Answer:
Chemical peeling with phenol is used to improve significant actinic damage as well as moderate wrinkling of the skin. It provides a relatively deep and predictable injury to the dermis. “Pure” phenol is 88%. The solution most commonly used was developed by Baker and Gordon and contains 3 ml USP liquid, phenol 88%, 2-ml water; 8 drops liquid soap (Septisol); and 3 drops croton oil. It has been shown through histologic studies that the Baker/Gordon formula penetrates deeper than pure phenol. Phenol itself causes both keratolysis and keratocoagulation. Since phenol can produce cardiotoxicity, patients must be monitored closely. Although the blond-haired, blue-eyed, light-complexioned individual is considered to be the ideal candidate for a phenol peel, many darker-complexioned patients have been peeled with success. Since phenol penetrates deep within the dermis, it works for a variety of problems: intrinsic aging, actinic keratoses, superficial basal cell carcinomas, and pigmentary problems such as melasma, solar lentigines, and postinflammatory hyperpigmentation. Phenol peels are significantly more painful than TCA peels. For this reason, the administration of preoperative analgesics or sedative hypnotics is often indicated. It is important to take a detailed history before a phenol peel is performed. It is probably prudent to have a routine electrocardiogram (ECG) and chest x-ray as a baseline for comparison. There are numerous methods of analgesia for performing a phenol peel. While some perform the procedure under general endotracheal anesthesia, most employ conscious sedation. Analgesics such as meperidine (Demerol) in combination with midazolam (Versed) are commonly employed. It should be stressed that all patients undergoing full-face phenol peels require cardiac monitoring as well as attachment to a pulse oximeter. The application of phenol to the skin is slightly different than for TCA. Because of the cardiotoxic effects of phenol, it must be applied to small subunits of the face. The skin is cleansed with acetone. The Baker’s solution is prepared fresh for each patient in the presence of another individual to serve as a crosscheck. The solution must be stirred thoroughly before application. A reasonable approach is to divide the face into six regions. The first region is comprised of the left brow, forehead, and temple. The second region is the left periorbital area, lateral nose, cheek, and upper lip. The third region is the left lower lip, chin, and mandibular areas. The other three regions are the corresponding contralateral subunits of the face. A cotton swab saturated in solution is used to apply the acid initially to the deepest wrinkles. An assistant places traction on the skin to allow even application to the “shoulders” of the wrinkle. After the deepest wrinkles have been pretreated, three saturated cotton swabs are used to treat the remaining portions of the subunit. Once a subunit has been completed it is best to wait several minutes before treating the next area. The peel should be extended beyond the edge of the cosmetic unit. Extending the peel into the frontal and temporal hairlines, into the vermilion border, and onto the ear lobule yields a more inconspicuous result. Applying the phenol peel should take at least 1 1/2 to 2 hours. The mask is left on for 48 hours. At that time the patient can be given an analgesic such as meperidine (Demerol) or a sedative such as diazepam (Valium) before removal of the mask, since this can be quite painful. However, in many patients, the peeled skin has formed a coagulum that seems to help float the tape off of the skin. Crusts that remain are gently cleansed by the patient at home. Normal saline or distilled water compresses can help loosen the crusts.
Keeping the skin moist with emollients such as petrolatum speeds re-epithelialization. Although the edema can make the patient appear quite frightening, the amount of accompanying pain is surprisingly little. Re-epithelialization usually progresses rapidly within the next 10 to 14 days. Afterwards, make-up can be applied with caution. Erythema is a normal consequence of any peel and can persist for months. If it is more noticeable in specific areas, the physician should treat these areas as if they were impending scars. Topical corticosteroids are the first line of treatment. If this fails to help and a scar is forming, intralesional corticosteroids may be necessary. Once the skin has re-epithelialized, the patient should avoid intentional sun exposure for at least 3 months. Sunscreen should be worn as part of the daily regimen. Pigment discoloration is particularly prone to develop during this recuperative phase. Bleaching agents are often helpful for the first 2 to 3 months following the peel.