What is the recommended anesthesia protocol for CO2 laser resurfacing, including facial nerve block?

Facial Nerve Block for CO2 Laser Resurfacing

Facial nerve blocks combined with topical and infiltrative anesthesia are recommended for full-face CO2 laser resurfacing procedures, as this multimodal approach provides superior pain control while minimizing the total dose of any single anesthetic agent. 1

Recommended Anesthesia Protocol

Multimodal Approach

The American Academy of Dermatology specifically recommends combining three forms of local anesthesia for full-face ablative laser resurfacing 1:

• Topical anesthesia (applied first)
• Facial nerve blocks (regional anesthesia)
• Local infiltrative anesthesia (as needed for supplementation)

This combination is considered safe and effective for larger, more complex cutaneous procedures, allowing you to prolong anesthesia, increase tolerability, and minimize adverse effects from higher quantities of a single agent 1.

Why Nerve Blocks Are Valuable

Nerve blocks provide several advantages over infiltrative anesthesia alone 2:

• Decreased tissue swelling and distortion
• Prolonged anesthesia duration
• Reduced postoperative discomfort
• Lower total anesthetic dose required

Practical Implementation

Step 1: Topical Anesthesia

• Apply topical anesthetic (EMLA cream or lidocaine/tetracaine-based preparations) 30-60 minutes before the procedure 3, 4
• Topical agents alone may be sufficient for some patients undergoing ablative laser resurfacing, though this is less common 1

Step 2: Facial Nerve Blocks

• Prepare injection sites with antiseptic solution 2, 5
• Use lidocaine with epinephrine as the primary agent 2
• Inject 1-2 mL at each nerve site bilaterally using 25-gauge, 1.5-inch needles 2
• Always aspirate before each injection to avoid intravascular administration 1, 2
• Inject slowly to minimize discomfort and tissue trauma 2, 5

Step 3: Supplemental Local Infiltration (if needed)

• Add infiltrative anesthesia to areas where nerve blocks provide incomplete coverage 1
• Use incremental injections 1
• Inject from healthy tissue toward treatment areas 2

Dosing Limits

Critical maximum doses for adults 1:

• Lidocaine without epinephrine: 4.5 mg/kg maximum
• Lidocaine with epinephrine: 7.0 mg/kg maximum
• For multistage procedures: 500 mg total lidocaine maximum over several hours

Safety Precautions

To minimize risk of local anesthetic systemic toxicity 1:

• Use the lowest effective dose
• Aspirate before each injection to avoid intravascular administration
• Use incremental injections
• Continually assess and communicate with the patient to monitor for early toxicity signs

Alternative Approaches

For patients with true lidocaine allergy (rare, representing only 1% of adverse reactions) 1, 2:

• Switch to ester-type local anesthetics
• Use 1% diphenhydramine (though it has longer onset time)
• Consider bacteriostatic normal saline (0.9% benzyl alcohol)

Topical-only protocols: Some evidence suggests that supplemented topical anesthesia alone (with oral analgesics and anxiolytics) can be effective for full-face CO2 laser resurfacing, with only 5% of patients requiring additional nerve blocks or infiltration 6. However, this approach is less predictable and the multimodal approach remains the standard recommendation 1.

Clinical Context

Important caveat: While no comparative studies demonstrate that one form of local anesthesia is safer or more effective than another, the work group considers topical, infiltrative, and nerve block anesthesia all safe for office-based settings 1. The recommendation for combining methods is based on expert consensus to optimize patient comfort and procedural success for extensive procedures like full-face laser resurfacing 1.