A new combination technique of local anesthesia for full-face dermabrasion

Journal of Drugs in Dermatology, August, 2007 by Kelley Pagliai Redbord, C. William Hanke

Abstract

We present a safer, more efficient, and more effective technique for full-face dermabrasion utilizing a combination of regional nerve block anesthesia, refrigerant spray cryoanesthesia, and local infiltration anesthesia. This combination provides a pain-free procedure with little to no discomfort for the patient while avoiding the risks of intravenous sedation or general anesthesia.

Introduction

Effective anesthesia is an integral component to performing dermatologic and cosmetic surgical procedures. Full-face dermabrasion can be performed using topical anesthesia, nerve block anesthesia, tumescent local anesthesia, intravenous sedation, general anesthesia, or a combination of these procedures. (1) Regional nerve block anesthesia alone is not adequate to provide full and profound anesthesia for full-face dermabrasion. We present a new, simple, and more effective technique for full-face dermabrasion utilizing a combination of nerve block regional anesthesia, local infiltration anesthesia, and dichlorotetrafluoroethane refrigerant spray cryoanesthesia (Frigiderm, Delasco Dermatologic Lab & Supply Inc, Council Bluffs, IA).

Anesthesia

Nerve Block Regional Anesthesia

The key to successful facial nerve blocks is familiarity with neuroanatomy and anatomic landmarks. The trigeminal nerve (cranial nerve V) is the main sensory innervation to the face. Its 3 branches originate at the gasserian ganglion and include the ophthalmic nerve (V1), maxillary nerve (V2), and mandibular nerve (V3). (2-4) Regional nerve block anesthesia of the branches of the trigeminal nerve at the supraorbital, supratrochlear, infraorbital, and mental foramen results in anesthesia to approximately 60% to 70% of the face (Figures 1-2). (5)

The facial skin is prepped and the area to be anesthetized is cleaned with alcohol. Landmarks are identified and marked for injection with a surgical pen. Nerve blocks are performed using lidocaine 1% with 1:100,000 epinephrine 5 to 8 ml total volume. (1,4) Injections are performed with a 30-gauge 1-inch needle. The anesthetic should be injected near, but not into, the nerve. Intraneural injection may cause nerve injury and dysesthesias. Injection into the accompanying blood vessels can be avoided by drawing back on the needle to make sure that the needle is not within a blood vessel. The supraorbital nerve block provides anesthesia to the forehead and frontal scalp. (2,4) The supraorbital foramen can be palpated at the orbital rim in the midpupillary line, approximately 2.5 cm lateral to the midline of the face. A total of 1 to 2 cc of the anesthetic solution is injected perpendicular to the surface of the skin superficial to the periosteum while withdrawing the needle. (2,4) The supratrochlear nerve block provides anesthesia to the midforehead, glabella, and frontal scalp. The superior medial orbital rim can be palpated at the junction of the glabella and eyebrow, 1 cm medial to the supraorbital foramen. One cc of the anesthetic solution is injected superficial to the periosteum while withdrawing the needle. (2,4) The external nasal branches of the anterior ethmoidal nerve provide anesthesia to the cartilaginous nasal dorsum and nasal tip. The junction of the nasal bone and the upper lateral cartilage can be palpated 6 to 10 mm from the midline. One cc of the anesthetic solution is injected at the upper lateral cartilage. (2,4) For complete forehead and frontal scalp anesthesia, the auriculotemporal nerve and the greater auricular nerve branches in the region can be infiltrated immediately superior and posterior to the attachment of the pinna. (2-4)

An intraoral approach is utilized for the infraorbital and mental nerve blocks. This approach is more reliable and less painful than the percutaneous approach. (1,2,4,6) The infraorbital nerve block provides anesthesia to the medial cheek, upper lip, upper teeth, lower eyelid, and nasal ala. Topical anesthetic is applied to the oral mucosa at the vestibular sulcus between the first and second premolars 2 minutes prior to the injection. The needle is inserted into the sulcus until the bone is reached. The needle is pulled back and 2 to 3 cc of the anesthetic is injected. The mental nerve block provides anesthesia to the lower lip and chin. (4-6) Topical anesthetic is applied to the oral mucosa at the gingival buccal sulcus at the apex of the canine fossa between the mandibular first and second bicuspids. The needle is inserted and 2 to 4 cc of anesthetic is injected.

Local Infiltration Anesthesia

Regional nerve blocks provide anesthesia to approximately 60% to 70% of the face. (5) Traditionally, only dichlorotetrafluoroethane refrigerant spray cryoanesthesia is used to supplement the nerve block anesthesia in an to attempt to approach 100% anesthesia of the face. Unfortunately, even with the additional cryoanesthesia, complete anesthesia is not achieved. Patients are uncomfortable for at least a portion of the dermabrasion procedure. Therefore, we present the simple and straightforward addition of local infiltration anesthesia to provide complete full-face anesthesia and improved patient comfort. Bilateral supraorbital and supratrochlear nerve blocks completely block the forehead while bilateral mental nerve blocks completely block the chin. However, bilateral infraorbital nerve blocks do not completely block the cheeks. The cheeks need additional anesthesia.