From the FDA Drug Label
The dose of any local anesthetic administered varies with the anesthetic procedure, the area to be anesthetized, the vascularity of the tissues, the number of neuronal segments to be blocked, the depth of anesthesia and degree of muscle relaxation required, the duration of anesthesia desired, individual tolerance, and the physical condition of the patient The smallest dose and concentration required to produce the desired result should be administered. In recommended doses, bupivacaine hydrochloride produces complete sensory block, but the effect on motor function differs among the three concentrations. 0.25% — when used for caudal, epidural, or peripheral nerve block, produces incomplete motor block. 0.5% — provides motor blockade for caudal, epidural, or nerve block, but muscle relaxation may be inadequate for operations in which complete muscle relaxation is essential. 0.75% — produces complete motor block.
The highest concentration of bupivacaine for permanent makeup is not explicitly stated in the label. However, based on the information provided, the highest concentration available is 0.75%.
- The 0.75% concentration is most useful for epidural block in abdominal operations requiring complete muscle relaxation, and for retrobulbar anesthesia.
- The maximum dosage limit must be individualized in each case after evaluating the size and physical status of the patient, as well as the usual rate of systemic absorption from a particular injection site.
- The maximum daily dose should not exceed 400 mg in 24 hours 1.
From the Research
For permanent makeup procedures, the highest recommended concentration of bupivacaine is typically 0.25% to 0.5%, with a maximum safe dose of 2 mg/kg of body weight (not to exceed 175 mg total), as supported by the most recent and highest quality study available 2. When considering the use of bupivacaine for permanent makeup, it's essential to weigh the benefits of longer-lasting anesthesia against the potential risks, including cardiac toxicity if accidentally injected intravascularly.
- The use of epinephrine (typically 1:200,000) is recommended to prolong the anesthetic effect and reduce bleeding, as seen in studies comparing different local anesthetic mixtures 3.
- The total volume of the anesthetic should be limited based on the area being treated, generally not exceeding 10-20 ml for facial procedures, to minimize the risk of systemic toxicity.
- Practitioners should be aware of the slower onset of bupivacaine (about 10-20 minutes) compared to lidocaine and monitor clients for signs of toxicity, such as dizziness, ringing in the ears, metallic taste, seizures, or cardiac arrhythmias, as noted in earlier studies comparing lidocaine and bupivacaine 4.
- Aspiration before injecting and careful monitoring of the client are crucial to avoid intravascular administration and ensure safe use of bupivacaine in permanent makeup procedures, as emphasized in the review of permanent makeup techniques and complications 2.