The Rullan Two-Day Croton Oil–Phenol Chemabrasion Peel

Introduction

The phenol peel has been called a chemical facelift because it removes photodamage-related wrinkles and tightens the skin more effectively than other ablative techniques. To accomplish this, a deep croton oil–phenol peel extends to the upper to midreticular dermis (approximately 600 microns). Many physicians who perform cosmetic surgery still equate deep phenol peels with the well-known Baker-Gordon phenol peel. However, formula modifications made in the last 20 years have led to much lower croton oil concentrations, resulting in phenol peels that are much less cardiotoxic, are less melanotoxic, and have less risk of scarring, as long as published formulas and techniques are followed.

The 2-day phenol chemabrasion technique that I developed is useful for deep wrinkles or acne scars. As a modified version of the chemabrasion technique introduced by Dr. Yoram Fintsi (2001) this technique includes the use of HyTape occlusion for 24 hours, the concept of debridement, the reapplication of a phenol formula into deep scars or wrinkles on day 2, and the use of a powder mask (bismuth subgallate) to absorb the ensuing drainage for 7 days. Additionally, this technique includes intravenous (IV) titratable conscious sedation, regional nerve blocks, and variations from the published formulas. A tongue depressor and varied curettes are used on day 2 (instead of sandpaper) to perform debridement of the necrotic coagulum and the remaining epithelium lining acne scars and deep wrinkles.

Benefits of the Rullan Method

• 1.

  The use of a lower croton oil concentration lowers the risk of hypopigmentation.

• 2.

  Useful for all skin types, especially among acne scar patients (44% of Dr. Rullan’s patients have ethnic skin).

• 3.

  Following these methods for application, hydration and pain control have been shown to reduce the risk of cardiac arrhythmias.

• 4.

  Chemabrasion with curettes allows better removal of epithelium and inflammatory coagulum, promoting secondary healing inside scars and wrinkles.

• 5.

  Segmental croton oil/phenol is effective and does not require monitoring

Safety Recommendations

• 1.

  Follow medical screening and Advanced Cardiac Life Support (ACLS) protocols.

• 2.

  Maintain PO ₂ above 90%, and prevent tachycardia.

• 3.

  Avoid pain-related adrenergic chaos by using effective sedation and analgesia.

• 4.

  Peel the neck and chest using either low percentage croton oil and phenol or TCA (15%–20%).

• 5.

  Consider peeling nonfacial regions with an intense pulsed light (IPL)/Erbium combination.

Patient Selection and Preoperative Protocol

The most common indication for deep peels is to treat moderate to severe wrinkles (Glogau scale wrinkles III through IV) in Fitzpatrick skin types I to III ( Figs. 12.1 and 12.2 ). If a patient has facial wrinkling accompanied by significant tissue laxity or volume deficiency, dermal fillers or cosmetic surgery may also be needed to achieve optimal results. In the case of acne scars, dark skin types IV through VI can be peeled as long as the patient understands the face–neck skin color tones will be discordant for almost 2 years ( Figs. 12.3 and 12.4 ). The patient must be willing to adopt strict avoidance of sun and the chronic use of skin lighteners on the neck during those 2 years. For patients with dark skin who do not want to make these long-term changes, a recommended alternative is to perform three to four sessions of chemical reconstruction of skin scars (CROSS), as discussed by Lee et al. (2002). See Chapter 13 for further discussion on effective treatment of acne scars using CROSS.

During the initial consultation for the peel, the physician should make note of the patient’s risk for demarcation lines and the tendency for postinflammatory hyperpigmentation (PIH). Assess factors that may impact the pigmentary healing process, such as the presence of a suntan or the patient’s exercise habits (specifically any temperature-increasing activities). The patient’s available downtime and ability or willingness to conceal lingering redness with makeup should also be taken into consideration. The patient will need to have family or nursing support for the first 3 days postpeel and must accept having a “mask” on their face for 8 days. During this time, they will only be able to eat liquefied food through a plastic bottle (provided by physician).

Patients with active acne should be treated with oral and topical antibiotics, retinoid creams, acne surgery, or isotretinoin before receiving the peel. The peel should be delayed until the patient has discontinued isotretinoin for 6 months or until the skin has regained its normal sebaceous activity. For patients with acne scarring, photographic documentation should be obtained with direct lighting and indirect (shadow) lighting.

Most patients with an oily complexion are prescribed a low-dose, 30-day course of isotretinoin after the peel, because I (and other experienced peelers, including Zein Obagi) believe excessive sebum is an inflammatory state that can lead to PIH. However, no controlled studies have been conducted on this yet.

The preoperative procedure for this technique requires a laboratory workup with hepatic, renal, and cardiac tests (10-lead electrocardiogram). Because phenol is hepatically metabolized and renally excreted, blood levels of phenol can become cardiotoxic if the liver or kidneys are not functioning well. The patient must procure a letter from their primary physician clearing them for the peel. Patients should also be screened for risk factors of QTc prolongation before the peel. Dr. Carlos Wambier (2018) has reported that phenol may cause a QTc prolongation, especially when other additive factors are present, such as certain medications (erythromycin, fluconazole, antimalarials, amiodarone, antidepressants, antipsychotics, terfenadine, hydrochlorothiazide, and others) or electrolytic abnormalities (hypomagnesemia, hypokalemia). When two or more of these factors are present, the risk for QTc interval prolongation occurs (dangerous if above 480 ms), triggering a potentially fatal torsade de pointe (TdP) ventricular arrhythmia during a phenol peel.

Procedure Protocol