6G : Dermabrasion, Chemical Peel, and Laser Procedures

E. Gaylon McCollough, M.D., F.A.C.S, Fred G. Fedok, M.D.

Anatomy
The cutaneous sensory Innervation of the face and neck is supplied by the
three divisions of the trigeminal nerve and the peripheral branches of the
upper cervical nerve roots of C2, C3, and C4 or the cervical plexus.
As is the case with most facial plastic surgical procedures, patients
undergoing dermabrasion, chemical peel, and laser procedures in the head
and neck are reutinely placed supine, with the head slightly elevated at 10 0
to 150. This lowers central venous pressure in the head and neck aress, and
thus tends to reduce bleeding during the procedure. The supine position
also provides easy access to the pattients airway. These procedures are
usualy performed using local anesthesia and intravenous sedation.
Material and Agents Used
Lidocaine and bupivacaine are the local anesthetic agents commonty used
for infiltrative and regional anesthesia for demabrasion, chemical peel,
and laser procedures. Although epinephrine containing anesthetic solutions
are very helpful in dermabrasion and laser procedures, they can be used
only cauntiously in patrients undergoing phenol chemical peeling.
Adequate local anesthesia for the majority of patrients using the
following agents : 1% lidocaline with and without 1 : 100.000 epinephrine,
0.5% lidocaine with and without 1200.000 epinephrine, 0.5% bupivacaine,
and 0.25 bupivacaine.
Patients are usually premedicated with oral diazepam and
dimenhydriuste several hours prior to the operative producedure.
Intravenous agents are administered at the time of the operative
producedure to obtain a twilight level of sedation. The comumonly used
intravenous

medicationus

include

diazepam,

midaxolam,

hydromorphorse, sentanyl, and dimenulydrinate. These agents are

administrated incremantally in accordance with the patiente clinical

response and generally accepted docage recommendations. Intravenous

scopolamine is administered as an amnestic and disciative agent prior to
the injection of the local anesthestic agents.
Teclinique of Administering the Agents
Techniques designed to obtain propers local anestisia will vary, depending
on the size of the operative area. Geracal principles. Howewer, remuin
consunt. After the patients are appropriately sedited, the authors generally
combine regional techniques or nerve blocks with field infiltration
techniques in order to obtain maximum local anesthesia. Spesific nerve
blockes on the supraorbical, suprabrochlear, zygomalicofacial, intraorbital,
and menital serves are performed. Buccal, auriculotemporal lacrimal, and
external rusal nerves are usually arlestherized through giel inlitration (6G1). A1.5 inch 27 guage needle and a 10 ml Luer-lock syringe are
recommended for both regional blocks and field infiltration. Pertiment
variations in the techniques as they apply to specicik procedures, such as
laser, chemical pee, and demabrasion, will be discussed later in the text.
Forehead : Suppraorbitial and Supratrochlear Nerves
Landmarks
Landmarks include the supraporbital tim, the supraorbital noth, and
adjaccent nasal bores.
Technique of Nerve Blockes
Regiorul nerve blockes of the fonehead are performed on the proximal
branches of the supratrochlear and the suppraorbital nerves. Firse, the
supraorbital rim and supraorbital notch are palpated. The palpating finger
is positioned on the notch to protect the orbital contents. The needle is
inserted throught the skin just lateral to the notch, above the level of the
supraorbital rim, and directed anedially and away from the orbit. After
aspirating, I mul of anes thetic solution is injected at the level of the

periosteum. The needle is then advenced medially, aspiration repreated,

and more sulution is injected. This prosess of medical advancement,
aspiration, and injection is continued until the glabella is reached. A total
of approximately 1.5 to 2 mml of the solution is injected in this region (fig.
6.G1).
Cheek : Infraorbital and
Zygomaticofacial Nerves
Landmarks
Landmarks are the infraorbital rim, the lateral orbital rim, and the mular
eminence.
Technique of Nerve Blocks
The intraorbital rim is palpated and the position of the pupil and nasal
bones is noted. The palpating finger is positioned on the infraorbital rim to
protect the orbital contents. The infraorbital nerve emerges from the
intraorbital foramen 1 cm below the intraorbital rim just medial to or
within, the sagital plane of the pupil. The needle is inserted through the
skin at this level and directed caudlly away from the orbit toward the
maxilla. When the periosleun is encountered. Aspiration is performed. A
total of 1 to 1.5 ml of anesthetic solution is deposited at this point.
In order to block the zygomaticolacial nerve effectively, the malar
enineone is first palpated in a line vertical with the lateral orbital rim. The
palating finger is kept on the orbital rim to protect the orbital contents. The
zygomaticofacial nerve emerges from the bone through its corresponding
foramen in this plane about 1 to 2 cm below the intraorbital rim. The
needle is inserted through the skin toward ine zygomatic bone and away
from the orbit. Anesthetic solution of 1 to 1.5 ml is injected at he level of
the perios teum after aspiration (Fig. 6.G1).

Chin and Lower Face : Mental Nerve

Landmarks
Landmarks are the midine of the mandible, the second premolar, and the
pupil.
Technique of Nerve Blocks
The midline of the mandible, the pupil, and the second premolar are
identified. The mental foramen lis in the vertical line that passes through
the second premolar and the ipsilateral pupil. It is localted at a point one
half the vertical height of the mandible. The palpating finger is kept on the
inferios rim of the mandible to stabilize it and mark ists position.
To block the mental nerve, the needle is inserted perpendicularty
through the skin, down to the level of the periosterum. After aspiration I
ml of anesthetic solution is injected at this point (Fig. 6.G3)
THE Neck : Cervical Plexus
Landmarks
Landmarks are the stemocleidomastoid musde and the extemual jugular
vein.
Technique of Nerve Block
The outhors generally anesthetize the skin of the neck by field infiltration.
Occasionally, however, it may be desirable to perform a superfical vervical
plexus in the nect

from under the posterius border of the

sternacheidomastoid musde at Erbs point. Erbs point is located

approximately at the midpoint of the posterior border stenodleidomastoid
muscle. The external jugular vein crosses the posterios border of the
muscle juse inferior to this point. A superficial block of these nerves can
be obtained by injecting 5 to 10 ml of anesthetic solution over the middle
third of the muscle at the posterior border. Repeated aspiration should be
done to minimize the rick of an intra vascular injection (Fig. 6.G1)

Field Infiltration Technique for

Dermabrasion, Chemical Peel, and
Laser Procedures
The terminual branches of the corresponding cutaneous nerves neside
within the dermis and the immediate sutdermis. Therefore. To obtain the
maximal anesthetic effect of field infiltration, the injections must be placed
into the immediate subdermal plane. To minimize discomfort, field
infiltration is performed after obtaining regional nerve block.
During injection, it is advisable to have a tranined assistant recond
the amount of anesthetic being injected. The recommerinded maximum
safe dose of lidocaine is 4.5 mg/kg (without epinephrine containing
solution) and 7 mg/kg (with epinephrine containing solution). The
recommended maximum safe dose of bupivacaine is 2.5 mg/kg (without
epinephrine containing solution) and 3.0 mg/kg (with epinephine
containing solution). The use of 0.5% lidocaine or 0.25% bupivacaine
solutions will allow the attainment of maximal anesthesia without
exceeding the recommeded maximum dosage limits. It is usually possible
to field infiltrate the entrire face and upper neck, including the eyelids,
nose, and lips, with a total of 40 ml of the appropriate anesthetic solution.
Ladmarks
Structures that might gustain injury from direct infection must be noted.
These include the eye, the external jugular and other superficial veins, and
the coarotid artery.
Tecnique
Field Intiltration of Face and Neck
Since the patient discomfort is most marked with each needle entry into
the skin, the outhors recommed begining injection at an area that has been
previously anesthetized by a regional nerve block. A 1.5 inch 27 gaugle
needle is recommended. Anesthetic solution is injected in a radial pattern
about the initial injection starting point. After a needle puncture is made in

the skin anesthetic solution is showly and methodically injected as the

needle is advvanced in one direction. The needle is when withdrawn to the
point where the initial skin entrance was made, but not removed. The
needle is then slowly advanced and solution injected in a new direction.
The process is repeated several times, cach time changing the direction of
advancement. The nex adjacent area of the face is then injected in a similar
fashion. By repeating the process, the entire face or neck region is
infiltrated. The sucgeons goal should be to obtain anesthesia in a large
beld with whe smallest number of skin punctures.
Demarasion And Laser
The local anesthetic technique varies for each specific type of procedure.
For demobrasion, both regional nerve blocks and field infiltration are
permormed. Generally, 1% lidocaine with 1:100,000 epinephrine is used
for the nerve block, and the field infiltration is performed using 0.5%
lidocaine with 1.200.000 epinephrine. This technique has been
successfully

used by us in dermabrasion with or withouyt cutaneous

freezing. Dermabrasion is extremely stimulating, and therefore, maximal

anesthesia is required. The infiltration must be placed in the immediate
subdermis and deep dermis.

Arteshesia for facial plastic surgery

The local anesthesia technique for laser procedures is similar to

that for dermabrasion. It is rare, however, to perform a full face procedure
using laser. Anesthesia, therefore, will usually only be necessary in a
spectific region of the face or neck. Smaller laser procedures, such as
ablation of small telangiestasias, generally require no local anesthesia.
Checal Peeling
Chemical peeling using phenol presents its own system of peculiarties.
Most importanty, the administration of epinephrine should be minimized
or avoided in the patient undergrond a phendol chemical peeling of a large
area. Pheriol can be cardiotixic in large doset, and thi risks of cardiac
arrhythmias are greatly increased if epinephrine is used. For thes reason,
we generally use 0.5% bupivacaine or 1% lidocaine without epinephrine
for the regional nerve 0.5% bupivacaine or 1% lidocaine without
epinephrine for the regional nerve blocks. Field infiltration is done with
0.25% bupivacaine or 0.5% udocaine without epinedphrine. The
recommeded safe levels of the local anesthetics will be reduced because of
the absence of epinephrine, and should be strictly observed. Lidocaing
cends to have a faster onset of action in producing local anesthesial under
these cincumstances, but begins to lose its effectiveness within minutes;
bupivacaine, although of slower onset. Will produre an anesthetic effect
that lasts for up to hours. Even thought, nerve blocks and field infiltration
have been properly carried out, some patients experience discomfort when
phenol comes in contact with their skin. This phenomenon is unique to
phenol and does not exist with abrasive, fulgrated, or incisionally inflicted
wounds.
Remarks
The local anesthetic techniques herin described are easy and safe
providing the general rules and guidelines as outlined are followed.

Local anesthesia techniques should usually be supplemented with

intravenour sedation.
When property performed, adequare anesthesia can be obtained
without subjecting the patient to a general anesthetic.
Bibliography