COSMETIC Outcomes Article

Outcomes Assessment of Combination Face Lift and Perioral Phenol–Croton Oil Peel Cemile Nurdan Ozturk, M.D. Franziska Huettner, M.D., Ph.D. Can Ozturk, M.D. Marisa A. Bartz-Kurycki, B.S. James E. Zins, M.D. Cleveland, Ohio; and Buffalo, N.Y.

Background: Face-lift surgery when combined with perioral phenol–croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction. Methods: A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient’s age. The apparent age was compared with the patient’s actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4). Results: Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients’ postoperative apparent age estimate was 8.2 years younger than their real age (p = 0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p < 0.0001). Conclusion: Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique.  (Plast. Reconstr. Surg. 132: 743e, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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espite the recent trends toward conservatism and the popularization of minimally invasive techniques, the face-lift operation remains the cornerstone of facial rejuvenation. A wide variety of face-lift techniques have proven effective, and a mounting body of recent evidence has objectively documented this with outcomes analysis.1–4 The face-lift operation has been

From the Department of Plastic Surgery, Cleveland Clinic; and the School of Medicine and Biomedical Sciences, University of Buffalo. Received for publication April 10, 2013; accepted May 7, 2013. Poster presentation at the Aesthetic Meeting 2013: Joint Meeting of the American Society for Aesthetic Plastic Surgery and the Aesthetic Surgery Education and Research Foundation, in New York, New York, April 11 through 16, 2013; and podium presentation at the Annual Meeting of the American Association of Plastic Surgeons, in New Orleans, Louisiana, April 20 through 23, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a4c40e

combined with a variety of skin resurfacing techniques, and numerous reports have documented the efficacy of this approach.5–22 However, most of these reports were subjective and descriptive in nature and did not use validated measures to assess their results, thus falling short of current evidence-based standards of reporting. Furthermore, in those patients with moderate to deep perioral wrinkles, obtaining an excellent result remains a challenge. In our opinion, combining perioral phenol–croton oil peel with the face lift is an underappreciated and underused technique, considering its efficacy in both reducing rhytides and tightening central perioral skin. We have therefore reviewed our experience with the simultaneous face lift and perioral phenol–croton oil peel technique using three outcomes measures: (1) patient satisfaction survey, (2) evaluation Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

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Plastic and Reconstructive Surgery • November 2013 of reduction in apparent age, and (3) objective assessment of perioral wrinkles. In addition, we have carefully documented our complications and provided a long-term follow-up assessment.

PATIENTS AND METHODS A retrospective review was performed to identify consecutive patients who underwent simultaneous face lift with perioral croton oil-phenol peel performed by a single surgeon (J.E.Z.) between August of 2001 and March of 2012. Information concerning patient age, Fitzpatrick skin type, history of prior face lift, history of prior resurfacing procedures, face-lift technique, and ancillary procedures at the time of face lift and chemical peel was obtained from our electronic medical record. Institutional review board approval for this study was obtained before initiating this review. Surgical Technique Patients who were considered candidates for the combined technique were light-skinned (Fitzpatrick I and II) individuals who, in addition to facial aging, demonstrated moderate to severe perioral rhytides at rest. They were pretreated with tretinoin and hydroquinone for 4 to 6 weeks to suppress melanin production. The patients were instructed to use 400 mg of acyclovir starting 2 days before the procedure and continuing until complete healing was observed. An extended superficial musculoaponeurotic system (SMAS) face-lift approach with submental platysmaplasty and lipofilling was the most common surgical procedure combined with perioral resurfacing. Ancillary procedures for all patients are listed in Table 1. The chemical peel was performed at the completion of surgery. The peel solution was prepared by mixing 4 cc of 88% phenol, 3 gtts of croton oil, 16 gtts of Septisol (Steris Corp., Mentor, Ohio), and 6 cc of purified water.23 The final concentration consisted of 33% phenol and 1.1% croton oil. The solution was applied to the upper lip, lower lip, and chin, with care taken to extend onto the vermilion. Swipes were applied until a dense white frost was obtained (usually 20 swipes). In none of the cases were undermined flaps peeled. Postpeel management consisted of a petrolatumbased ointment (e.g., Aquaphor; Beiersdorf, Inc., Wilton, Conn.) combined with 2% viscous lidocaine until healing was achieved. Reepithelialization typically occurred in 7 to 10 days, indicative of an intermediate depth peel. Once complete healing was observed, hypoallergenic moisturizer was begun daily.

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Table 1.  Details of Combined Surgery with Perioral Peeling, History of Prior Procedures, and Consequent Peeling Procedures No. (%) No. Face-lift type  Extended SMAS  Plication of SMAS  Lateral SMASectomy  Midface lift  Composite face lift Adjunct procedures  Perioral peeling  Platysmaplasty with lipectomy  Lipofilling  Periorbital peeling  Endoscopic brow lift  Upper blepharoplasty  Lower blepharoplasty  Chin implant  Malar implant  Temporal lift  Digastric muscle shaving Prior procedures  Face lift  Chemical peeling of face  Laser resurfacing of face  Dermabrasion of face Consequent peeling  Perioral peeling  Periorbital peeling

47 (100) 39 (83) 3 (6.4) 2 (4.3) 2 (4.3) 1 (2.1) 47 (100) 37 (78.7) 28 (59.6) 10 (21.3) 9 (19.1) 9 (19.1) 4 (8.5) 4 (8.5) 1 (2.1) 1 (2.1) 1 (2.1) 11 (23.4) 6 (12.8) 3 (6.4) 1 (2.1) 6 (12.8) 2 (4.3)

Patient-Reported Outcomes A validated questionnaire designed by Cox et al. to measure patient satisfaction after facial rejuvenation was used to evaluate patient-reported outcomes.24,25 It consisted of 14 items, including questions on overall satisfaction, improvement in facial lines and appearance, effect on self-confidence, side effects, and downtime associated with the procedure. The patients responded on a seven-point Likert response scale ranging from 1 = very dissatisfied to 7 = very satisfied. Higher scores suggested increased patient satisfaction. The survey was mailed to patients and was resent to the nonresponders a second time. Responses were returned anonymously in a plain envelope. Mean and standard deviation were calculated for each item on the questionnaire. Assessment of Apparent Age Preoperative and postoperative photographs of patients included in the study were mixed randomly to create a photograph book. The photograph book included frontal, profile, and oblique views of the face, which were taken with the same background color and camera settings, in neutral expression with the same degree of chin elevation, and without makeup or jewelry. All patients included in the photographic evaluation signed

Volume 132, Number 5 • Outcomes of Face Lift and Perioral Peel Table 2.  Glogau Classification of Photoaging Type I II III IV

Description

Skin Characteristics

No wrinkles Wrinkles in motion Wrinkles at rest Only wrinkles

Early photoaging with mild pigmentary changes Early to moderate photoaging with lentigines and smile lines Advanced photoaging with dyschromias and wrinkles Severe photoaging with wrinkles throughout, no normal skin

photograph-release consent forms, thereby approving use of their photographs for research purposes. The photograph book was shown to six independent reviewers, who were asked to estimate the age of the person in the photograph. Their responses constituted the “preoperative apparent age” and “postoperative apparent age” of the patients. All reviewers were blinded to patientand procedure-related information. For each patient, a preoperative and postoperative apparent age was obtained by calculating the mean ± SD of six reviewers’ estimates. The actual age of the patients was then compared with the apparent ages as estimated by the reviewers using an unpaired t test. Statistical significance was defined as p < 0.05. This was done for both preoperative and postoperative photographs. A second analysis was performed to calculate the reduction in apparent age. Because the actual age differed between preoperative and postoperative photographs, the formula (postoperative apparent age − postoperative actual age) − (preoperative apparent age − preoperative actual age) was used to account for the time lapse.1 This calibration of the formula eliminated the influence of aging with time and yielded an accurate calculation of reduction in apparent age. Assessment of Perioral Wrinkles A second photograph book was created similarly by randomly assorting preoperative and postoperative perioral close-up photographs. Objectivity was obtained by rating the perioral area according to the Glogau classification of photoaging (Table 2). The photographs were evaluated by two plastic surgeons who were blinded to patientand procedure-related information. Raters were assisted by sample photographs of Glogau class I to IV and were asked to rate the presented pictures. Patients’ preoperative Glogau class was compared with their postoperative class using a paired t test. Statistical significance was defined as p < 0.05.

RESULTS Forty-seven consecutive patients who had simultaneous face lift and perioral croton oil-phenol

peel over an 11-year period were included in the study. The average age of the patients was 63 ± 5.6 years and the average follow-up period was 23.2 months (median, 13 months). All patients had a minimum follow-up of 6 months. In all cases, patients’ skin types were Fitzpatrick I or II. Details of surgical procedures are listed in Table 1. The face lift was primary in 36 of 47 patients (76.6 percent), secondary in nine patients (19.1 percent), and tertiary in two patients (4.3 percent). The average time from previous face lift was 90 months. During the follow-up period, six patients (12.8 percent) underwent repeated peeling of the perioral region, usually of the vermilion-cutaneous junction. The average time to repeated peeling was 12 months (range, 5 to 18 months). Patient-Reported Outcomes Twenty-seven of 47 patients responded to the questionnaire, yielding a response rate of 57.4 percent. Mean scores of individual questionnaire items were calculated and are listed in Table 3. The satisfaction scale ranged from 1 = very dissatisfied to 7 = very satisfied. Overall satisfaction was rated as 6.5 (item 1). All of the items in the questionnaire had a mean score above 5, indicating satisfied or very satisfied.

Table 3.  Patient-Reported Outcomes for Individual Items in the Facial Lines Treatment Satisfaction Questionnaire (n = 27)* Item Overall satisfaction Improvement in facial lines Time to onset Improvement in appearance Look relaxed Appear rested Look better Look younger Look like you feel Confidence Competitive at work† Side effects No sign of a procedure No downtime

Score (Mean ± SD) 6.5 ± 1 5.9 ± 1.6 6.2 ± 1.4 6.4 ± 1.3 6.3 ± 1.4 6.3 ± 1.4 6.4 ± 1.3 6.3 ± 1.3 6.2 ± 1.4 6.3 ± 1.3 6.1 ± 1.5 6.4 ± 1.1 6.6 ± 0.7 6.3 ± 1

*Highest score for each item is 7 (very satisfied). †For the item ”Competitive at work,” n = 19, as some patients were not employed and therefore did not respond to this item.

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Plastic and Reconstructive Surgery • November 2013 Assessment of Apparent Age Of 47 patients, 20 gave consent for use of their photographs. The postoperative photographs were taken at an average of 14.5 months (range, 6 to 48 months) after the combined procedure. Table 4 summarizes the patient data pertaining to actual and apparent ages. When preoperative actual age was compared with preoperative apparent age, the patients appeared 2.9 years younger than their actual age. However, this difference was not statistically significant (p = 0.1331). In contrast, patients’ postoperative apparent age estimate was 8.2 years younger than their postoperative real age, with a 95 percent confidence interval of 4.17 to 12.14 years (Figs. 1 through 4). This difference between postoperative actual and apparent age was statistically significant (p = 0.0002). The mean reduction in apparent age after combined face lift with perioral peel was calculated using the formula described above and was found to be 5.3 years (range, 0.7 to 17.7 years). Assessment of Perioral Wrinkles The photographs of the same subset of 20 patients were used for objective evaluation of perioral wrinkles. The mean reduction in the Glogau score as evaluated by two surgeons was 1.15 (3.3 ± 0.6 preoperatively and 2.15 ± 0.7 postoperatively,

p < 0.0001, with a 95 percent CI of the reduction from 0.86 to 1.43) (Figs. 1 through 5). Complications Complications, treatment methods, and complication outcomes are summarized in Table 5. Several complications were related directly to peeling. These included contact dermatitis, which was treated with topical fluocinolone. Persistent redness was treated with topical clobetasol for 1 to 2 weeks. Two cases of hypertrophic scarring resolved with intralesional steroid injections (Fig.  6). A careful evaluation of postoperative photographs yielded the presence of subtle lightening of the perioral region in all cases.

DISCUSSION Although the face lift procedure is an effective means of addressing facial aging, it is generally accepted that it has little effect on perioral rhytides.5,6,10,15,26–28 Procedures performed at the time of face-lift surgery to improve these rhytides have been practiced for many years and include dermabrasion, a variety of chemical peels, laser resurfacing techniques, fillers, and botulinum toxin.5,6,8–12,15,17,18,22,27,29,30 Each modality has its advocates and opponents. Dermabrasion of the perioral area is a

Table 4.  Preoperative and Postoperative Actual and Apparent Ages of Patients (n = 20)* Preoperative Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Mean SD

Postoperative

Actual Age (yr)

Apparent Age (yr)†

Actual Age (yr)

Apparent Age (yr)†

67 63 65 59 60 59 52 56 70 63 52 68 62 64 64 68 68 63 62 64 62.5 5

63.7 68.7 70.2 60.5 56.3 53.3 54.7 54.0 60.3 61.8 44.2 66.7 72.3 52.5 60.0 60.3 62.8 58.0 56.2 54.7 59.6 6.8

68 64 67 61 62 62 53 59 71 65 53 69 63 66 65 72 69 64 63 65 64.1 5

58.7 60.0 69.8 44.8 54.0 52.0 49.8 56.3 56.0 58.7 43.3 63.0 72.5 49.3 52.8 59.7 54.2 58.3 51.8 53.0 55.9 7.2

Reduction in Apparent Age (yr)† −6.0 −9.7 −2.3 −17.7 −4.3 −4.3 −5.8 −0.7 −5.3 −5.2 −1.8 −4.7 −0.8 −5.2 −8.2 −4.7 −9.7 −0.7 −5.3 −2.7 −5.3

*Reduction in apparent age is also shown. Preoperative actual age, actual age of patient at the time of the preoperative photograph; preoperative apparent age, age of patient as guessed by observers in the preoperative photograph; postoperative actual age, actual age of patient at the time of the postoperative photograph; postoperative apparent age, age of patient as guessed by observers in the postoperative photograph; reduction in apparent age, calculated by the formula (postoperative apparent age − actual age) − (preoperative apparent age − actual age). †Average of six observers.

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Volume 132, Number 5 • Outcomes of Face Lift and Perioral Peel

Fig. 1. Preoperative view of a 64-year-old patient (above, left). She underwent extended SMAS face lift combined with perioral phenol–croton oil peel, endoscopic brow lift, platysmaplasty, and lipofilling. She is shown 11 months postoperatively (above, right). The close-up views demonstrate a preoperative Glogau score of 4 (below, left), which was reduced to 2.5 after postoperatively (below, right).

time-honored means of reducing perioral rhytides.9,22,29,31–33 Its documented efficacy is significant even beyond its apparent depth of injury. Because of the potential aerosolization of viral particles, it has fallen somewhat out of favor, and other techniques are now preferred.29,31,34,35 Carbon dioxide laser resurfacing, erbium laser resurfacing, and combinations of the two have also enjoyed recent popularity.27–29,35–39 Despite initial claims that carbon dioxide laser resurfacing would not cause hypopigmentation, long-term results have contradicted this assertion.40 In fact, hypopigmentation secondary to the carbon dioxide laser can be profound and progressive in the long term.28,38–41 Fractionated carbon dioxide was introduced to obviate these problems.36,41–43 Although effective in other areas of the face, moderate to deep

­ erioral rhytides appear to be recalcitrant to fracp tionated techniques. Trichloroacetic acid chemical peeling seems to act similarly. That is, although effective in rejuvenating other areas of the face, deep perioral wrinkles appear to be recalcitrant even at higher concentrations.22,35 Phenol-croton oil peeling is not new. Initially practiced by lay peelers, the phenol–croton oil peel was popularized by the Baker-Gordon group in the 1960s.5,6,8,44 Although dramatically effective, the untoward effect of long-term hypopigmentation resulting from the Baker-Gordon formula has led to its replacement by the above techniques.45,46 More recently, Hetter, Stone, and others have modified the phenol–croton oil formula, dispelled many of the dictums of the Baker-Gordon formula, and reportedly reduced the untoward peeling effects.23,47–51

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Plastic and Reconstructive Surgery • November 2013

Fig. 2. The patient was 52 years old at the time of the preoperative photograph (above, left). She underwent extended SMAS face lift combined with perioral phenol–croton oil peel, platysmaplasty, and lipofilling. She is seen 14 months postoperatively (above, right). The close-up views demonstrate a preoperative Glogau score of 4 (below, left), which was reduced to 3 postoperatively (below, right). A subtle lightening of the perioral region is present after peeling.

The combination of the face lift with phenol–croton oil perioral peeling is also not new.5,7,8,10,15,22,50,51 Multiple authors have described their experience with face lift and perioral peeling, either as staged5,6,8,10,50 or simultaneous procedures.8,15 Although wrinkle ablation has been consistently noted, the dramatic skin tightening that synergistically occurs when the two procedures are combined is underappreciated. In addition, these previous publications generally report subjective and descriptive experience on the value of the combined approach. We have therefore attempted to address this topic from an evidencebased approach using objective, validated outcomes measures.52 Apparent age evaluation was chosen as a method of quantifying this improvement.

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Previously, it was shown that face lift alone results in 4.6 years of reduction in apparent age.1 In this same report, Swanson reported that laser resurfacing provided an additional 2.5 years of apparent age reduction. Our results parallel his findings. We have found 5.3 years of reduction in apparent age after the combined face lift and perioral peel. In addition, we have compared the apparent age to the actual age, showing that the patients’ postoperative apparent age estimate was 8.2 years younger than their real age (p = 0.0002). The reader may object to the use of apparent age as a tool for the evaluation of surgical efficacy, arguing that we have taken subjective opinions and made them objective by declaration. Our intent rather was to provide an additional, non–patient-reported means of assessing the surgical result to the other two outcomes

Volume 132, Number 5 • Outcomes of Face Lift and Perioral Peel

Fig. 3. The patient was 64 years old at the time of the preoperative photograph (above, left). She is shown 11 months postoperatively following extended SMAS face lift combined with perioral phenol–croton oil peel, platysmaplasty, and lipofilling (above, right). The close-up views demonstrate a preoperative Glogau score of 2 (below, left), which was reduced to 1.5 after surgery (below, right). Mild hypopigmentation of the perioral region is visible at 11 months postoperatively (below, right).

measures used. We leave it to the reader to decide on the merits of this approach. The patient’s perception of the end result is now recognized as a critical part of outcomes assessment in cosmetic surgery. Therefore, using well-developed and validated questionnaires for this purpose has become an essential tool in evaluating patient-reported outcomes.52,54 With regard to a validated patient-reported outcomes measure following facial rejuvenation, we found the facial lines treatment satisfaction questionnaire by Cox et al. to be the best available instrument at the time our study was initiated.24,25,54 The FACE-Q, a more comprehensive instrument for assessing outcomes of facial cosmetic procedures, was still under development. This survey has only recently

been published and was therefore unavailable for use in our study.55 In our study, patient satisfaction was found to be high with the simultaneous approach. The survey results indicate that downtime was well tolerated, essentially the same as face-lift recovery time, and that improvement in facial lines was significant. Finally, the perioral phenol–croton oil peel resulted in significant and objective wrinkle improvement as shown by the reduction in Glogau score. The follow-up period in our series was relatively long, allowing a reasonable period for assessing the incidence of hypopigmentation. Critical analysis of our results using a concentration of 33% phenol and 1.1% croton oil belies Hetter’s suggestion that peeling with 1.1% croton oil

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Fig. 4. A 63-year-old woman presented with facial aging (above, left). She underwent an extended SMAS face lift combined with perioral phenol–croton oil peel, platysmaplasty, and lipofilling. The postoperative photograph was obtained at 13-month follow-up (above, right). The close-up views demonstrate a preoperative Glogau score of 3.5 (below, left), which was reduced to 2 after surgery (below, right). Typical lightening of the perioral region is visible in the postpeel photograph at 13 months (below, right).

concentration results in no incidence of hypopigmentation.23,47–49 In fact, careful review of our cases found that (1) some degree of hypopigmentation occurs with most patients and (2) hypopigmentation is subtly progressive. In contrast, when peeling is confined to lower Fitzpatrick skin types, it is not disabling. With regard to depth of peeling, our experience reflects that of Stone,50,51 who suggests that the depth of peeling is dependent on the concentration of both the phenol and croton oil, and not that of Hetter,23,47–49 who suggests that croton oil is the critical agent determining peel depth. Although the modified phenol–croton oil formula is safer compared with stronger concentrations, it is not without complications. Because of the general skin lightening, the technique is most effective in Fitzpatrick skin types I and II.18,22,56–58

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Hyperpigmentation is a problem most often associated with sun exposure.33,45,46,50,51,58 It is transient and can be treated with tretinoin and hydroquinone.22,58 Because darker skinned individuals are prone to showing an obvious line of demarcation between treated and untreated regions,56,58,59 Fitzpatrick skin type III patients benefit best from full face treatment performed before or after face-lift surgery. We do not treat any patients with Fitzpatrick skin types IV and above with phenol–croton oil peel. Although phenol–croton oil peel typically has a postprocedure erythema that requires weeks to disappear, it is readily camouflaged during this period.6,17,58,60,61 Major complications resulting from phenol peeling are unusual. Scarring remains the most significant complication and occurred in 2 percent of our patients. When induration first

Volume 132, Number 5 • Outcomes of Face Lift and Perioral Peel

Fig. 5. Perioral close-up views of a 63-year-old patient who underwent extended SMAS face lift combined with perioral phenol–croton oil peel, platysmaplasty, and lipofilling are shown. The preoperative Glogau score of 4 (left) was reduced to 3 after surgery (right). Twelve months postoperatively, the rhytides have improved but cobblestoning (arrows) remains in the chin region.

Table 5.  Description of Complications, Treatment Methods, and Outcomes Complications

No. (%)

Complications related to face lift  Delayed wound healing

6 (12.8)

 Transient marginal mandibular nerve weakness  Hematoma (minor collection of blood)  Seroma (minor collection of serous fluid)  Cellulitis (postauricular)  Residual neck laxity  Pulmonary embolism with DVT Complications related to perioral peel  Dermatitis  Milia  Persistent redness  Hypertrophic scar

3 (6.4) 3 (6.4) 3 (6.4) 1 (2.1) 1 (2.1) 1 (2.1)

 Hyperpigmentation

1 (2.1)

3 (6.4) 2 (4.3) 2 (4.3) 2 (4.3)

Treatment

Outcome

Dressings, débridement as required Observation Aspiration Aspiration Oral antibiotics Revision neck lift Heparin, Coumadin*

Complete recovery

Topical steroids Observation, unroofing Topical steroids Intralesional steroids, topical steroids Hydroquinone

Complete recovery Complete recovery Complete recovery Complete recovery

Complete recovery Complete recovery Complete recovery Complete recovery Complete recovery Complete recovery

Complete recovery

DVT, deep venous thrombosis. *Bristol-Myers Squib, New York, N.Y.

appears, aggressive treatment with weekly triamcinolone at a dose of 5 mg/cc proved to be most effective in resolving the problem rather than monthly treatments with higher concentrations. Unfavorable results can be prevented by careful application of the solution and discontinuing the peel when frosting occurs. Undertreatment is far better than overtreatment, with a second peeling session if necessary. Although perhaps controversial, myocardial toxicity is a real risk. However, it is associated with the peeling of larger areas and is not of concern with segmental treatments.6,17,60,61 Simultaneous face lift and full face resurfacing is a controversial subject. Several authors argue that undermined flaps can be resurfaced with light-based modalities or intermediate-depth peeling,12–14,16,19,21 whereas others condemn the procedure or suggest caution.5,6,11,17,18,20,57,62 The risk is dependent on the length of undermined

face-lift flaps, the plane of undermining, and the extent of resurfacing-induced skin injury.21 In our opinion, with a deep peel solution such as the one described in this study, the risk outweighs the benefit. When phenol–croton oil peeling is performed at the time of face lift, peeling should never be performed over undermined areas.46,51 The peel injury to the subdermal plexus would lead to compromised wound healing if performed over areas undermined at the time of face lift. Finally, the equipment needed to perform a phenol–croton oil peel is minimal. No expensive laser systems are required and no concerns of aerosolization of viral products exist. All that is required is 88% phenol, croton oil, Septisol, and water. The return on investment is much more rapid than with laser systems or other light-based or radiofrequency modalities, and the results are more consistent.

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Fig. 6. The close-up photographs of a patient who underwent the combined procedure are demonstrated. The patient developed mild hypertrophic scarring (black arrow) in the right perioral area (left). Intralesional steroid injections were performed. She is shown 2 years postoperatively, with complete healing of the lesion (right).

CONCLUSIONS Perioral phenol–croton oil peeling is a simple, cost-effective, and long-lasting procedure that can be performed simultaneously during face lift. It is effective in both eradicating perioral wrinkles and significantly tightening the central lower face, thus complementing surgery. Outcomes measurements including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age document the power of this technique. There are few procedures in aesthetic surgery that yield long-lasting and consistent results with so little cost. James E. Zins, M.D. Department of Plastic Surgery Cleveland Clinic 9500 Euclid Avenue, Desk A60 Cleveland, Ohio 44195 [email protected]

PATIENT CONSENT

Patients provided written consent for the use of their images. ACKNOWLEDGMENTS

The authors thank Rachel Schweizer and Patricia Shoda for their contribution in preparing the photograph books for this publication. REFERENCES 1. Swanson E. Objective assessment of change in apparent age after facial rejuvenation surgery. J Plast Reconstr Aesthet Surg. 2011;64:1124–1131. 2. Connell BF. Pushing the clock back 15 to 20 years with facial rejuvenation. Clin Plast Surg. 2008;35:553–566, vi.

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3. Sundine MJ, Kretsis V, Connell BF. Longevity of SMAS facial rejuvenation and support. Plast Reconstr Surg. 2010;126:229–237. 4. Friel MT, Shaw RE, Trovato MJ, Owsley JQ. The measure of face-lift patient satisfaction: The Owsley Facelift Satisfaction Survey with a long-term follow-up study. Plast Reconstr Surg. 2010;126:245–257. 5. Baker TJ. Chemical face peeling and rhytidectomy: A combined approach for facial rejuvenation. Plast Reconstr Surg Transplant Bull. 1962;29:199–207. 6. Baker TJ, Gordon HL. Chemical face peeling: An adjunct to surgical facelifting. South Med J. 1963;56:412–414. 7. Baker TJ, Gordon HL. Adjunctive aids to rhytidectomy. South Med J. 1969;62:108–112. 8. Baker TJ, Gordon HL. Chemical peeling as a practical method for removing rhytides of the upper lip. Ann Plast Surg. 1979;2:209–212. 9. Baker TM. Dermabrasion: As a complement to aesthetic surgery. Clin Plast Surg. 1998;25:81–88. 10. Becker FF. Circumoral chemical peel combined with cervicofacial rhytidectomy. Arch Otolaryngol. 1983;109:172–174. 11. Brackup AB. Combined cervicofacial rhytidectomy and laser skin resurfacing. Ophthal Plast Reconstr Surg. 2002;18:24–39. 12. Dingman DL, Hartog J, Siemionow M. Simultaneous deepplane face lift and trichloroacetic acid peel. Plast Reconstr Surg. 1994;93:86–93; discussion 94. 13. Fulton JE. Simultaneous face lifting and skin resurfacing. Plast Reconstr Surg. 1998;102:2480–2489. 14. Jackson IT, Yavuzer R, Beal B. Simultaneous facelift and carbon dioxide laser resurfacing: A safe technique? Aesthetic Plast Surg. 2000;24:1–10. 15. Kamer FM, Lefkoff LA. Injectable collagen, chemical peeling and dermabrasion as an adjunct to rhytidectomy. Facial Plast Surg. 1992;8:89–92. 16. Koch BB, Perkins SW. Simultaneous rhytidectomy and fullface carbon dioxide laser resurfacing: A case series and meta-analysis. Arch Facial Plast Surg. 2002;4:227–233. 17. Litton C. Chemical face lifting. Plast Reconstr Surg Transplant Bull. 1962;29:371–380. 18. Litton C, Szachowicz EH II, Trinidad GP. Present day status of the chemical face peel. Aesthetic Plast Surg. 1986;10:1–7. 19. Mayl N, Felder DS. CO(2) laser resurfacing over facial flaps. Aesthet Surg J. 1997;17:285–292. 20. Ramirez OM, Pozner JN. Laser resurfacing as an adjunct to endoforehead lift, endofacelift, and biplanar facelift. Ann Plast Surg. 1997;38:315–321; discussion 321.

Volume 132, Number 5 • Outcomes of Face Lift and Perioral Peel 21. Roberts TL III, Pozner JN, Ritter E. The RSVP facelift: A highly vascular flap permitting safe, simultaneous, comprehensive facial rejuvenation in one operative setting. Aesthetic Plast Surg. 2000;24:313–322. 22. Stuzin JM, Baker TJ, Gordon HL. Treatment of photoaging: Facial chemical peeling (phenol and trichloroacetic acid) and dermabrasion. Clin Plast Surg. 1993;20:9–25. 23. Hetter GP. An examination of the phenol-croton oil peel: Part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105:1061– 1083; discussion 1084. 24. Cox SE, Finn JC, Stetler L, Mackowiak J, Kowalski JW. Development of the Facial Lines Treatment Satisfaction Questionnaire and initial results for botulinum toxin type A-treated patients. Dermatol Surg. 2003;29:444–449; discussion 449. 25. Kosowski TR, McCarthy C, Reavey PL, et al. A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123:1819–1827. 26. Ponsky D, Guyuron B. Comprehensive surgical aesthetic enhancement and rejuvenation of the perioral region. Aesthet Surg J. 2011;31:382–391. 27. Ransom ER, Antunes MB, Bloom JD, Greco T. Concurrent structural fat grafting and carbon dioxide laser resurfacing for perioral and lower face rejuvenation. J Cosmet Laser Ther. 2011;13:6–12. 28. Perkins NW, Smith SP Jr, Williams EF III. Perioral rejuvenation: Complementary techniques and procedures. Facial Plast Surg Clin North Am. 2007;15:423–432, vi. 29. Kitzmiller WJ, Visscher M, Page DA, Wicket RR, Kitzmiller KW, Singer LJ. A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles. Plast Reconstr Surg. 2000;106:1366–1372; discussion 1373. 30. Agarwal A, Dejoseph L, Silver W. Anatomy of the jawline, neck, and perioral area with clinical correlations. Facial Plast Surg. 2005;21:3–10. 31. Holmkvist KA, Rogers GS. Treatment of perioral rhytides: A comparison of dermabrasion and superpulsed carbon dioxide laser. Arch Dermatol. 2000;136:725–731. 32. Niechajev I, Ljungqvist A. Perioral dermabrasion: Clinical and experimental studies. Aesthetic Plast Surg. 1992;16:11–20. 33. Perkins SW, Balikian R. Treatment of perioral rhytids. Facial Plast Surg Clin North Am. 2007;15:409–414, v. 34. Fulton JE Jr. Dermabrasion, chemabrasion, and laserabrasion: Historical perspectives, modern dermabrasion techniques, and future trends. Dermatol Surg. 1996;22:619–628. 35. Weinstein C, Roberts TL III. Aesthetic skin resurfacing with the high-energy ultrapulsed CO2 laser. Clin Plast Surg. 1997;24:379–405. 36. Ciocon DH, Hussain M, Goldberg DJ. High-fluence and high-density treatment of perioral rhytides using a new, fractionated 2,790-nm ablative erbium-doped yttrium scandium gallium garnet laser. Dermatol Surg. 2011;37:776–781. 37. Stuzin JM, Baker TJ, Baker TM. CO2 and erbium:YAG laser resurfacing: Current status and personal perspective. Plast Reconstr Surg. 1999;103:588–591. 38. Bisson MA, Grover R, Grobbelaar AO. Long-term results of facial rejuvenation by carbon dioxide laser resurfacing using a quantitative method of assessment. Br J Plast Surg. 2002;55:652–656. 39. Manuskiatti W, Fitzpatrick RE, Goldman MP. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am Acad Dermatol. 1999;40:401–411.

40. Schwartz RJ, Burns AJ, Rohrich RJ, Barton FE Jr, Byrd HS. Long-term assessment of CO2 facial laser resurfacing: Aesthetic results and complications. Plast Reconstr Surg. 1999;103:592–601. 41. Dijkema SJ, van der Lei B. Long-term results of upper lips treated for rhytides with carbon dioxide laser. Plast Reconstr Surg. 2005;115:1731–1735. 42. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: Our experience with more than 2000 treatments. Aesthet Surg J. 2009;29:317–322. 43. Tierney EP, Hanke CW. Fractionated carbon dioxide laser treatment of photoaging: Prospective study in 45 patients and review of the literature. Dermatol Surg. 2011;37:1279–1290. 44. Baker TJ, Gordon HL. The ablation of rhytids by chemical means: A preliminary report. J Fla Med Assoc. 1961;48:451–454. 45. Gatti JE. Eyelid phenol peel: An important adjunct to blepharoplasty. Ann Plast Surg. 2008;60:14–18; discussion 19. 46. Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45. 47. Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeons’ role. Plast Reconstr Surg. 2000;105:752–763. 48. Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000;105:240–248; discussion 249–251. 49. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast Reconstr Surg. 2000;105:227– 239; discussion 249–251. 50. Stone PA. The use of modified phenol for chemical face peeling. Clin Plast Surg. 1998;25:21–44. 51. Stone PA, Lefer LG. Modified phenol chemical face peels: Recognizing the role of application technique. Clin Plast Surg. 2001;28:13–36. 52. Alderman AK, Chung KC. Discussion. A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123:1828–1829. 53. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg. 1996;15:134–138. 54. Pusic AL, Klassen AF, Scott AM, Cano SJ. Discussion. The measure of face-lift patient satisfaction: The Owsley Facelift Satisfaction Survey with a long-term follow-up study. Plast Reconstr Surg. 2010;126:258–260. 55. Pusic AL, Klassen AF, Scott AM, Cano SJ. Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale: A new patient-reported outcome instrument for facial aesthetics patients. Clin Plast Surg. 2013;40:249–260. 56. Branham GH, Thomas JR. Rejuvenation of the skin sur face: Chemical peel and dermabrasion. Facial Plast Surg. 1996;12:125–133. 57. Spira M, Gerow FJ, Hardy SB. Complications of chemical face peeling. Plast Reconstr Surg. 1974;54:397–403. 58. Stuzin JM. Phenol peeling and the history of phenol peeling. Clin Plast Surg. 1998;25:1–19. 59. Landau M. Chemical peels. Clin Dermatol. 2008;26:200–208. 60. Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg. 1979;63:44–48. 61. Landau M. Cardiac complications in deep chemical peels. Dermatol Surg. 2007;33:190–193; discussion 193. 62. Guyuron B, Michelow B, Schmelzer R, Thomas T, Ellison MA. Delayed healing of rhytidectomy flap resurfaced with CO2 laser. Plast Reconstr Surg. 1998;101:816–819.

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