Sách Giáo Khoa Về Lột Da Hóa Học (Chemical Peels – Ấn Bản 2)

242      Textbook of Chemical Peels
which only disappear from the areas treated with phenol but
remain in the surrounding areas. The difference in skin quality
is also very visible. These patients should only be treated with
a full-face peel.
It is nevertheless possible for these patients to have a local
phenol peel combined with a full peel to the papillary dermis.
Combining Lip & Eyelid Formula with Unideep provides a phe-
nol peel and a peel to even out skin with lentigines, keratoses,
or freckles.6 The two peels should be done in the same session:
the phenol first, followed immediately by Unideep on the rest of
the face, around the area treated with phenol.
PHENOL PEEL VERSUS OTHER MEDICAL
OR SURGICAL TECHNIQUES
Peel versus Face-Lift
There is not much point in considering this question, as a
full-face peel is no substitute for a full face-lift, and vice versa
(Figures 29.7 and 29.8). The indications are different; peels and
face-lifts complement rather than compete with each other.7
When the damage is localized, the doctor alone can advise
his or her patient on which treatment or combination of tech-
niques to use. A face-lift cannot treat wrinkles on the upper lip,
but laser treatment, dermabrasion, or Lip & Eyelid Formula
can get rid of them. These treatments should be performed on
the same day as the surgical face-lift while the patient is still
under anesthetic. Wrinkles around the lips sometimes benefit
from a combination of dermabrasion and phenol: Lip & Eyelid
Formula is locally applied on the day of the face-lift and left
under occlusion for 24 hours; the following day, the surgeon
evaluates the results of the peel on the upper lip; if some wrin-
kles still persist, they can be touched up with the peel solution.8
It is also possible, on the first day, to perform dermabrasion9
after a focal application of phenol on the lip.
If surgical blepharoplasty is not combined with a face-
lift, Lip & Eyelid Formula can be applied on the eyelids at the
same time as the face-lift.
The patient in Figure 29.9 is a typical case where the facial
photoaging10 would benefit far more from a full-face phenol
peel than from a neck- and face-lift. Nevertheless, phenol, with
difficulty, tightens and rejuvenates the neck, which will only
benefit from surgery followed by a peel to the papillary dermis
or several peels to the Grenz zone (with Easy TCA) to improve
the quality and the color of the skin after the surgical face-lift.
Figure
29.7  The
sagging—more
pronounced
than
the
photoaging—contraindicates a phenol peel, which would have no
effect on this patient.
(a)
(b)
Figure 29.8  Excellent three-dimensional tightening effect from a phenol peel: (a) before treatment and (b) 3 months after.

Phenol: Choice of peel and combination treatments      243
When the wrinkles are on the eyelids and around the
mouth, the problem is therefore easily solved. In the case of
sagging and wrinkled skin, it is clear that the best results can
be achieved with a combination of treatments that should be
conducted at different times (see discussion later in this chap-
ter). The large majority of patients are in this situation, and the
degree of facial ptosis will be the deciding factor in whether to
suggest a face-lift or a phenol peel.
A face-lift gives better results for facial ptosis
(Figure  29.10); a peel gives better results for wrinkles and
dyschromias. A surgical face-lift can only tighten damaged
skin that will not have enough elasticity to remain tight
definitively.
Phenol Peel Combined with a Surgical Face-Lift
We have seen that there is no problem with performing a local-
ized phenol peel at the same time as a surgical face-lift if the
two treatments are aimed at different areas. When both treat-
ments are indicated for the whole face,11 the face-lift should
be done first, followed by a rest period of around 6 months
before the deep peel (Figure 29.11). The peel will have the addi-
tional advantage of softening the scars from the face-lift while
restructuring the histology of the epidermis and the dermis
and removing the marks and fine lines that did not respond to
the face-lift.
With a phenol peel, a demarcation line is left under the
jaw12 that is partially hidden by shadow. A face-lift after a phe-
nol peel could raise this demarcation line to the cheeks: any
face-lift should therefore be done before a phenol peel. More
importantly still, using a phenol peel (or even a deep TCA
peel13) at the same time of operation on an area that has just
been treated with a surgical lift can potentially cause extensive
facial necrosis. The general principle is not to undermine the
skin’s inner vitality with surgery at the same time as injuring
the outer layers of the skin with a peel. In other words: a face-
lift should not be done on the same day as a full-face deep phe-
nol peel.
A study14 from 1989 looked at the viability of dorsal skin
flaps (on guinea pigs) subjected in vivo to transposition and
suture immediately followed by a single application of phenol
(Baker’s solution) and 24-hour occlusive tape dressing. Thirty-
six skin flaps were raised and sutured back into place, and only
18 were treated with phenol. Analysis of the results clearly
shows that combining a surgical lift and phenol at the same
time of operation is not a wise choice, as the average necrosed
surface area without phenol was 3.1 cm2, compared with 6.3 cm2
for the peeled flaps.
Another study15 on animals came to the conclusion that
raising a skin flap causes changes in the tissue of the reticular
dermis and the underlying tissue, which makes it more sen-
sitive to any subsequent injury. The risk of compromising the
viability of a raised skin flap is therefore too high to opt for a
simultaneous face-lift and deep peel.
On the eyelids, however, the fat hernia around the orbit
was removed through the transconjunctival approach and
combined—in expert hand—successfully and safely with a
local phenol peel.16 McCollough and Maloney17 combined sur-
gical blepharoplasty with a phenol peel, but left the skin to rest
for 3 months before doing the eyelid peel.
(a)
(b)
Figure 29.9  (a) Photoaging, thin skin, and slight sagging: a good indication for a full-face phenol peel. Aging of the neck: a neck- and
face-lift is indicated before the phenol peel. (b) Results of a full-face phenol peel (Lip & Eyelid), 14 days after the peel. There is spectacular
improvement in the skin. Oddly enough, some of the lentigines have been replaced by telangiectasias. They must be treated quickly, to
avoid extravasation of iron pigments and potential multiple localized tattoo marks.

244      Textbook of Chemical Peels
Phenol Peel and Aptos Threads
A new technique involves inserting barbed or spiral threads
under the skin to tighten sagging tissue (Figures 29.12 and 29.13).
These are known as Aptos threads or Russian threads, as in
their current form they were designed by Dr. M. Sulamanidze
from Moscow.18 The Aptos threads are inserted deeper than
the phenol penetrates. There is therefore no risk of interaction
between the phenol and the thread that would, in any case,
resist it chemically.
However, this technique poses three problems:
1.
The entry points of the threads must not come into contact
with the phenol, as there is a risk that the inflammation
will push them out.
2.
The inflammation caused by the phenol peel affects all the
layers of the skin. This reaction, combined with the inflam-
mation caused by the thread itself, could make the tissue in
which the threads have to anchor themselves more fragile
and cause them to rapidly unhook.
3.
Phenol is, of course, a disinfectant, but a phenol peel coag-
ulates all of the skin’s immune structures, and the skin
becomes very prone to infection. The risk of secondary
infection from the thread is increased.
Figure 29.10  This is the same patient as in Figure 29.8. Two
years after full-face Exoderm, the improvement on the cheeks is
still well maintained. However, sagging has partially recurred, the
results on the upper lip are inadequate, and the color of the skin is
slightly uneven. The patient, who enjoys boating in sunny climates,
has not avoided the sun as recommended. Treatment will consist
of a spot application of Lip & Eyelid Formula on the upper lip (using
an occlusive technique), combined with one Easy TCA peel per
week for 4 weeks to even out the skin tone. Daily care comprises
Blending Bleaching Cream and Melablock-HSP® 50+. HSP (heat-
shock proteins) sunblock is sunblock containing stimulants that
produce proteins that protect against heat damage.
(a)
(b)
Figure 29.11  (a) A patient after surgical face-lift. (b) The same patient: phenol peel (Lip & Eyelid) after a face-lift.
Figure 29.12  Aptos thread.

Phenol: Choice of peel and combination treatments      245
It is therefore preferable not to insert Aptos threads at
the same time as performing a phenol peel. Moreover, phenol
partially tightens the skin, and it may well be more worth-
while to use Aptos threads as a second line of treatment,
when the phenol has taken full effect, after at least three
months. The presence of threads inserted in the skin several
months previously is not a contraindication for a phenol peel,
and it is possible to decide on the opposite course of action if
the doctor thinks this is a better option for the patient: Aptos
threads can be inserted first and a phenol peel can be done
afterward.
Phenol Peel versus Carbon
Dioxide Laser Resurfacing
Several studies have been conducted comparing the results of
a full-face phenol peel and resurfacing with a carbon dioxide
(CO2) laser, sometimes known as a carbon dioxide laser peel. A
study by Langsdon, Milburn, and Yarber19 looked at four female
volunteers with sun-damaged facial skin and wrinkles. A phe-
nol peel was applied to the left half of the face and a Sharplan
Silktouch Flashscanner CO2 laser was used to treat the right
half. The clinical results were similar in both cases, although
the laser appears to give better results in areas where the skin
is very thick (e.g., the chin). The laser, however, causes more
hypopigmentation and complications, and the postpeel period
is more comfortable for the patient with phenol than with laser.
Histologically, the depth of action of phenol is deeper than that
of the laser and reaches the reticular dermis. The authors con-
cluded that both ablative laser and phenol peels remain useful
clinical tools. The records show that the battle has been won by
phenol because of the high number and the severity of compli-
cations caused by CO2 lasers.
Fintsi also presented a split-face study, applying phe-
nol (Exoderm—Fintsi’s formula, congress presentation, Stiges,
Spain) on one half of the face. One of his colleagues, a laser
specialist, applied a CO2 laser to the other half of the face. The
results were clinically obvious, and it was clear that they were
better on the half of the face treated with phenol—so much so
that the patient asked for another phenol treatment to even out
the two sides.
We could perhaps conclude, however, that the CO2 laser
might be a better indication for patients with very thick and
oily skin, especially on the chin and nose.
EASY PHEN LIGHT
New peeling technologies have allowed the development of a
variety of phenol peels. Easy TCA Pain Control, a lighter peel
that contains a small amount of phenol, is a patented formula
that deepens the effect of the Easy TCA classic peel while con-
trolling the pain of TCA application.
Another phenol formula, Easy Phen Light, is a hybrid
peel that contains TCA and phenol (30%). Easy Phen Light is a
deep peel that acts at the level of the deep papillary dermis, or
superficial reticulary dermis. The depth reached by Easy Phen
Light is considered “the interface between the papillary and
reticulary dermis.” The results of this peel are usually deeper
than those of a papillary dermis TCA peel (e.g., Unideep) and
usually more superficial than a deep phenol peel (e.g., Lip &
Eyelid Formula).
The results of the Easy Phen Light peel vary depending
on the quantity of peeling solution allowed to interact with the
skin. The best results are obtained by application of the full 3
ml of the peeling solution to the face. Easy Phen Light presents
some advantages over Lip & Eyelid Formula (Table 29.1).
Deep phenol peels (e.g., Lip & Eyelid Formula) are com-
pared to light phenol peels (e.g., Easy Phen Light) in Table 29.2.
Postpeel recommendations for patients are listed
in Table  29.3, while general care is shown in Figure  29.14.
Figure 29.15 illustrates the clinical case of a patient who pre-
sented with photoaging. She had yellowish skin, with many
lentigines and one large keratosis on the forehead.
Table 29.1  Comparison of Easy Phen Light and Lip & Eyelid Formula
Lip & Eyelid Formula
Easy Phen Light
Type of procedure
Ideally should be applied in a surgical setting, respecting
every security rule.
Can be done as an office procedure, if every
security rule is respected.
Pain during application
Can be done without anesthesia when applied as a local
peeling (chemical blepharoplasty or cheiloplasty) but
needs nerve blocks and neuroleptanalgesia when
applied as a full-face procedure.
Is less painful than Lip & Eyelid: many
patients describe the pain of Easy Phen
Light as more tolerable than the pain
induced by Easy TCA.
Pain after application
Inflammatory pulsating burning sensation up to 4 a.m.
the next day. Pain stops but usually resumes, for
several hours only, during the third night.
Not painful after peel.
Quality of result
This is the deepest possible peeling: depth 7/7. Best
quality results of a photoaging treatment.
Better results than papillary dermis TCA peel
(depth 5/7). Results are of a lower quality
than with a deep phenol peel (depth 7/7).
(a)
(b)
Figure 29.13  (a) Aptos springs. (b) Springs.

246      Textbook of Chemical Peels
Table 29.2  Comparison of Deep and Light Phenol Peels
Deep phenol peel
Light phenol peel
Full face
Local
Full face
Local
Peel type
Deep phenol: Lip & Eyelid Formula
Light phenol: Easy Phen Light
Indication
Definitive photo aging
Deep wrinkles
Deep rejuvenation
Eyelids and/or lip-chin
Large lentigine
Pretragal or subglabella
folds
Important photoaging
Fine wrinkles (not deep
wrinkles)
Rejuvenation
Lentigine
Not for deep wrinkles
Combination treatment
“Botulinic toxin” suitable 3 to 8 days before peel
Suitable phototypes
I–IV
Ideal patient
45–85 years old: deep photo aging, deep wrinkles, little
sagging
35–65 years old: deep photo aging, superficial
wrinkles, little sagging
Main contraindications
Active infections, florid herpes, insulin-dependent diabetes, collagen diseases, immunity problems, Ehler
Danlos, pregnancy, breast-feeding, cancers, hepatic or renal or respiratory or cardiac insufficiency, recent
wounds or scars, hypertrophic scars, history of local radiotherapy, keloids, recent tretinoin use (less than 6
months), use of IMAO, other logical medical contraindications (children, risk of dyschromy, etc.)
Presentation
3 ml
Quantity needed
3 ml
0.15 to 0.40 ml
3 ml
0.15 to 0.40 ml
Peeling depth
Deep reticular dermis
Limit papillary-reticular dermis
Prepeel conditioning
Blending Bleaching Cream and sun protection 3 weeks before peel in case of hyperpigmentation risk (depends
on the patient)
Pain level during peel
Strong (due to large surface)
Light, 12 seconds
Very light to none
Pain after peel
+/– hot and pulsatile (inflammatory) up to 3 a.m. the
next day (acetaminophin can be taken)
Not painful
Anaesthesia
Nerve blocks +
neuroleptanalgesy
Nerve blocks + oral antalgic
None or nerve blocks
(sensitive patient)
Oral antalgic
(sensitive patient)
None
None
Application duration
Mandatory + 1 hour
Split application
—
+ 45 min
Split application
—
End point
Deep gray-white frosting + edema (proteocoagulation)
Light gray-white frosting; edema is more important
(proteolysis)
Occlusion
Occlusion 24 h
Occlusion 24 h except eyelids
No occlusion
No occlusion
Postpeel care if not
occluded
Occlusion 24 h
Specific postpeel mask +
Yellskreen powder
Specific postpeel mask +
Yellskreen powder
Specific postpeel mask +
Yellskreen powder
Remove occlusion
Day 1, apply Yellskreen
Day 1, apply Yellskreen
—
—
Control day 3
Apply Vaseline on the edges of treated areas, to make patient comfortable
Control day 6
Apply Vaseline at day 6, on the whole treated area, to unstick dead skin
Usual downtime
7–8 days
6 days
Depends on how many
points
Postpeel erythema
3 weeks to 3 months (shorter if IPLase cream [Skin Tech]
used)
Virtually no erythema (if there is: IPLase cream [Skin
Tech])
Desquamation
Very strong, 1 week
Thinner skin layer, 1 week
Sun protection
Melablock-HSP, SPF 50: 3 months
Melablock-HSP, SPF 30: 1 month
How to apply (video)
Divide the the face into several areas*
Postpeel care
IPLase to treat rednesses and inflammation, sun protection*
Result
Amazing rejuvenation, treats deep wrinkles,
tridimensional face-lifting
Very good rejuvenation, does not treat deep wrinkles
* See details at
Table 29.3  Patient Self-Care
General
Do not scratch; do not moisten, remove,
or peel away the yellow powder.
Contact doctor with any questions or doubts.
Day 0–1
At home, apply Yellskreen powder if the
treated area becomes wet.
Take a painkiller tablet if necessary (afternoon and/or before sleep).
Day 3
See the doctor; he or she will apply Vaseline on the edges of the treated area.
Day 6
See the doctor; he or she will apply Vaseline on the entire treated area to help remove Yellskreen.
Day 7
Makeup is allowed.
Days 8–15
Protective home care
1 . Cleanse the skin using Skin Tech Cleanser only.
2. Apply IPLase mask 3 times/day; it helps to reduce redness.
After Day 15
Specific home care
1 . Cleanse the skin using Skin Tech Cleanser only.
2. Refill dermis: Apply Atrofillin cream or use antioxidants and moisturizer:
Nutritive ACE lipoic complex cream.
3. Pigment control: Apply Blending Bleaching Cream morning and evening.
Sun
protection
Days 1–15: Avoid any sun exposure and
use Melablock-HSP, SPF 50+ (9 a.m.,
12 p.m., 3 p.m.)
Days 15–90: Be careful with sun exposure and use Melablock-HSP, SPF 30
(9 a.m., 12 p.m., 3 p.m.)

Phenol: Choice of peel and combination treatments      247
(a)
(b)
(c)
(d)
Figure 29.15  (a) Before treatment. (b) Topical application of Easy Phen Light, up to gray frosting + 24 hours’ occlusion. (c) On day 5
Vaseline dissolves the bismuth subgallate powder. (d) Final result.
Day 0
Apply: Easy
Phen Light,
postpeel
mask and
Yellskreen
Day 6
Check if
infection
Vaseline
everywhere
Day 3
Check if
infection
Vaseline on
the edges
– 2 Weeks
Day 7–8
Makeup
allowed
Protective Home care
IPLASE (reduces erythema) 3x/d
Skin Tech Cleanser (Cleanse skin)
if PIH risk, give the patient Blending Bleaching 3 x/day 2 weeks before treatment
BLENDING BLEACHING (Pigment control) 2x/d
Nutritive Vit ACE lipoic complex Evening
09 am–12 pm, 03 pm
DO NOT PULL AWAY YELLSKREEN
Skin is regenerating under the scab
Vaseline unsticks Yellskreen
Melablock HSP 50
4 to 6 weeks
09 am–12 pm, 03 pm
Melablock HSP, SFP 25
Day 0
EPL
EPL
EPL
1
2
4
5
3
6
7
8 to 15
After day 15 – During 3 months
EPL = Easy Phen Light
YELLSKREEN: Protective yellow powder
INFECTION* : appears as red points around Yellskreen
Specific Home care
Figure 29.14  Postpeel general care.

248      Textbook of Chemical Peels
Figure 29.16 illustrates the options with or without the
use of bismuth subgallate. With its use (Figure 29.16a and b),
a patient may be unhappy about his or her skin color for a
week, but without bismuth subgallate (Figure 29.16c and d),
the patient is not only unhappy about the skin appearance for
one week, but also is afraid to look at the skin and more at
risk for infection. Therefore, the use of bismuth subgallate is
recommended.
NOTES

1. The nasolabial folds respond to phenol only if they are light and
the skin is thin.

2. The contraindications are described in Chapter 31.

3. For photos, see Chapter 37.

4. TCA, for example: one session of Unideep (a peel to the papil-
lary dermis) or four sessions of Easy TCA (less aggressive). These
peels should be combined with a depigmenting cream such as
Blending Bleaching Cream.
(a)
(b)
(c)
(d)
Figure 29.16  (a) The cosmetic disadvantages to the use of bismuth subgallate last for a week. (b) The use of bismuth subgallate in
another patient. (c) A patient who has opted not to use bismuth subgallate still faces cosmetic disadvantages for a week, in addition to the
risk of infection. (d) Another patient who has opted not to use bismuth subgallate.

Phenol: Choice of peel and combination treatments      249

5. Chemical eyelid or lip surgery (see Chapter 36).

6. These disappear after Unideep, a TCA peel to the papillary dermis.

7. Stuzin JM, Baker TJ, Gordon HL. Treatment of photoaging.
Clinics in Plastic Surgery. 1993; 20: 9–25.

8. When wrinkles persist, the doctor might also decide on a second
period of occlusion.

9. Using sandpaper or a diamond fraise. Microdermabrasion is not
recommended here.
10. Atrophic, sallow skin, numerous lentigines and benign tumors,
solar/senile keratoses, Hutchinson’s freckle, wrinkles and fine
lines, and wrinkles around the mouth and eyes.
11. For example, when the patient presents with severe photoaging
and sagging skin at the same time.
12. For photos, see Chapter 37.
13. This refers to a TCA peel to the reticular dermis. A TCA peel to
the papillary dermis (e.g., Unideep) is, on the contrary, applied
immediately after a surgical lift.
14. Hayes DK, Stambaugh KI. Viability of skin flaps subjected to
simultaneous chemical peel with occlusive taping. Laryngoscope.
1989; 99: 1016–19.
15. Hayes DK, Berkland ME, Stambaugh KI. Dermal healing after
local skin flaps and chemical peels. Archives of Otolaryngology—
Head and Neck Surgery. 1990; 116: 794–7.
16. McKinney P, Zukowski ML, Mossie R. The fourth option: A novel
approach to low lip blepharoplasty. Aesthetic Plastic Surgery. 1991;
15: 293–6.
17. McCulloch EG, Langsdon PR, Maloney BP. Chemical Peel
with Phenol. In: Roenigk RK, Roenigk HH (Eds.). Dermatologic
Surgery, Principles and Practice. 2nd ed. Oxford: Marcel Dekker,
1996: 1147–60.
18. Some attempts at copies can be found on the market. Some of
these copies are extremely crude, others tend to break easily, and
others are too thick and can be felt through the skin.
19. Langsdon PR, Milburn M, Yarber R. Comparison of the laser
and phenol chemical peels produce similar results in facial skin
resurfacing. Archives of Otolaryngology—Head and Neck Surgery.
2000; 126: 1195–9.

30
Phenol
Indications
A phenol peel is the deepest type of peel, the one that gives
the most dramatic results but that is also the most dangerous.
Its indications are precise and limited to cases that cannot be
treated by other peels. If an alpha-hydroxy acid (AHA) or tri-
chloroacetic acid (TCA) peel can solve a skin problem, it will be
chosen over a phenol peel without hesitation. The main indica-
tion for a phenol peel is severe photoaging.
TREATING WRINKLES: PHENOL
PLUS BOTULINUM TOXIN
Fine lines, wrinkles, furrows, and folds do not respond to phe-
nol in the same way. Wrinkles and fine lines caused by sun
damage are far more responsive to phenol (Figure 30.1) than
expression lines or, above all, skin folds due to excess skin.
Deep Wrinkles
These can respond very well to a phenol peel (Figure  30.2).
Deep cheek wrinkles (Figure 30.3) caused purely by sun dam-
age are one of the best indications for a phenol peel. Expression
wrinkles are also an excellent indication, on condition that
movement is blocked by botulinum toxin approximately 8
days before the peel. Without this highly effective synergetic
combination, kinetic wrinkles will disappear during the first
few weeks after the phenol peel but will come back afterward,
much to the annoyance of patients.1 “Compression” wrinkles
that form during sleep are particularly problematic and diffi-
cult to eliminate: they come from an excess of skin combined
with loss of elasticity, and form during the night as a result of
continuous pressure from the head on the pillow that “chisels”
the skin. Filling techniques can be tried but can be disappoint-
ing in this indication in the long term. The only real solution is
to change unconscious sleeping habits, which is almost impos-
sible. Special pillows have been designed specifically to combat
this problem.
Folds and Furrows
These usually result from excessive skin laxity. Deep folds and
furrows are not a good indication for phenol. They result from
intrinsic aging and can sometimes be filled before a phenol
peel. There is no need for a long interval between filling and
peeling; the two treatments can even be done at the same time
if the filler is resorbable.2 Furrows and folds can be filled imme-
diately before the phenol peel. It is easy to understand how the
severity of the inflammatory reaction after the phenol peel does
not help the implant in the long term, but the clinical results of
this combination speak in its favor. Folds and furrows can also
be filled after a phenol peel, after the inflammatory erythema
has subsided. An injection given too soon after the peel, during
the erythematous phase, can easily cause bruising.
Expression Lines
Expression lines on the forehead and between the eyebrows
and crow’s feet have a natural tendency to recur partially and
rapidly, even after a phenol peel. A botulinum toxin injection
before the peel prevents expression lines from imprinting
themselves on the skin as it renews itself, and this combination
is very satisfactory, improving results significantly. The botuli-
num toxin should be injected 1 week before the peel so that new
collagen can be synthesized on an immobile dermis.
The injection can also be given 8 days after the phenol
peel, if not done beforehand. Injecting botulinum toxin during
the postpeel period of erythema and edema increases the risk
of the toxin moving as well as the risk of temporary cosmetic
complications caused by the toxin. The duration of the toxin’s
effect does not seem to change much, however.
Wrinkles around the Mouth and Eyes
The chemical blepharoplasty and/or cheiloplasty (labioplasty)
technique is described in detail in Chapter 36. Wrinkles on
the lower eyelids, drooping upper eyelids, and loss of elastic-
ity are excellent indications for a local application of phenol
(Figures 30.4 and 30.5). Wrinkles around the upper and lower
lips respond very well to a local application of Lip & Eyelid
Formula (Figure 30.6).
Radial Wrinkles on the Upper Eyelids
“Radial” wrinkles on the outer canthus of the upper eyelid
respond well to localized treatment with phenol using the
occlusive technique (Figure 30.7).
Other Wrinkles
Other wrinkles, such as cheek wrinkles or forehead wrinkles,
are excellent indications for a full-face phenol peel but are usu-
ally not treated locally, as not only are the results less obvious
than after a full-face peel but also the difference between the
treated area and the surrounding skin can be too obvious. This
type of local treatment is reserved for very particular cases,
when there is no risk of tone and structure differences between
the locally treated area and the surrounding skin.
LAXITY AND SKIN ELASTOSIS
Thin, elastotic, and distended skin is ideal for a phenol peel
(Figure 30.8). Results are better than with a surgical face-lift.
On the other hand, a phenol peel, even under the best condi-
tions, cannot completely lift jowls. Although phenol is indi-
cated in many cases of facial sagging, large amounts of excess
skin still have to be resected surgically. Surgery does not,
however, change the texture of the skin, and applying a phe-
nol peel after surgery rejuvenates skin texture, removing all

Phenol: Indications      251
the wrinkles and marks that surgery has no effect on. When
the skin is thin, a full-face phenol peel can often produce suf-
ficient retraction to make a surgical face-lift unnecessary. The
same applies for upper blepharochalasis: a surgical blepha-
roplasty is still the best choice in this indication, but excel-
lent results can be achieved with a single application of Lip
& Eyelid Formula, and drooping skin can be retracted satis-
factorily, as described in Chapter 36. Oddly enough, eyelid
retraction is automatically restricted to “normal” tension, and
the author has never had any cases of ectropion, entropion, or
lagophthalmia.
DYSCHROMIAS
We have seen that phenol has a marked effect on dyschromias,
and it incapacitates melanocytes, even if it does not destroy
them histologically (Figure 30.9). Even if many melanocytes are
still physically present in the basal layer,3 they can no longer
produce melanin (partially or completely).
Melasma and Postinflammatory
Hyperpigmentation
Phenol is a good indication for all types of hyperpigmented
lesions: lentigines, pigmented keratoses, chloasma, melasma,
freckles, and postinflammatory hyperpigmentation (PIH).4
However, phenol is not the first choice of treatment, as other, less
aggressive, peels will do most of the time. Hyperpigmentation
problems have to be treated differently depending on how deep
they are: epidermal hyperpigmentation can be treated with a
more superficial peel than dermal hyperpigmentation, which
will only respond to a deeper peel. Phenol may be indicated to
treat severe and resistant melasma definitively. Some patches
may recur after a period of lightening. Patients must be warned
of this possibility. The problem can largely be avoided by rec-
ommending that the patient uses Blending Bleaching Cream5
for several months after the phenol peel.
Asken6 has drawn attention to the fact that the distribu-
tion of melanosomes is particularly uneven in melasma; a phe-
nol peel may accentuate this uneven pigmentation even more.
Wood’s Lamp
It is useful to evaluate the depth of pigmentation: a Wood’s
lamp can be used to do this, as shown in Figure 30.10. The worse
the pigmentation appears when exposed to the Wood’s light
(i.e., the more patchy the skin appears), the more superficial the
melanin is and the treatment will soon take effect. Superficial
pigmentation does not need to be treated with phenol and can
be treated effectively with less aggressive peels.
Asian Skin
Light Asian skin is not a contraindication to phenol. Between
1986 and 1992, phenol was applied to 710 light-complexioned
Asian patients and proved to be highly effective and very safe
to use.7
Freckles
Histologically, freckles are characterized by a normal number
of melanocytes in the basal layer. The melanocytes are, how-
ever, larger and more “dendritic,” and give up their melano-
somes more readily to the keratinocytes. Freckles disappear
completely and definitively with phenol. A TCA peel to the pap-
illary dermis8 will also get rid of freckles. A local phenol peel is
contraindicated on light skin phototypes—which in principle
(b)
(a)
Figure 30.1  Full-face phenol (Lip & Eyelid Formula): (a) before and (b) 30 days after the peel. The combination of botulinum toxin and
phenol work together on the forehead, crow’s feet, frown lines, and sometimes wrinkles on the upper lip.

252      Textbook of Chemical Peels
are a good indication for phenol—with freckles, as they will
disappear where the phenol has been applied and will persist
in the surrounding areas. A combination of local Lip & Eyelid
and Unideep (TCA to the papillary dermis) is suitable to avoid
this freckle demarcation line.
Lentigo Maligna
Lentigo maligna9 is a flat, multicolored, pigmented lesion with
an irregular shape that may be precancerous. It has a slow radial
growth phase, and its diameter can vary from a few millimeters
to several centimeters. It is usually found on the face, temples,
or cheekbones, in patients more than 50 years old. The aver-
age age of onset is 65, and the incidence increases with age.
Lentigo maligna is formed by melanocyte proliferation that is
purely intraepidermal. Histologically, there is an increase in the
number of atypical melanocytes in the basal layer of the epider-
mis. Some of the melanocytes may have multiple nuclei. These
atypical melanocytes are found at a distance from the clinical
border of the lesion. The epidermis is atrophic and the dermis
elastotic. This lesion is, in fact, associated with chronic sun
(c)
(b)
(a)
Figure 30.2  (a) Before full-face phenol. (b) Fifteen days after full-face phenol (Exoderm). Kinetic wrinkles are starting to come back.
(c) Thirty days after full-face phenol: the phenol has solved all the skin problems apart from the expression lines, which have come back.

Phenol: Indications      253
(b)
(a)
Figure 30.3  (a) Sun-damaged cheek skin. (b) Complete restructuring, 30 days after a full-face phenol peel (Lip & Eyelid Formula).
(b)
(a)
Figure 30.4  Rejuvenation of the eyes: (a) before; (b) 30 days after a full-face phenol peel (Lip & Eyelid Formula).
(b)
(a)
Figure 30.5  Chemical blepharoplasty (Lip & Eyelid): (a) before; (b) after.

254      Textbook of Chemical Peels
exposure over many years, mainly in patients with a light skin
phototype. Adnexal spread is not uncommon, and numerous
melanophages are found in the dermis. This lesion can, how-
ever, degenerate into a superficial melanoma, whose prognosis
is good, as, more often than not, it does not produce metastases.
When lentigo maligna is diagnosed at the age of 45, the statisti-
cal risk of it developing into melanoma is 47% over the lifetime
of the patient. When it is diagnosed at the age of 67, the risk of
it turning into a malignant melanoma is 22%. In both cases, the
5-year survival rate is 90%. That is why dermatological monitor-
ing and sun protection are usually all that are recommended.
If the lesion is extensive, surgical excision and a skin graft
are sometimes necessary. The excision must be wide and the
excision margin at least 1 cm beyond the clinical border of the
lesion. The cure rate is then 91% with a 9% recurrence rate in
4 months. Mohs microsurgery is also widely used. Many other
treatments have been studied. Cryotherapy should theoreti-
cally produce good results because melanocytes are particu-
larly sensitive to cold, but this treatment has a 50% recurrence
rate. 5-Fluorouracil (5-FU), used alone, gives poor results. With
carbon dioxide and argon lasers, radiotherapy, and electron-
beam therapy, there have been many recurrences. Curettage,
dermabrasion, and electrodessication have produced few posi-
tive results and a high rate of recurrence. Topical hydroquinone
and tretinoin have no effect on the lesion. It is not the author’s
intention to suggest that a phenol peel is the ideal treatment
for lentigo maligna, but only to say that, unlike the majority of
other treatments suggested, the author has never seen a recur-
rence of flat lentigo maligna after a phenol peel, be it full-face
or local (Figure 30.11).
(a)
(b)
(c)
 
Figure 30.6  Long-term removal of wrinkles around the lips after a phenol peel: (a) before; (b) after 1 year; (c) after 3 years. The contour
of the lips has been plumped with an injection of a slow resorbable filler, 1 year after the phenol peel.
(a)
(b)
 
Figure 30.7  (a) Occlusion of localized phenol to treat the radial wrinkles of the outer canthus of the upper eyelids in a 75-year-old
Caucasian patient. This treatment should be combined with a botulinum toxin injection (8 days before the peel) and a TCA peel to the
papillary dermis (Unideep) in the same session to even out the skin tone of the rest of the face. (b) Three weeks after this combination of
treatments, the radial wrinkles have disappeared. There is no visible demarcation line.

Phenol: Indications      255
(b)
(a)
Figure 30.8  (a, b) Pronounced photoaging, combined with slight sagging, is an excellent indication for a full-face phenol peel.
(b)
(a)
Figure 30.9  Before (a) and after (b) a full-face phenol peel (Lip & Eyelid Formula): a combination of yellow skin, wrinkles, fine lines, and
lentigines in a patient who smokes. Thirty days after the peel the erythema is normal. The patient is not wearing any makeup. Botulinum
toxin was injected 8 days before the peel (forehead, frown lines, and crow’s feet).

256      Textbook of Chemical Peels
KERATOSES
Extensive multiple keratoses (solar or senile) on the entire face
should be treated with a full-face peel, whereas isolated kerato-
ses can be treated by other methods (see Chapter 22). According
to McCollough and Maloney,10 laser treatment has no advan-
tage over chemical treatment. Vergereau, for his part, published
a study confirming the advantage of applying Only Touch TCA
over laser, dry ice, or coagulation.
Several forms of keratoses can coexist.
Seborrheic Keratoses
Seborrheic keratoses (Figure 30.12) are very common and are
found on areas of skin that have been exposed to the sun as
well as unexposed areas. The lesions are always benign but can
sometimes be difficult to distinguish from malign melanomas.
Beyond a certain thickness, the keratotic layer makes them
unresponsive to peels, even to phenol. They can be treated
by shave excision with a snare and radiofrequency (Ellman
unit) immediately before applying the phenol. When treating
(a)
(b)
 
Figure 30.10  (a) Wood’s lamp. (b) Patient with melasma seen under this light.
(a)
(b)
Figure 30.11  Lentigo maligna combined with severe photoaging: (a) before and (b) after a full-face phenol peel.

Phenol: Indications      257
seborrheic keratoses by shave excision without combining it
with phenol, a TCA peel to the basal layer or to the papillary
dermis can be applied to even out the structure of the skin once
it has completely healed.
Actinic Keratoses
Actinic (or solar) keratoses11 form mainly on areas of skin that
have been exposed to the sun: the face, the pinna of the ear, and
the hands, for example. They are tumors that are often precan-
cerous: 10%–20% (25% according to some authors) develop into
skin cancer, often of the spinocellular carcinoma variety. Many
patients with actinic keratoses or even subclinical epithelioma
in situ could benefit from a phenol peel on the face,12 possibly
preceded by curettage of the largest lesions. Patients who have
been treated with 5-FU are often reluctant to put up with the
necrotic appearance of their skin after each treatment. A phe-
nol peel eliminates the actinic keratoses while making the skin
look younger overall. Many authors describe very long-term
results, if the patient is prepared to change his or her attitude
to sun exposure after the peel and, as well as avoiding the sun,
is prepared to use SPF 50+ sunblock every day thereafter. In
case of recurrence, inadequate results, or the appearance of new
lesions, the patient can be treated again 4–6 weeks after the first
peel. Patients treated with phenol are at far less risk of develop-
ing cancer later.4
SUPERFICIAL CANCERS
Phenol necroses the epidermis and part of the dermis and
eliminates intraepidermal skin cancers in situ. Carcinomas
form from cells in the epidermis. To the author’s knowledge, no
scientific article has reported skin cancers being caused by the
application of peeling agents. If the literature is to be believed, a
phenol peel treatment has the added advantage of lowering the
frequency of other precancerous lesions forming and probably
other cancers in situ in sun-damaged skin. From a toxicological
point of view, topically applied phenol13 is not recognized as a
carcinogenic or teratogenic agent. It is still necessary, however,
to make a definite diagnosis before applying chemical agents to
suspect pigmented lesions.
SUPERFICIAL TELANGIECTASIAS
A phenol peel is not used to treat telangiectasias, even though
the more superficial ones usually disappear through protein
coagulation along with the superficial layers of the skin. Deeper
telangiectasias can become even more deeply embedded in the
dermis as the new layer of dermal collagen and elastin form.
Therefore, a phenol peel usually brings about an improvement
in the appearance of telangiectasias. However, in some cases,
the extent of postpeel neovascularization can make them worse
or cause new vasodilations to appear.
“Raised” telangiectasias may become more visible in
patients with thin and transparent skin. Facial telangiectasias
can be electrocoagulated immediately before the phenol is
applied, while the patient is under nerve-block anesthesia for
the peel. An Ellman radiofrequency unit is completely satisfac-
tory in this indication.
XANTHELASMA
Xanthelasmas are permanent and often symmetrical yel-
lowish plaques that appear on the inner canthus of the eyes
(Figure 30.13). All four eyelids can be affected by this non-pre-
malignant dermatitis. They can be soft or hard. In 50% of cases,
they are associated with hyperlipidemia. Women are affected
twice as often as men.
Xanthelasmas are formed by a buildup of xanthoma cells:
macrophages swollen with free or esterified cholesterol and
mainly located in the superficial layers of the reticular dermis.
Phenol can therefore reach them (Figure 30.14). Other treatment
options include surgical excision, carbon dioxide laser, argon
laser, electrocoagulation, and cryotherapy. Dichloroacetic acid
has also been used in this indication, dissolving the xanthe-
lasma and healing with minimal scarring.
ACNE AND ACNE SCARS
Active acne is not an indication for phenol because of the
risk of secondary infection, among other things, and because
there are other less aggressive and highly effective treatments
(Box 30.1).14
Acne scars15 that are deep, adherent, crater-like, some-
times atrophic, sometimes hypertrophic, and keloid16 are a
complex problem, and it is clear that no easy treatment exists
to date that can claim to eliminate them completely and defini-
tively. Applying a phenol solution will of course bring about a
Figure 30.12  Seborrheic keratosis.
Figure 30.13  Xanthelasma. (Courtesy of Dr. Munelly, UK.)

258      Textbook of Chemical Peels
cosmetic improvement, but may well be disappointing to both
doctor and patient in some severe cases.
The patient in Figure  30.15 is an interesting case from
many points of view. A phenol solution (Exoderm) was applied
correctly and deeply enough to treat the many acne scars
(Figure 30.16).
An occlusive dressing was then applied for 24 hours.
On examining the skin at the end of occlusion, the scars had
improved only very slightly, and an extra coat of phenol was
applied to the cheeks after 24 hours, without occlusion this
time. On examination after seven days, the results appeared
inadequate (Figure  30.15) and another spot application was
made without much success.
When discussing treatment possibilities for acne scars
with a would-be patient, the doctor should be extremely cau-
tious. Skin that is very scarred can, however, be completely
renewed, evened out, and smoothed using a combination of
treatments such as subcision,17 dermal filling,18 dermabra-
sion, punch excision, punch elevation, possibly micro skin
grafts, or even injections of cultured stem cells or fibroblasts
(Isolagen).
BOX 30.1  Acne Scars Alternative Treatment
Acne scars are treated with a very high success rate by
using the anterior chemoabrasive technique described in
Chapter 21, in association with an Easy TCA peel.
• Superficial and medium-depth acne scars receive
a single anterior chemoabrasion.
• Deep acne scars might need a double anterior
chemoabrasion.
(b)
(a)
(c)
Figure 30.14  (a) Eyelid xanthelasma before a local phenol peel. (b) Five days after the peel: normal erythema. (c) Nine days after the
peel, the xanthelasma has gone.

Phenol: Indications      259
(b)
(a)
Figure 30.15  Acne scars treated with a full-face phenol peel (Exoderm). On the 8th day, there is a distinct improvement in the structure
of the skin: wrinkles have disappeared, along with small active acne lesions. However, the improvement in the acne scars remains limited.
(b)
(a)
Figure 30.16  (a) The application of phenol on this patient produced normal skin frosting but did not reach the deeper acne scars, which
are still the same color. (b) An extra coat of phenol causes “buff-colored” patches to appear—a sign that the product has reached the
maximum depth of penetration.

260      Textbook of Chemical Peels
Treating severe acne scars therefore requires specific
technical “preparation” before applying phenol to allow com-
plete and definitive renewal of the architecture of the skin, as
well as to even out the tone of skin that has been damaged by
the acne itself and by the treatments given before the phenol
peel. It is therefore imperative to cure the acne before treat-
ing the consequences and not to forget that taking isotretinoin
(Roaccutane) in the year before or after a phenol peel poses a
major risk of atypical scarring, often on the cheeks.
Results are excellent, however, on more superficial scars:
permanent removal of scars, tightening effect on the skin, and
overall normalization of skin tone.
Some authors19 prefer to treat acne scars with dermabra-
sion, on condition that the hand guiding the wheel is expert
enough to be able to control the depth of skin abrasion precisely
and to vary the depth depending on the area and the size of the
scars being treated. Dermabrasion may be prescribed as mono-
therapy or in combination with other techniques (Figure 30.17).
The results of microdermabrasion as monotherapy for treating
severe acne scars are disappointing.
OTHER SCARS
Atrophic Scars Resulting from a Face-Lift
A surgical face-lift always leaves scars. If there are no serious
complications, these scars are not really visible and patients do
not complain. Secondary infections are not common, but they
are not rare either, and in some patients the skin surrounding
the scar behind the ear becomes necrotic.
The scar shown in Figure 30.18 is the result of a secondary
infection after a surgical face-lift. Note the central atrophy and
depigmentation surrounded by a hyperpigmented ring. There is
a telangiectasia in the middle of the scar. The patient wanted to
have a phenol peel but was refused because of the risk of the face-
lift scar not healing properly. The telangiectasia can be treated
separately, however, and the peripheral PIH, which shows up the
central atrophic hypopigmentation, could be treated with a more
superficial peel (Easy TCA) combined with a topical depigment-
ing treatment (Blending Bleaching Cream). The visual impact of
the scar would be reduced if the skin tone were evened out.
Normal face-lift scars are not usually too unsightly, but
some patients want a treatment to soften them or eliminate
them. A full-face phenol peel is the best option (Figure 30.19),
but a local application of phenol precisely on the scar is also a
possibility, in combination with another more superficial peel
(to the papillary dermis, the Grenz zone, or the basal layer).
Standard scars from an upper blepharoplasty do not seem to
respond as well to a phenol peel. Scars on the body are not an
indication for phenol.
Traumatic Scars
These can be treated with localized application of phenol and a
series of Easy TCA peels (Figure 30.20).
Dermabrasion Scars
These too can be treated with a local phenol peel combined
with Easy TCA (Figure 30.21).
NEVUS
Another less well-known indication for a phenol peel is the
treatment of generalized verrucous epidermal nevi, a disorder
(b)
(a)
Figure 30.17  (a, b) A patient treated with an Exoderm peel (full-face phenol occlusive peel), followed by mechanical dermabrasion (post-
chemabrasion). (Courtesy of Dr. Y. Fintsi.)

Phenol: Indications      261
that can be associated with a certain number of bone, oph-
thalmic, or neurological malformations. Treatment consists of
shave excision of the lesions followed by an application of phe-
nol to the hyperpigmented areas of the face.20
Giant hairy nevi have been treated with phenol: 40%
solution, combined with croton oil (0.8%) and hexachlorophene
soap.
It should be remembered that some nevi fade after a
phenol peel and that others, after a period of fading, become
hyperpigmented.
OTHER INDICATIONS
Dilated Pores
Dilated pores are not the best indication for phenol, and the
abrasive technique21 combined with Easy TCA seems more
effective.
Neurolysis and Chemical Sympathectomies
Phenol is sometimes used in paraaortic injections in the semi-
lunar ganglions to achieve neurolysis as an analgesic technique
in cases of inoperable cancers (30 ml of a 6% phenol solution can
be injected in this indication) (see also Chapter 28).
There are descriptions in the literature of the use of
phenol in chemical sympathectomies in the treatment of pal-
mar hyperhidrosis, Raynaud’s syndrome, and obliterative
arteriopathy.
Urinary Incontinence
Phenol has been used in injections beneath the bladder trigone
in the treatment of urinary incontinence due to spina bifida
(30 ml of 6% phenol). Aqueous solutions of phenol have been
injected as a sclerosant in cases of hydrocele.22
Figure 30.18  Atrophic scar after a face-lift, resulting from a local
secondary infection.
(a)
(b)
Figure 30.19  (a) A face-lift scar that is not too unsightly. However, the skin tension lines converging on the scar emphasize it. (b) Thirty
days after a full-face phenol peel (Lip & Eyelid Formula), without any makeup; the tension lines have gone and the face-lift scar is less visible.

262      Textbook of Chemical Peels
(b)
(a)
(d)
(c)
Figure 30.20  (a, b) Post-traumatic scar and PIH, 6 years after a road accident. (c) Local application of phenol to the scar. Frosting occurs
immediately. An impermeable occlusion will be applied for 24 hours and followed in the standard manner with an application of bismuth
subgallate powder. The patient will also have four sessions of Easy TCA peels, at a rate of one peel per week, to produce cloudy white
frosting on the hyperpigmentation. Daily depigmenting care is Blending Bleaching Cream. (d) Results after the third Easy TCA peel and
one application of localized phenol to the scar between the eyebrows. The edges of the scar are less marked, the base of the scar appears
less atrophic, and the skin tone has evened out.
(b)
(a)
Figure 30.21  (a, b) A scar resulting from lip dermabrasion: the upper left half of the lip is still wrinkled because the mechanical dermabra-
sion was too superficial, whereas the upper right half of the lip is scarred as a result of the dermabrasion being too deep. The patient is seen
in an attempt to correct this unsightly scar and a local phenol peel is suggested. Lip & Eyelid solution will be used locally and combined
with four Easy TCA peels to even out the results.

Phenol: Indications      263
Spasticity and Chemical Neuroablation
Publications indicate 5% phenol injections to treat spasticity
in pediatrics. The use of chemical neuroablative techniques
dropped off rapidly with the arrival of more specific treat-
ments. Injecting neurolytic solutions (e.g., phenol23 or alcohol
solutions) causes nonspecific damage to all the structures
that come into contact with these products, namely both
motor nerves and sensory nerves, muscles, aponeuroses,
and subcutaneous tissue. The effects of chemical neuroly-
sis last several months, and subsequent injections often do
not produce the same results. It is now acknowledged that
the risk of complications linked with these injections is too
high, considering that there are other techniques that are less
dangerous, more specific, and more effective. Injecting phe-
nol for the purpose of chemical neurolysis is now only indi-
cated for patients suffering from pain that is unresponsive to
any other treatment and whose life expectancy is not longer
than 3 months. Recently, there have been reports of phenol
being used to produce chemical neurolysis and a “botulinum
toxin-like” effect.
Hemorrhoids
Martindale23 reports the use of injections of an oil solution of
phenol as a sclerosant for hemorrhoids. The phenol is injected
into the tissue surrounding the internal hemorrhoids as a hard-
ening agent and painkiller.
Various
Phenol has been injected into the soft tissue of the lower back to
relieve chronic pain. Phenol ablation is sometimes preferred to
surgery to treat ingrown toenails or onychogryphosis.
NOTES

1. See the section on inadequate results in Chapter 37.

2. It is possible, for example, to inject hyaluronic acid immediately
before the phenol peel.

3. Given that the exact role of melanocytes is not yet completely
understood—although we know that it is not just restricted to
the production of melanin—it is interesting to note that they are
still where they should be: in the basal layer of the epidermis.

4. Cortez E. Chemical face peeling. Otolaryngology Clinics of North
America. 1990; 23: 947–50.

5. Blending Bleaching Cream should be applied twice a day from
the 10th day after Lip & Eyelid, if the skin is ready.

6. Asken S. Unoccluded Baker–Gordon phenol peels—Review and
update. Journal of Dermatologic Surgery and Oncology. 1989; 15:
998–1008.

7. Wang Li, Zhao QM, Zhang CU, et al. Clinical observation of face
peeling for ephelides and phenol excretion in wine [in Chinese].
Journal of Clinical and Experimental Medicine. 1992; 8: 179–81, 247.

8. Unideep is therefore a good treatment for freckles.

9. Lentigo maligna is also known as Dubreuilh’s melanosis and
Hutchinson’s freckle. Different authors consider it either as a
malignant melanoma in situ or as a premalignant melanocytic
dysplasia.
10. McCulloch EG, Langsdon PR, Maloney BP. Chemical Peel with
Phenol. In: Roenigk RK, Roenigk HH (Eds.). Dermatologic Surgery,
Principles and Practice. 2nd ed. Oxford: Marcel Dekker, 1996:
1147–60.
11. See also treatment with localized TCA (Only Touch), described
in Chapter 22.
12. Usually, phenol peels are not recommended for nonfacial skin.
13. The same applies to AHAs and TCA.
14. Active comedonal, microcystic, papular, or papulopustular acne
are good indications for Easy TCA or Easy Phytic. Many derma-
tological treatments are equally effective.
15. See also Chapter 21.
16. They often result from pustular or nodulocystic acne or acne
conglobata.
17. With a Nokor needle or Sulamanidze’s wire scalpel.
18. Ideally combined with subcision.
19. Farrior RT. Dermabrasion in facial surgery. Laryngoscope. 1985;
95: 534–45.
20. Basex J, el-Sayd F, Sans B, et al. Share excision and phenol peeling
of generalized verrucous epidermal nevus. Dermatologic Surgery.
1995; 21: 719–22.
21. “Pre-chemabrasion”; see Chapter 21.
22. Martindale W, Reynolds JEF. The Extra Pharmacopoeia. 30th ed.
King of Prussia, PA: Rittenhouse Book Distributors, 1993.
23. “Phenolization”: 5%–7% phenol in aqueous solution.
(d)
(c)
Figure 30.21 (Continued)  (c) Frosting on the upper lip after application of Lip & Eyelid solution. The scar reacts with frosting of a different
color where the tissue is most fibrous. (d) Three weeks after treatment, the wrinkles on the upper left half of the lip have disappeared. The
scar on the upper right half of the lip has softened and evened out, and the color is similar to that of the surrounding skin.

31
Phenol
Contraindications, precautions, and safety
CONTRAINDICATIONS AND PRECAUTIONS
Insulin-Dependent Diabetes
Insulin-dependent diabetes is an absolute contraindication to a
phenol peel. Diabetes significantly increases the risk of second-
ary infection; the vascular and/or immune disorders associated
with this illness mean that complications are more of a prob-
ability than a possibility. Stabilized, non-insulin-dependent
type 2 diabetes is not an absolute contraindication to a phenol
peel. The doctor must take particular care with these patients to
avoid secondary infections.
Florid Herpes
Active herpes is an absolute contraindication to a phenol
peel. A history of herpes is not a contraindication to phenol,
but requires treatment to prevent herpes recurring. For more
details, see Chapters 32 and 37.
Other Obvious, Absolute Contraindications
Who would dream of doing a phenol peel on a woman who
is pregnant or breast-feeding? Or on a patient with an obvi-
ous malign lesion? Or a patient recovering from a serious ill-
ness? A patient with immunodeficiency?1 On a patient with
Ehlers–Danlos syndrome?2 On one with scleroderma or colla-
gen disease? The doctor must use his or her professional skill
and experience to rule out any patient who poses an increased
risk.
Local Anesthesia with Adrenaline (Epinephrine)
Adrenaline (epinephrine) is a cardiac irritant that increases the
risk of arrhythmias. For more details, see Chapter 37.
Preexisting Heart Condition
A phenol peel should not be performed after myocardial infarc-
tion or cardiac decompensation. Unstable angina also rules out
a phenol peel, as the stress associated with a peel could trig-
ger an angina attack. No clear link has ever been established
between a personal medical history of a heart condition, if cur-
rently stabilized, and the incidence of cardiovascular complica-
tions during a phenol peel. Apart from arrhythmias, to the best
of the author’s knowledge, there is no mention in the literature
of any serious heart problems occurring as a complication of a
phenol peel.3
Of course, we cannot know for certain that such compli-
cations are always reported in scientific journals, even though
any serious complications following cosmetic interventions
always make headline news in the popular press and on TV. As
far as the author knows, however, recently there have been no
serious health problems resulting from a phenol peel.
Preexisting Kidney or Liver Disease
Liver or kidney deficiency increases the risk of toxicity, as the
normal detoxification and elimination processes will not be
functioning properly (see Chapter 28).
Patient History
Recent Postoperative Wounds
As discussed in Chapter 30, a phenol peel can improve the
appearance of stabilized surgical scars on the face. Phenol
should not be used to treat recent postoperative wounds that
have not yet stabilized, however, as there is a significant risk
of necrosis.
History of Local Radiotherapy
In addition to all the structural changes that can follow expo-
sure to ionizing radiation, there is a possibility that the pilo-
sebaceous units might atrophy. This would delay epidermal
regeneration and promote the formation of nasty scars.
History of Keloid Formation
It is better to select a peel whose depth of action does not go
beyond the papillary dermis.
Use of Isotretinoin
Recent use of oral isotretinoin is an absolute contraindication
to phenol. For more information, see the section on scarring in
Chapter 37.
Use of MAO Inhibitors
Monoamine oxidase (MAO) inhibitors are contraindications to
the use of the majority of analgesics and psychotropic drugs
required for patient comfort. This would make a phenol peel
almost unbearable for a patient on MAO inhibitors, who is, by
definition, psychologically unstable.
Refusal or Inability to Wear Makeup
Patients who absolutely refuse to wear makeup during the
postpeel period are not the best candidates for a phenol peel,
as the erythema and potential dyschromias, even if temporary,
are best covered up with makeup.
Patients at Risk of Dyschromia
Patients with dark skin should be warned about the demarca-
tion line between the treated and untreated areas, both with a
full-face peel and a localized phenol peel.
Patients on estrogen–progesterone hormone-replacement
therapy (HRT) need close monitoring for pigmentary changes.
McCollough and Maloney4 ask their patients to try to stop HRT
or the contraceptive pill for at least the first 6 months after a

Phenol: Contraindications, precautions, and safety      265
peel. If they cannot stop HRT during this time, they are warned
of the risk of pigmentary changes.
Patients who work outside most of the time should also
be warned of the high risk of hyperpigmentation and of the
absolute necessity not only to wear an effective sunblock, but
also to change their general attitude to the sun.
Patients with Mental or Behavioral Risks
The patient has to understand the peel procedure and the limits
of a deep peel. He or she must agree to comply with the strict
rules of the procedure before, during, and after the peel. Any
cosmetic procedure in which the patient is required to take an
active part, and especially a deep peel, is strictly contraindi-
cated for patients who do not have a minimum level of intel-
ligence. The patient has to be capable of understanding and
accepting the necessity to wear sunblock and makeup after the
peel and be aware of the time needed for the skin to regenerate
completely.
Squeamish patients will overwhelm the doctor with
complaints, worries, questions, and reproaches. It is better to
test a patient’s mental and physical resistance by first suggest-
ing a painless peel without complications and then progress-
ing to a medium-depth peel before considering a phenol peel.
Individual tolerance can be tested in this way, and the patients
themselves gradually learn what a peel is and what it can do
for them.
Patients should be shown a series of photographs that
illustrate what the face looks like day by day during the first
week after a peel. Ideally, the patient’s immediate family should
also see these photographs. Without this precaution, paranoid
patients, friends, and family may not believe it when the doctor
tells them that everything is proceeding as normal.
Isolated Patients
Being alone is not in itself a contraindication to a phenol peel.
The dramatic results of a peel could in fact bring separated
couples back together,5 but a few rules are necessary for the
patient’s safety. Current phenol formulas allow patients to
remain on their feet: the patient can go home almost immedi-
ately after a phenol peel. However, phenol peels cause signifi-
cant edema that can sometimes make it difficult for patients to
open their eyes. It is therefore out of the question for a patient
who lives alone to go home after the peel. The patient needs
help performing daily activities during the first 3 days after the
peel. Clinics with hospital beds can keep patients on-site dur-
ing the first few days or even the first week after a peel.
Neck Peel
A phenol peel is better intended for facial skin, and there are
other treatments for the rest of the body.6
Specific Precautions
If a phenol peel on the neck proves necessary, the following
precautions must be taken:
•
No impermeable dressing should be applied: no occlusion.
•
The solution should be applied sparingly on the skin of the
neck.
•
Any movement or friction likely to cause scarring should
be avoided after the peel.
•
The phenol must not be allowed to macerate in the folds of
the neck. This maceration is equivalent to occlusion.
•
After treating the face, the solution should be applied
extremely slowly on the neck or, preferably, should be
postponed until the following day so as not to overload
the body’s metabolization and elimination pathways. It is
especially important in this case to avoid the toxic compli-
cations associated with phenol being applied too rapidly
on too large an area.
Skin Regeneration
After an intraepidermal peel, to the basal layer or the Grenz
zone, the skin regenerates from leftover islets of keratinocytes.
In the case of a deep peel, the skin regenerates from its append-
ages.7 The face has more pilosebaceous units than the neck, and
facial skin regenerates more quickly, with less risk of scarring.
Solution to the Problem of Neck Peels
The answer is to do a peel to the papillary dermis on the neck
and décolletage. This peel can be performed at the same time
as the phenol face peel or in the weeks following the face peel.
Sun Exposure
Complete sun avoidance and effective sun protection is a must
for 2 or even 3 months (see Chapters 2 and 3). Postinflammatory
hyperpigmentation (PIH) is not at all uncommon, even after
a phenol peel. After the immediate postpeel period, which
requires close and almost daily monitoring, it is advisable to
see patients again after 15 days, 30 days, and 2 months and to
warn them of the need to treat any early signs of hyperpig-
mentation immediately. It should be noted that PIH frequently
resolves itself without treatment after a phenol peel.
Cost
One of the drawbacks of a deep peel is the high cost, which
means that this technique is not within everyone’s reach. The
results that can be achieved offer excellent value for the money,
however, and no patient who has benefited from this treatment
has ever complained about the cost.
Disorders that May be Aggravated
Telangiectasias, seborrheic dermatitis, eczema, acne rosacea,
lupus, and other autoimmune disorders are among the forms
of dermatitis that may be aggravated by a phenol peel.
SAFETY FACTORS
Patient Selection
Choosing the right patient is a key safety factor. The few, but
strict, indications and contraindications should be taken into
account, as well as the results of the essential preliminary clini-
cal checkups.
Local and Systemic Safety
The following is a summary of some of the safety rules:
•
The product should only be applied to the face. There is a
large number of pilosebaceous units in the face that help
the epidermis regenerate properly.
•
It is better not to treat the neck with phenol, both for
local, dermatological reasons and so as not to increase the
absorption area.
•
Using the right formulation and the proper application
technique ensures perfect results every time. A “Number 1”

266      Textbook of Chemical Peels
phenol formula should not be applied using the applica-
tion procedure for a “Number 2” formula. In some cases,
this precaution is not essential, but in others it is.
•
All contact between phenol and the eyes should be
avoided.
•
No phenol should be applied in cases of liver or kidney
deficiencies or serious heart disease.
•
Phenol is contraindicated for patients with Ehlers–Danlos
syndrome, collagen disease, insulin-dependent diabetes,
and active infections (acne, herpes, etc.).
•
Phenol should be applied extremely carefully and in accor-
dance with all the safety rules (equipment, skill).
•
Doctors should inform their professional insurers that
they perform this type of peel.
•
The toxicity of phenol is paradoxical, and low-concentra-
tion solutions are potentially more toxic than high-concen-
tration solutions.
•
A phenol solution should contain oil to slow down absorp-
tion and allow enough time for the liver to detoxify it and
the kidney to eliminate it. The solution must be stable,
tamed, and adjuvanted.
•
As well as improving the cosmetic results, using occlusion
also slows down the absorption rate of phenol and reduces
its toxicity. Occlusive masks must be applied carefully to
prevent air bubbles or pools of phenol from forming.
•
The doctor must be aware of all the potential complica-
tions, watch out for any signs, and be ready to treat them
should they occur.
•
Phenol should be applied slowly, in a minimum of 1 hour,
on healthy patients with normal liver and kidney function
who can be expected to achieve good cosmetic results.
•
The patient should be hydrated, ventilated, and monitored
(pulse oximeter and electrocardiogram). A venous drip
should be set up beforehand, and if necessary glucose
serum can be administered to avoid hypoglycemia.
•
The risks of general anesthesia and products that could
irritate the myocardium can be avoided by using local
nerve blocks or deep sedation.
PHENOL-RELATED SPECIFIC PROBLEMS
Complete Contraindications
Contraindications include insulin-dependent diabetes; active
herpes; liver, respiratory, cardiac, or kidney insufficiency;
active infections; anemia; and logical contraindications such as
pregnancy, young age, cardiac problems, cancers, collagen dis-
eases, immune diseases, and so forth. The practitioner is fully
responsible for the selection of his or her patient and must be
fully informed about any potential contraindication described
in the medical literature. A non-limitative list of risks of compli-
cations is presented in the next section.
Phenol peelings are not usually used for treating skin
other than that of the face. Patients with active acne, skin types
greater than IV, nasolabial folds or marionette lines, or flaccid
necks are not appropriate indications.
Phenol peelings can be applied only on a surface equal or
less than 4% of the body surface (the face, for example).
Phenol is absorbed rapidly by the skin and mucous mem-
branes. It is also eliminated immediately by the lungs and
kidneys (in free form, as sulphate or glucuronide conjugates).
Detoxification begins immediately in the liver, after applica-
tion. A perfect aeration and ventilation of the treatment room
will prevent respiratory absorption by a patient already under
transcutaneous absorption. Phenol vapors enter the pulmonary
circulation very quickly, and it is recommended that the doctor
applying the phenol wear a mask to avoid breathing them in.
Keeping the patient well hydrated (with a bag of saline
solution IV) promotes diuresis and renal elimination of free,
conjugated, and oxidized phenol. Some writers recommend
intravenous hyperhydration before and during the peeling,
and sometimes forced diuresis with an intravenous injection
of furosemide. Hyperhydration is not necessary when phenol
is applied carefully—that is, in more than an hour, allowing the
detoxification mechanisms time to do their job.
Phenol toxicity problems, in particular cardiac arrhyth-
mia, are mainly associated with full-face techniques, when
application has been too fast and overpassed the detoxification
potential of the patient. It is the doctor’s responsibility to accept
or refuse to treat a patient, based on a clinical examination and
the results of additional tests requested. The doctor must use
his or her professional skills and experience to rule out any
patient at increased risk.
Risks of Complications
Arrhythmia
Respect for the 8 points listed below can help to reduce the risks
of cardiovascular arrhythmia during a full-face peel or if the
doctor has any doubts.
1.
Prepeel clinical examination and assessment: electrocar-
diogram (ECG), blood analysis, liver-kidney function.
2.
Slow application, for more than an hour, and a respect the
application protocol.
3.
Full monitoring (cardioscope, pulse oximeter, tensiometer).
4.
Patient in good general health: no infections, no anemia,
good respiratory health; obtaining a cardiological/pneu-
mological opinion, if necessary.
5.
Good selection of patients (note contraindications).
6.
Good hydration, intravenous saline solution.
7.
All required resuscitation equipment (verified and in good
working order) available, including a defibrilator, to deal
with any potential issues.
Insulin-Dependent Diabetes
Insulin-dependent diabetes is an absolute contraindication
for a phenol peel because of the risk of infection and of vas-
cular and/or immunity problems associated with this illness.
Diabetes mellitus type 2, controlled without insulin, is not
an absolute contraindication for a phenol peeling. Additional
attention must be paid to patients who are non-insulin-depen-
dent diabetics to avoid secondary infections.
Active Herpes
Active herpes is an absolute contraindication for a phenol peel-
ing. Any history of herpes requires prevention: on average 3
days before and 4 days after the peeling.
Other Obvious Absolute Contraindications
•
Pregnancy or breastfeeding.
•
Obvious malignant lesion.
•
Recovering from a grave illness.
•
Recovering from cardiovascular disease or anemia.
•
Depressed immune system.
•
Ehlers-Danlos syndrome.

Phenol: Contraindications, precautions, and safety      267
•
Scleroderma, connective tissue disease, wound healing
disorders, and any dermatological condition that might
interact with the phenol treatment.
•
Liver, kidney, or respiratory dysfunction; increases the
risk of toxicity, as detoxification and elimination are not in
proper functioning order.
•
Surgical intervention in the same area: a face-lift contra-
indicates the application of a full-face phenol peel, though
not on the area around the mouth or eyes (unless there has
been some surgical intervention in that area).
Local Anesthesia with Epinephrine
Epinephrine is a potential heart irritant that increases the risk
of arrhythmia.
Preexisting Heart Disease
The existence of angina pectoris is an exclusion factor. The exis-
tence of a heart condition in the patient’s personal history that
has been fully stabilized has not been linked with any certainty
to the occurrence of cardiovascular complications during phenol
peelings. However, in this case it is preferable to avoid peeling.
Recent Surgical Wounds
The peel can improve the appearance of facial surgical scars
that have stabilized. However, recent surgical wounds that
have not stabilized should not be treated with phenol due to
the major risk of necrosis.
History of Local Radiotherapy
In addition to all the structural changes that can follow the
skin’s exposure to ionizing radiation, the possible atrophy of
the sebaceous glands would delay regeneration of the epi-
dermis from these glands and encourage the development of
unsightly scars.
History of Keloids
For these patients, it is preferable to choose a peel that does not
go beyond the papillary dermis in depth.
Use of Retinoids
The recent use of retinoids is an absolute contraindication for
phenol. It is recommended to leave a period of at least 6 months
between the last use of retinoids (or similar medication) and
undergoing a phenol peel.
Use of Monoamine Oxidase Inhibitors
MAO inhibitors contraindicate the use of the majority of anal-
gesics and psychoactive drugs necessary for the comfort of the
patient. It is practically impossible for a patient on MAO inhibi-
tors, who is by definition psychologically unstable, to bear a
phenol peeling.
Patient Who Cannot or Will Not Wear Makeup
Patients who refuse to use any kind of makeup during the post-
peel period are not the best candidates for a phenol peel. Without
makeup, any persistent erythema would be very noticeable.
Patients with Risk of Dyschromia
Patients with dark skin (types IV–VI), or patients with lighter
skin types who have visible photoaging should be warned
that there will be a demarcation line between the treated and
untreated areas, and that this happens with a full-face peel as
well as a localized phenol peel.
Patients on estrogen or progesterone hormone replace-
ment therapy (HRT) should be monitored closely for pigment
changes. It is sometimes recommended that patients stop
(HRT) or the contraceptive pill for at least the first 6 months
after a peel. Patients who work mostly outdoors should also be
warned of the high risk of hyperpigmentation and the absolute
necessity not only to wear an effective sunscreen, but also to
modify their general “daylight” behavior.
Patients with Mental or Behavioral Disorders
The patient must be able to understand the process and limita-
tions of a deep peel. He or she must agree to comply with strict
rules before, during, and after the peel. Any cosmetic proce-
dure that requires intervention on the part of the patient, and
particularly a deep peel, is strictly contraindicated for patients
lacking minimum intelligence. The patient must be able to
understand and accept the need to wear sunblock and makeup
after the peel and be aware of the time needed for the skin to
recover completely.
Overly sensitive patients are likely to bombard the doctor
with complaints, worries, questions, and recriminations. It is
preferable to assess the patient’s mental and physical tolerance
and propose a less painful peel that does not entail complica-
tions before moving on to a deeper peel. Personal tolerance lev-
els can thus be tested, and patients gradually become aware of
what a peel involves and what it can do.
The patient should be shown a series of photographs
illustrating the appearance of the face day by day during the
first week following a peel. Ideally, these photos should also
be shown to the patient’s immediate family or friends. Without
this precaution, paranoid patients or family or friends might
not believe the doctor’s assurances that it is all part of the nor-
mal process.
Isolated Patients
Being alone is not in itself a contraindication for a phenol peel-
ing, but patient safety requires a few rules. Today’s phenol peel-
ings are formulated to allow outpatient treatment: the patient
can go home soon after the phenol peeling. However, a phenol
peeling triggers significant swelling that can sometimes make
it difficult for patients to open their eyes during the first night
or the day after the peeling. It is therefore out of the question
to allow a patient living alone to go home after the peeling. The
patient has to be helped in all aspects of daily life for the first
three days after the peeling. Clinics with hospital beds can also
keep patients on-site for the first few days.
Neck Peeling
Ideally, a deep phenol peeling (Lip & Eyelid Formula) is
intended for facial skin only, and the rest of the body should
be treated with other peels. Easy Phen Light or Easy TCA Pain
Control can be applied to the neck down to the 7th cervical and
collarbone, but not at the same time as the treatment of facial
skin, because the surface of absorption would be too large and
increase the risk of toxicity.
If a phenol peel is considered necessary on the neck, the
following points should be observed:
•
The peel on the neck should be performed the day after the
facial peel.
•
Do not apply any waterproof or occlusive bandage on the
neck.

268      Textbook of Chemical Peels
•
The solution should be applied sparingly to the skin of the
neck.
•
Motion and friction after the peel should be avoided, as
there is a risk of scarring.
•
Avoid maceration of phenol in the folds of the neck. Such
maceration is equivalent to an occlusive bandage.
Skin Regeneration
Regeneration comes from the pilo-sebaceous units in the case
of a deep peel. The face is more richly endowed with pilo-
sebaceous units than the neck, and regeneration on the face is
quicker and carries a lower risk of scarring than a peel per-
formed on nonfacial skin.
Sun Exposure
Exposure to the sun should be avoided completely, and an
effective sunblock (Melablock-HSP 50+ or 30) used for 6 months
following the peel. PIH is not uncommon, even after a phenol
peel. After the immediate postpeeling period, which requires
close and almost daily monitoring, it is advisable to see patients
again after 15 days, 30 days, and 2 months, and to warn them
of the need to treat the beginning of hyperpigmentation
immediately.
Conditions That Can Be Aggravated
Some skin disorders that can be made worse by a phenol peel
are telangiectasias, seborrhoeic dermatitis, eczema, acne rosa-
cea, lupus, and other (auto-)immune diseases. They are contra-
indicated for a phenol peel.
Choice of Patient
Choosing the right patient is one of the main rules of safety and
involves taking account of the indications, contraindications,
and results from a number of essential preliminary clinical
tests. A phenol peel should not be applied if there is any doubt
or if the hoped-for result is impossible to achieve.
Local and Systemic Safety
The following list summarizes some of the safety rules to
observe when applying a phenol peel.
1. The product should be applied only to the face, where the
numerous sebaceous glands allow the epidermis to regen-
erate better.
2. It is preferable not to treat the neck with phenol for local
dermatological reasons and so as not to increase the area
of absorption. It is important to determine the lower limit
of the treatment on the face. Do not go beyond the area of
shadow under the jawbone.
3. The right choice of formula and complying with the tech-
nical details of its application can give fully reproducible
results. The doctor must not apply a peeling with formula
“Number 1” using the application protocol for formula
“Number 2.” In some cases, this precaution is not essen-
tial, but in others it is.
4. Any risk of contact of the acids, especially phenol, with
the eyes should be avoided; in case of contact, flush with
saline and consult a specialist.
5. Do not use phenol on patients with liver, lung, or kidney
dysfunction; cardiovascular disease; or blood disorder.
6. Do not use phenol on patients suffering from Ehlers-
Danlos syndrome, connective tissue disorder, insulin-
dependent diabetes, or active skin disorders (acne,
herpes, lupus, etc.).
7. Great care should be taken, and all the safety rules (regard-
ing equipment and skills) should be observed.
8. Doctors should notify their professional insurers that they
perform this type of peeling.
9. The toxicity of phenol is paradoxical: less concentrated
solutions have the potential to be more toxic than solu-
tions of a higher concentration, depending on the speed of
application and the surface area treated.
10. The phenol solution must be stable. Unstable solution
should be discarded.
11. In addition to improving the cosmetic result, applying an
occlusive bandage slows down absorption of phenol and
can reduce toxicity. The masks must be properly fitted to
prevent air from getting trapped, folds from forming, or
phenol from pooling.
12. The doctor must be aware of all potential complications,
monitor for them, be able to treat them, and have the nec-
essary equipment to deal with them.
13. Phenol should be applied slowly, in at least 1 hour, on
patients in good health, with normal liver and kidney func-
tion, and who can be expected to have a good esthetic result.
14. Hydrate, ventilate, and monitor (pulse oximeter, car-
dioscope, tensiometer) the patient. An intravenous drip
should be set up beforehand and, if necessary, a glucose
solution can be administered to avoid hypoglycemia.
15. A local lidocaine nerve block and/or deep sedation avoid
the risks associated with general anesthesia or products
that might irritate the myocardium.
16. Do not leave the vial of phenol with the top off: if the vial
is open, the solution will evaporate, changing the con-
centration of the active product with potentially serious
consequences. Never handle the bottle of phenol near the
patient’s eyes, and generally avoid projection of phenol on
the patient or the caregiver.
NOTES

1. Because of the risk of secondary infection, patients with immu-
nodeficiency (e.g., HIV) should be ruled out from a full-face phe-
nol peel, as should patients with hypogammaglobulinemia.

2. See the section on scarring in Chapter 37.

3. Fiatsi Y. Exoderm, a novel, phenol based peeling method result-
ing in improved safety. American Journal of Cosmetic Surgery. 1997;
14: 49–54.

4. McCulloch EG, Langsdon PR, Maloney BP. Chemical Peel
with Phenol. In: Roenigk RK, Roenigk HH (Eds.). Dermatologic
Surgery, Principles and Practice. 2nd ed. Oxford: Dekker, 1996:
1147–60.

5. Doctors should not suggest a peel as the answer to a patient’s
personal problems. A peel repairs the skin, not the soul.

6. Vigneron JL. Les peelings en dehors du visage. Journal de Médecine
Esthétique et de Chirurgie Dermatologique. 1993; XX(75): 53–6.

7. Rusciani L, Rossi G, Bono R. Les peelings cliniques. Journal de
Médecine Esthétique et de Chirurgie Dermatologique. 1993; XIX(78):
75–80.

32
Phenol
Prepeel preparation
The preparation procedure for a local phenol peel has some
aspects in common with those for a full-face phenol peel; how-
ever, a local application of phenol is far easier.
EIGHT DAYS BEFORE THE PEEL
Photographs
Before any treatment, top-quality photographs (TIFF format)
should be taken of the patient’s face, profile, and three-quarter
profile (Figure 32.1), with and without flash. A flash changes the
appearance and color of the skin: dyschromias are less appar-
ent and reliefs are flattened. Pigmentation and relief are more
clearly visible on photos taken without flash, especially in natu-
ral, low-angled light (Figure 32.2).
Any preexisting abnormalities will be recorded to avoid
any potential medical and legal problems later. In this way, a
“round eye” appearance after surgery, lagophthalmia, or ectro-
pion should be photographed and noted in the file. Nevi and
other lesions should be photographed in particular. The whole
peel procedure could also be filmed. The patient, preferably
accompanied by a member of his or her family, will have seen
sequenced photos showing the after-effects of a phenol peel,
day by day.
Preparing the Skin
Many phenol peel techniques require skin preparation before
the peel to ensure that penetration is even and to reduce com-
plications (see Chapter 2). No specific preparation is necessary
before Lip & Eyelid Formula.
Botulinum Toxin
Botulinum toxin should be injected 1 week before the peel into
the patient’s forehead or glabellar wrinkles, crow’s feet, lip
wrinkles, or radial wrinkles around the outer canthus of the
upper eyelid. Blocking the muscles allows the skin to regener-
ate more evenly. The results will be of better quality and longer
lasting. This is also the ideal moment to shave off any benign
skin tumors, remove small sebaceous cysts, and fill any deep
furrows.
Medication
The patient should be given a prescription for:
•
A strong analgesic to be taken before the peel to test for
tolerance. Acetaminophen plus codeine is usually strong
enough and well tolerated. (Beware of patients on mono-
amine oxidase [MAO] inhibitors: they are contraindicated
in combination with many other drugs, including some
analgesics or sedatives that have to be used for the patient’s
comfort during and after the peel.)
•
A benzodiazepine (e.g., 2 mg lorazepam).
•
Aciclovir (or, better, valaciclovir) if the patient has a history
of herpes.
•
Sterile white Vaseline for postpeel care.
•
An antipruritic (e.g., promethazine).
•
Domperidone to settle the stomach in case of postpeel
nausea.
•
Makeup that matches the patient’s skin color: Couv-rance
or Covermark are both well tolerated by patients starting
on the 8th day after the procedure.
•
Single-dose carmellose sodium eye drops to be used freely
after the phenol peel to alleviate any eye irritation, which is
common during the hours following a full-face phenol peel.
Legal Documents
The patient should be given the following documents to read
and sign: informed consent (Box  32.1), authorization to take
and use photographs (Box 32.2), and a general questionnaire on
health and coagulation (Box 32.3).
Clinical Examination
The patient should be given a full clinical examination and
be questioned carefully; the results should be recorded in the
patient’s file. The patient should be given a cardiovascular
examination before the peel if there is any doubt as to his or
her cardiovascular health, or merely as a precaution; the doc-
tor then should obtain the opinion of a specialist to confirm
that there is no cardiovascular contraindication to the peel. The
patient should be asked to have a biological examination. The
results must be checked before the start of the peel. It is essen-
tial to check the patient’s blood count1 and liver and kidney
function, to make sure there is no bacterial or viral infection,
diabetes, or immunodeficiency.
THE NIGHT BEFORE AND MORNING
OF THE PEEL
The evening before the peel, patients should take lorazepam
if they are worried about not getting to sleep. Patients who
are very nervous or anxious can take another lorazepam
tablet on the morning of the peel, together with 10–20 mg of
domperidone.
ONE HOUR BEFORE THE PEEL
The patient should arrive at the clinic half an hour to an hour
before the peel and should not have eaten for more than 4 hours.
•
If the peel is to be done without deep sedation, the patient
should immediately be given premedication, as per the
doctor’s usual practice: for example, one sublingual tab-
let of Temesta 2.5  mg (lorazepam) if the patient has not
taken any that morning and 15 drops of tilidine (a major

270      Textbook of Chemical Peels
(c)
(b)
(a)
(e)
(d)
Figure 32.1  (a) Right profile. (b) Three-quarters right. (c) Full face. (d) Three-quarters left. (e) Left profile.
(b)
(a)
Figure 32.2  The same patient during the same consultation (a) without flash and (b) with flash; relief and lip wrinkles are flattened by the
effect of the flash. The nasolabial folds, on the other hand, are more clearly visible with flash.

Phenol: Prepeel preparation      271
analgesic) or any other strong analgesic the doctor usually
prescribes. It is best to use an analgesic that the patient can
tolerate easily.
•
If the peel is to be performed under deep sedation or
neuroleptanalgesia, the anesthetist should deal with
premedication.
ADVANTAGES OF BENZODIAZEPINE
Using benzodiazepine as premedication is very worthwhile.
There are four obvious advantages:
1.
Anxiety and fear of pain increase the perception of pain.
Benzodiazepines play an auxiliary role as an analgesic.
2.
Benzodiazepines cause a certain amount of amnesia. More
than 2.5 mg of sublingual lorazepam can produce partial
amnesia that lasts for more than 10 hours. Midazolam pro-
duces short-term but deep amnesia that makes the patient
forget any pain he or she may have felt in the course of the
treatment.
3.
Benzodiazepines are neurostabilizers that can counteract
the initial toxic neurological effects of local anesthetics or
phenol.
4.
A long-acting benzodiazepine greatly improves patient
comfort. It makes the patient feel drowsy, which reduces
facial movements and therefore helps keep the postpeel
occlusive mask in place. Also, when a patient has taken
2.5 mg of sublingual lorazepam as premedication, he or she
will feel much less pain immediately after the peel. A calm
patient is a patient who does not complain, does not fidget,
does not speak, does not smoke, and does not scratch.
BOX 32.2  Example of a Photographic Consent Form
Place and date
Mrs./Mr. –––––––––––––––––––––––––
Address: –––––––––––––––––––––––––
Date of birth: –––––––––––––––––––––
Tel: –––––––––––––––––––––––––
I authorize Dr. –––––––––––––––––––– to use the photographs taken before and after treatment in:
Medical science congresses or conferences
Scientific articles or papers to be published in medical reviews
Media publications
I do not authorize the use of photographs
I have checked the points I agree to and deleted the point or points that I do not agree to. This document comes in two copies: one
for the patient and one for the doctor.
Signature, preceded in handwriting by the words “read and approved.”
BOX 32.1  Example of an Informed Consent Form
Place and date
Mrs./Mr. –––––––––––––––––––––––––
Address: ––––––––––––––––––––––––
Date of birth: –––––––––––––––––––––
Tel: –––––––––––––––––––––––––––––
Authorizes Dr. –––––––––––––––––––– to perform on my person/on ––––––––––––––– for whom I am legally responsible.
A CHEMICAL PEEL OF THE TYPE –––––––––––––––––––––––––
I declare that I have been properly informed of the details of this treatment, of the composition of the solution that will be applied on
my skin, of its immediate effects, of the process of skin recovery, of the postpeel care after treatment, and of the precautions to be
taken during the months following the peel. I have also been informed that, because of the variability of individual reactions, it is not
possible to be given a precise date when normal activities may be resumed. I have also been informed of the usual risks of local
anesthesia, sedation, and the treatment itself, and I accept them.
The doctor has informed me of alternative methods of treatment to the above-mentioned chemical peel, and I choose this latter
course of treatment with full knowledge of the facts. Should any unforeseen situation or complication arise that requires medical
intervention not described in the explanations given beforehand, I authorize the medical team to make any decision that they deem
necessary or useful.
I have been fully informed of the fact that the doctor cannot guarantee perfect results after the first application, and accept the
possibility of having a touch-up.
I acknowledge that I have been given valid answers to all my questions, either in the written documentation that I have received
written in language I can understand and that I have read carefully, or orally by the doctor during consultations prior to treatment.
Date and signature preceded in handwriting by the words “read and approved.”
Originally drawn up by the Sociedad Española de Medicina y Cirugía Estética, Barcelona, SEMCC.

272      Textbook of Chemical Peels
PREPARING THE OCCLUSIVE MASK
Sleek, Micropore, Blenderm, or Leukoflex
The occlusive mask applied at the end of the peel will consist
of either a single or a double layer, depending on what type of
dressing is used. Sleek and Leukoflex2 can be used in a single
layer. Leukoflex has an advantage over other brands in being
transparent. Micropore can be applied in two layers, or a layer
of Blenderm can be applied on top of the first layer of Micropore
(Figure 32.3).
Whichever dressing is used, the tape should be precut
into 3–5 cm strips (Figure 32.4) and placed within easy reach,
ready for the occlusive mask (Figure 32.5) to be applied at the
end of the peel.
SETTLING THE PATIENT
The patient is placed in a comfortable position to be maintained
for over an hour without moving,3 covered in a warm electric
blanket or a metallic survival blanket.
Protecting the Eyes
A small quantity of sterile ophthalmic Vaseline should be
put in the conjunctival cul-de-sacs. The Vaseline deactivates
BOX 32.3  Example of a General Questionnaire
and Coagulation Questionnaire
Are you taking medication that contains aspirin or an
anti-inflammatory? Yes/No
Are you currently taking medication to thin the blood?
Yes/No
Do your gums bleed when you brush your teeth? Yes/No
Have you ever had any problems with bleeding:

During dental treatment? Yes/No

During child birth? Yes/No

During surgery? Yes/No
Have you ever had blood in your stools? Yes/No
Do you bruise easily? Yes/No
Do you feel that you bleed a long time when you cut
yourself? Yes/No
Are your periods abnormally heavy? Yes/No
Do you have any other problems with bleeding? Yes/No
Do any members of your family have problems with
bleeding? Yes/No
Are you on any medication at present? Yes/No
If yes, which? (give details below)
–––––––––––––––––––––––––––––––––––––––––––––––
Have you ever been treated for heart trouble? Yes/No
Do you get palpitations? Yes/No
Have you ever had any treatment for the lungs? Yes/No
Do you have asthma? Yes/No
Have you ever had phlebitis? Yes/No
Have you ever had a pulmonary embolism? Yes/No
Have you ever had an operation? Yes/No
For what? (give details below)
–––––––––––––––––––––––––––––––––––––––––––––––
Have you ever had a local anesthetic? Yes/No
If you did not tolerate it, what happened? (give details
below):
–––––––––––––––––––––––––––––––––––––––––––––––
Are you allergic? Yes/No
To what?
–––––––––––––––––––––––––––––––––––––––––––––––
Figure 32.5  After cutting, the pieces of occlusive dressings are
installed on a sterile base, easy to take.
Figure 32.4  The most common technique involves the use of
occlusion for 24 hours. An assistant prepares the strips of occlu-
sive tape, cutting them to the right size (about 3–5 cm long) so that
the occlusive mask can be applied immediately after the peel.
Figure 32.3  Four different types of occlusive dressing that can
be used for occlusive phenol.

Phenol: Prepeel preparation      273
the phenol and protects the eyes from accidental contact.
Terramycin ointment or ophthalmic gentamicin can be used
instead of ophthalmic Vaseline.
A syringe of physiological saline (200 cm3 at least) should
be prepared, to be kept at hand to rinse out the eyes immedi-
ately in case of contact with phenol (which is highly unlikely if
the peel is applied correctly).
Ventilation
Keeping the treatment room properly aired and ventilated4 and
fanning the patient’s face help make the patient more comfort-
able when the doctor goes through the essential phase of care-
fully cleansing the skin with acetone and alcohol before the
peel (Figure 32.6). It is most unpleasant for a patient to have to
inhale the fumes when these products are being wiped on the
lips, cheeks, and chin.
Good ventilation prevents sweating, especially in hot cli-
mates: sweat overhydrates the superficial layers of the epider-
mis, which can lower the concentration of the active products
locally and increase skin permeability. Ventilation also creates
drafts that will stop the phenol vapors from stagnating in the
immediate vicinity of the patient and doctor.
INTRAVENOUS DRIP AND MONITORING
Diuresis
Osmotic balance across the plasma membrane is regulated by
the concentration of proteins (albumin more than globulins).
Relative dehydration would increase plasma oncotic pressure
and capillary absorption of water and water-soluble molecules.
Phenol is soluble in water, and its absorption rate could be
accelerated by the slightest dehydration.
Intravenous access should always be set up to help diure-
sis by infusing 1 liter of physiological saline or glucose solution
throughout the procedure and for 1 hour afterward. Proper
diuresis is usually considered to be an effective way of reduc-
ing the toxic effects of phenol by helping renal elimination.
Cardiorespiratory Monitoring
Every patient must be properly monitored with pulse oxim-
etry and electrocardiography (ECG). Even if the peel is done
by the book and even when the simplest and least aggressive
techniques are used, stress can cause vagal reactions, low blood
pressure, and tachycardia. Pulse oximeter monitoring can pick
up on any drop in oxygen saturation that could accentuate
myocardial irritability and cause arrhythmias.
Without monitoring, a simple vagal reaction can go
undetected, and if it is not treated correctly, the patient can
pass out or even stop breathing. The pulse oximeter is not very
effective at detecting arrhythmias; continuous ECG monitor-
ing is essential, even though some authors5 recommend simply
checking the heartbeat and vital signs when more than half
the face is treated with a phenol peel. This vague recommenda-
tion could be taken as encouraging an amateurish approach,
while close and continuous monitoring is essential as a simple
precaution. Other authors,6 on the other hand, recommend
monitoring the patient up to 4 hours after a phenol peel, which
seems excessive given the results of toxicological studies
showing how quickly phenol is metabolized and detoxified.
The blood levels of phenol recorded by Deichmann and Litton
during a full-face phenol peel show a rapid drop in plasma
values 2 hours after the beginning of the application. The
blood level of phenol always remains below toxicity thresholds
when phenol is applied slowly. It is therefore not unreason-
able to stop monitoring the patient shortly after the occlusive
mask has been applied. By then, approximately 2 hours after
the beginning of the application, the liver is detoxifying the
phenol effectively, the kidneys are eliminating it, and plasma
levels are already going down.
Corticosteroids, Atropine, and Antibiotics
Some authors recommend injecting 125  mg of solumedrol
intravenously before starting a phenol peel: injecting a steroid
is said to reduce postpeel edema and to prevent some of the
complications described earlier. However, the author has not
noticed any advantage from this injection. The aftereffects of
the peel are similar with or without corticosteroids. However,
it is worth considering an intravenous injection of prednisolone
for patients who smoke and do not have any history of gas-
tric ulcers. Smokers have an increased risk of laryngeal edema
immediately after a full-face phenol peel.
Atropine should not be injected automatically before a
full-face phenol peel. It should be at hand, however, to treat
any incidence of bradycardia. As a precaution, it has been
recommended to inject a broad-spectrum antibiotic before a
phenol peel, although this is not essential for the correct peel
procedure.
CLEANSING, DEGREASING, AND DISINFECTING
Once the patient is settled in comfortably in the dorsal decu-
bitus position and put on a monitor and drip, the doctor can
start cleansing the skin either before or after the anesthetist
has started injecting the sedatives. The skin is cleansed and
disinfected with a mixture of chlorhexidine,7 water, and alco-
hol in equal parts (5 cm3 of each). It is then rinsed and dried
thoroughly. The whole area is carefully degreased with a swab
lightly soaked in acetone (or ether) until all traces of oil or skin
debris are gone. The skin must be degreased very carefully,
applying medium pressure8 and paying special attention to the
base of wrinkles and acne scars. The patient should be properly
ventilated (with an electric or handheld fan) to avoid inhaling
the acetone and alcohol vapors. It takes approximately 10 min-
utes to cleanse the skin thoroughly. Applying medium pressure
helps extract and eliminate some of the residual sebum from
the sebaceous glands, but should not take off the stratum cor-
neum: the doctor must be careful not to abrade the skin with
the swab before a phenol peel. Acetone has various functions:
it degreases, cleans, and helps the phenol penetrate; it also
Figure 32.6  Ventilation during a local application of phenol
(chemical cheiloplasty; see Chapter 36).

274      Textbook of Chemical Peels
breaks down the barrier function of the epidermis.9 This pre-
liminary phase of careful cleansing, disinfecting, and degreas-
ing is essential to get perfect results. Phenol does not penetrate
as evenly and as well through skin that has not been properly
cleansed.
ASEPSIS
It is easier and more precise to hold the phenol-soaked cotton-
tipped applicator with a bare, ungloved hand. It is therefore
imperative for the doctor to disinfect his or her hands surgi-
cally to avoid infecting the patient’s skin. The assistant who
cuts the occlusive dressings and helps the doctor put them in
place should also disinfect his or her hands in the same way,
for the same reasons.
There are two reasons a mask should be worn: first to
avoid contaminating the patient’s skin with respiratory bacte-
ria, responsible for many of the cases of secondary infection
described, and second to protect the doctor from partially
inhaling the phenol vapors. Standing above the phenol vapors
for over an hour, the doctor inhales a fair amount of this vola-
tile chemical, which can have unpleasant side effects such as
dysgeusia or nausea.
Any person with any kind of infection should be kept
away from the treatment room: it is out of the question for a
doctor to perform a phenol peel when suffering from a sore
throat, tracheitis, impetigo, or a fungal infection on the hands.
NOTES

1. To screen for anemia, an obvious contraindication for a full-face
phenol peel.

2. Leukoflex is included in the Lip & Eyelid Formula kit.

3. Particular care must be taken with patients who suffer from lum-
bago, as they sometimes find it difficult to remain in a dorsal
supine position on a hard surface for a prolonged period of time.

4. By mechanical ventilation with an electric fan, air conditioning,
fanning by hand, and so forth.

5. Benatar D. Le peeling au phénol. Journal de Médecine Esthétique et
de Chirurgie Dermatologique. 1988; XV(60): 319–23.

6. Konior RJ, Kerth JD. Selected approaches to the aging face.
Otolaryngology Clinics of North America. 1990; 23: 1083–95.

7. If there is no chlorhexidine, simple disinfection with 70% alcohol
is sufficient.

8. The pressure should be equivalent to scratching.

9. Simply applying acetone increases DNA synthesis as well as
synthesis of skin lipids.

33
Full-face phenol
Nerve block anesthesia and/or sedation
PROPERTIES OF COLD
Cold has interesting anesthetic properties1 that develop when
the surface of the skin reaches 5°C. The temperature of the
dermis and hypodermis is then 15°C. Even if the skin can
withstand this temperature for a long time without any obvi-
ous damage, in practice it is unthinkable to use cryoanesthesia
alone for a full-face phenol peel. Limited areas can, however,
be cooled before applying the acids2 to make the application
more bearable, when no other anesthetic is being used. To do
this, the practitioner can use 3M cold packs (Figure 33.1) or
surgical gloves filled with an aqueous solution mixed with
antifreeze (75% water and 25% antifreeze). The skin must not
be frozen, of course. Some doctors use a facial anesthetic tech-
nique that consists in injecting Klein solution3 cooled to just
a few degrees Celsius under the skin of the face. This pain-
ful technique does not produce sufficient surface anesthesia,
and changes all the parameters of how the phenol penetrates
through the skin. The skin itself, as opposed to the subcuta-
neous tissue, is only partially anesthetized by this type of
injection, and the peel is still very painful. It is also impos-
sible to inject this solution in the lips, nose, eyelids, and so
forth. Doctors who use lasers are familiar with the Dermacool
device: it generates cooled air that can be directed locally
using a handpiece. This cooling device is sometimes used for
local applications of phenol.
ANESTHETIC PROPERTIES OF PHENOL
Phenol was used widely in the First World War as an antisep-
tic and a local anesthetic in surgery. Depending on the concen-
tration and the different adjuvants used, phenol can induce
coagulation or lysis of the membrane and interstitial proteins,
which clinically manifests as the whitening of the skin that
occurs when phenol is applied. An application of phenol imme-
diately triggers intense pain followed by local anesthesia that
takes effect within about 15 seconds, as the skin whitens. The
pain caused by an application of phenol is therefore very brief.
The local anesthetic effect lasts for 20–30 minutes, shortly after
which the processes of dermal inflammation intensify and trig-
ger a painful, pulsing heat that, depending on the patient’s own
perception, is relatively intense. This pain gradually subsides
over the following few hours and goes completely once edema
sets in and the inflammation has stabilized, usually the morn-
ing after the peel. Phenol can therefore be applied on very small
surface areas without any anesthetic: it is enough to tell patients
that they will feel an intense burning for 15 seconds, immedi-
ately after the phenol has been applied on the skin. The patient
should be given painkiller tablets to alleviate the postpeel pain,
which can last until the following morning.
The eyelids and upper lip can be treated with Lip & Eyelid
Formula, without any analgesic other than an acetaminophen
plus codeine tablet to be taken 1 hour before treatment. Patients
should also be given a clear description of the pain they will
feel. By the time they have counted to 15, the pain will have
gone.
TYPE OF ANESTHESIA FOR A FULL-FACE PEEL
Unlike a local application of phenol, a full-face phenol peel
cannot be done without anesthetic.4 There are several different
possibilities.
General Anesthesia
According to the medical literature, general anesthesia (GA)
should not be considered as an additional cardiovascular risk
factor during a phenol peel. However, there are other effec-
tive techniques that are less complex and also less dangerous.5
Furthermore, pain is at its height in the hours following treat-
ment—a long time after the GA has worn off. GA is a needless
source of stress.
GA does not make the patient more comfortable or any
safer. On the contrary, it adds the inherit risks of GA to those of
the phenol peel. GA is not the ideal choice for a full-face phenol
peel. It is never indicated for a local phenol peel.
Facial Nerve Blocks
Facial nerve blocks (FNBs) are quick and easy to administer,
are not painful, and cause few complications in the hands of
an experienced doctor. A drop of 2% lidocaine can be injected
very superficially with a fine-gauge (32G) needle in precisely
the same place that the nerve itself is injected with a 25-gauge
needle. It is not possible to see the backflow of blood before
injection with a 32G needle.
Allergy to Local Anesthetics
Allergies to local anesthetics (LAs) are rare, and the term allergy
is often used to describe numerous problems that are more
likely an overdose or a vagal reaction. Publications report that
the frequency of allergic reactions to LAs is no more than 1%
of all the side effects encountered.6 Lidocaine is an amide local
anesthetic that does not cause many allergies.
Procaine, on the other hand, is an ester-type local anes-
thetic: when it is injected into the organism, it is transformed
into N,N-diethylaminoethanol and para-amino-benzoic acid
(PABA) when the ester link that binds these two components
of procaine is broken. PABA is a well-known allergen. Methyl
para-hydroxybenzoate, whose structure is similar to that of
PABA, is also called PAB or methylparaben. It is a preservative
that binds, like a hapten, to the immunoglobulin E (IgE) on the
surface of mast cells and basophils and may be the cause of
the few cases of anaphylactic shock that have been described.
Other patients may be allergic to metabisulfite conservative,
found in preparations containing adrenaline (epinephrine).

276      Textbook of Chemical Peels
Toxicity of Local Anesthetics
When nerve fibers depolarize, the sensation of pain is carried
from the periphery to the brain. LAs are molecules that stabilize
the membranes of excitable cells that are susceptible to depolar-
ization. Their general toxicity is directly linked to this property.
In cases of overdose, excessive cell membrane stabilization in
the central nervous system (CNS) and the cardiovascular sys-
tem produces severe side effects. Different factors influence the
risk of intoxication with LAs. For example, capillary absorption
is more rapid in the face than on the body. The large number
of facial blood vessels is one factor that speeds up absorption.
Other factors that can cause intoxication include lack of adrena-
line, low body weight (<45 kg), advanced age, and competition
with other molecules that use the same detoxification path-
ways. Intoxication with lidocaine is dose-related: unless there is
a gross error when injecting, the symptoms are gradual and do
not start with loss of consciousness or convulsions. The toxicity
of bupivacaine, on the other hand, can trigger cardiovascular
symptoms together with neurological symptoms.
The first signs of local anesthetic CNS toxicity are drows-
iness, yawning, and a general feeling of malaise. The patient
may complain of feeling lightheaded, anxious, or dizzy. They
may appear confused, pale, or disoriented and complain of
visual, auditory, or gastric symptoms. When blood levels of
lidocaine increase and reach 4–7  µg/ml, muscle spasms or
tremors may start. The patient may have difficulty speaking
and suffer from hallucinations, nystagmus, and dizziness. Loss
of consciousness follows, as blood levels of lidocaine reach or
go beyond 8 µg/ml. Muscle spasms and tremors can develop
into convulsions. Severe respiratory depression can lead to
respiratory arrest, and the patient goes into a coma and dies if
not properly ventilated. Death can come from both respiratory
arrest and arrhythmia.
The cardiovascular system is actually more resistant to
LAs than the CNS, and cardiac toxicity starts at much higher
blood levels of lidocaine. The first stages of cardiovascular tox-
icity are spontaneously reversible; they manifest in changes
in blood pressure: stable or higher to start with, due to vaso-
constriction or the increase in cardiac sympathetic tone, it then
drops because of the decrease in cardiac output without any
change in peripheral resistance.7 Circulatory collapse occurs as
a result of negative inotropic effects, bradycardia caused by the
reduced excitability of the myocardial cells, decreased intra-
cardiac nerve impulse conduction, and the direct myorelaxant
effect on the vascular fibers that causes peripheral vasodilation.
Cardiorespiratory resuscitation should be carried out immedi-
ately. Caution therefore dictates setting up venous access for
fluid administration, an electrocardiograph, a pulse oximeter,
and a sphygmomanometer.
The first thing a doctor faced with LA toxicity must do
is to ensure good ventilation, while monitoring the patient’s
heartbeat. An upset stomach, one of the first signs of intoxica-
tion, can trigger vomiting. If the patient is not placed correctly
in the “safety” position, the airways can become blocked, caus-
ing respiratory arrest and convulsions or inducing hypoxemia,
hypercapnia, or acidosis, all conditions that can aggravate
arrhythmias. The low quantities of lidocaine needed to do the
facial nerve blocks for the hour that the peel will last make CNS
and cardiovascular toxicity to LAs almost impossible. It is nev-
ertheless essential to recognize the symptoms and to be able to
treat them.
Choosing the right LA agent is also a safety factor, and
the discussion later in this chapter will reveal why simple lido-
caine without adrenaline is the best choice of molecule for a
phenol peel, both local and full-face.
Bupivacaine
Bupivacaine is an amide-type anesthetic and rarely causes
allergic reactions. It is stronger than lidocaine and has a lon-
ger duration of action (anesthesia for about 3–6 hours). It also
has a slow onset of action, and it takes 20–30 minutes for the
anesthetic effect to develop. Mixing bupivacaine with lidocaine
speeds up the onset of action, as lidocaine anesthetizes almost
immediately. It is therefore very tempting to combine the two
products to achieve immediate anesthesia with the lidocaine
as well as a longer duration of anesthesia with the bupiva-
caine, which starts to take effect almost as the lidocaine stops.
Bupivacaine is far more toxic than lidocaine, however, and no
more than a total of 10 cm3 should be used for all of the nerve
blocks on the face.8 The threshold value for the onset of neuro-
logical toxicity in humans is 6.4 mg/kg for lidocaine and only
1.6 mg/kg for bupivacaine. The threshold value for the onset
of neurological side effects in a patient weighing 50 kg would
therefore be 80 mg. A 10 cm3 phial contains 50 mg of bupiva-
caine. Intravascular injection is instantly toxic to the heart and
can induce ventricular arrhythmias, ventricular tachycardia,
ventricular fibrillation, and cardiac arrest.
Moreover, injecting small quantities of bupivacaine in the
head or neck can cause symptoms of systemic toxicity similar to
those caused by the accidental intravascular injection of much
larger quantities. If it is not possible to avoid using bupivacaine,
it is essential to do an aspiration test before each injection.
There are many drawbacks to using this product in a
full-face phenol peel: its slow onset of action requires patience,
and the nerve block takes about 30 minutes to set up but lasts
180–360 minutes. This product is painful to inject. The doses
required to produce a nerve block of the whole face are lower
than the neurotoxic doses, but not by much. As discussed ear-
lier, the dose required for the face is at least 50 mg, while the
toxicity threshold starts at 80 mg and the maximum allowed
dose is 150 mg. As mentioned in Chapter 28, Lalanne’s9 experi-
ment clearly shows that perivascular injections, even when the
Figure 33.1  3M cold pack. This photo shows the forehead being
cooled prior to a trichloroacetic acid peel to the papillary dermis
(Unideep).

Full-face phenol: Nerve block anesthesia and/or sedation      277
blood vessels have been properly dissected and are in plain
view, can be followed by vascular absorption and trigger seri-
ous rhythm disorders. It is therefore advisable not to use bupi-
vacaine for facial nerve blocks, especially in a full-face phenol
peel, when any molecule likely to irritate the heart must be
avoided. Besides, the most painful part of a phenol peel is the 20
seconds immediately following the direct application of phenol
to the skin. The pain caused by postpeel inflammation is soon
alleviated with painkiller tablets and lorazepam.
Ropivacaine
Ropivacaine is an amide-type LA, a vasoconstrictor at less
than 1% and a vasodilator at more than 1%.10 The fact that it
is the pure S-enantiomer reduces its toxicity. Like phenol, it is
metabolized by the liver and eliminated by the kidneys. When
administered by dermal injection, it has a rapid onset of action
(less than a minute), and the duration of action is longer than
or equal to that of bupivacaine. Combining it with adrenaline
does not prolong its duration of action, and a concentration of
0.75% provides longer anesthesia than a concentration of 1%.
Neurological and cardiovascular tolerance to ropivacaine is
much better than to bupivacaine. What is more, there is a con-
siderable difference between the neurotoxic and cardiotoxic
doses. The toxicity of ropivacaine is intermediate between that
of lidocaine and bupivacaine. Direct intravascular injection of
ropivacaine is still dangerous, however.
Prilocaine
Prilocaine is an amide-type LA, with a very low allergenic poten-
tial and low toxicity11 and is nonvasodilating. Unfortunately,
prilocaine is metabolized into ortho-toluidine, a chemical that
can induce methemoglobinemia. In doses higher than 500 mg,
it can cause cyanosis and reduce the oxygen-carrying capacity
of the blood.
Mepivacaine
Mepivacaine is intermediate between bupivacaine and lido-
caine in its kinetics of action. The FNB is set up more slowly
than with lidocaine, in 10–15 minutes, although it lasts 90–180
minutes. Mepivacaine has no real advantage over lidocaine, as,
at the same dose, its duration of action is only slightly longer.
Mepivacaine does not cause vasodilation but, unlike lidocaine,
it does not have an antiarrhythmic action.
Lidocaine
Lidocaine is an amide-type LA with a very short onset of action.
It produces an immediate FNB that lasts from 25 to 45 minutes,
depending on whether it is combined with adrenaline.
Unlike other LAs, lidocaine has an anticonvulsant action
through the competitive inhibition of the subcortical receptors
(0.5–4 mg/ml). It stabilizes the heartbeat:12 an intravenous injec-
tion of lidocaine is an effective treatment for heart arrhythmias
resulting from phenol intoxication.
The toxicity of lidocaine is increased by beta-blockers and
cimetidine, as they decrease blood flow in the liver, slow down
detoxification, and increase plasma levels. Calcium channel-
blocking agents increase the risk of arrhythmia by altering the
electrical activity of the myocardial cells. Digitalis glycosides
also alter atrioventricular conduction and increase the risk of
rhythm disorders. Diphenylhydantoin can increase the free
fraction of lidocaine by competing with the plasma proteins at
the binding site. Stabilization of the CNS with benzodiazepines
can mask the first signs of lidocaine intoxication. However,
the body easily eliminates the low doses of lidocaine used in a
series of FNBs, and there have been no reported cases of lido-
caine intoxication during a full-face phenol peel performed
with FNB.
Combination with Adrenaline (Epinephrine)
Adrenaline stops LA spreading and shortens the onset of
action; it prolongs the duration and improves the depth of
local anesthesia. Adrenaline slows down capillary absorption
of LAs and therefore makes metabolization and detoxification
easier.
Adrenaline is contraindicated in cases of diabetes, hyper-
thyroidism, serious heart arrhythmias, and coronary insuf-
ficiency or in combination with beta-blockers or monoamine
oxidase (MAO) inhibitors. Lidocaine with adrenaline has a very
rapid onset of action. Its duration of action is longer than that
of lidocaine without adrenaline. However, inadvertent injec-
tion of a lidocaine–adrenaline solution into the vessels located
near the nerve trunks increases the heart rate (immediate sinus
tachycardia at more than 130 beats per minute, spontaneously
reversible in around 15 minutes) and increases ventricular
excitability (risk of fibrillation). It can trigger angina attacks
that may lead to a heart attack. It is therefore preferable not to
use adrenaline before a full-face phenol peel.
Topical Anesthesia: EMLA
The Eutectic Mixture of Local Anesthetics (EMLA) is used suc-
cessfully in many brief but painful minor operations. EMLA has
been tried as a local anesthetic for phenol peels. However, the
following arguments should restrict its use in this indication:
•
There is no denying that EMLA anesthesia for a phenol
peel is not as easy as it appears. It is a time- and space-
consuming local anesthetic procedure: a large quantity of
EMLA must be applied to the whole face, in a thick and
even layer, without occlusive dressing, for 1 hour and with-
out any contact with the eyes.
•
The skin on the face has a greater absorption capacity than
the rest of the body, and the duration of anesthesia may not
be long enough to finish applying the phenol in time and
in optimal conditions of comfort, as it takes over an hour
to apply phenol.
•
Mixing lidocaine base and prilocaine base in equal parts, at
room temperature, gives a “eutectic” mixture. This mixture
is emulsified in a base that consists mainly of water and
polyoxyethylene castor oil, and the anesthetics are added
to the oily phase. Phenol has an excellent oil/water parti-
tion coefficient. The oils lower the toxicity of phenol, but
also slow down its rate of penetration as well as absorption
of the local anesthetics. There is a competition between the
phenol solution and the EMLA, which changes the activity
and penetration of the combined molecules.
•
Applying an occlusive dressing, necessary for the EMLA
cream to work, causes significant changes in the hydration
of the stratum corneum and increases permeability. Under
occlusion, the corneocytes swell with water and become
more permeable. The potential interactions are so complex
that it is not possible to predict the results of combining
EMLA and phenol peel formulations.
•
With EMLA, liposoluble anesthetic molecules penetrate
the stratum corneum and the rest of the epidermal barrier

278      Textbook of Chemical Peels
and soon reach the skin nerve endings. The phenol, which
is also liposoluble, can get through the epidermis more
quickly. On the surface, the shorter contact time between
the epidermis and the phenol could reduce epidermal liq-
uefaction. Deep down, a higher concentration of phenol in
the reticular dermis could cause the formation of retractile
scar tissue. The concentration gradient created in the peri-
vascular spaces of the dermis speeds up the absorption of
phenol. The risk of systemic toxicity can also increase.
•
EMLA causes vasoconstriction followed by vasodilation.
Vasodilation can sometimes be seen after only 30 min-
utes of EMLA under occlusion. How will these vasomotor
changes affect the effectiveness or absorption of phenol—
and therefore its toxicity?
•
There have been studies to prove that EMLA is not toxic.
Quantities of up to 150 g of cream applied on 1300 cm2 of
intact skin and left under occlusive dressing for 7 hours
did not produce toxic levels. Other studies show that
injured skin allows EMLA to penetrate much more rapidly.
Blood levels, although subtoxic, are then much higher than
when EMLA is applied on normal, healthy skin. When 10 g
of EMLA is applied to healthy skin, maximum blood lev-
els of the anesthetics are reached after 2–3 hours. Phenol
substantially changes the structure of the skin and causes
intense vasodilation: how will it affect the absorption of
the anesthetics in the EMLA?
•
The facial skin is more permeable than the skin on the
rest of the body. It allows the EMLA to penetrate twice as
quickly as the skin on other parts of the body.13 Proper anes-
thesia of large surface areas requires approximately 1–1.5 g
of EMLA/10 cm2. The surface area of the face is around
500 cm2 (5% of the body surface area), and the maximum
acceptable dose in an adult with a healthy skin is 50 g.
•
Because of the high cost of such large quantities of the
product, practitioners have sometimes resorted to using
copies that are not always standardized. It should be noted
that there is an increased degree of uncertainty with the
use of nonstandardized products.
•
It is recommended not to use EMLA as an anesthetic before
doing epicutaneous allergy tests, as EMLA blocks the
vasodilation induced by certain mediators, such as hista-
mine and antigens.14
•
The presence of prilocaine is a (relative) contraindication to
combining EMLA with products with a potential to cause
methemoglobinemia. Combined use with acetamino-
phen, for example, should be avoided. Acetaminophen is
a derivative of phenol (N-acetyl-para-aminophenol) and
is subject to the same detoxification pathways as phenol.
Acetaminophen inherits its properties of causing met-
hemoglobinemia from phenol. Large doses of EMLA
(>600 mg of prilocaine, or four 5 g tubes) should therefore
not be applied prior to phenol.
•
Eye contact with EMLA must be avoided, as it causes
intense and painful irritation. Using EMLA on the eyelids
significantly increases the risk of eye contact. The vehicle
for EMLA contains carbomer 934, which only gels in an
alkaline environment. The alkalinity of the mixture also
contraindicates its use on the eyelid skin.
•
The pH of EMLA cream is 9.4 (the excipient contains
sodium hydroxide). Phenol is more active in an acid envi-
ronment. Impregnating the skin, for 1 hour, with a mixture
at pH 9.4 will change the physiological balance of the skin,
its acidity, its permeability, and the activity of phenol.
•
A few (unsuccessful) attempts to use EMLA as a topical
anesthetic before a trichloroacetic acid (TCA) peel have
been published, but the authors reported that they were
not impressed by the results.
Therefore, EMLA should not be used as an anesthetic
before a phenol peel.
The Best Choice of LA for FNB: Lidocaine
without Adrenaline (Epinephrine)
Lidocaine without adrenaline is therefore the best choice of LA
for FNB before a full-face phenol peel. Lidocaine stabilizes the
heartbeat, so accidental intravascular injection of small quan-
tities would not be dangerous during a phenol peel. Its short
duration of action is the only drawback, but we have seen above
that acetaminophen plus codeine and cold packs are enough to
alleviate the postpeel pain in the hours following a phenol peel.
Sedation Plus FNB with Lidocaine
without Adrenaline (Epinephrine)
This is the best technique for doing a full-face phenol peel. The
patient and the doctor are at ease, under the benevolent pro-
tection of the anesthetist. Applying phenol to the whole face
is completely painless, and the patient does not experience or
remember any stress or pain. Sedation and intravenous analge-
sia make up for the speed of sensory recovery after FNB with
lidocaine without adrenaline.
HOW TO APPLY FACIAL NERVE BLOCKS
Before a full-face phenol peel, the patient is always put on a
drip, electrocardiographic monitoring, pulse oximeter, and
blood pressure monitor. The doctor has everything he needs
at his disposal in case of any allergic, vagal, or other reactions.
Although bupivacaine, ropivacaine, or mepivacaine can be
employed for FNB, these products should not be used for the
reasons outlined earlier, and anesthesia should consist of FNB
with lidocaine without adrenaline and with deep sedation.
It takes approximately 15 minutes to do all the nerve
blocks needed to anesthetize the whole face. If the skin has not
been cleaned and degreased before the FNB, the phenol will
not be applied until about half an hour after the beginning of
the first nerve block on skin that is already recovering sensa-
tion. The FNB should therefore be done after the skin has been
cleaned and degreased. The FNB should be done in a clock-
wise (or anticlockwise) sequence, where the phenol needs to be
applied. This has the added advantage of diluting the doses of
lidocaine in time and leaving a rest period between each zone.
The hepatocytes, which initiate phenol detoxification by gluc-
uronide and sulfate conjugation as soon as it is applied to the
skin, benefit from these pauses between the different blocks.
Administering the nerve blocks sequentially also helps reduce
the risks of systemic phenol toxicity.
Frontal and Upper Eyelid Block
A frontal FNB anesthetizes the supraorbital nerve, the supra-
trochlear nerve, and the external nasal nerve (Figures 33.2 and
33.3). The quantities required to anesthetize the whole of the
frontal region are two times 1.5 cm3 of 2% lidocaine without
adrenaline.
The phenol can be applied to this area soon after the
anesthetic has been injected (with onset in around 1 minute).

Full-face phenol: Nerve block anesthesia and/or sedation      279
(a)
(b)
(c)
Figure 33.2  (a–c) Frontal and upper eyelid block.
(a)
(b)
Figure 33.3  (a, b) Frontal and upper eyelid block.

280      Textbook of Chemical Peels
Midface and Outer Eyelid Block
The midface block anesthetizes the lower eyelid, part of the
cheek, part of the nose, and the upper lip. This second phase is
done after the phenol has been applied to the frontal area. The
infraorbital nerve can be reached from the outside (Figure 33.4)
or from inside the mouth. The internal route is preferable, as it
is easier to anesthetize the upper lip, the nostrils, and the tip of
the nose (Figure 33.5). It is best to anesthetize the upper eyelid
from the outside, however.
The small, outer eyelid nerve block (0.5 cm3 of lidocaine
without adrenaline) anesthetizes the zygomatic and lachrymal
branches of the facial nerve (Figures 33.6 and 33.7).
Approaching the infraorbital nerve internally allows the
injection to “fan out” toward the tip of the nose. This technique
provides perfect anesthesia of the upper half-lip, the nostril,
and half of the tip of the nose on the same side: 1–1.5 cm3 of 2%
lidocaine without adrenaline is injected in each side.
Lateral Regions
The temporal region can be anesthetized by blocking the auric-
ulotemporal nerve (Figure 33.8). After raising a skin wheal with
a 32G needle just in front of the opening of the ear, a 25-gauge is
introduced perpendicularly, immediately in front of the tragus
Figure 33.5  Internal route for blocking the infraorbitary nerve.
(b)
(a)
Figure 33.4  (a, b) External route for blocking the infraorbitary nerve.

Full-face phenol: Nerve block anesthesia and/or sedation      281
and behind the mandibular condyle (Figure 33.8). It is essential
to do an aspiration test because of the proximity of the superfi-
cial temporal vessels. The injection should be done slowly and
should not meet with any resistance. Resistance would sig-
nal that the injection had gone into the intracapsular joint or
the posterior meniscus of the temporomandibular joint. If the
­peeling is performed under deep sedation, this area is usually
not blocked.
The lower cheek region now needs to be anesthetized
(Figure  33.9). This area is not sensitized by the trigeminal
nerve but by the ascending branches of the superficial cervical
plexus. Sensitivity in the lower cheek can easily be blocked by
injecting a “line” of lidocaine under the skin along the lower
jaw (Figure 33.9). The pulse of the facial artery should be pal-
pated over the jaw before injecting the lidocaine. The lidocaine
should be injected in a line parallel to the lower jaw, on both
sides of the pulse, over a few centimeters.
The anesthetist should inject a small dose of analgesic
before phenol is applied on this area, which is less sensitive and
not protected by a nerve block.
Mental Block
A drop of lidocaine is deposited in the gingival crevice so that
the injection will be painless. Bilateral injection of 0.5–1  cm3
of 2% lidocaine without adrenaline (canine teeth or premo-
lar–canine junction) anesthetizes the whole of the chin region
(Figures 33.10 and 33.11). The lidocaine should be injected in a
line and slightly fanned. The older the patient, the further back
the injection has to be, as the mental nerve foramen recedes as
the bones age.
The nerve block anesthetic is applied gradually to the
whole face: the forehead and the right midface region followed
by the right lateral region. The chin is then blocked and treated
before blocking the left midface region and finally the left lat-
eral region. The lateral regions are often treated without nerve
blocks; they are more complex and patients can easily tolerate
an application of phenol to the sides of the face thanks to anal-
gesics, sedation, or the anesthetizing effect of the phenol itself.
Figure 33.7  The small, outer eyelid nerve block (0.5 cm3 of lido-
caine without adrenaline) anesthetizes the zygomatic and lachry-
mal branches of the facial nerve.
(b)
(a)
Figure 33.6  (a, b) The small, outer eyelid nerve block (0.5 cm3 of lidocaine without adrenaline) anesthetizes the zygomatic and lachrymal
branches of the facial nerve.

282      Textbook of Chemical Peels
(b)
(a)
Figure 33.8  (a, b) Block of the auriculotemporal nerve.
(b)
(a)
Figure 33.9  (a, b) Palpate the pulse of the facial artery over the jaw before injecting the lidocaine. The lidocaine should be injected in a
line parallel to the lower jaw, on both sides of the pulse, over a few centimeters.

Full-face phenol: Nerve block anesthesia and/or sedation      283
The quantities of lidocaine injected are thus diluted in time,
and peak levels of lidocaine are not reached under these condi-
tions. The phenol must be applied in over 1 hour to the whole
face: there is no justification for blocking all the sensory nerves
in the face at the same time before starting to apply the phenol.
This would also increase the risk of toxic peaks of lidocaine in
the blood.
EVOLUTION OF PAIN IN THE
COURSE OF THE PEEL
In the course of a phenol peel performed under FNB with lido-
caine without adrenaline and with no analgesic sedation, the
patient gradually feels a painful, but bearable, sensation of heat
develop in the treated areas. The patient will complain of this
unpleasant sensation on the forehead as treatment of the mid-
face region is ending. While the second midface region is being
treated, the patient feels this heat in the first midface region.
The burning sensation on the forehead is subsiding at this stage
of the treatment, and so on and so forth. At the end of the peel,
the effect of the FNB has worn off, and if the patient has not
been given an analgesic before or during the peel, he or she will
usually feel a painful burning sensation over the whole face.
This can soon be alleviated with a strong analgesic adminis-
tered by mouth. It is important to check beforehand that the
patient can tolerate the analgesic.
At the end of the peel, the barrier function of the epider-
mis is completely incapacitated, and it is possible to achieve
rapid and effective analgesia by applying a few grams (at most)
of EMLA on the areas where the burning sensation is most pain-
ful and where treatment has finished. EMLA should be used
only rarely in this indication. This recommendation does not
conflict with the previous recommendations, as the speed with
which analgesia is produced in this way means that only very
small quantities of EMLA need to be applied to the face after a
deep peel—far from toxic plasma levels. Also at this point in
the procedure, the interactions between the small quantities of
EMLA applied and the quantity of active residual free phenol
left on the surface of the skin will be insignificant.
The burning sensation on the skin is much improved by
applying a cooling mask (Figure 33.12) in the hours or days fol-
lowing the peel.
SEDATION
Premedication
Thirty to 60 minutes before the peel, a 100 mg tablet of hydroxy-
zine or intramuscular promethazine is usually sufficient. The
patient can also benefit from the rapid sedative properties of
sublingual lorazepam, as discussed earlier in this chapter.
Atropine should not be injected automatically but should be
available in case of bradycardia.
Analgesic sedation consists of minimal doses of mid-
azolam or intravenous fentanyl, with blood pressure, cardiac,
and pulse oximeter monitoring.
Fentanyl
This is a strong, short-acting analgesic. The anesthetist “titrates”
the analgesic slowly with repeated intravenous injections of
25 µg when the patient complains about the pain. A total dose
of 100 µg can be given safely. Some authors administer 50 µg at
a time to reach a maximum dose of 250 µg in 1.5 hours.15
Midazolam
This is a strong sedative with a short onset of action that can be
administered intravenously, rectally, intramuscularly, or sublin-
gually. Midazolam can be used as premedication: 4 or 5 drops
are given sublingually as soon as the patient arrives at the clinic.
Figure 33.10  Mental block: external route.
Figure 33.11  Mental block: internal route (better).

284      Textbook of Chemical Peels
It has a short half-life. The anesthetist injects a dose of 1 mg
intravenously under pulse oximeter monitoring, even if the risk
of respiratory depression is very rare with a 5 mg dose. In case
of overdose, flumazenil (Anexate, which comes in 1 mg/10 ml
vials) takes less than 1 minute to compete with the central recep-
tors occupied by the midazolam: 0.2 ml is injected intravenously
(15 seconds). Additional doses of 1 ml can be reinjected every
minute until the patient regains consciousness. Flumazenil has
very low toxicity, and doses of up to 100 mg have been injected
intravenously without any signs of overdose.
Fintsi16 recommended simple intravenous sedation with-
out FNB: he used promethazine and morphine sulfate (5–15 mg)
and titrated the doses until the burning sensation subsided.
According to him, nerve block anesthesia is not essential with
this procedure, but without the FNB, the patient is in pain
during the peel and this makes it uncomfortable for both the
patient and the doctor. The patient only has a vague memory
of the pain. Asken15 reported on a study by Litton showing an
accelerated heartbeat slowing down when deep sedation is
combined with nerve block anesthesia.
NOTES

1. Cold temperatures slow nerve conduction. Furthermore, the vaso-
constriction caused by cold temperatures slows down the rate at
which local anesthetics are absorbed, and their effect is prolonged.

2. This is applicable to all types of peels.

3. Klein solution: a mixture of saline solution, lidocaine, adrenaline
(epinephrine), and sodium bicarbonate normally used as a local
anesthetic in liposuction procedures.

4. Various phenol peel formulas can be found on the market that
boast of the possibilities of doing a full-face peel “without
anesthetic.” In some cases, this means “without general anes-
thetic” and in others the patient is put on strong analgesics, seda-
tion, and premedication. Some low-dose phenol peels (around
30%) are no more painful than a trichloroacetic acid to the papil-
lary dermis, but they are not much more effective either.

5. There is no such thing as a “small” general anesthetic.

6. Which in no way means that 1% of patients are allergic. In an
almost 30-year medical career, the author has never come across
a patient who is allergic to lidocaine.

7. Correct treatment consists in filling the blood vessels, raising the
legs, and putting the patient on oxygen.

8. It must be remembered that the large number of facial blood ves-
sels speeds up the absorption of LAs.

9. Lalanne B, Baubion O, Sezeur A, Tricot C, Gaudy JH. Circulatory
arrest after splanchnic neurolysis with phenol in unrespectable
corner of the pancreas. Annales de Chirurgie. 1994; 48(11): 1025–8.
10. Which explains why the effect is not prolonged even when the
injected dose is increased.
11. The toxicity of prilocaine is 40% of that of lidocaine.
12. Dose-related action. High doses are toxic. Toxic convulsions
occur when blood levels of lidocaine reach 10–22 mg/ml.
13. Juhlin L, Hagglund G, Evers H. Absorption of lidocaine and pri-
locaine after application of a eutectic mixture of local anesthetic
(EMLA) on normal and diseased skin. Acta Dermato Venerologica
(Stock). 1989; 69: 18–22.
14. Ferrari FP, Rosario Filho NA, Schmidt AV. Allergy skin testing
after topical anesthesia [in Portuguese]. Jornal de Pediatria. 1996;
72(4); 215–20.
15. Asken S. Unoccluded Baker–Gordon phenol peels—Review and
update. Journal of Dermatologic Surgery and Oncology. 1989; 15:
998–1008.
16. Fintsi Y. Exoderm, a novel, phenol based peeling method result-
ing in improved safety. American Journal of Cosmetic Surgery. 1997;
14: 49–54.
(a)
(b)
Figure 33.12  A cooling mask (a) can be put in a freezer and placed on the face as soon as the peel is over (b).

34
Full-face phenol
Application
PREPARING THE SOLUTION
Lip & Eyelid Formula
Lip & Eyelid Formula is an oily solution of phenol, often called
phenol oil. The solution is ready for use, and no preparation is
involved. The flask contains 3 ml of solution, which is the quan-
tity usually needed to treat the whole face or perform approxi-
mately 15 eyelid treatments.1 It is easy to plunge the applicator
straight into the container and to squeeze it out correctly on
the neck of the flask. Lip & Eyelid Formula remains stable for
many years.
Baker–Gordon Solution
The four ingredients must be mixed immediately before the
peel:
Liquid phenol (88%), 3 ml
Croton oil, 3 drops
Septisol, 8 drops
Distilled water, 2 ml
Other formulas also have to be prepared immediately
before the peel; for more information, see Chapter 25.
Mixing the four ingredients of Baker’s solution produces
an unstable emulsion rather than a truly stable solution. It is
recommended to keep strictly to the formula, as any attempt
at customizing it can lead to unexpected results and relatively
serious complications. Because the emulsion (soap + oil +
phenol + water) is unstable, the solution has to be freshly pre-
pared. It must be shaken continuously throughout the peel to
keep the emulsion as homogenous as possible. This essential
task should be given to an assistant who will be responsible
for holding the container throughout the peel. If the Baker–
Gordon solution is left unattended, without being shaken, it
separates into different phases. Each of these phases has a
specific concentration of phenol and produces different peel
depths. If the solution is not shaken continuously, each phase
could be applied in turn to the patient’s skin and the results
would be uneven: inadequate in some places and too deep
in others. This could cause scarring, hypopigmentation, or
hyperpigmentation. Not shaking the solution could certainly
cause certain postpeel complications.
Litton’s Solution
If stored in the right conditions, away from sources of air, light
and heat,2 Litton’s solution remains stable for several years.
After shaking the flask,3 the quantity required for the peel is
drawn out (usually 3–5 ml, depending on how thick the appli-
cator is and how much of the product it retains).
APPLYING THE PEEL SOLUTION
Preparing the Applicator
The applicator should not be too thick, so as not to retain too
much of the product and to reduce the risk of drips. The doc-
tor usually prepares it “by hand” before starting application
and after disinfecting his or her hands. Ideally, the applicators
should be prepared beforehand and left in sterile covers. The
simplest and most efficient applicator consists of a wooden
skewer approximately 15  cm long with cotton wound uni-
formly around one end to form a cylinder of even diameter
(Figure 34.1).
Other types of applicators can be used, depending on
the doctor’s experience. Some authors suggest applying phenol
with a brush to get a more superficial phenol peel.4 The bristles
of the brush must be tested for resistance to phenol. Synthetic
brushes can react chemically with the phenol. This reaction
denatures them and can change the composition of the phenol
solution. A gauze pad should not be used to apply a phenol
peel, as the rough texture of this applicator could allow the phe-
nol to penetrate too rapidly; besides, the large quantities of solu-
tion that gauze can absorb may cause drips and runs or deposit
uneven quantities of the product on the skin too quickly; the
most serious complications can only be avoided by slow and
even application. The use of cotton balls is not advised, as they
are not easy to handle in “delicate” areas such as the eyelids
and also because of the risk of runs.
Cotton buds are not suitable for large surface areas, as
they do not allow even application. In a very localized phenol
peel (i.e., eyelids or upper lip), however, phenol is applied with
a single cotton bud, as it is more precise and uses up less of the
product. The applicator should only be used once.
A simpler and more recent application mode for full-face
phenol uses a double cotton bud, the same as for Easy TCA
application. Cotton buds are soaked in the solution, spun dry
on the neck of the peeling solution container, and the solution is
applied progressively, using circular movements. Circular move-
ments allow a totally uniform application and reduce irregular-
ities in results. Cotton buds can be changed during the peeling
if they are damaged.
Reminders about Skin Preparation
No skin preparation is necessary during the weeks preceding
the use of Lip & Eyelid Formula. For other formulas, refer to the
recommendations that come with the product. Muscle mobil-
ity will have been blocked by an injection of botulinum toxin
8 days before the peel. Small benign tumors, in low numbers,
can be treated by shave excision immediately before the peel
and will therefore benefit from the local anesthesia induced by
the nerve blocks. If there are a large number of tumors, they

286      Textbook of Chemical Peels
can be excised after frosting is obtained to avoid creating too
many rapid transcutaneous penetration routes in the treated
areas. Telangiectasias can also be electrocoagulated immedi-
ately before the phenol is applied. Urkov applied phenol and
cauterized deep wrinkles at the end of the peel, before putting
on an occlusive mask.
Precautionary Details
The flask of peel solution is put on a table, within reach of the
doctor, and the top should be easy to take off and replace.
Replacing the top on the bottle after each use (the assis-
tant’s responsibility) helps reduce the amount of phenol in the
air and prevents accidental spills.
For all peels, the doctor should avoid holding any vessel
containing a chemical peel solution in his hand for a long time
and should not hold the product in front of his face.
The air space above the face should not be violated. On the
same table, a 20 ml syringe of sterile physiological saline and a
row of makeup remover pads (preferably sterile) are placed at
hand. The doctor will use some of the pads to spread the phenol
evenly on the patient’s skin, and the assistant will use the rest
to immediately sponge away any tears, often a unilateral reflex
reaction. The patient should be on a drip and monitors; the eyes
are protected with ophthalmic Vaseline.
Setting the Lower Limits of the Peel
Before treatment, the lower limits of the peel must be estab-
lished with the patient in a sitting position. The practitioner,
with hand outstretched, places four fingers on the edge of the
patient’s lower jaw, halfway between the chin and the angle of
the jaw, and lifts the skin upward. A surgical skin marker is
then used to draw the line marking the lower limits of the peel
on the stretched skin: the line should start at the angle of the
jaw and go toward the chin. The lower demarcation line will be
hidden in the shadow of the jaw (Figure 34.2). If the demarca-
tion line is drawn when the patient is lying down, the peel will
(c)
(b)
(a)
Figure 34.1  (a–c) Wooden skewer, approximately 15 cm long, with cotton wound uniformly around one end to form a cylinder of even
diameter.
Figure 34.2  End of the third phase of treatment, up to the lower
demarcation line. The phenol has gradually penetrated through the
keratosis that was still visible at the end of the second phase of
treatment.

Full-face phenol: Application      287
not go far enough under the jaw, and the line between treated
and untreated skin may be more visible.
Application Technique
The applicator is soaked in Lip & Eyelid solution and carefully
squeezed out on the inside of the neck of the bottle to get rid of
any excess and avoid drips. The solution must be applied slowly
and conscientiously to each square millimeter of the facial skin.
Long Applicator
The right hand5 holds the handle of the applicator (see
Figure 34.1) between the thumb, index finger, and middle fin-
ger. By moving the thumb smoothly over the other two fingers,6
the applicator can be rolled over the skin: it is not a rubbing
movement but a rolling one. The applicator is pressed on the
skin with the same amount of pressure that would be used for
scratching. The solution is applied uniformly and the pressure
is firm and even.
Double Cotton Buds
Two cotton buds can be used as an applicator. Open the vial of
Lip & Eyelid Formula solution, soak the double cotton buds in
the solution, and spin them dry on the neck of the vial.
Lip & Eyelid Formula is applied using small circular
motions with a double cotton bud, until uniform gray frosting
gradually begins to appear. The pressure on the cotton buds is
the same as when scratching the skin.
The phenol is applied first in the base of the wrinkles. The
doctor’s gloved left hand holds the patient’s skin taut to make it
easier to apply the phenol and to help it penetrate. Care should
be taken to avoid maceration in the bottom of skin folds. A first
layer of phenol is gradually applied to the whole region that
has been anesthetized. To even out penetration of the phenol
that has just been applied, the area should be immediately gone
over again with a makeup remover pad, moved perpendicular
to the direction of application. The same cotton pad can be used
throughout the peel, as it does not come into contact with the
eyes. If the phenol is applied horizontally, the pad should be
applied vertically and vice versa.
Approximately 3 ml of solution is applied on the skin in
successive coats to complete a full-face peel in over an hour.
The endpoint is the appearance of an even gray-white frosting
(see discussion of frosting later in this chapter). An assistant
constantly sponges away any small reflex tears with a cotton
ball or makeup remover pad, which is thrown away after each
use to make sure that the next time the eyes are wiped, no
phenol is carried into them with the tears that have just been
sponged away. Any touch-ups can be done the next day on the
same patient with the solution left in the bottle. Even though a
phenol solution is antiseptic, it is out of the question to use this
remaining solution on any other patient.
Practitioners often ask how many coats should be applied
to the skin. Phenol has reached its peak effect when a gray-white
frosting appears. Some patches of buff yellow may also appear
when the maximum depth has been reached (Figure  34.5).
Pink-white or pure white frosting occurs when the phenol has
penetrated the papillary dermis (Figure 34.3), and the results
would be comparable to those of a trichloroacetic acid (TCA)
peel, which is not as good as can usually be achieved with phe-
nol. Some phenol peel formulas need several coats of solution
to achieve this type of frosting. Lip & Eyelid Formula is usually
applied in a single coat, and only a little patience is required for
the pure white frosting to turn gray-white.
Clinical Signs of the Phenol Application
Frosting
Applying Lip & Eyelid Formula to the skin triggers frosting8
(Figures 34.4–34.6) that is more or less intense and occurs more
or less rapidly depending on the skin type. Thinner skin frosts
more quickly than thick and oily skin (Figure 34.4). The rapid-
ity of the onset of frosting is not always related to the depth of
the phenol peel. As soon as the skin comes into contact with an
aqueous9 solution of highly concentrated phenol, protein coag-
ulation is abrupt (pure white frosting) but relatively superficial,
and this stops the rest of the phenol applied on the skin from
penetrating deeply. With an oily solution, on the other hand,
frosting occurs more slowly and the color is less intense, which
is a sign of deeper penetration.
Rapid frosting is often pure white in color, whereas
slower frosting gradually turns into a gray-white color that
indicates deeper penetration of the phenol into the skin. The
appearance of buff yellow patches signals even deeper pen-
etration (Figure  34.5). It is therefore relatively easy to judge
the depth of action of phenol: frosting that remains pure white
shows that penetration is not as deep as with frosting that turns
gray-white. The appearance of buff yellow patches shows that
maximum penetration has been reached. Any additional appli-
cation of phenol would be associated with a major risk of local
complications.
Figure 34.3  Pure white frosting after an application of Lip & Eyelid
Formula to the right midface region. The frosting on the forehead
has already faded during the rest period.

288      Textbook of Chemical Peels
Edema
Severe edema (Figure  34.7) occurs quickly after phenol has
been applied. The skin soon feels like cardboard because of the
speed and extent of the edema that sets in and stretches it.
Gradual Application
Nerve block anesthesia is performed sequentially (anesthetize
one nerve trunk and apply phenol on the anesthetized area;
Figure 34.4  Phenol penetrates more slowly on keratoses. A little
patience is required.
Figure 34.5  When Lip & Eyelid is being applied, a pure frost-
ing appears temporarily. It is soon replaced by gray-white frosting
that turns a buff yellow color in places, as can be seen here. The
appearance of buff yellow patches is a sign that the phenol has
reached maximum penetration.
Figure 34.6  All the colors associated with a phenol peel can be
seen here. The chin has pure white frosting just after the phenol
has been applied. The cheeks have gray-white frosting after the
same amount of phenol as applied on the chin has penetrated
more deeply. The forehead is a pink color, where the frosting is
fading, with patches of buff yellow.
Figure 34.7  Edema is clearly visible on the left side of the face,
which was treated before the right side. The arch of the left eye-
brow is more prominent than the right. The left side of the nose is
swollen, as well as the upper left half lip. The edema line is very
visible on the neck. Edema usually occurs at the same time as the
frosting fades. The erythema goes beyond the limits of the edema,
which in turn goes beyond the limits of the phenol application.

Full-face phenol: Application      289
anesthetize the next trunk and apply phenol on the correspond-
ing area, etc.). This means dividing the face into as many areas
as there are nerve trunks to block. The full-face phenol peel is
thus done gradually, area by area. Particular care must be taken
not to leave thin strips of skin untreated on the borders between
the different areas: this would make the face appear “striped,”
as the strip of untreated or undertreated skin would show up
clearly between the areas regenerated by the phenol. It is easy
to be misled by the erythema and edema that develop approxi-
mately 10 minutes after frosting and that extend beyond the
area that has been in physical contact with the phenol. When
treating the next area, the applicator should be taken slightly
into the area of erythema and edema. The different cosmetic
units are treated in turn, after each corresponding nerve block.
First Phase
The first phase covers the forehead, the upper eyelids and a
temporal “extension zone” on the right-hand side (Figure 34.8).
A frontal block and an outer eyelid block (see Chapter
33) are done on each side of the face. The phenol is applied vig-
orously in the base of each forehead wrinkle before treating
the whole of the forehead. There are three borders to this first
phase: the anterior hairline, the eyebrows and upper eyelids,
and the temporal region.
Anterior Hairline  Phenol is not toxic to the pilosebaceous units.
To avoid creating a visible demarcation line between the skin of
the forehead and the hair, the applicator is taken 1 cm into the
anterior hairline.
Eyebrows  The phenol is applied to the eyebrows against the lie
of the hairs to ensure proper contact with the skin. Its action is
not deep enough to remove any permanent makeup.10
Upper Eyelids  After the eyebrows, the doctor treats the upper
eyelids (Figure 34.9). Any excess of phenol is avoided by using
an applicator that has already been used to treat an adjacent
area and that has not just been soaked in phenol. The upper
eyelid tarsus does not have to be treated; this would cause
severe palpebral edema. When the eyelids are being treated, the
assistant should be ready to rinse out the eyes with a syringe
of sterile physiological saline (prepared before the peel) and
sponge away any reflex tears.
Temporal “Extension Zone”  At the border between the frontal
and temporal zones, it is worth making the most of the anes-
thesia that the phenol has induced and that extends about 1 cm
beyond the frosting (Figure 34.10).
The skin of the forehead is thoroughly anesthetized by
the nerve blocks, and the phenol application should extend
slightly into the temporal zone. Patients should be warned
that they will feel a burning sensation on the temples for
15–20 seconds as the phenol is applied to this unanesthetized
Figure 34.8  A single coat of Lip & Eyelid has just been applied
to the first zone. The frosting will turn gray-white without another
application.
Figure 34.9  Day 1 after a localized Lip & Eyelid peel of the four
eyelids. The upper eyelid tarsus was not treated with phenol: it
does not show any skin change, just edema and severe erythema.
Figure 34.10  End of first phase of treatment. The white line is the
virtual borderline passing through the pupils. The area marked out
by the colored line is the temporal “extension zone.”

290      Textbook of Chemical Peels
area. The temporal regions are treated gradually up to a vir-
tual horizontal line that goes through the center of the pupils.
The extension zone includes part of the wrinkles of the crow’s
feet. The phenol is first applied at the base of these wrinkles;
the left hand stretches the skin to make it easier to reach the
base of the wrinkles with the applicator. The peel solution is
then applied to the rest of the area.
Rest Period
The phenol is applied slowly and carefully. A rest period of
10–15 minutes is obligatory after the end of the first phase of
treatment. It takes approximately 15 minutes to treat the frontal
region, the upper eyelids, and the temporal “extension zone.”
Twenty-five minutes after the beginning of the treatment, the
second phase can be started. Well-equipped clinics can make
the most of the obligatory rest period to treat two patients at the
same time, in two different rooms.
Second Phase
The second phase covers the central right-hand side: lower
eyelid, midface region, half of the nasal pyramid, upper
half lip, periauricular “extension zone,” earlobe, and tragus
(Figure 34.11).
Lower Right Eyelid  Phenol is applied up to 1–2  mm from the
eyelashes. Nerve blocks do not always succeed in fully or prop-
erly anesthetizing the eyelid skin. If intravenous sedation is
not being used, patients should be warned that they might feel
an intense but brief burning sensation. If the peel is done step
by step, very slowly, the anesthesia caused by the phenol itself,
together with reduced sensitivity caused by the analgesics, are
sufficient to apply phenol on the eyelids without causing much
pain. “Vocal” anesthesia is essential in this area, and I usually
use the following “trick” for the eyelids: the area is suppos-
edly anesthetized by the nerve blocks; I tell the patient that I
am going to test the depth of the anesthesia and that if it is
not deep enough, it can be improved. Inadequate anesthesia is
signaled by a burning-type pain that lasts around 15 seconds.
The phenol is applied to the eyelid as if it were properly anes-
thetized. The patient interprets any pain as a simple test and
finds it bearable, whereas in fact the phenol has been applied.
The phenol itself produces sufficient anesthesia for treatment to
continue without pain. As soon as the eyelid frosts, application
can be completed painlessly.
The practitioner and assistant should watch out for any
reflex tears while the eyelids are being treated.
Nose and Right Midface Region  The right side of the nasal pyra-
mid is treated, as well as the skin just on the edge of the right
nostril. As the face ages, the subcutaneous fat in the nose
atrophies, and this, together with degeneration of the liga-
ments or connecting fibers, leads to loss of tip support. The
­resulting nasal tip ptosis contributes to the classic impression
of increased nose size with aging. There are surgical nose
lift techniques as well as a filling technique11 that raises the
tip of the nose. A phenol peel is a valuable alternative: the
tightened dermis often gives the tip of the nose a clinically
visible lift.
Upper Right Half Lip  The upper lip requires careful treatment:
several coats of Lip & Eyelid should be applied. Before treat-
ing the whole lip, the solution is applied vigorously in the base
of each wrinkle, the skin of the lips is stretched between two
fingers of the gloved left hand to open the wrinkles and make
the atrophic base accessible (see Figure 34.12). Dermabrasion
can be performed after the phenol has been applied,12 when
frosting is still apparent, if the doctor considers that phenol
alone is inadequate. The term chemabrasion can be reserved for
this technique.13 After 24 hours of occlusion, if some lip wrin-
kles still persist, either the base of the wrinkles can be treated
again with phenol or the whole lip can be treated with chem-
abrasion. To avoid creating a demarcation line on the vermil-
ion portion of the lip, the phenol must go 1–2  mm into the
red lip. If the phenol does not penetrate the red lip, not only
will there be a demarcation line, but fine lines will also persist
and lipstick can bleed into the white lip area. Aging of the
lips, combined with fat and jawbone atrophy, often starts with
upper-lip ptosis that hides the teeth. In young subjects (under
30 years old), 1–2  mm of the upper teeth can often be seen
Figure 34.12  As for the upper lip, the base of the wrinkles on the
chin should be treated first before applying the phenol to the whole
chin area.
Figure 34.11  The second zone being treated with Lip & Eyelid
Formula.