Application of the Wounding Agent

On the day of the procedure, the patient cleanses their face, does not apply any cosmetics, and should be fasting prior to the procedure. Since anesthesia is generally required for deep chemical peels, a thorough preoperative history and physical must be completed prior to beginning the peel. In addition, intravenous hydration with a liter of lactated Ringer’s solution should be given prior to the procedure as well as another liter during the procedure. Cardiac monitor, pulse oximetry, and blood pressure monitoring with full resuscitation capabilities are mandatory for full-face deep peeling with phenol, even if the anesthesia is restricted to light intravenous sedation or local nerve blocks with 1% lidocaine. After thorough cleansing and degreasing of the skin, the chemical agent is applied sequentially to six aesthetic units: forehead, perioral region, right cheek, left cheek, nose, and periorbital region, proceeding from one segment to the next after an interval of 10–15 min between each cosmetic unit, allowing 60–90 min for the entire procedure [19, 43].

Of importance, the Baker-Gordon solution must be prepared at the time of the procedure and repeatedly stirred to keep the various components evenly mixed. After mixing, the solution should be kept in a glass bowl or basin with a broad bottom so the solution can be gently agitated or stirred without danger of spilling or splashing. One to two cotton-tipped applicators are used to stir the solution and to apply it to the skin. The patient’s eyes must be kept closed throughout the procedure. The applicator tip is stroked quickly and with moderate pressure over the cosmetic unit while watching for a whitening frost that appears within 10 s. The cosmetic segment is considered “painted” once an opaque white frost is observed. After each segment is evenly frosted, dry cold compresses and fanned air are used to help minimize the burning sensation. Also, ice packs can be used to symptomatically cool the skin [43]. It is important to remember that diluting phenol compound with water may increase the depth of penetration of injury, so tears spilling onto treated areas must be avoided, and if the eyes need to be flushed in the event contact occurs, mineral oil rather than water should be used [34].

After the entire face is treated, at the physician’s discretion, waterproof zinc oxide tape may be placed on the skin to create an occlusion peel. The tape is left in place for 24 h, at which time the normal exudates and edema that follow injury cause the tape to spontaneously separate from the skin. The tape is then removed by the patient in the shower. Taping is thought to result in extra penetration of the wounding agent to the applied areas to achieve optimal cosmetic results, particularly areas of deep rhytids such as the perioral areas, glabella, and lateral crow’s feet.For untaped peels, petrolatum is applied, and a biosynthetic dressing is used for the first 24 h.