Dermatology Online Journal
Minimizing Discomfort during the injection of Radiesse™ with the use of either local anesthetic or ice
- Author(s): Comite, Stephen
- Greene, Alexis
- Cieszynski, Sabina A
- Zaroovabeli, Pauline
- Marks, Karen
- et al.
Minimizing Discomfort during the injection of Radiesse™ with the use of either local anesthetic or ice1. Mount Sinai Department of Dermatology
Stephen Comite MD1, Alexis Greene, Sabina A Cieszynski, Pauline Zaroovabeli, Karen Marks
Dermatology Online Journal 13 (3): 5
Radiesse™ or calcium hydroxylapatite has been used for years in patients with HIV associated lipoatrophy  as well as for facial wrinkles and nasolabial folds [2, 3], but can be painful to inject especially in the latter area. This discomfort can be severe enough that after an injection with Radiesse™, a patient, despite excellent results, may refuse additional treatments. We hereby describe several methods of minimizing discomfort during Radiesse™ injections of nasolabial folds and other facial areas.
The FDA has approved Radiesse™ in the past few years for a variety of indications, such as radiographic tissue marking, vocal cord insufficiency, oral and maxillofacial augmentation, and urinary incontinence. It was recently approved by the FDA for the treatment of wrinkles and folds and HIV lipoatrophy. The pain involved with Radiesse™ injections of the nasolabial folds has been described as deep, burning, and similar to a very bad toothache.
Topical anesthetic alone is inadequate. Regional blocks involve extra anesthetic and extra time but still some of the deeper pain can persist. Local anesthetic alone can be uncomfortable and can potentially distort the field if too much is used. Vibration anesthesia  can be helpful but the vibration must be applied close to the injection site, so this is impractical for the practitioner to use.
One of our techniques initially involves the use of topical anesthetic on the nasolabial folds. Many practitioners use LMX™ (lidocaine 5% cream), which provides for topical anesthetic in about 30-60 minutes. Other practitioners recommend individualized combinations of topical anesthetics, usually involving betacaine, which provide for quicker topical anesthetic, generally in about 20-30 minutes.
Once the topical anesthetic is effective, we wipe if off of the nasolabial fold about an inch below the superior edge of the fold. We judge the length of where to insert the needle by how much of the nasolabial fold needs to be injected. Generally we inject about an inch diagonally below the tip of the nasolabial fold. We inject a small amount of anesthetic, about 0.1 cc of local anesthetic, 1 percent lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate, per side. We try not to raise much of a wheal in order not to distort the fold.
After we inject the local anesthetic, we then use a 30-gauge one-inch needle (such as a B-D PrecisionGlide®) first with a push towards the superior aspect of the fold to be injected and then with a retrograde technique back to the insertion point. One only needs about 0.1 cc to 0.2 cc's per side in order to obtain effective anesthesia. We repeat this process on the other side to complete bilateral anesthesia consequently using about 0.2 cc's in total of local anesthetic, trying not to distort the nasolabial folds.
One can often inject the Radiesse™ right away, but we generally wait a few more minutes to assure that the local anesthetic takes effect. We always test for anesthesia before injecting the Radiesse™. Like local anesthetic elsewhere, the anesthetic effect lasts about 30 minutes to 1 hour, allowing plenty of time to complete the Radiesse injections. We generally use a 27-gauge 1¼-inch needle or a 25-gauge one or 1½-inch needle (again such as the B-D PrecisionGlide®) to inject the Radiesse™.
Using this technique, Radiesse™ injections have been tolerated much better with wider patient acceptance. This contrasts to the extreme discomfort felt by some patients when anesthesia is inadequate.
Our anesthetic procedure takes a short amount of time. Many patients, especially those who have undergone other anesthetic techniques, will be grateful and more likely to return for additional Radiesse™ or other injectible treatments.
For the treatment of other areas on the face such as the malar area and chin, we also start with topical anesthetic. We supplement this with local anesthetic at the margins of the area where we need to insert the needle in order to inject the Radiesse™ retrograde. Unlike the nasolabial folds, we do not generally need to infiltrate with local anesthetic throughout the field to be treated though this can be performed if necessary.
A second and effective but noninvasive technique involves the use of an ice cube for anesthesia. Ice has been helpful for such procedures as injection of Botox® into palms and soles for the treatment of hyperhidrosis . Our technique involves the placement of an ice cube, grasped by a gauze pad, directly for 45 seconds to the area to be injected such as the nasolabial fold. Ideally, we recommend using an ice cube whose shape can cover the entire fold. We find that cold or ice compresses do not provide effective anesthesia as compared to an ice cube.
Topical anesthetic may be used prior to applying the ice as previously described. We recommend keeping a gauze pad available inferiorly, as the ice may drip. One may apply ice applied directly to the skin after injection of the Radiesse™ to minimize any post-treatment discomfort. We have found the technique using ice to be both noninvasive and quick, but in general can be slightly more uncomfortable than infiltration with local anesthetic.
The use of ice is based on the gate control theory of pain, as described by Melzack and Wall [11, 12]. Cooling in the form of sprays, cold air, ice packs, ice, and cool gels have been used to minimize discomfort of a variety of dermatological procedures for many years [13, 14, 15, 16, 17, 18].
The advantages of using ice are that it is noninvasive, quick, and readily available. The disadvantages are that it may not provide pain free anesthetic and that not everyone has ice cubes available.
We hereby describe two methods, first by the use of both topical and injectable anesthetic, and second by the use of ice cubes, to ameliorate any potential discomfort associated with the injection of Radiesse™ into the nasolabial folds and face. As patients can differ in their perception of pain, some may prefer one technique to another so it is helpful for the dermatologist to have a variety of ways to minimize pain in one's armamentarium.
Our techniques do not involve the use of regional or infraorbital nerve blocks and thus are simpler to perform for many dermatologists who do not routinely perform these kinds of blocks, yet can provide adequate anesthesia to help the practitioner inject Radiesse™. Further and controlled studies into the use of these techniques to minimize pain would be helpful.
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