Deep Chemical Peels and Facial Cosmetic Surgery: Where Do We Stand in 2026? by Dr Marina Queiroz

Introduction 

In my aesthetic dermatology practice, I am regularly consulted by maxillofacial and oculoplastic surgeons to help optimise facial rejuvenation protocols. The recurring question is: under which conditions can a deep phenol–croton oil peel be safely combined with surgery, and with what level of evidence? 

Reference reviews remind us that chemical peels are classified as superficial, medium, or deep depending on depth of tissue injury; deep peels reach the reticular dermis and induce long-lasting collagen remodelling, at the cost of higher morbidity [1–3]. Existing guidelines emphasise strict patient selection, skin priming, and photoprotection, and advise against deep phenol peels in Fitzpatrick skin types IV–VI [2]. 

In this context, I propose here a focused overview of the association between: ● maxillofacial surgery (cervicofacial lifting, perioral procedures), 

● oculoplastic surgery, and 

● deep phenol–croton oil chemical peels. 

Modern basis of phenol–croton oil peeling 

Historical Baker–Gordon formulas have progressively been replaced by “Hetter-modified” formulations with lower phenol and croton oil concentrations, offering more controlled depth and improved tolerability [4–6]. 

A major review by Wambier et al. (International Peeling Society) underlines that:

● phenol–croton oil peels remain the reference for deep rhytides and severe photoaging, 

● peel depth can be modulated by croton oil concentration, volume applied, and vehicle, 

● segmental peels (perioral, peri-orbital) allow targeting of the most damaged areas while limiting overall morbidity [4]. 

More recently, a series of 64 patients treated with phenol/croton oil peels (21 perioral, 15 lower eyelid, 22 full-face, 2 acne scarring, 4 seborrheic keratoses) showed marked improvement in wrinkles and scars across the cohort, re-epithelialisation within 10–15 days, and only a few mild, reversible adverse events [6]. Histology demonstrated new band-like collagen deposition in the reticular dermis, confirming the potential for deep dermal remodelling [6]. 

Combination with maxillofacial surgery 

Historical perspective: from “adjunct to facelift” to segmental approaches 

The idea of using a deep peel as an adjunct to facelifting dates back to the work of Baker and Gordon in the 1960s, who described phenol peeling as an “adjunct to surgical facelifting” [7]. 

In 1983, Becker reported a series of 40 cervicofacial rhytidectomies, in which 32 (80%) were combined with a circumoral chemical peel performed on the day of surgery or the following day [8]. This pioneer series demonstrated the feasibility of combined treatment, with a clear objective: enhance correction of perioral wrinkles that facelift alone only partially improves. 

Contemporary data: facelift + perioral phenol–croton oil peel 

One of the most cited studies is a retrospective series by Ozturk et al., including 47 patients who underwent facelift combined with a perioral phenol–croton oil peel [9]. 

Key findings: 

● Overall satisfaction: 6.5/7 on a validated scale (1 = not satisfied, 7 = very satisfied) [9]. 

● Apparent age: patients looked on average 8.2 years younger than their chronological age postoperatively (p = 0.0002) [9]. 

● Perioral wrinkles (Glogau scale): mean score improved from 3.30 ± 0.47 to 2.15 ± 0.59, i.e. a 1.15-grade reduction (p < 0.0001) [9].

These data nicely illustrate the specific contribution of the deep peel on the surface component (deep rhytides, texture) where surgery acts mainly on ptosis and volume. 

Segmental strategies and “no-go zones” 

Recent work on MACS lifts and modern cervicofacial lifts confirms the value of segmental phenol–croton oil peels targeting perioral and peri-orbital rhytides, while sparing lifted flaps, which are more fragile vascularly [10]. 

Two practical principles are now reasonably consensual: 

1. Target the most affected aesthetic units (upper lip, commissures, sometimes chin) with a modulated phenol–croton peel. 

2. Avoid applying a deep peel directly over widely undermined flaps or high-tension suture lines, to reduce the risk of delayed healing and scarring [10]. 

In practice, this often translates into facelift + perioral phenol–croton peel in a single stage, or facelift followed by a segmental peel 4–6 weeks later, depending on the patient profile and team logistics. 

Combination with eyelid and peri-orbital surgery 

Eyelid phenol peel as an adjunct to blepharoplasty 

Gatti popularised, as early as 2008, the concept of lower eyelid phenol peel as an adjunct to blepharoplasty to treat residual fine wrinkles and hyperpigmentation that surgery alone does not address [11]. The article emphasises a point still valid in 2025: blepharoplasty corrects fat pads and skin excess very well, but not epidermal/dermal quality (texture, dyschromia). 

More recent series, such as those by Orra et al., describe peri-orbital phenol–croton oil peels combined with blepharoplasty as part of evolving peri-orbital rejuvenation protocols [12]. Although sample sizes remain modest, authors consistently report significant improvement in peri-orbital laxity, fine wrinkling, and pigmentation, at the cost of prolonged downtime. 

Randomised trial: blepharoplasty with or without phenol peel 

A randomised clinical trial by Asilian et al. provides particularly interesting data. The authors included 30 patients scheduled for “micro-invasive” lower blepharoplasty: 

● 15 patients underwent blepharoplasty alone, 

● 15 patients underwent blepharoplasty + 89% phenol peel of the entire peri-orbital region [13].

Key outcomes: 

● Patient and physician satisfaction: no significant difference between the two groups (p > 0.05) [13]. 

● Mean recovery time: 1.8 days in the blepharoplasty-only group vs 7.3 days in the blepharoplasty + peel group (p < 0.0001) [13]. 

● Complication rate: significantly higher in the “blepharopeel” group (p < 0.05), including more prolonged erythema and irritation [13]. 

This trial highlights an essential point: increasing the aggressiveness of surface treatment (89% phenol on a delicate zone) can dramatically increase morbidity and downtime, without proportional gain in global satisfaction. 

In my reading, this study does not condemn peri-orbital peeling but supports: ● lower phenol concentrations, 

● more limited and carefully dosed application areas, 

● and very clear patient counselling regarding expected downtime. 

Safety data: what do we know in 2025? 

Systemic toxicity of phenol 

Historically, the main concern limiting widespread use of phenol–croton oil peels has been phenol-related cardiotoxicity. Gross (1984) reported that: 

● 39% of 54 patients receiving rapidly applied full-face phenol peels developed cardiac arrhythmias, 

● whereas this rate dropped to 22% when the face was treated in two stages on two different days, and arrhythmias were less severe [14]. 

In 1988, Botta et al. proposed a prevention protocol including aggressive hydration, forced diuresis, and lidocaine prophylaxis to reduce arrhythmia risk [15]. 

Modern series, such as that of Liapakis et al. (64 patients treated between 2014 and 2023), reported no cardiac or respiratory complications, thanks to strict protocols: 

● splitting the face into aesthetic units with at least 15 minutes between applications,

● adequate hydration, 

● and, where appropriate, short-acting beta-blockers in patients already on antihypertensives [6]. 

A more recent letter by Rullan et al. on the cardiac safety of full-face phenol–croton peels points in the same direction, suggesting that contemporary, well-conducted protocols may be associated with lower arrhythmia rates than historical series [16]. 

Local complications: pigmentation, scarring, infections 

Guidelines and major reviews agree on the most frequent complications: ● prolonged erythema, 

● post-inflammatory hyper- or hypopigmentation, 

● delayed re-epithelialisation, 

● hypertrophic or keloid scarring, 

● and bacterial (Staphylococcus, Streptococcus, Pseudomonas) or viral (HSV) infections [1–3,6,17]. 

In Liapakis’ 64-patient series, only a few cases of prolonged hyperpigmentation and erythema in 2 patients were reported, all reversible with topical depigmenting agents [6]. 

To mitigate these risks, several practical points emerge: 

● Skin type: deep peels are best reserved for Fitzpatrick I–III; high caution or avoidance in darker phototypes [1,2]. 

● Skin priming 2–4 weeks before with hydroquinone, topical retinoids, and strict photoprotection [2,3]. 

● Systematic HSV prophylaxis for perioral and peri-labial peels. 

● Close early follow-up, especially when the peel is combined with a facelift or blepharoplasty. 

Practical implications for maxillofacial and oculoplastic surgery 

In light of these data, this is how I personally integrate deep peels into combined programmes alongside surgeons:

1. Cervicofacial facelift + perioral modulated phenol–croton peel ○ Patients: Fitzpatrick I–III, severe photoaging, “barcode” wrinkles. 

○ Peel limited to upper lip and commissures, carefully avoiding directly peeled undermined areas. 

○ The Ozturk series (satisfaction 6.5/7, apparent rejuvenation of 8.2 years) provides a solid argument to propose this combination to well-informed, motivated patients [9]. 

2. Blepharoplasty + light-to-moderate peri-orbital phenol–croton peel 

○ Approach inspired by Gatti and Orra [11,12], but downscaled in light of Asilian’s trial (89% phenol clearly increasing morbidity) [13]. 

○ I favour lower concentrations and smaller treatment areas, accepting a less “maximal” effect to preserve safety and manageable downtime. 

3. Single-stage vs staged procedures 

○ When operative time and patient status allow, I am comfortable with a single operative session combining surgery and segmental peel (perioral or peri-orbital). 

○ For fragile patients or extensive surgical procedures, I prefer to delay the peel by 4–6 weeks, taking into account data on complications and wound healing [6,14,15]. 

4. Patient communication 

○ I systematically stress that this is a strategy with high potential benefit but heavy downtime (marked erythema for 2–3 weeks, strict photoprotection for months). 

○ I make it clear that available data show real but not “magical” improvement, and that there are gentler alternatives (fractional lasers, serial medium-depth peels) with less dramatic but more gradual effects. 

Conclusion 

In 2025, deep phenol–croton oil peels are no longer confined to a handful of pioneers: they are better understood, more protocolised, and supported by recent data on efficacy and safety.

Studies of facelift + perioral peel and blepharoplasty + peri-orbital peel demonstrate that these combinations can provide: 

● significant reduction in deep wrinkles, 

● measurable improvement in apparent age, 

● and high patient satisfaction, 

provided that practitioners accept higher cutaneous morbidity and adhere to strict safety protocols. 

As a dermatologist, my role alongside maxillofacial and oculoplastic surgeons is to: ● select appropriate candidates, 

● adapt formulas and treatment zones, 

● secure the procedure (monitoring, hydration, prophylaxis), 

● and manage cutaneous recovery (topicals, photoprotection, follow-up). 

I am convinced that, in experienced hands and within a multidisciplinary setting, phenol–croton peels remain a powerful adjunct to improve skin quality in surgical facial rejuvenation programmes. 

References 

1. Fischer TC, Perosino E, Poli F, Viera MS, Dreno B; Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: an update 2009. J Eur Acad Dermatol Venereol. 2010;24(3):281-292. 

2. Khunger N; IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(Suppl):S5-S12. 

3. Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. J Clin Aesthet Dermatol. 2018;11(8):21-28. 

4. Wambier CG, Lee KC, Soon SL, et al. Advanced chemical peels: phenol-croton oil peel. J Am Acad Dermatol. 2019;81(2):???-???. doi:10.1016/j.jaad.2018.11.060.

5. Hetter GP. An examination of the phenol-croton oil peel: Parts I–IV. Plast Reconstr Surg. 2000;105:1229-?. 

6. Liapakis IE, Ismailos GK, Michail A, et al. Clinical aspects and risks of the phenol/croton oil peel. Exp Ther Med. 2024;28(3):422. doi:10.3892/etm.2024.12711. 

7. Baker TJ, Gordon HL. Chemical face peeling: an adjunct to surgical facelifting. South Med J. 1963;56:412-414. 

8. Becker FF. Circumoral chemical peel combined with cervicofacial rhytidectomy. Arch Otolaryngol. 1983;109(3):172-174. 

9. Ozturk CN, Huettner F, Ozturk C, Bartz-Kurycki MA, Zins JE. Outcomes assessment of combination face lift and perioral phenol-croton oil peel. Plast Reconstr Surg. 2013;132(5):743e-753e. 

10. Sommar P, et al. Use of ancillary procedures in combination with the MACS lift. Aesthet Plast Surg. 2025;??:??-??. 

11. Gatti JE. Eyelid phenol peel: an important adjunct to blepharoplasty. Ann Plast Surg. 2008;60(1):14-18. 

12. Orra S, Waltzman JT, Mlynek K, et al. Periorbital phenol-croton oil chemical peel in conjunction with blepharoplasty: an evolving technique for periorbital facial rejuvenation. Plast Reconstr Surg. 2015;136(4 Suppl):99-100. 

13. Asilian A, Shahmoradi Z, Talakoub M, et al. Evaluation of combination therapy with peeling added to minimal invasive blepharoplasty in lower eyelid rejuvenation. J Cosmet Dermatol. 2020;19(11):2922-2928. 

14. Gross BG. Cardiac arrhythmias during phenol face peeling. Plast Reconstr Surg. 1984;73(4):590-594. 

15. Botta SA, Straith RE, Goodwin HH. Cardiac arrhythmias in phenol face peeling: a suggested protocol for prevention. Aesthetic Plast Surg. 1988;12(2):115-117. 

16. Samargandy S, et al. Chemical Peels for Skin Resurfacing. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. 

17. The Plastics Fella. Chemical Peels: Classification, Indications, & Complications. 2025 (accessed 2025). 

18. Lee KC, Wambier CG, Soon SL, et al. Segmental phenol-croton oil chemical peels for treatment of perioral and periorbital rhytides. J Am Acad Dermatol. 2019;81(2).

About the author 

Dr Marina QUEIROZ(Brazilian dermatologist) is a physician specialized in clinical, aesthetic, and procedural dermatology, with advanced training in Brazil and France

AIME CONGRESS 2026