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Cosmetic: Special Topic

Chemical Peels: Role of Chemical Peels in Facial Rejuvenation Today

Pathak, Abraham M.D.; Mohan, Raja M.D.; Rohrich, Rod. J. M.D.

Author Information
Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 58e-66e
doi: 10.1097/PRS.0000000000006346
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Abstract

Chemical peels remain an important skin rejuvenation tool of the aesthetic plastic surgeon, and despite past predictions of their disappearance in favor of lasers or other noninvasive therapies, their use continues to grow. According to the American Society for Aesthetic Plastic Surgery, there was a 28 percent increase in chemical peels in 2016 compared with 1996, with a total of 616,225 procedures performed last year.1 Peels became one of the five most popular nonsurgical procedures for men in 2016, joining neurotoxins, hyaluronic acid, hair removal, and photorejuvenation.

In appraising the history of chemical peels, two periods are readily distinguishable. The initial period began with discovery followed by subsequent application furthered by empirical studies. A second period occurred when classic formulas and protocols were refashioned based on further histologic and clinical study.

In the 1990s, there was a revival of the use of trichloroacetic acid peels largely promoted by Dr. Zein Obagi,2 with his series of instructional courses that helped redefine the clinical emphasis of depth control. During that same period, Hetter and Stone independently altered the perception of the 30-year-old Baker-Gordon phenol-croton oil formula with their groundbreaking conclusions. The continuous evolution of chemexfoliation techniques has provided the practitioner of today with increased safety and versatility. The aesthetic surgeon should be familiar with the various skin peels, their historical use, and current evidence-based applications. We present here the current role of chemical peels in skin rejuvenation today.

INDICATIONS

Chemical peels have a longstanding and widespread acceptance as a treatment modality for facial rejuvenation, with their cosmetic use focused on addressing rhytides and dyschromias (Table 1).

Table 1. - Chemical Peel Summary Indications
Chemical Peel Indication Mechanism of Action Practical Considerations
Recovery Time Other Considerations
Superficial peels
 Alpha hydroxy acids (e.g., glycolic acid 30–70%) Mild skin damage; dyschromias Low concentrations (5–10%) produce corneolysis; high concentrations (50–70%) induce epidermolysis Minimal (24- to 48-hr downtime) Do not self-neutralize, need water or weak buffer; require serial treatments; no effect on wrinkles or deep pigmentations
 Beta-hydroxy acids (e.g., salicylic acid) Mild skin damage; dyschromias Corneolysis Minimal (24- to 48-hr downtime) Exfoliative activity is almost devoid of any inflammation; preferred agent over other superficial peels in cases of acne and PIH; require serial treatments (6 peels 2–4 wk apart)
 Jessner solution (4 g resorcinol, 14 g salicylic acid, and 14 g lactic acid in alcohol solution) Mild skin damage; dyschromias Corneolysis, increasing the effect of other keratolytic agents Minimal (24- to 48-hr downtime) Reported concerns regarding resorcinol toxicity, including thyroid dysfunction
Medium depth peels (variable middepth attainable)
 Glycolic acid 70% Fine wrinkles and acne scars; dyschromias (mainly solar lentigines and keratosis) Epidermolysis 3- to 5-day downtime Controlled by neutralization (commonly water or 10% sodium carbonate solution), inadequate control increases risk of dermal scarring
  TCA 35% Fine wrinkles and acne scars; dyschromias Coagulative necrosis of dermal and epidermal proteins, keratolytic effect (desquamation) 3- to 5-day downtime Great risk of scarring when applied in concentrations above 50%, which are not recommended
 Augmented TCA peels (Monheit-Jessner TCA peel, Coleman TCA peel, Brody TCA peel) Fine to coarse wrinkles; dyschromias Improved penetrance rendering deeper extent of coagulative necrosis of dermis proteins, keratolytic effect 5- to 8-day downtime Monheit Jessner-TCA peel most popular
 Obagi TCA peel Fine to coarse wrinkles; dyschromias Coagulative necrosis of dermal and epidermal proteins, keratolytic 7- to 10-day downtime Tailor treatment with Frost level indicated depths:
• Level 1 (epidermal): suitable for fine lines, dermal melanosis, and epidermal actinic damage
• Level 2 (middermis): most fine wrinkles and scars
• Level 3 (deep reticular dermis): deeper wrinkles and scars
Deep peels (midreticular dermis penetration creates maximal collagen production effect)
 Baker-Gordon formula Fine and coarse wrinkles; dyschromias; acne scars Coagulation of epidermal and deep dermal proteins 10- to 14-day downtime Phenol-based peels need to be performed with cardiac monitoring and IV fluids; may require IV sedation or regional blocks
 Hetter’s “All Around Use Formula” (33% phenol/volume, 0.35% croton oil) Fine/coarse wrinkles; aesthetic units; dyschromias; acne scars Coagulation of epidermal and deep dermal proteins 10- to 14-day downtime By titrating croton oil concentration, can variably treat different units of face (e.g., eyelids, forehead, perioral region)
P
IH, postinflammatory hyperpigmentation; TCA, trichloroacetic acid; IV, intravenous.

APPLICATION OF CHEMICAL PEELS

Patient Selection

Careful patient selection and individualized treatment considering a patient’s skin type, texture, thickness, degree of photoaging, and severity of facial rhytides render the best results.

Skin Assessment

Evaluating a patient’s complexion is important in determining their risk of pigmentation complications. The Fitzpatrick classification of skin types (I to VI) based on the ability of skin to acquire a tan or burn after ultraviolet light exposure, and the Glogau classification system, which provides an objective assessment of the degree of photoaging by categorizing skin damage into mild, moderate, advanced, or severe (groups I through IV), are most frequently used (Tables 2 and 3).3 Fitzpatrick skin types I to III do not usually develop postinflammatory hyperpigmentation and are considered excellent candidates.4 The scarce literature regarding peeling techniques in Fitzpatrick IV to VI skin types espouses a higher risk of hypopigmentation or hyperpigmentation, which should prompt close postprocedural surveillance by the practitioner.

Table 2. - Fitzpatrick Classification of Skin Types*
Skin Type Color of Skin Reaction to UV Radiation
I White Always burns, never tans
II White Usually burns, difficult to tan
III Light brown Sometimes mild burn, tans gradually
IV Brown Rarely burns, tans easily
V Dark brown Very rarely burns, tans very easily
VI Black Never burns, tanned/dark pigment
U
V, ultraviolet.
*Adapted from Fitzpatrick TB. Soleil et peau
. J Med Esthet. 1975;2:33–34.

Table 3. - Glogau Classification of Photoaging*
Group Severity Classification Typical Age Range (yr) Skin Characteristics
I Mild 28–35 Early photoaging; minimal wrinkles; no keratosis or acne scarring; minimal or no makeup
II Moderate 35–50 Early keratosis; early wrinkling—smile lines; some makeup
III Advanced 50–65 Obvious keratosis; discoloration with telangiectasia; wrinkling—present at rest; always wear makeup
IV Severe 60–70 Actinic keratosis; skin cancers; severe acne scarring; severe wrinkles throughout; when wearing makeup, it cakes or cracks
*Adapted from Glogau RG. Chemical peeling and aging skin.
J Geriatr Dermatol. 1994;2:30–35.

As a general rule, patients with mild facial rhytides and/or minimal dyschromias are best suited for superficial to medium-depth chemical peels.5 Deeper rhytides and excessive facial skin respond best to other modalities, including laser therapy and traditional surgical techniques (i.e., rhytidectomy).

PRETREATMENT IS PARAMOUNT

The importance of skin preconditioning is well disseminated among experienced practitioners. The objectives of skin activation, depth control, and shortened recovery can be routinely realized through three active ingredients: topical tretinoin (0.05 to 0.1%), hydroquinone (2 to 4%), and alpha hydroxyl acid (4 to 10%).6

Tretinoin

Tretinoin is the standard for evidence-based retinoid skin care. Dosing requires titration to achieve the intended result while minimizing dose-dependent side effects. Notwithstanding, the majority of patients using 0.05% concentrations daily and over 90 percent of patients treated with the higher 0.1% concentration exhibit the “retinoid reaction,” characterized by erythema, scaling, xerosis, and pruritus.7 Hevia et al. demonstrated more intense and uniform frosting with tretinoin application on account of the compacted stratum corneum, and a statistically significant increase in reepithelialization after 1 week.8 Doppler velocimetry studies of cutaneous circulation further support improved wound healing and shorter recovery times.9

Hydroquinone

Hydroquinone is a phenolic depigmenting agent that acts on melanocytes with active tyrosinase and is the most studied topical agent in the treatment of melasma, dyschromia, or hyperpigmentation. At a 4% concentration, it has been shown to provide significant improvement of melasma dyspigmentation and thought to lessen postinflammatory hyperpigmentation when included in the pretreatment process.10 It is usually recommended for patients with Fitzpatrick type III skin or greater, or patients with pigmentary dyschromias.

Alpha Hydroxy Acid

Alpha hydroxy acids are relatively weak acids used in the treatment of photoaged skin. Randomized controlled studies have shown they decrease epidermal atypia, induce epidermal hyperplasia, disperse melanosomes, and increase elastin fiber thickness. Glycolic acid at 20 to 70% concentrations is most commonly used in peeling, but when used as a prepeel adjunct, lower concentrations of 4 to 10% are used, rendering a good safety profile to this exfoliative process with only local irritation and increased ultraviolet sensitivity reported.

Pretreatment should commence 4 to 6 weeks before and continue into the week preceding the peel (Fig. 1). Some practitioners recommend longer preconditioning programs for individuals with darker complexions.11 Erythematous, flaky skin is something the patient must accept as a normal effect, and the clinician should look for this as an indicator of pretreatment effectiveness. Other goals during pretreatment not to be overlooked are skin hydration with continued use of a moisturizer and sun protection with broad-spectrum sunscreen use. In patients with a history of herpes simplex, antiviral therapy with acyclovir should be initiated, beginning 2 days before the procedure and continued for 7 to 10 days until complete reepithelialization.12,13

Fig. 1.
Fig. 1.:
Chemical peel pretreatment. This figure demonstrates the senior author’s (R.J.R.) chemical peel pretreatment protocol, emphasizing the typical initiation and cessation timetable for various treatment adjuncts.

CLINICAL ASSESSMENT OF DEPTH OF PEEL

Pivotal to any resurfacing technique is a reliable clinical endpoint. With the use of chemical peels, this is visually determined, dependent on a practitioner’s assessment of frosting. In 1995, Dr. Obagi elucidated histologically the validated visual signs for peel depth penetrance to aid clinicians.2 His consistent visual cue endpoints provide an intraprocedural guide for depth control (Table 4). A thin, transparent frost with a pinkish background indicates a peel depth down through the epidermal layer to the papillary dermis. A solid, organized frost with minimal erythema strikethrough denotes a depth down to the upper to mid reticular dermis. A thick, solid gray-white sheet of frost, with eventual darker red-brown hues, means a depth down to the mid dermis and the recommended maximal depth to minimize the incidence of scarring and hypopigmentation. Epidermal sliding is a tangible means of assessment seen when the peel reaches the level of the papillary dermis and the epidermis is separated from the underlying reticular dermis and slides as a thin, independent sheet. This sliding is evident to a practitioner performing a medium peel and subsides once peeling advances to the immediate reticular dermis, whereupon the epidermis and dermis bond to form a single protein block.

Table 4. - Obagi Grades of Frosting
Level of Frosting Histologic Correlate Clinical Cue
1 Limited to epidermis Cloudy white frost on pink background
2 Penetration to papillary dermis (into upper stratum papillare) Regular white-coated frosting with continued erythema strikethrough
3 Penetration through papillary dermis Solid intense white frosting, with no background erythema

POSTPEEL CARE

Postpeel management begins before the peel itself is performed, with the patient being properly informed of the effects of the peel. Superficial peeling therapies require only simple hydration. For medium depth peels, a short downtime period of 1 week is required, even with pretreatment. During this time, treatment is largely based on moisturizers. Petroleum-based cream can be applied to treated areas for comfort and to moisturize, thus expediting sloughing during the reepithelialization process. Patients may resume facial cleansing without scrubbing and allow contact with direct shower water at approximately 3 days after peel. Petroleum-based cream can then be applied after washing and gently patting dry the treated areas.

Deeper dermal regeneration requires new collagen production and neovascularization, a process that can take 6 weeks, but ultimately depends on peel depth and patient skin quality. For deep peels, postoperative care is more intense, with a 10-day period of unsightliness that may impose social isolation. Care during this time is largely based on moisturizers or bandages with recommended daily surveillance. During the initial 12 weeks, the patient is particularly susceptible to ultraviolet light exposure and resultant hyperpigmentation. Sunscreens, however, should be avoided for the first 2 weeks until the patient is less sensitive and reepithelialization is ensured, as the paraaminobenzoic acid found in many sunscreen products can cause irritation, increased erythema, and induration. Strict avoidance of direct, prolonged sun exposure should be stressed during the healing period.

It is important to note that reactive hyperpigmentation can occur after any peel depth. Lighter complexions have a lower risk for hyperpigmentation, but as genotype does not always correspond to phenotype, some light skin patients of mixed lineage will unexpectedly hyperpigment. Postinflammatory hyperpigmentation generally develops when the pink stage begins to fade. Elevated vigilance for hyperpigmentation and early treatment are recommended in high-risk patients. On noticing any hyperpigmentation, the use of hydroquinone alone or in combination with a glycolic cream or retinol should be commenced twice a day or at bedtime, depending on irritation. Sun avoidance and the liberal use of sunscreen with higher sun protection factor is recommended. The senior author has performed early use of class V or VI steroid creams as effective means in reversing the first signs of postinflammatory hyperpigmentation for more severe cases. As the redness fades, the use of the steroid cream can be discontinued and replaced with barrier-repair creams.

Along with the continuation of antiviral therapy 7 days postoperatively, patients with a history of herpes infection should be closely monitored every 2 to 3 days. Persistent painful erythema should prompt a concern for a yeast infection and be treated with two doses of fluconazole (100 to 150 mg). If no improvement is noted in 48 hours, the subsequent application of nystatin topical antifungal is generally effective in eradicating the infection. In most cases, the infection stems from artificial nails or patients touching their face postoperatively, which should be mentioned to the patient before the procedure. Furthermore, the patient should be counseled that excessive application of moisturizers could increase the likelihood of fungal colonization and limit the peel’s effectiveness.12

CHEMICAL PEEL SELECTION

Chemical peels are classified according to the depth of peel they cause, which is in turn determined by multiple variables. These factors include the nature and concentration of the peeling agent, the number of applied coats coupled with the contact time with skin, application technique, patient skin type, anatomical area being treated, and any prior skin priming.

Trichloroacetic Acid Peels

Trichloroacetic acid is a versatile keratolytic acid that coagulates and denatures proteins as it penetrates the skin. It can be used in different concentrations: 10 to 20% trichloroacetic acid for superficial peels and 35% more routinely used for medium-depth peels. In general, concentrations higher than 35% are not recommended given less predictable results and higher scarring potential. Trichloroacetic acid solutions are compounded in a weight-to-volume preparation and when purchased should come from a reliable source that uses this method to calculate concentration. It self-neutralizes once it has coagulated a certain amount of protein; therefore, subsequent application will drive the peel deeper until deeper proteins react to the acid. To enhance the penetrance and efficacy of low-concentration trichloroacetic acid peels while minimizing scarring risks, it can be combined with Jessner solution (Monheit method), 70% glycolic acid (Coleman method), or solid carbon dioxide (Brody method).14–16 Dr. Monheit’s method has become the most popular, combining 35% trichloroacetic acid with the classic Jessner solution composed of three keratolytic elements: 14 g of resorcinol, 14 g of salicylic acid, and 14 g of lactic acid in an ethanol solution. The senior author (R.J.R.) previously described a four-step application process of this method.17 [See Video 1 (online), which highlights the senior author’s technique for treatment of facial aging with a chemical peel. First, alcohol is applied to cleanse the face, and then acetone is applied to degrease the skin. The first superficial peel that is performed using Jessner solution exfoliates the skin and helps increase the depth and uniformity of the trichloroacetic acid peel. After application of Jessner solution, a gauze pad is used to apply the trichloroacetic acid chemical peel. The pad is soaked with the solution and wrung out before application. Multiple passes are performed until the appropriate endpoint is achieved. This treatment can be applied to the face or the neck. See Video 2 (online), which demonstrates the senior author’s application of combination Jessner solution with 35% trichloroacetic acid peel when treating the neck. First, alcohol is applied to cleanse the face, and then acetone is applied to degrease the skin. The first superficial peel that is performed using Jessner solution exfoliates the skin and helps increase the depth and uniformity of the trichloroacetic acid peel. After application of Jessner solution, a gauze pad is used to apply the trichloroacetic acid chemical peel. The pad is soaked with the solution and wrung out before application. Multiple passes are performed until the appropriate endpoint is achieved. This treatment can be applied to the face or the neck.] Alcohol is first applied to cleanse the face, followed by the second step involving acetone for degreasing of the skin. Jessner solution is then applied to act as an exfoliant and superficial peel, helping to provide a more uniform peel once the 35% trichloroacetic acid solution is applied as the fourth and final step. Application endpoint is indicated by a uniform white frost to treat moderate rhytides and a pink hue with epidermal sliding for the obliteration of superficial rhytides.

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Dr. Zein E. Obagi formulated a coating system for achieving depth-controlled trichloroacetic acid peels based on described intraoperative clinical signs.18 Lauded as an easier method to peel skin of all racial backgrounds, it has since been widely adopted. It is referred to as the Obagi TCA-Blue Peel when it combines a nonionic dye, glycerin, and a saponin with a specified volume of 30% trichloroacetic acid to render a 15 or 20% trichloroacetic acid blue peel solution. The blue dye facilitates even application, and the saponin, being an emulsifying agent, creates a homogenous trichloroacetic acid–oil-water emulsion that penetrates at a slower but even pace, in contrast to the other aforementioned trichloroacetic acid formulations. The number of applied coats is tailored to skin thickness.

Phenol-Croton Peels

Phenol peels were used extensively by lay peelers in the first half of the twentieth century until their use by plastic surgeons was popularized by Baker and Gordon in the 1960s. In the original formulation, the assumption prevailed that phenol was the active ingredient, water was a diluent, Septisol was a contributor to a deeper peel, and croton oil served as only an irritant. In 2000, Dr. Hetter published a series of articles analyzing the Baker-Gordon phenol peel and convincingly proved that croton oil was the critical peeling agent and not phenol.19–22 He attributed the high 2.1% croton oil concentration in the Baker-Gordon formula for the notorious “all-or-none” deep peeling phenomenon that resulted in dense frosting and the problems of hypopigmentation. He published five easily mixed “heresy phenol formulas” in 2000 (Table 5), and with this new understanding, surgeons gained greater control in treating areas of diverse relative skin thickness by varying the croton oil concentration in addition to how it is applied.

Table 5. - Hetter’s Heresy Phenol Formulas
Formula Concentration
Medium-light peel formula (most common all-around use)
 4 cc phenol 88% 33% phenol
 6 cc water
 16 drops Septisol
 1 drop croton oil 0.35% croton oil
Very light peel formula (used for eyelids and neck)
 Take 3cc of above mixture and add the following:
  2 cc phenol 88% 27.5% phenol
  5 cc water 0.105% croton oil
Medium-heavy peel formula (not for temples, lids, preauricular area, or neck)
 2 cc phenol 88% 33% phenol
 6 cc water
 16 drops of Septisol
 2 drops croton oil 0.7% croton oil
Heavy peel formula (not for temples, lids, preauricular area, or neck)
 4 cc phenol 88% 33% phenol
 6 cc water
 16 drops of Septisol
 3 drops croton oil 1.1% croton oil
Heaviest peel formula* (Baker-Gordon formula) (not for temples, lids, preauricular area, or neck)
 3 cc phenol 88% 50% phenol
 2 cc water
 8 drops of Septisol
 3 drops croton oil 2.1% croton oil
*
Used for perioral rhytides or heavy, desiccated, pale skin.

Dr. Stone further modified the approach to peeling techniques, with his studies proposing the actual application technique; in particular, the number of times each area is “rubbed” was the principal factor in determining depth.23,24 Using a standard cotton-tipped applicator technique, he concluded that increased number of rubbings, pressure, and abrasiveness of the application coupled with the amount of volume of acid used and time in contact with the skin were the more important factors in peel penetrance over the croton formulation. He found frost density to not be a completely reliable indicator and therefore included a time component to his application process corresponding to target rhytide severity. The practical ramifications from these studies were profound, providing greater flexibility to treat different areas of the face based on relative skin thickness and obtain desired clinical results without peeling to a depth that causes the troublesome waxy hypopigmentation of previous phenol peels. Table 6 presents some general recommendations and frost-determined application endpoints for croton peels when treating different areas of the face.25

Table 6. - Croton Peel Recommendations*
Location Concentration Clinical Considerations Frost Endpoint
Forehead and temporal region 0.2–0.4% Glabellar area can be peeled deeper than lateral forehead and temporal area; peel can be safely extended to hairline and brows to avoid lines of demarcation; for focal peeling of individual lines, use wetter cotton-tipped applicator and blotting dry as frost appears Transparent with a pink background
Upper and lower eyelids Upper eyelids, 0.1–0.05%; lower eyelids, 0.1% Considering it is the thinnest skin on face, prudent to use the lowest concentration, especially below the tarsal fold Even, white frost
Cheeks, preauricular region 0.2–0.4% Deep peeling is often not needed in this area; therefore, caution should be exercised in peeling of this area Thin, white frost with pinkish background
Perioral region 0.4–0.8% Resilient area requiring higher concentration; precise deeper peeling of individual lip lines is useful; peel can be extended onto vermilion to address lip wrinkles Solid, dense, opaque, even frost
Neck 0.1% This extension is largely meant for blending of color and not for overt improvement of neck rhytides; light strokes Light, wispy frost
*Adapted from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008;28:33–45.

Phenol peels have long had the stigma of cardiac complications associated with them, and with the higher concentrations resulting in increased toxicity. Deaths are anecdotal, with no evidence to implicate phenol toxicity. The general recommendation is that full-face phenol treatments should include continuous electrocardiographic monitoring, intravenous access, and be performed in aesthetic units with a time lapse of 10 to 15 minutes between units with the understanding that this complication is more common when more than 50 percent of the face is treated in less than 30 minutes.26,27

Anesthesia

The anesthetic methods used during chemical peels are variable, with their individual practicality subject to the resources available in one’s practice. Superficial peels require no anesthesia, with local cold stimuli or nonsteroidal antiinflammatory drugs generally sufficient.28 For deeper peels, interventions range from the use of topical anesthetics, to regional nerve blocks, to sedation with oral analgesia, to general anesthesia with the help of an anesthetist. The practitioner should be aware that topical anesthetics vasoconstrict and thus increase the depth of a peel.29 The entire face can be adequately anesthetized with administration of 0.5 to 1 ml of local anesthetic per nerve to 12 mapped injection spots in an amenable patient, allowing for office-based performance of medium trichloroacetic acid, combined trichloroacetic acid, and deep phenol peels.30 Patients who are anxious or extremely sensitive should be offered sedation.

DISCUSSION

Over the past two decades, the techniques available to the clinician for chemical facial peeling have evolved greatly and, simultaneously, the population’s desire for nonsurgical means of facial rejuvenation has grown. With regard to chemical peels, it has been dermatologists that have largely adopted these practice advances, with facial plastic surgeons and plastic surgeons demonstrating a more moderate presence. Although the overall use of chemical peels by plastic surgeons continues to grow, the latest year-to-year growth rate of 2.1 percent shows a less robust implementation than the double-digit growth of competing specialties.1 This is perhaps attributable to the newer generation of plastic surgeons having little exposure during their training to chemical peel techniques and the decision-making processes involved in selecting appropriate candidates. It should appeal to the aesthetic plastic surgeons to incorporate chemical peels into their regular practice. Their versatility and relative simplicity should make using them as comfortable as modifying the settings of a laser.

The trichloroacetic acid peel stands as the workhorse peel for many practitioners, able to achieve a variety of peel depths. Dr. Obagi’s elucidation of the degrees of frosting has provided improved control and readily determinable penetrance of the peel, with level I corresponding to superficial penetration, level II corresponding to medium depth peels, and level III corresponding to deep peels.

The excellent chemoablative resurfacing capabilities of the Baker-Gordon formula long ago established it as the gold standard. The contributions by Hetter and Stone rendered previous criticisms less valid and ushered in a resurgence in the safe practice of phenol peels, more often referred to as croton oil peels in their modern-day configurations. These newer peel formulations warrant consideration by plastic surgeons, especially with the increasing trend toward nonsurgical treatments. Although surgery remains the most definitive means of dealing with the gravitational and volume changes associated with aging, chemical peels are an excellent adjunct to treat textural and photoaging pigmentary skin changes.

CONCLUSIONS

The versatility, predictability of treatment, and favorable risk profile of superficial to medium-depth chemical peels in experienced hands solidify this modality as being essential to a plastic surgeon’s nonsurgical methods of approaching skin rejuvenation. Although not discussed here, based on experience and available means, it is recommended that chemical peels be combined with other rejuvenating techniques as indicated to achieve the best results and patient satisfaction.

REFERENCES

1. American Society for Aesthetic Plastic Surgery. 2016 cosmetic surgery national databank statistics. Available at: https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf. Accessed September 2, 2017.
2. Johnson JB, Ichinose H, Obagi ZE, Laub DR. Obagi’s modified trichloroacetic acid (TCA)-controlled variable-depth peel: A study of clinical signs correlating with histological findings. Ann Plast Surg. 1996;36:225–237.
3. Rubin M. Manual of Chemical Peels. 1995:Philadelphia, Pa: Lippincott; 120–121.
4. Brody HJ. Medium-depth peeling. In: Chemical Peeling and Resurfacing. 1997:St. Louis, Mo: Mosby; 109–110.
5. Monheit GD. Advances in chemical peeling. Facial Plast Surg Clin North Am. 1994;2:5–9.
6. Coleman WP III, Brody HJ. Advances in chemical peeling. Dermatol Clin. 1997;15:19–26.
7. Weiss JS, Ellis CN, Headington JT, Tincoff T, Hamilton TA, Voorhees JJ. Topical tretinoin improves photoaged skin: A double-blind vehicle-controlled study. JAMA 1988;259:527–532.
8. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after trichloroacetic acid chemical peel. Arch Dermatol. 1991;127:678–682.
9. Grove G, Grove M, Zerweck C, et al. Determination of topical tretinoin effects on cutaneous microcirculation in photoaged skin by laser Doppler velocimetry. J Cutan Aging Cosmet Dermatol. 1988;1:27–33.
10. Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis 2004;74:362–368.
11. Fulton JE, Porumb S. Chemical peels: Their place within the range of resurfacing techniques. Am J Clin Dermatol. 2004;5:179–187.
12. Herbig K, Trussler AP, Khosla RK, Rohrich RJ. Combination Jessner’s solution and trichloroacetic acid chemical peel: Technique and outcomes. Plast Reconstr Surg. 2009;124:955–964.
13. Monheit GD. Skin preparation: An essential step before chemical peeling or laser resurfacing. Cosmet Dermatol. 1996;9:13–14.
14. Monheit GD. The Jessner’s-TCA peel. Facial Plast Surg Clin North Am. 1994;2:21–27.
15. Coleman WP III, Futrell JM. The glycolic acid trichloroacetic acid peel. J Dermatol Surg Oncol. 1994;20:76–80
16. Brody HJ, Hailey CW. Medium-depth chemical peeling of the skin: A variation of superficial chemosurgery. J Dermatol Surg Oncol. 1986;12:1268–1275.
17. Rohrich RJ, Herbig KS. The role of modified Jessner’s solution with 35% trichloroacetic acid peel. Plast Reconstr Surg. 2009;124:965–966.
18. Obagi ZE, Obagi S, Alaiti S, Stevens MB. TCA-based blue peel: A standardized procedure with depth control. Dermatol Surg. 1999;25:773–780.
19. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast Reconstr Surg. 2000;105:227–239; discussion 249–251.
20. Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000;105:240–248; discussion 249–251. Erratum in: Plast Reconstr Surg. 2000;105:1083.
21. Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeons’ role. Plast Reconstr Surg. 2000;105:752–763.
22. Hetter GP. An examination of the phenol-croton oil peel: Part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105:1061–1083; discussion 1084–1087.
23. Stone PA. The use of modified phenol for chemical face peeling. Clin Plast Surg. 1998;25:21–44.
24. Stone PA, Lefer LG. Modified phenol chemical face peels: Recognizing the role of application technique. Facial Plast Surg Clin North Am. 2001;9:351–376.
25. Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.
26. Vermeer BJ, Gilchrest BA. Cosmeceuticals: A proposal for rational definition, evaluation, and regulation. Arch Dermatol. 1996;132:337–340.
27. Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg. 1979;63:44–48.
28. Halaas YP. Medium depth peels. Facial Plast Surg Clin North Am. 2004;12:297–303, v.
29. Rubin MG. The efficacy of a topical lidocaine/prilocaine anesthetic gel in 35% trichloroacetic acid peels. Dermatol Surg. 1995;21:223–225.
30. Collins PS. Trichloroacetic acid peels revisited. J Dermatol Surg Oncol. 1989;15:933–940.
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