Performing Deep Chemical Peels

It’s fair to say that deep chemical peels have received their fair share of bad press. Both patients and doctors are familiar with the devastating complications that can happen in the hands of an inexperienced practitioner.1 However, when performed by an experienced doctor, I believe that the results of this treatment can be far superior to any other including fractional and ablative lasers. In this article, I will explore when a deep chemical peel is suitable for your patient and discuss considerations around this. It is important to note here that these treatments should only be performed by highly qualified and experienced doctors who have undergone specialised training in performing phenol peels. What is a deep chemical peel? A deep chemical peel is performed using a substance called phenol. This procedure has been around since the 1930s and has been adapted and altered by many practitioners throughout the decades.2,3 The most common adaptation is the variation of the components that make a phenol peel, including the phenolic acid itself and croton oil, discussed in more detail below. Various formulations are currently available on the market with different percentages of phenol mixed with other substances and varying percentages of croton oil, which is another substance that enhances phenol penetration.2 In short, the higher the croton oil percentage, the deeper the peel will go. Due to these variations, many of the phenol-containing peels on the market do not give the results of a deep peel but instead enhance the tolerance of other peels such as trichloroacetic acid (TCA). Deep peels can only be performed on the face and not on any body parts. This is because the skin outside of the facial area is too thin and contains far less pilosebaceous units, therefore it cannot recover itself and will scar.2 They can be performed on the entire face or in separate cosmetic units. My preference is to treat the full face (shown in Figure 1 and 4), however sometimes a

patient can have severe sun damage or laxity, for example lines around the eyes or the mouth such as smoker’s lines. The rest of the face may not be bad enough to require a phenol peel, hence why sometimes it is appropriate to divide the face as you can see in Figure 2 and 3. Why perform a deep chemical peel? Deep peel treatment enables complete removal of most wrinkles on the face and, as such, can create a ‘facelift effect’ due to the post-procedure collagen and elastin repair of the skin.2 Compared to many other resurfacing procedures on the market, both ablative and non-ablative, the results are, in my opinion, superior. However, the downtime of the procedure may put many practitioners and patients off, which I discuss in more detail later on. Who is the ideal candidate? The most ideal candidate would be Caucasian with a Fitzpatrick skin type between I-III who has moderate to severe sun damage and/or skin laxity. This is because, as we know, darker skin types run the risk of hypo and hyperpigmentation after Dr Xavier Goodarzian provides an overview of such treatment. With this in mind, I would strongly recommend that phenol is avoided on skin types IV, V performing full face deep chemical peels and VI, purely because of a severe risk of permanent hypopigmentation and possibly scarring. I would suggest that a deep peel is not great for acne-scarred skin and, in my experience, TCA medium-depth peels or TCA pixel peels (combined with microneedling) are far more effective to treat acne scarring.4,5 In my experience, deep peels are also not suitable to treat pigmentation disorders as there are far safer options available. I would also not recommend deep peels for patients with minor imperfections or very few fine lines. Again, they would get much better results with TCA peels. It’s all about understanding your patient, their concerns and ensuring that you are able to recommend the most suitable, safe option to achieve fantastic results. Pre-peel preparation First of all, spotting the ideal candidate during your consultation is key, as many patients do not come in asking for this procedure or may have not even heard of it. Secondly, explaining the procedure in detail is extremely important. If I believe a patient would benefit from a deep phenol peel, I would present this solution during their consultation, briefly explaining the procedure and showing them before, during and after pictures. If the treatment interests the patient and they are not put off by the pictures, I would Before After generally organise a second consultation to go through the procedure in full detail. My consent form for this procedure is more than 20 pages long so that should give Figure 1: Patient before and three months after a full-face phenol peel. you an idea of how Images courtesy of Dr Xavier Goodarzian. much detail I go into.

It explains the procedure in minute detail and explains what they need to do to get the best results such as skincare preparation, medication, prepeel tests, medical history and so forth. I feel this is very important as patient cooperation is crucial to the success of the procedure. Once the consultation is done, I give the patient the full consent form and the extended medial history questionnaire to take home to read and sign in their own time. It’s important procedures such as these are not rushed or forced. I also ask their spouse, next of kin or whoever will be looking after them for the first couple of days post procedure to read and sign the consent form. I also recommend that they come along to the second consultation. The process begins with skin preparation. This is an important step in any peeling procedure and unfortunately can often be omitted by practitioners to cut down cost. In my experience, well-prepared skin with effective topicals has a much higher chance of good recovery after any peel and enhances the results dramatically.6 I would recommend a three-week skin preparation cycle as the absolute minimum. This would consist of a good twice daily routine, containing antioxidants, SPF (lots of it) possibly skin-lightening agents and sometimes retinoids, although a long gap is required between the use of strong retinoids and a phenol peel. All of which would be discussed in the consultation. It is also my preference to always include a full-face botulinum toxin treatment about one to two weeks before the peel as this will prevent the expression lines from deteriorating post peel on fresh skin that is

recovering. I also recommend a full blood count, liver function tests and urea and electrolytes (U&Es) to be done before the peel. An electrocardiogram may be necessary if there is a history of cardiac illness, all of which I perform in my clinic.1 This is because phenol is detoxified by the liver and kidneys and is also toxic to the heart, potentially causing cardiac arrhythmia.2 Several medications are then prescribed for the patient including strong analgesia, benzodiazepines, sedating antihistamines, antivirals and antibiotics. A chart is given to the patient explaining exactly when and how It is important to note, that frequently to take these drugs on a daily basis for a period of two weeks.these treatments should only be Performing the peelperformed by highly qualified and The patient arrives at least an hour before the procedure and is offered analgesia and experienced doctors who have benzodiazepines to relax. An intravenous (IV) cannula is inserted and a half litre of saline is administered undergone specialised training in slowly, sometimes with additional IV non-steroidal antiinflammatory drugs (NSAIDs). This is primarily for pain performing phenol peels relief and hydration to cleanse the kidneys. Blood pressure, pulse and oxygen saturation levels are monitored during the procedure and a small cardiac monitor can be used to assess the heart rhythm if there are any palpitations or for random checks. In my experience, it is always beneficial to have an assistant present to help with anything from setting up the room or prepping various steps of the peel. The assistant can be a medical professional or a therapist who has been specifically trained to assist the doctor in this procedure. The face is cleansed, disinfected and degreased thoroughly with alcohol and acetone and then a full-face local anaesthetic block is performed to anaesthetise the majority of the face. This allows a full phenol peel to be performed without sedation or general anaesthetic which can significantly increase the risk of arrhythmia during the procedure.2 The face is then divided into several cosmetic units using a white eyeliner/marker pen and the peeling process can begin. The phenol is applied in specific quantities and in a specific number of coats to each cosmetic unit with a gap of at least 10 minutes

Before After between to ensure phenol detoxification and avoid cardiac side effects. For the eyelid, I would use two coats, however for the top lip, I would use three of four. Once the full face has been treated, an occlusive tape can be applied over the entire face which will remain in place for about 12-24 hours. This process of occlusion allows epidermal maceration and further penetration of the phenol.2 Once the procedure has finished, the patient is generally unable to open their eyes due to oedema and their ‘carer’ should get them home with accurate instructions. Hygienic environments are absolutely crucial at this stage, so I always recommend no contact with pets, young children, no touching and no scratching. You can also advise Figure 2: Patient before and three months after a phenol peel around the eyes. patients to change their pillowcases and towels daily. Images courtesy of Dr Xavier Goodarzian. The following day the ‘carer’ brings the patient back to the practice

Before After Figure 3: Patient before and three months after a phenol peel around the eyes. Images courtesy of Dr Xavier Goodarzian.

Figure 4: Patient before and three months after a full-face phenol peel. Images courtesy of Dr Xavier Goodarzian.

where the occlusive mask is removed and bismuth subgallate is applied to the face. This allows the skin under the powder to heal while protecting it from the outside world. This mask, which becomes semi solid, has to remain in place for seven days and should under no circumstances be removed. At this point the practitioner is able to help open the eyes for the patient, which gives them back a bit of their independence after not being able to see for almost 24 hours. During this week there is really not much the patient can do except to stay at home and rest. The medication allows prolonged and deep sleep for the patient at home which makes this week much more tolerable. Any form of exercise is strictly forbidden. Solid foods and excessive chewing have to be avoided so most people stay on a liquid or semi-liquid diet for the week. At the end of this healing and isolation period, the patient applies a thick layer of occlusive ointment to their face at night which allows the mask to come off the following day. Of course, there are variations to this description as sometimes the occlusive mask may not be applied, or only a part of the face will be treated with phenol, such as the periorbital region.

Aftercare The skin is very red and very sensitive for at least six weeks, but it’s sometimes longer. The patient should accurately follow the post-peel protocols with their topicals, instructed by their practitioner to avoid any complications such as infection or scarring.2 Usually, there is minor skin shedding in the following 10 days as the new skin starts settling and adapting. I also advise that makeup can be applied almost as soon as the yellow crust comes off to cover redness and provide further SPF. It is crucial for the patient to be seen at the practice several times during the following weeks to ensure potential complications don’t go unnoticed. As a minimum, I like to see my patients at day 10 and one, two, three and six months’ following treatment. Full sun protection (no lower than SPF 30) and sun avoidance are compulsory for the first few months. This is because new skin will be very sensitive and can burn or pigment very easily. I would say that even though the immediate results are great, the full effect can only be appreciated around three to six months’ post procedure, as this waiting period is necessary for the collagen and elastin fibres to rebuild and restructure.2 I would recommend that the final ‘after’ pictures are taken around that time. The results from this type of peel are very long lasting without promising permanent results. Histologically, the skin changes can be seen decades later.7 As we very well know, the face continues to age, and sun exposure is inevitable even when all sun protection measures have been complied with. Generally, the more sun damaged and wrinkled the face, the more dramatic and long lasting the effects.

Considerations As mentioned, cardiotoxicity is one of the most dangerous side effects of performing this treatment.2,8 If a patient has any form of cardiac medical history, the treatment should not go ahead. Once all medical contraindications such as diabetes, infections, autoimmune illness, genetic collagen abnormalities have been excluded, it still comes down to the practitioner’s discretion to decide if the patient is a good candidate or not. As mentioned, there is a high risk of infection immediately after the peel.2 The yellow mask acts as an antimicrobial shield and prophylactic antibiotics are also prescribed. The most important thing is to communicate all of the risks associated with this procedure clearly and document that you have done so. Reiterating the importance of hygienic environments will also aid in making treatment outcomes successful.

The results from this type of peel are very long lasting without promising permanent results. Histologically, the skin changes can be seen decades later

Dr Goodarzian would like to thank Dr Phillippe Deprez for his extensive work involving chemical peels

Dr Xavier Goodarzian is the medical director and coowner of the national award-winning Xavier G. Clinic in Southampton. He is a lecturer and trainer at major conferences throughout the UK and abroad and the past lead trainer for Innomed Training. Dr Goodarzian is a member of the Royal College of General Practitioners and has postgraduate degrees is clinical dermatology and cosmetic medicine. He is a member of BCAM and also a past committee board director.

REFERENCES

1. Nikalji N, Complications of medium depth and deep chemical peels, Journal of Cutaneous and Aesthetic Surgery, October 2012 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560165/> 2. Deprez P, Textbook of chemical peels second edition, July 2016 3. Shuster M, The Baker Phenol Peel, Plastic and Reconstructive Surgery, July 1998 <https://journals. lww.com/plasreconsurg/Citation/1998/07000/The_Baker_Phenol_Peel_Formula.60.aspx> 4. Castillo D, Keri J, Chemical peels in the treatment of acne: patient selection and perspectives, Clinical, Cosmetic and Investigational Dermatology, July 2018 <https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC6053170/> 5. Hay A et al., Interventions for acne scars (review), Cochrane Library, 2016 <https://www. cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011946.pub2/pdf/full> 6. Rendon M, Berson D et al.,Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing, Journal of Clinical and Aesthetic Dermatology, July 2010 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921757/> 7. Bensimon R, Croton Oil Peels, Aesthetic Surgery Journal, ,January 2008 <https://academic.oup.com/ asj/article/28/1/33/218367> 8. Landau M, Cardiac complications in deep chemical peels, Dermatologic Surgery, February 2007 <https://www.ncbi.nlm.nih.gov/pubmed/17300604>