Techniques of different types of anesthesia in dermatocosmetology practice

Vladlena Averina, doctor of the highest category, member of EADV, dermatovenerologist, KB "Feofaniya", scientific coordinator of the "Academy of Scientific Beauty" (Ukraine)

The main sensory nerve of the face and oral cavity is the trigeminal nerve. It also contains motor fibers that innervate the masticatory muscles. The zones of cutaneous innervation of each of the three branches of the trigeminal nerve do not have strict boundaries. On the contrary, innervation of individual areas from two sources is observed. Thus, branches from both the ophthalmic and maxillary nerves approach the eyelids and conjunctiva of the eye. Overlapping areas of nerve supply from different sources is observed in the area of the mucous membrane of the nasal cavity, into which the nasal branches penetrate from the first, second and third branches of the trigeminal nerve.

A feature of the trigeminal nerve is the formation of numerous connecting branches connecting it with the branches of the facial and hypoglossal nerves. Through these connections, mutual exchange of fibers occurs, in particular, sensory fibers of the trigeminal nerve enter the muscle branches of these cranial nerves. They are not only conductors of general (pain, tactile and temperature) sensitivity, some of them relate to conductors of muscle-joint sensitivity. Afferent fibers of the trigeminal nerve innervate the skin of the face, the mucous membranes of its cavities, muscles, bone base, and teeth. They take the place of the afferent link in the structures of reflex arcs, which are the substrate of neurogenic effects on the muscles, glands and vessels of the face.

Local anesthesia

Local anesthesia (anaesthesia localis) is an artificially induced suppression of sensitivity (primarily pain) in limited areas of the body, which is provided by blockade of the peripheral nervous system at different levels. Local anesthesia allows you to painlessly perform various surgical interventions, dressings and diagnostic procedures. In this case, the feeling of pain first disappears, then temperature sensitivity is impaired, and lastly, tactile sensitivity, as well as the feeling of pressure. Local anesthesia is widely used in outpatient practice.

Local anesthesia can be obtained in several ways:

• cooling the skin;
• lubrication of the skin and mucous membranes;
• introducing solutions of anesthetic substances into tissues or body cavities.

So, let’s figure out what type of anesthesia, on what area and for what procedures it is recommended to use.

Local anesthesia does not require special long-term preoperative preparation. In addition, after surgery or other manipulation performed under local anesthesia, the patient usually does not need the constant monitoring required after general anesthesia.

Contraindications to local anesthesia are:

• intolerance to local anesthetics due to increased individual sensitivity;
• increased neuropsychic excitability or mental disorders of the patient;
• inflammatory or scarring changes in tissues that prevent infiltration anesthesia.

In preparation for the operation, which is supposed to be performed under local anesthesia, the patient is explained that during the operation he will retain consciousness, tactile and deep sensitivity, but there will be no sensation of pain; patients with a labile nervous system are prescribed tranquilizers.

Complications of local anesthesia are usually associated with individual intolerance, overdose of local anesthetics, or violations of anesthesia technique. To prevent complications, it is necessary to determine individual sensitivity to local anesthetics and carefully follow their dosage and anesthesia technique.

Anesthesia can be a consequence of depression of the central nervous system with loss of consciousness (anesthesia) or blockade of the peripheral nervous system at various levels with preserved consciousness - local anesthesia.

Cooling method

In aesthetic cosmetology, cooling anesthesia is used before mesotherapy of the body and scalp. It has a short-term effect – from a few seconds to a minute. This is usually achieved by spraying special sprays or a stream of chloroethyl from an ampoule on the desired area of the body until a white spot appears on the skin. Also, a slight analgesic effect occurs when coolants are applied to the skin for 2–3 minutes.

Anesthesia by lubrication

Anesthesia by skin lubrication followed by occlusion (Emla, 5%) is most often used on almost all areas of the face, neck, décolleté, and body. The same can be said about the range of procedures - before contouring, biorevitalization, botulinum toxin injection, laser hair removal, mesoscooter.

Emla cream contains lidocaine 25 mg/g and prilocaine 25 mg/g - amide-type local anesthetics. Due to the penetration of lidocaine and prilocaine into the layers of the epidermis and dermis, skin anesthesia occurs. The degree of anesthesia depends on the time of application and dose. On average, pain relief to a depth of 2 mm occurs in 30–40 minutes, and to a depth of 3 mm – in 50–60 minutes.

Due to the effect of the cream on the superficial vessels, temporary paleness or redness of the skin area is possible. Such reactions develop faster (within 20 minutes after applying the cream) in patients with widespread neurodermatitis (atopic neurodermatitis), which indicates a faster penetration of the cream through the changed skin.

The effectiveness of the cream does not depend on the color and pigmentation of the skin (skin types I–IV).

Contraindications :

• violation of the integrity of the skin at the site of application of the cream (active herpes zoster, atopic dermatitis or wounds);
• hypersensitivity to amide-type local anesthetics or any excipient.

Injecting solutions of anesthetic substances into tissues

The drugs of choice today are solutions of lidocaine, articaine, prilocaine and others. Ultracaine D-S is the most commonly used combination drug containing a vasoconstrictor component and a local anesthetic. Designed for regional or infiltration local anesthesia. Atrocaine hydrochloride is an amide local anesthetic from the tiaprofen group. Epinephrine hydrochloride is a vasoconstrictor that prevents atrocaine from entering the blood, thereby reducing the likelihood of its side effects.

Ultracaine D-S begins to act within 1–3 minutes after administration (very quickly). It is well tolerated by tissues and has a reliable, pronounced, quickly onset anesthetic effect. After administration, a significant analgesic effect lasts for at least 45 minutes. Since Ultracaine has a weak vasoconstrictor effect and is well tolerated by tissues, it does not delay the process of wound regeneration. The content of epinephrine hydrochloride in the drug is insignificant, which prevents the occurrence of increased blood pressure or the appearance of palpitations.

Infiltration anesthesia

Layer-by-layer impregnation of tissues with an anesthetic solution acting on sensitive nerve endings and nerve trunks passing in the area of distribution of the solution.

The most advanced method of infiltration anesthesia is sheath anesthesia according to the method of A. V. Vishnevsky. The essence of the method lies in tight infiltration of fascial spaces with an anesthetic solution. The infiltrate seems to “creep” along the fascial spaces (“creeping infiltrate”), washing the nerve endings.

Anesthesia using this method begins with an intradermal injection of a solution through a thin needle (a so-called lemon peel is formed - Fig. 2). Then, with separate injections of another (long) needle, the solution is injected into the subcutaneous tissue. The further anesthesia technique is determined by the type of operation and the area of intervention.

Conduction anesthesia

It is achieved by introducing an anesthetic solution into the sheath of large nerve trunks or, more often, into the tissues surrounding them. The result is a loss of pain sensitivity in the area innervated by this nerve (regional anesthesia).

For anesthesia of the maxillofacial area, infiltration or conduction anesthesia is used. For conduction anesthesia of the face, an anesthetic substance is injected into the area of the tubercle of the upper jaw, infraorbital, palatine, and incisive foramen. Blockade of the second branch of the trigeminal nerve is carried out by injecting a solution into the area of the pterygopalatine fossa. During operations on the lower jaw, the solution is injected into the area of the mandibular foramen or mandibular eminence. Blockade of the third branch of the trigeminal nerve is performed at the foramen ovale at the base of the skull. Some methods of conduction anesthesia of the maxillofacial area are presented at.

Anesthesia in the upper jaw

Conduction anesthesia in the area of the upper jaw is done at the tubercle of the upper jaw (tuberal anesthesia), in the area of the infraorbital foramen (infraorbital anesthesia), the incisive foramen and the greater palatine. The posterior superior alveolar nerves branch from the maxillary nerve in the pterygopalatine fossa and descend down the tubercle of the maxilla. With this method of local anesthesia, the solution is injected at the tubercle of the upper jaw, where these nerves are most accessible. Another common name for this method is tuberal (from the Latin tuber - tubercle) anesthesia.

Tuberal anesthesia (according to many authors) is the most dangerous in terms of the likelihood of post-injection complications. This is due not only to the complex, individually varying anatomy of nerves, blood vessels, muscle and bone tissues of the upper jaw and other parts of the maxillofacial region. Above the tubercle of the upper jaw is the pterygoid venous plexus, which is a deep venous network consisting of a large number of veins of various calibers, forming numerous looped anastomoses. This venous plexus connects the main collectors of all venous tracts of the maxillofacial region: facial, retromaxillary, middle meningeal, superficial veins, as well as veins of the same plexus of the opposite side. The pterygoid venous plexus occupies an area that is limited by the muscles of the lower jaw, the outer surface of the lateral pterygoid muscle and the inner surface of the temporal muscle, located in the temporopterygoid cellular space. The plexus extends from the infraorbital fissure to the neck of the articular process of the mandible. Consequently, piercing this area with a needle threatens to damage the vessels of the pterygoid venous plexus and the formation of an extensive hematoma, which is almost impossible to avoid. The traumatic nature of tuberal anesthesia, which is not based on sufficiently clear anatomical landmarks, is so high that experienced clinicians do not recommend its use to young specialists.

There is a method developed by Dr. P. M. Egorov. It ensures not only high efficiency, but also the safety of this anesthesia, combined with the ease of its practical implementation. The basis of the method of blocking the posterior superior alveolar nerves (tuberal anesthesia), according to Egorov P.M., is the determination of individual anatomical landmarks of the injection site, the direction of insertion and the depth of immersion of the needle. Between the skin and the infratemporal surface of the upper jaw there is only weakly vascularized subcutaneous fatty tissue and the fatty body of the cheek, the upper part of which occupies the entire space between the tubercle of the upper jaw, the ramus of the lower jaw and the pterygoid muscles. The pterygoid venous plexus is located below and laterally. The masseter muscle is also located lateral to this area of the infratemporal surface. Therefore, immersion of the needle in this place from the anterior lower corner of the zygomatic bone under the zygomatic bone is not accompanied by injury to the masticatory muscle and vessels of the pterygoid venous plexus.

The solution injected in this place of the infratemporal surface enters the layer of fiber, which is adjacent to the tubercle of the upper jaw and has quite large dimensions: the average height is 29 mm, width - 21 mm and thickness - 6 mm. Spreading through this layer of fiber, the local anesthetic solution reaches all branches of the posterior superior alveolar nerves and blocks them. Sometimes the zone of distribution of the solution rises higher - to the infraorbital nerve, which is accompanied by a blockade of the anterior and middle superior alveolar nerves.

To perform the method, Egorov P.M. recommends using the extraoral route of needle insertion. With extraoral methods of local anesthesia, the surgical field is more accessible for viewing, the injection site, direction and immersion path of the needle are better determined. In addition, there are all conditions for reliable antiseptic treatment.

Thanks to the anatomically based injection site and the correct direction of immersion, the needle passes to the layer of fiber adjacent to the tubercle of the upper jaw, piercing only the skin and weakly vascularized tissues of the subcutaneous fatty tissue and the fatty body of the cheek. This ensures high safety of the method. After immersing the needle to a predetermined depth, an anesthetic solution is injected. When using modern articaine anesthetics, tissue anesthesia in the area of innervation of the superior posterior alveolar nerves develops within 3–5 minutes.

Incisal anesthesia

It is practically not used in aesthetic medicine.

Infraorbital (infraorbital) anesthesia

It is carried out in two ways - intraoral and extraoral. With the intraoral method, the needle is inserted into the transitional fold above the lateral upper incisor of the corresponding side, and then moved upward and laterally to the palpable infraorbital foramen. This hole is located 0.5 cm below the middle of the lower orbital margin. The syringe is placed obliquely at the level of the upper central incisor of the opposite side. As the needle moves to a depth of 1.5–2 cm, 1.5–2 ml of anesthetic solution is injected at the topography of the infraorbital foramen. The area of anesthesia includes the anterior and middle superior alveolar nerves, which arise from the inferoorbital nerve.

With the extraoral method of infraorbital anesthesia, the needle is injected above the infraorbital foramen to the bone, this hole is found with the tip of the needle, then the needle is inserted into it and advanced along the infraorbital canal to a depth of 0.8 to 1.0 cm, where it is released slowly 1.5– 2 ml of anesthetic. The direction of the syringe and needle is similar to that for the intraoral method. The corresponding side of the upper lip, the wing of the nose and the front of the cheek are anesthetized.

Mandibular (mandibular) anesthesia

Can be achieved by various injection methods. The intraoral technique is most often used in practice using the finger and apodactyl (fingerless) approach.

Anesthesia using a finger is carried out with the mouth wide open by injecting a needle to the bone along the upper edge of the terminal phalanx of the index finger of the left hand, located in the retromolar triangle of the corresponding side, while retracting the syringe to the premolars of the lower jaw of the opposite side. Then the syringe is moved to the incisors, the needle is advanced 2 cm deep into the bone and 2-3 ml of anesthetic is injected.

The apodactyl approach is guided by the pterygomandibular fold. With the patient's mouth wide open, the syringe is placed at the level of the small molars or the first large molar of the opposite side, and the needle is inserted into the outer slope of the said fold at the middle of the distance between the chewing surfaces of the upper and lower large molars (in the absence of teeth - at the middle of the distance between the ridges alveolar processes). The needle is advanced until it contacts the bone at a depth of 1.5–2 cm, after which 2–3 ml of anesthetic is injected.

The anesthesia zone corresponds to the switching off of the lower alveolar and lingual nerves - the bone tissue of the alveolar process and the tooth of the lower jaw of the corresponding half (from the third molar to the second incisor), the mucous membrane of the floor of the mouth and the tongue on 2/3 of its surface. In this case, the buccal nerve is switched off by additional infiltration anesthesia along the transitional fold.

The method of mandibular anesthesia proposed by Dr. Egorov consists of topographic and anatomical justification of the needle insertion landmark for more accurate delivery of the anesthetic to the inferior alveolar nerve. To do this, on the skin of the face in the area of the jaw branch on the side of anesthesia, the projection of the pterygomandibular space and the upper edge of the mandibular foramen is determined. For this purpose, with the mouth open, use a ruler to measure the distance between the lower edge of the zygomatic arch (in front of the articular tubercle) and the lower edge of the lower jaw, as well as between the anterior and posterior edges of the ramus. Two mutually perpendicular lines drawn through the center divide the ramus of the lower jaw into four quadrants.

The projection of the pterygomandibular space above the mandibular foramen on the skin is determined using a finger, which is placed according to the resulting superolateral quadrant.

The needle is inserted 1.5 cm below and outward from the hook of the pterygoid process of the sphenoid bone, that is, into the intermuscular triangle located below the middle edge of the external pterygoid, lateral to the internal pterygoid muscle and medial to the temporal muscle. Without touching the muscles, the needle is advanced through the intermuscular space to the area of the lower jaw branch, fixed by the tip of the middle finger of the left hand.

Along the path of the needle, 2-3 ml of anesthetic solution is slowly injected at the inner surface of the lower jaw branch. Switching off the lower alveolar, lingual, and often buccal nerves occurs within 10–15 minutes. The area of anesthesia is typical for conduction anesthesia in the lower jaw.

Rabinovich S. A. and Moskovets O. N. (1999) proposed using the following manual technique. Holding the syringe in the right hand, the index finger of the left hand is placed in the external auditory canal or on the skin of the facial part of the head immediately in front of the lower border of the tragus of the ear at the intertragal notch. Using the sensations of the index finger of the left hand to control the movement of the head of the condylar process onto the articular tubercle as the patient opens his mouth wide, the neck of the condylar process is determined and the needle is directed to a point in front of the end of the index finger, which will also correspond to the direction to the tragus. The described manual technique does not require careful visual control or construction of spatial images and is successfully performed with satisfactory coordination of movements.

Anesthesia of the mental nerve

There are extraoral and intraoral methods of blocking the mental nerve. Currently, highly effective local anesthetic drugs make it possible to achieve sufficient pain relief without inserting a needle into the canal, infiltrating the tissue near the mental opening. Thanks to this, it is possible to significantly reduce the trauma of anesthesia, as well as to use the intraoral method of administration and not strictly adhere to the direction of needle orientation, which simplifies the technique.

It is interesting to note the proposal of Malamed SF (1997), who recommends the following technique to increase the effectiveness of blockade of not only the mental nerve, but also the incisive branch. After inserting the tip of the needle into the area opposite the mental foramen, apply gentle pressure to this area with your finger. Pressure can be applied either to the mucous membrane (with the finger placed inside the mouth) or on the skin (with the finger placed outside the oral cavity). Maintaining this pressure, a local anesthetic solution is injected. Under these conditions, tissue swelling at the injection site will be significantly less. According to Malamed SF, when pressed with a finger, the solution spreads into the canal through the mental foramen, which makes it possible to create a high concentration of anesthetic around not only the mental nerve, but also the incisive branch of the inferior alveolar nerve. After completing the injection and removing the needle from the tissue, the pressure is maintained for at least 2 minutes to prevent the injected solution from flowing out of the hole. After another 3 minutes, anesthesia develops in the tissues innervated by these nerves.

Regional (trunk) anesthesia

Anesthesia at the outer base of the skull in practical dentistry is called stem, since the anesthetic solution is injected into the infratemporal fossa, from where it spreads to the pterygopalatine, and turns off the second branch of the trigeminal nerve; passing below, it also affects the third branch of the trigeminal nerve at the foramen ovale. In this case, anesthesia occurs over a large area of innervation, which corresponds to the concept of regional anesthesia.

This method of anesthesia, taken from practical dentistry, can be used in aesthetic medicine for extensive correction and when introducing threads into soft tissues.

The classic method of anesthesia of the second and third branches of the trigeminal nerve is the subzygomatic-pterygoid approach according to Weisblatt, which should be performed with the patient in a horizontal or semi-horizontal position. With this method, the needle is inserted directly under the lower edge of the zygomatic arch and advanced through the notch of the mandibular ramus towards the base of the outer plate of the pterygoid process. In front of the pterygoid process there is a pterygopalatine fossa, through which the trunk of the second branch of the trigeminal nerve passes, and behind the pterygoid process there is an oval foramen through which the third branch of the trigeminal nerve exits from the cranial cavity. The outer plate of the pterygoid process serves as a guide for the correct direction of the needle. Its projection onto the skin is located in the middle of the distance from the tragus of the auricle to the lower outer corner of the orbit.

After treating the skin with alcohol, a needle is inserted halfway along the lower edge of the zygomatic bone and perpendicular to the surface, moving it before applying the solution deep into the bone, which corresponds to the outer plate of the pterygoid process. Having noted the depth of the needle, it is brought out to the subcutaneous tissue and, deflected forward by 20–25 degrees, is reinserted at the same distance, reaching the entrance to the pterygopalatine fossa, where 8–10 ml of anesthetic is slowly released from a syringe, saturating the tissue. This achieves anesthesia of the second branch of the trigeminal nerve.

The same is done when anesthetizing the third branch of the trigeminal nerve, only the needle is directed back at this angle. The anesthesia zone covers the exclusion of pain sensitivity in half of the lower jaw, half of the tongue, buccal nerve, auriculotemporal and motor branches of the trigeminal nerve.

Egorov P.M. proposed a simplified version of this anesthesia at the infratemporal crest. In both cases, the needle is inserted perpendicular to the skin surface under the zygomatic arch 2 cm in front of the tragus of the ear, moving it through the semilunar notch of the mandible to a depth of 2–2.5 cm deep to the bone, deflecting the syringe downwards and the needle upwards by 15 degrees from planes of the face. The injection depth should not exceed 3–4 cm. An anesthetic solution in an amount of 5 ml is injected slowly, anesthesia occurs after 10 minutes. The analgesic effect is controlled by the painlessness of opening the mouth.

Possibility of complications

Complications associated with injection anesthesia in maxillofacial surgery can be divided into local and general, as well as early (detected immediately after the injection or during surgery) and late (developing one day or later after the injection).

The doctor must anticipate the possibility of these complications in order to take the necessary preventive measures and correctly prescribe treatment.

All post-injection complications can be divided into the following groups:

• general complications that occur during and immediately after injection of an anesthetic solution;
• general complications that appear some time after the injection;
• local complications that appear during or immediately after the injection;
• local complications that develop some time after anesthesia.

The above classification is conditional, since some of the complications (for example, as a result of erroneous administration of non-anesthetic fluids) reach their full subsequent development (in this example - tissue necrosis, jaw contracture, facial nerve paralysis, etc.) in a significantly long-term period, after 5 –8 weeks or more.

Among the complications that occur during anesthesia, the most common are fainting , intoxication with an anesthetic drug, and adrenaline intoxication.

As for complications that appear after some time, due to damage to the nerves of the maxillofacial area with a needle (during injection), neuralgic pain and paresthesia sometimes develop not only in the face and head, but also in other areas. Damage to the branches of the trigeminal, facial and other cranial nerves with a needle can cause persistent dizziness, headaches, gastrointestinal and cardiac disorders, general weakness, psychopathological syndromes, etc.

Local complications during or immediately after injection include:

• complications associated with the action of injected solutions;
• complications associated with errors in pain management techniques. The first include: ischemia of the corresponding area of the face, diplopia, paralysis or paresis of facial muscles; the second group includes injuries to blood vessels, nerves, muscles, needle breakage, etc.

Use of anesthesia for contour correction

When carrying out contour correction in the area of the forehead, bridge of the nose, brow ridges, temporal fossae, nose, oval of the face, parotid folds, neck, décolleté, cutaneous application of Emla cream under occlusion is most often used.

When correcting nasolabial folds, cheek-zygomatic area, lips, purse-string wrinkles, marionette lines, and chin, conduction, infiltration anesthesia, and skin application of Emla cream under occlusion are used.

A special place is occupied by anesthesia during contour correction using cannulas. In this case, anesthesia is necessary only at the injection site of a large-diameter needle when a hole is formed for the passage of the cannula. For this purpose, a targeted intradermal injection of 0.1–0.2 ml of anesthetic is carried out at the injection site with infiltration to the “lemon peel”.

If it is impossible to carry out anesthesia (if there is a history of allergic reactions to anesthetics), the following technique can be used. Before piercing the skin, ask the patient to take a deep breath and hold it. Holding your breath will reduce the number of possible unwanted movements of the patient while advancing the needle to the target point. Preliminary additional ventilation of the lungs during a deep breath will increase blood oxygen saturation and lead to a slight increase in heart rate due to the cardiorespiratory reflex, which will increase blood flow to the vessels.

This technique will further reduce the risk of tissue trauma and will prevent vascular reactions during injection, as well as an easy distraction.

The choice of anesthesia depends on the procedure and the clinical case. Sometimes there is no need to do it at all, but the patient’s comfort is no less important than the technical result of the procedure itself. It is very important for a doctor of aesthetic medicine to understand even the smallest details and be able to build the right approach to each patient in his office.

First published : Les Nouvelles Esthetiques Ukraine, No. 1 (71), 2012