Pain management in aesthetics

01 Jul 2014

Clinicians today have a whole toolbox of options to keep patient discomfort to a minimum. Kathryn Senior speaks to practitioners about their preferred methods for managing pain.

Any aesthetic procedure in which the skin is penetrated or modified is potentially painful, but individual patients vary enormously in how they perceive the sensation and how much it bothers them. It is well known that anxiety and fear play a huge role in elective as well as unplanned medical procedures. This is particularly true for facial aesthetic treatments; our sense of self is intimately related to our facial appearance and expectations of what may go wrong can play a major role in pain perception. “I would say that patients attach more psychological pain to not having what they want corrected, enhanced or fixed, than to the physical pain that they fear may be caused by the procedure,” says Sloan Sheridan-Williams, clinical hypnotherapist and life coach for clinicians. Managing pain is just as much about managing expectations and perceptions as it is about using a pharmacological approach to limit the nerve impulses generated by pain receptors. Today’s aesthetic professionals must create a clinic environment and an experience that minimises the fear of pain, as well as dealing effectively with any physical pain that ensues.

First impressions are crucial

Health professionals who deliver potentially uncomfortable aesthetic procedures on a daily basis agree that the opportunity to minimise pain starts at the initial consultation. Dr Rachael Eckel, cosmetic dermatologist, believes it is possible to pick up many crucial insights at this first meeting. She asks herself, “Is this an anxious patient? Has this patient had a bad experience? Does he or she seem to have a low pain threshold? Is this patient showing signs of body dysmorphic disorder?”

“Past experiences play a huge role in how a patient perceives any type of treatment,” observes Sheridan-Williams. Taking a detailed history from each patient to identify any concerns is therefore essential. “If you don’t know that a patient has fainted in the past, you are going to come unstuck,” cautions Dr Ravi Jain, consultant aesthetic physician and owner of Riverbanks Clinic. “You really have to understand the patient’s needs and concerns about pain, their attitude to needles, and then plan accordingly,” he advises.

Addressing the issue

To fulfil the requirements of informed consent, the amount of pain that a patient can expect during an aesthetic procedure has to be discussed but, as Dr Jain points out, “You have to be careful; if you ask people about pain before you start, you will set them up for pain.” Dr Eckel agrees that there is a fine line between not giving enough information, and giving too much. “If you don’t explain every step of what is going to happen in a procedure – such as a chemical peel – and suddenly the patient feels burning or stinging, he or she will naturally assume something is going wrong. They need to be prepared, but you don’t say, ‘This will be very painful.’ You have to be wise in the words you use,” she says.

A bespoke and holistic approach

Creating the right atmosphere in your aesthetic clinic is paramount. Experienced aesthetic practitioners aim to create a welcoming, relaxing ambience in their clinics, as far removed from a traditional ‘hospital’ atmosphere as possible, to help decrease stress and dissipate anxiety. Dr Jain’s treatment room at Riverbanks overlooks beautiful gardens and a river. “Straight away patients are de-stressed by looking out onto the gardens, rather than thinking about their treatment. Having the radio on works too, because they can listen to it and comment on it,” he says. Making sure people don’t feel rushed is also a priority: “During a consultation, the patient is the most important person in the world to you at that moment, that’s what they need to believe, you need to have a nice calm voice and exude confidence.” Dr Vincent Wong of La Maison de L’Esthétique rarely wears scrubs, or a suit and tie, preferring to meet patients wearing semi-casual, everyday clothes. “This is something that new patients will not expect – and almost immediately I get a non medical conversation going to get to know the patient better as a person,” he says. At every stage, managing pain means dealing with anxiety. “When your client is calm, collected and relaxed, any actual pain will be minimised” says Sheridan-Williams.

Engaging all the senses

Many techniques can be used within the context of a holistic approach to distract the patient from any discomfort. Together, they form a strategy that fits into the holistic approach, complementing and supporting pharmacological pain relief. Dr Eckel deploys a five-pronged approach to managing pain for the patient, addressing all the senses to ensure that the patient is calm and relaxed.

Sight - An aesthetic procedure needs to take place in an environment that is clean, clear and calm, says Dr Eckel. Beautiful scenery is a bonus.

Hearing - It’s easy, thanks to technology and the web, to enable every patient to listen to the music they want during a treatment. Talkesthesia, distracting the patient using conversation, is also a useful therapy. Dr David Eccleston, aesthetic physician and clinical director of MediZen prides himself on his skills in this area, saying, “I have, on more than one occasion, had patients fall asleep during a procedure involving multiple injections.”

Smell - Dr Eckel often lights a scented candle in the treatment room and offers each patient a warm scented towelette on arrival. “I have a generalised minted theme in my clinic – mint candles and mint-basil fragranced towelettes. Mint is a calming, soothing, relaxing scent, and it sets the tone for the whole experience.”

Taste - Dr Eckel also offers a small helping of homemade mint chocolate ice cream, or a healthier mint protein shake after the procedure, other practitioners also give chocolates. “It’s good that patients have something before they leave that is going to make them feel good and lift their spirits. Sweet treats also deliver a surge in serotonin and raise blood sugar,” she says. “This also means they are much less likely to faint – we always advise people to eat normally beforehand too,” adds Dr Jain.

Touch - Hand massages during facial treatment offer a pleasant distraction, but there are many other options. During Botox procedures Dr Eckel favours having an assistant tap in the middle of the patient’s forehead, lightly but repetitively as a distraction, having learned the technique in Australia. Dr Eccleston offers patients a stress ball to squeeze – “or, if they wish, a friend or member of staff just to hold their hand.”

Pharmalogical pain relief

Traditional pain relief has an important role to play in enhancing patient comfort during and after aesthetic procedures, but it should be treated as a well integrated part of making each patient feel calm, relaxed and cared for. Today, aesthetic clinics are able to offer the latest pain relief delivery technology as well as the range and formulation of active compounds available. Creams such as EMLA (lidocaine plus prilocaine), LMX4 (lidocaine) and Pliaglis (lidocaine and tetracaine), are used by many practitioners. Dr Jain favours the latter for procedures such as Smart Xide CO2 laser resurfacing and tattoo removal. “EMLA and LMX4 take about an hour to take effect and they need to be occluded, which means wrapping the face in film. The nice thing about Pliaglis is that it is effective in 30 minutes and it self-occludes. It just peels off when it’s dry, so it’s easy to put on and easy to take off.” Plastic surgeon Mr Dalvi Humzah’s practice uses a Clarisonic brush to clean the facial skin before applying a topical anaesthetic. “It has to be proven yet, but we think that using the brush to clean the skin to an ultra level, taking the surface layers off, helps with the absorption of the local anaesthetic. It also gives the patient a two minute time-out period before the procedure, which is psychologically very calming.” The general consensus is that having a separate room for patients to sit privately once the cream has been applied is essential to the patient’s overall experience. Mr Humzah is very much against the idea of patients sitting in the general waiting room with white cream on their face for 30 minutes. He uses nerve block injections around the face, near to the nerves that supply the area to be treated. Nerve blocks work quickly, within 15-20 seconds. “The other advantage is that when the area is completely numb, you can really concentrate on getting the result right, rather than simultaneously working hard to allay a patient’s anxiety and fear because they are feeling some discomfort,” explains Mr Humzah. “You also need to make sure you inject nerve blocks properly, which means very slowly,” he adds.

Dr Eckel also uses a complete facial nerve block, consisting of nine injections before a chemical peel. “I combine lidocaine with epinephrine to give me a faster onset of action and reduced toxicity, which means I can double the amount I use before running into problems,” she says. Dr Eckel also buffers the lidocaine with sodium bicarbonate to reduce the pH, and warms the solution before injection, again to reduce pain during injection and to speed up onset of action. For patients particularly susceptible to the initial pain of any injection, using Coolsense, a small device with a metal cartridge that is kept in a freezer and then applied to the skin for four seconds, gives 10 minutes of instant numbness. “Coolsense works the same way as ice, but ice can get messy with water dripping all over the face once it melts,” says Mr Humzah. Although it needs to be applied carefully during the procedure to avoid burning the skin, some patients are able to tolerate Botox injections with cooling only.

Treatment techniques to decrease discomfort

When delivering injectable therapies such as botulinum toxin or dermal fillers, good technique and the use of supportive therapies can help minimise discomfort. For filler injections, it is important to think about the volume being delivered, “The evidence shows that the greater the volume of product injected, the greater the displacement of tissue and the greater the pain level. We try to use products with small volumes to give the best results,” Mr Humzah explains. “Splitting a larger dermal filler volume into two sessions a couple of weeks apart can also reduce pain.” Dr Jain tends to use a cannula rather than a needle to introduce dermal fillers because, he says, “this means only 1-2 pin pricks on each side of the face rather than several, which reduces pain significantly.” It’s also Mr Humzah’s experience that cannula injections are better tolerated than those administered with a needle. “Interestingly, the bigger the cannula, the less painful it is; I discovered that by accident but I always use the biggest one possible for each procedure now.”

Invasive procedures

Intravenous sedation is available in an aesthetic clinic, at a level similar to that used before a colonoscopy. “I have an anaesthesiologist come into my practice for procedures and patients that require sedation – it essentially makes the patient feel very relaxed during the procedure and then dims their memories of it afterwards,” says Dr Eckel. Mr Chris Inglefield, consultant surgeon at London Bridge Plastic Surgery and Aesthetic Clinic, uses Hilotherapy after the most invasive procedures or for treatments that are likely to induce swelling. “Hilotherapy is beneficial for filler treatments, particularly facial voluminising, fractional laser treatments, laser lifting, mid to deep chemical peels and all facial surgery such as blepharoplasty and mini-facelift,” he says. Water at the required temperature is passed through a mask or cuff that is applied directly to the skin, providing the optimal temperature for healing. “The technique minimises swelling, bruising and pain after a procedure, which is just as important for patient experience as managing their comfort during that procedure,” explains Mr Inglefield.

Pain management for 2014 and beyond

With so many approaches, techniques and pain relief formulations available in aesthetics, clinics need to keep their protocols under constant review. The best practitioners operate a feedback system with patients, learning from individual experiences, adapting how to tailor future experiences. “We have enough tools available to us that patients should come in looking forward to the treatment they are having. The old saying, ‘No pain, no gain’ should not have a place in aesthetics in 2014,” concludes Dr Eckel.

Case study: Pain management during Utherapy

It is rare to find published studies that assess pain perception during aesthetic treatments, or that determine the impact of strategies used to reduce that pain. The collection of small but randomised and double-blinded trials that have been performed for Ultherapy are therefore of great interest. These have sought to assess the impact of different forms of analgesia and to explore procedural techniques that could help to reduce discomfort.

About Ultherapy

Ultherapy uses six DeepSEE transducers to deliver ultrasound into the dermis, deep dermis, or the subdermal tissues to tighten and lift the brow, face, neck or chest. The high-intensity ultrasound stimulates new collagen formation, lifting the skin back into a firmer, younger-looking position at the surface. Some of the treated tissue is coagulated during treatment, which can stimulate pain receptors in the skin.

Research findings

  • Patients given a single dose of 800mg ibuprofen 60 minutes before Ultherapy experienced statistically comparable discomfort (p=0.14, no significant difference) as those given 10mg hydrocodone, combined with 500mg paracetamol (acetaminophen), and they were able to drive immediately afterwards.
  • In a second study, patients receiving Ultherapy were given 800mg ibuprofen an hour before treatment and then had either LMX4 cream or a placebo cream applied to the treatment area. No difference in the level of pain reported was seen between the two groups.
  • In a third study, patients were treated on one side of the face with the highest energy level of ultrasound per transducer, and with the lowest energy setting on the other side. All also received 800mg ibuprofen an hour before treatment. In the study there was a significant reduction in the overall levels of discomfort reported on the sides of the face where the lower energy was used, but there was no difference in efficacy between sides.

What the studies demonstrated

Ibuprofen at an over-the-counter dose is a suitable method of pain relief for Ultherapy but patient comfort can be further enhanced without compromising beneficial effects if energy levels are reduced. Ultherapy’s Amplify software was upgraded in 2012 to incorporate lower Amplify settings. According to Dr Matthew White, Director of Facial Plastic and Reconstructive Surgery at the Langone Medical Center, New York, this upgrade results in increased patient comfort during the procedure, demonstrating that pain management is a key consideration across the industry.

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