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The Lost Art of Chemical Peeling
Advances in Ophthalmology and Optometry 2 (2017) 391–407
ADVANCES IN OPHTHALMOLOGY AND OPTOMETRY
The Lost Art of Chemical Peeling My Fifteen Year Experience with Croton Oil Peel Lawrence G. Kass, MDa, Kathryn S. Kass, MDb,* a
Private Practice, Kass Center for Cosmetic Surgery, 6025 4th Street North, St. Petersburg, FL 33703, USA; bLehigh Valley Hospital, Allentown, PA 18103, USA
Keywords
Laser skin resurfacing Chemical peels Dermabrasion Croton oil Phenol
Key points
Croton oil peels can peel as deeply as any other means of facial resurfacing and can be used to achieve remarkable results.
Unlike ‘‘phenol’’ peels, which were originally thought to be ‘‘all or nothing,’’ the croton oil concentration can be varied, allowing different facial areas to be peeled to different depths.
Croton oil peels result in less down time, less redness, and fewer complications than other techniques for a similar depth achieved.
Indications for croton oil peels include facial rhytids, uneven pigmentation, adjunct treatment in transconjunctival lower blepharoplasties and festoons, acne scars, and nonmelanoma skin cancer prophylaxis.
Unlike lasers, croton oil peels can be performed with little cost to the provider.
INTRODUCTION Chemical peels have been around for a very long time. Ancient Egyptian women developed the technique of applying sour milk to their faces, the first use of lactic acid (an alpha-hydroxy acid) peels for skin rejuvenation [1]. The ancient Romans applied grape juice to their faces, developing the use of tartaric acid as a chemical peel procedure. This practice continued for hundreds of years, leading to the development of other fruit acid chemical peels. Disclosure Statement: The authors have nothing to disclose.
*Corresponding author. 6025 4th Street North, St. Petersburg, FL 33703. E-mail address: [email protected] http://dx.doi.org/10.1016/j.yaoo.2017.03.015 2452-1760/17/ª 2017 Elsevier Inc. All rights reserved.
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Phenol peels were used as early as 1903 for acne scarring and as acceptable treatment for gunpowder burns of the face during World War I. The techniques of that war were brought to the United States, and lay peeling centers were established shortly after in South Florida and in Los Angeles, California [1]. The benefits of this treatment were brought to medical doctors by Brown and colleagues and Litton around 1960 [2,3], followed shortly after by the publication of the easily mixed Baker-Gordon formula [4]. Over the last 2 decades, the techniques available in modern medicine for facial peeling have grown exponentially while the patient’s desires for beautiful and youthful-appearing skin remain unchanged. Dermatologists have led the charge in most of these advances, while ophthalmologists, facial plastic surgeons, and plastic surgeons sit mainly on the sidelines, having little exposure during their training to the decision-making processes involved in selecting appropriate techniques of facial skin rejuvenation for any given patient. Some lucky residents and fellows may be exposed to the use of a particular laser by a particular surgeon at a particular surgery center, but facial rejuvenation considerations based on skin type, skin color, age, desired results, and the current condition of the skin and its location on the face are rarely discussed and even more rarely taught. The purpose of this article is to address some of these omissions within the ophthalmic community. In the early 1990s, I was introduced to trichloroacetic acid (TCA) peels, then to carbon dioxide and erbium YAG laser resurfacing, and then to the ‘‘phenol’’ peel. For various reasons, I soon grew dissatisfied with each of these resurfacing techniques and quickly adapted the croton oil peel as my main means of performing facial resurfacing shortly after the publication of Gregory Hetter’s work in 2000 [5–8]. The easily mixed ‘‘phenol’’ peel formula published around 1960 had 4 components: phenol, septisol, croton oil, and water, but it was the phenol that was thought to be the active ingredient. Hetter adjusted the proportions of these ingredients and concluded that the croton oil, and not the phenol, was the actual peeling agent. Croton oil peels, as these peels came to be known, use the same 4 ingredients, including phenol but in different proportions from the classic Baker-Gordon peeling formula. Hetter published his 5 easily mixed ‘‘Heresy Formulas’’ in 2000, and I began using 4 of these 5 formulas in my private practice shortly after their publication (Fig. 1) [8]. For 15 years, I have performed croton oil peels for a growing list of indications, and the purpose of this article is to disseminate the usefulness of this technique and the pearls that I have learned through experience to as wide an audience within the ophthalmic community as possible (Fig. 2). EVALUATION Any ophthalmologist or other physician who is interested in encouraging patients to improve their skin aesthetically should have some knowledge of both skin anatomy and skin classification. The skin has 3 layers, the epidermis, the dermis (separated into the more superficial papillary and the deeper
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Fig. 1. Hetter’s Heresy Formulas: Although Hetter disliked the inexactitude of drops and later advocated using a ‘‘stock’’ solution to avoid the need to use drops, I still mix my solutions using the formulas in this table.
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Fig. 2. A 46-year-old woman who had bilateral upper and lower (transconjunctival) lower blepharoplasties with full face croton oil peel. Note the improvement in skin texture and skin tightening of the lower eyelid.
reticular dermis), and the subcutaneous tissue (hypodermis), composed of connective tissue and fat. All resurfacing techniques can be classified by how deeply they extend into the skin’s layers. The most superficial techniques may extend only into the epidermis and therefore results in no dermal injury. Examples of such are microdermabrasion, peels using Jessner’s solution (lactic acid, salicylic acid, resorcinol in ethanol) (2 layers), or alpha-hydroxy acids, such as glycolic and lactic acids, and TCA peels of 10% to 20%. Medium depth resurfacing techniques reach the papillary dermis or upper reticular dermis, resulting in not just epidermal necrosis but also clinical vesiculation and are seen in TCA peels (35%–50%), Jessner’s (4 layers or in combination with TCA 35%), unoccluded phenol peels, and with the application of dry ice followed by 35% TCA [1], and with ablative (CO2) laser (2 passes). Deep resurfacing is seen with peels reaching the midreticular dermis, and examples of such occur with the addition of croton oil to phenol, skin occlusion after phenol peeling (occluding the skin with tape deepens the effects of any peel), and with continuous ablative CO2 (3 passes) [1] Any resurfacing technique that extends to the deep reticular dermis or to the subcutaneous tissue may result in scarring and should be avoided. Before resurfacing the skin, it is necessary to analyze the skin of the patient who presents to you. All skin analysis begins with an evaluation of the Fitzpatrick skin type [9]. Developed originally by a dermatologist on the basis of skin and eye color, it was altered for improved accuracy of classification, to estimate the response of different types of skin types to the sun (UV) exposure. The following list shows the 6 categories of the Fitzpatrick scale [9]:
Type I: Always burns, never tans (pale white; blond or red hair; blue eyes; freckles) Type II: Usually burns, tans minimally (white; fair; blond or red hair; blue, green, or hazel eyes) Type III: Sometimes mild burn, tans uniformly (cream white; fair with any hair or eye color)
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Type IV: Burns minimally, always tans well (moderate brown) Type V: Very rarely burns, tans very easily (dark brown) Type VI: Never burns, never tans (deeply pigmented dark brown to darkest brown)
Skin analysis also includes notation of racial background [10] as well as an analysis of extent and severity of wrinkling as measured by the Glogau classification of photoaging [11] and the Rubin classification, which assesses pigmentation, keratoses, and texture in addition to just wrinkling [12]. Skin rejuvenation for any patient begins by the physician educating the patient to avoid further skin damage and deterioration by decreasing the development of harmful free radicals [13]. The further development of free radicals can be lessened by limiting further exposure to both UV light from the sun and the harmful effects of cigarette smoking [14]. Without patient modification of these behaviors, any attempt at skin rejuvenation is doomed to fail and should not be attempted. The next step in the process is to begin a daily skin care regimen that includes tretinoin and sunscreen and may include hydroquinone (4%–8% depending on Fitzpatrick skin type) [1], buffing grain cleansers, alpha-hydroxy acid toners, and vitamin A conditioning lotions, all customized to each patient to induce slight peeling without distinctive discomfort [14]. The daily regimen detailed above is extremely important because it not only improves the appearance of the skin but also conditions the skin, reduces pigmentation, and stops the deleterious effects of free radical formation. The regimen accelerates skin turnover (a positive effect), reducing this number usually from 28 days to 10 to 12 days. After doing the daily skin care program for several weeks, the skin’s response improves to any type of more in-depth skin resurfacing technique that follows. Interestingly, the recommendation for ‘‘conditioning’’ the skin before resurfacing as described above is not universally accepted [15,16]. Resurfacing techniques All resurfacing techniques can be classified as superficial, intermediate, or deep. Superficial Superficial resurfacing techniques result in skin rejuvenation by primarily working at the level of the epidermis or the upper papillary dermis. The techniques include, alone or in combination, glycolic acid (20%–30%) peels, microdermabrasion, TCA (10%–20%), and intense pulsed light devices (photofacials). The degree of exfoliation of the epidermis depends on the patient’s skin type, and the frequency and combination of treatments given. Intermediate For patients with problems that extend deeper into the papillary dermis, somewhat more aggressive techniques can be used to achieve intermediate depth facial resurfacing. These techniques include applying multiple (4) coats of Jessner’s peel [17], or TCA 35% to 50% [18]. TCA in higher
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concentrations (35% or greater) can penetrate more deeply but results in greater risks of scarring because of irregular penetration. The combination of Jessner’s and TCA has been popularized by Monheit [19], and this has been considered to be safer and more effective than either treatment alone. Similarly, the combination of CO2 plus 35% TCA has been popularized by Brody to achieve excellent medium depth chemical peels [1]. I have heard it said that 3 or 4 monthly applications of an intermediate technique will yield the same results as that which is achieved with a deep technique with lower risk of complications. The suggestion that repeated intermediate procedures can yield the same results as a deep procedure has not been consistent with my own experience. Deep Deep techniques are best reserved for patients with problems that extend into the reticular dermis. The treating physician enters the reticular dermis with great wariness and caution, because it is possible for the treatment to leave the patient looking worse than before. Besides the usual resurfacing risks of viral, fungal, bacterial infections, undercorrection and hyperpigmentation, additional risks of deep techniques include permanent scars and hypopigmentation if the wrong patient is selected or the treatment goes too deeply. Evolution of peeling procedures to the croton oil peel The original technique developed to treat deeper skin changes was dermabrasion, mechanical sanding, or planing of the skin. Not to be confused with microdermabrasion, a superficial resurfacing technique, dermabrasion has been supplanted by lasers and deep chemical peels, because it is highly dependent on the skills and experience of the surgeon and because of the significant bleeding and aerosolization of viral particles, such as human immunodeficiency virus and hepatitis C, which have been shown to occur with the spray from the procedure [20]. Laser skin resurfacing began in the 1990s with the development of the ablative CO2 laser [21,22]. Using a laser to perform resurfacing sounded cutting edge, and many practitioners used ablative laser resurfacing for marketing purposes. I remember one doctor in my area advertised this technique as a means of performing a state-of-the-art, nonsurgical facelift. This technique was supposed to avoid scarring and the generation of excessive heat, allowed vaporization of 50, 100, or even 150 l per pass, and was supposed to be free of serious complications. However, soon complications of permanent scarring and hypopigmentation were reported. I put my CO2 ablative laser resurfacing behind me after having a few of these types of complications as well as after the development of an unfortunate, and recalcitrant to treatment, case of cicatricial ectropion after using the laser to tighten the skin at the time of transconjunctival lower blepharoplasty. CO2 ablative resurfacing gave way to erbium-YAG ablative resurfacing, combinations of the 2, and now fractional CO2 laser resurfacing. Admittedly without any formal data to back my conclusion, I consider fractional CO2 lasers to be a fancy way of performing a light- to intermediatedepth chemical peel (ie, TCA 15%–35%).
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A formula for deep facial resurfacing (Baker-Gordon formula) was published in the early 1960s and was popularized as a ‘‘phenol’’ peel [23]. The manner in which this formula was ‘‘taken’’ from the lay peelers of Miami and Hollywood was well described by Hetter [6] and is a fascinating read for any who are interested in the history of these peels, the surprising perfidy of physicians, and the occasionally peculiar manner that modern medicine advances. Because the ‘‘phenol’’ peel was a very deep resurfacing technique, it was certainly subject to the risks of any deep technique, including risks of permanent dermal scars and permanent hypopigmentation. In addition, the high phenol concentration was known to lead potentially to renal and cardiac complications. The percentage of croton oil in the Baker-Gordon formula was later calculated to be 2.1% [4]. The formula was said to be ‘‘all or none,’’ for instance, it could not be modified to adjust to the severity of the patient’s problem and/or to adjust for the patient’s skin type. In the late 1990s, 2 physicians independently altered the 30-year-old standard Baker-Gordon formula [23], and although they ultimately settled on somewhat similar formulations, they reached 2 startlingly different conclusions. Gregory Hetter [5–8] performed a series of experiments using different formulations and reached the surprising conclusion that it was the croton oil, not the phenol, within the Baker-Gordon formula that was the true peeling agent. Although he briefly stated that peel depth was somewhat dependent on application technique, he concluded that the croton oil concentration was the leading factor resulting in varying peel depth. Hence, the ‘‘phenol’’ peel was not ‘‘allor-none,’’ and by decreasing the concentration of croton oil, the formulas could be used to treat more delicate areas that could not be treated with the higher Baker-Gordon (2.1%) croton oil concentration. Hetter, basing his work on that of Obagi and colleagues [24], divided the face into 5 facial zones, which could be peeled to different depths by using different strength croton oil solutions. Hetter applied his solutions in a similar manner as Obagi applied his own—using cotton pads dipped in the solutions and wrung out, folded over thumb and applied to the face and neck in multiple coats. Hetter, like Obagi, based his endpoint on the development of frost density and on ‘‘experience.’’ One shortfall of Hetter’s original work is that he based his conclusions on peel depth on how long it took for reepithelialization to occur and not on actual histologic studies. To this day, I am not certain that this assumption is unassailable. Like Hetter, the work of Phillip A. Stone [25,26] led greatly to the improved peeling techniques used today. Stone also modified the Baker-Gordon formula, decreasing both the phenol and the croton oil concentrations to markedly improve patient safety and reduce complications. To an extent greater than Hetter, Stone [26] emphasized the need to ‘‘prepare’’ the skin beforehand for improved results. Stone also developed his own proprietary formulations, which he popularized, and he concluded that while croton oil concentration played a role in peel depth, it was the application technique (particularly the number of times each area is ‘‘rubbed’’) that was of primary importance in this regard. Because of this conclusion, he did not refer to his technique as
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croton oil peeling, describing his procedure as ‘‘modified phenol’’ peelings. He used the more standard Q-tip (cotton buds) technique and concluded that increased number of rubbings, the pressure and abrasiveness of the application, the amount of volume of acid used, and the amount of time the acid is in contact with the skin, were all important factors in determining peel depth. Other factors influencing peel depth include degreasing the skin to be peeled immediately before the procedure and the use of occlusive dressings. Although Stone, like Hetter, found that the addition of croton oil to phenol increased peel depth compared with the use of phenol alone; unlike Hetter, he concluded, based on his own actual histologic studies, that there was no significant increase in peel depth as the croton oil concentration was increased from 0.4% to 2.2%, assuming application techniques were kept constant. Although Stone also based his endpoint on frost density, he deemed this not completely reliable and added a time component to the application process. My technique My indications for croton oil resurfacing continue to grow. At present, my indications include facial rhytids, uneven pigmentation, adjunct treatment in transconjunctival lower blepharoplasties and festoons, skin lightening, acne scars, and nonmelanoma skin cancer prophylaxis [27]. For 15 years, I have used 4 of the 5 original Hetter Heresy Formulas, those with croton oil concentrations ranging from 0.105% to 1.1%. I do not use the original Baker-Gordon formula calculated by Hetter as 2.1%. Consequently, the very strongest solution that I will ever use is only half as strong as the original Baker-Gordon formula by croton oil concentration. Although decried by Hetter in his final article (he did not approve of the inexactitude of his previously stated ‘‘drops’’), I, and several other physicians, continue to use an eye dropper to add the Septisol and croton oil to the phenol and bacteriostatic water as he originally described in his Heresy Formulas (see Fig. 1) [8]. Until recently, all of the materials were obtained from Delasco Laboratories (Council Bluffs, IA, USA) at no financial gain to this author. Recently, again at no personal financial gain, it became necessary to purchase Septisol from another vendor because it was no longer carried by Delasco. I do not use general anesthesia or intravenous sedation but do use oral (PO) sedation, and I have found that this works very well. Use of the restroom is encouraged before the procedure. PO fluids are pushed during the procedure, which generally takes about 60 to 90 minutes to perform (full face). The nonsterile procedure is done after the previously prepared and conditioned facial skin is degreased by my assistant with both acetone and alcohol. Although not universally accepted as discussed earlier [15,16], Stone and others believe that adequate skin conditioning/preparation reduces the incidence of prolonged erythema and other complications after the procedure and makes for a more even peel [1,14,26,28]. During breaks in the procedure, the doctor can choose to do other procedures on the same patient or can go to see other patients (while the staff encourages additional PO fluids).
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Although a student of Hetter, I condition and degrease the skin beforehand like Stone, and I apply the solutions using Q-tips (cotton buds) as used by Stone. I absolutely agree with Stone, who emphasizes that application technique (including number of rubs, pressure of rubbing, volume of formula fluid used) is vitally important in determining peel depth. I have seen remarkable results from physicians using just one strength croton oil solution but who achieve different depths in different facial zones by varying their application technique alone (Stone technique). Unlike Stone, I do not time the application of formula or use occlusion after treatment. Perhaps there is no better area for the blepharoplasty surgeon to gain experience and confidence with these peels than in the eyelid area. For delicate areas like the eyelids (labeled 4 in Fig. 5), I use less rubbing and either 0.105% with multiple rubs or 0.35% with fewer rubs. Although the eyelid skin is quite thin and I routinely use Hetter’s lowest croton oil concentration (0.105%), this area is relatively forgiving and multiple rubs (2–5 times, for example), after the incisional part of the procedure is complete and while the area remains anesthetized, should yield excellent results in improving skin texture. Initially, I recommend beginning to perform this procedure on patients with Fitzpatrick skin types I or II for best results. I peel close to the ciliary margin of the lower eyelids and only inferiorly to the level of the superior tarsal border in the upper lids. The patient is best treated with the head of the bed slightly elevated to avoid the possibility of peeling solution flowing toward the conjunctiva. After wiping away the betadine and any dried blood from the skin, which may have resulted from the incisional part of the procedure, dip a nonsterile cotton applicator in the 0.105% croton oil solution you prepared, wring it out slightly by tapping it against the side of the container to avoid inadvertent dripping, and begin by rubbing the applicator across the skin at the level of the inferior orbital rim. The nondominant hand can be used to stretch the skin, and as the cotton bud dries, you can work safely closer to the ciliary margin. You can safely go over each area a few times and then ‘‘blend’’ the resurfaced area to the surrounding skin by lightly going over fresh skin at the borders of the initial treatment a single time. I do believe that the patient’s facial skin should be preconditioned (tretinoin, hydroquinone, and sun avoidance) because this will likely reduce the possibility of demarcation lines between peeled and unpeeled areas and will allow for a more even peel. I do not believe there is much need for narcotic pain medications, antibiotics, and antivirals in this situation unless part of the surgeon’s usual routine (Figs. 3 and 4). In the unlikely event that demarcation lines occur between peeled and unpeeled areas that are bothersome to the patient, the rest of the face can be easily peeled with the same solution or with a light TCA solution (15%–20%) to rectify the problem. Shortly after gaining confidence with peels of the eyelid area, it is time to move on to performing full face procedures. For full facial resurfacing, it is important to visualize the face as being composed of different facial zones as originally described by Obagi [24]. Different zones can be peeled to different
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Fig. 3. A 39-year-old woman 2 weeks after bilateral upper and lower (transconjunctival) blepharoplasties with segmental croton oil peeling to the lower eyelids and upper cheeks. Note the improvement in the skin of the lower eyelids and in her bilateral festoons.
depths based both on the croton oil concentration (Hetter) and on the application technique (ie, number of rubs) (Stone). The perioral area and the lower half of the nose (labeled 1 in Fig. 5) have the thickest skin and can be treated most aggressively, such as with additional solutions and additional rubs, with the least risk of complications. The cheeks (labeled 2) can be treated next most aggressively, followed by the forehead
Fig. 4. Alternatively, the peels can be used to assist with incisional procedures. On this 49-yearold patient, a bilateral upper and lower (transconjunctival combined with a ‘‘pinch’’ skin excision) blepharoplasty was performed. (A) Before surgery. (B) One month after surgery. The patient expressed dissatisfaction with the persistent wrinkles of skin on his lower eyelids (C) Final results. After waiting three more months for additional healing, I performed a croton oil peel segmentally to the lower eyelids. The patient was happy when he healed from this touch-up procedure.
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Fig. 5. Labeling of different facial zones. The perioral area and lower half of the nose are labeled with the number 1 and can be treated most aggressively, followed by the cheeks (2) and the forehead (3). The delicate skin of the eyelids and the slow-to-heal neck should be treated least aggressively and are labeled 4.
(labeled 3), and the eyelids (labeled 4). If not peeling the neck, I blend the face into the cervicomandibular angle. If peeling focally or segmentally, I blend peeled areas into the surrounding skin using lower croton oil concentrations or less rubbing to avoid demarcation lines (which are rarely seen). One author suggests starting full face peeling by using a maximum croton oil concentration of 0.4% [28]. I would combine the 0.35% with the 0.105% (used safely in the eyelids and in the neck). It is possible to achieve remarkable results using just these concentrations alone. I would recommend that the neophyte peeler counsel his or her patients that not infrequently the procedure may need to be repeated to achieve the optimal result. With additional experience, one can begin using the 0.7% croton oil solution in the perioral area, and later, with a light application to the cheeks (a commonly involved site of troublesome acne scars). Finally, when thoroughly comfortable with this technique, 1.1% croton oil solution can be used safely in the perioral area in the patients with the greatest need of treatment of the deep lines above the upper lip and on the chin (Fig. 6). As with the laser procedure, it can be difficult to determine the endpoint of the peel, but there are visual clues. I have never found it practical to quantify the number of rubs (times that I go over each facial zone with the cotton bud) that I use but do use additional rubs and acid volume to extend more deeply. One investigator writes that a solid, thick gray-white, organized frost means the peel depth is to the upper to mid reticular dermis (Fig. 7) [28]. He asserts that this is as deep as the peel should go. However, some assert that using the appearance of frost as a measure of depth is not as valuable as the actual selection of the proper wounding technique or agent [1]. Personally, I do like seeing the described thick frost in the areas where I wish to achieve the greatest correction. In areas with little need where I am peeling lightly (ie, eyelids), I do not
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Fig. 6. A 69-year-old woman with deep perioral rhytids (sometimes called ‘‘smoker’s lines’’ but seen in nonsmokers too). The patient shows resolution of these lines after a 1.1% croton oil peel. Note the improvement in lip appearance as a result of the peel (no lip augmentation was performed).
always use a sufficiently strong solution or repeat the rubs enough times to achieve such a frost. In contradistinction, sometimes I will go over areas again even after achieving such frost in the areas of greatest need. In general, because I know that I will go over each area many times, I try to use the lowest concentration of croton oil that will give me the results I desire. Preoperative and postoperative management Before treatment, multiple digital photos are taken, usually attempting different lighting situations to best show the areas that are of greatest concern to the patient. I place each patient on the skin conditioning program previously described. Immediately after the procedure, the assistant applies both a topical analgesic and a topical antibiotic to the peeled areas. The patient is sent home after a posttreatment electrocardiogram is performed (for full face office procedures only). After treatment, I ask the patient to use petroleum jelly before bed and to soak their faces with a mixture of white vinegar and tap water frequently
Fig. 7. By use of a single cotton tip applicator, a white frost is achieved on this 42-year-old woman. This type of visual clue aids in assessing peel depth and in determining the desired endpoint of the procedure.
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during the day. Most patients do not have significant pain, but I do write prescriptions for pain medications, a broad spectrum antibiotic, and an anxiolytic. I give each patient a 10-day prescription for an antiviral agent, starting 2 to 3 days before the procedure. No occlusive dressings are placed, and although phone follow-up is performed by my staff, I do not usually see the patient for about a week. I have found that reepithelialization almost always occurs by the 10th day, at which time I allow my patients to wear concealer to hide their erythema. However, the truth is that very few of my patients do this because most believe that the erythema is not marked. Although practicing in Florida, my patients rarely develop postinflammatory hyperpigmentation, a complication which I believe occurs much more commonly with laser procedures. Postoperative issues and complications I have been very gratified with the results of this procedure and adamantly believe that there are far fewer risks of complications with this than with laser procedures performed to a similar depth. I have had no cases of arrhythmias during or after these procedures. Because I use reduced phenol concentrations and because the procedure is done slowly and with fluid intake, I have had no cases of renal or cardiac complications. This experience confirms that of others [29]. I have not seen posttreatment herpes presumably because all of my full face patients are placed on a 10-day course of antiviral prophylaxis beginning 2 days before the procedure. I have seen 1 to 2 cases of prolonged erythema (which resolved over time), one case of either a yeast infection or hypersensitivity reaction, which I attributed to this patient using a thick application of petroleum jelly around the clock (I advise my patients to use only before bed), and perhaps 1 to 2 cases of postinflammatory hyperpigmentation. Patients are returned to their skin conditioning routine once reepithelialization occurs. Early on, I had 1 to 2 cases of facial scars in cases where I was using solutions 10 to 12 months old. I now believe that the solutions strengthen over time, and I have not seen this complication since I began discarding the solutions after 3 to 4 months. After preparing the solutions that I can use on multiple patients, I store the solutions in glass bottles within a darkened cabinet. I have had largely wonderful results treating patients with acne scars and treating Fitzpatrick skin types III, IV, and even V, but there are a few specific patients that have been more difficult to treat successfully. For example, although I have had great results peeling patients with acne scars in conjunction with subcision, punch excisions, CROSS (Chemical Reconstruction Of Skin Scars) and fillers, I have been disappointed when treating patients specifically with diffuse ice pick scars. Recently, although I believed that I was treating her conservatively, I was dismayed (and humbled) by how long it took for normal pigmentation to return on a Fitzpatrick VI patient with the worst acne scars I have ever seen. Finally, I will offer that I perform croton oil peels by themselves or I may combine them with other facial procedures, including blepharoplasties, festoon
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Fig. 8. This 69-year-old woman had a facelift with a full face croton oil peel. I frequently perform these procedures together even though some compromise of the resurfacing depth is necessary to avoid compromising the vascular supply to the skin raised in the facelift flap.
treatments, brow lifts, and facelifts (Fig. 8). Only with the raising of the skin flap used during face-lifting are some compromises required, because only mild/superficial resurfacing should be done to the area of skin raised in the elevated flap in order to avoid further disruption of the vascular supply to the flap. Of course, facial skin areas not to be undermined during the lift can be treated as aggressively as required to achieve the desired results. I have found that when the peels are done along with other procedures (ie, blepharoplasty, brow lift, face lift), the patient has multiple other areas of concern and does not fixate just on the effects of the peel. Combining incisional procedures with a croton oil peel seems to allow for a smoother recovery than sometimes seen when a deep peel is performed alone. SUMMARY There is no question that both Hetter and Stone have contributed greatly to current skin resurfacing techniques. Students of either one of their techniques can and usually do achieve great results. Although they reached different conclusions, I do not think that their work is contradictory or mutually exclusive. Despite the work of Hetter and Stone and the fabulous results they achieved, outside the dermatology community, these remarkable advances in chemical peel techniques have largely fallen on deaf ears. Far too many physicians, surgeons in particular, are addicted to the use of lasers to achieve facial resurfacing. The need to use lasers to perform facial rejuvenation seems to be particularly true in the ophthalmic community. In my opinion, the reliance on lasers by surgeons is largely due to the appeal of light-based energy treatments and certainly what the laser companies prefer. I do not know how many surgeons have come up to me after hearing my presentations on this technique expressing how tired they have become ‘‘working for the laser companies’’ and not for themselves. The excellent results achieved with croton oil peels at little materials cost to the provider liberate doctors who are interested in facial resurfacing to work for themselves. Perhaps Hetter said it best when he stated, ‘‘So many physicians are witlessly hooked on burning up faces with
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lasers. People are prisoners of their own devices’’ (G.P. Hetter, personal communication, 2016). Before the publication of Hetter’s work, I used lasers to perform my resurfacing. I found it very difficult to judge the endpoints of the resurfacing. I do not think that I was alone in trying to determine the depth of vaporization with the laser procedures. Usually, the endpoint was simply described as requiring 2 or more passes, but I found it difficult to understand what the laser was actually accomplishing with regard to depth of wounding on subsequent passes in the face of the coagulative necrosis achieved with the initial pass and whether this was consistent in different facial zones. To simplistically recommend 2 or 3 passes with the laser failed, in my own imagination, to account for different skin thicknesses found in different facial zones as well as areas with the greatest need of resurfacing. Multiple passes undoubtedly caused greater thermal injury leading to greater risks of complications and longer recovery. Because of the documented coagulative necrosis of skin caused by the initial pass, additional passes were less beneficial and proved to be more risky. I am uncertain whether many doctors who perform laser resurfacing truly consider these factors during the procedure. I have used the Hetter Heresy Formulas for 15 years. In general, both my patients and I have been enthralled by the results that I have achieved. Using the different croton oil concentrations and applying them personally make me think about what I am doing. Also, I consider how many times I should go over each area to achieve the best depth to correct the patient’s problems. I perform each peel personally, and slowly, to avoid complications and to consider the various factors at play. In my mind, using different croton oil concentrations, different fluid volumes, and different number of rubs, all while carefully considering the patient and the preoperative photographs, makes what I am doing individualized for the patient. I am drawn to the procedure, because I believe that the mechanism of trying to achieve the ideal result relies as much on the art of the procedure as it does on the science. I believe my results compare favorably and/or are actually superior to those that could be achieved with any laser procedure with little cost of materials to the provider. In 15 years and hundreds of cases, I have had no cases of renal or cardiac complications from phenol. I am certain that this is the result of the reduced phenol concentrations in the formulas that I use compared with that of the original Baker-Gordon formula, and in the slow manner the procedure is performed. Despite often achieving truly remarkable results, I have found the vast majority of my patients have significantly reduced downtimes compared with laser procedures and do not develop significant after-peel erythema or other significant complications. I believe that as far as deep resurfacing techniques go, for a similar depth achieved, that there will be far less erythema, less downtime, and less risk of complications with current croton oil peels than with any laser procedure. In my opinion, it is high time that ophthalmologists, facial plastic surgeons, and plastic surgeons adopt this resurfacing technique (long known by the dermatologic
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community) and stop relying on outdated, costly, and more harmful laser procedures. References [1] Brody HJ. Chemical peeling and resurfacing. 2nd edition. St Louis (MO): Mosby-Year Book; 1997. [2] Brown AM, Kaplan LM, Brown ME. Phenol induced histological skin changes: hazards, techniques, and uses. Br J Plast Surg 1960;13:158–69. [3] Litton C. Chemical face lifting. Plast Reconstr Surg 1962;29:371. [4] Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuvenation. Plast Reconstr Surg 1962;29:199. [5] Hetter GP. An examination of the phenol-croton oil peel: part I. Dissecting the formula. Plast Reconstr Surg 2000;105:227–39. [6] Hetter GP. An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg 2000;105:240–8. [7] Hetter GP. An examination of the phenol-croton oil peel: part III. The plastic surgeon’s role. Plast Reconstr Surg 2000;105:752–63. [8] Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg 2000;105: 1061–83. [9] Fitzpatrick TB. The validity and practicality of sun reactive skin types I through VI. Arch Dermatol 1988;124:869–75. [10] Fanous N. TCA peel for Asians: a new classification and a modified approach. Facial Plast Surg Clin 1996;4:1195–200. [11] Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 1994;2(1):30–5. [12] Rubin MG. Photoaged and photodamaged skin. In: Rubin MG, editor. Manual of chemical peels. Philadelphia: Lippincott; 1995. p. 5–10. [13] Black HS. Potential involvement of free radical reactions in ultraviolet light-mediated cutaneous damage. Photochem Photobiol 1987;46:213–9. [14] Fulton JE, Porumb S. Chemical Peels: their place within the range of resurfacing techniques. Am J Clin Dermatol 2004;5(3):179–87. [15] Stegman SJ, Tromovitch TA. Cosmetic dermatologic surgery. Arch Dermatol 1982;118: 1013–6. [16] Kotler R. Letter to the editor. Croton oil peels. Aesthet Surg J 2008;28:470. [17] Elle JJ, Wolff S. Skin peeling and scarification. JAMA 1991;116:934–41. [18] Resnik SS, Lewis LA. Trichloroacetic acid peeling in dermatology. South Med J 1973;66: 225–7. [19] Monheit GD. The Jessner’s þ TCA peel: a medium depth chemical peel. J Dermatol Surg Oncol 1989;15:945–50. [20] Cortez EA, Fedok FG, Mangat DS. Chemical peels: panel discussion. Facial Plast Surg Clin North Am 2014;22:1–23. [21] Fulton JE Jr. Skin resurfacing and laser ablation with the Ultrapulse CO2 laser. Am J Cosm Surg 1996;13:323–37. [22] Fitzpatrick RE. Facial resurfacing with the pulsed CO2 laser. Facial Plast Surg Clin 1996;4: 231–40. [23] Baker TJ, Gordon HL. The ablation of rhytides by chemical means: a preliminary report. J Fla Med Assoc 1961;48:541. [24] Obagi ZE, Sawaf MM, Johnson JB, et al. The controlled-depth trichloroacetic acid peel: methodology, outcome and complication rate. Int J Aesthet Restorat Surg 1996;4:81–9. [25] Stone PA. The use of modified phenol for chemical face peeling. Clin Plast Surg 1998;25: 21–44. [26] Stone PA, Lefer LG. Modified phenol chemical based peels: recognizing the role of application technique. Facial Plast Surg Clin North Am 2001;9(3):351–76.
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[27] Hantash BM, Stewart DB, Cooper ZA, et al. Facial resurfacing for mom-melanoma skin cancer prophylaxis. Arch Dermatol 2006;142:976–82. [28] Bensimon RH. Croton oil peels. Aesthet Surg J 2008;28:33–45. [29] Baker TJ. Is the phenol-croton oil peel safe? Plast Reconstr Surg 2003;112:353–4.
ADVANCES IN OPHTHALMOLOGY AND OPTOMETRY
The Lost Art of Chemical Peeling My Fifteen Year Experience with Croton Oil Peel Lawrence G. Kass, MDa, Kathryn S. Kass, MDb,* a
Private Practice, Kass Center for Cosmetic Surgery, 6025 4th Street North, St. Petersburg, FL 33703, USA; bLehigh Valley Hospital, Allentown, PA 18103, USA
Keywords
Laser skin resurfacing Chemical peels Dermabrasion Croton oil Phenol
Key points
Croton oil peels can peel as deeply as any other means of facial resurfacing and can be used to achieve remarkable results.
Unlike ‘‘phenol’’ peels, which were originally thought to be ‘‘all or nothing,’’ the croton oil concentration can be varied, allowing different facial areas to be peeled to different depths.
Croton oil peels result in less down time, less redness, and fewer complications than other techniques for a similar depth achieved.
Indications for croton oil peels include facial rhytids, uneven pigmentation, adjunct treatment in transconjunctival lower blepharoplasties and festoons, acne scars, and nonmelanoma skin cancer prophylaxis.
Unlike lasers, croton oil peels can be performed with little cost to the provider.
INTRODUCTION Chemical peels have been around for a very long time. Ancient Egyptian women developed the technique of applying sour milk to their faces, the first use of lactic acid (an alpha-hydroxy acid) peels for skin rejuvenation [1]. The ancient Romans applied grape juice to their faces, developing the use of tartaric acid as a chemical peel procedure. This practice continued for hundreds of years, leading to the development of other fruit acid chemical peels. Disclosure Statement: The authors have nothing to disclose.
*Corresponding author. 6025 4th Street North, St. Petersburg, FL 33703. E-mail address: [email protected] http://dx.doi.org/10.1016/j.yaoo.2017.03.015 2452-1760/17/ª 2017 Elsevier Inc. All rights reserved.
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Phenol peels were used as early as 1903 for acne scarring and as acceptable treatment for gunpowder burns of the face during World War I. The techniques of that war were brought to the United States, and lay peeling centers were established shortly after in South Florida and in Los Angeles, California [1]. The benefits of this treatment were brought to medical doctors by Brown and colleagues and Litton around 1960 [2,3], followed shortly after by the publication of the easily mixed Baker-Gordon formula [4]. Over the last 2 decades, the techniques available in modern medicine for facial peeling have grown exponentially while the patient’s desires for beautiful and youthful-appearing skin remain unchanged. Dermatologists have led the charge in most of these advances, while ophthalmologists, facial plastic surgeons, and plastic surgeons sit mainly on the sidelines, having little exposure during their training to the decision-making processes involved in selecting appropriate techniques of facial skin rejuvenation for any given patient. Some lucky residents and fellows may be exposed to the use of a particular laser by a particular surgeon at a particular surgery center, but facial rejuvenation considerations based on skin type, skin color, age, desired results, and the current condition of the skin and its location on the face are rarely discussed and even more rarely taught. The purpose of this article is to address some of these omissions within the ophthalmic community. In the early 1990s, I was introduced to trichloroacetic acid (TCA) peels, then to carbon dioxide and erbium YAG laser resurfacing, and then to the ‘‘phenol’’ peel. For various reasons, I soon grew dissatisfied with each of these resurfacing techniques and quickly adapted the croton oil peel as my main means of performing facial resurfacing shortly after the publication of Gregory Hetter’s work in 2000 [5–8]. The easily mixed ‘‘phenol’’ peel formula published around 1960 had 4 components: phenol, septisol, croton oil, and water, but it was the phenol that was thought to be the active ingredient. Hetter adjusted the proportions of these ingredients and concluded that the croton oil, and not the phenol, was the actual peeling agent. Croton oil peels, as these peels came to be known, use the same 4 ingredients, including phenol but in different proportions from the classic Baker-Gordon peeling formula. Hetter published his 5 easily mixed ‘‘Heresy Formulas’’ in 2000, and I began using 4 of these 5 formulas in my private practice shortly after their publication (Fig. 1) [8]. For 15 years, I have performed croton oil peels for a growing list of indications, and the purpose of this article is to disseminate the usefulness of this technique and the pearls that I have learned through experience to as wide an audience within the ophthalmic community as possible (Fig. 2). EVALUATION Any ophthalmologist or other physician who is interested in encouraging patients to improve their skin aesthetically should have some knowledge of both skin anatomy and skin classification. The skin has 3 layers, the epidermis, the dermis (separated into the more superficial papillary and the deeper
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Fig. 1. Hetter’s Heresy Formulas: Although Hetter disliked the inexactitude of drops and later advocated using a ‘‘stock’’ solution to avoid the need to use drops, I still mix my solutions using the formulas in this table.
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Fig. 2. A 46-year-old woman who had bilateral upper and lower (transconjunctival) lower blepharoplasties with full face croton oil peel. Note the improvement in skin texture and skin tightening of the lower eyelid.
reticular dermis), and the subcutaneous tissue (hypodermis), composed of connective tissue and fat. All resurfacing techniques can be classified by how deeply they extend into the skin’s layers. The most superficial techniques may extend only into the epidermis and therefore results in no dermal injury. Examples of such are microdermabrasion, peels using Jessner’s solution (lactic acid, salicylic acid, resorcinol in ethanol) (2 layers), or alpha-hydroxy acids, such as glycolic and lactic acids, and TCA peels of 10% to 20%. Medium depth resurfacing techniques reach the papillary dermis or upper reticular dermis, resulting in not just epidermal necrosis but also clinical vesiculation and are seen in TCA peels (35%–50%), Jessner’s (4 layers or in combination with TCA 35%), unoccluded phenol peels, and with the application of dry ice followed by 35% TCA [1], and with ablative (CO2) laser (2 passes). Deep resurfacing is seen with peels reaching the midreticular dermis, and examples of such occur with the addition of croton oil to phenol, skin occlusion after phenol peeling (occluding the skin with tape deepens the effects of any peel), and with continuous ablative CO2 (3 passes) [1] Any resurfacing technique that extends to the deep reticular dermis or to the subcutaneous tissue may result in scarring and should be avoided. Before resurfacing the skin, it is necessary to analyze the skin of the patient who presents to you. All skin analysis begins with an evaluation of the Fitzpatrick skin type [9]. Developed originally by a dermatologist on the basis of skin and eye color, it was altered for improved accuracy of classification, to estimate the response of different types of skin types to the sun (UV) exposure. The following list shows the 6 categories of the Fitzpatrick scale [9]:
Type I: Always burns, never tans (pale white; blond or red hair; blue eyes; freckles) Type II: Usually burns, tans minimally (white; fair; blond or red hair; blue, green, or hazel eyes) Type III: Sometimes mild burn, tans uniformly (cream white; fair with any hair or eye color)
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Type IV: Burns minimally, always tans well (moderate brown) Type V: Very rarely burns, tans very easily (dark brown) Type VI: Never burns, never tans (deeply pigmented dark brown to darkest brown)
Skin analysis also includes notation of racial background [10] as well as an analysis of extent and severity of wrinkling as measured by the Glogau classification of photoaging [11] and the Rubin classification, which assesses pigmentation, keratoses, and texture in addition to just wrinkling [12]. Skin rejuvenation for any patient begins by the physician educating the patient to avoid further skin damage and deterioration by decreasing the development of harmful free radicals [13]. The further development of free radicals can be lessened by limiting further exposure to both UV light from the sun and the harmful effects of cigarette smoking [14]. Without patient modification of these behaviors, any attempt at skin rejuvenation is doomed to fail and should not be attempted. The next step in the process is to begin a daily skin care regimen that includes tretinoin and sunscreen and may include hydroquinone (4%–8% depending on Fitzpatrick skin type) [1], buffing grain cleansers, alpha-hydroxy acid toners, and vitamin A conditioning lotions, all customized to each patient to induce slight peeling without distinctive discomfort [14]. The daily regimen detailed above is extremely important because it not only improves the appearance of the skin but also conditions the skin, reduces pigmentation, and stops the deleterious effects of free radical formation. The regimen accelerates skin turnover (a positive effect), reducing this number usually from 28 days to 10 to 12 days. After doing the daily skin care program for several weeks, the skin’s response improves to any type of more in-depth skin resurfacing technique that follows. Interestingly, the recommendation for ‘‘conditioning’’ the skin before resurfacing as described above is not universally accepted [15,16]. Resurfacing techniques All resurfacing techniques can be classified as superficial, intermediate, or deep. Superficial Superficial resurfacing techniques result in skin rejuvenation by primarily working at the level of the epidermis or the upper papillary dermis. The techniques include, alone or in combination, glycolic acid (20%–30%) peels, microdermabrasion, TCA (10%–20%), and intense pulsed light devices (photofacials). The degree of exfoliation of the epidermis depends on the patient’s skin type, and the frequency and combination of treatments given. Intermediate For patients with problems that extend deeper into the papillary dermis, somewhat more aggressive techniques can be used to achieve intermediate depth facial resurfacing. These techniques include applying multiple (4) coats of Jessner’s peel [17], or TCA 35% to 50% [18]. TCA in higher
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concentrations (35% or greater) can penetrate more deeply but results in greater risks of scarring because of irregular penetration. The combination of Jessner’s and TCA has been popularized by Monheit [19], and this has been considered to be safer and more effective than either treatment alone. Similarly, the combination of CO2 plus 35% TCA has been popularized by Brody to achieve excellent medium depth chemical peels [1]. I have heard it said that 3 or 4 monthly applications of an intermediate technique will yield the same results as that which is achieved with a deep technique with lower risk of complications. The suggestion that repeated intermediate procedures can yield the same results as a deep procedure has not been consistent with my own experience. Deep Deep techniques are best reserved for patients with problems that extend into the reticular dermis. The treating physician enters the reticular dermis with great wariness and caution, because it is possible for the treatment to leave the patient looking worse than before. Besides the usual resurfacing risks of viral, fungal, bacterial infections, undercorrection and hyperpigmentation, additional risks of deep techniques include permanent scars and hypopigmentation if the wrong patient is selected or the treatment goes too deeply. Evolution of peeling procedures to the croton oil peel The original technique developed to treat deeper skin changes was dermabrasion, mechanical sanding, or planing of the skin. Not to be confused with microdermabrasion, a superficial resurfacing technique, dermabrasion has been supplanted by lasers and deep chemical peels, because it is highly dependent on the skills and experience of the surgeon and because of the significant bleeding and aerosolization of viral particles, such as human immunodeficiency virus and hepatitis C, which have been shown to occur with the spray from the procedure [20]. Laser skin resurfacing began in the 1990s with the development of the ablative CO2 laser [21,22]. Using a laser to perform resurfacing sounded cutting edge, and many practitioners used ablative laser resurfacing for marketing purposes. I remember one doctor in my area advertised this technique as a means of performing a state-of-the-art, nonsurgical facelift. This technique was supposed to avoid scarring and the generation of excessive heat, allowed vaporization of 50, 100, or even 150 l per pass, and was supposed to be free of serious complications. However, soon complications of permanent scarring and hypopigmentation were reported. I put my CO2 ablative laser resurfacing behind me after having a few of these types of complications as well as after the development of an unfortunate, and recalcitrant to treatment, case of cicatricial ectropion after using the laser to tighten the skin at the time of transconjunctival lower blepharoplasty. CO2 ablative resurfacing gave way to erbium-YAG ablative resurfacing, combinations of the 2, and now fractional CO2 laser resurfacing. Admittedly without any formal data to back my conclusion, I consider fractional CO2 lasers to be a fancy way of performing a light- to intermediatedepth chemical peel (ie, TCA 15%–35%).
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A formula for deep facial resurfacing (Baker-Gordon formula) was published in the early 1960s and was popularized as a ‘‘phenol’’ peel [23]. The manner in which this formula was ‘‘taken’’ from the lay peelers of Miami and Hollywood was well described by Hetter [6] and is a fascinating read for any who are interested in the history of these peels, the surprising perfidy of physicians, and the occasionally peculiar manner that modern medicine advances. Because the ‘‘phenol’’ peel was a very deep resurfacing technique, it was certainly subject to the risks of any deep technique, including risks of permanent dermal scars and permanent hypopigmentation. In addition, the high phenol concentration was known to lead potentially to renal and cardiac complications. The percentage of croton oil in the Baker-Gordon formula was later calculated to be 2.1% [4]. The formula was said to be ‘‘all or none,’’ for instance, it could not be modified to adjust to the severity of the patient’s problem and/or to adjust for the patient’s skin type. In the late 1990s, 2 physicians independently altered the 30-year-old standard Baker-Gordon formula [23], and although they ultimately settled on somewhat similar formulations, they reached 2 startlingly different conclusions. Gregory Hetter [5–8] performed a series of experiments using different formulations and reached the surprising conclusion that it was the croton oil, not the phenol, within the Baker-Gordon formula that was the true peeling agent. Although he briefly stated that peel depth was somewhat dependent on application technique, he concluded that the croton oil concentration was the leading factor resulting in varying peel depth. Hence, the ‘‘phenol’’ peel was not ‘‘allor-none,’’ and by decreasing the concentration of croton oil, the formulas could be used to treat more delicate areas that could not be treated with the higher Baker-Gordon (2.1%) croton oil concentration. Hetter, basing his work on that of Obagi and colleagues [24], divided the face into 5 facial zones, which could be peeled to different depths by using different strength croton oil solutions. Hetter applied his solutions in a similar manner as Obagi applied his own—using cotton pads dipped in the solutions and wrung out, folded over thumb and applied to the face and neck in multiple coats. Hetter, like Obagi, based his endpoint on the development of frost density and on ‘‘experience.’’ One shortfall of Hetter’s original work is that he based his conclusions on peel depth on how long it took for reepithelialization to occur and not on actual histologic studies. To this day, I am not certain that this assumption is unassailable. Like Hetter, the work of Phillip A. Stone [25,26] led greatly to the improved peeling techniques used today. Stone also modified the Baker-Gordon formula, decreasing both the phenol and the croton oil concentrations to markedly improve patient safety and reduce complications. To an extent greater than Hetter, Stone [26] emphasized the need to ‘‘prepare’’ the skin beforehand for improved results. Stone also developed his own proprietary formulations, which he popularized, and he concluded that while croton oil concentration played a role in peel depth, it was the application technique (particularly the number of times each area is ‘‘rubbed’’) that was of primary importance in this regard. Because of this conclusion, he did not refer to his technique as
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croton oil peeling, describing his procedure as ‘‘modified phenol’’ peelings. He used the more standard Q-tip (cotton buds) technique and concluded that increased number of rubbings, the pressure and abrasiveness of the application, the amount of volume of acid used, and the amount of time the acid is in contact with the skin, were all important factors in determining peel depth. Other factors influencing peel depth include degreasing the skin to be peeled immediately before the procedure and the use of occlusive dressings. Although Stone, like Hetter, found that the addition of croton oil to phenol increased peel depth compared with the use of phenol alone; unlike Hetter, he concluded, based on his own actual histologic studies, that there was no significant increase in peel depth as the croton oil concentration was increased from 0.4% to 2.2%, assuming application techniques were kept constant. Although Stone also based his endpoint on frost density, he deemed this not completely reliable and added a time component to the application process. My technique My indications for croton oil resurfacing continue to grow. At present, my indications include facial rhytids, uneven pigmentation, adjunct treatment in transconjunctival lower blepharoplasties and festoons, skin lightening, acne scars, and nonmelanoma skin cancer prophylaxis [27]. For 15 years, I have used 4 of the 5 original Hetter Heresy Formulas, those with croton oil concentrations ranging from 0.105% to 1.1%. I do not use the original Baker-Gordon formula calculated by Hetter as 2.1%. Consequently, the very strongest solution that I will ever use is only half as strong as the original Baker-Gordon formula by croton oil concentration. Although decried by Hetter in his final article (he did not approve of the inexactitude of his previously stated ‘‘drops’’), I, and several other physicians, continue to use an eye dropper to add the Septisol and croton oil to the phenol and bacteriostatic water as he originally described in his Heresy Formulas (see Fig. 1) [8]. Until recently, all of the materials were obtained from Delasco Laboratories (Council Bluffs, IA, USA) at no financial gain to this author. Recently, again at no personal financial gain, it became necessary to purchase Septisol from another vendor because it was no longer carried by Delasco. I do not use general anesthesia or intravenous sedation but do use oral (PO) sedation, and I have found that this works very well. Use of the restroom is encouraged before the procedure. PO fluids are pushed during the procedure, which generally takes about 60 to 90 minutes to perform (full face). The nonsterile procedure is done after the previously prepared and conditioned facial skin is degreased by my assistant with both acetone and alcohol. Although not universally accepted as discussed earlier [15,16], Stone and others believe that adequate skin conditioning/preparation reduces the incidence of prolonged erythema and other complications after the procedure and makes for a more even peel [1,14,26,28]. During breaks in the procedure, the doctor can choose to do other procedures on the same patient or can go to see other patients (while the staff encourages additional PO fluids).
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Although a student of Hetter, I condition and degrease the skin beforehand like Stone, and I apply the solutions using Q-tips (cotton buds) as used by Stone. I absolutely agree with Stone, who emphasizes that application technique (including number of rubs, pressure of rubbing, volume of formula fluid used) is vitally important in determining peel depth. I have seen remarkable results from physicians using just one strength croton oil solution but who achieve different depths in different facial zones by varying their application technique alone (Stone technique). Unlike Stone, I do not time the application of formula or use occlusion after treatment. Perhaps there is no better area for the blepharoplasty surgeon to gain experience and confidence with these peels than in the eyelid area. For delicate areas like the eyelids (labeled 4 in Fig. 5), I use less rubbing and either 0.105% with multiple rubs or 0.35% with fewer rubs. Although the eyelid skin is quite thin and I routinely use Hetter’s lowest croton oil concentration (0.105%), this area is relatively forgiving and multiple rubs (2–5 times, for example), after the incisional part of the procedure is complete and while the area remains anesthetized, should yield excellent results in improving skin texture. Initially, I recommend beginning to perform this procedure on patients with Fitzpatrick skin types I or II for best results. I peel close to the ciliary margin of the lower eyelids and only inferiorly to the level of the superior tarsal border in the upper lids. The patient is best treated with the head of the bed slightly elevated to avoid the possibility of peeling solution flowing toward the conjunctiva. After wiping away the betadine and any dried blood from the skin, which may have resulted from the incisional part of the procedure, dip a nonsterile cotton applicator in the 0.105% croton oil solution you prepared, wring it out slightly by tapping it against the side of the container to avoid inadvertent dripping, and begin by rubbing the applicator across the skin at the level of the inferior orbital rim. The nondominant hand can be used to stretch the skin, and as the cotton bud dries, you can work safely closer to the ciliary margin. You can safely go over each area a few times and then ‘‘blend’’ the resurfaced area to the surrounding skin by lightly going over fresh skin at the borders of the initial treatment a single time. I do believe that the patient’s facial skin should be preconditioned (tretinoin, hydroquinone, and sun avoidance) because this will likely reduce the possibility of demarcation lines between peeled and unpeeled areas and will allow for a more even peel. I do not believe there is much need for narcotic pain medications, antibiotics, and antivirals in this situation unless part of the surgeon’s usual routine (Figs. 3 and 4). In the unlikely event that demarcation lines occur between peeled and unpeeled areas that are bothersome to the patient, the rest of the face can be easily peeled with the same solution or with a light TCA solution (15%–20%) to rectify the problem. Shortly after gaining confidence with peels of the eyelid area, it is time to move on to performing full face procedures. For full facial resurfacing, it is important to visualize the face as being composed of different facial zones as originally described by Obagi [24]. Different zones can be peeled to different
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Fig. 3. A 39-year-old woman 2 weeks after bilateral upper and lower (transconjunctival) blepharoplasties with segmental croton oil peeling to the lower eyelids and upper cheeks. Note the improvement in the skin of the lower eyelids and in her bilateral festoons.
depths based both on the croton oil concentration (Hetter) and on the application technique (ie, number of rubs) (Stone). The perioral area and the lower half of the nose (labeled 1 in Fig. 5) have the thickest skin and can be treated most aggressively, such as with additional solutions and additional rubs, with the least risk of complications. The cheeks (labeled 2) can be treated next most aggressively, followed by the forehead
Fig. 4. Alternatively, the peels can be used to assist with incisional procedures. On this 49-yearold patient, a bilateral upper and lower (transconjunctival combined with a ‘‘pinch’’ skin excision) blepharoplasty was performed. (A) Before surgery. (B) One month after surgery. The patient expressed dissatisfaction with the persistent wrinkles of skin on his lower eyelids (C) Final results. After waiting three more months for additional healing, I performed a croton oil peel segmentally to the lower eyelids. The patient was happy when he healed from this touch-up procedure.
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Fig. 5. Labeling of different facial zones. The perioral area and lower half of the nose are labeled with the number 1 and can be treated most aggressively, followed by the cheeks (2) and the forehead (3). The delicate skin of the eyelids and the slow-to-heal neck should be treated least aggressively and are labeled 4.
(labeled 3), and the eyelids (labeled 4). If not peeling the neck, I blend the face into the cervicomandibular angle. If peeling focally or segmentally, I blend peeled areas into the surrounding skin using lower croton oil concentrations or less rubbing to avoid demarcation lines (which are rarely seen). One author suggests starting full face peeling by using a maximum croton oil concentration of 0.4% [28]. I would combine the 0.35% with the 0.105% (used safely in the eyelids and in the neck). It is possible to achieve remarkable results using just these concentrations alone. I would recommend that the neophyte peeler counsel his or her patients that not infrequently the procedure may need to be repeated to achieve the optimal result. With additional experience, one can begin using the 0.7% croton oil solution in the perioral area, and later, with a light application to the cheeks (a commonly involved site of troublesome acne scars). Finally, when thoroughly comfortable with this technique, 1.1% croton oil solution can be used safely in the perioral area in the patients with the greatest need of treatment of the deep lines above the upper lip and on the chin (Fig. 6). As with the laser procedure, it can be difficult to determine the endpoint of the peel, but there are visual clues. I have never found it practical to quantify the number of rubs (times that I go over each facial zone with the cotton bud) that I use but do use additional rubs and acid volume to extend more deeply. One investigator writes that a solid, thick gray-white, organized frost means the peel depth is to the upper to mid reticular dermis (Fig. 7) [28]. He asserts that this is as deep as the peel should go. However, some assert that using the appearance of frost as a measure of depth is not as valuable as the actual selection of the proper wounding technique or agent [1]. Personally, I do like seeing the described thick frost in the areas where I wish to achieve the greatest correction. In areas with little need where I am peeling lightly (ie, eyelids), I do not
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Fig. 6. A 69-year-old woman with deep perioral rhytids (sometimes called ‘‘smoker’s lines’’ but seen in nonsmokers too). The patient shows resolution of these lines after a 1.1% croton oil peel. Note the improvement in lip appearance as a result of the peel (no lip augmentation was performed).
always use a sufficiently strong solution or repeat the rubs enough times to achieve such a frost. In contradistinction, sometimes I will go over areas again even after achieving such frost in the areas of greatest need. In general, because I know that I will go over each area many times, I try to use the lowest concentration of croton oil that will give me the results I desire. Preoperative and postoperative management Before treatment, multiple digital photos are taken, usually attempting different lighting situations to best show the areas that are of greatest concern to the patient. I place each patient on the skin conditioning program previously described. Immediately after the procedure, the assistant applies both a topical analgesic and a topical antibiotic to the peeled areas. The patient is sent home after a posttreatment electrocardiogram is performed (for full face office procedures only). After treatment, I ask the patient to use petroleum jelly before bed and to soak their faces with a mixture of white vinegar and tap water frequently
Fig. 7. By use of a single cotton tip applicator, a white frost is achieved on this 42-year-old woman. This type of visual clue aids in assessing peel depth and in determining the desired endpoint of the procedure.
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during the day. Most patients do not have significant pain, but I do write prescriptions for pain medications, a broad spectrum antibiotic, and an anxiolytic. I give each patient a 10-day prescription for an antiviral agent, starting 2 to 3 days before the procedure. No occlusive dressings are placed, and although phone follow-up is performed by my staff, I do not usually see the patient for about a week. I have found that reepithelialization almost always occurs by the 10th day, at which time I allow my patients to wear concealer to hide their erythema. However, the truth is that very few of my patients do this because most believe that the erythema is not marked. Although practicing in Florida, my patients rarely develop postinflammatory hyperpigmentation, a complication which I believe occurs much more commonly with laser procedures. Postoperative issues and complications I have been very gratified with the results of this procedure and adamantly believe that there are far fewer risks of complications with this than with laser procedures performed to a similar depth. I have had no cases of arrhythmias during or after these procedures. Because I use reduced phenol concentrations and because the procedure is done slowly and with fluid intake, I have had no cases of renal or cardiac complications. This experience confirms that of others [29]. I have not seen posttreatment herpes presumably because all of my full face patients are placed on a 10-day course of antiviral prophylaxis beginning 2 days before the procedure. I have seen 1 to 2 cases of prolonged erythema (which resolved over time), one case of either a yeast infection or hypersensitivity reaction, which I attributed to this patient using a thick application of petroleum jelly around the clock (I advise my patients to use only before bed), and perhaps 1 to 2 cases of postinflammatory hyperpigmentation. Patients are returned to their skin conditioning routine once reepithelialization occurs. Early on, I had 1 to 2 cases of facial scars in cases where I was using solutions 10 to 12 months old. I now believe that the solutions strengthen over time, and I have not seen this complication since I began discarding the solutions after 3 to 4 months. After preparing the solutions that I can use on multiple patients, I store the solutions in glass bottles within a darkened cabinet. I have had largely wonderful results treating patients with acne scars and treating Fitzpatrick skin types III, IV, and even V, but there are a few specific patients that have been more difficult to treat successfully. For example, although I have had great results peeling patients with acne scars in conjunction with subcision, punch excisions, CROSS (Chemical Reconstruction Of Skin Scars) and fillers, I have been disappointed when treating patients specifically with diffuse ice pick scars. Recently, although I believed that I was treating her conservatively, I was dismayed (and humbled) by how long it took for normal pigmentation to return on a Fitzpatrick VI patient with the worst acne scars I have ever seen. Finally, I will offer that I perform croton oil peels by themselves or I may combine them with other facial procedures, including blepharoplasties, festoon
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Fig. 8. This 69-year-old woman had a facelift with a full face croton oil peel. I frequently perform these procedures together even though some compromise of the resurfacing depth is necessary to avoid compromising the vascular supply to the skin raised in the facelift flap.
treatments, brow lifts, and facelifts (Fig. 8). Only with the raising of the skin flap used during face-lifting are some compromises required, because only mild/superficial resurfacing should be done to the area of skin raised in the elevated flap in order to avoid further disruption of the vascular supply to the flap. Of course, facial skin areas not to be undermined during the lift can be treated as aggressively as required to achieve the desired results. I have found that when the peels are done along with other procedures (ie, blepharoplasty, brow lift, face lift), the patient has multiple other areas of concern and does not fixate just on the effects of the peel. Combining incisional procedures with a croton oil peel seems to allow for a smoother recovery than sometimes seen when a deep peel is performed alone. SUMMARY There is no question that both Hetter and Stone have contributed greatly to current skin resurfacing techniques. Students of either one of their techniques can and usually do achieve great results. Although they reached different conclusions, I do not think that their work is contradictory or mutually exclusive. Despite the work of Hetter and Stone and the fabulous results they achieved, outside the dermatology community, these remarkable advances in chemical peel techniques have largely fallen on deaf ears. Far too many physicians, surgeons in particular, are addicted to the use of lasers to achieve facial resurfacing. The need to use lasers to perform facial rejuvenation seems to be particularly true in the ophthalmic community. In my opinion, the reliance on lasers by surgeons is largely due to the appeal of light-based energy treatments and certainly what the laser companies prefer. I do not know how many surgeons have come up to me after hearing my presentations on this technique expressing how tired they have become ‘‘working for the laser companies’’ and not for themselves. The excellent results achieved with croton oil peels at little materials cost to the provider liberate doctors who are interested in facial resurfacing to work for themselves. Perhaps Hetter said it best when he stated, ‘‘So many physicians are witlessly hooked on burning up faces with
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lasers. People are prisoners of their own devices’’ (G.P. Hetter, personal communication, 2016). Before the publication of Hetter’s work, I used lasers to perform my resurfacing. I found it very difficult to judge the endpoints of the resurfacing. I do not think that I was alone in trying to determine the depth of vaporization with the laser procedures. Usually, the endpoint was simply described as requiring 2 or more passes, but I found it difficult to understand what the laser was actually accomplishing with regard to depth of wounding on subsequent passes in the face of the coagulative necrosis achieved with the initial pass and whether this was consistent in different facial zones. To simplistically recommend 2 or 3 passes with the laser failed, in my own imagination, to account for different skin thicknesses found in different facial zones as well as areas with the greatest need of resurfacing. Multiple passes undoubtedly caused greater thermal injury leading to greater risks of complications and longer recovery. Because of the documented coagulative necrosis of skin caused by the initial pass, additional passes were less beneficial and proved to be more risky. I am uncertain whether many doctors who perform laser resurfacing truly consider these factors during the procedure. I have used the Hetter Heresy Formulas for 15 years. In general, both my patients and I have been enthralled by the results that I have achieved. Using the different croton oil concentrations and applying them personally make me think about what I am doing. Also, I consider how many times I should go over each area to achieve the best depth to correct the patient’s problems. I perform each peel personally, and slowly, to avoid complications and to consider the various factors at play. In my mind, using different croton oil concentrations, different fluid volumes, and different number of rubs, all while carefully considering the patient and the preoperative photographs, makes what I am doing individualized for the patient. I am drawn to the procedure, because I believe that the mechanism of trying to achieve the ideal result relies as much on the art of the procedure as it does on the science. I believe my results compare favorably and/or are actually superior to those that could be achieved with any laser procedure with little cost of materials to the provider. In 15 years and hundreds of cases, I have had no cases of renal or cardiac complications from phenol. I am certain that this is the result of the reduced phenol concentrations in the formulas that I use compared with that of the original Baker-Gordon formula, and in the slow manner the procedure is performed. Despite often achieving truly remarkable results, I have found the vast majority of my patients have significantly reduced downtimes compared with laser procedures and do not develop significant after-peel erythema or other significant complications. I believe that as far as deep resurfacing techniques go, for a similar depth achieved, that there will be far less erythema, less downtime, and less risk of complications with current croton oil peels than with any laser procedure. In my opinion, it is high time that ophthalmologists, facial plastic surgeons, and plastic surgeons adopt this resurfacing technique (long known by the dermatologic
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community) and stop relying on outdated, costly, and more harmful laser procedures. References [1] Brody HJ. Chemical peeling and resurfacing. 2nd edition. St Louis (MO): Mosby-Year Book; 1997. [2] Brown AM, Kaplan LM, Brown ME. Phenol induced histological skin changes: hazards, techniques, and uses. Br J Plast Surg 1960;13:158–69. [3] Litton C. Chemical face lifting. Plast Reconstr Surg 1962;29:371. [4] Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuvenation. Plast Reconstr Surg 1962;29:199. [5] Hetter GP. An examination of the phenol-croton oil peel: part I. Dissecting the formula. Plast Reconstr Surg 2000;105:227–39. [6] Hetter GP. An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg 2000;105:240–8. [7] Hetter GP. An examination of the phenol-croton oil peel: part III. The plastic surgeon’s role. Plast Reconstr Surg 2000;105:752–63. [8] Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg 2000;105: 1061–83. [9] Fitzpatrick TB. The validity and practicality of sun reactive skin types I through VI. Arch Dermatol 1988;124:869–75. [10] Fanous N. TCA peel for Asians: a new classification and a modified approach. Facial Plast Surg Clin 1996;4:1195–200. [11] Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 1994;2(1):30–5. [12] Rubin MG. Photoaged and photodamaged skin. In: Rubin MG, editor. Manual of chemical peels. Philadelphia: Lippincott; 1995. p. 5–10. [13] Black HS. Potential involvement of free radical reactions in ultraviolet light-mediated cutaneous damage. Photochem Photobiol 1987;46:213–9. [14] Fulton JE, Porumb S. Chemical Peels: their place within the range of resurfacing techniques. Am J Clin Dermatol 2004;5(3):179–87. [15] Stegman SJ, Tromovitch TA. Cosmetic dermatologic surgery. Arch Dermatol 1982;118: 1013–6. [16] Kotler R. Letter to the editor. Croton oil peels. Aesthet Surg J 2008;28:470. [17] Elle JJ, Wolff S. Skin peeling and scarification. JAMA 1991;116:934–41. [18] Resnik SS, Lewis LA. Trichloroacetic acid peeling in dermatology. South Med J 1973;66: 225–7. [19] Monheit GD. The Jessner’s þ TCA peel: a medium depth chemical peel. J Dermatol Surg Oncol 1989;15:945–50. [20] Cortez EA, Fedok FG, Mangat DS. Chemical peels: panel discussion. Facial Plast Surg Clin North Am 2014;22:1–23. [21] Fulton JE Jr. Skin resurfacing and laser ablation with the Ultrapulse CO2 laser. Am J Cosm Surg 1996;13:323–37. [22] Fitzpatrick RE. Facial resurfacing with the pulsed CO2 laser. Facial Plast Surg Clin 1996;4: 231–40. [23] Baker TJ, Gordon HL. The ablation of rhytides by chemical means: a preliminary report. J Fla Med Assoc 1961;48:541. [24] Obagi ZE, Sawaf MM, Johnson JB, et al. The controlled-depth trichloroacetic acid peel: methodology, outcome and complication rate. Int J Aesthet Restorat Surg 1996;4:81–9. [25] Stone PA. The use of modified phenol for chemical face peeling. Clin Plast Surg 1998;25: 21–44. [26] Stone PA, Lefer LG. Modified phenol chemical based peels: recognizing the role of application technique. Facial Plast Surg Clin North Am 2001;9(3):351–76.
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[27] Hantash BM, Stewart DB, Cooper ZA, et al. Facial resurfacing for mom-melanoma skin cancer prophylaxis. Arch Dermatol 2006;142:976–82. [28] Bensimon RH. Croton oil peels. Aesthet Surg J 2008;28:33–45. [29] Baker TJ. Is the phenol-croton oil peel safe? Plast Reconstr Surg 2003;112:353–4.