient can continue showering or gentle washing w ithout any
rubbing or use of a washcloth. If areas of drying are noted, a petrolatum -based
ointment may be applied.
Days Four to Seven
-
-


Days Seven to Ten
Between days 7 and 10, reepithelialization usually completes, and the skin dries.
Areas where the peel was deeper w ill take a few m ore days to heal. The skin
should be moisturized, and a mild emollient free of fragrances and other irritants
can be used. A petrolatum -based ointment can also be used. Strict sun avoidance
-
tory hyperpigmentation. The patient should wear a hat if going outside and be
cautious of sun coming through windows, such as in a car. Because of the sensi-
tivity of the skin, it may take longer before sunscreen can be used; when resumed
a physical block with titanium dioxide or micronized zinc oxide should be used
rather than a chemical block.
After the initial recovery, the skin is erythematous; this marks the beginning of
the next phase. Although the erythema may be intense, it is usually easily man-
aged with m akeup. Any areas that have not healed by 2 weeks postoperatively
are potential problems and should be carefully monitored.

The second phase of recovery is m arked by erythem a and lasts between 6 and

paradoxical depression, because they are eager to normalize their lives but may
feel inhibited by the erythema. This is a good time to show empathy and encour-

• The Technical Use of Croton Oil Peels
agement, evaluate prepeel photographs, and show the changes already evident.

Week Two
Fairly intense erythema can be seen with deeper peels after 2 weeks. Judicious
-
tivate 0.05%) or m om etasone furoate (Elocon 0.1%) can be helpful. Careful at-
tention should be given to any area that is slow in healing. Such areas should

until it has improved.
Weeks Two and Three
Most patients return to normal social interaction around weeks 2 or 3. Sun avoid-
ance still must be a priority; sunblock can be used.
Weeks Four to Eight
Weeks 4 to 8 are m arked by resolving erythem a. Obvious redness subsides be-
tween 6 and 12 weeks. Milia m ay be seen at this tim e and can be treated with
small doses of tretinoin on the involved areas. If milia occur early in the recovery,


seen at this time, and although it is blotchy and troublesome, it can be success-

for weeks, but it is not a permanent problem. The treatment of areas of indura-
tion or scars is discussed later.

As previously mentioned, the use of triple-antibiotic ointment and lidocaine jelly
has been used successfully for years. Potential problems include sensitization to
the antibiotic leading to acnelike breakouts and rashes. Milia may result from the
occlusive nature of the ointm ent, and the erythem a, which is som etim es quite
intense, may be a reaction to this regimen. Alternative approaches have focused
on improving the recovery period.
A number of posttreatment routines may be used after peels and laser resurfac-
ing. One such method is taping with zinc-oxide–impregnated tape followed by
the application of thymol iodide powder on day 1. This creates a thick, greenish
mask that remains until day 7, when it is gently removed. The simplicity of this
technique is enticing, but the bizarre appearance is not always well tolerated by
the patient, and it is impossible to exam ine and assess the skin until day 7 if a
problem occurs. A dermatology-grade skin cream such as Eucerin can be used to

• The Art and Science of Croton Oil Peeling
and although they are a little messy to use, they are an option. Other com mer-
cially available skin care ointments that are petrolatum based, such as Aquaphor,
are com m only used for m oisturizing and protection. This type of ointm ent is
favored by derm atologists but can be irritating and uncom fortable on freshly
peeled skin because of the presence of som e alcohols. Silvadene cream is a po-
tential option, although the m essiness m ay be objectionable to m any patients.
Many other nonprescription “medical-grade” ointments and creams may have
a role in treating resurfaced skin. There is no clear best choice.
My practice prepares individualized balm s w ith natural ingredients know n
to have healing properties and lim ited irritants (such as antibiotics) that m ay
worsen the erythem a. Many variations are possible; the follow ing is a conve-
nient recipe:
15 cc organic coconut oil

6 cc poloxamer 188

The disadvantage of this technique is that it looks “weird” and m ay elicit poor
patient acceptance, but early experience has not borne this out and the advan-
tages are notable.

to all peel surfaces except the upper lid below the tarsal fold, after an emollient
ointm ent is applied to the hairline and brows to prevent sticking of the tape.
The use of tape precludes applying the anesthetic ointment, but the tape is very

help keep the tape on (Fig. 13-12). If upper lid is not taped, the standard oint-
ment or an unscented emollient is applied to the infrabrow area (but no lower,
to prevent irritation of the eye).
This tape is left on 24 hours. Because it is soothing and can calm the patient,
keeping it on for a second day may be worthwhile. The tape is then removed, a
Fig. 13-12 Zinc-oxide tape m ask applied imm ediately after a peel.

• The Technical Use of Croton Oil Peels

the peel to which the upper forehead tape can be adhered spares the hair. Re-
moval proceeds from inferior to superior, seamlessly and painlessly (Fig. 13-13
and Video 13-3).
The pink zinc-oxide tape typically comes in 0.5 inch and 1 inch width. The nar-
rower tape is best for fram ing boundaries, such as the nose, lower eyelid, and

After the tape removal, all peeled skin is covered with a paste of bismuth subgallate
powder mixed with saline or poloxamer 188; the goal is for the paste to adhere
to the skin and form a covering crust (Fig. 13-14, A). The paste is applied with a
tongue depressor, cotton-tipped applicator, or makeup brush (Fig. 13-14, B).
Fig. 13-13 A, Tape mask after removal. B, Postpeel day 1 after tape mask removal.
B
A
Fig. 13-14 A, Bismuth subgallate paste. B, Paste applied to the face.
B
A

• The Art and Science of Croton Oil Peeling
After the crust is formed, the patient does nothing, allowing the tissue beneath
to reepithelialize and shed the crust (Figs. 13-15 and 13-16). The tim e for the

7 to 10 days. The patient is advised not to pick at, wash, or touch the face. After
7 to 8 days, the patient is instructed to apply petrolatum ointment without fra-
grance to loosen the crust and gently shower the following morning. The patient

on day 10 or later, after which new, pink skin is evident. Any nonhealing areas
are potentially problematic and are treated as previously described.
The bism uth powder has a yellow-orange color that turns to a peculiar green
when the paste is made and applied to the peeled skin. Surprisingly, patients are
typically amused by this “ogre” appearance and are very tolerant of it. Moreover,

-
nution of the postpeel erythema.
Bismuth is a heavy metal whose salts have antiseptic and antimicrobial proper-

used as a topical astringent, as a hem ostatic agent, and to treat skin lesions.
Over-the-counter form ulations are ingested as internal deodorants for ostomy
patients, and 3% bismuth tribromophenate is the active ingredient of Xeroform
medicated gauze, used by many plastic surgeons.
Fig. 13-15 Bismuth subgallate healing. A, Day 1. B, Day 5. C, Day 7.
B
A

C

• The Technical Use of Croton Oil Peels
The tape–bismuth powder regimen may not be ideal for every patient or situa-
tion, but my recent early experience has been very positive, particularly because
of the ease of management and a notable decrease of erythema compared with
occlusive ointment techniques.
ANCILLARY PROCEDURES
Partial or segmental peels are possible but carry the risk of a mismatch in color;
therefore good judgment and planning are important. Patients with widespread
solar dam age have an increased risk of dem arcation, so a full-face peel is pref-
Fig. 13-16 Bismuth subgallate treatment after taping. A, Taping immediately after the peel. B, Day
1 after tape removal and application of bismuth subgallate paste. C, Interim healing. D, Fully shed.
B
A
D
C

• The Art and Science of Croton Oil Peeling
erable. This is not because the peeled area w ill be hypopigm ented, but rather
that the peel will bring out the more accurate color of the skin, which will be in
stark contrast to the sun-dam aged skin. Exam ination of the volar aspect of the
forearm , generally protected from sun exposure, will m ore realistically give a
representation of the true skin color. Segmental perioral peels that are medium
depth at most can be performed; the skin color takes 8 to 10 weeks to blend ad-

lip lines without extensive surrounding solar damage, peeling the mustache area

The eyelids are an excellent area for segmental peeling. Lower eyelid skin in par-

rim. As previously described, the thin eyelid skin is attached medially and later-
ally and lacks support centrally, making it susceptible to gravity and the contrac-
tile action of the densely attached orbicularis oculi muscle. This skin is often the


The thin lid skin, if peeled appropriately, is very forgiving, and the erythema is
well tolerated and easily hidden with makeup or glasses. It is feasible to extend
the peel onto the m ore lateral crow’s feet, with the proviso that the erythem a
will be longer lasting and more noticeable. A notable advantage of the lower lid
peel is that it can easily be repeated in a graded fashion; sequential peels will
give additive results (Fig. 13-17).
Fig. 13-17 Additive result of multiple peels. A, Preoperatively. B, After one peel. C, After a second

B
A
C

• The Technical Use of Croton Oil Peels
This is an inherent safety feature in that if the primary peel has given incomplete
results, it can simply be repeated rather than pushing the limits during the ini-
tial treatment.
Another tactic is to perform a lighter peel than ultim ately necessary depend-
ing on logistics (patient’s need for a quicker recovery) or skin color, w ith the
thought of repeating it for a m ore complete result. With the additive results of
m ultiple peels, the lower eyelids can usually be treated to the patient’s satis-
faction. The previously described aging changes are ubiquitous in the general

m uch m ore palatable than surgery, especially if it can be perform ed w ithout
form al anesthesia. Patients should be advised that the goal of the peel is to
soften static lines; w rinkles and folds created by sm iling (contracting the zy-
gom atic m uscles) m ay be softened but not eradicated by the peel (Video 13-4).
A very common unfavorable result in plastic surgery is ectropion or rounding of
the lateral canthus after traditional transcutaneous blepharoplasty. These some-

a subciliary incision and accessing the fat pads by traversing the orbicularis mus-
cle and orbital septum . After dealing with the fat, surgeons are often tempted
to pull on the skin and rem ove the “excess” to improve wrinkling and textural
changes. The structural result is that the septum contracts as a response to in-
jury, and the removal of skin disrupts the balance of the lid. The inevitable result
is rounding of the lateral canthus, if not frank ectropion.
A better and m ore elegant alternative is to use the “bilam ellar approach”
to changes in the lower lid. Protrusion of orbital fat can be corrected w ith a
transconjunctival approach in the posterior lamella. If the aging changes in the
anterior lam ella are prim arily w rinkling or textural, a peel can be done at the
same time, because there is adequate separation between the zones of injury. If
improvement of the anterior lamella requires resection of a true excess of skin
or manipulation of the orbicularis oculi muscle, these are addressed anterior to

at a later time. This results in a true anatomic correction without disrupting the
septum that preserves the natural shape of the eye.

Regardless of the technique chosen, the surgeon must remember that wrinkles
cannot be simply “operated away.” A wise surgeon who heeds this advice pre-
vents troublesom e complications. Peeling of the lower eyelid is one of the best
applications of modern croton oil peels because of its safety and predictability.
It is an essential tool for any surgeon operating on the lower eyelid.
Upper blepharoplasty, if properly perform ed, is straightforward and well tol-
erated; therefore peeling has a lesser role. Regardless, if surgery is not being
contemplated, overall shrinkage of upper lid skin can give a refreshing look that

• The Art and Science of Croton Oil Peeling
mimics surgery. Also, if an upper blepharoplasty has been previously performed

The versatility and control of modern peels coupled with the new simplicity of

lower eyelid can greatly improve the early changes seen on younger individuals.
The skin is changed anatomically by the peel, but of course it continues to age.
If after several years (or more) new aging changes become evident, the peel can
simply be repeated and the skin again rejuvenated. Assuming the patient exer-
cises a m odicum of care regarding lifestyle, skin care (tretinoin, antioxidants,
moisturizers, and sun protection), and avoidance of sun exposure, this is an ef-
fective way to combat aging. The upper eyelid can likewise be peeled when early
skin redundancy is seen, but before it requires surgical correction.

of the face along with a dull appearance and sun-damage spots. More generally
stated, the skin has lost the luster of youth. These changes can often be seen in
younger women not yet considering any surgery, but also not achieving adequate
results with standard epidermal peels, microdermabrasion, or neurotoxins. These


The recovery will be proportionally quicker than with deeper peels and the result
and longevity much better than with TCA peels or fractionated laser treatment.
Any persistent wrinkles can be touched up as previously described. Repeating
this approach periodically is an excellent way to keep up w ith aging and also
targets a large portion of the population. Ironically, the original “phenol peels”
that were mainly performed on older, heavily wrinkled individuals have evolved
into a peel for which younger patients m ay be equally appropriate candidates.
Segmental peels and light peels can be an excellent adjunct to many facial sur-
geries. The possibility of a peel at the time of a facelift is intriguing, because the

I have no personal experience with this, but it warrants further consideration.

• The Technical Use of Croton Oil Peels
RESULTS AND OUTCOMES



collagen in the derm is that is aligned in an orderly m anner and is rem arkably
stable for years, even decades. The net result is a change in the skin anatomy that
improves wrinkles. The skin looks younger because, in a real sense, younger skin
-
ing away with the dull, ashen, sallow look of sun-dam aged skin. A generalized

in facial rejuvenation. The results of a well-done facelift without the lum ines-
cence of youth is incomplete and still looks old. These improvements have been
attainable without depigmentation, and rather than showing deterioration, the
skin appears to improve with time. Figs. 13-18 through 13-25 exhibit the stark
improvement croton oil peels can produce.
Fig. 13-18 A, This 45-year-old wom an had elastosis and etching of the skin. B, At 1 year after a

chin wrinkles. C, At 6 years postoperatively. The stability of the result is common, and results tend

B
A

C

• The Art and Science of Croton Oil Peeling
B
A
D
C
Fig. 13-19 A and C, This 47-year-old woman had severe sun damage with widespread elastosis,
pigmentary changes, and thick, opaque skin. B, At 4 years after croton oil peeling. Generalized im -
provem ent in the quality of the skin with softened wrinkles and even pigm entation are notable.
D,

28:33-45, 2008.)

• The Technical Use of Croton Oil Peels
Fig. 13-20 Left, This 59-year-old wom an has the typical ashen, sallow look of sun dam age and
prominent perioral lines. Right, The result 1 year after croton oil peeling. She has dramatic improve-

• The Art and Science of Croton Oil Peeling
B
A
Fig. 13-22 A,
of her face but not the posterior. B, Postoperative result at age 81 years, 5 years after a facelift and
1 year after a croton oil peel. This result demonstrates the value of correcting both the structural

B
A
Fig. 13-21 A, If this 65-year-old wom an had a facelift without resurfacing, the result would be
an aesthetic failure, because the main component of her aging appearance is textural. B, At 1 year
after croton oil peeling. A deep peel alone has greatly improved her appearance while retaining

• The Technical Use of Croton Oil Peels
Fig. 13-23 A, This 63-year-old woman had structural changes of aging, jowling, neck laxity, mild
hollowing of upper lids. B, Result 1 year after facelift and fat transfer. Despite structural improve-
m ent, the textural changes detract from the result, so she opted for a peel. C, At 1.5 years after
peeling. The combination of surgery, fat transfer, and peeling can give a very comprehensive, bal-

B
A

C
A

B
Fig. 13-24 A, The only prominent changes of aging this 44-year-old man experienced were crepi-
ness and slight redundancy of lower eyelid skin. B, Result 6 m onths after segm ental peel of the
lower eyelids w ithout surgery. The tone of the lower eyelid and the shape of the lateral canthus
have not been altered.

• The Art and Science of Croton Oil Peeling
Fig. 13-25 Left, This 61-year-old woman was an active smoker with extensive wrinkling, sun dam-
age, and pigm entary changes. She presented with widespread sun dam age and wrinkling. Right,
Dramatic improvement 6 months after croton oil peel alone. She has generalized skin tightening
and shrinking of the upper lid skin.

• The Technical Use of Croton Oil Peels
Fig. 13-25, cont’d Left, This 61-year-old woman was an active smoker. She presented with wide-
spread sun dam age and wrinkling. Right, Dramatic improvement 6 months after treatment.

• The Art and Science of Croton Oil Peeling
Microscopic studies of peeled skin show destruction of actinic keratoses and
nascent cancer cells.8,9 This is logical, because deep peels clearly go the depth
where these cells reside. The anecdotal impression of experienced practitioners,
with which I concur, is that individuals who have been peeled do not develop
facial basal cell or squam ous cell cancer. Studies in the derm atologic literature

keeping susceptible patients free of nonmelanoma skin cancers for the studied
5 years.10 Others have shown successful treatment of basal cell cancer with TCA
and phenol peels. These are exciting developm ents that will expand the use of

PROBLEMS AND COMPLICATIONS
Complications from croton oil peels are the sam e as those that occur with any
other deep resurfacing technique. The m ain complications, scarring and hy-
popigm entation, are usually preventable by controlling the depth of the peel.
Delayed healing (longer than 14 days) and skin thickening suggest that the peel
has reached the deep reticular dermis. If skin thickening occurs, early treatment
-
itored to prevent atrophy. If it progresses to an early scar, intralesional injection

quite impressive and they are useful on all scars, even old ones. The injections
are performed every 1 or 2 weeks, depending on the results, and monitoring for
atrophy continues. 5-FU is a common intravenous chemotherapeutic agent that

Potential trouble areas that m ay result in scarring include the temporal area,
the preauricular area, the geniom andibular border, and the m edial upper lid.
The corridor between the mandibular angle and the geniomandibular groove is
delicate and should not be overpeeled, especially because it is rarely necessary.

of the upper lid, so it may inadvertently be peeled twice. Attention to this detail
is important. An interesting observation of the other areas is that they overlie
regions of dense ligamentous attachment. Whether this is coincidental or caus-
ative deserves further investigation.
-
ventable. If a patient has very pronounced wrinkles, it may be necessary to peel
deep enough to cause hypopigm entation. This needs to be discussed with the
patient, but in most instances the improvement is well worth it; the pronounced,
shiny porcelain look of older peels is not seen. The surgeon must pay careful at-
tention to the upper lip, because naturally lighter upper lips may become more
evident once solar damage is corrected. This is not new hypopigmentation. Like-
wise, if a patient has had hypopigm entation from a previous resurfacing, such
as a carbon dioxide laser treatm ent, the peel can unm ask it by the general im-
provement of the skin, so the patient should be forewarned.