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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 o the ace and neck is su!!lied "y the

three divisions o the trigeminal nerve and the !eri!heral "ranches o the

u!!er cervical nerve roots o C#, C$, and C% or the cervical !le&us.

As is the case 'ith most acial !lastic surgical !rocedures, !atients

undergoing derma"rasion, chemical !eel, and laser !rocedures in the head

and neck are reutinely !laced su!ine, 'ith the head slightly elevated at () )

to (* ) . This lo'ers central venous !ressure in the head and neck aress, and

thus tends to reduce "leeding during the !rocedure. The su!ine !osition

also !rovides easy access to the !attient+s air'ay. These !rocedures are

usualy !er ormed using local anesthesia and intravenous sedation.

Material and Agents sed

-idocaine and "u!ivacaine are the local anesthetic agents commonty used

or in iltrative and regional anesthesia or dema"rasion, chemical !eel,

and laser !rocedures. Although e!ine!hrine containing anesthetic solutions

are very hel! ul in derma"rasion and laser !rocedures, they can "e used

only cauntiously in !atrients undergoing !henol chemical !eeling.

Ade uate local anesthesia or the ma/ority o !atrients using the

ollo'ing agents 0 (1 lidocaline 'ith and 'ithout ( 0 ()).))) e!ine!hrine,

).*1 lidocaine 'ith and 'ithout (#)).))) e!ine!hrine, ).*1 "u!ivacaine,

and ).#* "u!ivacaine.

2atients are usually !remedicated 'ith oral dia3e!am and

dimenhydriuste several hours !rior to the o!erative !roducedure.

Intravenous agents are administered at the time o the o!erative

!roducedure to o"tain a t'ilight level o sedation. The comumonly used

intravenous medicationus include 0 dia3e!am, mida&olam,

hydromor!horse, sentanyl, and dimenulydrinate. These agents are

administrated incremantally in accordance 'ith the !atiente clinical


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res!onse and generally acce!ted docage recommendations. Intravenous

sco!olamine is administered as an amnestic and disciative agent !rior to

the in/ection o the local anesthestic agents.

Teclini ue o Administering the Agents

Techni ues designed to o"tain !ro!ers local anestisia 'ill vary, de!ending

on the si3e o the o!erative area. Geracal !rinci!les. 4o'e'er, remuin

consunt. A ter the !atients are a!!ro!riately sedited, the authors generally

com"ine regional techni ues or nerve "locks 'ith ield in iltration

techni ues in order to o"tain ma&imum local anesthesia. S!esi ic nerve

"lockes on the su!raor"ical, su!ra"rochlear, 3ygomalico acial, intraor"ital,

and menital serves are !er ormed. 5uccal, auriculotem!oral lacrimal, and

e&ternal rusal nerves are usually arlestheri3ed through giel inlitration 678

G(9. A(.* inch #: guage needle and a () ml -uer8lock syringe are

recommended or "oth regional "locks and ield in iltration. 2ertiment

variations in the techni ues as they a!!ly to s!ecicik !rocedures, such as

laser, chemical !ee, and dema"rasion, 'ill "e discussed later in the te&t.

Forehead 0 Su!!raor"itial and Su!ratrochlear ;erves

-andmarks

-andmarks include the su!ra!or"ital tim, the su!raor"ital noth, and

ad/accent nasal "ores.

Techni ue o ;erve 5lockes


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!eriosteum. The needle is then advenced medially, as!iration re!reated,

and more sulution is in/ected. This !rosess o medical advancement,

as!iration, and in/ection is continued until the gla"ella is reached. A total

o a!!ro&imately (.* to # mml o the solution is in/ected in this region 6 ig.

7.G(9.

Cheek 0 In raor"ital and

=ygomatico acial ;erves

-andmarks

-andmarks are the in raor"ital rim, the lateral or"ital rim, and the mular

eminence.

Techni ue o ;erve 5locks

The intraor"ital rim is !al!ated and the !osition o the !u!il and nasal

"ones is noted. The !al!ating inger is !ositioned on the in raor"ital rim to

!rotect the or"ital contents. The in raor"ital nerve emerges rom the

intraor"ital oramen ( cm "elo' the intraor"ital rim /ust medial to or 'ithin, the sagital !lane o the !u!il. The needle is inserted through the

skin at this level and directed caudlly a'ay rom the or"it to'ard the

ma&illa. >hen the !eriosleun is encountered. As!iration is !er ormed. A

total o ( to (.* ml o anesthetic solution is de!osited at this !oint.

In order to "lock the 3ygomaticolacial nerve e ectively, the malar

enineone is irst !al!ated in a line vertical 'ith the lateral or"ital rim. The

!alating inger is ke!t on the or"ital rim to !rotect the or"ital contents. The3ygomatico acial nerve emerges rom the "one through its corres!onding

oramen in this !lane a"out ( to # cm "elo' the intraor"ital rim. The

needle is inserted through the skin to'ard ine 3ygomatic "one and a'ay

rom the or"it. Anesthetic solution o ( to (.* ml is in/ected at he level o

the !erios teum a ter as!iration 6Fig. 7.G(9.


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Chin and -o'er Face 0 Mental ;erve

-andmarks

-andmarks are the midine o the mandi"le, the second !remolar, and the

!u!il.

Techni ue o ;erve 5locks

The midline o the mandi"le, the !u!il, and the second !remolar are

identi ied. The mental oramen lis in the vertical line that !asses through

the second !remolar and the i!silateral !u!il. It is localted at a !oint one

hal the vertical height o the mandi"le. The !al!ating inger is ke!t on the

in erios rim o the mandi"le to sta"ili3e it and mark ists !osition.

To "lock the mental nerve, the needle is inserted !er!endicularty

through the skin, do'n to the level o the !eriosterum. A ter as!iration I

ml o anesthetic solution is in/ected at this !oint 6Fig. 7.G$9

T4E ;eck 0 Cervical 2le&us

-andmarks-andmarks are the stemocleidomastoid musde and the e&temual /ugular

vein.

Techni ue o ;erve 5lock

The outhors generally anestheti3e the skin o the neck "y ield in iltration.

?ccasionally, ho'ever, it may "e desira"le to !er orm a su!er ical vervical

!le&us in the nect rom under the !osterius "order o thesternacheidomastoid musde at Er"+s !oint. Er"+s !oint is located

a!!ro&imately at the mid!oint o the !osterior "order stenodleidomastoid

muscle. The e&ternal /ugular vein crosses the !osterios "order o the

muscle /use in erior to this !oint. A su!er icial "lock o these nerves can

"e o"tained "y in/ecting * to () ml o anesthetic solution over the middle

third o the muscle at the !osterior "order.


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Field In iltration Techni ue or

Derma"rasion, Chemical 2eel, and

-aser 2rocedures

The terminual "ranches o the corres!onding cutaneous nerves neside

'ithin the dermis and the immediate sutdermis. There ore. To o"tain the

ma&imal anesthetic e ect o ield in iltration, the in/ections must "e !laced

into the immediate su"dermal !lane. To minimi3e discom ort, ield

in iltration is !er ormed a ter o"taining regional nerve "lock.

During in/ection, it is advisa"le to have a tranined assistant recond

the amount o anesthetic "eing in/ected. The recommerinded ma&imum

@sa e dose o lidocaine is %.* mgBkg 6'ithout e!ine!hrine containing

solution9 and : mgBkg 6'ith e!ine!hrine containing solution9. The

recommended ma&imum sa e dose o "u!ivacaine is #.* mgBkg 6'ithout

e!ine!hrine containing solution9 and $.) mgBkg 6'ith e!ine!hine

containing solution9. The use o ).*1 lidocaine or ).#*1 "u!ivacaine

solutions 'ill allo' the attainment o ma&imal anesthesia 'ithout

e&ceeding the recommeded ma&imum dosage limits. It is usually !ossi"le

to ield in iltrate the entrire ace and u!!er neck, including the eyelids,nose, and li!s, 'ith a total o %) ml o the a!!ro!riate anesthetic solution.

-admarks

Structures that might gustain in/ury rom direct in ection must "e noted.

These include the eye, the e&ternal /ugular and other su!er icial veins, and

the coarotid artery.

Tecni ue

Field Intiltration o Face and ;eck

Since the !atient discom ort is most marked 'ith each needle entry into

the skin, the outhors recommed "egining in/ection at an area that has "een

!reviously anestheti3ed "y a regional nerve "lock. A (.* inch #: gaugle

needle is recommended. Anesthetic solution is in/ected in a radial !attern

a"out the initial in/ection starting !oint. A ter a needle !uncture is made in


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the skin anesthetic solution is sho'ly and methodically in/ected as the

needle is advvanced in one direction. The needle is 'hen 'ithdra'n to the

!oint 'here the initial skin entrance 'as made, "ut not removed. The

needle is then slo'ly advanced and solution in/ected in a ne' direction.

The !rocess is re!eated several times, cach time changing the direction o

advancement. The ne& ad/acent area o the ace is then in/ected in a similar

ashion. 5y re!eating the !rocess, the entire ace or neck region is

in iltrated. The sucgeon+s goal should "e to o"tain anesthesia in a large

"eld 'ith 'he smallest num"er o skin !unctures.

Demarasion And -aser

The local anesthetic techni ue varies or each s!eci ic ty!e o !rocedure.

For demo"rasion, "oth regional nerve "locks and ield in iltration are

!ermormed. Generally, (1 lidocaine 'ith (0()),))) e!ine!hrine is used

or the nerve "lock, and the ield in iltration is !er ormed using ).*1

lidocaine 'ith (.#)).))) e!ine!hrine. This techni ue has "een

success ully used "y us in derma"rasion 'ith or 'ithouyt cutaneous

ree3ing. Derma"rasion is e&tremely stimulating, and there ore, ma&imalanesthesia is re uired. The in iltration must "e !laced in the immediate

su"dermis and dee! dermis.


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Arteshesia or acial !lastic surgery


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The local anesthesia techni ue or laser !rocedures is similar to

that or derma"rasion. It is rare, ho'ever, to !er orm a ull ace !rocedure

using laser. Anesthesia, there ore, 'ill usually only "e necessary in a

s!ecti ic region o the ace or neck. Smaller laser !rocedures, such as

a"lation o small telangiestasias, generally re uire no local anesthesia.

Checal 2eeling

Chemical !eeling using !henol !resents its o'n system o !eculiarties.

Most im!ortanty, the administration o e!ine!hrine should "e minimi3ed

or avoided in the !atient undergrond a !hendol chemical !eeling o a large

area. 2heriol can "e cardioti&ic in large doset, and thi risks o cardiac

arrhythmias are greatly increased i e!ine!hrine is used. For thes reason,

'e generally use ).*1 "u!ivacaine or (1 lidocaine 'ithout e!ine!hrine

or the regional nerve ).*1 "u!ivacaine or (1 lidocaine 'ithout

e!ine!hrine or the regional nerve "locks. Field in iltration is done 'ith

).#*1 "u!ivacaine or ).*1 udocaine 'ithout e!ined!hrine. The

recommeded sa e levels o the local anesthetics 'ill "e reduced "ecause o

the a"sence o e!ine!hrine, and should "e strictly o"served. -idocaingcends to have a aster onset o action in !roducing local anesthesial under

these cincumstances, "ut "egins to lose its e ectiveness 'ithin minutes

"u!ivacaine, although o slo'er onset. >ill !rodure an anesthetic e ect

that lasts or u! to hours. Even thought, nerve "locks and ield in iltration

have "een !ro!erly carried out, some !atients e&!erience discom ort 'hen

!henol comes in contact 'ith their skin. This !henomenon is uni ue to

!henol and does not e&ist 'ith a"rasive, ulgrated, or incisionally in licted'ounds.


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-ocal anesthesia techni ues should usually "e su!!lemented 'ith

intravenour sedation.

>hen !ro!erty !er ormed, ade uare anesthesia can "e o"tained

'ithout su"/ecting the !atient to a general anesthetic.

5i"liogra!hy

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