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« Nick Carr MD, FRCSC, Canadian Plastic Surgeon & Educator | Main | Dr. Alexander E. Handschin, Plastic Surgeon In Germany »
Friday
Sep072012

Painless Neurotoxin Injection Method? Join the Discussion!

What injection methods are most useful and reliable for neurotoxin injections: Botox & Dysport.

I have been in clinical private practice going on 14 years now and enjoy a busy and healthy cosmetic surgery practice.  Injectables, both fillers and neurotoxins, remain an integral part of my practice and I suppose that the loyalty my patients show by continuing to return to me as their injection provider is testament that my skills must be competitive with the many other local physicians who offer the same procedures.  I definitely do not price cut to keep the volume or attract new patients, and I believe I price fairly taking into consideration both my training and experience with typical pricing in my area by "mainstream" cosmetic providers.

I continue to strive to offer the least painful experience for my patients and have tried multiple different methods to decrease the degree of injection discomfort for my patients.  From topical anesthetics, icing, slow injection delivery, and currently vibration-distraction techniques, I have yet to find the WOW approach. I do use lidocaine-treated fillers and believe that these have advanced our patients' injection experience to an appreciable degree.

My intent for this entry is to stimulate a healthy community discussion on what methods the readers have found useful and reliable for neurotoxin injections (to keep this discussion focused I am not encouraging discourse on filler injections but perhaps this can be a future topic of discussion), in addition to disregarding any approach that they have found particularly not beneficial.  We all want to make our injections as easy as possible for our patients, so I am hopeful that this topic can generate healthy dialogue!

Reader Comments (16)

We've tried the "painless" needle that attaches to a syringe. You then press a button prior to injection which fires a cool spray. Most patients did not feel it made a difference. If the spray could somehow be part of the syringe instead of an external clip on it may have worked better.

I'd be interested in some comments that lay out all of the painless methods in common use so we could discuss pros/cons.... I'd like to get off the ice and find something truly painless since it's always a little bit of a concern and sometimes costing us treatments with the needle-phobes.

09.10 | Unregistered CommenterShane MD

Why is the injector in the photo not wearing gloves? Regarding Botox, we were taught to uncap the vial and draw up the Botox without touching the glass inside the vial. This keeps the needle pristine and thus less pain and no "crunching" with injection. We use also use a specific 31 gauge needle and never give more than 3 or 4 injections per needle (gets dull). We don't ice and people that have had Botox done elsewhere are often surprised at how much less painful our injections are. Filler is another discussion.

Agree that a sharp needle is really helpful in keeping pain to a minimum. Also, reconstituting so that there is a small volume of product to inject is helpful.

09.11 | Unregistered Commenterdrpamfp

Great point about the photo with a glove-less injector. I do agree that using a sharp needle lessens the pain. The forehead, where the dermis is often "fibrous" can quickly dull a needle and in my experience the needle needs to be changed here most often of all areas. I have not yet tried the 31 gauge needle but will look into this as it makes intuitive sense, so thanks for that.

i haven't found dilution 1cc vs 2.5 cc to make any difference but the former means a lot less product as each needle hub loss can be up to a 0.1cc. i use 32g needles and start with the crow's feet first as the skin is thinnest. If there is any suggestion of a barb or dulling, i change it. Ice definitely helps and for your needle phobic, topicals or vibration can help. But it's best to be quick and i don't inject as many spots as some people because the products spread pretty well.

"Touch" and "Speed"

As we know "gate theory", we can sense only one stimulus a time.So as I inject the toxin, I slightly pinch or touch the patient's skin or I use left hand to "bring" the skin under the needle. Using left hand, I can make the procedure quite precise and give the skin less damage.

Speed is also very important. If you inject slowly, they feel more pain.But try injecting quickly with the help of left hand. Your patients will say, they don't feel anything.

My patients say, they don't feel pain, as I put the needle inside of their skin. But they do feel pain when the Botox is injected. So I tried bicarbonate to balance the pH balance and it did work, but I don't know if the viability of Botox is still intact with that method or not.

Any comment?

Using "Preserved" saline helps. Benzyl alcohol is the preservative and converts to Benzyl chloride which acts as an anesthetic. I have done split patient injections with nonpreserved saline on one side and preserved on the other and patients prefer preserved. There has been no decrease in efficacy noted.

The combination of the 31 gauge needle, preserved saline and some local anaesthetic cream applied a few minutes before treatment greatly enhances patient comfort and delight.

I also use preserved saline for reconstitution and have not seen any subjective decrease in efficacy of the neuromodulator. There is some question as to whether or not using the preserved saline or the use of sodium bicarbonate has a negative clinical effect on efficacy, but there are not any definitive studies on this as of yet. Great input from everyone sofar!

At one injector training, it was suggested to enter the skin through a hair follicle or larger pore as there is less resistance and thus less pain felt by the patient. I have incorporated this technique for the past 5 yrs and my patients always remark on how painless my injections are. Requires good vision, or a pair of reading glasses, but once you get the hang of it, it's second nature. For very sensitive patients, I offer 10 min of pre numbing with a compounded BLT cream. Works well.

09.21 | Unregistered CommenterNurse Roni

I have always used bacteriostatic saline and do not think that it effects the longevity of the Botox or Dysport. I do think it makes it less painful. I use frozen peas prior to injection and numbing cream only very rarely for the really nervous patients. I use a separate needle to draw up and to inject and only use BD needles. I try to pinch up the skin as I inject, in areas where that is practical(glabella). My patients claim that they have a better experience with this than they have had elsewhere.

09.22 | Unregistered CommenterJo Herzog

I agree with Wrinkle Free. I use a 31 gauge needle and am careful not to touch the side of the vial as I draw into the syringe.

Has anyone tried different injection techniques for less pain? I was taught instead of going in at a 90 degree angle, trying a more angled approach, like 30-45 degrees. My clients seem to really like it when I use this approach. I agree with Dr. Barnett, that starting with the crows feet is best due to the thinner skin in this area, then proceding to the other areas.

I love the ouchless needle (cold spray device) I find patients do not bruise or feel the pain from the needle. I agree a 31 g needle and slow injection helps. Pinching up the skin and holding the muscle in GL area helps too.

Thanks to everyone's input on this topic. In my opinion, although there are many excellent recommendations provided in the feedback and I have modified my own approach as a result, we still have yet to find the holy grail of painless injection techniques. As Necessity is the Mother of Invention, I hope that someone will soon capitalize on a much-needed discovery. The demand for the cosmetic injection industry is likely to grow dramatically as a result!

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