AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The application of chemicals to the skin is a well-described method to attempt to restore a more youthful appearance. Chemical peeling is the chemical removal of layers of skin to improve dermatologic defects. For information on other skin resurfacing techniques, see the Skin section of eMedicine’s Plastic Surgery journal.

History of the Procedure

Chemical peels currently are performed commonly by many different medical and paramedical personnel and laypersons. The lay peelers of the 1920s dominated the field and then essentially were attacked legally and placed at a legal disadvantage by the medical peelers, who often sent their wives in for peels to learn the secret arts. Chemical peeling did not become prominent in plastic surgery literature until 1960.

Sir Harold Gillies used pure carbolic acid in a painting and taping technique for correction of "slight laxity of the lid" for many years prior to 1960. Also prior to that time, dermatologists used phenol peels to remove superficial blemishes, and lay peelers gave peels a mixed notoriety. These lay peelers, largely in California and Florida, had developed effective peeling solutions and concoctions. In September of 1961, Litton presented 50 patients with 2-year follow-up periods on whom chemical peels had been performed using a minute amount of croton oil in a 50% solution of phenol with glycerin and water. He had paid Coopersmith, a lay peeler in Fort Lauderdale, for the formula in 1958 or 1959. He published his findings in 1962 but did not include a specific formula in the article.¹

Concurrently, Brown and the surgeons and dermatologists who followed him popularized and refined the technique. In November of 1961, Baker contributed a specific and easily measured formula, with one patient identified with a 3-month follow-up period.² Baker had approached a lay peeler in Miami, Miriam Maschek, and Coopersmith to discuss the formula. In 1962, Baker published the formula that essentially remained unchanged—to the exclusion of all others—for the next 35 years.³

In recent years, a large shift has occurred in the manner and depth to which peels are performed. Lasers largely have supplanted deep chemical peeling because of the control of depth they afford, their lesser effect on pigmentation, and their ease of use, with no chemical adverse effects. Superficial peels, in contrast, have increased in popularity. Various agents are used; for simple exfoliation, glycolic or lactic acids are now commonly found in almost all moisturizers and in many makeup bases.

Problem

Aging skin undergoes a number of changes. With time, it thins, falls, and creases along muscular and gravitational folds. Compared to the effects of simple aging on skin, sun damage leads to additional and different problems including thickening, solar elastosis, and resultant pigmentary irregularities. Carcinogenic effects lead to actinic keratoses, basal and squamous cell cancers, and, less directly, to melanomas. For more information, visit Medscape's Skin Cancer Resource Center.  

Scarring from trauma or acne contributes to an irregular skin surface. True skin laxity in the form of brow ptosis, eyelid bags, jowls and loss of neckline, ear lobule elongation, nasal tip drop, upper lip thinning, and other manifestations are currently treated surgically with facial rejuvenation procedures (eg, face lift, brow lift, rhinoplasty, lip augmentation). Conversely, these procedures do not help skin textural damage. Fine lines, pigmentary irregularities over a broad area, and aging skin are treated with peeling using either chemical or mechanical means.

A discussion of mechanical peeling is warranted for thoroughness. Lasers largely are used for skin ablation, with the carbon dioxide ultrapulsed laser currently used most often. The erbium:YAG laser is used more for superficial resurfacing when little tightening and superficial depth of peel are required. Many surgeons still use dermabrasion. The lack of control and lack of ability to resurface evenly have resulted in the supplantation of this technique by those already discussed. Microdermabrasion is currently a popular technique because no downtime or discomfort is associated with the procedure. Medical devices tend to have stronger suction, and more abrasive crystals are used, while spa and lay devices tend to be gentler, with less overall effect but increased safety. In general, mechanical abrasion tends to improve scarring more than chemical peeling agents given similar depth of penetration.

Chemical peeling agents are extremely varied, particularly among lay peelers. A great deal of medical and lay "magic" and superstition exist regarding peels and peeling agents. For example, a widely held belief for more than 30 years stated that a stronger phenol concentration used in a deep phenol peel resulted in more superficial depth. This largely has been disproved recently. An excellent series of reviews of phenol peels by Hetter was published in 2000; the reader is referred to this series, cited in the Bibliography, for more information.^{4, 5, 6}

Frequency

Chemical peeling is performed extremely frequently. Considering that alpha-hydroxy acid (AHA) exfoliants are currently found in many cosmetic products, peeling is essentially performed with each application of makeup or skin care. Peeling to depth continues to be a popular and excellent means of achieving textural skin improvement. Hundreds of thousands and perhaps more than 1 million phenol peels have been performed in the United States during the last 40 years.

The frequency of aging skin and contributing factors such as smoking, pollution, rampant oxidants of skin molecules, and weather are self-explanatory and are discussed further in Etiology.

A note must be added regarding cutaneous malignancy. The skin is by far the organ most commonly affected by cancer; 1 in 5 people develops skin cancer. More than 1 million cases of skin cancer occurred in the United States in 1997. One half of cancers of the body are skin cancers. Although common skin cancers (ie, basal cell, squamous cell) tend to be localized and nonmetastatic, melanoma incidence doubled from 1973-1991. Of the 8,500 skin cancer deaths in the United States in 1991, melanoma accounted for 6 in 7 deaths.

Etiology

The etiology of facial aging is a large subject. This article briefly discusses aging and contrasts it with sun and environmental damage.

When not compounded by extraneous factors, skin aging basically is the process of atrophy. Loss of subcutaneous tissue is the most obvious and recognizable sign of aging; however, skin, skin appendages, and cutaneous blood supply also atrophy with age. Both the epidermis and dermis thin, and cutaneous strength and elasticity are lost. Dermal-epidermal adherence afforded by rete pegs is lost, and blistering or superficial epidermal loss commonly occurs with aged skin. Overall thinning and loss of integrity and wall strength of the cutaneous vasculature cause easy bruising.

Environmental damage to skin often is explained incorrectly in the literature because of confusion between the short-term and long-term changes that occur. Initially, as with most damage to the human body, the response is inflammatory. This tends to subside rather quickly in the skin, but continuous damage can result in prolonged inflammatory responses. Although postinflammatory hyperpigmentation is often considered a limited medical condition, most individuals express it to some extent, and prolonged exposure to damaging environmental factors results in tanning and prolonged hyperpigmentation. The increased volume of skin from inflammation tends to be transient and caused by increased water volume from increased proteoglycans and glycosaminoglycans.

The true long-term damage to skin from environmental stresses is a decrease in the water volume and increase in damaged cutaneous proteins. In particular, the elastic fibers tend to form tangled masses of nonelastic elastin remnants. This leads to increased volume of skin without functional elements. The solar elastosis or heliosis that is observed histologically is the end stage of this damage. In much the same manner that scarring or fibrosis is observed as the end stage of renal or hepatic disease, scarring and remnants of proteinaceous elements tend to be the end stage of cutaneous disease. Although contracture is present, the general trend in environmental damage of the skin is toward increased thickness, especially of the dermis. This thickening is with nonelastic and structurally weak skin. Sun damage, especially from UV-A wavelengths, causes ionization and oxidation of dermal elements and genetic information, resulting in premalignant and malignant skin lesions.

Many years of acne (both cystic and rosacea) increase the blood flow to skin and tend to hypertrophy the basic elements. Scar tissue also deposits and can contract, leading to uneven skin surfaces. True cysts and sinus tracts commonly result, and ice pick lesions usually are the visible manifestations of these processes.

Pathophysiology

The mechanism of action of peeling agents is relatively straightforward. Stronger agents such as phenol (with various additives such as croton oil and glycerin) and trichloroacetic acid (TCA) produce a chemical necrosis of the skin to variable depths, depending on numerous controlled and uncontrolled variables. The weaker agents (eg, AHAs) change the pH sufficiently to cause a superficial shock to the cells and, depending on many variables, cell injury or death. When used with a moisturizer, the acid acts simply to cause cellular and intercellular swelling and plumping, leading to transient increase in cell and matrix size and lessening of fine lines and rhytides. Sequential treatments lead to exfoliation and a smoother complexion. Continued irritation can lead to many of the same effects of tretinoin or retinoid treatment (ie, increased thickness of dermis, increased blood flow to skin).

The phenol peel deserves special consideration. The Baker formula published in 1962 is as follows: phenol USP 88% 3 cm³ 49%; distilled water 2 cm³ 44%; croton oil 3 drops 2.1% (correct percent if 1 gutta = 27 drops/cm³); and Septisol 8 drops 4.5%.³

The following beliefs remain commonly held about the formula:

1. Phenol was the only active ingredient.
2. Lower concentrations of phenol penetrate deeper than higher concentrations. This was believed to be due to the denaturation of superficial proteins with higher concentrations leading to nonpermeability of the remainder of the solution.
3. Lower concentrations are more dangerous.
4. Septisol (a detergent or surface tension–lowering agent) causes deeper penetration.
5. Croton oil is present only as an irritant.

Clinicians now know that phenol actually peels deeper in higher concentrations. Septisol causes deeper penetration of phenol and a deeper peel. Croton oil (especially the toxic fraction solubilized in phenol) causes a deeper peel.

Other factors that affect the depth of peel include the presence of skin surface oils and dirt; skin water content; temperature of the room, skin, and solution; humidity of the air; length of time the solution is left in contact with the skin; occlusion or nonocclusion; batch of croton oil; thickness of epidermis and dermis; and presence of hyperkeratotic lesions. It is evident why laser resurfacing largely has supplanted phenol peels as a predictable means of deeply removing layers of skin.

Several superficial peels are not equal in result to one deeper peel. Determine the depth of the peel by the severity of the condition being treated; also consider the length of time that a patient will allow for recovery. A deeper peel by any method results in a relatively longer period of redness and inflammation.

Clinical

Aging faces are common to all and recognized as such. Distinguish between textural skin damage treatable by resurfacing or skin rejuvenation (see Images 1-15) and actual ptosis or falling of major structures treatable by surgical interventions (Images 3-10).

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The indications for a chemical peel, since it is largely a cosmetic procedure, depend on the patient's tolerances and wishes for correcting skin textural problems. Many individuals do not wish to improve skin texture despite severe problems, and others desire marked improvement in relatively minor problem areas. Treatments vary with the severity of the condition and the wishes of the patient. Temper these wishes with information on what is possible and what is desirable for the patient in terms of treatment. Approach each patient truthfully, discussing possibilities, risks, benefits, and alternatives.

The ideal candidate has minimal sag or severe skin excess but many fine lines and rhytides. Patients with fair complexions are better suited to peels primarily because of possible postinflammatory hyperpigmentation in other skin colors. These long-term concerns can largely be circumvented with proper pretreatment and posttreatment using bleaching agents. The hypopigmentation commonly observed after deep chemical and laser peels generally occurs in whites and can be avoided with a more superficial peel or by peeling adjacent areas lightly to blend the areas. If a deep peel is necessary, discussing the likely probability of hypopigmentation with the patient is best to ensure that when it occurs it is an acceptable result.

A noted decrease in the incidence of superficial skin cancers and actinic keratoses occurs after resurfacing procedures. Consider a deep full facial resurfacing procedure for individuals with multiple lesions and a splotchy complexion after treatment with liquid nitrogen or dry ice. An alternative treatment is 5-fluorouracil, but it is tolerated poorly by many patients because of the length of time for treatment and healing. This is particularly true on the face. True skin cancers and invasive skin cancers are treated surgically; perform a biopsy on concerning lesions prior to resurfacing.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

See Surgical Therapy.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Contraindications to chemical peeling include documented hypersensitivity to the peeling agent, any of the peel components, or any sedatives used. The procedure also is contraindicated in the presence of facial cancers, with an absolute contraindication in a patient with a facial melanoma or a skin condition such as pemphigus.

Chemical and laser peels are not treatments for all skin cancers. Find and remove these prior to treatment. (For more information on the treatment of skin cancer, visit Medscape's Skin Cancer Resource Center.) Conversely, carcinoma in situ and actinic keratoses are well treated with deep chemical and laser peels.

Some have stated that chemical peels and laser peels are not useful in individuals who are not white; however, once postinflammatory hyperpigmentation is controlled, few reasons exist not to perform such procedures (see Images 1-10).

Deep phenol peels over extensive areas with large amounts of phenol absorption can lead to fatal cardiac arrhythmias. Monitoring is necessary during panfacial procedures, with attention to small areas (usually one fourth) of the face at a time. Therefore, consider cardiac arrhythmic potential a contraindication to the procedure.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Workup is dictated by the patient's underlying health status and the type of sedation considered necessary for the procedure.

Other Tests

• If an extensive area is to be peeled with phenol, perform a preoperative ECG and intraoperative monitoring.

Histologic Findings

With deep chemical peels, a grenz zone of essentially scar tissue is found within the deep layer of the skin, with superficial healthy new skin laid down following the procedure.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical Therapy

Although essentially a continuum of treatments bridges superficial and deep chemical peels, the pretreatment, intratreatment, and posttreatment protocols are better divided within these categories rather than along the lines of agents or lasers used.

Superficial skin peel

• After proper patient selection, history, physical examination, and preparation of the patient regarding appropriate expectations, begin the procedure.
• The patient may take 1-2 ibuprofen tablets (400 mg) 1 hour prior to the procedure.
• Mix the solution to be applied and/or ensure freshness and proper concentration.
• Wash the skin the night before the procedure and again the morning of the procedure with any detergent soap. The skin may be dry and flaky; this is desired. If the skin remains oily, a degreaser (eg, alcohol, weak acetone solution) may be used immediately prior to the procedure (see Image 11). Ether was used in the past and is an excellent degreaser; however, storage and hazardous goods concerns in an office setting preempt its use today.
• Cover areas adjacent to the area to be peeled and protect clothing.
• Many commercially available peels have applicators and are thickened with glycerin or similar substances so that they do not run. Avoid pooling of peeling solutions to ensure an even application. Only a thin coat is necessary, but it must be even (see Images 12-13).
• Peeling agents vary from fruit acids to weaker solutions of TCA. A superficial peel results in partial loss of the epidermis. Some light frosting of the skin may occur, but skin loss should not be obvious at the time of the procedure.
• The length of time that the agent is used depends on the solution and the desired depth of peel.
• Wash with copious amounts of water to end the reaction (see Image 14). When TCA is used, a fan helps to decrease intensity of the tingling sensation.
• Usually, 2 days of redness followed by superficial peeling of the skin for another 3-5 days follows the procedure.
• Use of cosmetics and moisturizers during the time of the peel generally is avoided if at all possible.

Deep skin peel

• Skin preparation is essentially the same as that for the superficial peel. For 2 weeks prepeel, use tretinoin or some other irritant to potentiate the healing process. Tretinoin can cause severe skin irritation (which is why it is used in this capacity), redness, flaking, and sun sensitivity. Allergic reactions are possible (eg, anaphylaxis, hives, rash, nausea, vomiting), and prolonged inflammation poses a risk of worsening pigmentation. Use it sparingly and for a defined length of time. Tretinoin is approved by the Food and Drug Administration (FDA) only for treatment of acne, which it can transiently worsen. Skin improvement is an off-label use of this substance.
• A bleaching agent is often used to prevent postinflammatory hyperpigmentation.
• Begin use of perioperative antibiotics and antiviral agents the night before the procedure and continue use for approximately 10 days.
• If phenol is used, demarcate the areas of treatment to disallow overlap or nonapplication of the agent to any areas.
• Some form of sedation or anesthesia is required for this depth of peel.
• The solutions used are usually higher concentrations of TCA (>35% unbuffered) or phenol solutions.
• Apply the solution, usually in an operating room with continuous monitoring when phenol is used. Leave the solution on for the desired effect and then wash it off with copious amounts of liquid. Thymol can be used to stop the phenol peel.
• Use occlusion (either taping or a nonpermeable membrane or substance [usually petroleum jelly]) if a deeper peel is desired. A semipermeable membrane often is used afterward for patient comfort, or the petroleum jelly can be continued.
• The length of time of peeling usually is similar to that for superficial peels, but because of the depth of peel, redness may be present afterward for 6-8 weeks.
• Caution the patient against sun exposure during this period.
• After re-epithelialization occurs, re-institute the bleaching agent used preoperatively.
• Take care to prevent infection in the healing period and to provide prophylaxis for activation of oral herpes. If an outbreak of oral herpes occurs, quadruple the dose of the antiviral agent and use it for treatment rather than prophylaxis. This generally subdues the outbreak.
• Follow-up care is frequent, with visits every 2-3 days until re-epithelialization is complete, then every week until the redness is gone.
• Avoid steroids so as not to interfere with the maturation and thickening process of the new skin.

Follow-up

Patients are seen frequently following the procedure for the above-mentioned reasons and also, in the case of deep peels, to lend assurance that all is proceeding normally. The skin takes many months to heal completely and goes through many changes during this time. An experienced physician can allay many fears on the patient's part by making certain that all is proceeding normally.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The risk of complication is not observed with superficial peels, nor is great benefit. In patients prone to hyperpigmentation, pretreatment and posttreatment with a bleaching agent are necessary. Sun exposure must be avoided, especially in these individuals. Deep peeling is a risk. Avoiding the ever-present risk of scarring is of paramount importance, but this is difficult when a marked result is desired and when little control over many of the variables of depth is possible. Conscientious attention to every detail of the peel and experience with the procedure are necessary. Hypopigmentation in white persons after a deep peel is almost universal and should be an accepted sequela of the procedure.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The outcome generally is excellent once patient expectations are adjusted to the procedure. The patient must know what to expect from the surgery and during the healing process. Giving the patient realistic expectations for each stage of healing is imperative to the success of the entire procedure.

After a deep peel, the skin is new and supple. Some of the rhytides return as the swelling resolves. Approximately 1 month after the peel, the skin appears wrinkled. After it begins to thicken, many of these rhytides resolve over the ensuing months. A repeat peel can be performed after 1 year if necessary. Superficial peels can be repeated every few weeks if needed. Many superficial peels do not produce the same effects as a deep peel. The skin continues to weather and age after the procedure, but the effects of the peel are permanent.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Deep chemical peels have mostly been supplanted with laser peels, and controversy remains over which is better. Deep laser resurfacing is a more controlled and elegant procedure, with faster postoperative healing than chemical peels of similar depth. Laser peels also have less effect on pigment than chemical peels performed to the same depth. Both have risks, and when performed by experienced practitioners, both are safe and effective. The author prefers to use lasers for deep resurfacing and chemical peels for more superficial procedures since using an incredibly expensive apparatus for a simple superficial peel is not necessary. The results from superficial chemical peels and superficial erbium:YAG laser resurfacing procedures are similar. Microdermabrasion largely has supplanted epidermal peels because the procedure has no downtime and peeling does not occur to any extent afterward.

A newer fractional resurfacing device is very encouraging, especially for acne scarring. It allows for the resurfacing of one small area at a time, with several treatments required to complete the process. This device reduces the downtime from each procedure, but each procedure is still painful and requires about 7-10 days of recovery time, which is not that much shorter than a true, complete resurfacing procedure. A number of second generation fractional resurfacing devices are being introduced which have less down-time and are, essentially, pain free. The question remains whether they offer the same results as the more invasive procedures.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Preoperative view of patient with severe panfacial acne scarring, multiple seborrheic keratoses, nevi, and panfacial actinic skin damage.
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Media file 2:  Postoperative view (6 mo) after full-face carbon dioxide laser resurfacing with up to 8 passes used in some areas.
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Media file 3:  View of the infraorbital area of an African American patient. Although a mid face lift was offered to correct the deep nasojugal groove, this was declined, and the patient wanted mere removal of bags and a less tired appearance.
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Media file 4:  Additional view of the infraorbital area of patient in Image 3. This African American patient wanted mere removal of bags and a less tired appearance, although a mid face lift was offered to correct the deep nasojugal groove.
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Media file 5:  Additional view of the infraorbital area of patient in Images 3-4. This African American patient wanted mere removal of bags and a less tired appearance, although a mid face lift was offered to correct the deep nasojugal groove.
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Media file 6:  Postoperative view (3 mo) after transconjunctival lower eyelid blepharoplasties and carbon dioxide laser resurfacing of the lower eyelids. Note the slight redness that remains, but essentially no change in pigmentation has occurred.
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Media file 7:  Additional postoperative view (3 mo) of patient in Image 6 after transconjunctival lower eyelid blepharoplasties and carbon dioxide laser resurfacing of the lower eyelids. Note the slight redness that remains, but essentially no change in pigmentation has occurred.
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Media file 8:  Additional postoperative view (3 mo) of patient in Images 6-7 after transconjunctival lower eyelid blepharoplasties and carbon dioxide laser resurfacing of the lower eyelids. Note the slight redness that remains, but essentially no change in pigmentation has occurred.
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Media file 9:  Patient in Images 6-8 2 years postoperatively after transconjunctival lower eyelid blepharoplasties and carbon dioxide laser resurfacing of the lower eyelids.
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Media file 10:  Additional view of patient in Images 6-9, 2 years postoperatively after transconjunctival lower eyelid blepharoplasties and carbon dioxide laser resurfacing of the lower eyelids.
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Media file 11:  Patient's neck area after preparation with 20% methanol.
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Media file 12:  Patient 2 minutes after application of 40% trichloroacetic acid (TCA) solution.
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Media file 13:  Patient 8 minutes after application of additional trichloroacetic acid (TCA) to even the peeled surface.
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Media file 14:  Patient following completion of the chemical peel at 10 minutes and after neutralization with water.
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Media file 15:  Patient after completion of the chemical peel and a single pass with a carbon dioxide laser on the face. This patient had a 35% trichloroacetic acid (TCA) peel performed on the face 2 months previously but desired a deeper peel.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

1. Litton C. Chemical face lifting. Plast Reconstr Surg Transplant Bull. Apr 1962;29:371-80. [Medline].
2. Baker TJ. The ablation of rhitides by chemical means. A preliminary report. J Fla Med Assoc. Nov 1961;48:451-4. [Medline].
3. Baker TJ. Chemical face peeling and rhytidectomy. A combined approach for facial rejuvenation. Plast Reconstr Surg Transplant Bull. Feb 1962;29:199-207. [Medline].
4. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast Reconstr Surg. Jan 2000;105(1):227-39; discussion 249-51. [Medline].
5. Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. Jan 2000;105(1):240-8; discussion 249-51. [Medline].
6. Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeons' role. Plast Reconstr Surg. Feb 2000;105(2):752-63. [Medline].
7. Brown AM, Gordon HL, Brown ME. Phenol-induced histological skin changes: hazards, technique, and uses. Br J Plast Surg. Jul 1960;13:158-69. [Medline].

Article Last Updated: Mar 28, 2008