Phenol Peeling: New Standards of Excellence

Abstract: Phenol peeling remains the gold standard of chemical peeling because no other agent can compare in the treatment of patients with moderate and deep rhytids. However, phenol peeling can be very painful and is associated with many tradeoffs. Plastic surgeons have boldly modified their approach to TCA peeling to improve their results and we would like to see the same applied to phenol peeling. The purpose of this article is to initiate new thinking about phenol peeling and to correct misconceptions that commonly appear in the literature. By modifying our technique we have been able to perform virtually painless phenol peels and to reduce the tradeoffs commonly seen. Our modifications are discussed in detail along with a discussion of the new concepts we led are supported by our experience.

Phenol chemical peeling if one of the most difficult procedures for patients to endure. And yet, phenol peeling has been in demand for many years and remains the “gold standard’ of chemical peels because phenol enables us to rejuvenate skin to a far greater degree than any other method. No other method will remove deep wrinkles as well or for as long as phenol peeling [1]. This is why patients have been willing to endure the pain and tradeoffs associated with the process.

The purpose of this article is to introduce some new concepts that will enable you to perform virtually painless phenol peels. Also, by modifying the formula and the technique, you can reduce the severity of the tradeoffs. I also wish to address misconceptions about phenol peeling.

Materials, Methods, and Results

We performed 35 facial peels over a 12-month period using the modifications that will be described. The results of all patients were analyzed. All procedures were performed in the operating room under sedation and full monitoring including EKG, blood pressure, pulse, and oxygen saturation. The sedation consisted of Versed^® (Roche Laboratories. Nutley, NJ. USA), Fentanyl (Janssen Pharmaceutica, Inc., Titusville, NJ, USA), low-dose Ketamine (Parke-Davis, Morris Plains, NJ, USA), and Brevital (Eli Lilly & Co., Tndianapolis, IN, USA) and was maintained at a level at which patients were comfortable and unaware of their surroundings. The full face was peeled in less than 15 minutes in each case. There was insignificant change in EKG in all patients while using this rapid technique.

We believe that the concept of systemic absorption and cardiac toxicity is overstated. The key to preventing tachyarrhythmias is to adequately sedate patients and keep them pain-free. Once the entire face was treated, the phenol provided a short-lived topical anesthesia effect. The key to safely blocking the intense burning pain that follows is to prolong the topical anesthesia. Also, since taping has problems of its own, including traumatic removal, we prefer to occlude the face in a safer and less traumatic fashion. We accomplished both goals by using a gel that was applied to the face immediately after the conclusion of the phenol application. The gel consists of 5% prilocaine and 5% lidocaine in a 4% aqueous methylcellulose gel base. The formula is adequately strong to enable the topical anesthetics to penetrate through the damaged layer and almost totally eliminate the burning pain. Also, the gel dries to form an occlusive layer that potentiates the effectiveness of the peel. Often one application is sufficient but additional gel can be applied later if needed. All patients were monitored overnight in our facility. The gel can be removed easily with mild soap and water this was done the following day when we began our regimen of gently cleaning the entire face with mild soap and wat