• Always test first. I will not carry out a phenolic peel without testing beforehand. Patients are informed that testing is not a perfect way to predict outcomes, but it allows me to observe the healing process. I use a very wet Q-tip (cotton bud) to apply Baker’s solution in the left preauricular area (Figs 15.1 and 15.2) and straight phenol on the right. I tell patients I want to produce the worse scenario I can where it is easily concealed. Patients are not charged for these tests or follow-ups to evaluate them. Tests not only give you a chance to observe a patient during the healing process and look for common complications (particularly hyper- or hypopigmentation (Figs 15.3 and 15.4) or prolonged erythema), but they also give you a chance to get to know the patient well enough to determine both their psychological and medical suitability for deeper peels. Prolonged erythema (lasting several months) is often an indication that hypopigmentation will occur. Rarely a patient will develop hyperpigmentation following these tests (Fig. 15.5).

• Take plenty of photographs. Digital photography is useful for monitoring patient progress. In my experience, conventional photography produces superior pictures. We take front and side views using flash photography and employ surgical lights placed close to the face to side-light textural irregularities and deep rhytides (Fig. 15.6). When taking conventional photographs take them early in the consultative process to make sure of their quality.

• Be prepared to discuss the reasons why you use, or will not use, a particular peel or type of peel, the alternatives, and the possible range of complications.

• Do not hesitate to discuss your plans for phenolic peels with the patient’s other medical providers if the patient has medical problems which are pertinent.

Figure 15.1 The preauricular area is an excellent place to test deep peels. Note the type of blanching which has occurred following the application of Baker’s solution using a saturated Q-tip (cotton bud). In this case the sideburns were long enough to conceal the test area

Figure 15.2 For patients who wear bangs (a fringe), testing can be carried out on the frontal hairline. In this case blanching resulting from Baker’s solution, 30% trichloroacetic acid (TCA), and 50% TCA is demonstrated

Figure 15.3 An exception to the rule that lighter peels produce hyperpigmentation is seen in this patient who developed hyperpigmentation following both straight Baker’s solution and straight phenol applied in large volumes using a saturated Q-tip. Her pigmentation disappeared spontaneously over a 6 month period. Hyperpigmentation following deep peel testing often suggests that the patient will not develop subsequent hypopigmentation

Figure 15.4 In this patient a skin test using Baker’s solution and 50% TCA was carried out. The hypopigmentation that resulted made deep peels an unacceptable option for this patient

Figure 15.5 This patient has had an excellent result following a Baker’s peel without hyperpigmentation

Figure 15.6 Side lighting will often give a more detailed picture of the patient’s skin texture. In this case a surgical light was used to illuminate the skin

See Boxes 15.1 and 15.2.

Educating Patients

The most important thing you can do when discussing chemical peels with patients is to be totally transparent about the indications, advantages, and drawbacks for the peels you employ. Be blunt, and keep it simple; patients should be told that shallow or deep, successful chemical peels are nothing more than well-controlled burns. If the patients can be made to understand the factors which make the skin heal well or poorly after a burn they will understand the complications and drawbacks of chemical peels. Get to know your patients and share with them your knowledge about the advantages, risks, and benefits of specific peels for their particular problems. An adequately informed patient must understand first the general risks involved in any chemical peel, and whether any features in her or his history or physical examination suggest the possibility of greater risks or greater benefits.

• Discussing options

When discussing chemical peels with patients I arbitrarily divide them into three classes. Light peels, which are good for certain types of pigmentary disorder, textural abnormalities, and acne are described as ‘maintenance peels’ and do not require much downtime or carry much risk, but their results occur slowly (Fig. 15.7). Long term improvement is highly dependent on careful home programs which include the daily use of sunscreens and in many cases bleaching agents. Medium peels are described as capable of imparting a noticeable improvement in the patient’s appearance with the caveats of downtime while the patient is unpresentable, transient hyperpigmentation, and remote possibilities of more serious problems such as scarring. Deeper phenolic peels are described as more risky but absolutely necessary for deep wrinkles or severe photoaging. The possibility of serious complications, including hypopigmentation, scarring, systemic toxicity, and interaction with preexisting disease states or intraoperative medications, is carefully spelled out. I also discuss the medications we will be using or may need to use to carry out the procedure. These include local anesthetic with adrenaline, antibiotics, antiviral agents, and pain medications. It is also important to discuss the ‘no free lunch’ concept; that is, repeated applications of light peels ‘won’t make a dent in deep wrinkles’, but will often improve skin texture and dyspigmentation. Patients need to know that changes in skin color of either a transient or permanent nature are a major concern. As peels become deeper, the potential for permanent changes in skin color and lines of demarcation is greater (Fig. 15.8). Fair-skinned patients are told that there is a very high possibility of the skin being permanently lighter when deeper peels must be employed to efface deep rhytides. Very dark-skinned individuals are poor candidates for deep peels. Patients who tan well are told they might expect transient hyperpigmentation from any type of peel. Experience with curling irons and other forms of cutaneous trauma have often educated patients as to how their skin may respond to a peel.

• When patients present with pigmentary abnormalities (particularly melasma), ‘black-light’ examination using ultraviolet light (UVL), as well as UVL photography, will help determine whether or not any type of peel may be effective. (Epidermal pigment fluoresces, dermal pigment does not.) Patients who wish treatment for pigmentary disorders are often told that ‘sunlight is their enemy’. Sunscreens are mandatory and all the good results which can result from successful peels can be reversed by one good sunburn. The effects of female hormones and hereditary factors are also discussed.

• It is also worthwhile talking about typical postoperative patterns, such as crusting, swelling, and the common sequelae of medium to deep peels that will definitely keep people out of circulation. Patients need to know how much time they will need to set aside, and for deeper peels they need to become familiar with cosmetics which will conceal post-treatment erythema. If patients cannot deal with the realities of deeper peels they are not suitable candidates.

Figure 15.7 Patients are often unhappy with the outcomes following a very light TCA or glycolic peel, as evidenced by this phone call

Figure 15.8 This patient developed a clear line of demarcation following a periocular phenolic peel and a Baker’s peel periorally. She preferred the use of make-up to further peeling

Informed Consent

Patients with cognitive impairment cannot give an informed consent. Patients who have certain physical disabilities may not be able to perform the tasks necessary to optimize peel results.

Informed consent has a great deal more to do with the sharing of your information and expertise than protecting you against a malpractice suit. The scribbled signature on an information-dense form is not a magic amulet, protecting you against malpractice claims. Juries are sympathetic when patients who develop complications plead ignorance and state that they simply signed the paper without reading it. In the case of informed consent, unlike the process which ordinarily occurs in the legal system, ‘ignorance of the law is an excuse’, and the physician may be held responsible for the patient’s ignorance. When patients understand the rationale for different types of peels and recognize the warning signs and specific risks of certain kinds of complication, they become colleagues and not potential litigants.

The Psychology of Peels

Certain types of patient are easier or harder to please. Far and away the patients who are happiest with peel outcomes are those with Fitzpatrick skin type I or II who have very deep wrinkles, who use make-up, and are willing to put up with hypopigmentation. Hardest to please are patients with minimal wrinkling who use magnifying mirrors and scrupulously point out every single defect. There are four phases to chemical peels: the anticipatory, the intraoperative, the early (1–6 weeks) postoperative, and the late postoperative (6 months). Each phase requires a careful description which details the possibility of minor and major complications as well as specific skin care instructions. It is worthwhile discussing all of these phases well in advance with your patient. Following medium peels there is often a ‘honeymoon’ phase in which the fresh-scrubbed texture of the face and mild edema may produce a stunning improvement in patient appearance. Patients should be prepared for this phenomenon and learn how to prolong their improvement by using home programs, sunscreens, and so forth.

• You are what you wear

Patients who wear designer clothes and beautiful jewelry are often extraordinarily detail oriented and may be very hard to please. One of my patients suggested that patients in this category exhibit the ‘Rolex sign’. Do not hesitate to discuss the possibility of unmet expectations quite openly. The treatment of certain kinds of defects, which are amenable to both peels and volume changes, can be initiated using temporary soft tissue augmentation agents such as hyaluronic acid. Tissue fillers are often an excellent way to begin facial rejuvenation.

• The open door policy – making the patients feel welcome

When I carry out deep peels I give patients my home phone number. I want them to call me if they are frightened and I will see them as needed.

I follow medium and deep patients very closely, examining them every few days. If they are concerned they are encouraged to come to the office anytime they want to without an appointment. We often open a side door so that a patient does not have to walk through a waiting room full of curious patients wearing dressings or looking swollen.

Evaluating the Patient

Patients exhibit their history on their skin (Fig. 15.9). Unlike other organs, this one is accessible. I ask them if they have been burned and look where they were burned. I ask them if they have had a brown spot after a burn or a light spot (Fig. 15.10). Look for surgical scars, ask about previous experience with burns (i.e., with curling irons) and whether the patient has had any procedures before. You frame your questions in the context of what effect something might have on the peel outcome. Do not forget to examine non-sun-exposed skin to see the patient’s true skin color.

Figure 15.9 Patients carry their history on their skin. In this case hypopigmentation resulting from cryotherapy for actinic keratoses will give both the patient and the physician a pretty good indication of what might happen following a deep peel

Figure 15.10 Patients who develop pigmentation, as this patient did following a burn, have no problem understanding the possibility that they may develop hyperpigmentation following a peel

Get a good drug history. Photosensitizing drugs (such as minocycline, St. John’s wort, topical benzoyl peroxide, amiodarone, sulfonamides, thiazide diuretics, tricyclic antidepressants), and oral contraceptives may increase the risk of pigmentary problems. Previous dermabrasions or deep resurfacing procedures may increase the potential for scarring following deeper peels, possibly on the basis of impaired wound healing due to subclinical fibrosis. Patients with atopy may be more sensitive to superficial peels. Stronger peeling agents are suitable for older patients with more chronic sun exposure, solar lentigines, and deep wrinkles. This may be due to the accumulation of solar elastosis. Thicker, more sebaceous quality skin often tolerates deeper peels better than thinner, less sebaceous skin.

• Personal habits/home regimens

Topical medications such as tretinoin (Retin-A), scrubs, cleansing granules, creams, and products bought at health food stores, as well as facial waxing, electrolysis, hair plucking, etc., can exert both preoperative and postoperative effects on peel outcomes (Fig. 15.11) Simple scrubbing to remove make-up immediately before a light peel can produce unexpectedly deep penetration of the agent. Sun exposure, certain types of medication, and certain skin types make a patient prone to specific types of complication.

Figure 15.11 Hypopigmentation and atrophic scarring occurred in this 34-year-old woman who vigorously scrubbed a ‘brown spot’ using an over the counter glycolic acid preparation

• Sorting out patients

The most important evaluations have to do with patients who are going to need deep chemical peels. Patients with histories of hypertrophic scarring, dark-skinned patients, and patients with serious medical problems are not candidates for phenolic peels. Patients who do not use cosmetics (e.g., male patients) may be very poor candidates for deep chemical peels although they can certainly tolerate light and medium peels. I am particularly careful about employing periocular phenolic peels on patients who have had multiple blepharoplasties (Fig. 15.12) or who have undergone recent (less than 6 months) undermining plastic surgery or other types of resurfacing procedure. Heavy smokers are notoriously poor healers and are often poor candidates for deeper peels (Table 15.1).

Figure 15.12 Ectropion PT/ST. This patient developed severe ectropion following a ‘light’ Baker’s peel. She had previously undergone three blepharoplasties

Table 15.1 Factors in patient evaluation for phenol-based chemexfoliation

General	General state of physical and mental health
	Medications
	Pregnancy history
	History of herpes simplex
	Skin pigmentation classification evaluation
	History of hypertrophic scarring
	History of facial radiation or use of isotretinoin (Accutane)
	Realistic expectations
Relative contraindications	Cardiac disease
	Renal disease
	Hepatic disease
	Hormone replacement therapy
	Continued exposure to ultraviolet light
	History of radiation exposure or use of isotretinoin
Contraindications	History of hypertrophic scarring or keloid formation
	Fitzpatrick skin classification of IV–VI
	Recent facelift (deep chemical peeling in areas of recently undermined skin may result in vascular compromise and resultant scar formation)