Full-face phenol: Application 291
when the face is at rest and the mouth slightly open. Surgical
techniques that reduce the height of the upper lip have been
described, such as “moustache plastic surgery”:14 a simple
technique performed under local anesthetic that requires spe-
cial care in the suturing to do a perfect edge-to-edge repair of
the epidermis.
After a phenol peel, the upper white lip retracts slightly,
and this is often enough to make the whole area look younger
and the upper lip appear plumper without resorting to filling
techniques.
Pretragal “Extension Zone,” Earlobe, Right Tragus A pretragal
nerve block can be done to anesthetize this area, although it
can easily be treated without a nerve block, gradually, up to the
virtual line between the corner of the mouth and the earlobe.
Lip & Eyelid can be applied more vigorously in the pretragal
folds, using the left hand to stretch the skin and expose the
base of the wrinkles to the phenol. The earlobe and the tragus
must be treated so that the results are even over the whole area
(Figure 34.13). If the earlobe and tragus are not treated, an area
of sun-damaged skin would be clearly visible on either side of
the rejuvenated face.
Rest Period
After these areas have been treated, the 10- to 15-minute rest
period between the two phases can be used to apply the occlu-
sive dressing to the first zone that was treated.15 The third
phase starts approximately 50 minutes after the start of the
treatment.
Third Phase
This essential phase of the peel covers the rest of the right-hand
side: half chin and lower lip, and the right jaw “extension zone”
to the neck (Figure 34.14).
Lower Half Lip and Right Half Chin The corner of the mouth
requires careful treatment, as the wrinkles here are deep and
atrophic. The fingers of the left hand stretch the skin to expose
the atrophic base of the wrinkles to the phenol.
The lower lip is treated in the same way as the upper lip
(see earlier discussion). The skin on the chin is often resistant to
treatment, and several coats may be required. Acne scars and
deep wrinkles are particularly resistant in this area, and some-
times require chemabrasion during the peel itself or after 24
hours of occlusion.
Right Jaw “Extension Zone” There is one small lateral region that
has not been treated. This region can be anesthetized with a
lateral nerve block (see Chapter 33) or can be treated slowly and
gradually. This latter option is always chosen when the full-face
peel is performed under deep sedation.
Lower Limits of the Peel and the Neck Phenol is applied up to
the lower limits set before the start of the peel; this forms the
demarcation line (Figure 34.15). The skin on the neck is struc-
turally different to that on the face: it has fewer appendages
and pilosebaceous units. After a deep peel, the skin regenerates
from these appendages. A phenol peel on the neck carries an
increased risk of scarring. In addition, the usual postpeel facial
edema tends to extend downward to the neck, and if the neck is
Figure 34.13 End of second phase of treatment. The white line
shows the virtual line from the corner of the mouth to the earlobe.
The colored line shows the pretragal and cheek “extension zone.”
The lower part of the extension zone shows a darker patch of
skin that comes from the slow penetration of the phenol through
keratoses.
Figure 34.14 End of the third phase of treatment. The occlusive
dressing has been placed on the frontal region during the sec-
ond rest period; the second zone will be covered with an occlu-
sive dressing during the third rest period. The color of the frosting
will gradually turn gray-white without any additional application of
phenol.
292 Textbook of Chemical Peels
treated at the same time, then the edema that builds up in this
area can make patients feel as if they are suffocating—a very
unpleasant sensation. Therefore, the neck could—possibly16—
be treated at a different time than the face. The best treatment
for a sagging neck is still a surgical lift of the lower half of the
face, and a “medium-depth” peel can improve the photoaging:
a phenol peel on the neck can be avoided in the majority of
cases. Nevertheless, some authors (including Baker) treat the
neck at the same time as the face: they apply the product up
to the clavicles on the anterior neck and up to the 7th cervical
vertebra on the posterior neck. Other authors suggest treating
the face on the first day and the neck the day after to reduce the
risks of toxicity associated with applying greater quantities of
phenol to a larger surface area.
Rest Period
After these areas have been treated, the 10- to 15-minute rest
period can be used to apply the occlusive dressing to the sec-
ond zone that was treated.
Fourth Phase
This phase of the peel covers the left-hand side: lower eyelid,
midface region, half of the nasal pyramid, upper half lip, peri-
auricular extension zone, earlobe, and tragus (Figure 34.16). See
the details of application in the second phase.
Rest Period
After these areas have been treated, the 10- to 15-minute rest
period can be used to apply the occlusive dressing to the third
zone that was treated.
Fifth Phase
This phase marks the end of the peel, with an application of phe-
nol to the left-hand side, to half of the chin and the upper half
lip, and to the jaw “extension zone” to the neck (Figure 34.17).
Finishing the Occlusive Mask
The occlusive mask is applied to the rest of the treated areas (for
details, see Chapter 35).
Figure 34.17 End of application of the phenol peel. Occlusion
dressing is nearly complete.
Figure 34.16 Application of Lip & Eyelid: fourth phase.
Figure 34.15 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 293
At the end of the peel, the edema on the face will not be
even, as it will have developed phase by phase (Figure 34.18).
The patient may complain of a pulsing heat, which can soon be
alleviated by applying a cold pack. New, long-acting analgesics
can be used to reduce the pain.
FULL-FACE DEEP PEEL USING
LIP & EYELID FORMULA
Prepeel Care
•
The patient should apply Skin Tech Blending Bleaching
Cream twice a day for 2–3 weeks before the peel.
•
Herpes prevention is necessary if the patient has a history
(valacyclovir twice a day, 4 days before up to 4 days after
the peel).
•
Give the patient an analgesic (acetaminophen and codeine)
30 minutes before the peel.
•
The patient’s skin should always be disinfected and
degreased before application (with a mixture of 50% alco-
hol and acetone).
•
Place one drop of Vaseline-based ophthalmic ointment in
the patient’s eyes (i.e., Terracortril ophtalmicum) before
starting the procedure and at its end, to avoid postpeel
ocular irritation.
Application
Toxicity avoidance should be the major concern when apply-
ing a deep phenol peel. The physician must strictly follow the
general instructions for peels and recommendations of medi-
cal literature.
Position the patient in accordance with the convention-
ally accepted rules for phenol peels. Prepare the patient and any
equipment that might be necessary to deal with any incidents
or complications. Among other things, a source of oxygen, an
intravenous infusion, a cardioscope, and oximetry monitoring
should be available. A defibrillator and standard resuscitation
equipment should be installed before performing potentially
arrhythmic peeling, such as phenol peelings.
Postpeeling monitoring is also very important, and the
doctor should make the necessary arrangements for regular
follow-ups with the patient and be available at any time for him
or her.
A phenol peel is a deep peeling technique with which the
doctor must be fully acquainted; the doctor must know how
to treat any complications that may arise. Any peel containing
phenol should be applied with professionalism and patience.
The peel solution should be applied slowly and evenly, using
a double cotton bud applicator (ear bud). It is extremely impor-
tant to wipe the patient’s tears with a new cotton pad each time
during a phenol peel. Discard each cotton pad after use.
After the treatment, the patient will not be allowed to
sleep with the treated skin pressing against any surface (i.e.,
a pillow), as the treated area might stick to the surface, result-
ing in infection, scarring, prolonged erythema, and other
complications.
Lip & Eyelid Formula: Full-Face Application
Divide the face into five areas to be treated in succession
(Figure 34.19).
The end point of the peel is gray frosting, eventually
associated with yellowish areas showing the maximum pos-
sible depth of any peel. The doctor should use two cotton buds
as an applicator. Open the vial of Lip & Eyelid solution, soak
the double cotton bud in it, and then spin the buds dry on the
neck of the vial.
Typically, application on one area lasts 5 minutes, and
the rest time before application on the next area is 15 minutes.
Therefore, each area will take 20 minutes and the full-face peel
will be completed in 100 minutes, avoiding cardiac toxicity
problems that have been reported in the literature. No toxicity
has been reported after a phenol peel since this recommenda-
tion has been used.
Figure 34.18 Appearance of the face at the end of the peel (Lip &
Eyelid). The mask (here Leukoflex) is complete. The appearance of
ptosis of the right eyelid comes from the edema that started earlier in
this area as a result of the “phased” application of the peel solution.
1
2
5
4
3
Figure 34.19 Zones of the face for application.
294 Textbook of Chemical Peels
Lip & Eyelid Formula is applied using small circu-
lar motions until uniform gray frosting gradually begins to
appear. The pressure on the cotton buds is the same as when
scratching the skin.
1.
Slowly apply the solution on area 1. Allow time for the
frosting to appear, and do not apply too much solution.
Wait at least 15 minutes before moving to the next area.
2.
Apply the solution in the same way on area 2. Wait at least
15 minutes before moving on to the next area.
3.
Apply the solution on area 3. Wait at least 15 minutes before
moving to the next area.
4.
Apply the solution on area 4. Wait at least 15 minutes before
moving on to the next area.
5.
Apply the solution on area 5. The peeling is done when the
3 ml of the peeling solution have been applied on the face.
Keep any solution that remains for a touch-up on day 1.
Apply an occlusive dressing, using the transparent tape
from the kit. Ensure that there are no bubbles under the dress-
ing. The occlusive dressing may be applied progressively dur-
ing the waiting time between areas. For example, the dressing
can be applied to area 1 after the application of the solution on
area 3. The dressing can be applied to area 2 after the applica-
tion of the solution on area 2, and so on.
Day 1
The occlusive dressing should stay in place for 24 hours. After
24 hours, remove the occlusive dressing and apply one thick
coat of Skin Tech postpeel mask and then apply a uniform layer
of Yellskreen directly on the postpeel mask cream and leave it
to dry.
Follow-Up
See the patient on the 3rd and 6th days following the peel to
monitor progress and ensure that there is no infection. In case
of infection, the patient should be given antibiotics (usually
orally).
On the 3rd day, apply sterile white Vaseline around the
edge of the treated areas. On the 6th day, apply sterile white
Vaseline on the entire treated area. Vaseline will unstick the
Yellskreen powder. The patient usually is allowed to wear
makeup on the 8th day if the skin is in acceptable condition.
Also see Box 34.1.
NOTES
1. With one flask, it is possible to treat the upper or lower eyelids of
15 different patients, as approximately only 0.2 ml is needed to
do a peel on two eyelids.
2. The refrigerator is an ideal place to keep peel solutions.
3. For phenol as well as other peel solutions: even if a solution is
said to be stable, there is no harm in shaking the bottle to avoid
all risk.
4. Though using phenol to do a superficial peel means both patient
and doctor taking a pointless risk where less toxic agents are
available (TCA, AHA, salicylic acid, etc.).
5. Left-handers will understand that they must reverse the hands
used.
6. Making the gesture that universally means “to pay.”
7. Cortez E. Chemical face peeling. Otolaryngology Clinics of North
America. 1990; 23: 947–60.
8. As with TCA, the frosting is caused by protein coagulation: the
three-dimensional structure of the proteins is changed and they
become opaque. The same phenomenon is responsible for egg
whites becoming opaque when cooked.
9. This is not the case with Lip & Eyelid Formula, which is, on the
contrary, a very oily solution.
10. However, the eyebrows may become a little lighter.
11. Developed by Dr. Sammy Passy, Brazil.
12. It is preferable to apply the phenol before dermabrasion, as the
dermabrasion might cause the phenol to penetrate too quickly
and too deeply through skin whose permeability has been sig-
nificantly altered by the abrasion. Also, the diffuse bleeding that
accompanies the abrasion would partially neutralize the phenol.
13. Asken S. Unoccluded Baker–Gordon phenol peels—Review and
update. Journal of Dermatologic Surgery and Oncology. 1989; 15:
998–1008.
14. Regis-Milano G. La plastie en moustache. XIX° réunion du
GRCD, Paris, Janvier 1996: 17–18.
15. Information on the choice and preparation of the occlusive post-
peel mask can be found in Chapter 35.
16. See Chapter 31 for more information on the risks of treating the
neck with phenol. The increased absorption area also carries an
additional and unnecessary risk of toxicity for the patient.
BOX 34.1 Bad Practice
A few doctors have been known to talk (sometimes proudly)
of conduct that has more to do with greed than good medical
practice: They try to economize on the volume of peel solu-
tion by whatever means they can. Technically, it is of course
possible to use less solution for a full-face peel, but this kind
of misplaced economy is not recommended. The efficacy of
a phenol peel is also dependent on the total quantity of phe-
nol that is applied to the skin and that reaches the dermis.7
If too little phenol is applied, the results will be inadequate,
and in the long run it will cost the doctor more to do touch-
ups than to apply the right amount of good-quality solution
in the first place. As in many other areas, false economies
are not worthwhile.
35
Full-face phenol
Postpeel care
IMMEDIATE POSTPEEL CARE
The care required for the skin and patient after an application
of phenol largely depends on the formulation and the doctor’s
experience.
Hospitalization or Ambulatory Peel?
The first question to ask is whether or not the patient should be
hospitalized. Some hospitals or cosmetic clinics like to combine
a phenol peel with other treatments: surgical or medical, nutri-
tional or cosmetic. In these cases, patients remain in the hospi-
tal, clinic, or spa for 8–15 days. Some peels require complex and
repeated sessions of postpeel care that can only be given if the
patient is hospitalized for 8–10 days. It is clear that hospitaliza-
tion can contribute to patients’ well-being, making life easier
and helping them avoid any contact with the public, friends,
or relatives during the first week of—unsightly—skin regen-
eration. Some practitioners, for fear of the potential toxicity of
phenol and the possibility of heart rhythm disorders, prefer to
hospitalize patients the first night after the peel until the occlu-
sive mask has been removed 24 hours later. This brief period of
hospitalization can also be beneficial to the patient, who can be
given a titrated intravenous analgesia until the morning after
the peel.
Some more recent techniques provide a phenol peel of the
same quality and are completely ambulatory. Patients are taken
home by a friend or relative. They can leave the clinic a few
hours after the end of the phenol application,1 on condition that
someone stays with them around the clock for the first 72 hours
and that the patient can get to the doctor’s office quickly,2 when-
ever advised or necessary. The severity of the edema on the first
day means that the patient is completely dependent on others,
and it is important that any localized treatment can be given
rapidly. Cardiac toxicity has been discussed in Chapter 28: in
summary, when the peel is performed slowly, in over 1 hour,
there is no cardiac toxicity. If phenol is applied too quickly on
too large an absorption area, arrhythmias develop rapidly; this
occurs while the phenol is being applied. Detoxification starts
immediately. A few hours after the peel, the risk of phenol-
induced arrhythmia is practically nonexistent, if the liver has
been able to detoxify the phenol and the kidneys eliminate it
normally (see Chapter 28). Peels of the Baker–Gordon or Litton
type are often performed with hospitalization. Exoderm or
full-face Lip & Eyelid peels are usually ambulatory procedures.
With the exception of some techniques, hospitalization, even if
brief, no longer seems to be a necessity but is more of a comfort
factor for both patient and doctor. Patients are often happy to be
able to go home and be in familiar surroundings.
Occlusive or Open Technique?
Publications on peels mention different possibilities, and once
again it is the formula used that determines the application
procedure and the need for an occlusive or open technique.
Both techniques have been described as giving excellent
results. The following discussion weighs the pros and cons of
occlusion.
Ease and Speed
The doctor may find it easier and quicker not to apply an
occlusive mask, but this is a hasty conclusion: applying an
occlusive mask is a simple procedure and can be done in the
obligatory rest periods between each treatment area. No time
is wasted.
Comfort
The occlusive mask improves patient comfort: the skin liquefies
beneath the mask, and the liquefied integuments do not drip
on the skin. The occlusive mask prevents the skin from sticking
to clothes or pillows. When an occlusive mask is put in place,
the patient can apply a cooling cold pack to alleviate the pain-
ful burning sensation, whereas with the open technique, direct
contact with the skin is not possible.
Safety
With an occlusive mask, patients do not have to treat them-
selves or be treated by anyone else; nothing has to be applied
to the skin, which reduces the risk of involuntary errors, aller-
gies, or secondary infections. The mask prevents patients from
touching their skin and importing bacteria from their fingers.
The mask prevents contact between the skin and any insects
or pets carrying infectious agents, which may be dangerous to
skin deprived of its immune defenses. With transparent occlu-
sion (Leukoflex), it is possible to evaluate how the treated skin
is developing through the mask.
When phenol is applied to healthy skin,3 occlusion slows
down the absorption rate but does not alter the total quantity
absorbed.4 The liver therefore has more time to detoxify the
phenol and the kidneys have more time to eliminate it. This
increases the peel’s safety margin.
Effectiveness
Unlike trichloroacetic acid (TCA), whose effect is restricted by
occlusion,5 the effectiveness of phenol is improved by macera-
tion. Stegman proved that applying an occlusive mask allows
the phenol to penetrate more deeply and improves the cosmetic
results.6
296 Textbook of Chemical Peels
Asken1 reported that it is possible to increase the pen-
etration and effectiveness of phenol with occlusion, but that
the same results can be achieved by vigorously cleansing and
degreasing before the peel or by repeatedly applying hydrating
and covering agents (Vaseline- or silicone-based products) after
a phenol peel.7 This principle is applied in certain phenol peel
protocols that vaunt the merits of replacing 24-hour postpeel
occlusion with continual application of hydrating products.
Using cream- or Vaseline-based occlusion rules out any pos-
sibility of a touch-up after 24 hours and deprives the doctor of a
valuable weapon in his treatment arsenal.
Cortez,6 Beeson et al.,8 and McCullough and Maloney9
have achieved excellent results without occlusive masks,
although Cortez applies a hydrating cream such as Eucerin that
patients must continue applying themselves throughout the
first night and up to 5 days after the peel. The face is washed
with a showerhead with warm water every 4–5 hours, before
each coat of cream is applied. On the 5th day, the Eucerin is
replaced with white Vaseline until the 10th day. This proce-
dure, more complicated for the patient, often results in bacte-
rial infections, which is why other authors9,10 have replaced the
hydrating cream with an antibiotic cream such as bacitracin.
Fungal resistance or secondary infections are not uncommon,
however, and there have been reports of allergic reactions to
antibiotic creams applied on skin that is completely permeable.
McCullough and Maloney9 recommend the following method.
During the first day and night, swabs of cold physiological
saline are applied. Thereafter, patients rinse their face under
the shower four times a day and apply a bacitracin-type anti-
biotic cream up until at least the 8th day. Healing takes 10–14
days.11 Any scabs are rinsed under the shower and softened by
the water, then coated in bacitracin.
Another occlusive technique consists in applying ster-
ile white Vaseline after the phenol: the Vaseline provides per-
fect occlusion but can sometimes be unpleasant, as heat from
the skin liquefies it, making it to drip and shifting bits of skin
debris. The patient is then led to wiping the skin frequently
and the risk of secondary infection is increased. Prolonged use
of Vaseline after a peel is known to cause acneiform or milia
lesions to appear.
Whichever technique is used instead of the occlusive
mask, there is an increased risk of infection, injury, allergies, or
errors, and a transparent occlusive mask is recommended dur-
ing the first 24 hours to improve the peel’s effectiveness, reduce
the need for patient participation in postpeel care, and lower
the risk of secondary infection.
How to Use the Occlusive Mask
Pitfalls to Avoid
The occlusive mask must be perfectly even. The main pitfalls to
avoid are as follows.
Air Bubbles, Pockets of Maceration, Tension Lines The presence of
air bubbles reduces local maceration and therefore effective-
ness. Pockets of maceration increase local penetration of phenol
(risk of dyschromia and scarring).
Any tension lines in the mask are transferred onto the
skin; they can cause unnecessary pressure and may generate
areas of necrosis. Some protocols, however, take advantage of
the benefits of intentional, well-thought-out, and controlled
tension on the skin while it is regenerating: for example, the
Molding Mask (Dr. Roige, Spain). Postpeel care in this case
includes the precise positioning of support strips.
Occlusive Mask Coming Unstuck: The occlusive mask some-
times comes unstuck around the edges of the mouth, and lip
wrinkles are among the most difficult to treat. Lack of macera-
tion where the mask has come unstuck can lead to inadequate
results (Figure 35.1).
The mask comes unstuck all the more easily if the
patient talks, laughs, eats, chews, or smokes. The patient
should therefore be kept in complete isolation for the first
24 hours, without social contact, except for close friends
or relatives, who should be encouraged to help the patient
avoid facial expressions and communicate without talking.
Smoking is strictly contraindicated on the first day because
of the lip movements required for puffing on a cigarette and
inhaling the smoke. These movements soon make the mask
come unstuck around the mouth. However, it is preferable
to have a patient smoke calmly and cautiously rather than
getting irritable and pulling off the mask too soon in his or
her haste for a cigarette or frantically and carelessly inhaling
smoke in secret.
Vigorous chewing motions also make the mask come
unstuck. The patient should therefore be put on a carbohydrate
and protein liquid diet so as to avoid chewing movements.
A feeding cup should be used instead of a straw to avoid suck-
ing movements. If the mask comes unstuck before the end of
24 hours, the patient should substitute the Leukoflex occlusion
with Vaseline.
Making the Occlusive Mask
The occlusive mask can be put on the lower part of the face
with the patient in a half-sitting position at the end of the peel
to make it hold better.
Figure 35.1 An occlusive mask that has come mostly unstuck
after 24 hours; the results of this peel will be inadequate.
Full-face phenol: Postpeel care 297
Precut Epstein Mask
Epstein recorded the facial measurements of 24 patients; from
there, he determined the average size and designed an adhe-
sive mask that he considers ideal and that includes 10 pieces of
precut, standard-sized Steridrape.12 This first occlusive layer is
covered with a second layer of adhesive tape. The Steridrape is
thin, very adhesive, and completely impermeable, and is per-
fectly suited to the skin. It is quick to put on, as it only consists
of 10 pieces and is easy to adapt to faces that are especially wide
or narrow.
Classic Mask: Waterproof Tape
Choice and preparation of these tapes are discussed in Chapter
32. At the end of the peel, the doctor has several rows of pre-
cut strips that can be picked up with the fingertips. They are
placed gradually on the skin, with several millimeters of over-
lap between them, as on a tiled roof.
Only one layer of Sleek is necessary. Garcia (Spain) has
suggested replacing Sleek with a first layer of Micropore, over
which a second layer of Blenderm is applied. Santos (Brazil)
uses a double layer of Micropore. The author of this book rec-
ommends using Leukoflex, an impermeable and transparent
dressing, which is applied in a single layer and through which
the skin can be seen on the first day.
Specific Areas
The anterior hairline is a special area. A first strip of Leukoflex
is placed directly on the patient’s skin, at the edge of the hair-
line. Any hair sticking out over this edge should be cut off so
that it does not get pulled out when the mask is removed 24
hours later. A hairnet is placed on the patient’s hair. An imper-
meable or plastic shower cap should not be used, as it holds
the sweat on the scalp and makes the occlusion very uncom-
fortable for the patient. The (loose) elastic edge of the hairnet
is positioned on the first strip of Leukoflex. A second layer of
Leukoflex holds the elastic of the hairnet in place; the net thus
forms an integral part of the occlusive mask and can be used to
pull off the whole dressing smoothly and painlessly when the
time comes to remove the mask.
A simple gauze pad can be used instead of a hairnet
(Figure 35.2). The gauze should be cut close enough to the
dressing for the patient to be able to brush or comb the hair,
and at the same time there must be enough gauze to hold
onto to remove the occlusive mask later. Around the eyes,
the occlusion should completely cover the eyebrows but leave
enough room for the eyes to open normally (Figure 35.3). The
eyelids, where occlusive dressing is not used, should be coated
in ophthalmic antibiotic ointment or sterile Vaseline. The
nose must be properly covered—several thin strips of occlu-
sive dressing are needed to do this. The area underneath the
jaw, treated up to the preset limits, should only be partially
occluded. Partial occlusion of the area under the jaw serves to
create an area of feathering that ends on the demarcation line
on the neck.
The earlobes should not be occluded.
Medical Postpeel Treatment
A drop of artificial tears should be placed in the patient’s eyes
at the end of the peel and several times a day over the follow-
ing few days to reduce eye irritation, common after a phenol
peel.
An ophthalmic antibiotic cream should be applied to the
eyelids. The patient must eat and drink as soon as possible after
the peel to enhance elimination of the phenol. A sedative is rec-
ommended to reduce anxiety, which can amplify the feeling of
pain: lorazepam (2.5 mg) is highly indicated and well tolerated
by patients. Medication to regulate gastric emptying (domperi-
done) can be administered intramuscularly or orally before the
patient leaves to prevent any nausea in the first few hours after
the peel. In patients with a history of herpes labialis, antiviral
prevention should be continued. Patients should be given a tele-
phone number or other means of communication so that they
can contact the doctor at any given moment. They should also
have a strong analgesic at hand: acetaminophen plus codeine is
an effective option and alleviates the pain during the first few
days.13 Applying cold packs can also alleviate the sensation of
heat after the peel.
Figure 35.2 Close-up of the top of the occlusive mask, near the
anterior hairline. The sterile gauze included in the mask serves as
a “handle” for removing the occlusion after 24 hours.
Figure 35.3 Close view of the occlusive mask in the eye area.
Eyebrows are covered but eyelids are not.
298 Textbook of Chemical Peels
POSTPEEL CARE AFTER 24 HOURS
After 24 hours, the occlusion has reached its full effect
(Figure 35.4). Maceration is finished and the superficial layers of
the skin have been liquefied. It is not necessary for the occlusion
to be kept on any longer, as after 24 hours the skin has absorbed
all the phenol and the risk of infection increases proportionally
with the duration of the occlusion.
Removing the Occlusive Mask
A phenol peel causes a liquid to form that unsticks and gradually
lifts the occlusive mask during the first 24 hours, which means
that it is often easy and relatively painless to remove, though
this is not always the case. Removing the occlusive mask can
certainly be painful (though only briefly) if the mask is “pulled
off” rather than pulled down. When the mask is made correctly,
the first few centimeters are left loose on the anterior hairline. It
is easy to take hold of the mask here and to pull it down hard,
removing it in one swift movement. The patient might cry out
at this point, but it is more from surprise than from pain. The
patients who find the first 24 hours the most painful are also the
ones who find it more difficult to bear the occlusive mask being
pulled off: they have a lower pain threshold and can be given
a strong analgesic or sublingual midazolam 30 minutes before
the mask is removed. Some practitioners suggest (needlessly,
in the author’s opinion) removing the mask under anesthetic
or sedation, which increases the overall risks and the cost for
the patient.
Appearance of the Face
Underneath the mask, the skin is coated in a thick liquid14 with
a distinctive smell; this liquid results from the liquefied epider-
mal layers mixed with inflammatory lymph (Figure 35.5). Good
epidermal liquefaction seems to make for a good prognosis,
although the final results will not necessarily be proportional to
the amount of liquid found beneath the occlusion. After remov-
ing the mask, the face is very swollen and looks severely burnt,
but the patient does not feel much pain.15 The skin appears
crumpled in places, as the edema develops rapidly beneath the
rigid mask and the skin cannot stretch. This crumpled appear-
ance soon disappears. The residual liquid is wiped from the
rest of the face with a sterile cotton pad.
Touch-Ups
When the mask is removed, wrinkles and marks should have
disappeared completely. Any persistent marks or wrinkles can
be touched up immediately after the mask has been removed
(Figure 35.6) by applying more Lip & Eyelid solution in the
Figure 35.4 The same patient as in Figure 35.3: appearance of
the face after 24 hours of occlusion (Lip & Eyelid Formula).
Figure 35.5 Appearance of the face after the occlusion has been
removed after 24 hours (Lip & Eyelid Formula).
Figure 35.6 Immediate touch-up of the upper lip and chin after
the occlusive mask has been removed after 24 hours.
Full-face phenol: Postpeel care 299
base of the wrinkles or on any resistant marks. Wrinkles on
the upper lips are usually the most resistant. Small touch-ups
do not require anesthesia: the pain does not last long, as the
phenol has produced neurolysis of the sensory nerves. Patients
should just be warned that they might feel a brief burning
sensation, and the undertreated areas should be treated again
slowly. More extensive touch-ups (e.g., the whole midface
region) might require short-term nerve block anesthesia in
sensitive areas.
After 24 hours of occlusion, persistent wrinkles on the
upper lip can be treated with chemabrasion: Lip & Eyelid
solution is again applied to the whole of the lip, with special
emphasis on the base of the wrinkles. Frosting occurs rela-
tively quickly. When the frosting has stabilized, the skin can
be abraded with a diamond fraise or sandpaper on the frosting
itself. The doctor then decides whether to reapply the occlu-
sive dressing; the duration of occlusion depends on the results
achieved with the chemabrasion: if the results are still no better
than after the first treatment, the “secondary” occlusion should
be left on longer.
The skin now needs to be protected and regeneration
encouraged.
Bismuth Subgallate Mask or Antibiotic Cream?
The advantages of moist or closed occlusive dressings have
been extolled since ancient times. Ayurvedic doctors, the
Egyptians, the Chinese, and the Greeks all maintained that a
closed dressing, often coated in honey, enhanced wound heal-
ing. At the beginning of the 20th century, doctors who treated
burns with gauze pads soaked in picric acid knew and made
the most of the virtues of healing “under a scab.” Thomas
Bayton (1797) was the first to rediscover the benefits of occlu-
sion in treating venous ulcers after centuries of medical obscu-
rantism. The latest studies confirm that exposing a wound to
the air slows down healing and that occlusion accelerates heal-
ing and reduces the risk of infection and pain.
The term moist technique could lead to some confusion.
A moist technique does not involve applying dressings soaked
in physiological saline, for example. The presence of textile
or skin debris can actually cause infection and delay wound
healing. Nor does a moist technique involve using antibiotic
creams. What is referred to as a moist technique is actually
any procedure that allows the skin to regenerate in conditions
that are close to the skin’s physiologically moist environment.
Postpeel regeneration is radically different from the regenera-
tion that follows mechanical abrasion or ablative laser treat-
ment. Unlike ablative laser treatment or dermabrasion, a peel
does not physically remove the skin, even though it devital-
izes it completely. The skin can be considered as the base of a
“moist” dressing, even though using powder makes it appear
rather dry (Figure 35.7). Sprinkling powder on skin that has
been devitalized by phenol but that still serves as a protective
layer creates the ideal conditions for rapid skin regeneration
without infection.16
The type of powder that can be used is discussed later
in this chapter. One of the advantages of using a powder mask
is that the patient does not have to treat the skin at all. This
reduces the risk of secondary infection, errors, or allergies, and
also means that the new epidermis, which is in the horizontal
growth phase, will not be pulled away by the constant cleans-
ing of the skin that goes hand in hand with the use of antibi-
otic creams. As the skin begins to regenerate, the keratinocytes
are not yet anchored by desmosomes and the dermal papillae
have not yet formed. This new, growing epidermis is an impor-
tant source of cells with a great potential for regeneration and
should not be removed by untimely cleansing. Sprinkling
bismuth subgallate on what remains of the skin after removing
the 24-hour occlusive mask anchors the dead cells in a sort of
membrane and actually forms a kind of natural dressing that is
dry on the outside but physiologically moist on the inside.
There is often discussion about the best postpeel care
(Figure 35.8). Occlusive dressings often have been disparaged
for fear of secondary infection that could delay healing. A phe-
nol peel has one big advantage over laser or abrasion in that
phenol is a powerful disinfectant in vivo even more than in vitro.
Infections are less common with phenol than with TCA, for
example. Sprinkling on an antiseptic is preferable to applying
an antibiotic cream. Indeed, antiseptics discourage the growth
(b)
(a)
Figure 35.7 (a) On the 7th day after a Lip & Eyelid peel, the film formed by the necrosed skin, the bismuth subgallate, or Vaseline does
not stick to the skin. (b) It comes off in one piece like an occlusive dressing under which the skin receives moisture.
300 Textbook of Chemical Peels
of any microorganisms in the wound, whereas antibiotics only
work against certain strains of bacteria. Bacterial resistance to
antiseptics is much lower than it is to antibiotics. There have
been no reports of cross-resistance to different antiseptics,
whereas this phenomenon has been widely reported with anti-
biotics. Allergies are far more common with antibiotics than
with antiseptics. The presence of a large amount of exudate
can, on the other hand, render many antiseptics ineffective, but
a phenol peel does not generate much liquid, and any excess
inflammatory liquid is soaked up when the skin is powdered. It
is therefore far more advantageous to use a powder mask than
antibiotic creams. When this author has used antibiotic creams
on patients, secondary infections have been very common,
while this has rarely been the case with a mask of bismuth sub-
gallate powder.
Several different powders for peels are described in the
literature.
Thymol
Thymol (thymic acid) is extracted from essence of thyme. It is
4 times more bactericidal than phenol and 10 times less toxic.
Thymol iodide is used on burns in the same way as iodoform
but has the advantage of not being absorbed and not having any
odor. It is less irritating on wounds and mucous membranes
than dithymol diiodide or aristol. Thymol iodide powder, an
antiseptic that is used often after a phenol peel, physically alters
the selective permeability of plasma membranes. It is neverthe-
less a protoplasmic poison that denatures enzyme proteins and
is also an allergen.
Bismuth Subnitrate
Bismuth subnitrate is an inert powder that has healing and
absorbent properties. It sticks well to the skin. It is not very
toxic by the systemic route, but can be more so by the local
route as a result of combining with proteins.
Gallic Acid–Iodoform
Gallic acid was used in the past to treat wounds, as was iodo-
form. Iodoform was discovered in 1822 and used by Hebra for
its local anesthetic action—in the form of an iodoform gauze—
on burns.
Bismuth Gallate
Bismuth gallate (formerly known as Dermatol) is antisep-
tic, astringent, and siccative. Gallium nitrate reduces metal-
loproteinase activity in wounds and promotes the migratory
phenotype of keratinocytes that can move more easily over
the temporary protein matrix and close the wound more quickly.
It reduces keratinocyte ability to synthesize the desmosomes
that anchor the cell locally and limit its movements.
(b)
(a)
Figure 35.8 (a) A patient wearing bismuth subgallate powder after an Easy Phen Light peeling (Skin Tech): she is not happy to have to live
with this yellowish face color during 8 days. (b) A patient wearing no bismuth subgallate powder, after an Easy Phen Light peeling. She is
not happy to see her face and she is afraid to see her skin. Moreover, the risk of infection is much higher in her case. Ultimately, it is better
to have a patient simply unhappy than a patient unhappy, afraid, and at risk.
Full-face phenol: Postpeel care 301
Bismuth Subgallate
Bismuth subgallate is also known as bismuth 3,4,5-trihydroxy-
benzoate dihydroxide, basic bismuth gallate, and gallic acid
bismuth basic salt. Its molecular weight is 394.09. It has low
toxicity; not much bismuth is absorbed. If bismuth subgallate
comes into contact with the eyes, eye drops should be used.
Zinc Stearate
Urkov used zinc stearate as a healing powder for 5 days after
removing the occlusive mask.
Making the Bismuth Subgallate Mask
Before sprinkling the powder on the face, a drop of artificial
tears should be put in both of the patient’s eyes and protec-
tive cotton pads placed on the eyes (Figures 35.9–35.11). The
patient is placed in the dorsal decubitus position with eyes
closed. A thick coat of postpeel mask is applied on the skin
and the Yellskreen (Bismuth subgallate) is sprinkled on the
postpeel mask, on which it will stick. This makes an anti-
inflammatory, anti-erythema, anti-infectious mask that
speeds up skin healing. The mask must not be too rigid,
however.17
Bismuth subgallate comes in two formats: the Lip &
Eyelid kit contains 12 separate sachets for deep localized peels
(Figure 35.12a). A large bottle is also available (Figure 35.12b)
that allows for easy application by sprinkling the powder
directly on the skin. An assistant should gently compact the
powder with sterile gauze.
Too much powder makes the mask rigid, which is
unpleasant for the patient and is sometimes difficult to remove
later. A mask that is too thick may also crack after the third day
and form jointed plates that can leave visible lines imprinted
on the skin and sometimes even wrinkles that were not there
before the peel. The mask should be monitored closely starting
on the 3rd day. As can be seen in Figure 35.13, a powder mask
that is too dry should be treated locally with an application of
sterile white Vaseline.
Figure 35.9 The eyes are protected before powdering with bis-
muth subgallate.
Figure 35.10 Bismuth subgallate powder mask: end of making
the mask. Note that the peri-ophthalmic area is covered with pet-
rolatum jelly.
Figure 35.11 Eye protection before sprinkling the bismuth sub-
gallate powder on the skin.
302 Textbook of Chemical Peels
FOLLOWING DAYS
Days 1–6
During the first two days, the patient puts artificial tears in
both eyes. For 48 hours, it is the patient who puts the subgal-
late powder on the areas that need it, that is, where the powder
appears moist. Where the powder has not stuck, because of a
lack of skin liquefaction, a little Terramycin ointment or sterile
white Vaseline should be applied.
The patient and doctor should be in contact—even if
only by telephone—every day, as the appearance of the face is
very worrying for both the patient and friends and relatives
(Figure 35.14). The person in contact with the patient must be
able to answer any questions, allay any fears, and possibly
examine the patient. It is essential that the patient is regularly
reassured by the doctor that things are proceeding as normal
(Figure 35.15).
The pain usually intensifies suddenly on the 3rd and 4th
days: patients generally consider the night of the 3rd day to be
the most “unpleasant” of the whole week. Strong analgesics
might be necessary. Acetaminophen plus codeine, which the
patient should have on hand, is sufficient to ease the pain in
most cases.
Cold packs—chilled but not frozen—can help alleviate
the sensation of burning or pulsing heat. Many patients
complain of severe itching that can be relieved with a seda-
tive antihistamine such as promethazine. In some cases, the
antihistamine can be combined with lorazepam. A patient who
is asleep on promethazine and lorazepam does not scratch.
(b)
(a)
Figure 35.12 (a) The Lip & Eyelid kit contains 12 sachets of bis-
muth subgallate. (b) A sprinkler is also available. This makes it
easier to apply the powder.
(b)
(a)
Figure 35.13 (a) A bismuth subgallate mask that is too dry. (b) Application of sterile white Vaseline around the eyes and mouth.
Full-face phenol: Postpeel care 303
(c)
(a)
(b)
Figure 35.14 (a) Bismuth subgallate mask on day 1. (b) Day 3: The edema is going down quickly. (c) Day 3: Close-up of the mask on the
eyelids. The upper eyelids are coated in an antibiotic ointment instead of the powder.
(b)
(a)
Figure 35.15 The lower demarcation line on the neck should be given special attention and should be coated with Vaseline in case
movement is awkward (patient on the 3rd day). (b) The same patient after repeated applications of Vaseline on the 4th and 7th days. The
edema that could be seen in (a) has gone.
304 Textbook of Chemical Peels
No other specific treatment should be applied on the face
during the first week. The patient should be seen again on the
4th or 6th day, and the doctor should carefully check for any
secondary infections (Figure 35.16).
The doctor should apply a thick coat of sterile white
Vaseline to the patient’s skin and gently rub it in when he or
she sees the patient on the 6th day (Figure 35.17). The doctor
can also help flaking along but must take care not to damage
the skin. Anything that is not stuck to the regenerating skin can
be removed. Once the patient is back home, he or she continues
to apply a thick coat of sterile white Vaseline to the face and
gently rubs it in after carefully washing the hands with anti-
septic soap. A thick coat of Vaseline creates an impermeable
dressing that prevents transepidermal water loss (TEWL). The
water accumulates between the Vaseline and the skin—that is,
in the bismuth subgallate powder. It hyperhydrates the powder
mask, helping it come away without the patient having to do
anything other than pick up the strips (skin plus powder) that
fall off by themselves. Throughout the first week, the patient
should be told quite firmly to sleep on his or her back instead
of on the side, so that the skin on the face does not stick to the
pillow (see Chapter 37).
Day 7
The doctor can use forceps to remove any small bits of the mask
that are still on the face. On some patients, the powder mask
has not come off by the 7th day, and the doctor should then
remove it, taking care not to damage the skin. The skin some-
times appears a bit crumpled under the mask, but the crum-
pling, caused by the pressure of the mask, disappears within
moments (Figure 35.18).
If the skin is in good enough condition, camouflage
makeup (Avène® or Covermark®) can be applied immediately
after sun protection. Sun avoidance and the use of a total
Figure 35.16 An infection may occur in the form of a papular
reaction on the neck. Oral antibiotics are essential in this case.
(b)
(a)
Figure 35.17 (a) Day 6 after Lip & Eyelid Formula: appearance of the patient on arrival at the medical center. The doctor should apply the
first coat of Vaseline and can help flaking along, taking care not to damage the skin. (b) Immediately after an application of Vaseline and
doctor-assisted flaking.
Full-face phenol: Postpeel care 305
sunblock must be kept up for 3–6 months. Patients who are
averse to the idea of having to put any product whatsoever
on the skin should be ruled out from a phenol peel. Flaking
does not stop on the 7th day, and it is common to see it last
several weeks. Applying hydrating cream (Vit E Antioxidant
or Nutritive ACE Lipoic Complex) helps to reduce any itching
caused by the persistent flaking.
FOLLOWING WEEKS
The patient applies a hydrating cream with vitamin E (see
Chapters 2 and 3) four or five times a day to prevent the skin
from drying out and becoming itchy and to prevent scratching
and/or complications. The patient can continue to apply a thin
layer of Vaseline as long as it is needed to improve dryness or
itching.
On the 10th day, the patient can usually return to nor-
mal activities, making sure that the skin is protected with an
effective sunscreen and wearing makeup to hide the very pink
color of the skin. A colorless sunscreen can be mixed with
the patient’s usual foundation as well as a colored sunscreen
(Metablock-HSP 50 color). Erythema remains severe for the first
few weeks but gradually fades within 4–8 weeks. Patients with
dark skin or who live in sunny climates should apply Blending
Bleaching Cream once or twice a day to reduce the incidence of
pigmentary changes.
SUN AVOIDANCE
Sun avoidance should be aggressive and permanent during
the first 3 months after the peel. Patients who work outdoors
are most likely to suffer from uneven skin color or post-inflam-
matory hyperpigmentation. Permanent sun protection does not
mean that patients should stay out of the sun for the rest of
their lives, but that they should actively protect their “new” and
more sensitive skin. Patients have a natural tendency to avoid
sun exposure for some time after a peel. After strict sun avoid-
ance for up to 2–3 months, outdoor activities can be resumed
with total sunblock, although sunbathing is forbidden during
the first year after a peel.
During the first few months, wearing sunglasses (that do
not press too hard on the temples or the nasal pyramid) pre-
vents reflex squinting against excess light. It is possible, like
Cortez,6 to recommend using a cream with 0.05–0.1% tretinoin
for 3 months after the peel, although this is not recommended
for use before then, as recent studies show that although reti-
noids improve postpeel skin regeneration when used before the
peel, it seems that they can delay regeneration when they are
applied too quickly after a peel or dermabrasion. The patient
should be seen again during the 3rd week to make sure there
are no pigmentary changes or other complications and to be
treated if necessary. It is sometimes necessary to use a depig-
menting cream during the first 6 weeks, especially for patients
who live in very sunny climates.
TOUCH-UPS
Phenol peels do not always produce the results hoped for, but
fortunately it is rare that the results are so inadequate as to
require extensive touch-ups or a complete re-peel. An exten-
sive touch-up can be done 6 weeks after the peel. Fintsi18
reported an incidence of 30% of local touch-ups after Exoderm.
In his study, 21 cases out of 558 had to be given more extensive
touch-ups: 20 times for acne and once for a hyperpigmentation
problem.
POSTPEEL CARE
Care surrounding the peel is divided into four phases:
1.
Prepeel
a.
Three weeks before, application of Blending Bleaching
Cream 2 times/day.
b.
Herpes prevention 4 days before and 4 days after peel
(valacyclovir 500, 2/day).
c.
Botulinic toxin injection 1 to 8 days before peel.
2.
Days 1–8 postpeel: see Figure 35.19. At day 1, remove
occlusion, apply postpeel mask and Yellskreen. Important:
Yellskreen has to stay in place for 6 days.
3.
Days 8–15 postpeel: see Figure 35.19. IPLase allows a strong
reduction of postpeel redness.
4.
Days 16–90 postpeel: see Figure 35.19.
Sun protection is mandatory until the total end of ery-
thema plus 4 weeks.
Figure 35.18 The usual appearance of the skin, 7 days after a
phenol peel. The skin is thin, sensitive, and red. The demarcation
line is particularly visible between the face and the neck. A TCA
peel (Easy TCA) was applied to the neck and décolletage on the
3rd day after the peel, and these areas are now flaking (see also
Figure 30.8).
306 Textbook of Chemical Peels
NOTES
1. According to Asken, the patient can go home 6 hours after the
peel (Asken S. Unoccluded Baker–Gordon phenol peels—Review
and update. Journal of Dermatologic Surgery and Oncology. 1989; 15:
998–1008).
2. The patient should be able to get to the doctor within 1–2 hours
at the most.
3. As opposed to the use of phenol in the past as a disinfectant for
wounds, when occlusion does not slow down the rate of penetra-
tion of phenol.
4. Ruedemann R, Deichmann WR. Blood phenol level after topical
application of phenol-containing preparations. JAMA. 1953; 152:
506–9.
5. Occlusion dilutes the TCA and reduces its effectiveness.
6. Cortez E. Chemical face peeling. Otolaryngology Clinics of North
America. 1990; 23: 947–60.
7. Applying Vaseline or silicone after the peel acts as occlusion. It is
in fact cosmetic occlusion rather than physical occlusion.
8. Beeson WH, McCollough EG. Chemical face peeling without
taping. Journal of Dermatologic Surgery and Oncology. 11: 985–90.
9. 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.
10. Konior RT, Kerth JD. Selected approaches to the aging face.
Otolaryngology Clinics of North America. 1990; 23: 1083–95.
11. With Lip & Eyelid Formula (for a full face), healing takes
7–8 days.
12. This is a sterile adhesive plastic used in surgery to cover a field of
operation and through which the surgeon can make incisions.
13. Acetaminophen must not be injected intravenously during the
peel, however, to avoid any competition among the enzymes
responsible for liver detoxification.
14. Patients often complain that some liquid has leaked out from the
bottom of the occlusive mask and that they have had to cover
their necks.
15. Recall that phenol is a neurolytic agent.
16. It is recommended not to remove the skin on top of a blister for
the same reasons.
17. A mask that is too thick or rigid is extremely unpleasant for the
patient and could make the skin unusually tight and promote
infections. If the mask is too thick or rigid, it must be covered
immediately in sterile white Vaseline to soften it.
18. Fintsi Y. Exoderm-lift—liquid formula. 1996.
Day 0
Lip & Eyelid
Occlusion 24 h
Day 1
Occlusion OUT
Postpeel mask
Yellskreen
Day 6
Check if infection
Vaseline full area
Day 3
Infection*?
Vaseline/edges
– 2 Weeks
1
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 Cream (Pigment control) and/or Atrofillin (2x/day)
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
Full-face deep phenol peeling (Lip & Eyelid Formula)
09 am–12 pm, 03 pm
Melablock HSP 30
Day 0
LE
LE
LE
1
2
4
5
3
6
7
Days 8 to 15
Days 16 up to 90
LE = Apply Lip & Eyelid on lips
YELLSKREEN: Protective yellow powder
INFECTION* : appears as red poinds around Yellskreen
Specific Home care
Figure 35.19 Protocol for care post-full-face deep phenol peeling.
36
Phenol
Chemical blepharoplasty and cheiloplasty
CHEMICAL BLEPHAROPLASTY
Introduction
Surgical blepharoplasty is a technique that has become progres-
sively easier as it has been removed from the strict framework
of surgery requiring hospitalization. Once performed readily
under general anesthesia, it soon was performed under local
anesthesia combined with neuroleptanalgesia, then deep seda-
tion, and is now often done under simple local anesthesia with
lidocaine. Lip & Eyelid Formula allows treatment without any
kind of anesthesia. Surgical blepharoplasty, when performed
by a skilled surgeon, should give excellent results that last sev-
eral years, after which patients go back to the doctor as they are
no longer happy with the results. A second blepharoplasty is
then performed, and the results are no different from the pre-
vious results. It is common to come across patients who have
“benefited” from three successive surgical blepharoplasties
over 15 years. The cosmetic results of multiple surgical blepha-
roplasties are not always of good quality, and patients who have
been operated on too often are as easy to spot as patients with
rotation-flap hair transplants or large cylindrical punch grafts.
Surgical blepharoplasty can change the look of the pal-
pebral aperture, especially when patients want their eyes to
look more “cat-like.” A second blepharoplasty can make the
tarsal region of the upper lid slightly darker. A third blepharo-
plasty can be disastrous: the palpebral aperture loses its elas-
ticity and narrows, the eye becomes smaller and less mobile,
the skin above the tarsus of the upper eyelid takes on a very
dark color that stops abruptly on the scar because of the altered
distribution of dilated vertical blood vessels (Figure 36.1).
Lagophthalmia entropion or ectropion can develop.
The author performed his first chemical blepharoplasty
with localized phenol in the 1990s to treat blepharochalasis that
had developed just a few years after a surgical blepharoplasty
of the four eyelids. The blepharoplasty had been done correctly,
well before the patient had reached 40, and 4 years later there
was once again a significant excess of skin on the upper eyelid
that made the patient’s eyes look heavy and sad. The patient
preferred to have nonsurgical treatment.
Clinically, it was reasonable to investigate the problem
with her. Apart from surgery, what treatment options were
there to lift the “curtain” of the upper eyelids? After a quick con-
sideration, a peel seemed to be the only option. Alpha hydroxy
acids (AHAs) were ruled out immediately because of the risks
involved and the fact that they are ineffective on the eyelids.
Trichloroacetic acid (TCA) was ruled out, as the high concentra-
tions needed to get the skin to retract would be dangerous and
in any event ineffective. There was therefore only one option
left: phenol. The author has not encountered many problems
with regular use of full-face phenol peels and, on the contrary,
has found them to be very successful. The results achieved
locally on the eyelids have often been remarkable (Figure 36.2).
Phenol therefore seemed to be an excellent option for
treating drooping eyelids. In fact, the general toxicity of phenol
is nonexistent when treating limited areas, and a local anes-
thetic is all that is needed given the anesthetic properties of the
phenol itself.
Anesthesia
Chapter 33 is devoted to the details of anesthesia for a phenol
peel. Lip & Eyelid Formula can be applied without any anes-
thetic on small areas, however. Patients feel an intense burning
sensation a few seconds after application. They will have been
told that the burning sensation lasts only for 15 seconds and
that they can have a nerve block if they want. Vocal anesthesia
plays an important part, and the patient can take an acetamin-
ophen plus codeine tablet 1 hour before the treatment. Nerve
blocks are often used to increase patient comfort: 2% lidocaine
without adrenaline (epinephrine) is used, and its duration of
action is sufficient. The patient should be given acetaminophen
plus codeine tablets for the postpeel pain, which is inevitable
during the first 24 hours because of the severity and rapidity of
inflammation caused by the peel.
Protecting the Eyes
A small quantity of ophthalmic Vaseline is put in the conjuncti-
val cul-de-sacs to protect the cornea, before the bottle of phenol
has even been opened. The Vaseline actually deactivates the
phenol. The patient has eye drops (artificial tears) to put in the
conjunctivae as soon as the phenol has been applied and several
times a day over the following days.
Phenol Solution
There are many different phenol formulations, and differ-
ent combinations have been tested with varying results. The
Baker–Gordon or Litton formulas potentially pose an increased
risk because of their depth of penetration in the thin eyelid
skin. After using several different formulas, the author gradu-
ally came to develop a phenol oil that meets his high standards
of safety and effectiveness. Adapted for the treatment of the
eyelids and lips, this solution is called Lip & Eyelid Formula.
The eyelids and the lips do not, of course, have the same thick-
ness, resistance, permeability, or reactivity; they are very dif-
ferent, and this is why the application protocol is also different
in each case.
Application to the Eyelids (Figures 36.3–36.5)
The choice of applicator is important: the large cotton buds
normally used in a full-face phenol are not precise enough and
absorb too much of the product. Cotton wool or gauze soaked
in solution is not suitable because of the risk of drips on the
neck or, even worse, in the eyes (remember that phenol is a
308 Textbook of Chemical Peels
protein coagulant, and any contact with the cornea could dam-
age it irreversibly).
A double cotton bud would not be precise enough either.
The ideal applicator is a single cotton bud: it is light, precise,
and simple—all of which are good qualities when it comes to
using phenol. Using a 1 cm3 syringe, 0.2 cm3 is drawn up from
the 3 cm3 bottle of Lip & Eyelid, and the cotton bud is soaked
by “injecting” 0.10–0.14 cm3 of the peel solution directly onto it.
After disinfecting the area with alcohol and carefully degreasing
with acetone, Lip & Eyelid is applied carefully on the lower lids
with the cotton bud. Distinct frosting occurs rapidly and marks
the end of the phenol application. The tarsus of the upper eye-
lid is not usually treated. Applying Lip & Eyelid on the eyelid
tarsus induces severe edema that is very uncomfortable for the
patient and does not significantly improve results. To treat the
second eyelid, the remaining 0.06 cm3 should be “injected” onto
the end of the same cotton bud. A bottle of Lip & Eyelid Formula
provides enough solution to treat two eyelids on 15 patients.
The same quantity of solution is needed to treat the upper
eyelids. An assistant should be present whose sole duty is to
mop up any tears as soon as they appear to prevent any diluted
phenol from dripping onto the face or going up into the con-
junctivae by capillarity. A fresh cotton pad should be used for
each tear.
An evening-out peel is necessary to prevent demarca-
tion lines. It should be applied on the rest of the face when the
Lip & Eyelid application has finished and before any occlusion
is applied. Patients with a light skin type could be given four
Figure 36.1 Typical abnormalities of the upper eyelid after sev-
eral surgical blepharoplasties.
Figure 36.2 Full-face Lip & Eyelid peel: Close-up of the eyelids
30 days after treatment; note the significant retraction of the eyelid.
(a)
(b)
Figure 36.3 (a) Lip & Eyelid to the lower eyelids and an application of Only Touch (lentigo to the forehead and right cheek) plus Easy TCA
as an evening-out peel. (b) Lip & Eyelid on all upper and lower eyelids. The tarsus of the lower lid is not treated.
Phenol: Chemical blepharoplasty and cheiloplasty 309
weekly sessions of Easy TCA (to the Grenz zone) or a single ses-
sion of Unideep (to the papillary dermis).
Occlusion versus Open Technique
Occlusion causes the phenol to macerate, which is often unnec-
essary on the eyelids. The lower eyelid can be covered with
impermeable tape (there is a roll of tape in the peel kit) if a
greater depth of action is required (Figure 36.6), if the wrinkles
are deep, or if there is xanthelasma, for example. No occlusion
is applied otherwise.
Occlusion of the upper eyelid, which is only indicated
to increase the depth of action of the peel, will always be
essentially extratarsal (Figure 36.6). In the large majority of
cases, a chemical blepharoplasty is done without occlusion.
After applying the phenol, the doctor applies an evening-
out peel, either Easy TCA or Unideep, to the rest of the face.
Both of these peels consist of an acid solution and a postpeel
cream that stimulates healing, is antioxidant, and is tyrosinase-
inhibiting. This special postpeel cream should be applied once
only by the doctor at the end of the facial peel. When the phenol
is used without occlusion and without impermeable dressing,
the Easy TCA or Unideep postpeel cream is applied on the area
treated with Lip & Eyelid at the same time as it is applied to the
rest of the face.
Immediate Postpeel Care
With Occlusion
Any occlusion is removed after 24 hours, and the dermis is
usually laid bare (Figure 36.7) and needs protecting. Applying
bismuth subgallate, although highly effective at wound heal-
ing in general and in phenol peels in particular, has always
caused minor problems for the author on the mobile region of
the patient’s upper eyelid. The powder easily falls into the eyes
(Figures 36.8 and 36.9). When the powder, which has first been
soaked with the products of epidermal liquefaction, dries on
the skin, it can form crusted plates that hinge on the skin and
that (in the author’s experience) have occasionally created wrin-
kles that did not exist before the peel. I therefore do not put any
powder on the mobile part of the upper eyelid and rather use
a “moist” technique—an antibiotic ointment (e.g., ophthalmic
Terramycin during the first week after the peel) or just Vaseline.
Applying this type of ointment is, in any event, equivalent to
occlusion.1
Without Occlusion
The patient’s skin, dried out by the phenol, provides an ideal
physiological dressing. The doctor can, however, apply a thick
coat of anti-inflammatory, antioxidant, anti-erythema post-
peel mask (included in the kit) immediately before applying
Yellskreen powder (bismuth subgallate), The powder will per-
fectly stick on the postpeel mask and form a good protective
Figure 36.4 Lip & Eyelid to the upper eyelids.
Figure 36.5 The upper and lower eyelids have been treated with
Lip & Eyelid, and the frosting has already faded. The rest of the
face has been treated with Unideep as an evening-out peel: Note
the even pink-white frosting from the Unideep and the postpeel
Unideep cream on the forehead.
Figure 36.6 Occlusion can be applied if necessary, although this
is rarely the case. Here, occlusion has been applied using Sleek
(see Chapter 32).
310 Textbook of Chemical Peels
barrier, allowing wet skin regeneration under the powder,
which is not water soluble. After day 6, the patient should apply
Vaseline (ophthalmic if possible) several times a day so that the
bismuth subgallate powder comes away from the skin by itself,
without any outside help.
Subsequent Postpeel Care
Patients should be given a small sachet of bismuth subgallate
(there are some small sachets in the Lip & Eyelid kit), which
they should apply with a cotton bud to any area that appears
moist. The patient should be seen as often as necessary, usu-
ally on the 1st, 3rd, 6th, and 10th days. The treated area is usu-
ally dry within 48 hours, at the most. If additional bismuth
subgallate powder will not stick to the skin, it is not necessary
(Figure 36.10). Patients should not touch their skin with their
bare hands to avoid any risk of infection. In cases where the
doctor has opted for a “moist” postpeel technique and has
applied an antibiotic ointment or Vaseline, the patient should
wash the area with thermal water spray or with a showerhead
before each application of cream. The different layers of antibi-
otic ointment or Vaseline should not be allowed to accumulate
without washing in between.
(b)
(a)
Figure 36.7 (a) After 24 hours of occlusion, the dermis has been destroyed. Note the significant amount of skin liquefaction. (b) Destruction
of the dermis after 24 hours of occlusion.
Figure 36.8 Bismuth subgallate powder on lower eyelid.
Figure 36.9 Application of bismuth to all four eyelids: chemi-
cal blepharoplasty and evening-out peel (Unideep). The Unideep
postpeel cream is applied to the face immediately after the peel, on
the evening of the peel, and on the following morning. This photo-
graph was taken on day 1.
Phenol: Chemical blepharoplasty and cheiloplasty 311
Patients sometimes feel some considerable discomfort
that they describe as a pulling sensation, a tightening of the
skin, caused by the powder mask. This sensation is usually
localized around the edge of the mask, where it meets the skin
that has not been treated with phenol. Applying Vaseline with
a cotton bud to the edge of the treated area can help alleviate
this feeling of tightness (see the yellow dots in Figure 36.10:
on day 5, the subgallate is dry). From the 5th day onward
(or the 4th day if need be), and as long or as often as neces-
sary, sterile white Vaseline or ophthalmic Vaseline should be
applied on the bismuth subgallate so that it comes off with-
out any outside help (Figure 36.11). The borderline between
the area treated with Lip & Eyelid and the area treated with
the more superficial peel may feel painful or just uncomfort-
able. The doctor should apply a little Vaseline on this area to
soften it, even if only a few days have passed since the peel
was applied.
Postpeel Developments
Eyelid Edema
Severe eyelid edema, which resolves quickly and lasts 7 days
at the most, appears immediately after the solution has been
applied (Figure 36.12). It peaks on the morning of the 1st and
2nd days. The edema goes down during the day when the
patient is no longer lying down. It spreads to the upper cheek
on the 2nd day, the lower cheek on the 3rd day, the lower jaw
on the 4th day, and on the 5th day is barely noticeable. It is not
uncommon for the patient to be unable to open his or her eye-
lids on the morning of the 1st day. If the edema lasts longer than
10 days, it is not normal.
Erythema
Erythema develops equally rapidly, a few minutes after Lip &
Eyelid has been applied. It peaks during the first few weeks
(Figure 36.13) and fades, more or less slowly depending on the
patient, in 3 weeks to 3 months. The erythema takes longer
to fade on lighter, more transparent skin. It always resolves,
however, and is easily covered up with makeup. (A green
makeup stick should be applied first, followed by camouflage
makeup, e.g., Couvrance by Avène.)
The bismuth subgallate powder comes away from the
skin automatically (Figure 36.14) with the Vaseline that prevents
transepidermal water loss (TEWL) evaporation. The downtime
is 8–10 days maximum.
Effectiveness and Indications
The results of a chemical blepharoplasty may be inadequate if
there is a large amount of excess skin or for lower eyelid fat pads.
In these cases, surgical blepharoplasty is indicated. Applying Lip
& Eyelid to the eyelids treats wrinkles and fine lines, dyschromia,
keratoses, and sagging eyelids (Figure 36.15) but improves eye
bags only when they are caused by sagging skin rather than the
presence of subcutaneous fat. Surgery is indicated in this case.
Complications
Lip & Eyelid is one of the safest phenol peels on the market, but
incorrect application can lead to the usual local side effects of
chemical peels.
Pain
Taking a painkiller tablet half an hour before treatment alleviates
the pain resulting from the inflammatory edema. A second tablet,
taken before going to bed, ensures the patient gets a good night’s
sleep. The following morning, the pain will have almost com-
pletely gone. It is common for some pain to recur on the third day.
Risk of Pigmentation Disorders and Prepeel Preparation
Even if it is generally accepted that phenol has more of a depig-
menting than a hyperpigmenting effect, the doctor must be
Figure 36.10 Day 3: The bismuth subgallate is dry.
Figure 36.11 From the 5th day, Vaseline should be applied on the
bismuth subgallate so that it comes off without any outside help.
312 Textbook of Chemical Peels
prepared for any reactional hyperpigmentation. If the skin
being treated is a very “melanin-reactive” phototype or might
have a severe inflammatory reaction, the melanocytes should
be “sedated” with tyrosinase inhibitors and antioxidants
(Blending Bleaching Cream) before and after Lip & Eyelid, both
on the areas to be treated and on the surrounding areas. The
cream should be applied twice a day for 2 weeks before the
peel and as soon after the peel as possible. The skin can usually
tolerate Blending Bleaching Cream from the 10th day after the
peel. Melanocyte “sedation” should be continued for a mini-
mum of 6 weeks.
If the peel is being performed on a skin phototype I–III
and if the patient follows advice to keep out of the sun and use
sun protection, there should be no post-inflammatory hyper-
pigmentation, but there is an increased risk of prolonged
erythema on lighter skin types. The sun should be avoided
completely, and effective sun protection (Melablock-HSP SPF
50+) should be used for up to 3–6 months. Exposure to UV light
should be gradual thereafter. Even when the peel is applied
correctly, there is still a risk of pigmentary changes, which are
always reversible with Blending Bleaching Cream. Avoiding
pigmentary changes is mainly a matter of pre- and postpeel
care. Local depigmentation, which can only be treated with a
(c)
(a)
(b)
Figure 36.12 Normal edema over the first 2 days that has spread
to the cheek area. (a) Chemical blepharoplasty of the four eyelids.
(b) Chemical blepharoplasty of the upper eyelid only. (c) Chemical
blepharoplasty of the lower eyelids only.
Figure 36.13 Normal erythema on the 13th day.
Figure 36.14 Vaseline has been applied the night before, on the
5th day, to remove the subgallate powder.
Phenol: Chemical blepharoplasty and cheiloplasty 313
full-face application of Lip & Eyelid, can be avoided by careful
patient selection.
Demarcation Line
There is clearly a risk of a demarcation line on skin with
severe dyschromia or sun damage, a lot of wrinkles, freck-
les, keratoses, or lentigines, as the skin treated with Lip &
Eyelid will look rejuvenated and stand out clearly from the
surrounding damaged skin. In these cases, it is especially
important to combine the peel with Easy TCA or Unideep to
minimize the demarcation line if the skin phototype has been
properly selected (see earlier discussion). Healthy skin with-
out dyschromia, of phototype I–III, IV at the most, does not
pose the risk of a marked demarcation line. The demarcation
line can be seen most clearly on the edges of the occlusion.
When using the occlusive technique, it is best not to cover the
whole treated area but to leave an area unoccluded to create
a graduated area of penetration. If results prove inadequate,
they can be touched up or avoided altogether through proper
patient selection.
Delayed Healing
When a chemical blepharoplasty is performed without occlu-
sion, the increased depth of action of the phenol sometimes
translates into a persistent moist scab in the inside corner of
the upper eyelid (Figure 36.16), where the phenol has macer-
ated more intensely. Applying an antibiotic cream or ointment
remedies the problem, and it should resolve before the 15th day.
There are no sequelae from this slow healing. If the scab per-
sists for more than 2 weeks, the doctor should remain alert and
monitor the patient more closely.
Other Complications
Poor application technique can lead to inadequate results. The
technique should be corrected and Lip & Eyelid should be reap-
plied after 6 weeks. The second peel will heal more quickly
than the first.
The author has never experienced scarring, entropion,
or ectropion with this treatment, but in theory they are pos-
sible. Prolonged erythema of several months can be treated, if it
bothers the patient, with alternating applications every 2 weeks
of corticosteroids (hydrocortisone) and antioxidant creams
(Renutriv ACE Lipoic Complex). Bacterial infections should not
occur if the technique is correct and postpeel care is conscien-
tious. Herpes prevention is essential in patients with a history
of herpes.
Postpeel anxiety is common, and the extent of anxiety
depends on the patient’s state of mind before the peel. Patients
should be able to contact the doctor whenever they feel the need.
(b)
(a)
(c)
(d)
Figure 36.15 Examples of the results of chemical blepharoplasty.
(a, b) Chemical blepharoplasty of the upper eyelids and Easy TCA
as an evening-out peel. (c, d) Chemical blepharoplasty of the lower
lids and Easy TCA as an evening-out peel.
Figure
36.16 Benign
delayed
healing
after
chemical
blepharoplasty.
314 Textbook of Chemical Peels
Results
A photographic record of results is shown in Figures 36.17
and 36.18.
Summary
Chemical blepharoplasty of the upper and/or lower eyelids
with Lip & Eyelid Formula is a relatively simple technique
that does not cause bleeding and is very quick (a few min-
utes). It does not change the appearance of the eyes but, on
the contrary, restores their original qualities. It is easy to per-
form without local anesthetic or with nerve blocks of lidocaine
without adrenaline. Results are inadequate for treating fat pads
but are excellent, if not perfect, in all resurfacing indications.
The low rate of local complications and the lack of general
(b)
(a)
(d)
(c)
(e)
Figure 36.17 Developments and results: (a) before; (b) +24 hours; (c) +3 weeks; (d) +6 weeks; (e) +14 months.
Phenol: Chemical blepharoplasty and cheiloplasty 315
complications make it an ideal technique to rejuvenate the eyes
when the patient does not want laser treatment or surgery, and
the doctor is experienced in performing peels in general and in
using phenol in particular. It is obvious that a chemical bleph-
aroplasty should not be the first peel performed by a doctor
who is inexperienced in this branch of medicine or cosmetic
dermatology.
HOW TO DO A CHEMICAL BLEPHAROPLASTY
USING LIP & EYELID FORMULA
Figure 36.19 illustrates the process for a chemical blepharo-
plasty using Lip & Eyelid Formula.
Prepeel Care
•
The patient should apply Skin Tech Blending Bleaching
Cream twice a day for 2–3 weeks before peel.
•
Give the patient an analgesic (acetaminophen plus codeine)
30 minutes before the peel.
•
The skin should always be degreased with acetone,
disinfected with alcohol, and degreased/disinfected
with a mixture of 50% alcohol and 50% acetone before
application.
•
Place one drop of Vaseline-based ophthalmic ointment
in the eyes (i.e., Terracortril ophtalmicum) before starting
the procedure and at its end, to prevent postpeel ocular
irritation.
•
Herpes prevention is necessary if the patient has a history
(valacyclovir 500 twice a day for 4 days before up to 4 days
after the peel).
General Application
Position the patient in accordance with the conventionally
accepted rules for phenol peels. Prepare the patient and any
equipment that might be necessary to deal with any incidents
or complications. Among other things, a source of oxygen, an
intravenous infusion, a cardioscope, and oximetry monitoring
should be available.
A defibrillator and standard resuscitation equipment
should be installed before performing potentially arrhythmic
peels, such as phenol peels.
Postpeel monitoring is also very important, and the
doctor should make the necessary arrangements for regular
follow-ups with the patient to check the progress of the peel
and be available at any time for him or her.
A phenol peel is a deep peel technique with which the
doctor must be fully acquainted to avoid the complications
specific to these peels; the doctor must know how to treat any
complications that may arise.
Any peel solution containing phenol should be applied
with professionalism and patience. Phenol peels should be
applied slowly and evenly, using a double-type applicator cot-
ton swab (ear bud). It is extremely important to check for tears
during a phenol peel and swipe each with a new cotton pad.
Discard every cotton pad after use.
After the treatment, the patient should not be allowed to
sleep with the treated skin pressing against any surface (i.e.,
a pillow) as the treated area might stick to the surface and
result in infection, scarring, prolonged erythema, or other
complications.
Local Application
Carefully read the directions included in the Lip & Eyelid kit
for warnings about side effects and contraindications. Any
contact between phenol and the eyes can cause partial or total
loss of vision.
When treating sensitive patients, the doctor should
perform nerve blocks. Thirty minutes before the peel, the patient
should be given an acetaminophen and codeine tablet. Herpes
prevention is necessary for patients with a history of herpes.
About Pain
In the absence of nerve blocks, applying Lip & Eyelid triggers
a strong burning sensation for approximately 15 seconds, after
which the skin is numb for about 15 minutes. After 15 min-
utes, the patient will experience a gradual, unpleasant, warm
pulsatile inflammatory sensation that generally lasts until the
middle of the first night.
Uniformity of Results
A local application of phenol should be always performed
in combination with a peel of the full area around the
(a)
(b)
Figure 36.18 Long-lasting results: (a) before treatment; (b) 1 year after a localized peel with Lip & Eyelid on the lower lid; Unideep was
employed as an evening-out peel.
316 Textbook of Chemical Peels
phenol-treated one. In the case of chemical blepharoplasty,
another peel (i.e., Easy TCA Pain Control, Unideep, Easy Phen
Light) should be performed to prevent color or texture differ-
ences between the treated area and the rest of the face.
Application Protocol
Using a 1 ml syringe, draw out 0.3 ml of the Lip & Eyelid solu-
tion and drop 0.15 ml directly on a cotton bud; the cotton bud
should be moist and shiny but not drip.
Then carefully apply the first layer of solution on the
upper and/or lower eyelid.
Stop the application at 1 mm from the eyelashes of the
lower eyelid and before the tarsus of the upper eyelid. The tar-
sus of the upper eyelid should not receive an application of the
peel solution.
Uniform frosting appears rapidly, causing a burning
pain for 15 seconds followed by local numbness. When the cot-
ton bud appears to be dry, add another 3 drops of the Lip &
Eyelid solution to it. A second layer of solution is then applied
after obtaining the anesthetic effect of phenol. Allow time for
the frosting to appear; do not apply too much solution.
At the end of the application, apply the postpeel mask
over the entire treated area. Then apply a uniform layer of
Yellskreen on the treated eyelids. Do not apply Yellskreen on
the tarsus of the upper eyelid.
The procedure is now complete.
Follow-Up
See the patient on the 1st, 3rd, and 6th days following the peel
to monitor progress and ensure that there is no infection. In
case of infection, give the patient antibiotics (usually orally).
On the 3rd day, apply sterile white Vaseline on the edge of the
treated areas.
On the 6th day, apply sterile white Vaseline on the entire
treated area. Vaseline will help unstick the Yellskreen powder.
The patient can wear makeup beginning on the 8th day, if the
skin is in the right condition.
Home Care
Home care for the peel is divided into four phases (see Figure
36.19).
1.
Prepeel:
a.
Three weeks before, ask the patient to apply Blending
Bleaching Cream two times per day.
b.
Patients with a history of herpes should perform her-
pes prevention (valacyclovir 500, two times per day)
4 days before and 4 days after the peel.
c.
Botulinic toxin injection previous to application of the
peeling solution keeps the muscles paralyzed dur-
ing the skin regeneration phase and allows a better
and longer lasting result. Injection of botulinic toxin
should take place 1 to 8 days before the peel.
Day 0
Apply: Lip & Eyelid
Postpeel mask Yellskreen
NON OCCLUSION
NO YELLSKREEN on sup. eyelid tarsus
Day 6
Check if infection
Vaseline everywhere
Days 3
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 Cream (pigment control) or Atrofillin (2x/day)
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
Eyelids Deep Peeling (Lip & Eyelid Formula)
09 am–12 pm, 03 pm
Melablock HSP 30
Day 0
LE
LE
LE
1
2
4
5
3
6
6
7
Days 8 to 15
Days 16 up to 90
LP = Lip & Eyelid on eyelids
YELLSKREEN: Protective yellow powder
INFECTION* : appears as red poinds around Yellskreen
Specific Home care
Figure 36.19 Protocol for eyelid deep peeling
Phenol: Chemical blepharoplasty and cheiloplasty 317
2.
Days 1–8 postpeel: See Figure 36.19. Yellskreen must stay in
place for 6 days.
3.
Days 8–15: See Figure 36.19. IPLase greatly reduces post-
peel redness.
4.
Days 16–90: See Figure 36.19. Sun protection is mandatory
until the total end of erythema plus another 4 weeks.
Repeating the Peel
If needed, the full procedure could be repeated after 4–6 weeks
of skin regeneration, if the condition of the skin allows it.
CHEMICAL CHEILOPLASTY
A chemical cheiloplasty or labioplasty treats wrinkles around
the lips. The principle of the treatment is identical to that of
a chemical blepharoplasty, but it is easier to treat wrinkles on
the upper lip than on the eyelids. It is also less stressful for an
inexperienced doctor.
The skin on the lips is more resistant than the skin on
the eyelids. It has more appendages and is more apt to heal
well.
Chemical Resurfacing of the Upper Lip
in Combination with Easy TCA
Lip & Eyelid Formula can be applied to the upper lip with-
out nerve block anesthesia. A first quick coat of peel solution
induces local anesthesia within 15 seconds. Subsequent appli-
cations of phenol will therefore be painless.
Easy TCA is applied without anesthetic, and Lip & Eyelid
and Easy TCA can be combined when the wrinkles are mainly
located around the lips and the skin on the rest of the face does
not require a peel to the papillary dermis, which is often the
case. The procedure is then very quick. Figure 36.20 shows an
example of this approach. When there is more extensive sun
damage, it is preferable to combine Lip & Eyelid with Unideep.
Figure 36.20 shows an example of a case of upper lip wrinkles
in a patient who does not require a peel to the papillary der-
mis on the rest of the face. Upper lip wrinkles are more com-
mon in smokers and in patients whose mouths are very mobile
and who use the orbicular muscle of the mouth too often or
too vigorously: an injection of botulinum toxin reduces upper
lip mobility and produces better results in combination with a
deep peel. Because of the severe inflammation resulting from a
deep peel, the toxin is injected before the peel (at least 24 hours
before). Fifteen units of Dysport or 4 units of Botox are usu-
ally enough, injected at four different points on the upper lip
(Figure 36.20).
Chemical Resurfacing of the Upper Lip
in Combination with a Peel to the Papillary Dermis
When sun damage is more severe or if the patient has asked for
an evening-out peel at the same time to minimize sometimes
long treatments, Lip & Eyelid can be combined with Unideep
(Figure 36.21).
Although both peels can be done without nerve blocks,
patients often appreciate them as they make the procedure
more comfortable, especially when TCA is being applied.
Patients who are very squeamish may benefit from
sedation.
Results
Results, as we have seen elsewhere in this chapter and this
book, can sometimes be perfect. In other cases they are not per-
fect but still appreciated by the patient. Results can last for 3–10
years. More superficial peels should be done on a yearly basis
to maintain the results.
How to Do a Chemical Cheiloplasty
with Lip & Eyelid Formula
Prepeel Care
•
The patient should apply Skin Tech Blending Bleaching
Cream twice a day for 2–3 weeks before peel.
•
Give the patient an analgesic (acetaminophen plus codeine)
30 minutes before the peel.
•
The skin should always be disinfected and degreased
before application (with a mixture of 50% alcohol and 50%
acetone).
•
Place one drop of Vaseline-based ophthalmic ointment
in the eyes (i.e., Terracortril ophtalmicum) before starting
the procedure and at its end, to prevent postpeel ocular
irritation.
•
Herpes prevention is necessary if the patient has a history
(valacyclovir 500 twice a day for 4 days before up to 4 days
after the peel).
General Application
Although phenol toxicity has never been described after a local
treatment, the same security procedure as for a full-face peel-
ing is recommended.
Position the patient in accordance with the convention-
ally accepted rules for phenol peels. Prepare the patient and any
equipment that might be necessary to deal with any incidents
or complications. Among other things, a source of oxygen, an
intravenous infusion, a cardioscope, and oximetry monitoring
should be available.
A defibrillator and standard resuscitation equipment
should be installed before performing potentially arrhythmic
peels, such as phenol peels.
Postpeel monitoring is also very important, and the doc-
tor should make the necessary arrangements for regular fol-
low-ups with the patient to check the progress of the peel and
be available at any time for him or her.
A phenol peel is a deep peel technique with which the
doctor must be fully acquainted to avoid the complications spe-
cific to these peels; the doctor must know how to treat any com-
plications that may arise.
Any peel solution containing phenol should be applied
with professionalism and patience. Phenol peels should be
applied slowly and evenly, using a double-type applicator cot-
ton swab (ear bud). It is extremely important to check for tears
during a phenol peel and swipe each with a new cotton pad.
Discard every cotton pad after use.
After the treatment, the patient should not be allowed to
sleep with the treated skin pressing against any surface (i.e., a
pillow) as the treated area might stick to the surface and result in
infection, scarring, prolonged erythema, or other complications.
Local Application
Any contact of phenol with the eyes can cause partial or total
loss of vision.
One drop of ophthalmic Vaseline is placed in the eyes
before starting the procedure and at the end of the latter, in
order to avoid eye irritation post-peeling.
Eventually, perform nerve blocks.
Eventually give the patient one acetaminophen and
codeine tablet 30 minutes before peeling.
Herpes prevention is necessary.
318 Textbook of Chemical Peels
(b)
(a)
(d)
(c)
(f)
(e)
Figure 36.20 Chemical cheiloplasty of the upper lip in combination with Easy TCA as an evening-out peel. (a, b) Before treatment.
(c) Application at the base of the wrinkles. (d) Fading frosting. (e) Even application to the whole treatment area: appearance of gray-white
frosting (Easy TCA is applied after the lip has frosted and before occlusion). (f) Occlusion, beginning of occlusion.
(Continued)
Phenol: Chemical blepharoplasty and cheiloplasty 319
(h)
(g)
(j)
(i)
(k)
(l)
Figure 36.20 (Continued) Chemical cheiloplasty of the upper lip in combination with Easy TCA as an evening-out peel. (g) Occlusion
+24 hours. (h) Skin liquefaction after 24 hours, when the occlusion has been removed; note the edema on the upper lip. (i) Bismuth subgal-
late. (j) Results after 30 days (flash photography, with the patient wearing makeup). (k) Results after 60 days (photograph without flash,
with patient not wearing makeup). (l) Result of a chemical cheiloplasty. The yellow dots show where the botulinum toxin was injected 8 days
before the phenol peel.
320 Textbook of Chemical Peels
Pain In the absence of nerve blocks, applying Lip & Eyelid
triggers a strong burning sensation for approximately 15 sec-
onds, after which the skin is insensible for about 15 minutes.
After 15 minutes, the patient will experience a gradual, warm
pulsatile inflammatory unpleasant sensation that lasts until the
middle of the first night.
Uniformity of Result A local application of phenol should be
always associated with a peeling of the full area around the
phenol treated one: in the case of chemical blepharoplasty,
another peeling should uniformize the result on the entire face
for avoiding color or texture differences (i.e., Easy TCA PC,
Unideep, Easy Phen Light).
(a)
(b)
(c)
(d)
Figure 36.21 (a) Appearance of the patient’s upper lip before the peel. The rest of the skin is quite badly sun damaged and requires an
application of Unideep, a TCA peel to the papillary dermis, if not a full-face phenol peel. (b) After disinfecting and degreasing the whole
face, Unideep is applied gradually in sequence. (Unideep is applied in sequence, like phenol, but without the rest periods: see Chapters 23
and 34.) (c) Lip & Eyelid is applied to the right half of the upper lip. (d) Immediately after Unideep has been applied, the patient feels a slight
burning sensation that can be alleviated with a cold pack placed directly on the acid before it has dried. The cold pack must be completely
dry so that it does not dilute the peel solution.
Phenol: Chemical blepharoplasty and cheiloplasty 321
(e)
(g)
(h)
(f)
Figure 36.21 (Continued) (e) The forehead was treated first and the frosting has faded. Some pinpoint frosting (gray-white) remains in
places where the peel has penetrated more deeply (there is a chance of infection or scratching, etc., later on). The pinpoint frosting is simi-
lar to that produced by One Touch peel. The midface and cheek region have been treated as described earlier. Unideep is applied to the
chin at the same time as the jaw area, where the patient also benefited from a cold pack. The Unideep postpeel cream has been applied
to the whole treated area, apart from the lips, which are to be occluded. (f) The base of the lip wrinkles is treated (Lip & Eyelid). (g) This is
followed by an application of Lip & Eyelid to the whole of the left half of the upper lip. (h) Unideep is applied to the left midface region and
the cheek. The postpeel cream is applied. The chin region and the jaw area are treated with Unideep.
(Continued)
322 Textbook of Chemical Peels
Application of Peeling Syringe out 0.3 ml of the Lip & Eyelid
solution and drop 0.15 ml directly on a cotton bud.
Carefully apply Lip & Eyelid solution directly on the bot-
tom of deep wrinkles (a white frosting should appear) before
applying the peeling solution on the entire upper lip, until an
even gray frosting quickly appears. When the cotton bud appears
as dry, drop again 3 drops of the Lip & Eyelid solution on it.
A second or third layer could be applied if necessary, after
obtaining the anaesthetic effect of phenol, in order to reach the
proper frosting: a gray white frosting.
At the end of the procedure, apply an occlusive dressing
(dressing included in the kit) and then uniformize the results
by applying a less deep peeling (e.g., Easy TCA PC, Unideep, or
Easy Phen Light) on the rest of the face.
Day 1
The occlusive dressing should stay in place during 24 hours.
After 24 hours, remove the occlusive dressing and
apply one coat of “Skin Tech® Post Peel Mask,” then apply on
it, a uniform layer of Yellskreen and leave to dry and form a
crust.
Follow-Up
See the patient on the 3rd and 6th day following the peeling to
monitor progress and ensure that there is no infection. In case
of infection or any other problem, the patient should be given
antibiotics (usually orally).
On the 3rd day, apply sterile white vaseline exactly on
and only on the edge of the treated areas.
(i)
(j)
(k)
Figure 36.21 (Continued) This photograph shows an impermeable keratosis that will be treated with a single application of Only Touch
(i, j). (k) Shows occlusion of the upper lip after Lip & Eyelid application.
Phenol: Chemical blepharoplasty and cheiloplasty 323
At the 6th day apply sterile white vaseline on the whole
area. Vaseline will unstick the Yellskreen powder. Makeup is
allowed on the 8th day, if the skin is in a condition to receive it.
Home Care
The care to be given round the peel is divided into four phases
1.
Prepeel:
a.
3 weeks before, ask the patient to apply Blending
Bleaching Cream 2 times/day
b.
Herpes prevention 4 days before and 4 days after peel
(valacyclovir 500, 2/day)
c.
Botulinic toxin injection 1 to 8 days before peel
2.
Postpeel (see Figure 36.22):
a.
Days 1–8: At day 1, remove occlusion, apply postpeel
mask and Yellskreen. Important: Yellskreen must stay
in place for 6 days.
b.
Days 8–15: IPLase allows a strong reduction of post-
peel redness.
c.
Days 16–90: Sun protection is mandatory until the
total end of erythema + 4 weeks.
Repeating the Peel
If needed, the full procedure can be repeated after 4-6 weeks
regeneration if the status of the skin allows it.
Complications
See Chapter 37.
SUMMARY OF THE CHEMICAL
RESURFACING TECHNIQUE
Prepeel
•
If risk of pigmentary changes:
•
Skin phototype I–III: Blending Bleaching Cream twice
a day for 2–3 weeks before the peel.
•
Skin phototype IV: Blending Bleaching Cream and 4%
hydroquinone 3–4 weeks before the peel.
•
If risk of herpes: valaciclovir or aciclovir.
•
Do not treat very squeamish or low-IQ patients.
•
Tell the patient how the skin will look during the first week:
•
Crust of yellow powder.
•
Swollen face.
•
Social life impossible.
•
Give the patient a painkiller tablet 30 minutes before the
peel.
Preparation and Application of the Peel
•
Degrease the skin with acetone (ventilation).
•
Disinfect with alcohol (ventilation).
•
Protect the eyes with sterile ophthalmic Vaseline.
Day 0
Lip & Eyelid
Occlusion 24 h
Day 1
Occlusion OUT
Postpeel mask
Yellskreen
Day 1: after 24 hours occlusion
Day 3: vaseline on edges
Day 6
Check if infection
Vaseline full area
Day 3
Infection*?
Vaseline/edges
– 2 Weeks
1
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 Cream (pigment control) or Atrofillin (2x/day)
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
LIPS Deep Peeling (Lip & Eyelid Formula)
09 am–12 pm, 03 pm
Melablock HSP 30
Day 0
LE
LE
LE
1
2
4
5
3
6
7
Days 8 to 15
Days 16 up to 90
LE = Apply Lip & Eyelid on lips
YELLSKREEN: Protective yellow powder
INFECTION* : appears as red poinds around Yellskreen
Specific Home care
Figure 36.22 Postpeel care for the lips (deep peel).
324 Textbook of Chemical Peels
•
If the evening-out peel is Easy TCA: Start with phenol and
apply Easy TCA after the phenol.
•
If the evening-out peel is Unideep:
•
Start with Unideep (see the details of application ear-
lier in this chapter).
•
Inject ±0.14 cm3 of Lip & Eyelid solution directly onto
a cotton bud.
•
Apply Lip & Eyelid Formula to the whole treatment
area.
•
With nerve block anesthesia: Start at the base of the wrin-
kles and then apply to the whole area.
•
Without nerve block anesthesia:
•
Apply a quick coat of Lip & Eyelid to the whole area;
warn the patient how long the burning will last (15
seconds).
•
Apply the solution in the base of the wrinkles and to
the whole area.
Eyelids Immediately After the Peel
•
(In general) no occlusion; only Unideep or Easy TCA® post-
peel cream is applied to the eyelids.
•
Eyedrops (artificial tears) several times a day.
•
A painkiller tablet for the evening or night (more if painful).
•
Lorazepam 2 mg to be taken before going to bed.
Upper Lip and Chin Immediately After the Peel
•
Twenty-four hours of occlusion: The transparent occlusive
dressing can be found in the Lip & Eyelid kit.
•
If the occlusive dressing comes off accidentally before 24
hours, apply Vaseline as emergency occlusion.
•
A painkiller tablet for the evening or night (more if painful).
•
Lorazepam 2 mg to be taken before going to bed.
The Evening of the Peel
•
The treated area must not be washed.
•
If the evening-out peel was Unideep: Apply the rest of the
tube of postpeel cream.
•
If the evening-out peel was Easy TCA: No particular
treatment.
The Following Morning
•
The face can be washed with water, but the area treated
with Lip & Eyelid should not be washed.
•
If the evening-out peel was Unideep: Apply the rest of the
tube of postpeel cream.
•
If the evening-out peel was Easy TCA: No particular
treatment.
•
In all cases: Start sun protection (Melablock-HSP) 50+.
See the Patient Again After 24 Hours
•
If occlusion: Remove occlusion.
•
If no occlusion: No treatment (maybe remove Vaseline).
•
Occlusion or not: Powder with bismuth subgallate.
•
If the subgallate does not stick: Spray with thermal
water (such as Vichy water) to enable the powder to
stick.
•
If it still does not stick: Antibiotic cream or sterile
Vaseline to be applied four times a day; rinse the skin
under the showerhead before applying another layer
of cream.
•
Patients should wash their hands thoroughly before touch-
ing their skin.
•
If there is an unpleasant sensation of tightness in the area
treated with phenol: Apply neutral sterile Vaseline to the
edges of this area.
The 3rd Day
•
Normal recurrence of pain for several hours: Acetamino
phen plus codeine tablet.
See the Patient Again on the 4th Day
•
Check that there is no bacterial, viral, or fungal infection.
•
If infection: Treat by mouth, not topically.
•
Apply sterile white Vaseline to any cracks (very locally).
After the 6th Day
•
The patient applies white Vaseline several times a day to
help the powder come away.
See the Patient Again on the 7th Day
•
Help remove the bismuth membrane.
After the 8th Day
•
The patient can wear makeup or carefully shave.
•
Sun avoidance and protection: SPF 50+ UVA–UVB
(Melablock-HSP) for 3–6 months.
•
Blending Bleaching Cream (as soon as the skin can tolerate
it) twice a day.
•
Tyrosinase inhibitors, antioxidants, and vitamins to block
excess melanin synthesis.
•
Renutriv ACE Lipoic Complex (antioxidant) 2–3 times a day.
See the Patient Again After 15 Days and 1 Month
•
If there are pigmentary changes (after approximately 1
month):
•
Do a few sessions of Easy TCA (pinpoint or cloudy
white frosting).
•
May be combined with a corticosteroid such as
clobetasol.
See the patient again after 3 months for the end of treatment.
NOTE
1. See Chapter 32 for more information on the use of Vaseline
immediately after a peel.
37
Complications of chemical peels
GENERAL REMARKS
We must humbly accept the fact that there is no magic formula
that even the most experienced practitioner could use on all
skin types without taking precautions and without risk and
whose results would be both spectacular and permanent. Some
formulations are of course simpler and less dangerous to use
than others, but there is no guarantee of automatic success and
complete safety. The practitioner must follow the rules of appli-
cation for each peel; be aware of its limitations, risks, and indi-
cations; and know how to avoid and treat any complications.
“Artistic” improvisation usually leads to disastrous results.
It is vital to read the instructions for use for each peel before
applying it. A thorough knowledge of the symptomatology and
physical and chemical mechanisms of peels is essential for the
practitioner to be able to work confidently, safely, and efficiently.
It is child’s play for any competent doctor to apply liquid to a
patient’s skin, but the true skill lies in anticipating the com-
plications, being able to prevent them, and, if prevention fails,
being able to treat them. Patients deserve to be treated consci-
entiously, with respect and optimum safety, by true profession-
als. Any peel, even a superficial one that is neutralized quickly
and even in the most experienced hands, can lead to complica-
tions that are not necessarily serious or permanent, but that are
more than what a particular patient is prepared to put up with.
The deeper a peel penetrates, the sooner it is effective and the
greater the risk of serious and permanent complications.
This chapter will look at each complication in detail, how
to prevent it, and how to treat it. Systemic complications,1 exclu-
sive to phenol peels, are dealt with in Chapter 28.
The magnitude of the risk depends on the following
factors:
•
The type of peeling agent used, its concentration, how it is
applied, and the depth it reaches.
•
The doctor’s (lack of) experience, the monitoring and treat-
ment equipment used.
•
Skin preparation (when necessary) and postpeel care rec-
ommended by the doctor.
•
The patient’s own sensitivity and compliance with the pre-
and postpeel treatment.
•
The patient’s medical and treatment history.
•
The area to be treated (e.g., the neck poses a greater risk
than the forehead).
•
Countless individual and impromptu factors.
It is therefore essential to be knowledgeable, consider,
weigh, compare, photograph, note, record, film, explain, pal-
pate, measure, monitor, diagnose, check, and so forth.
GENERAL SAFETY FACTORS
If there were a secret to safety, it would lie in a thorough knowl-
edge and understanding of this type of treatment. For doctors
to give patients a wide range of choices, they must know how
to use at least the three main types of conventional peels cor-
rectly: alpha hydroxy acids (AHAs), trichloroacetic acid (TCA),
and phenol (for phenol, the doctor should at least know how to
apply it locally). For each type of peel, the doctor must be per-
fectly acquainted with its indications, results, limitations, and
complications to be able to choose the right product for a given
patient and to be able to apply it correctly. The patient should be
informed of alternative techniques, their possibilities, contrain-
dications, side effects, and cost.
The application technique must be flawless and in keep-
ing with the particular procedure for each peel, appropriate
to the patient’s skin type and the results expected. The doc-
tor must be aware of and acquainted with the risks of compli-
cations and the means to prevent and treat them. It is better
to avoid complications through prevention rather than treat
them. Each patient is different, and each peel must be suited
to each patient, which in no way means trying dangerous
experiments with different formulas on a case-by-case basis.
On the contrary, it is a matter of choosing among tried and
tested treatments the one that is most suitable for the patient’s
skin structure and that will give the best results with a mini-
mum of inconvenience. For example, the practitioner should be
able to decide whether it is preferable to perform several more
superficial treatments or, on the contrary, to do a single phenol
peel. If the latter option is chosen, which formula should be
used: Baker–Gordon, Grade’s or Litton’s, Verner, Hetter, mold-
ing mask, Cora Valenti, Exoderm, or Lip & Eyelid? Should an
occlusive mask be applied? Should the peel be neutralized?
Should occlusion be left on for 24, 36, or 48 hours? Is postpeel
care necessary? If so, what? If TCA is the treatment selected,
should it be medium or deep, or is it better to do several ses-
sions with Easy TCA or Unideep? If an AHA peel seems the
best choice, should it be glycolic acid, mandelic acid, or lactic
acid? Or Easy Phytic peel? Should the peels be combined with
other treatments, such as botulinum toxin, dermabrasion, fill-
ing, surgery, coagulation of telangiectasias, shave excision,
mesotherapy, and so forth? In which order should the com-
bined treatments be performed? Peel before toxin or vice versa?
Peel before a face-lift or vice versa? Peel before mesotherapy or
vice versa?
Most peels carry a risk of one of the complications dealt
with in this chapter. The likelihood of these complications
occurring largely depends on the type of peel and the patient.
Classifying peels as very superficial, superficial, medium, or
deep is purely theoretical and should not make the doctor any
less vigilant. A low-concentration TCA or a simple glycolic acid
peel can penetrate deep into the dermis if the peel is applied
repeatedly and vigorously, or, as far as glycolic acid is con-
cerned, if the peel is not neutralized in time. Depending on the
agent and technique used, complications can be systemic or
local, permanent or temporary, serious or not.
326 Textbook of Chemical Peels
INADEQUATE RESULTS
Inadequate results are an acceptable complication when the
patient has been forewarned and the practitioner is prepared to
compensate and do a proper touch-up. It is unacceptable when
the patient has not been warned of this possibility and the doc-
tor does not provide the care the patient deserves.
Reasons for Inadequate Results
Wrong Indication
If the doctor’s aim is to improve the texture of the skin, treat
hyperpigmentation, and even-out the complexion, a single peel
to the papillary dermis or four Easy TCA peels to the basal
layer Grenz zone are good indications. On the other hand, it
would be dreaming to expect to eliminate surgical or acne scars
or the wrinkles on the cheek of the patient in Figure 37.1 with
glycolic acid or even TCA. Scars are treated with deep peels,
often in combination with other treatments (punch eleva-
tion, dermabrasion, subcision, laser, filling, etc.). Wrinkles are
treated with phenol.
Poor Product Knowledge
Attempting to use glycolic acid or TCA to achieve a visible lift-
ing effect on “shar-pei skin” is inviting disappointment; only
cosmetic and plastic surgery can achieve a lifting effect. It is
better to warn patients of the possibility of inadequate results
with any peel, even a deep one, if their skin is very thick, oily,
and sagging. It is likely that a deep peel would have to be
repeated (locally or completely) to achieve the desired results.
In these cases, it is worth considering a combination of a surgi-
cal face-lift and a peel.
Sagging, thick skin is not a good indication for peels in
general (Figure 37.2). Peels can eliminate fine lines, hyperpig-
mentation, and keratoses and improve the quality of sun-dam-
aged skin.
Lack of Prepeel Preparation, Proper Cleansing,
and/or Degreasing the Skin
The presence of a lipid film on the skin partially deactivates
many peels and limits their penetration. An unprepared stra-
tum corneum may be too thick—too impermeable—in places.
This relative local impermeability means that the acids do not
penetrate evenly and the results will also be uneven. Prepeel
preparation is essential for certain peels2 but unnecessary, or
even dangerous, for others.3 It is essential to follow the recom-
mendations for each peel solution to the letter.
Facial Expressions
After a deep peel, facial expressions imprint lines in the newly
regenerating dermis and epidermis (Figure 37.3). Injecting bot-
ulinum toxin (before or after a peel) prevents dynamic wrinkles
from reappearing after a peel. Smoking should be forbidden
after a deep peel to prevent the rapid reappearance of “accor-
dion folds” around the mouth. As well as requiring sucking
movements,, smoking reduces the oxygen supply to the newly
regenerating skin while dramatically increasing the number of
free radicals. Smoking accelerates skin aging and slows down
healing.
Figure 37.1 Wrinkles on the cheeks that will not respond or
respond poorly to superficial or medium peels.
Figure 37.2 Sagging skin that does not respond well to peels.
Complications of chemical peels 327
Combined Techniques
Nonsurgical facial rejuvenation often requires a combination of
different techniques, such as (micro)dermabrasion, filling treat-
ments, shave excision, prior surgical removal of small benign
tumors, punch elevation of scars, stimulating facial mesother-
apy, peels of different depths, and so forth. The doctor can only
learn by experience what results to expect, which techniques
should be combined, and how best to use the chosen peel on a
particular patient. Therein lies the art of peeling.
Histology of Lesions Undergoing Treatment
Lentigines, for example, result from a problem in the basal
layer of the epidermis. Remember, however, that the epidermis
extends to varying depths into the dermis to form the dermal
papillae. If a lentigo originates in a relatively superficial papilla,
a peel to the Grenz zone will solve the problem,4 but if the len-
tigo originates in a deep papilla, it would take a very deep peel
to dislodge it. Histologically, lentigines often have a deep “golf
club” structure that makes them difficult to reach. In this way,
some problems that are histologically epidermal can only be
treated by deep peels. In the diagram in Figure 37.4, a peel to
the Grenz zone can resolve problem A, whereas problem B will
only respond to a peel to the reticular dermis. This reticular
peel can be localized (e.g., with Only Touch) or full-face (phe-
nol peel). Repeated intraepidermal peels, no matter how often
they were performed, would do nothing to solve the problem.
Stretch marks, to give another example, are characterized by
epidermal and dermal atrophy. They can be improved only by
combining epidermal resurfacing with strong and deep dermal
stimulation.
Prevention of Inadequate Results
Prevention of inadequate results requires the following:
•
Proper targeting of patients.
•
Following the indications and application method of the
chosen peel.
•
Thorough knowledge of the products used.
•
Possible combination with other treatments.
In all cases, caution dictates that the patient should be
promised less dramatic results than might be hoped for. In this
way, in the best-case scenario, the patient will get a nice sur-
prise and be happy with the better-than-expected results. In
the worst-case scenario, the doctor will not have made prom-
ises he cannot keep.
Patients should be made fully aware of the limitations
of their treatment. They should be shown photographs—and
not necessarily the ones showing the best results. It is always
essential to talk with patients before treatment to find out what
they want and make sure they get the results they are looking
for. It would be pointless to suggest a series of superficial peels
to patients who want to eliminate crow’s feet, when a botuli-
num toxin injection would provide them with the quick results
they want. False hopes always create problems for the doctor
that raised them. Some patients’ disappointment can turn into
a nightmare for the doctor.
Treatment
Touch-Up or Different Technique
If the selected peel turns out not to be strong enough, a differ-
ent peel should be used or it should be combined with other
treatments. Local or general touch-ups can be done as soon as
the condition of the skin permits, that is, when the skin has
completely regenerated and when all erythema and flaking has
finished. The “rest” time between two peels is usually between
4 and 6 weeks.5 Many peels produce results only after fairly
frequent repetition.
Repeating Peels
•
Very superficial (stratum corneum) and superficial (intraepider-
mal: Easy Phytic) peels have to be repeated to produce visible
results. Results usually show only after a certain number
of sessions, as they are stimulating rather than destructive.
•
Peels to the basal layer (Easy TCA) can be repeated four or
five times on an average of one session a week. The doctor
should always wait for the skin to recover before re-peel-
ing. Skin that is actively flaking should not have another
peel applied to it. Some patients need a fifth peel (patients
with oily skin or resistant hyperchromia, squeamish
patients who do not allow the doctor to apply the solution
properly, etc.).
•
TCA peels to the papillary dermis (Unideep) should not be
repeated until at least 1 month later and on condition
that the skin has completely recovered from the previous
session.
•
Localized TCA to the reticular dermis (Only Touch): In some
cases, lentigines or keratoses do not disappear after the first
session of Only Touch. The application protocol for Only
Touch provides for a second application where necessary.
Figure 37.3 Reappearance of dynamic wrinkles 10 days after a
full-face phenol peel.
A
B
Reticular dermis
Grenz zone
Figure 37.4 Lentigines at different depths.
328 Textbook of Chemical Peels
The Only Touch peel should be combined with Easy TCA
to avoid pigmentary changes and can be applied before the
first and the fourth Easy TCA peels. If some lesions resist
or recur, a complete cycle of Only Touch plus Easy TCA
can be started again after a 6-week rest period. Resistant
lesions on the face can be treated locally with a spot appli-
cation of Lip & Eyelid. However, applying very localized
phenol often produces long-lasting (3–6 months or more),
localized erythema. This erythema tends to resolve natu-
rally but should be accompanied with protective measures
against postinflammatory hyperpigmentation (PIH).
•
Phenol (Lip & Eyelid Formula): If a full-face phenol peel
does not produce adequate results, a second peel can be
applied to the areas that did not respond to the first peel.
The touch-up can be localized or full-face, if the condition
of the skin permits and if there has been a long rest period.
Skin regeneration after the second peel is much quicker,
there is less edema, and postpeel erythema is of a much
shorter duration (2 weeks at the most). If a third phenol
peel were indicated (in extremely rare cases of very thick
skin, patients who smoke, or rapid resumption of facial
expressions), it would most often be localized. The author
has only once had to do a third phenol peel on the lip
and cheek area after inadequate results on skin that was
extremely oily and thick. Recovery was even faster after a
third application of phenol, and there was hardly any ery-
thema. It should be noted that if a second phenol peel can
boost inadequate results, a third phenol peel only brings a
very slight improvement over the second.
MELANOCYTE TOXICITY
Melanocytes are located in the basal layer of the epidermis
and form part of the dermoepidermal interface. Skin color
depends—among other things—on the melanocytes’ capacity
to give up their melanosomes to neighboring keratinocytes and
thus provide a homogenous photoprotective layer of pigments
on the surface of the epidermis. It has been shown6 that mela-
nocytes have three different ways of transporting melanin to
keratinocytes:
•
Melanocyte phagocytosis: Transfer of melanin plus cyto-
plasm plus melanocyte dendrites to the keratinocyte.
•
Membrane fusion between melanocytes and keratinocytes,
leading to direct exchanges between melanocytes and
keratinocytes.
•
Exocytosis of melanosomes by melanocytes to the extracellu-
lar environment, where they are picked up again by kera-
tinocyte endocytosis.
Each melanocyte communicates with 35–40 keratino-
cytes through its dendrites and forms one “melanization unit.”
If the melanocyte transmits eumelanosomes, the keratinocytes
receive effective sun protection. On the other hand, if phe-
omelanosomes are transmitted to the keratinocytes, they will
not be properly protected against UV rays. Keratinocytes can
synthesize active substances that alter the proliferation, dif-
ferentiation, and certain biological functions of melanocytes.6
An agent’s melanocyte toxicity is an advantage when treating
melanin hyperpigmentation. On the other hand, it is an adverse
effect when melanocyte toxicity results in partial, complete,
localized, or generalized depigmentation. Complete, general-
ized, and permanent depigmentation results in “porcelain”
skin and, according to Litton,7 occurs in 3% of phenol peels
with his formula. This complication has not been described to
date with the Lip & Eyelid Formula.
Melanocyte Toxicity of Different Types of Peels
AHAs
AHAs are not considered toxic to melanocytes. Therefore, there
is little fear of depigmentation when these peels are applied
according to the rulebook. When these peels are neutralized,
their effect stops, and AHAs cannot therefore do any irrevers-
ible damage to melanocytes. If they are not neutralized soon
enough, they can, however, cause melanocytic lesions and
areas of depigmentation as a result.
Uneven penetration of AHAs can damage melanocytes
locally. Uneven penetration can occur when:
•
There is no skin preparation (except for Easy Phytic peel8).
•
The doctor does not apply the peel evenly.
•
The patient has applied products locally that reduce the
thickness of the stratum corneum (tretinoin, glycolic acid,
benzoyl peroxide, etc.).9
•
The patient has used abrasive or hair-removing techniques
that alter the relative impermeability of the skin before the
peel.
In general, the appearance of frosting during an AHA
peel is a sign of overpeeling, and pigmentation problems may
well occur. An AHA peel should always be neutralized after
erythema and before frosting.
TCA
TCA is not considered toxic to melanocytes. High concentra-
tions of TCA can, however, coagulate melanocytes and destroy
them. Areas of depigmentation can therefore appear if TCA
has been too aggressive locally. Aqueous solutions of TCA in
particular can penetrate more deeply than they should, as they
are neither homogeneous nor stable. An even, intraepidermal
TCA peel to the basal layer or Grenz zone does not cause depig-
mentation. Easy TCA, in the basic protocol, does not produce
depigmentation.
A TCA peel to the papillary dermis, if applied evenly,
does not usually cause permanent, pathological depigmenta-
tion. If the TCA penetrates too deeply into the dermis, depig-
mentation is sometimes accompanied by scarring. Three
different degrees of TCA penetration cause three different
complications: scarring results from the deepest penetration;
depigmentation without scarring results when the TCA pen-
etrates too deeply (but not deep enough to cause scarring) and
is melanolytic; and a hyperpigmented halo results from an
untreated, peripheral inflammatory reaction.
Phenol
Phenol is considered toxic to melanocytes, although pigmen-
tary changes can sometimes occur after a phenol peel (see later
in this chapter). Phenol is by far the most effective agent when it
comes to treating many facial hyperpigmentations. In general,
a slight loss of pigment should be considered as normal after
a phenol peel, and not as a complication. For a given concen-
tration, depigmentation is proportional to the total quantity
of phenol applied to the skin. That means that several coats of
the same product will cause depigmentation more often than a
smaller number of coats. The presence of adjuvants can also be
Complications of chemical peels 329
a risk factor for depigmentation: croton oil is a common adju-
vant in phenol formulas and enhances penetration of the phe-
nol. If there is too much croton oil, the phenol can penetrate
more deeply and cause depigmentation. The use of thymol
iodide as a postpeel mask is another risk factor, as thymol is
a phenol derivative that can have a toxic effect on melanocytes
in the period immediately following the phenol peel. This
risk can be avoided by using bismuth subgallate as a postpeel
mask. Phenol is not melanolytic, however: it does not physically
destroy melanocytes. Melanocytes are not simply melanin-
producing organelles but play an active part in many of the bio-
logical processes in the skin:
•
Cytokine production.
•
Inflammation mediator.
•
Enzyme production.
•
Synthesis of molecules in the extracellular matrix.
Histological sections taken after phenol peels show that
melanocytes are still present, though many of them are inac-
tive. Clinically, fewer melanocytes are rendered inactive with
the latest formulas (e.g., Lip & Eyelid). This means that long-
term prognosis for sun exposure can be better with these peels
than with older phenol formulations and that a few months or
even a year after the peel, it is often difficult to see a demarca-
tion line.10 The melanocyte toxicity of phenol means the prac-
titioner must choose the product most suited to the patient’s
complexion.
When persistent (absolute or relative) depigmentation is
likely after a phenol peel, it is essential to warn patients that the
texture of their skin will be rejuvenated but that in all likeli-
hood they will have to wear foundation on a permanent basis to
hide the difference in color between the treated and untreated
skin.
The risk of depigmentation can pose a problem with
badly sun-damaged skin, but, at the same time, this is one of the
best indications for phenol. The extraordinary results achieved
on photoaged skin are often accompanied by a more visible
demarcation line between the areas of healthy, treated skin and
the old, untreated skin. Combined use of phenol on the face and
Easy TCA or Unideep on the neck help attenuate this demar-
cation line (see Figure 30.1). The melanocyte toxicity of phenol
poses different problems depending on whether the treatment
has been applied to the whole face or just locally (e.g., the upper
lip). Depigmentation of the whole face is easier to hide with
makeup than localized depigmentation, and this should be dis-
cussed with the patient. Usually, older patients whose upper lip
is very damaged will accept this local depigmentation, easily
disguised with camouflage makeup, whereas younger patients
find it more difficult to accept being condemned to wearing
makeup every day, and often prefer other treatment options.
Prevention
The selected peel must be applied in strict accordance with
the instructions for use. The practitioner should always bear
in mind that the deeper the peel, the more effective it is, but
also the more dangerous it is and that phenotype does not
always correspond to genotype: an individual who appears
to have a light complexion may react dermatologically like a
much darker phenotype. With this in mind, family anamnesis
might well prove worthwhile. Examining the areas of the body
that have never been tanned can provide a clue to the patient’s
“base” color, and the area treated with phenol may well return
to this original color.
Melanocyte Toxicity Depending on Skin Phototype
Black Patients
Black patients can be treated with correctly neutralized glycolic
acid or with Easy Phytic Solution. Easy TCA can also be used
(pinpoint or cloudy-white frosting); TCA should never be
allowed to penetrate the reticulary dermis (see Chapter 16).
Phenol should not be applied on patients with a skin phototype
above IV.
Asian Patients
Asian patients might pose a problem of residual depigmenta-
tion with deep peels. Patients with dark Asian skin are treated
like those with black skin. Lighter Asian skins can be treated
with deeper peels. Fintsi69 and Professor Damiano Kim (Korea)
applied phenol successfully to patients with light Asian skin.
AHAs, Easy Phytic, and Easy TCA can be used in all cases. TCA
in simple aqueous solution (TCA–SAS) often triggers PIH on
Asian skin. Unideep should be used with caution on Asian skin
phototypes.
Dark-Skinned Patients
Mediterranean or Latin American skin types can be treated
with AHAs, superficial TCA, or Easy TCA. A TCA peel to the
papillary dermis can be used with caution, avoiding overpeel-
ing and postpeel inflammatory reactions. Patients with skin
phototype IV can be treated with phenol if the patient is warned
of the possibility of depigmentation in the treated skin. Results
can be very satisfactory, as the difference in color between the
treated and untreated areas may not be too marked.
Red-Haired Patients
Red-haired patients, whose skin is often covered in freckles, do
not pose any problems with AHA peels or Easy TCA. A TCA
peel to the papillary dermis eliminates most of the freckles, and
Easy TCA in the basic protocol lightens them.
In principle, the texture of their skin makes them good
candidates for phenol, as they get wrinkles sooner than darker
skin phototypes and do not often suffer from PIH after a
medium or deep peel. All the freckles will disappear, however,
leaving the skin depigmented and a demarcation line on the
neck. Red-haired patients are the ones most at risk of complete
depigmentation after phenol: porcelain skin that often will take
on the color of areas that have never been exposed to the sun.
Treating Melanocyte Toxicity
As yet there is no easy and effective treatment to return color to
a skin that has lost it. No doubt in the future melanocyte grafts
will be a possibility. For now, makeup is the only solution.
ERYTHEMA
Postpeel erythema can be perfectly normal (Figure 37.5) or a
warning sign of a more serious complication. Erythema can
occur as a reaction even after simply cleansing thin and sensi-
tive skin before a peel. If an erythema develops after the skin
has been cleansed gently and without acid products, it may be
concluded that it is hypersensitive and should be treated with
caution.
Chronologically, the skin’s first response to an applica-
tion of acid is usually erythema. This erythema is caused by the
330 Textbook of Chemical Peels
inflammatory vasodilation of the blood vessels in the dermis in
response to chemical injury. The vasodilation triggers transient
dermal edema. This edema is largely responsible for the rapid
disappearance of fine lines after superficial peels. The dermis
fills with extravasated fluids as a result of vasodilation, and this
stretches the epidermis. The fine lines disappear temporarily.
Erythema may therefore be the only clinical sign of a superfi-
cial peel. The deeper the peel, the more erythema is replaced by
frosting due to protein coagulation. The speed with which ery-
thema is replaced by frosting largely depends on the strength
of the acid used. Some very strong acids trigger frosting even
before erythema becomes apparent.
AHAs and Erythema
AHAs in Aqueous Solution
Essentially, AHAs trigger erythema—a sign that the peel
should be neutralized. Erythema appears more quickly when
the skin has been prepared (certain products increase the per-
meability of the stratum corneum) during the weeks before the
peel.
•
Very localized, isolated erythema signals an area where the
AHAs have penetrated rapidly. The doctor should keep a
close eye on this area and neutralize it with sodium bicar-
bonate or another alkaline solution, while leaving the peel
to work a little longer on the rest of the treated area that has
not yet reached the stage of erythema. Great care should be
taken not to let the acid penetrate too deeply locally and
trigger frosting, which can lead to complications. After
neutralizing, it can help to apply a little cortisone cream on
an area of erythema.
•
Even and light erythema is a clear sign that it is time to neu-
tralize the peel with an alkaline solution prepared before
the peel has been applied. After the acid has been properly
neutralized, the erythema should be transient and last one
hour at the most.
•
If the practitioner ignores the erythema and does not neutralize,
the AHA peel can cause localized pinpoint frosting that
will gradually converge and become relatively uniform.
An AHA peel that is not neutralized causes scabbing
and, in the most serious cases, dyschromia and scarring.
Patients often give up on the treatment if the peel is not
properly neutralized. Erythema from overpeeling can last
for several weeks or months and leave areas of skin that are
“smoother” than the surrounding skin.
Easy Phytic Solution
This peel deserves special attention because of the fact that it
does not need neutralizing (see Chapter 11). It triggers light
and uniform erythema that lasts for a few hours at the most.
Neutralizing this peel would reduce its effectiveness and
negate any benefit. If any abnormal frosting occurs, the peel
should be neutralized immediately.
TCA and Erythema
TCA in Simple Aqueous Solution (TCA–SAS)
The appearance of light, uniform, and widespread erythema
after a TCA–SAS peel does not usually lead to any problems
and has a natural tendency to resolve gradually without treat-
ment. The appearance of localized erythema, especially on the
cheekbones, should alert the doctor, as it can be a sign of local
overpeeling or one or more of the following:
•
Too high a concentration of TCA.
•
An inhomogeneous TCA solution.
•
Too many coats of acid applied locally.
•
Too aggressive or uneven prepeel preparation.
•
Scratch lesions becoming infected.
•
The start of a viral infection.
•
An incorrect application technique.
Applying TCA to the skin produces, in sequence, the fol-
lowing clinical signs: erythema, pinpoint frosting, cloudy-white
frosting, converging cloudy frosting, even pink-white frosting,
pure white frosting, and finally gray-white frosting. The speed
with which one sign replaces another is dose-dependent.
These signs should appear in sequence when a low-
concentration TCA peel is applied in successive coats. A more
concentrated TCA peel will trigger converging clouds of
frosting at the same time as erythema around the frosting
(Figure 37.6). Higher concentrations trigger pink frosting
instead of erythema, and erythema only appears only as the
frosting fades in the treated areas.
Highly concentrated TCA triggers immediate “pure
white” frosting without any hint of pink or gray, which signals
coagulation of the skin proteins and the walls of the dermal
blood vessels.
Although the erythema from TCA is often less severe
than that from phenol, it can be vivid and last 15 days to several
months.
TCA–SAS peels sometimes produce prolonged and spec-
tacular erythema, as can be seen in Figure 37.7. These simple
aqueous solutions do not penetrate evenly, and uneven path-
ological erythema often results. Erythema after a peel to the
papillary dermis with TCA in simple aqueous solution is usually
Figure 37.5 Normal erythema after a full-face phenol peel.
Complications of chemical peels 331
expected to last 1–2 months. A peel to the top of the reticular
dermis can last 1–3 months. Persistent erythema is often fol-
lowed by inflammatory hyperpigmentation that is aggravated
by sun exposure. Effective sun protection (see Chapter 3) is
therefore essential as long as the erythema persists.
Indurated erythema might lead to scarring, and pre-
ventive treatment should be started (see the section on scar-
ring later in this chapter). When intraepidermal TCA peels
or TCA peels to the basal layer are repeated too often,11 ery-
thema can last even longer. Using tretinoin during the weeks
before or after a TCA peel is also likely to trigger or exacerbate
erythema.
Easy TCA
Basic Protocol (Pinpoint or Cloudy-White Frosting) Light ery-
thema develops immediately after the peel and disappears in
around 30 minutes (Figure 37.8). The skin may appear “sun-
burned,” and this can last up to a maximum of 48 hours in
patients with thin and sensitive skin. Because of the action of
the postpeel cream, there is often no observable erythema dur-
ing the days following this peel if it has not gone beyond pin-
point or cloudy-white frosting. The postpeel mask scavenges
free radicals and breaks the vicious inflammatory cycle that
sets in after any peel. Scratch lesions can, as with TCA–SAS
solution, cause localized erythema resulting from local infec-
tion (Figure 37.9), which should be treated.
Treating Stretch Marks This more aggressive protocol involves
sandpaper abrasion prior to the application of Easy TCA solu-
tion and 12–24 hours’ occlusion of the postpeel mask cream. It
causes severe erythema within the first few hours of occlusion.
After the occlusion has been removed, the skin looks swollen
and red (Figure 37.10). During the first week, overall develop-
ments are comparable to those of a phenol peel. The erythema
can last for several weeks, and the next peel can only be per-
formed after the erythema has completely resolved. As with
TCA–SAS, persistent localized erythema is a sign of local com-
plications and should be monitored, while uniform erythema
has a natural tendency to resolve gradually without treatment
(Figure 37.11).
Figure 37.6 Normal erythema around an area of frosting during
a TCA peel to the papillary dermis (Unideep) on the décolletage.
Figure 37.7 Uneven, pathological erythema after TCA in
aqueous solution—a peel to the papillary dermis. (Courtesy of
Dr. A. Carvajal, Colombia.)
Figure 37.8 Normal and transient erythema 30 minutes after
Easy TCA.
332 Textbook of Chemical Peels
Unideep
Unideep is a TCA peel to the papillary dermis. Adapted from
Easy TCA technology, it consists of a peel solution and a post-
peel mask. Thanks to the postpeel mask, the erythema fol-
lowing the peel does not last as long as the erythema after a
peel with TCA–SAS to the same depth. The erythema follow-
ing Unideep lasts approximately 5–8 days (Figure 37.12), and
the only treatment that it requires is an application of antioxi-
dant cream (e.g., Renutriv ACE Lipoic Complex) and Vaseline
Figure 37.9 Localized erythema around scratch lesions after an
Easy TCA peel to the papillary dermis.
Figure 37.11 Erythema totally disappeared 5 weeks after Lip &
Eyelid Formula of upper eyelid and Unideep (TCA peel to papillary
dermis) in the rest of the face.
Figure 37.10 Erythema 24 hours after treatment of stretch marks:
abrasion-occlusion protocol.
Figure 37.12 Erythema 5 days after Unideep on the face, apart
from the area around the mouth, which was treated with occlusive
Lip & Eyelid.
Complications of chemical peels 333
(see Chapter 23). If there is persistent localized erythema, there
might be a local complication, and treatment is necessary.
Effective sun protection must be used.
Only Touch
Only Touch is an adjuvanted, stabilized, and concentrated TCA
peel, used to reach the reticular dermis locally. It should be
applied in strict accordance with the recommendations for use
(see Chapter 22).
The erythema that always follows an application of Only
Touch usually lasts 2–3 weeks and gradually resolves without
treatment (Figure 37.13). Only Touch should be applied care-
fully, avoiding any excess product and limiting contact time
between the applicator and the skin: the skin should just be
touched lightly, with the same pressure as for pushing the
buttons on a telephone to dial a number. If contact time is any
longer, the acid solution will penetrate too deeply. Too much
solution and too long a contact time can cause small, erythema-
tous lesions that do not last longer than 3–4 months and that
gradually resolve with treatment. The erythema caused by
Only Touch can easily turn into PIH if the product is used
alone,12 but PIH is rare if Only Touch is combined with an “eve-
ning-out” Easy TCA peel. Any erythema warrants effective sun
protection, and any erythema lasting longer than 2 weeks must
be treated.
Phenol and Erythema
Full-Face Phenol
Phenol peels are always accompanied by severe erythema
(Figures 37.14 and 37.15). The erythema appears immedi-
ately around the edges of the frosting caused by the phenol
and can then be seen on the entire treated area as soon as
the frosting fades. This immediate erythema results from
inflammatory vasodilation that follows chemical injury and
is normal. After 24 hours, the patient appears severely burnt,
as can be seen in Figure 37.14. The classical phenol formu-
las often cause erythema that lasts more than 3 months, or
sometimes even several years. It can be permanent (in some
rare cases). Lip & Eyelid causes erythema that lasts 1–3
months on average.
This erythema results from the combined effects of:
•
Temporary thinning of the epidermis (4–6 weeks).
•
A reduction of the overall quantity of pigments in the epi-
dermis (permanent after phenol).
•
An increase in the vascular network of the dermis (rarely
permanent).
The first two changes make the third more clearly visible
through the transparent skin. Within a few weeks or months,
(b)
(a)
Figure 37.13 Normal erythema after Only Touch and Easy TCA for lentigines: (a) before; (b) 2 weeks after treatment.
Figure 37.14 Normal erythema and edema 24 hours after full-
face phenol.
334 Textbook of Chemical Peels
the restructured epidermis will cover up the hypervasculariza-
tion, which tends to gradually diminish.
Local Phenol
The eyelids, upper lip, and the area around the mouth can all
be treated locally, in combination with an “evening-out” peel
on the rest of the face.
The usual erythema caused by phenol appears locally
and lasts from 3 weeks to 3 months (Figure 37.16). The localized
erythema, surrounded by skin of a normal color, is more visible
than with a full-face peel, where the demarcation line is in less
visible areas. It is essential to warn the patient of the need to
wear camouflage makeup. Persistent, localized erythema in the
treated area means that complications are likely and should be
closely monitored. Figure 37.17 shows erythema of the whole
area treated with phenol. This is not a dangerous, “localized”
erythema.
Prevention
The basic rule is “the deeper the peel, the more severe and lon-
ger-lasting the erythema.”
Rules of Conduct
•
Avoid situations that subject the facial skin to extreme
changes in temperature.
•
Avoid vasodilating agents such as spicy food or alcohol.
•
Avoid exposure to “daylight.”
•
Use effective sun protection (see Chapter 3).
•
After a peel, avoid using photosensitizing products (hair-
spray, perfumes, etc.) or products that induce erythema
(e.g., tretinoin).
•
Avoid secondary infections and skincare products that are
too aggressive. Beware of “scrubs” used too soon after a
peel. Some patients cannot tolerate flaking and try to pull
off the strips of flaking skin. Others try to get rid of the
“dead skin” with abrasive creams. In both cases, the skin
can be damaged and localized erythema or hyperpigmen-
tation can occur. With Easy TCA (pinpoint frosting), there
may be some light exfoliation before the end of the first
week after the peel.
•
Do not repeat peels more often than necessary, and wait
for the erythema from the previous peel to subside before
applying the next peel.
Figure 37.15 Normal erythema 15 days after full-face phenol.
Figure 37.16 Normal erythema 15 days after localized phenol
(Lip & Eyelid Formula). The rest of the face was treated with Unideep.
Figure 37.17 Normal erythema 7 days after Lip & Eyelid around
the mouth and chin. The whiteness comes from an application of
antioxidant cream and the shine from Vaseline. The rest of the face
has been treated with Unideep (TCA peel to the papillary dermis).
Complications of chemical peels 335
•
Apply the peel evenly, using a stable and homogenized
formulation.
•
Avoid peeling techniques that do not allow monitoring of
how the skin is reacting throughout the procedure (e.g.,
“opaque masks” or thick, colored pastes).
•
If patients have been asked to prepare their skin, make
sure that they have done so regularly and evenly.
AHAs: Erythema Prevention
The practitioner should monitor the whole peel procedure
closely and carefully and make sure that the acid is neutral-
ized at the right time (except for Easy Phytic, which does not
require neutralization). Any frosting will result in prolonged
erythema. The neutralizing solution should be prepared before
the start of the peel.
TCA: Erythema Prevention
TCA–SAS The peel should not be applied more often than the
patient’s skin can tolerate it. After a peel to the papillary dermis,
erythema cannot be avoided. Flaking should not be forced pre-
maturely by pulling off strips of flaking skin. On the 8th or 10th
day after a peel to the papillary dermis, persistent erythema
and/or slightly infected areas without any trace of flaking sug-
gest that the skin has been pulled off or that the patient has
been scratching, sometimes completely unconsciously at night.
A TCA–SAS peel can be repeated after 4–6 weeks at the earliest,
once the erythema has completely disappeared. Effective sun
protection is essential.
Easy TCA The very light erythema that follows Easy TCA dis-
appears very rapidly. It is the only peel where it is not strictly
forbidden to help flaking along. Bleeding should, of course, be
avoided, as this would trigger erythema. The erythema soon
subsides and does not cause any adverse sequelae unless there
is a secondary infection. The maximum frequency for repeat-
ing the basic protocol (pinpoint frosting) is four peels at 5-day
intervals. The ideal frequency is four peels at 8-day intervals.
Effective sun protection is essential.
Only Touch Local erythema is inevitable after a peel to the
reticular dermis. Pulling off scabs must be avoided at all costs.
Only Touch can be combined with Easy TCA to reduce ery-
thema and hyperpigmentation. The maximum frequency for
repeating the peel is when the erythema has completely disap-
peared. Effective sun protection is essential.
Unideep Erythema clears up rapidly after this peel to the
papillary dermis, usually within 8 days. The maximum fre-
quency for repeating the peel is 3–4 weeks and once the ery-
thema has completely cleared. Effective sun protection is
essential.
Phenol–Resorcinol
Erythema is inevitable after a phenol peel (Figure 37.18). It
can sometimes be less severe and of a shorter duration if a
corticosteroid is injected intravenously at the beginning of
the peel. Its intensity varies from patient to patient, from
light and imperceptible to severe and deep. Resorcinol is a
potentially allergenic phenol derivative: persistent, pruritic
erythema after a resorcinol peel might be a sign of contact
dermatitis.
Treating Erythema
Erythema has a natural tendency to resolve spontaneously
without treatment. The patient should be told to see the doc-
tor if there is any abnormal, localized, and persistent erythema.
A peel can reveal a subclinical condition of eczema or lupus.
Clinical examination and close questioning of the patient is
of prime importance to bring these problems to light before
treatment.
Treat until Complete Resolution
Persistent, localized erythema means that there is a risk of
hyperpigmentation or scarring. Erythema can be extremely
unpleasant for patients, and they might ask for a treatment to
eliminate it more quickly. Localized erythema requires topical
treatment, and erythema in the whole treated area requires sys-
temic treatment.
Recommended Treatments
Topical Cosmetics Effective sun protection is always indi-
cated with erythema, as it tends to develop into hyperpig-
mentation after UV exposure. Antioxidant creams can limit
the negative effects of free radicals and the damage they
cause to the cells. Creams containing vitamins A, C, and E
and lipoic acid13 can be combined with an antioxidant cream.
The Easy TCA postpeel mask provides effective protection
against erythema.
Local Corticosteroids Treatment consists in prescribing a cream
containing steroid anti-inflammatories. The sooner treatment is
started, the more effective it is with low-dose products. If treat-
ment is delayed, higher doses of fluoro-corticosteroids have to
be used, and the results are less satisfactory. A (2.5%) hydro-
cortisone cream or a topical clobetasone cream applied three
or four times a day for 2 weeks should be sufficient. If treat-
ment is started later still, fluocinolone or halcinonide must be
prescribed. Some authors recommend preventive application
of a cortisone cream immediately after a peel, although these
creams do not help skin regeneration and penetrate far more
Figure 37.18 Normal, localized erythema 8 days after Lip &
Eyelid on the upper lip and Unideep on the rest of the face. Note
the light erythema from the Unideep on the 8th day.
336 Textbook of Chemical Peels
readily and rapidly through skin that is far more permeable.
Applying a corticosteroid during the first week after a peel
does not pose any problems. On the other hand, excessive use
of corticosteroids increases the risk of acne and bacterial, viral,
and fungal infections, and can cause telangiectasia. In addition,
long-term use of topical corticosteroids thins the skin, causing
atrophy that defeats the purpose of a peel. In cases of indu-
rated erythema likely to lead to scarring, corticosteroids can
be repeatedly injected locally into the erythema, and the lesion
can be covered with a silicone sheet pressure dressing, day and
night, until the lesion disappears.
General Treatments Corticosteroids by the systemic route will
only be needed very rarely to treat erythema. They can be
administered in a single and preventive injection at the start of
a phenol peel. Promethazine can be recommended, at a maxi-
mum dose of six times 25 mg/day, when the erythema causes
pruritus and reflex scratching that could lead to unsightly
scars, infections or dyschromia.
Lasers
Rubin describes using the Candela pulsed dye laser to good
effect to reduce persistent erythema. Intense pulsed light can
also be used to treat postpeel erythema.
TELANGIECTASIAS
Telangiectasias result from vasodilation and a proliferation
of dermal blood vessels. There are many different causes: sun
aging, hormone therapy, inflammatory dermatosis, corticoste-
roids, alcohol, and so forth.
AHAs
These do not usually have any effect on telangiectasias and do
not cause neovascularization.
TCA
In the month following a TCA peel to the papillary dermis, pre-
existing telangiectasias can be seen more clearly through the
relatively transparent epidermis because of the temporary loss
of thickness and pigmentation. It is rare for new telangiectasias
to develop, and this does not often pose a problem after a peel,
even a deep one.
The doctor can coagulate the telangiectasias immediately
before applying an Easy TCA peel (Figures 37.19 and 37.20). The
fact that the solution will penetrate into the small holes left
after coagulating the blood vessels does not cause any compli-
cations. On the contrary, this prevents the usual scabs that form
after the coagulation of telangiectasias and that can last up to
2 weeks. The duration of scabbing is more than halved, and
there is less risk of secondary infection.
Phenol
Phenol can improve the appearance of very fine, superficial tel-
angiectasias through coagulation. Deeper telangiectasias may
be pushed deeper into the skin by the synthesis of new colla-
gen in the upper part of the dermis, and will be less visible. On
the other hand, inflammatory vasodilation can also aggravate
them. The patient should be warned that telangiectasias are not
in themselves an indication for a peel and that results vary. The
doctor should be wary of raised telangiectasias that are diffi-
cult to hide. There are reported cases of deep peels being per-
formed despite the presence of telangiectasias, which remain
unchanged by the peel, but a phenol peel can also cause numer-
ous small telangiectasias to appear during the first weeks after
the peel. These telangiectasias must be treated to stop them
turning into hyperpigmented marks.
Prevention
The type of peel must be carefully chosen. These vascu-
lar dilations must be treated preventively as indicated above
(see Figure 37.20).
(b)
(a)
Figure 37.19 (a) In this case where there are many telangiectasias and lentigines, a combination of treatments will be used in the same
session: coagulation of the telangiectasias with a Kobayashi needle mounted on the handpiece of a radiofrequency unit (Ellman), an
application of Only Touch to the lentigines, and finally an application of Easy TCA to the whole face. Coagulation and Only Touch will be
repeated just before the fourth session of Easy TCA. (b) Results of these combined treatments. The lack of nasolabial folds in (a) comes
from the patient’s position.
Complications of chemical peels 337
Treatment
This can involve electrocoagulation, Surgitron (Ellman),15
scarification, microsclerosis, laser, or flashlamp. These treat-
ments should be performed 1–2 weeks before the peel. The one
exception is Easy TCA, where the telangiectasias can be treated
immediately (a few minutes) before the peel solution is applied.
SCARRING AND DYSCHROMIA
Intraepidermal Peel
An intraepidermal peel (Figure 37.21) is characterized by the
following symptoms: erythema without frosting after an AHA
peel, or erythema and maybe some pinpoint frosting after a
TCA peel. Phenol is not indicated for this depth of action.
Risk of Scarring
This is nonexistent. Reepithelialization after an intraepidermal
peel is rapid and easy, as it comes from growth stimulation
in the still intact basal layer of the epidermis. The epidermis
“feels” the loss of the stratum corneum as a dangerous attack
and reacts by sending a clear growth message to the “mother”
keratinocytes in the basal layer. These keratinocytes divide16
and rebuild a normal epidermis as quickly as possible. A local
increase in the concentration of tumor necrosis factor alpha
(TNF-α) stimulates the keratinocytes to transform themselves
into corneocytes and restore the skin’s initial state of imperme-
ability. The stratum corneum is largely responsible for the skin’s
total impermeability (maybe >70%). This relative impermeabil-
ity affects not only the fluids coming in and going out, but also
fungal, bacterial, or viral invasion. The constant shedding of
dead cells from the stratum corneum is in itself a phenomenon
of great importance to homeostasis: it eliminates epidermal
garbage and a large quantity of xenobiotic microorganisms.
Risk of Dyschromia
Intraepidermal peels do not stimulate melanocytes and never
cause achromia. There is no risk of skin discoloration. However,
some sensitive skin reacts to any inflammation by stimulating
melanogenesis. The risk of postpeel hyperpigmentation cannot
therefore be ruled out completely.17
Peel to the Basal Layer
A peel to the basal layer (Figure 37.22) is characterized by ery-
thema and the appearance of pinpoint frosting after TCA or
generalized erythema after AHAs. Phenol is not indicated for
this depth of peel.
The acids destroy most of the epidermis. Histologically,
the basal layer does not form the perfect sine wave that is usu-
ally shown in diagrams. On the contrary, the keratinocytes are
embedded deeply and unevenly in the dermis and form the
deep “dermal papillae.”
Even if the acid reaches the papillary dermis in places,
a large number of keratinocytes survive, allowing the skin to
regenerate very quickly. The process of reepithelialization is
(c)
(b)
(a)
Figure 37.20 (a) Telangiectasia on the tip of the nose, treated by coagulation with a Kobayashi needle mounted on the handpiece of an
Ellman unit (radiofrequency). Immediately after coagulation, Easy TCA solution is applied. (b) When it is dry, the postpeel cream is applied.
(c) The almost total lack of scabbing on the fourth day after the combined treatment.
Figure 37.21 Intraepidermal peel.
338 Textbook of Chemical Peels
the same as for intraepidermal peels: the basal layer keratino-
cytes are stimulated to grow.
Risk of Scarring
This is nonexistent. The skin can easily repair itself without
having to rely on stimulation of the myofibroblast system to
contract an area that is taking too long to heal.
Risk of Dyschromia
There is no risk of achromia. Melanocytes are stimulated more
directly, and the risk of hyperpigmentation is higher. The
inflammatory reaction that follows any peel to the basal layer
can cause PIH, even if it is slight. A vicious cycle can set in that
has the potential to cause postpeel pigmented marks: the peel
causes inflammation—that is, among other things, vasodila-
tion that brings oxygen as well as pro-inflammatory substances
to the treated areas. Free radicals are formed that damage the
structures regenerating the skin. The structural damage main-
tains inflammation, and postpeel hyperpigmentation may
occur on dark and reactive skin types. It is important to break
this vicious inflammatory cycle by scavenging free radicals as
soon as they are produced. Large quantities of antioxidants are
therefore needed in the skin, in the same places where the free
radicals are produced.18
Peel to the Grenz Zone
The Grenz zone19 is a transition area between the epidermis
and the dermis. A TCA peel to the Grenz zone (Figure 37.23)
is characterized by the appearance of cloudy-white frosting in
which spots of normal skin color can be seen where the kera-
tinocytes of the deepest dermal papillae have not been coagu-
lated by the acid. AHA and phenol peels are not appropriate
for this depth, but TCA is ideal for a peel to the Grenz zone.
The process of skin repair is slightly more complex and relies
on both the many surviving keratinocytes being stimulated
to divide and the keratinocyte reserve in the pilosebaceous
units.
Risk of Scarring
The keratinocyte reserves allow rapid and easy regeneration
of the epidermis. The retractile myofibroblast system is not
stimulated. There is no risk of scarring.
Risk of Dyschromia
The skin becomes lighter simply because of the epidermal
melanin stock being eliminated. Enough melanocytes survive
for the skin not to lose its natural color permanently. There are
substantial reserves of melanocytes in the pilosebaceous units.
Hypochromia is therefore rare after a peel to the Grenz zone,
and there is no reason why achromia should occur. On the con-
trary, melanocyte stimulation is relatively strong and the risk
of hyperpigmentation is increased. With this kind of peel, the
preventive measures described in the section on hyperpigmen-
tation later in this chapter should be heeded.20
Peel to the Papillary Dermis
AHAs and phenol are not indicated, and TCA is again the
gold-standard peel to the papillary dermis (Figure 37.24).
The following signs show that the papillary dermis has been
reached: even, pink-white frosting and epidermal sliding sign.
Reepithelialization after a peel to the papillary dermis is slower
as it relies on:
•
The keratinocytes on the edges of the treated area.
•
The keratinocytes still present in the basal layers most
deeply embedded in the dermis that have been spared by
the acids.
Figure 37.22 Peel to the basal layer.
Figure 37.23 Peel to the Grenz zone.
Figure 37.24 Peel to the papillary dermis.
Complications of chemical peels 339
•
The keratinocytes in the pilosebaceous units.
•
The keratinocytes in the excretory ducts of the sweat
glands.
•
The sebocytes of the sebaceous glands, which are differen-
tiated keratinocytes that specialize in sebum production;
they must first dedifferentiate before they can regenerate
the epidermis.
Risk of Scarring
The papillary fibroblasts are stimulated directly.22 They will
produce a layer of collagen that can differentiate histologically
from the collagen that is naturally present in the papillary der-
mis. The fibrils of the new collagen are aligned horizontally.
This more complex process of skin regeneration can give rise to
more complications than more superficial peels.
In principle, only the fibroblasts in the papillary dermis
are stimulated, and an effective keratinocyte layer can be regen-
erated quickly enough to avoid activation of the myofibroblast
system and scar retraction. Only overpeeling can cause local-
ized scarring. A peel to the papillary dermis is still very safe as
far as scarring is concerned.
Risk of Dyschromia
A peel to the papillary dermis causes severe inflammation
and strongly stimulates melanogenesis, often irregularly, with
a risk of PIH. Preventive treatment of this is one of the most
important phases in a peel to the papillary dermis. Areas of
achromia may also appear when the peel has penetrated too
far locally.
A peel to the papillary dermis therefore marks the safety
limit beyond which the risks are higher, though most often
controllable. How far this limit can be stretched depends on—
among other things—how permeable the skin is: in local areas
of increased permeability, the TCA can penetrate too deeply.
Peel to the Reticular Dermis
Phenol is the ideal agent for a peel to the reticular dermis
(Figure 37.25). The following signs indicate that the peel has
reached the reticular dermis: even, pure white, or gray-white
frosting. Occasionally, small, buff-yellow patches may appear.
Epidermal sliding is soon replaced by edema.
Skin repair after a peel to the reticular dermis is slower,
as all the basal layer keratinocytes have been destroyed and
the skin can only rely on the differentiated keratinocytes of the
pilosebaceous units and the intradermal excretory ducts of the
sweat glands. To repair the dermis, the sebocytes in the pilose-
baceous units must dedifferentiate, and horizontal growth is
required to “close” the skin quickly. Next comes a phase of ver-
tical growth whose purpose is to regenerate a physiologically
sound epidermis that will maintain homeostasis and restore
the vital barrier function after the keratinocytes have differen-
tiated into corneocytes.
Risk of Scarring
Under ideal conditions, healing after a peel should be supple
and constant, leaving skin that is rejuvenated, hydrated, even in
texture, and without scars. The risk of scarring is much higher
after a peel to the reticular dermis than after a peel to the pap-
illary dermis. Delayed healing, resulting from excessive local
penetration or local infection, strongly stimulates all of the
skin’s regeneration mechanisms; they can trigger the pheno-
typic conversion of simple fibroblasts into myofibroblasts and
start retractile-type healing. Particular attention must be paid to
scar prevention measures (see later in this chapter).
Risk of Dyschromia
There is a major risk. Achromia is possible.
Difference between a Facial Peel and a Body Peel
It is conventionally accepted that postpeel regeneration on the
body takes twice as long as on the face. With peels to the papil-
lary dermis, and especially the reticular dermis, it is important
to consider the number of pilosebaceous units. The more pilo-
sebaceous units there are, the greater the chances of healing
without major problems (Figure 37.26). It is easier for the skin to
heal on the scalp than on the face, and easier on the face than on
the neck or décolletage.
Rapid skin regeneration means that there is little chance
of infection and retractile scar formation. Slow and difficult
regeneration sharply increases the risk of retractile scars, infec-
tion, and dyschromia.
HYPERPIGMENTATION
General Considerations
The skin responds to any lesion, burn, or abrasion with an
inflammatory reaction that may be accompanied by melano-
cyte stimulation and excessive melanin production. This reac-
tion is generally considered to last for 3 months at the most.
Different types of pigmentation disorders can occur after
a peel:
•
Partial or total depigmentation (see melanocyte toxicity).
•
Local or general hypopigmentation (see melanocyte
toxicity).
•
Local or general, absolute, or relative hyperpigmentation.
Fitzpatrick skin phototypes I–III rarely develop PIH,
whereas skin phototypes IV–V carry a much higher risk. PIH
can be “absolute” or “relative” to the surrounding skin. Relative
PIH occurs when some areas of skin do not lighten as much as
the surrounding areas and therefore appear darker. An area of
normal skin color surrounded by an area of a lighter tone can
look like PIH. Absolute PIH consists of a patch of skin that is
hyperpigmented in relation to the normal skin color that sur-
rounds it. Figure 37.27 shows an absolute PIH reaction.
Figure 37.25 Peel to the reticular dermis.
340 Textbook of Chemical Peels
Risk Depending on Peel Type
On the whole, the risk of PIH is proportional to the depth of
the peel.
AHAs
The risk of hyperpigmentation is low and often results from
localized overpeeling or delayed neutralization that leads to
excessive penetration and possibly epidermolysis. There is still
a risk of PIH, however, even if the peel has been neutralized
correctly (Figure 37.28).
TCA–SAS
As the risk increases with the skin phototype, it is obvious
that a patient with Fitzpatrick skin type III will have fewer
pigmentary changes than a patient with Fitzpatrick type V.
Skin type V most often develops hyperpigmentation. That is
why some authors maintain that TCA cannot be used to treat
hyperpigmentation, whereas in fact it produces excellent
results when used correctly and as part of an overall treatment
program for the patient, possibly including repeated peels and
the use of appropriate topical treatments between and after the
TCA peels. Patients with dyschromia always require an overall
treatment program, no matter which type of peel is used. TCA
in aqueous solution is nevertheless a molecule that carries a
higher risk of PIH (see Figure 37.27). Many publications stress
the absolute necessity to prime the skin for an application of
TCA in aqueous solution. Any peel of this type requires 3–4
weeks of preparation, with tretinoin (to speed up recovery and
even out penetration) and hydroquinone (to induce melano-
cyte sedation).
Easy TCA
One of the four weekly peels sometimes causes transient and
limited PIH (Figure 37.29), often on the sides of the face, and
mainly occurs when the patient has not used effective sun
protection from the morning after the first treatment. This
PIH is easily reversible, erased by the following treatment,
and can be avoided with good application techniques: the cot-
ton bud should be partially squeezed out before applying the
solution and only the beginnings of pinpoint frosting should
be achieved. The deeper Easy TCA is allowed to penetrate,
the greater is the risk of hyperpigmentation: pinpoint frost-
ing is far less likely to trigger PIH than even, pink frosting.
Repeating the peel is an important part of the strategy of
avoiding PIH. The risk of PIH is sharply increased if only one
Easy TCA is done instead of the four included in the usual
protocol.
Only Touch
Applying the Only Touch peel too deeply can cause prolonged
punctiform erythema that has a strong tendency to cause
hyperpigmentation when exposed to daylight. The contact time
between the applicator and the skin must be brief—the equiva-
lent of the contact time between the fingers and a phone keypad
(Figure 37.30).
If an application of Only Touch is followed by prolonged,
punctiform erythema, treatment consists of avoiding pulling
off the small scabs, effective sun protection of the whole face
and sun avoidance, applying a cortisone cream locally, apply-
ing an antioxidant cream and tyrosinase inhibitors on the
whole face, and close monitoring.
Figure 37.27 Postinflammatory hyperpigmentation (PIH): TCA
peel, aqueous solution with uneven penetration to the papillary
dermis.
(a)
(b)
Figure 37.26 (a, b) Papillary dermis on body skin: only few pilosebaceous units are able to regenerate the destroyed layers of skin.
Healing is slow and risk is higher.