Lasers in Surgery and Medicine 34:269–272 (2004)

Anesthesia Technique for OutpatientFacial Laser Resurfacing

Agustın Ramos-Zabala, MD,1,2* M.T. Perez-Mencıa, PhD, MD,1,3 R. Fernandez-Garcıa, MD,2

and M.R. Cascales-Nunez, MD1

1Department of Anesthesiology, Corporacion Dermoestetica, Madrid, Spain2Department of Anesthesiology, Hospital Universitario Ramon y Cajal, Madrid, Spain3Department of Anesthesiology, Hospital Universitario de Mostoles, Madrid, Spain

Background and Objectives: Multiple anesthetic ap-proaches exist for full-face laser resurfacing. The purpose ofthis study was to describe an anesthesia technique based oncombination of eutectic mixture local anesthetics (EMLA)and remifentanil sedation, that can be utilized by anesthe-siologists in the ambulatory environment.Study Design/Materials and Methods: Fifty patientselected for facial laser resurfacing. All patients receivedtopical anesthesia in full face with EMLA cream at60 minutes (min) before laser procedure. On arrival at theoperating room, intravenous (IV) sedation was administeredwith remifentanil (0.20 mcg/kg/minute), midazolam (1.5–2 mg bolus IV), and propofol infusion (0.5–1 mg/kg/hour).The subsequent infusion rate of remifentanil was varied tomaintain an adequate level of sedation and analgesia. Fiveminutes before the operation conclusion, the sedationinfusion was discontinued. Patients were discharged afterachieving a minimum criteria for recovery.Results:Almost all the patients were successfully anesthe-tized by this combination technique, only four patientsneeded complementary anesthesia with regional nerveblockade. The mean level of sedation scored 2–3 on theRamsay scale. The mean discharge time was 55 minutes.No complications were observed.Conclusions: The use of a combination of topical EMLAanesthesia and IV conscious sedation based on remifentanilprovided an adequate depth of anesthesia for outpatientfacial laser resurfacing without complications. LasersSurg. Med. 34:269–272, 2004. � 2004 Wiley-Liss, Inc.

Key words: ambulatory anesthesia; ambulatory surgery;EMLA; intravenous anesthesia; laser; office-based; out-patient anesthesia; remifentanil; sedation

INTRODUCTION

During the past 15 years, safer and more predictabletechniques have been introduced to rejuvenate the skin [1].In recent years, cutaneous laser resurfacing has becomeone of the most popular methods of skin rejuvenationbecause of its ability to safely improve facial rhytides andatrophic scars [2]. Laser resurfacing induces a controlledskin injury, with removal of the epidermis and variableportions of the dermis. The most common indications forskin resurfacing are photoaging (including elastosis, rhy-tides, and lentigines) and acne scarring [1]. Erbium:

yttrium–aluminum–garnet (Er:YAG) laser resurfacingwas introduced as an alternative to carbon dioxide (CO2)laser surgery in the hope of maintaining clinical benefitswhile decreasing the recovery period and side-effect profile[1,2]. The Er:YAG used for facial resurfacing proceduresrequires intense analgesia.

Anesthetic technique is required for cutaneous laserresurfacing procedures to alleviate discomfort resultingfrom epidermal ablation and dermal heating [1–3] in keep-ing with the standards for office-based anesthesia practice.For procedures requiring more than local anesthesia, forexample, intravenous (IV) sedation or general anesthesia,there are various anesthetic techniques available for faciallaser resurfacing [3–7]. The goals of anesthesia are toprovide optimal conditions for the operating surgeon whileensuring the safety and comfort of the patient, withminimal complications and rapid recoveries [3].

Total IV anesthesia (TIVA) is well suited for outpatientplastic surgery procedures [4,5]. The TIVA technique usedfor laser resurfacing has utilized propofol, midazolam,fentanyl, and ketamine with good results [4,5]. Short-acting drugs allow better titration of anesthesia and may,therefore, reduce the incidence of respiratory depressionand permit rapid recovery, which is especially desirable forambulatory surgery. Remifentanil is a rapidly acting esteropioid, which is metabolized by non-specific esterases. Thisresults in a much higher clearance and shorter eliminationhalf-life than other opioids and allows administration byinfusion without accumulation [8]. Thus, remifentanil is anoptimal drug for outpatient anesthesia [9,10].

Many dermatologic laser procedures, particularly exten-sive facial treatments, can be accomplished by using acombination of regional nerve blockade and monitoredanesthesia care (MAC). These procedures typically involveconscious sedation in which patients maintain their pro-tective airway reflexes. Occasionally, heavy sedation, orunconscious sedation may also be needed [7]. Topicalanesthetics have been used for cutaneous procedures[11,12]. Eutectic mixture local anesthetics (EMLA) cream

*Correspondence to: Dr. Agustın Ramos-Zabala, MD, C/Finisterre 8 13-C, Madrid 28029, Spain.E-mail: arramos@wanadoo.es

Accepted 19 November 2003Published online in Wiley InterScience(www.interscience.wiley.com).DOI 10.1002/lsm.20007

� 2004 Wiley-Liss, Inc.

is the topical anesthetic most commonly used by physiciansperforming dermatological surgery [11].

We describe a combination anesthetic technique,with topical anesthesia and sedation based on remifentanil,that has facilitated the performance of facial resur-facing procedures in the ambulatory surgery unit withoutcomplications.

MATERIALS AND METHODS

The study protocol was approved by the InstitutionalMedical Ethics Committee and all patients gave their oraland written informed consent. Fifty patients undergoingelective laser facial resurfacing (Er:YAG laser; Derma20 Medi Form1) were prospectively included in the study.

All patients were premedicated 2 hours before surgerywith hydroxyzine 25 mg orally. On arrival at the Ambula-tory Surgery Unit anesthesia monitoring standards werestrictly followed. Monitoring included electrocardiography,pulse oximetry, and non-invasive arterial pressure. Allpatients then received topical anesthesia in full face withEMLA cream (lidocaine 2.5% and prilocaine 2.5%) at60 minutes before laser procedure (Fig. 1). The maximumdose applied was 30 g of cream. In the operating room (OR)the IV sedation was started 5 minutes before initiating thelaser procedure. Sedation consisted of remifentanil infu-

sion of 0.20 mcg/kg/minute, midazolam 1.5–2 mg bolus, andpropofol infusion of 0.5–1 mg/kg/hour. TIVA sedationwas maintained with the minimum dosage necessary toensure the safety and comfort of the patient. The subse-quent infusion rate of remifentanil was varied (0.05–0.3 mcg/kg/minute) to maintain an adequate level ofsedation, spontaneous respiration, and analgesia. Contin-uous clinical observation and vigilance are essential for safeanesthesia care (e.g., loss of spontaneous respiration).During the procedure (Fig. 2), the anesthesiologist mustcontinuously assess patient responses to the anesthetic andsurgical intervention, by evaluating oxygenation, ventila-tion, and circulation parameters, and intervene as requiredto maintain patients in a satisfactory physiological condi-tion. Special laser safety precautions are necessary in theOR. During the laser procedure the anesthesiologist avoidsthe use of oxygen because of its incendiary potential. Allpatients received ondansetron 4 mg IV for prevention ofpostoperative nausea and vomiting. Thirty minutes beforethe end of the procedure, ketorolac 1 mg/kg (maximum60 mg) IV and propacetamol 2 g IV were administered. Fiveminutes before the end of the operation the sedationinfusion was discontinued. After completion of the laserprocedure occlusive dressings were placed over all laseredsurfaces (Fig. 3). Ten minutes after the laser procedure wasfinished, the patients left the OR. Patients were dischargedafter achieving a minimum criteria for recovery [13]. Theymust exhibit stable vital signs, be alert and oriented to time,place and person, be free of nausea, vomiting and dizziness,have a steady gait, and demonstrate no bleeding. It isimportant that patients only be discharged in the care of aresponsible adult who must accompany them home, andthey receive their discharge instructions in writing.

Patient demographics, procedure duration, dosages ofthe sedation drugs, level of sedation on the Ramsay scale(levels 1–6) [14], numerical visual analog scale (nVAS),discharge times, and complications were recorded. A simpledescriptive statistical analysis of these variables wasperformed (Table 1).

Fig. 1. Topical eutectic mixture local anesthetics (EMLA)

anesthesia time. Fig. 2. Laser procedure time.

270 RAMOS-ZABALA ET AL.

RESULTS

A 92% of patients were successfully anesthetized utiliz-ing this combination technique (Table 1). Only four patientsneeded complementary anesthesia with regional nerveblockade. The sample consisted of 32 females and 18 males;41 were American Society of Anesthesiologists (ASA)status classification I and 9 were ASA II. The mean age of

patients was 37 (21–74) years. The mean procedureduration was 65.7� 21 minutes. The mean dosage ofpropofol infusion was 0.8 mg/kg/hour, and midazolam boluswas 1.78 mg. The mean dosage of remifentanil infusion ratewas 0.13 mcg/kg/minute. All patients preserved sponta-neous respiration and no patients needed supplementaryoxygen to maintain a hemoglobin oxygen saturation value�90%. The mean level of sedation was 2–3 on the Ramsayscale. The mean maximum level of nVAS was 1.02� 0.9The mean discharge time was 55� 10 minutes. Nocomplications were observed. None of the patients requiredadmission to hospital for postoperative nausea and vomit-ing or pain. Results are summarized in Table 1.

DISCUSSION

Several anesthesia techniques have been utilized forfacial laser resurfacing. Although, many procedures canbe accomplished with topical or local-regional anesthesiaalone, surgeons often request that patients receive a deeperform of anesthesia to ensure their safety and comfort.John Bing et al. [7] and Blakeley et al. [4] described acombination anesthetic technique, with regional nerveblockade and IV sedation (midazolam, ketamine, andpropofol). This technique was developed to achieve ade-quate intraoperative patient comfort while minimizing theneed for opioid compounds and for interventions to manageairway-related problems. However, this technique hasdisadvantages, such as inadequate nerve blockade inci-dence, side effects of the sedation drug (hallucinations andcardiostimulatory activity from ketamine) and the possibi-lity of increasing the incidence of postoperative facialdiscomfort. Perhaps regional anesthesia combined withsedation based on remifentanil could give improved results.For this reason, this technique has been utilized in ourAmbulatory Surgery Unit when the patient refuses toreceive EMLA cream during an hour.

Many anesthesiologists provide general anesthesia foroutpatient facial laser resurfacing. TIVA techniques withminimal complications and extremely rapid recoverieshave been described and are well suited for laser facialresurfacing [5]. Trytko et al. [5] prefer general anesthesiabecause this technique decreases the time requirements forthe operating practitioner and the postoperative compli-cations and discomfort are minimized; moreover usinglaryngeal mask airway insertion with spontaneous re-spiration minimizes the management of airway-relatedproblems. We believe that general anesthesia with remi-fentanil–propofol may be an adequate alternative topropofol–fentanyl techniques because it provides extre-mely rapid recoveries with minimal complications. How-ever, surgeons often request conscious sedation to facilitatethe collaboration of the patient during the intraoperativetime and occlusive dressings period; also many patientsprefer conscious sedation to general anesthesia.

This series of cases demonstrates the feasibility ofperforming painful laser procedures under a combinationanesthetic technique, with topical EMLA anesthesia andsedation based on remifentanil. This technique has the

Fig. 3. Occlusive dressing time.

TABLE 1. Demographic Characteristics, Procedure

Duration, Drug Dosages, Sedation Levels, and

Recovery Profiles

Sex

Females 32 (64%)

Males 18 (36%)

Age (years) 37� 10

Weight (kg) 60� 12

Topical EMLA anesthesia time (minutes) 55.6� 5.4

Laser time (minutes) 65.7� 21

Intraoperative anesthesia drugs

Remifentanil (mcg/kg/minute) 0.13� 0.05

Propofol (mg/kg/hour) 0.8� 0.2

Midazolam (mg) 1.78� 0.35

Ramsay scale (1–6)

Level 2 27 (54)

Level 3 20 (40)

Level 4 3 (6)

Maximum numerical VAS (0–10) 1.02� 0.94

nVAS 0 17 (34%)

nVAS 1 19 (38%)

nVAS 2 10 (20%)

nVAS 3 4 (8%)

Complementary regional anesthesia 4 (8%)

Postoperative emetic symptoms 0 (0%)

Discharge time (minutes) 55� 10.1

Values are mean�SD or n (%).

ANESTHESIA TECHNIQUE FOR OUTPATIENT FACIAL LASER RESURFACING 271

same advantages as regional and general anesthesia. Thus,airway management is not necessary, ensuring the intraand postoperative safety and comfort of the patient, withminimal complications and rapid recoveries. Furthermore,this technique facilitates the collaboration of the patientduring the intraoperative and occlusive dressings periods.None of our patients demonstrated postoperative nausea orvomiting, nor other side effects that delay discharge. Thedischarge time may be reduced to a few minutes.

Continuous clinical observation and vigilance from ananesthesiologist is essential to safe anesthesia care; so thistechnique should only be delivered or directed by ananesthesiologist.

Patients that needed complementary regional anesthe-sia had a topical EMLA time less than 50 minutes.Therefore, increasing the topical EMLA anesthesia timeby 10–15 minutes improves the outcome [11]; however, thecollaboration of the patient is required during this time.There are several topical anesthetics that may be used forlaser resurfacing [11]. Alster and Lupton [12] obtained bestresults using lidocaine/tetracaine-based cream peel.

CONCLUSIONS

In conclusion, the use of a combination of topical EMLAanesthesia and IV conscious sedation based on remifentanilprovided an adequate depth of anesthesia for outpatientfacial laser resurfacing without complications. This tech-nique is therefore a good alternative to avoid regional orgeneral anesthesia for facial laser resurfacing in theambulatory environment.

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