Introduction

To extol the virtues of modified phenol chemical face peeling is an exercise in the obvious. The main purpose of this chapter is to describe the author’s method of phenol face peeling. This method, based on objective clinical and experimental data, is easily incorporated into your practice of facial enhancement. It will show a brief evolution of phenol used by the author, which formulae were used, which were discarded and why, and which formulae are currently used and the reasons why.

Modified phenol as described in this chapter can be used for a variety of skin conditions. Hyperpigmentation in Hispanics will improve dramatically with a 15-second application of the Stone Venner-Kellson (Stone VK) formula. The author has no personal experience with hyperpigmentation in African Americans or Mestisos (Mexican Americans). Others have reported improvement with hyperpigmentation in these conditions. Mild rhytids and hyperpigmentation with early actinic and seborrheic keratoses will benefit significantly from a 1-minute application of the Stone VK formula. Moderate and severe rhytids and keratoses will improve 80 to 100% with 1 minute of Stone VK followed by 4 minutes of Stone II formula. With the control offered by modified phenol there is virtually no reason to continue with the laser juggernaut. Indeed, when Coherent introduced the CO₂ laser, soon to be followed by Sharplan, the author pursued this alternative to chemical peels. Now, countless others and many iterations of technological wizardry later, the mortal among us are confused and financially unable to keep up. Modified phenol has been a better substitute for facial rejuvenation because of safety, efficiency, efficacy and, lastly, economics.

The formulae described in this chapter have been standardized and are readily available from Delasco Laboratories (Council Bluffs, Iowa) at no financial gain to the author. The author has been a student of phenol since 1971 – first with industrial phenol burns, next with Baker-Gordon formula (1975–1991), and currently with modified phenol (1991 to date). The author is convinced that virtually any type of resurfacing need can be met with chemicals.

The Baker-Gordon formula, published in its revised form in 1962 (3 mL phenol, 2 mL H₂O, 8 drops of septisol, and 3 drops of croton oil yield 48.5% phenol and 2.2% croton oil) was used for deep rhytids. Healing time was said to be long, redness prolonged, hypopigmentation common, and scars not unusual.

The reported unfavorable and variable results from phenol can be attributed to the belief that the formula itself was of paramount importance. Little or no effort was given to skin preparation since it was thought that the ‘formula’ was inherently deep and that no additional exfoliation or pigment control (not widely utilized before 1991) was necessary. Little attention was given to the application technique since it was commonly held that phenol was ‘all-or-none’ and that technique of application was inconsequential. The importance of application technique was described by Stone in 1998 and 2001.

The story of modified phenol was elegantly told by Marmelzat and Hetter. Hetter is to be congratulated on his award-winning papers where he called attention to the importance of croton oil. Although Hetter states that application techniques are important, it is this author’s opinion that he leads his students to the conclusion that croton oil is the agent most responsible for the changes in peel depth on the five described facial zones. In this author’s opinion this may be so, but only if application technique is concurrently modified. Hetter states that ‘the end point is a subjective one based on the degree of whitening, which is based on experience’. Hetter’s results are exceptionally good. His formulae dilutions, use of cotton pads dipped in solution and wrung out, folded over thumb and brushed over face and neck in multiple coats – more in some areas than others – represent a change in technique from the standard Q-tip (cotton bud) application. These techniques were difficult for this author to translate to his practice. Hetter’s Obagi technique of application of phenol raised some questions for this author such as:

It was the author’s goal to simplify the process and make learning easier by standardizing the peel formulae and quantifying the application technique, thereby facilitating the procedure for any interested physician.

The distribution of peel patients used for this chapter are seen in Table 8.1. Factors affecting phenol peel depth are shown in Box 8.1. One hundred and fifty-nine full face phenol peels and nine human biopsy studies were used in this study. Results of these efforts were published in Clinics in Plastic Surgery.

Table 8.1 Distribution of peel patients in this study

Based on these studies and two new experiments reported below, the author concluded that: (1) rubbing increased the depth of injury (agree with Hetter); (2) the thickness of papillary dermis injury, the degree of fibrosis, and the degree of inflammation were less with 5 rubs and more with 50 rubs (Fig. 8.1); (3) phenol is not all-or-none (agree with Hetter); (4) croton oil increased depth of injury (agree with Hetter); (5) there was little observable difference between 0.4% croton oil and 2.2% croton oil when application techniques were kept constant (disagree with Hetter), and (6) human experimental models have inherent variables.

Figure 8.1 Test peel patches on day 4, left cheek, in Fitzpatrick skin type I treated with four formulae: (1) 48% phenol, 0% croton oil; (2) 35% phenol, 0.4% croton oil; (3) 35% phenol, 2.2% croton oil, and (4) 35% phenol, 0% croton oil. Each formula was tested with 50, 20 or 5 rubs with small semi-dry Q-tips (cotton buds). Results showed: (1) phenol is not ‘all-or-none’; (2) croton oil increases depth of injury; (3) in this study there was little observable difference between 0.4% and 2.2% croton oil; (4) rubbing increases depth of injury, and (5) human experimental models have inherent variables

Based on quantifiably reproducible experimental test peel patch studies on the right cheek and, later, left cheek test peel patches (reported below), using 48% phenol with 0.0% croton oil, 35% phenol with 0.4% croton oil, 35% phenol with 2.2% croton oil, and 35% phenol with 0.0% croton oil (see Fig. 8.1), a lowering of the threshold affect to create injury (Fig. 8.2) to between 5 and 20 rubs can be seen when croton oil is added. This is down from the 20 to 50 rubs required when croton oil is excluded. The early appearance of coagulation is not a true indicator of depth of peel, nor is the immediate density of frost as evidenced by the reported superficial results from 88% USP Phenol which can produce an immediate, dense, white frost. The length of time a given formula is applied, the concentration of phenol and croton oil, the volume of acid, the vigor and abrasiveness of the application and predegreasing procedure, and the occlusive technique all play a vital role in the final result.

Figure 8.2 Threshold effect: the depth of peel, as measured by papillary thickness injury, degree of fibrosis, and degree of inflammation, is more readily reached with fewer applications when croton oil is added. The same degree of injury is seen between 5 and 20 rubs with croton oil and 20 to 50 rubs without croton oil. There is little difference between 2.2% croton oil and 0.4% croton oil

In order to further test the hypothesis that length of application or number of rubs plays a paramount role in peel result, an African-American male, age 37, with a truncal congenital nevus of Becker was tested with one formula: the Stone II (60% phenol, 0.2% croton oil) (Fig. 8.3A–E). Twelve test patches, six in each of two rows, were rubbed with 1, 5, 10, 20, 50, and 100 coats using twice-blotted, semi-dried Q-tips. The top row was covered with tape for 48 hours followed by thymol iodide powder (Delasco Laboratories, Council Bluffs, IA) for 7 days. The bottom row was covered with Aquaphor ointment until healed. A clear threshold between 10 and 20 rubs was seen by day 10 and persisted through to day 73, the last day of the study.

Figure 8.3 African-American with truncal congenital Becker nevus treated with one formula (Stone II: 60% phenol, 0.2% croton oil) over twelve test patches, six in each of two rows. (A) Immediately after peel applications (from left to right) of 1, 5, 10, 20, 50, and 100 rubs; (B) top row covered with waterproof tape, bottom row covered with Aquaphor ointment; (C) at 48 hours; tape removed, thymol iodide powder applied. Threshold effect between 10 and 20 rubs seen at 10 days (D) and 73 days (E) post peel

This patient, with melanin as a biological marker, clearly demonstrated that when all factors are kept constant and time/quantity of application is controlled, a threshold is reached where melanin is either preserved or reduced. The return of melanin is least with 100 rubs and normal with one to five rubs. This correlated well with changing depth of peel.

Translating number of rubs to a timed approach relied on the appearance of the skin during the procedure (like Hetter). It was clear that Obagi, using TCA (trichloroacetic acid) and Hetter, using the Heresy formulae, relied on the appearance of frost density to reach a given end point. The use of the Stone VK and Stone II formulae employ the same principles, but in addition add a time component to the application process, thus standardizing and controlling the procedure.

Based on this objective data, it is the author’s conclusion that both the Hetter and Stone techniques can produce excellent results with modified phenol. The student is left with a clear choice. Using the Hetter technique the student will employ several dilutions over multiple facial and neck zones with an ointment occlusion, or will choose one formula with a timed application and a waterproof tape/ powder occlusion. It is a bit like comparing proven facelift techniques. Not one method is good for all students or all patients. See Box 8.2 for key features.

Treatment Approach

• Definition of zones

It is a well known fact that a thorough phenol peel should take a minimum of 1 hour to avoid too rapid absorption of phenol. Therefore, the face is divided into zones for the purpose of ensuring that the procedure takes a minimum of 90 minutes to complete (Fig. 8.4).

Zone I – forehead and upper lids.

Zone II – right cheek and lower lid.

Zone III – left cheek and lower lid.

Zone IV – nose, lips, chin.

Zone V – neck.

Figure 8.4 Peeling zones

Each zone is peeled, wiped lightly with a gauze pad to remove any oil and occluded with waterproof tape (when indicated) before proceeding to the next zone. In this way the proper time will elapse between zones to preclude phenol toxicity.

• Set up and procedure

(Table 8.3 shows medication used before, during, and after the peel.)

• Patient comfortable with head up 20 degrees.

• Blue towels around face for photo background.

• Pile of paper tissues to wipe the inevitable tear.

• Pile of gauze on which to dab the swab before application.

• Separate mayo stand for peel emulsion (away from patient’s eyes).

• Prepare skin in usual fashion:

1 Septisol ×3 – with 4″ × 4″ (10 cm²) gauze pad rubbed with moderate vigor

Table 8.3 Medications used in chemical peels

Medications	Dosage
Preoperative medications
Meperidine HCl/Pethidine (Demerol) 50 mg	1 tab PO 1 hr prepeel
Diazepam (Valium) 10 mg	1 tab PO 1 hr prepeel
Valacyclovir (Valtrex) 500 mg	1 tab PO bid for 10 days starting 2 days before peel
Methylprednisolone (Medrol) dose pack	Take as directed starting day of peel
Dicloxacillin 500 mg	Take 1 tab PO bid for 5 days
Intraoperative medications
Morphine sulfate 2 mg	IV at start of peel, repeat ×1 prn
Postoperative medications
Meperidine HCl/Demerol 50 mg	PO on arrival home and at bed around 6 p.m.
Diazepam 10 mg	PO on arrival home and at bed around 6 p.m.
Meperidine HCl/Demerol 50 mg	PO 9 p.m. night of peel
Flurazepam (Dalmane) 30 mg	PO 9 p.m. night of peel
Meperidine HCl/Demerol 50 mg	PO midnight night of peel
Flurazepam 30 mg	PO midnight night of peel
Valacyclovir 500 mg	PO bid for 10 days starting 2 days prepeel
Dicloxacillin 500 mg	PO bid for 5 days
Methylprednisolone dose pack	Take as directed, starting night of peel
Hydroxyzine (Atarax) 25 mg	PO bid for itching prn
Meperidine HCl/Demerol 50 mg	PO prn pain (usually not necessary)
Betamethasone diproprionate (Diprolene cream) 0.05% Resume hydroquinone 4% retin-A 0.1% at 3–4 weeks PRN hyperpigmentation	tid for 1 wk starting at day 10 (to reduce redness)

Alcohol ×3 – with 4″ × 4″ gauze pad rubbed with moderate vigor

Acetone ×3 – with 4″ × 4″ gauze pad rubbed with moderate vigor.

2 Expect to see skin become pink during degreasing (good exfoliation).

3 Fan is blowing gently across patient’s face (attach to nearby light or IV pole stand) (Fig. 8.5).

• Gently shake stock bottle to mix emulsion.

• Pour 10 mL into medicine cup.

• Maintain gentle fan blowing across face to deflect fumes and to cool the face.

Figure 8.5 The fan blowing gently across the face during degreasing and actual peel disperses fumes and improves comfort

Stone VK Peel Technique

Using large rectal swab mix emulsion, wring out swab with gentle twisting on side of tilted cup, dab lightly twice on stack of 4″ × 4″ gauze pads adjacent to patient’s shoulder and paint rapidly with the side of swab the entire forehead, eyebrows, and upper lids, massaging well into the hairline and eyebrows. Switch to small Q-tip to reach within 2 mm of the ciliary margin. Repeat, rubbing briskly for 15 seconds for light Hispanic skin with spotty hyperpigmentation, 1 minute for mild rhytids in Caucasians, and 2 minutes for moderate rhytids in Caucasians. It is not necessary to redip or use a second applicator with this peel. Deeper applications will require a new applicator to be dipped into the peel solution for additional coating rather than reusing a once dipped applicator. There are now several occlusion technique options.

Option 1

Option 2

Option 3

• Stone II peel technique

The Stone II peel emulsion is applied after the Stone VK peel emulsion to take advantage of the higher pH and diminished pain upon application of the Stone VK. With general anesthesia, only the Stone II peel emulsion need be used.

• Prepare skin in usual fashion:

1 Septisol ×3 – with 4″ × 4″ gauze pad rubbed with moderate vigor

Alcohol ×3 – with 4″ × 4″ gauze pad rubbed with moderate vigor.

Acetone ×3 – with 4″ × 4″ gauze pad rubbed with moderate vigor.

2 Expect to see skin become pink during degreasing (good exfoliation).

3 Fan is blowing gently across patient’s face (attach to nearby light or IV pole stand) (see Fig. 8.5).

• Moisten large rectal swab in emulsion, stir well, wring out with spiral motion on side of medicine glass, dab twice on pile of 4″ × 4″ gauze pads and proceed. Note that after the brief application of Stone VK, the patient is pain-free for 20 minutes.

• On Zone I: quickly paint the entire forehead, directly over the translucent pink frost created by the Stone VK application, rub well into brows and hairline, go down onto upper lids. Finish lids to within 1–2 mm of ciliary margin with small Q-tip (again well dabbed on gauze). Loupes help here. This application of Stone II is painless.

Keep painting over entire area during allotted time (4 minutes for moderate lines, up to 5 minutes for severe lines; use no more than two dips into emulsion, one fresh swab per dipping. Gently sponge away the oily surface with 4″ × 4″ gauze. Apply tape using many overlapping pieces of and 1″ waterproof tape. Leave brows untapped, and go over pretarsal skin leaving 1–2 cm of untapped skin adjacent to lashes (Fig. 8.6).

Figure 8.6 Tape lids leaving 1–2 cm of pretarsal skin untaped

Proceed to zones 2, 3, and 4 (Box 8.7).

Box 8.7

Pearls

• Pearl 1: Place lip and chin tape vertically for first layer, horizontally for second layer and join to cheek tape in weaving fashion (Figs 8.7 and 8.8)

• Pearl 2: Use Spandage (Meditech International, Brooklyn, N.Y.), one layer to hold tape gently in place for 48 hours, or Kling (Johnson & Johnson, New Brunswick, NJ)

• Pearl 3: Tape shower cap (Fig. 8.9) in place along hairline. This keeps moisture in, promotes exudate and facilitates tape removal

Figure 8.7 First layer of lip tape should be vertical

Figure 8.8 Completed tape mask; note irregular margins

Figure 8.9 Tape the shower cap across the forehead and preauricular areas. This will keep moisture in and facilitate tape mask removal

By using this timed approach, what to look for with the frost as it changes appearance will be seen in Table 8.4. You will see pink translucent frost at around 15 seconds (Fig. 8.10) and opaque white (Fig. 8.11) at 4 minutes. After 5 minutes the gray tone will slowly seep through and flecks of brown pigment will begin to show (Fig. 8.12). This is a good end point for a deep peel (a must around the lips and chin with deep rhytids).

Table 8.4 Application of phenol peels

Figure 8.10 Stone VK 1 minute showing pink translucent frost

Figure 8.11 Stone II 4 minutes over Stone VK 1 minute showing opaque frost

Figure 8.12 Stone II 7 minutes over Stone VK 1 minute showing gray opaque frost with emergent pigment

After all zones have been taped and final photographs have been taken, empty all unused chemicals into urine cup, cover and dispose in red bin. Other swabs, Q-tips, tissues and gauze are double red-bagged.

• Tape mask for 48 hours

At the completion of the procedure, when the patient meets discharge criteria, they are sent home with the medicine schedule listed in Table 8.3. Based on the fact that the peel process produces pain for 6 hours, the phenol peels are performed at 4 p.m. The patient is usually in their own bed by between 6 p.m. and 7 p.m., which means they have to be made comfortable until about midnight, at which time they take the next set of medications and usually fall asleep for the remainder of the night. They wake up swollen, but pain free. Patients and family are tutored on what to expect by seeing photos and videos of the procedure.

The patient sleeps with head elevated 45 degrees, stays warm, even hot, so as to sweat and produce exuberant exudate beneath the tape. Towels are placed around the neck to absorb the inevitable seepage from beneath the lower edge of the tape mask. The midnight dose of flurazepam (Dalmane) 30 mg will usually produce comfortable sleep through the rest of the night. Liquids are given through a straw held at the corner of the mouth to avoid pursing the lips. A diet of food prepared in a blender is encouraged for 1 week. After 48 hours the patient returns to the office for tape removal and thymol iodide powder application. They are given Meperidine Hydrochloride (Demerol) 50 mg and diazepam (Valium) 10 mg PO 1 hour prior to tape removal. The mask is removed quickly from above, pulling down in one fell swoop using the shower cap as a handle (see DVD for tape removal).

Figure 8.13 shows a typical mask at 48 hours, just prior to removal, and the mask after removal. At this point, there should be abundant wet, yellow exudate (Fig. 8.14). The more the better! Exposed lids, nose and any area where the tape has loosened will show darker, dry eschar (Fig. 8.15). These areas actually will be less deep, heal faster and probably not be a problem in the patient with mild to moderate rhytids. In the patient with severe rhytids, effort is made to keep the tape more adherent with Kling and Spandage, especially around the lips. It is difficult to keep tape adherent in these areas and in the author’s opinion this explains the sometimes less than dramatic results around the lips. But here again, we are not trying to equal the Baker-Gordon result; rather, we welcome a kinder, gentler peel with less hypopigmentation. Better to be underdone than over.

Figure 8.13 Typical waterproof mask. Appearance at 48 hours (A); mask of tape removed in one piece from above downwards by pulling gently on shower cap (B)

Figure 8.14 Abundant yellow exudate seen immediately after tape mask removal

Figure 8.15 Another patient showing face after most exudate removed using gauze pads and q-tips (cotton buds). Note epithelialization is already visible. Also note the dry eschar where the tape loosened or was not applied

• After tape mask removal

The exudate excess is gently removed with swabs and gauze but no attempt is made to remove all. Thymol iodide powder is applied with large rectal swabs in a rolling fashion. The patient is supplied with powder and swabs to use at home with four to five reapplications recommended daily. The compulsive patient will look like Figure 8.16 with a good opaque yellow mask at day 6. The less compulsive will look like Figure 8.17 with a brown dry eschar beginning to crack, revealing pink underlying new epithelium.

Figure 8.16 Good thymol iodide powder mask

Figure 8.17 Poor thymol iodide mask. Notice peeling of the mask at day 4 of powder (day 6 of peel) with pink epithelium showing

After 7 days of powder – nine days after the peel itself – all areas should be epithelialized. That night the patient starts compresses of warm face towel (wrung out wet, warm towel), moistened liberally with mineral oil, 20 minutes on, 20 minutes off. In the interim, Vaseline and/or vitamin A&D ointment is frosted over the entire mask, using tongue blades supplied to the patient. This is done during the 20 minutes that the skin is not being treated with a compress. This process is done for approximately 3 hours prior to going to sleep with the last layer of ointment. Some patients are good at this and come to the office the next morning all ‘peeled’ and pink. Others are more squeamish and wish to have the mask peeled off by the doctor (Fig. 8.18). This is fun for the doctor and painless for the patient since all is epithelialized.

Figure 8.18 Peeling of thymol iodide mask after treatment with warm compresses of mineral oil and vitamin A&D ointment. Notice pink, smooth epithelium at day 9 post peel

At this point, patients may shower and shampoo freely and wash the face with gentle products. The author’s favorites are LaRoche-Posay Gentle Dermo Cleanser and Biomedic Gentle Healing Ointment (LaRoche-Posay, France) as moisturizer of choice. Other gentle cleansers and moisturizers may be substituted. Some patients will be more inflamed or red and will be given a course of betamethasone diproprionate (Diprolene Cream 0.05%, Schering Corp., NJ) three times a day for up to 1 week. This is applied before the moisturizer because sometimes it burns a little. By 2 weeks post peel SkinTech SPF 30 (www.skintech.com.au) with titanium dioxide can be used to mask the red. Other products with same function are permissible. Make-up can go over the SPF. By 14 to 21 days the patient is fully epithelialized, comfortable with camouflage make-up, and can return to relatively normal activity. Patients having light peels will reach this stage at between 7 and 12 days.

They will soon have some mild itching, which is best treated with hydroxyzine (Atarax) 25 mg po bid for 1–2 weeks. Most of the swelling has subsided by 4 weeks and redness is largely gone by 12 weeks. Milia is not uncommon but temporary; dryness requires a moisturizer of choice. Hypopigmentation will develop to some degree in all but the very light peels, although this may not be apparent for 1 year. It is usually well received by the patient since the mild hypopigmentation is mostly relative to the sun damaged neck and chest hyperpigmentation. And now, with resorcinol, other light peels, micropeels, bleaching creams, and SPF with sun avoidance, this difference can be lessened.

• Touch up

For those patients at three months or later who have persistent perioral or periorbital lines, a repeat peel is done using the same approach. No tape or powder are used during the touch ups. Aquaphor ointment (Fig. 8.19) or vitamin A&D ointment is frosted on the peeled surface immediately. This procedure takes about 10 minutes on the presedated patient. No IVs, EKG (ECG), or other monitors are used because of the small areas involved. There is very little pain with this second Stone VK touch up peel. Rarely, the Stone II is used for touch ups. The patient is obviously not charged for this procedure.

Figure 8.19 Immediate application of Aquaphor ointment after secondary Stone VK 30 seconds, Stone II 2-minute perioral touch up

Results, Comments, and Philosophy

This chapter was designed to be a primer for modified phenol face peeling. The formulae and methods were standardized to meet this author’s clinical needs. The method works. Once the basics are in place, you can modify the method to suit your needs. Controlling the peel process to achieve the desired end result is key. This author found that the original Venner-Kellson formula, modified and made available by Delasco, meets all of the requirements for a safe, effective, reproducible peel, and useful for a variety of skin conditions by changing the length of time of application. Changing the method of occlusion is done mainly for expediency since it does not affect the depth of peel as much as the uniformity or evenness of result. The Hispanic patient shown in Figure 8.20 demonstrated a uniform improvement using a 15-second application of the Stone VK. She was treated with Aquaphor ointment through the healing process. One year prior to the Stone VK she had a resorcinol peel (also available from Delasco as the Stone Resorcinol peel formula). This is a topic for another discussion but suffice it to say that resorcinol is the preferred blending peel for neck, chest, arms, and hands.

Figure 8.20 Hispanic Fitzpatrick type IV. (A) Pre 15-seconds Stone VK peel; (B) 1 year post peel

The patient shown in Figure 8.21 is a Caucasian with Fitzpatrick II skin type who was treated with a 5-minute Stone II peel followed by thymol iodide powder at 24 hours until healed at 1 week (see Fig. 8.21D). This was before it was realized that the Stone VK was definitely less painful to apply than the Stone II. The same result could have been expected with a 5-minute Stone VK.

Figure 8.21 Caucasian Fitzpatrick II skin type. (A) Pre 5-minute Stone II. No Stone VK was used in this patient. This was before the author realized the analgesic effect of Stone VK was an important adjunct to the peel; (B) 24 hours after 5-minute Stone II with no occlusion. Note dry eschar; (C) 24 hours after 5-minute Stone II showing first thymol iodide powder application; (D) 1 week post peel. Healed, even, and pink

The patient shown in Figure 8.22, a Caucasian with Fitzpatrick skin type III, was treated with a 1-minute Stone II peel followed by waterproof tape occlusion for 48 hours and 3-day blending resorcinol peel to neck. (The face was treated with Aquaphor ointment after tape removal, as was the neck after the 3rd day of five coats of resorcinol – one every 5 minutes for five coats on three consecutive days.) The resorcinol is put on like glycolic acid, one even coat every 5 minutes for five coats and repeated 3 days in a row. On the 3rd day after the five coats of resorcinol have dried, either thymol iodide powder is applied to form a crust or Aquaphor ointment is applied throughout healing. Either occlusion method works well.

Figure 8.22 Caucasian Fitzpatrick III skin type. (A) Pre 1-minute Stone II; (B) 2 weeks post Stone II. Note blending in neck with resorcinol and no significant hypopigmentation

Figure 8.23 shows a Caucasian, 60-year-old female of Fitzpatrick II skin type and with moderate rhytids who was treated with a 5-minute Stone VK peel followed by a 2-minute Stone II, with tape and powder occlusion. Her neck was not treated with resorcinol but easily could have been. She was seen at 12 months post peel (see Figure 8.23B).

Figure 8.23 Sixty-year old Caucasian Fitzpatrick II with moderate rhytids. (A) Pre 5-minute Stone VK and 2-minute Stone II; (B) 12 months post peel treated with waterproof tape and thymol iodide powder

The patient shown in Figure 8.24, a fifty-five-year-old Caucasian with red hair, Fitzpatrick I skin type, and looking older than her stated age, responded well to a 13-minute Stone VK peel and a 1-minute Stone II peel followed by tape and powder. Note that after 6 months she still had a ruddy complexion and some persistent perioral lines (Fig. 8.24B). Her neck was not treated (now she would have a 3-day resorcinol peel). The patient has not been seen in follow up beyond 6 months but it is assumed she would be lighter.

Figure 8.24 Fifty-five-year-old Caucasian Fitzpatrick type I looking older than stated age. (A) Pre 13-minute Stone VK, 1-minute Stone II, neck not treated; tape and powder used; (B) 6 months post peel. Note persistence of some rhytids about lips

The patient shown in Figure 8.25A and B, a 65-year-old Caucasian has a Fitzpatrick II skin type showing moderate to severe rhytids and actinic keratosis and was treated with a 2-minute Stone VK peel and 4-minute Stone II peel, followed by tape and powder. Her forehead after a 1-minute Stone VK peel is seen in Figure 8.25C. Her forehead after a 4-minute Stone II peel on top of a 2-minute Stone VK peel shows how the peel is carried well into hairline, brows, and upper lids as part of a zone I peel (Fig. 8.25D). Also note the shower cap before it is taped in place. Figure 8.25E and F shows frontal and lateral views at 3 months. Note her neck was not peeled. At 3 months there is no hypopigmentation but at 2 years post peel (Fig. 8.25G) she is more hypopigmented. She also let her hair dye grow out, actually making her appear older. She needed a perioral touch up, seen after a 2-minute Stone VK peel at 3 days in Figure 8.25H. Note the vitamin A&D ointment occlusion technique, feathering at edges with new epithelium, and thicker adherent coagulum over heavier rhytids. She is seen at 9-days showing increased redness from herpes simplex super infection in Figure 8.25I (when the patient discovered she was using Flagyl given by her pharmacist rather than Famvir), and at 5 weeks in Figure 8.25J with resultant prolonged but temporary redness. (The actual real-time touch up peel can be seen on the DVD). This patient would benefit from a resorcinol neck peel, facelift, make-up and hair styling.

Figure 8.25 Sixty-five-year-old Caucasian Fitzpatrick II skin type. (A) Pre 2-minute Stone VK, 4-minute Stone II, tape and powder; (B) oblique view showing multiple actinic keratosis and seborrheic keratosis; (C) forehead after 1-minute Stone VK; (D) forehead after 4-minute Stone II, peel carried well into hairline; (E) 3 months post peel; (F) 3 months post peel, lateral; note absence of actinic changes

(G) 2 years post peel; (H) Stone VK 2-minute touch up at 3 days. Note combination of new, pink epithelium, feathered edges and adherent coagulum over deeper rhytids; (I) Stone VK 2-minute touch up at 9 days showing superimposed herpes simplex infection with delayed healing and increased erythema; (J) Stone VK 2-minute touch up at 5 weeks showing smooth lips, healed herpes simplex but persistent erythema. This takes up to 4 months to disappear

Figure 8.26 show a sixty-five year old Caucasian Fitzpatrick II skin type. Her forehead is white, on account of being hidden by her hair for a long period, while the lower face shows freckles and moderate to severe rhytids, hyperpigmentation, and sagging. She was treated with one minute Stone VK peel and five minute Stone II peel followed by tape and powder. She is seen in the second photograph 2 years and 9 months after the chemical peel and 2 years 6 months after blepharoplasty and facelift, wearing only eyelid make-up and lipstick. Note her original pallor has been restored, not a waxy porcelain mask of hypopigmentation. This patient also participated in the right and left cheek test peel patch studies which left no tell tale signs. This is the expected result from peel followed by facial surgery.

Figure 8.26 Sixty-four-year-old Caucasian Fitzpatrick II skin type. (A) Pre 1-minute Stone VK, 5-minute Stone II; tape and powder; (B) 2 years, 9 months post chemical peel, 2 years, 6 months post facial surgery. Note patients requiring both lift and peel will always start with the peel, followed in 3 months with lift surgery. Peels and surgery are not combined except for minor touch ups

Figures 8.27 and 8.28 show groups of happy patients in various stages of their peels. They became supportive of one another, and patient advocates for my practice. Figure 8.28 shows what the modified phenol face peel can do for your patients: expect a group of very satisfied people who will be proud to share their experiences with other new patients.

Figure 8.27 A group of happy patients sharing experiences and supporting one another

Figure 8.28 The real end result. A group of happy patients. This is what makes the peel procedure so worthwhile