The Journal of Craniofacial Surgery
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 Volume 32, Number 8, November/December 2021 Brief Clinical Studies
FIGURE 1. CT scan of the patient revealed unilateral fracture of the left
mandible with 908 of medial displacement of the condylar process. CT,
computed tomography.
displacement of the condylar process (Fig. 1). Fractures segments
were accessed through the preauricular incision. A 7 mm-long
2.0 mm self-drilling IMF screw (Lorenz Plating System, BIOMET
Jacksonville, FL) was inserted to the condylar neck by using the
battery charged screwdriver (Power Driver) of the same plating
system. The cerclage wire was passed through the ring of the IMF
screw, which then made it possible to retracted and manipulate the
proximal bone segment. Internal fixation was achieved with 2.0 mm
4-hole medium titanium plate and 4 screws (2 on each side of the
fracture line) at the reduced position of the fragmented bones and in
the end IMF screw was extracted (Fig. 2). In long-term follow-up,
there were no problems for occlusion and normal range of tempor-
omandibular joint motion at 12-months (Fig. 3). The proximal bone
fragment, that is, condylar process is prone to dislocate medially
under the mechanical forces of the lateral pterygoid muscles on the
condylar process of the mandible, whereas the distal bone fragment
is prone to displaced toward the condylar fossa under the mech-
anical forces of the masseter and medial pterygoid muscles inserter
to the mandibular angle and of the temporalis muscle inserted to the
coronoid process.1 It is not easy to manipulate the proximal segment
effectively, that is, to bring the displaced condylar process in its
anatomic position and to hold it there until the rigid internal fixation
process is completed. Application of a self-drilling IMF screw,
mostly overcomes this problem. Insertion of the self-drilling IMF
screw is a straightforward easy procedure. Once the proximal
FIGURE 2. Internal fixation was achieved with 2.0 mm 4-hole medium titanium
plate and 4 screws (2 on each side of the fracture line) at the reduced position of
the fragmented bones and in the end IMF screw was extracted. IMF,
intermaxillary fixation.
# 2021 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FIGURE 3. Postoperative 3D CT scan. 3D CT, three-dimensional computerized
tomography.
segment is visualized, neither to widen the dissection around the
bone for inserting the bone holders nor drilling to put the screw are
necessary. The screw head with the hole at the tip can be used as
bucket handle in holding the bone or pulling it outward by passing a
wire through the hole. Additionally, if the condylar head is dis-
located and/or medially displaced with the contraction force of the
lateral pterygoid muscle, a countertraction force applied via the
screw put on the lateral surface of the condylar head does not only
bring the medially displaced bone out linearly but rather causes
counterrotation (rotation in the opposite direction of medial dis-
placement) and reduces the angulation between the fragments.
Moreover, once the fracture reduction is achieved, it is crucial to
maintain that correct alignment until the rigid internal fixation is
completed. With the wire applied to the IMF screw, primary
surgeon can work with both hands to apply the screws to the
fixation plate while the traction is maintained by somebody else
(assistant or scrub nurse) without obscuring the surgical field.
REFERENCE
1. Canter HI, Kayikcioglu A, Aksu M, et al. Botulinum toxin in closed
treatment of mandibular condylar fracture. Ann Plast Surg
2007;58:474–478
Medium-depth Trichloroacetic
Acid and Deep Phenol–Croton
Oil Chemical Peeling for Facial
Rejuvenation: An Update
Bishara Atiyeh, MD, Ahmad Oneisi, MD, and Fadi Ghieh, MD
Abstract: Face-lift is an established rejuvenation modality; how-
ever, when performed alone, it lacks the ability to improve the
appearance of fine wrinkles and dyschromias that are an important
component of facial rejuvenation. Although it is only natural to be
attracted by the latest technologically advanced innovative skin
resurfacing techniques, chemical peeling has been proven to be a
simple and effective method with a relatively good safety profile.
Unfortunately, the practice of chemical peeling has relied for a long
time on dogmas perpetuated by early reports without any real
scientific basis. Moreover, application of peels has been hindered
by difficult estimation of penetrance and control of depth. Three
decades ago, a shift has occurred from early dogmatic empirical
e745
 Brief Clinical Studies The Journal of Craniofacial Surgery
application to better understanding of the peeling formulations and
mechanism of action together with appreciation of the interaction
between the various components of the peeling formulations in
addition to better estimation of clinical end points and peel depth.
Given the increasing demand for none or minimally invasive
cosmetic procedures, the current review is aimed at highlighting
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the recent applications of available medium-depth and deep chemi-
cal peels for optimal facial rejuvenation and for the treatment of
photo-related aging skin changes.
Key Words: Chemexfoliation, chemical peels, facial rejuvenation
S ymmetry and proportions determine primarily facial aesthetics
and beauty. In recent years, skin appearance and texture have
been recognized as an essential factor considerably affecting per-
ception of beauty and youth.1 Cutaneous photoaging is character-
ized by breakdown of the elastic fiber network and thinner
epidermis with cellular atypia; it often manifests as irregular
pigmentation, wrinkling, and development of solar lentigines and
actinic keratosis.2
In addition to surgery and volume restoration, the ability to
improve the appearance of fine wrinkles and dyschromias is emerging
as an important component of facial rejuvenation. Several options
exist, each with indications, advantages, and disadvantages.3 Chemi-
cal peels, or chemabrasion, chemexfoliation, chemical exfoliation,
chemical face lifting, chemosurgery, dermapeeling, and surface
surgery as sometimes referred to, are one of the oldest forms of skin
resurfacing. A wide variety of chemical peeling agents are available
with different mechanisms of actions.2 Application of 1 chemical
ablative agent to the skin induces keratolysis or keratocoagulation.
With controlled injury to the epidermis and dermis of specific depth,
exfoliation and stimulation of organized cutaneous regeneration
occurs through epidermal growth, collagen deposition, and a more
even distribution of melanin.2,4 Chemical peeling has withstood the
trials of time and scrutiny with peeling agents being relatively
inexpensive, cost-effective, and generally reliable and safe. Chemical
peeling has a longstanding and widespread acceptance as an efficient
and valuable treatment modality for rhytids, actinic damage, lentigos,
and dyschromias, and is the standard by which other resurfacing
methods are measured.5–7
Chemical peels date back to ancient Egypt and likely are the
oldest esthetic procedure performed; animal oils, salt, and alabaster
mixtures for ‘‘improving beauty of the skin" and ‘‘removing
wrinkles" have been mentioned as early as 1550 BC in the Ebers
Papyrus.5,7–9 Ancient Greeks and Romans used plasters made of
mustard, sulfur, and corrosive limestone for chemexfoliation and 27
agents for cleansing, brightening, darkening, softening, and esthe-
tical improvement of the skin were known since antiquity.7,9
From the Division of Plastic and Reconstructive Surgery, American
University of Beirut Medical Center, Beirut, Lebanon.
Received February 7, 2021.
Accepted for publication March 3, 2021.
Address correspondence and reprint requests to Fadi Ghieh, MD, Division
of Plastic and Reconstructive Surgery, American University of Beirut
Medical Center, Riad El-Solh/Beirut 1107 2020 Lebanon;
E-mail: fadi.ghieh@gmail.com
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2021 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000007729
e746 # 2021 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 32, Number 8, November/December 2021
Treatment of furuncular infections and pemphigus with phenol
by British dermatologist Tilbury Fox in 1871 is probably the first
description of chemical peeling in the modern medical literature.7
Borelli et al10 have recently published an interesting comprehensive
historical review of chemical peeling with phenol, resorcinol,
trichloroacetic acid (TCA), and salicylic acid in Europe in the
19th century. In the early 20th century, Jean DeDesly and Antoinette
LaGasse, in addition to other laypeelers, Gardé, and Kelsen in
Hollywood and Coopersmith and Mascheck in Florida, were pio-
neers in the pursuit of beauty; they catered for celebrities and movie
stars with ‘‘European secret formulas’’ most of which contained
small amounts of croton oil.5,11,12 Publicity about laypeelers led in
the late 1950s to much interest by physicians.11 In 1959, Brown
described a formula containing phenol and croton oil.13,14 On
September 1961, Litton reported chemical face lifting in an oral
communication then published his work in 1962 describing chemi-
cal peeling with a ‘‘minute amount’’ of croton oil and a 50%
solution of phenol with glycerin and water.15,16 Several years later,
Litton published the composition of his formulation that he appar-
ently had obtained from Coopersmith in Fort Lauderdale.15,17 From
an obscure anecdotal technique, chemical peels emerged gradually
to their present acceptance as a scientifically based procedure for
skin resurfacing.18
With the assumption that phenol is the active ingredient
responsible for epidermal and superficial dermal coagulation,
Baker19 detailed in November 1961 the exact composition of a
peeling formula containing 1.2% croton oil in 47.5% phenol.
Subsequently, the Baker-Gordon formula consisting of 3 mL of
phenol, 2 mL of tap water, 8 drops of liquid soap (Septisol - Steris
Corp, Mentor, OH), and 3 drops of croton oil (1cc ¼ 27 drops)
became widely adopted as the standard chemical peel formu-
lation.20 – 22 Since that time, although laypeelers continued practi-
cing with their own formulas, plastic surgeons have used to the
exclusion of others the Baker-Gordon phenol-croton oil peel.11,15
In 2016, chemical peels were the third most commonly performed
noninvasive cosmetic procedure in the United States23; they are
currently witnessing an upsurge in clinical applications and
research interest.2,4
Peeling produces a controlled, partial-thickness chemical burn
of the epidermis and the outer dermis.24 Peels alter the epidermis by
inducing a more normal histologic pattern with columnar cells
showing return of polarity and more regular distribution of mel-
anocytes and melanin granules.2 They are classified by the depth of
injury into superficial, medium, and deep depending on the con-
centration, pH, and type of peeling agent used; depth of the peel is
also influenced by anatomical location, epidermal integrity,
adnexal structure density, and skin thickness as well as cutaneous
priming, application technique, occlusion, and contact
time.2,4,8,23,25,26 Using the correct depth chemical peel, based
on the disorder to be treated and the histological level or severity
of the skin pathology, is critical for treatment success.2 A peel too
superficial will not be effective to efface rhytides; if too deep,
scarring or hypopigmentation would result.27 Agents for super-
ficial peels today include various alpha hydroxy acids; TCA can be
used for superficial peels at 10% to 20% concentration and for
medium-depth peels at 35%. Deep peels are typically performed
with phenol-based solutions, including Baker-Gordon and the
more recent Hetter phenol-croton oil peels.2 Deep phenol peels
provide the most dramatic results but also hold the highest potential
for systemic complications, particularly serious cardiac arrhyth-
mias that should not be underestimated.28 – 30
Superficial peels target the epidermis and the epidermal-dermal
interface. They are characterized by greater safety, fewer compli-
cations, and are appropriate for patients with mild actinic damage
and fine rhytids. They exfoliate the skin from the stratum corneum
 The Journal of Craniofacial Surgery  Volume 32, Number 8, November/December 2021
down to the papillary dermis. Deep peels on the other hand
penetrate to the mid-reticular dermis denaturing epidermal keratin
and dermal proteins causing complete epidermolysis with mid-
dermal injury and inflammation of the reticular dermis; they are
indicated for patients with Glogau types III or IV photo-aging and
Fitzpatrick type I and II skin. Although most effective in erasing
deep rhytids, deep peels carry the highest risk of local compli-
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cations, such as scarring or hypopigmentation. The medium-depth
peels penetrate the papillary dermis to the upper reticular dermis;
they balance appropriate results with low risks and are particularly
indicated to treat moderate photo-aging (Glogau II).2,4,5
As with any therapeutic resurfacing technique, a reliable clinical
endpoint is essential. With TCA peels, visual determination of
frosting and epidermal sliding as described and histologically
elucidated by Obagi et al are reliable indicators for determination
of peel depth penetrance.6,26 Epidermal sliding indicates a medium
peel penetrance to the level of the papillary dermis. It is observed
when the coagulated epidermis becomes separated from the under-
lying reticular dermis and slides as a thin independent sheet. It
subsides once peeling advances deeper to the immediate reticular
dermis bonding epidermis and dermis into a single protein block.
This indicates maximal relatively safe depth with the least inci-
dence of scarring and hypopigmentation.26 With phenol-croton oil
peels, frost density was not found by Stone31 to be a completely
reliable indicator. The application technique, in particular increased
number of rubbings, pressure, and abrasiveness of the application,
coupled with the amount of volume of acid used and time of contact
with the skin, is more important in peel penetrance and is a principal
factor in determining depth.
An essential component of deep peels is croton oil obtained from
the seeds of croton tiglium, a small shrub native of India and Sri
Lanka; it is a vegetal matrix of phorbol esters that are specific
activators of protein kinase C enzymes. Croton oil was used in India
as a purgative and became known in Europe in 1630.15 It has been
used for medicinal applications since the 19th century then mixed
with other ingredients in the 1900s, particularly with phenol, that
has the ability to increase phorbols’ deep penetration.11,13 Unfortu-
nately, the finding as early as 1935 by an organic chemist that croton
oil causes severe vesiculation and deep burns has been largely
overlooked.15 It was not until several years after the original
description of the Baker-Gordon formula that Hetter demonstrated
that croton oil, not phenol, was the primary active agent and that by
altering concentrations of croton oil rather than phenol, it was
possible to vary the peel depth.11,32 Hetter stressed that the strength
and corresponding depth of penetration of phenol-croton oil peel
can be manipulated by varying the concentration of croton oil and
outlined the rationale for referring to formulas by the percentage of
croton oil and phenol.11,13 He described 5 easily mixed ‘‘heresy
phenol formulas’’ and suggested a metric standard for drop size at
0.04 mL allowing greater control in treating areas of diverse skin
thickness and thereby accomplishing a more uniform result.6,33
With the advent of laser resurfacing and other innovative
nonsurgical facial rejuvenation modalities, chemical peeling has
been disregarded by many and considered as an out-of-date pro-
cedure. Nevertheless, it remains an important nonsurgical modality
available to the aesthetic plastic surgeon. It definitely still has a role
in the aesthetic armamentarium of rejuvenation either as a mono-
therapy or as a combination therapy with other cosmetic procedures.
Despite predictions of their disappearance in favor of lasers, the
overall use of chemical peels continues to grow.4,5,7,15,23,26 Given
the increasing demand for none or minimally invasive cosmetic
procedures, the present review is aimed at highlighting the recent
applications of available medium-depth and deep chemical peels for
optimal facial rejuvenation and for the treatment of photo-related
aging skin changes.
# 2021 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
MATERIALS AND METHODS
A preliminary PubMed search of published manuscripts in English
from 1990 to 2020 was performed using the search term ‘‘chemical
peel.’’ It identified 2239 manuscripts, the titles of which were
screened for relevance. A second advanced search with MESH
terms chemexfoliation and rejuvenation was conducted: (‘‘chemi-
cal peel’’[All Fields] OR (‘‘face peel’’[All Fields] O ‘‘face pee-
ling’’[All Fields] OR ‘‘face peels’’[All Fields]) OR
(‘‘chemexfoliation’’[All Fields] OR ‘‘chemexfoliation classifica-
tion’’[All Fields] OR ‘‘chemexfoliation methods’’[All Fields]) OR
‘‘chemabrasion’’[All Fields] OR (‘‘chemical exfoliation’’[All
Fields] OR ‘‘chemical exfoliation method’’[All Fields]) OR
(‘‘chemical facial’’[All Fields] OR ‘‘chemical facial peel’’[All
Fields]) OR ‘‘chemosurgery’’[All Fields] OR ‘‘surface surger-
y’’[All Fields] OR ‘‘dermapeeling’’[All Fields]) AND (‘‘rejuvena-
te’’[All Fields] OR ‘‘rejuvenated’’[All Fields] OR
‘‘rejuvenates’’[All Fields] OR ‘‘rejuvenating’’[All Fields] OR
‘‘rejuvenation’’[MeSH Terms] OR ‘‘rejuvenation’’[All Fields]
OR ‘‘rejuvenations’’[All Fields] OR ‘‘rejuvenative’’[All Fields]
OR ‘‘rejuvenator’’[All Fields] OR ‘‘rejuvenators’’[All Fields]).
‘‘rejuvenations’’[All Fields] OR ‘‘rejuvenative’’[All Fields] OR
‘‘rejuvenator’’[All Fields] OR ‘‘rejuvenators’’[All Fields]). 163
articles were retreived. Abstracts of all relevant manuscripts were
reviewed independently by 2 authors. Inclusion criteria were
clinical cohort trials or comparative studies about medium and
deep chemical peels for facial and neck rejuvenation. Experimental
chemical peeling studies were also included. Manuscripts about
superficial peels, or peels of body areas other than face and neck,
were excluded as well as chemical peels used for other indications
than rejuvenation such as for melasma and acne. All reviews,
letters-to-the-editor, and comments were also excluded. Identified
relevant manuscripts were grouped into 4 major categories: exper-
imental studies about chemical peels, trichloroacetic acid peels,
phenol-croton oil peels, and comparative and/or combined peel
studies. A final PubMed search performed again with each of the 4
categories did not retrieve any additional manuscripts. Full texts of
all identified articles were reviewed along PRISMA guidelines for
size of study groups, study design, outcome measurements; out-
come level of evidence was classified according to the rating scale
of Ackley et al for experimental studies and ASPS Evidence Rating
Scales for Therapeutic Studies for clinical case series.34,35
RESULTS
Experimental Studies
Six experimental studies have been identified within the
30 years’ time frame of this review (Supplementary Digital Content,
Table 1, http://links.lww.com/SCS/C696). Vagotis et al confirmed
that Retin-A treatment before 50% phenol chemical peel or der-
mabrasion, results likely in accelerated healing, whereas Butler et al
confirmed histologically the beneficial effects of deep 50% TCA
and Baker-Gordon phenol peels.32,38 In addition to phenol-Baker
and TCA, a study in an animal experimental model about the more
common chemical peels revealed that, despite the fact of a minimal
peeling effect, glycolic and pyruvic acids induced a disproportion-
ate increased collagen deposition suggesting direct stimulation by
these 2 agents.36 Han et al40 investigated the mechanism of wrinkle
reduction and the effects of TCA 30%, TCA 50%, and Baker–
Gordon formula peeling in photo-aged hairless mice skin. They
observed that each chemical substance penetrated to a particular
depth with infiltration of inflammatory cells extending to the
epidermis and papillary dermis in the TCA 30% group, to the
lower reticular dermis in the TCA 50% group, and to the subcu-
taneous fat in the phenol group. The authors concluded that
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 Brief Clinical Studies The Journal of Craniofacial Surgery
chemical peeling reduces wrinkles and regenerates skin by increas-
ing dermal thickness and the amount of collagen and elastic fibers.
This effect is greater for more deeply penetrating chemicals. Larson
et al39 for their part tested in an animal experimental study the
hypothesis of Hetter regarding the phenol-croton oil solution to
establish persuasive scientific evidence regarding the role of each
ingredient as well as the effect of the application technique. The
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authors confirmed the validity of the concentrations and formu-
lations suggested by Hetter.15 With increasing concentrations,
phenol peels more deeply; addition of Septisol causes deeper injury;
croton oil added to any concentration of phenol increases peel depth
proportional to its concentration; multiple applications of croton oil
in phenol increases the depth of peel. However, in an earlier study
on Yucatan minipigs, histologic, quantitative, and mechanical
analysis of skin at 5 intervals over 6 months following 25% and
50% TCA, Baker’s phenol, and dermabrasion, the long-term effi-
cacy of TCA and deep Baker’s phenol peels was questioned.37
Trichloroacetic Acid Peel
Five studies with TCA peels were identified (Supplementary
Digital Content, Table 2, http://links.lww.com/SCS/C696).6,41 – 44
Dailey et al41 demonstrated histologically that the depth of
necrosis increases with increasing TCA concentrations. Fanous
et al recommended varying depths of peel based on their proposed
genitico-racial skin classification to limit complications, whereas
the studies of Obagi et al and Johnson et al emphasized clinical
signs of peeling depth.6,43 Although with great clinical implica-
tions, these studies were not comparative, with low level of
evidence. Moreover, evaluating changes in Langerhans cells
following 40% and 60% TCA peels compared to control liquid
nitrogen, concerns were raised about potential carcinogenesis
following repeated TCA peels due to temporary impairment of
the skin defense system.42
Comparative and/or Combined Peel Studies
Two studies investigated a combined 70% glycolic acid (GA)
and 35% TCA peel (Supplementary Digital Content, Table 3, http://
links.lww.com/SCS/C696).45,50,56 Coleman et al45 described both
clinical and histological medium-depth injury following GA-TCA
peel; however, their report was mostly descriptive without any
information about the study group nor objective assessment of
clinical outcome. Electron microscopic examination conducted
by El Samahy et al50 concluded that more profound changes can
be observed than those with simple histological examination.
Kubiak et al53 for their part compared 70% GA with 15% TCA
and 35% TCA peels and did not demonstrate any clinically sig-
nificant difference between the 2 peeling protocols. Four other
studies reported on observed outcome of combined Jessner’s
solution (14% salicylic acid, 14% lactic acid, and 14% resorcinol
in 95% ethanol) and TCA peel.46,47,49,52 Monheit described in 2
separate publications his experience with 500 patients treated with
the combined Jessner’s-TCA 35% medium depth peel.46,47 The
author detailed the application technique and presented illustrative
cases without, however, providing any objective data to justify his
claim that Jessner’s solution allows deeper TCA penetration
through papillary dermis. However, the study by Tse et al is
interesting in the sense that the authors have treated each of the
13 patients included in their study with 70% GA plus 35% TCA
(GA-TCA) to the right face and Jessner’s solution plus 35% TCA
(JS-TCA) to the left face.48 Clinical outcome by 3 independent
evaluators was based on photographic documentation and 2 inde-
pendent investigators evaluated histological changes. Authors
concluded that GA-TCA medium-depth chemical peel was effec-
tive in treating photo-damaged skin and was slightly more
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Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 32, Number 8, November/December 2021
efficacious in removing actinic keratosis than JS-TCA. One last
study reported on the effect of Jessner’s solution and TCA Mask.49
This report was mainly descriptive with a low level of evidence. An
immunohistochemical study comparing 40% and 60% TCA to
100% pure phenol demonstrated overexpression of proliferating
cell nuclear antigen, a marker of epidermal cell proliferation, with
40% TCA within 12 hours after peeling. Authors warned about
long-term potential carcinogenic effect of frequent low concen-
tration TCA peels and recommended special attention for unex-
pected cutaneous lesions and skin tumors.51
Phenol and Phenol–Croton Oil Peel
One study investigating a new peeling application technique of
pure phenol peel is reported without conclusive clinical benefits
(Supplementary Digital Content, Table 4, http://links.lww.com/
SCS/C696).44 On the contrary, 2 studies by Stone et al, (one being
published in 2 different journals54,55), demonstrated that for
phenol–croton oil peels, the application technique is the more
important determining factor than phenol or croton oil concen-
tration.31,54
DISCUSSION
Efficacy of chemical peels as a photo-damage treatment modality
has been repeatedly reported and is well documented. Its practice,
however, has relied for a long time unfortunately on dogmas
perpetuated by early reports without any real scientific basis, in
particular reports about phenol-croton oil peels.15,57 Moreover,
difficulty in predicting an agent’s penetrance with relative lack of
precise depth control and even distribution of the chemical over the
treatment area are the main disadvantages that have halted wide-
spread acceptance of chemical peeling as a reliable treatment
option.58 Although practiced with much hesitation by plastic
surgeons and considered by many to have unpredictable and
possibly dangerous results,23 chemical peeling for facial skin
resurfacing and rejuvenation, compared to recent technologically
advanced modalities claiming to offer better control of ablative
depth with easier use and relative lack of systemic toxicity and side
effects, continues to be an integral part of rejuvenation pro-
grams.8,23,59 Recent reports reveal that chemical peels constitute
a large fraction of office-based cosmetic practice mostly by
dermatologists.60,61
Much like the disproven incorrect dogmas that were followed
for decades in the twentieth century, general fears and apprehen-
sions about complications, scarring, and pigmentation changes are
proving to be far from real.5 The most important advancement that
has affected the acceptance of chemical peels as a valid and reliable
non or minimally invasive facial rejuvenation alternative with
increased safety and versatility, was a shift >3 decades ago from
early empirical application to better understanding of the mechan-
ism of action of the peeling formulations based on histologic and
clinical studies together with the appreciation of the interaction
between the various components of the peeling formulations. It was
recognized also that the morbidity of the traditional Baker-Gordon
phenol peel and its frequently observed poor outcome with waxy
‘‘milky face’’ appearance and disturbing permanent hypopigmenta-
tion was due to uniform application of the peeling formulation
regardless of variable skin thickness. Face and neck depth maps
have since been developed to balance safety with efficacy.27 In that
regard, the experimental study of Larson et al that has scientifically
demonstrated what Hetter has emphatically stressed, in addition to
the clinical signs of peel depth pioneered by Obagi and Stone are
important milestones rendering chemical peeling a safe and valid
alternative and a true competitor of technologically advanced
resurfacing modalities.6,31,39
# 2021 Mutaz B. Habal, MD
 The Journal of Craniofacial Surgery  Volume 32, Number 8, November/December 2021
Another important progress witnessed in the practice of chemi-
cal peels similar to other nonenergy rejuvenation modalities, was
the appreciation of prepeel skin preparation, peel application, and
post-peel skin care as critical components of the rejuvenation
process for the prevention and/or treatment of postprocedural
adverse events such as inflammation, infection, and scarring.26,62
The objectives of skin activation, depth control, and shortened
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recovery can be routinely realized mainly through 3 active ingre-
dients: topical tretinoin (0.05%–0.1%), hydroquinone (2%–4%),
and alpha hydroxyl acid (4%–10%).25,26 Tretinoin (Retin-A) pre-
treatment improves epidermal regeneration, 4% hydroquinone les-
sens postinflammatory hyperpigmentation, and alpha hydroxyl acid
decreases epidermal atypia, induces epidermal hyperplasia, dis-
perses melanosomes, and increases elastin fiber thickness.32,63,64
However, despite published detailed protocols and guidelines for
periprocedural management, lack of standardization and consist-
ency is the norm and evidence-based recommendations to optimize
patient outcomes, reduce and manage adverse events, and shorten
healing time are still missing.26,62 It is also unclear from the
literature when prophylactic anti-viral therapy for herpes simplex
should be started and for how long it should be continued, and
whether it is indicated in patients without a history of herpes
simplex.62
Ironically, this increased knowledge arrived at a time when the
demise of chemical peeling was expected with the advent of laser
technology that offered an increased ability of depth control by
varying flux energy for different skin thicknesses.15,26 Moreover,
contrary to the large number of heterogeneous nonstandardized
publications over the last 30 years about combined medium and
deep peels with surgical or other nonsurgical rejuvenation options
as well as reports about unproven combinations of peeling formu-
lations and protocols, valuable published chemical peeling litera-
ture with high level of evidence to override deeply anchored
dogmas and to dramatically alleviate surgeons’ apprehensions
unfortunately is relatively sparse as evidenced by this review.
Among the profusion of positive reports, an early experimental
study in pigs has questioned the long-term efficiency of chemical
peeling. No change in quality, structure, or arrangement of elastic
fibers could be observed 6 months after single application of 25%
and 50% TCA. Morphologic change and decreased amount of
elastic fibers on computerized digital morphometry in addition to
weaker and stiffer tissues determined by biophysical analysis were
observed following Baker’s phenol peel.37 Moreover 2 separate
studies by a single investigating group warned against potential
carcinogenic effects of repeated TCA peels.42,51 However, no
subsequent studies substantiating this concern could be identified.
CONCLUSIONS
With increasing rejuvenation demands, skin resurfacing is advan-
cing at a rapid pace and is emerging as an essential component of a
comprehensive approach to reduce the stigma of photo-aging.1,65,66
Over the last 30 years, management of skin photo-aging has
expanded beyond a one-stage procedure and our understanding
of the role of skin peeling agents with preparatory and post-
treatment topical therapy to enhance and maintain results and
prevent further photo-damage has greatly evolved. Similarly,
synergy between peels and other procedures has been established
and well recognized.2,65,67,68 Unfortunately, current marketing of
exaggerated unrealistic outcomes and cobranding with cosmetic
products of ‘‘boutique peels’’ are overshadowing the real benefits of
well-performed medical chemical peels.4
Although clinical indications of medium and deep chemical
peels overlap with other skin resurfacing procedures popular among
plastic surgeons, cost–benefit profile of chemical peels should be
# 2021 Mutaz B. Habal, MD
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
highly attractive to any plastic surgery practice. However,
despite its apparent simplicity, the procedure must not be taken
lightly; it is technique-sensitive and requires thought, training,
and experience with the greatest ability in determining clinical
end points to avoid complications.18,58 As the line between
effective results and complications is very thin, predictability
and consistency of results require proper preoperative patient
evaluation and selection in addition to strong familiarity with the
application techniques as well as knowledge of the pharmaco-
logic fundamentals and intricacies of cutaneous penetrance of the
various formulations.5,52,67
Multiple modalities are currently available to rejuvenate visible
cutaneous signs of aging.66 Although it is only natural to be
attracted by the latest technologically advanced innovative tech-
niques, chemical peeling has been proven to be a simple and
effective method with a relatively good safety profile. Despite
some conflicting reports, outcomes to be expected with chemical
peeling are largely comparable to laser resurfacing modalities.7,18
Problems of the epidermis and superficial papillary dermis may
even be more easily and less expensively treated with chemical
peeling though rhytids of deeper papillary dermis and reticular
dermis may probably respond to laser resurfacing with a more
natural clinical outcome.69 Unfortunately, objective and scientific
evaluation of emerging peeling modalities and protocols with well-
defined outcome measures such as evaluation of wrinkle improve-
ment and reduction in apparent age, is still largely deficient.
Moreover, proven clinical and histologic outcomes of deep peels
compared to other more attractive innovative approaches for skin
resurfacing and wrinkle treatment, such as fractional ablative and
non-ablative lasers, fractional ablative radiofrequency, and micro-
needling, are also still lacking.13,18,70 Evidently, comparative vali-
dation of effectiveness of these treatments combined with an
evidence-based approach is required.
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