Phenol-Croton Oil Peels

Question 1

How was the 1st phenol-croton oil peel created ?

Answer 1

• The formulas involved boiling crystals to obtain liquid phenol
• to which were added drops of the caustic acid croton oil, among other ingredients

Question 2

Thomas Baker original formula

Answer 2

• liquid phenol, 3 drops of croton oil, water, and the surgical soap Septisol
• which acted as a surfactant to allow the aqueous & oily parts to mix

Question 3

Who proved that croton
oil & not phenol was the peeling agent ?

Answer 3

• plastic surgeon Gregory Hetter
  in Las Vegas

Question 4

pros & cons of original Baker formula

Answer 4

• pros: highly effective in treating deep wrinkles
• cons: significant hypopigmentation, creating unnatural alabaster look, phenol’s reputation of being cardiotoxic

Question 5

croton oil concentration at original Baker’s formula

Answer 5

2.1%

Question 6

what caused the all-or-none phenomenon seen with the Baker peel ?

Answer 6

high croton oil concentration

Question 7

advantage of modified Baker formula

Answer 7

• practicioner can choose different concentrations on different areas of the face depending on need & relative skin thickness
• It is feasible to peel to the desired clinical result without reaching a depth that causes hypopigmentation

Question 8

main contraindication in peeling

Answer 8

• patient who is expected to be uncooperative in the postoperative care & may not refrain from picking

Question 9

Liquid phenol concentration

Answer 9

• 88% or 89%
• its corrosive effect allows passage into the dermis

Question 10

croton oil features

Answer 10

• extracted from the seeds of Croton Tiglium ,a tree indigenous to Asia
• Full-strength croton oil is highly caustic and will result in a full-thickness burn if applied to the skin
• However, when correctly diluted & appropriately applied, croton oil will yield remarkable aesthetic improvement

Question 11

what is Septisol ?

Answer 11

• surgical soap that has been historically
  used as a surfactant to allow miscibility of the aqueous & oil components
• contains triclosan as a preservative, and this has become problematic as of late
• banned by FDA, allowed in Europe in low concentrations
• triclosan is inconsequential to the peel

Question 12

Formulas With 35% Phenol Concentration

Answer 12

Question 13

what is the effeft of applying dilute phenol solution to the skin ?

Answer 13

• dilute phenol solution (i.e.,50%) caused an initial stinging that lasted 10-15 sec after which the skin appeared insensate

Question 14

anesthetic technique with phenol ?

Answer 14

• peeling by applying a first pass of 50% phenol to one segment of skin (such as one-half of the forehead)
• The patient would experience definite stinging for 10 to 15 seconds, after which the discomfort dissipated completely
• At this point, the skin treated with phenol is numb and can be comfortably peeled
• If the entire face is to be peeled, it is first gradually treated with 50% phenol for the anesthetic effect & then peeled

Question 15

what technique can be added in order to perform a deep peel ?

Answer 15

• oral sedation ( 1/2 tb Xanax & 1/2 tb Stilnox, prior to treatment )
• IM pain medication, if regulations allow
• use of an apparatus that
  delivers 50% oxygen and 50% nitrous oxide on demand by the patient (Pro-Nox CAREstream Medical LTD)

Question 16

To significantly improve wrinkles, deep peels must reach at what skin depth ?

Answer 16

• upper to middle reticular dermis

Question 17

how can we evaluate the degree of peel depth ?

Answer 17

• by constantly evaluating the degree of frost opacity

Question 18

what is the significance of a thin transparent frost with pink background ?

Answer 18

• indicates that the peel has passed through the epidermis into the dermis
• The translucent quality of the frost reveals the dermal vessels—hence the pink color
• Depending on the circumstance & location, this may be the correct endpoint

Question 19

what do we expect if more passes are applied once thin frost with pink background has been observed ?

Answer 19

• With more passes, the peel proceeds to the upper & middle dermis
• The frost forms a solid, opaque, even white frost
• The pink hue is lost because the acid has destroyed the intradermal vessels & the opacity hides the deeper subdermal plexus

Question 20

reliable sign that the upper to mid-reticular dermis has been reached ?

Answer 20

• frost is gradually lost in about 15 minutes
  (“defrosting”), and the skin turns into a red-brown or tan color
• Further peeling after a solid white frost results in a gray-white color indicative of reaching the lower reticular dermis, which is not advisable

Question 21

Another sign to evaluate depth of peeling ?

Answer 21

• epidermal sliding
• This occurs when the peel reaches the papillary dermis and the normal bonds between epidermis & dermis are broken and the epidermis can now slide as a thin independent sheet
• This sliding disappears when the peel reaches the reticular dermis & a solid protein block is formed

Question 22

practical recommendations during peeling procedure

Answer 22

• always be mindful & protective of the eyes
• head of the bed is gently elevated to prevent acid running into the eye
• never using an applying sponge so wet that it can drip, and never crossing over the eye with an applying gauze in hand
• To keep the operator’s hands dry, a surgical towel can be clipped to the shoulder of the
  scrub skirt and draped over the front to easily wipe the hands
• Clearly labeled containers are lined up with glass
  bowls and arranged in ascending strength in a consistent manner to prevent confusion

Question 23

What is the specific action of the acid?

Answer 23

• to precipitate & coagulate the protein of the skin, forming a “frost,” of varying degrees of white appearance
• The frosting becomes progressively more dense and opaque as the peel passes through the papillary dermis into the upper & mid-reticular dermis

Question 24

What is the key concept with weaker concentrations ( [croton oil] ) < 2,1%?

Answer 24

• main factor of the depth reached is the application technique, which is directly controlled by the surgeon
• Nuance in the technique can involve how wet the gauze is, how many passes are made, and how much pressure is applied
• The same depth can be reached using different techniques or even different concentrations

Question 25

Answer 25

Question 26

Answer 26

Question 27

How to treat deeper wrinkles in the
lips, glabella, forehead & midface ?

Answer 27

Question 28

postpeel care

Answer 28

Question 29

Results of phenol-croton oil peel

Answer 29