20 Anesthesia for Cosmetic Procedures
Providing adequate anesthesia is an essential part of performing cosmetic procedures and successfully incorporating them into practice. In addition to offering the patient a better procedural experience, minimizing discomfort ensures greater treatment precision and may improve outcomes.1 Cosmetic treatments that commonly require anesthesia include laser treatments, such as ablative skin resurfacing, tattoo removal and hair reduction, dermal filler injections, and occasionally botulinum toxin injections.2
Four anesthesia modalities are commonly used with cosmetic procedures:
TABLE 20-1 Anesthetic Modalities Used for Cosmetic Procedures
Anesthetic Modalities | Cosmetic Procedures |
|---|---|
| Injectable anesthetics | |
| Local infiltration | Dermal fillers Laser tattoo removal |
| Regional block | Dermal fillers Ablative lasers |
| Topical anesthetics | Botulinum toxin Dermal fillers Laser hair reduction Laser tattoo removal Laser photorejuvenation for pigmented lesions Ablative lasers |
| Contact cooling | Botulinum toxin Dermal fillers Laser hair reduction |
| Analgesic devices | Laser hair reduction Ablative lasers |
Injectable Anesthetics
Injectable lidocaine (1% to 2%) reduces pain by blocking neural cell membrane sodium channels and inhibiting impulse propagation. Initially, small delta nerve fibers, which are responsible for pain and temperature sensations, are blocked. Larger beta nerve fibers, which are responsible for pressure and vibration, take longer to anesthetize. For this reason, injectable anesthetics have a rapid reduction of pain but a slower reduction in sensations of pressure and pulling.3
Regional Nerve Blocks
Lidocaine without epinephrine is used for nerve blocks. Facial nerve blocks are beneficial for cosmetic procedures because anesthetic is placed outside of the treatment area. Profound anesthesia can be achieved with minimal distortion of the treatment area, which is particularly useful with dermal filler treatments.2,4 Nerve blocks are also useful for painful procedures such as ablative laser resurfacing, particularly in the sensitive perioral area.
Infraorbital Nerve Block
The infraorbital nerve innervates most of the upper lip, lower eyelid, lateral portion of the nose, and medial cheek. An infraorbital nerve block can anesthetize all of these regions (Figure 20-2).3 The intent of the infraorbital nerve block technique described here, utilizing a short 0.5-inch needle, is to reach the distal portions of the infraorbital nerve, not the nerve foramen, which would require a longer needle (approximately 
inches long). The philtrum and the corners of the mouth are typically poorly anesthetized with infraorbital blocks, and additional local infiltration is also required when treating these areas.
