Fraxel: Pain Control when doing Fractional Treatments

To the group: What is the strongest numbing cream that you can order from a compounding pharmacy? I currently get a combination of lidocaine/prilocaine that the pharmacy will not tell me how and what concentration it is. It is better than Emla, but is there anything else out there? Currently we are getting people through the CO2 first pass with my cream, a 10 mg of Vicodin and 2 mg of Ativan, all PO, but when it comes to the dynamic phase where I blend, they start squirming. I am at the point, I may start to do conscious sedation with Fentyl and Versed. If anyone is using the Lutronic CO2, my settings are 100-160 mJ and 100-150 spots/cm2(density is automatically calculated for you). Thank you.




Sandra, have you considered IM Toradol or IM Versed? Conscious Sedation is an interesting idea. I was just speaking with an anesthesia doctor friend of mine about this. He said you would need a anesthesia nurse ($100 per hour) and you might need certain credentials in certain states (surgi-center?). I think Dentists do this all the time. It is an idea worthy of further discussion.


Jeff E


What about Nitrous Oxide (gas)? I have a patient who received cosmetic treatments in FL with this and always asks why we don’t do it. Any thoughts?


Susan DeGuide


I have been told that it will increase your malpractice insurance and it is expensive to get started.



nitrous use requires a proper "scavenging system" - OSHA rules. It's not just about having a tank...




Toxic to officepersonnel-- especially women of child bearing age.




Our doctor did her initial training in FL. They used nitrous oxide for everything, including injectables. They positioned themselves as a place to go for pain freecosmetic procedures. We bought a nitrous oxide cart system when we were down there, but we did not realize the laws in PA were so different than FL and we have not used our nitrous yet (a couple of years now) because we can't find anywhere to go to get certified to use it. We have tried dental schools, dentists, etc and have had no luck. If anyone knows how we can do that, we would love to hear some feedback, otherwise we are now trying to sell it.




In most states your malpractice insurance will go up significantly if you start doing conscious sedation.




Hi Sandra
Toradol does make a big difference for 'heat pain'. Also consider using Intramuscular demerol instead of vicodin. I use a blt in a specially prepared base, demerol, ativan and toradol and it goes well. Must time the dosing right though


In PA surgicenters used to be ways of getting more money out of insurance companies (speaking very frankly). Medicare and Ins. Co.'s got wise to it and now these entities are falling off.


Gotta balance the risk/benefit of having someone under anesthesia -- even via 'conscious sedation' without the STANDARD OF CARE (legal sticking point) offered forresuscitationsay, as in a hospital setting.


This is why (at least in PA) the plastics docs and surgeons use Short Procedure Units. Saves on both liability and cost of equipment in the office setting.


This brings me back to setting your panel of procedures to optimal revenue generation -- for the requests of those most willing and able to pay -- at the lowest risk. Then do a lot of them. The best way to do a lot is (if you can) to leverage your time by getting staff to do as much as possible for you -- thus the popularity of IPL devices in Jersey -- docs have to do the real lasers.