Key Points
Question
Is the trichloroacetic acid peel a safe and efficient treatment modality for light and dark skin types?
Findings
This case series demonstrates that the use of a novel genetico-racial skin classification and a standardized “strip” technique of acid application allows for decreased peel risks and enhanced results.
Meaning
When based on proper guidelines for preoperative evaluation and acid application, trichloroacetic acid peel is a helpful and efficient tool for the enhancement and rejuvenation of light and dark skins.
Abstract
Importance
Despite their great potential, medium and deep trichloroacetic acid peels are underused in light-skinned patients and are rarely used in darker-skinned patients because of the widespread fear of pigmentary complications and scarring. This concern has led many physicians to opt for the use of lighter types of peels (glycolic acid peel, Jessner peel, etc) and different lasers and intense light technologies. Trichloroacetic acid peels have been described in numerous publications. However, no study to date has described the precise technique and the practical pearls of a successful trichloroacetic acid peel approach in a clear, detailed, and reproducible manner.
Objectives
To clarify a practical approach to a universal trichloroacetic acid peel and to offer novice and experienced facial plastic surgeons an organized, easy, and safe technique for medium and deep trichloroacetic acid peels.
Design, Setting, and Participants
This study was a case series of universal trichloroacetic acid peels in an academic setting. The study dates were January 1, 1996, to November 1, 2015.
Main Outcomes and Methods
This article discusses the preoperative evaluation for a chemical peel, a previously published genetico-racial skin classification, and the trichloroacetic acid peel technique, which aims at standardizing and controlling the application of the acid to improve results and lessen complications. The “strip” technique is described, which increases the physician’s control over the peel depth.
Results
A total of 923 trichloroacetic acid peels in 803 female patients (87.0%) and 120 male patients (13.0%) were reviewed (mean age, 41.59 years). The follow-up period ranged from 6 months to 13 years (mean, 13 months). This case series revealed a low incidence of complications, including 54 patients (5.9%) with persistent hyperpigmentation, 3 patients (0.3%) with mild telangiectasia, 2 patients (0.2%) with acute herpesvirus infection, 2 patients (0.2%) with bacterial Staphylococcus infection, and 1 patient (0.1%) with hypopigmentation.
Conclusions and Relevance
When properly applied, trichloroacetic acid peels are efficient and safe for light and dark skin. The technique can be an easily implementable addition to a physician’s cosmetic practice.
Level of Evidence
4.
This case series describes a practical approach to a universal trichloroacetic acid peel.
Introduction
In the 1990s, the trichloroacetic acid peel approach was popularized by Obagi, a renowned American dermatologist. Obagi is credited for the revival of the trichloroacetic acid peel technique through a series of instructional courses.
Our general impression is that the interest in trichloroacetic acid peels has decreased somewhat in the past 2 decades. Concern regarding pigmentary complications and scarring has led many physicians to opt for the use of lighter types of peels (glycolic acid peel, Jessner peel, etc) and different lasers and intense light technologies. This fear is regrettable because medium and deep trichloroacetic acid peels, when performed according to specific rules and precautions, can be an invaluable part of a physician’s cosmetic practice. With an increasingly diverse racial/ethnic population in North America comes the need to develop a universal approach to trichloroacetic acid peels that can be applied to different skin types.
No study to date has described the precise technique and the practical pearls of a successful trichloroacetic acid peel approach in a clear, detailed, and reproducible manner. This article discusses the basic rules and techniques involved in a novel approach to the trichloroacetic acid peel procedure, including the prepeel preparation, anesthesia modality, standardization of factors controlling the peel depth, “strip” application technique, and postpeel care. It is anticipated that this article will assist other physicians in adding a rewarding trichloroacetic acid peel to their present cosmetic practice.
Herein, we present a universal approach to trichloroacetic acid peels performed on almost 1000 patients during the past 20 years (January 1, 1996, to November 1, 2015). We believe that this approach can safely and efficiently be applied by other facial plastic surgeons to patients with light and darker skin types and can greatly enhance their practices.
Methods
Prepeel Skin Classification
The goal of an ideal prepeel skin classification is not simply to label a patient’s skin under one category or another but to help predict the response of each skin type to the chemical peel and its potential for complications. Current popular skin classifications, mainly types identified by Fitzpatrick, consider the degree of skin pigmentation and the susceptibility to tan and burn. Skin color, whether white, yellow, olive, brown, or black, is widely considered to be the main factor in predicting the skin reaction to a peel or laser.
One of us (N.F.) developed and published a novel classification system, the genetico-racial skin classification, that takes into account a patient’s racial/ethnic background in addition to his or her skin color. As such, this classification is centered on skin color and facial features rather than skin color alone. The aim of this classification is to assist the physician in predicting, with a reasonable degree of accuracy, the response to a peel and the possible complications associated with different patient groups.
Genetico-Racial Skin Classification Categories
If one examines the world map and proceeds from north to south across the 3 ancient continents (Europe, with mostly Caucasians; Africa, with mostly blacks; and Asia, with mostly Asians) (Figure 1), you will notice that the skin color and features change gradually and predictably from lighter, thinner skin and smaller features in the north to darker, thicker skin and larger features in the south. For simplicity, these 3 main racial/ethnic categories are further subdivided. The Caucasians in Europe (and around the Mediterranean Sea in northerly Africa and western Asia) are subdivided into 4 subcategories, the blacks in Africa are subdivided into 2 categories, and the Asians in Asia are subdivided into 3 subcategories.
Figure 1. Genetico-Racial Skin Classification of Skin Color and Features.
The classification runs in a north to south manner vertically across Europe and Africa and in a parallel vertical manner across Asia. In Europe and Africa, we find the roots of the northern Europeans (Nordics) (pink), mid-Europeans (red), southern Europeans (Mediterraneans) (green), southern Caucasians (Indo-Pakistanis) (brown), and central and southern Africans (gray). In eastern Asia, we find the roots of the northern (yellow), central (light orange), and southern (dark orange) Asians.
Predicting the Skin’s Response to a Peel
Using the genetico-racial skin classification, the response to a peel is based not simply on skin color but also on the genetico-racial origins (which affect the skin color and features). By using this classification, physicians may better predict a patient’s response to the peel, adjust the treatment, and lessen complications (Table).
Table. Characteristics of the Different Genetico-Racial Skin Classification Categories and Their Responses to the Trichloroacetic Acid Peel.
| Category | Geographic Origin | Skin Characteristics | Features | Skin Reaction to Peela | Rating |
|---|---|---|---|---|---|
| Northern Europeans (Nordics) (eg, Scandinavian, Irish, or Scottish) | Northern Europe | Thin white, with a pink element | Fine | Erythema (+++), telangiectasia (+), and scarring rare (if peel too deep) | Good (with light and medium peels) |
| Mid-Europeans (eg, French, German, or English) | Central Europe | Average thickness, white or light tan | Medium in size | Mild reaction, with erythema (+) and hyperpigmentation (+) | Excellent (with all peels) |
| Southern Europeans (Mediterraneans) (eg, Spanish, Greek, Italian, or Turkish) | Southern Europe, northern Africa, and western Asia | Slightly thick, with a medium tan | Slightly large | Erythema (++), hyperpigmentation (++) | Good to very good (with medium and medium to deep peels) |
| Southern Caucasians (Indo-Pakistanis) (eg, Egyptian, Saudi Arabian, or Indian) | Northern Africa, western Asia | Thick, with a deep tan to dark brown | Moderately large | Hyperpigmentation (+++), hypopigmentation rare (if deep peel) | Passable to good (with light peels) |
| Central (eg, Ethiopian) and southern Africans | Central and southern Africa | Thick, with black to deep black | Large | Hyperpigmentation (+++), hypopigmentation (if deep peel) | Passable (with very light peels) |
| Northern, central, and southern Asians (eg, Chinese, Japanese, or Filipino) | Eastern Asia | Thick, with light, medium, or dark brown | Moderately large | Hyperpigmentation (++), erythema (++) (turning later to hyperpigmentation), and hypopigmentation rare (if peel too deep, especially in southern Asians) | Good (with light to medium and medium peels) |
A single plus sign indicates mild, 2 plus signs indicate moderate, and 3 plus signs indicate severe.
Based on our experience, the candidates with the most favorable reaction to a peel and with the fastest recuperation are the mid-Europeans (eg, French, German, or English). Second best are the northern Europeans (Nordics [eg, Scandinavian, Irish, or Scottish]) and the southern Europeans (Mediterraneans [eg, Spanish, Greek, Italian, or Turkish]). The characteristics of each of the genetico-racial skin classification categories, their early response to treatment, and the potential risks are summarized in the Table. In addition to the obvious genetic characteristics (skin color and features), asking the patient where his or her parents and grandparents originate from can help determine the patient’s classification category.
Universal Trichloroacetic Acid Peel
Trichloroacetic Acid and Its Indications
Trichloroacetic acid is a keratolytic acid that produces protein denaturation. It is a bactericidal agent with no known systemic toxic effects. Trichloroacetic acid works differently than 88% phenol, which is a keratocoagulant. The trichloroacetic acid used in our practice is available in different concentrations ranging from 35% to 45%.
In current practice, most patients interested in a peel are seen with specific problems, with the most common being hyperpigmentation (melasma, ephelides, and lentigo). Other inquiries are regarding acne vulgaris (comedones and papules), fine wrinkles, dilated pores, scars, and keratosis (seborrheic and actinic). The more superficial the skin problem, the better the response of a peel, which is why deep wrinkles do not respond to peels as adequately as fine, superficial wrinkles.
Choice of the Peel Depth
Medium and medium to deep trichloroacetic acid peels are the 2 most commonly used modalities in our practice. Deep peels are avoided in Nordics because of fear of scarring and especially in Indo-Pakistanis and Africans for fear of hypopigmentation. Novice physicians are advised to restrict their trichloroacetic acid peel practice to superficial peels (light or light to medium depth) until they have gained substantial experience. In general, we use (1) medium to deep peels for mid-Europeans and southern Europeans (Mediterraneans), (2) medium and light to medium peels for northern Europeans (Nordics) and Asians, (3) light peels for southern Caucasians (Indo-Pakistanis), and (4) very light peels for Africans.
Prepeel Preparation
The 3 goals of the prepeel preparation are to activate the skin, control the peel depth, and shorten the recuperation. These objectives are achieved through the use of 3 active ingredients, namely, retinoic acid, alphahydroxy acid, and hydroquinone. Their mechanisms of action facilitate uniform peel penetration, provide more skin vascularity, stimulate faster epithelialization, and lessen postinflammatory hyperpigmentation. Other less important goals of the prepeel preparation are to hydrate the skin by using a moisturizer and to provide the skin with sun protection through application of a broad-spectrum sunscreen.
We have found the change in skin color to be a good indicator of the effectiveness of the prepeel preparation using these 3 ingredients. The target color strived for by this preparation is a medium pink hue, which can be detected even in patients with dark skin. This target color requires a preparation treatment ranging from 3 to 6 weeks in general.
Preoperative Skin Preparation and Local Anesthesia
Lorazepam (1 mg) is given sublingually to the patient approximately 30 minutes before the procedure. Half a tube of prilocaine cream (about 15 g) is spread all over the face and neck, covered with saran wrap, and left for approximately 20 minutes (Figure 2A). The face is then cleaned with towels saturated with tap water to ensure that there is no leftover cream or makeup. We have stopped using alcohol as a degreasing agent. We believe that it has no substantial role and causes unnecessary skin irritation before the peel, which may affect homogeneous peel absorption.
Figure 2. Trichloroacetic Peel Technique Sequence, Showing the Successive Steps During 5 to 10 Minutes.
A, Half a tube of prilocaine cream (approximately 15 g) is spread on the face and neck. After application of the prilocaine cream, it is then covered with saran wrap and left for approximately 20 minutes. Next, the anesthetic cream is removed gently from the face and neck. B, The trichloroacetic acid concentration is 30% to 35% for a light peel, 35% to 40% for a medium peel, and 40% to 45% for a medium to deep peel and a deep peel. A piece of cotton gauze (one 4 × 4-in folded piece or a stack of four 2 × 2-in pieces) is moistened with a standard amount of acid by holding it firmly against the opening of the bottle and then turning the bottle upside down for 1 second to moisten one corner at a time, which is repeated for each of the 4 corners. The folded cotton gauze is then squeezed to distribute the acid evenly in it. The goal is to have a wet cotton gauze but not too wet. C-G, Application of the acid (see also Figure 3). H, A cold cotton towel is used on treated areas during the procedure to soothe a burning sensation. By standardizing all other variables, the operator can concentrate on the single variable that can control the peel depth, namely, the frost sign (white color of the peeled skin).
Control of the Peel Depth
Most peel techniques use a combination of factors to evaluate the depth of the peel during its application, such as the acid concentration, number of passes, degree of cotton gauze saturation, and skin color, among others. This combination confuses estimation of the peel depth, resulting in a poorly controlled depth and therefore an unpredictable result.
For simplicity, our evaluation of the peel depth is based solely on the frost sign (the white color of the peeled skin). All other variable factors affecting the depth of the peel are standardized.
A target white color frost exists for each of the 3 main peels that will signal the end point of the procedure. The target frost for the 3 basic types of peels is as follows: (1) light peel (the frost is light white, made of scattered white spots, like “white stars on pink skies”), (2) medium peel (the frost is medium white), and (3) deep peel (the frost is deep white).
This classification system is easy to remember: the goal is to reach light white for a light peel, medium white for a medium peel, and deep white for a deep peel. The only exception is the neck area, which should be less white (more superficial) than the face because of its skin sensitivity and slower recuperation.
Strip Technique
The aim of the strip technique is to standardize all factors that may affect the depth of the peel, leaving the frosting (whitening of the skin) as the only variable sign. Figure 2 and Figure 3 show the successive steps of this technique.
Figure 3. Dividing the Face Into Subunits to Simplify and Control the Peel Variables.
The face is divided into sections called strips. The goal is to move across the face in a calculated fashion when applying the acid. The number of passes (trichloroacetic acid layers) applied to each strip is identical. In addition, the directions of such passes (the strokes with the wet cotton gauze) per strip are identical (horizontal and vertical in each strip). The sequence in this figure is shown as an example. The surgeon is standing behind the patient’s head during the peel. Therefore, the reader is encouraged to turn the figure upside down to perceive the view during the procedure. The surgeon uses the left hand to peel the left face and neck and the right hand to peel the right face and neck.
This technique takes between 5 to 10 minutes. It proceeds as follows:
(1) The prilocaine cream is removed gently from the face and neck using a wooden tongue depressor. Removal continues with wet cotton towels and then by dry cotton ones.
(2) The face is divided mentally into sections called strips (Figure 3). The goal is to move across the face in a calculated fashion when applying the acid.
(3) The trichloroacetic acid concentration is standardized. For example, it is 30% to 35% for a light peel, 35% to 40% for a medium peel, and 40% to 45% for a medium to deep peel or a deep peel.
(4) A piece of gauze (one 4 × 4-in folded piece or a stack of four 2 × 2-in pieces) is moistened with a standard amount of acid. First, the corner of the folded cotton gauze is held firmly against the neck of the acid bottle (Figure 2B). Second, the bottle is turned upside down for 1 second to moisten the corner. Third, the same procedure is repeated on the other 3 corners of the double-folded 4 × 4-in cotton gauze. Fourth, the cotton gauze is squeezed between the fingers to distribute the acid evenly in it.
(5) The acid is then applied to the skin in a precise sequence. Application begins on the left side of the face, then the right side, then the forehead, then the eyelids, and then the neck (Figure 3).
(6) The number of passes (trichloroacetic acid layers) applied to each strip is identical. In addition, the horizontal and vertical directions of the strokes with the wet cotton gauze per strip are the same. The sequence is shown in Figure 3.
By standardizing all of those variables, the operator can concentrate on the single variable sign left, namely, the frosting (white color). The last step in the peel is to add extra passes only on areas that have lighter frost than the ideal level desired to achieve a homogeneous frost level across the face.
Postpeel Care
The wet technique is preferred for trichloroacetic acid postpeel skin care because of the added patient comfort and the benefit to skin recovery. Starting on the same day of the peel, patients are encouraged to keep their skin moist by taking multiple lukewarm showers (without shampoo) and then applying a very thin layer of petroleum jelly sparsely on the face and neck only if the skin is dry. Starting 1 week after treatment, patients are instructed to avoid sun exposure and to begin applying postpeel creams, mainly retinoic acid. Occasionally, skin lighteners and topical corticosteroids may be needed for hyperpigmentation. Figure 4, Figure 5, and the eFigure in the Supplement show examples of preoperative and postoperative trichloroacetic acid peel results.
Figure 4. Patient Undergoing a Medium Trichloroacetic Acid Peel.
Prepeel and postpeel views are shown in a 19-year-old southern European patient with acne lesions, generalized postinflammatory hyperpigmented spots, and rough skin surface.
Figure 5. A 33-Year-Old Southern African Patient Undergoing a Medium Trichloroacetic Acid Peel.
A-F, The rejuvenating effect is remarkable: the patient is 11½ years older in F than in A but looks almost the same age. C, An area of hypopigmented spots is noted along the right mandibular border. D, The hypopigmented areas are resolving. E, The skin color has improved. F, The skin is close to normal. Regarding the postoperative hypopigmentation, most hypopigmented lesions become permanent. However, they can recover with time if the original peel was not too deep. In this case, the complication could have been avoided if the peel had been a light peel rather than a medium peel.
Adverse Effects and Complications
Erythema is generally resolved within 4 to 7 days. It may persist longer in northern Europeans (Nordics) but should not remain a permanent complication unless the peel was deeper than it should have been. Telangiectasia is also seen more often in northern Europeans, especially if their peel was deeper than ideal.
Postinflammatory hyperpigmentation is more common in southern Europeans (Mediterraneans), Asians, and especially southern Caucasians (Indo-Pakistanis). It usually occurs in the same areas of the early postpeel erythema and is temporary in most cases.
Hypopigmentation is rare. The most susceptible patients are those with the darkest skins. These patients primarily include southern Caucasians (Indo-Pakistanis), Africans, and southern Asians, especially as a result of relatively deep peels.
Hypertrophic scarring is a rare complication that usually follows a relatively deep peel. The Nordic population is the most susceptible. A clue to its pending development is the appearance of persistent deep erythema combined with skin induration. This complication requires early and successive treatments with intralesional corticosteroids.
Another potential complication is herpesvirus infection, which is suspected when patients report burning or pain during the first 7 days after the peel. However, the onset of herpesvirus infection may be painless in some cases. The most important sign is a typical herpetic ulceration of the skin that will spread to the rest of the face and neck rapidly if left untreated. Therefore, it is advisable to give all patients a prophylactic low dosage of antiviral oral treatment starting the day before the peel and continuing for 7 days afterward. If herpetic ulcerations still develop, the dosage is increased. Bacterial or fungal infections are uncommon complications.
Results
Patients
A total of 923 universal trichloroacetic acid peels were reviewed. There were 803 female patients (87.0%) and 120 male patients (13.0%) (mean age, 41.59 years). The follow-up period ranged from 6 months to 13 years, with a mean of 13 months. The patients’ genetico-racial skin classification categories are summarized in the eTable in the Supplement. Figures 4 and 5 and the eFigure in the Supplement show examples of trichloroacetic acid peel results.
Complications
There were 54 patients (5.9%) with persistent hyperpigmentation, mostly Asians and Indo-Pakistanis, requiring repetition of the peel on the remaining spots (“spot peels”) 1 or more times. Three patients (0.3%) had mild telangiectasia, occurring in 2 Nordics and 1 Nordic European. In 2 patients (0.2%), acute herpesvirus infection developed early in this case series before introducing the prophylactic use of antiviral medication. Two other patients (0.2%) developed bacterial Staphylococcus infection, which were successfully treated with oral and topical antibiotics. There was a single African patient (0.1%) with hypopigmentation (Figure 5), which eventually improved to some extent. Most important, there was no occurrence of scarring in our case series.
Discussion
This article describes a trichloroacetic acid peel technique that is simple, safe, and reproducible. Our results have shown acceptable complication rates compared with the medical literature on chemical peels.
There are 2 aspects of this trichloroacetic acid peel approach that render it novel and different. First, the genetico-racial skin classification, as discussed previously, offers a novel method of categorizing patients based on skin color and facial features rather than on skin color alone. This classification allows physicians to predict the response of various skin groups to the trichloroacetic acid peel and therefore lessen the chance of complications. Second, the trichloroacetic acid application technique standardizes all variables that may affect the depth of the peel, with the frost sign becoming the main depth indicator. This standardization allows for more predictable results while diminishing complication risks.
The trichloroacetic acid peel described herein provides a generalized, homogeneous effect to the skin of the face and neck. Another advantage of the trichloroacetic acid peel is that it does not require expensive, sophisticated, or cumbersome equipment: only the acid and cotton gauze are needed.
Limitations
Limitations of this study mainly include the retrospective nature and the limited number of male patients. Furthermore, we chose not to include the Fitzpatrick skin classification because of the belief, as previously stated in the article, that the genetico-racial skin classification is of greater aid in management decisions and a more accurately predictor of prognosis.
Conclusions
This article proposes a tailored, all-inclusive trichloroacetic acid peel technique aimed at maximizing results while minimizing complication risks. The universal approach to a trichloroacetic acid peel is based on the following 2 components: (1) the genetico-racial skin classification, which predicts the approximate response of each skin type to the peel and determines the proper peel depth for a patient, and (2) the strip technique, which eliminates all variables except the frost sign, increasing the physician’s control over the peel depth.
The suggested depth of the trichloroacetic acid peel for different skin types, and their target frost, is as follows: (1) for northern Europeans, medium (medium frost) or light to medium peel (light to medium frost); (2) for mid-Europeans, medium to deep peel (medium to deep frost); (3) for southern Europeans (Mediterraneans), medium peel (medium frost) or medium to deep peel (medium to deep frost); (4) for southern Caucasians (Indo-Pakistanis), light peel (light frost); (5) for Africans, very light peel (very light frost); and (6) for Asians, medium peel (medium frost) for northern and central Asians and light to medium peel (light to medium frost) for southern Asians. In addition, the prepeel preparation and postpeel care are important to lower the risks of peeling and to shorten the recuperation period.
When properly performed, the universal trichloroacetic acid peel technique improves the condition and quality of the skin in light- and dark-skinned patients. It can be an easily implementable addition to a physician’s cosmetic practice.
eFigure. Additional Patients Undergoing a Trichloroacetic Acid Peel
eTable. Genetico-Racial Skin Classification Categories Among 923 Patients
References
- 1.Johnson JB, Ichinose H, Obagi ZE, Laub DR. Obagi’s modified trichloroacetic acid (TCA)–controlled variable-depth peel: a study of clinical signs correlating with histological findings. Ann Plast Surg. 1996;36(3):225-237. [DOI] [PubMed] [Google Scholar]
- 2.Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060. Washington, DC: US Census Bureau; 2014:25-1143. [Google Scholar]
- 3.Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869-871. [DOI] [PubMed] [Google Scholar]
- 4.Brody H. Chemical Peeling. St Louis, MO: Mosby; 1992:35-41. [Google Scholar]
- 5.McCollough G, Langston P. Dermabrasion and Chemical Peeling: A Guide for Facial Plastic Surgeons. New York, NY: Thieme Medical Publishers; 1998. [Google Scholar]
- 6.Fanous N, Hopping S TCA peel course. In: Proceedings from the 1995 Annual Meeting of the American Academy of Cosmetic Surgery; January 1995; Los Angeles, CA. [Google Scholar]
- 7.Fanous N. TCA for Asians. Facial Plast Surg Clin. 1996;4:195-200. [Google Scholar]
- 8.Fanous N, Prinja N, Sawaf M. Laser resurfacing of the neck: a review of 48 cases. Aesthetic Plast Surg. 1998;22(3):173-179. [DOI] [PubMed] [Google Scholar]
- 9.Fanous N, Bassas AE, Ghamdi WA. CO2 laser resurfacing of the neck and face: 10 golden rules for predicting results and preventing complications. Facial Plast Surg Clin. 2000;8(2):405-413. [Google Scholar]
- 10.Fanous N. A new patient classification for laser resurfacing and peels: predicting responses, risks, and results. Aesthetic Plast Surg. 2002;26(2):99-104. [DOI] [PubMed] [Google Scholar]
- 11.Fanous N, McCurdy JA, Lam SM. Cosmetic Surgery of the Asian Face. New York, NY: Thieme Medical Publishers; 2005:253-254. [Google Scholar]
- 12.Côté V, Fanous N. The new “genetico-racial” skin classification: maximizing the safety of skin treatments for Asians. Facial Plast Surg Clin North Am. 2010;18(1):99-104. [DOI] [PubMed] [Google Scholar]
- 13.Fanous N, Côté V, Fanous A. The new genetico-racial skin classification: how to maximize the safety of any peel or laser treatment on any Asian, Caucasian or black patient. Can J Plast Surg. 2011;19(1):9-16. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. Additional Patients Undergoing a Trichloroacetic Acid Peel
eTable. Genetico-Racial Skin Classification Categories Among 923 Patients
