By Laura Ellis, MD

You know how important it is to make your vein patients comfortable. After treatment they report back to their primary care provider as well as to friends and family. It is important to make sure they’re happy by providing compassionate care and excellent anesthesia.

It is no less, perhaps even more, important with aesthetic patients. Here is a simple guide to excellent anesthesia for aesthetic facial procedures.

Follow these rules along with good aesthetic technique and the confidence you instill in your patients will provide you with new business, their own and their referrals.

1. Injection of neurotoxin typically requires only reassurance and good technique. The medication does not “burn” and using a small (30guage ½-inch), sharp (replace after each 4-5 injections) needle will earn your patient’s confidence. No ice is necessary; it just slows you down and can give the patient a “cold headache” and red skin. If they’re accustomed to using ice with another provider ask them to try it your way and make them a believer. It works and patients appreciate the simplicity.

2. The type of filler and location of injection dictate the type of anesthesia needed, although some seasoned aesthetic patients prefer simply ice or vibratory anesthesia. Injection of fillers into the lips, nasolabial folds and the chin almost always requires nerve blocks to provide a painless and even enjoyable treatment for the patient. A pain-free experience allows them the ability to “follow along” without anxiety. Give them a hand-held mirror so they can check your work and let you know when they are satisfied with the volume. Cheeks, temples and the pre jowl sulci are less sensitive and may simply require ice or vibratory anesthesia. Patients can hold the Hitachi Magic Wand to distract nerve endings. This technique of vibratory anesthesia has been well established as effective and is simple and safe. I use a lot of Sculptra in my practice and find that the small amount of lidocaine used to create the suspension along with changing the 25guage needle with each injection are all that is necessary for great patient comfort.

3. Non ablative laser and light procedures are easily tolerated by most patients with only chilled coupling gel and/or a chilled crystal plate on the hand set. Some may request pretreatment with a topical anesthetic cream but you know that this may reduce the effectiveness of the treatment by transiently increasing the water content of the skin.

4. Ablative laser resurfacing of the face used to require general anesthesia. With advances in laser technology allowing us to provide excellent rejuvenation of the skin with a fractionated beam, fully ablative laser resurfacing is not as attractive as it used to be. Similar results can often be obtained with fractionated resurfacing without the need for deep anesthesia and without many of the complications related to wound healing. In my practice I believe that to provide patients significant results, the level of laser energy required produces enough pain to necessitate sedation and analgesia. I use oral diazepam 20mg with an oral narcotic (meperedine, hydrocodone or codeine derivative).

Oral pre medication is desirable in the outpatient office setting. Diazepam, a benzodiazepine, is purely sedative with rapid onset of action. It is absorbed completely within 20-30 minutes.
Besides its obvious sedative properties, it also possesses some anticonvulsive and muscle-relaxant effects.

Diazepam has no analgesic effect. In fact, it seems to decrease the plasma beta-endorphin levels, lowering the pain threshold. Diazepam is metabolized rapidly and has a half-life of 2 ½ hours. There are few contraindications to the use of diazepam. It should not be used in patients with severe psychosis and in the very elderly. No serious interactions with other medications have been observed.
Perform the procedure 30 minutes after oral administration of 10-20mg of Diazepam and a useful dose of an analgesic.

Laura Ellis, MD, operates Laura Ellis MD Skin Care & Vein Centre PLLC  (www.LauraEllisMD.com) in Asheville, N.C., and is a member of Vein Affiliates and ASLMS.