Pain Management for Botox and other Cosmetic Injectables

cosmetic injectables

Pain Management for Botox and other Cosmetic Injectables

At the IAPAM’s Aesthetic Medicine Symposium with Botox Training we are often asked about what keeps patients coming back to your aesthetic practice? The answer is a painless experience. Patients do not want to experience pain when they are having aesthetic medicine procedures. Part of the IAPAM’s botox injection training program includes covering the best practices in Botox injection pain management.

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Universally, experts agree that the critical factor in minimizing discomfort and bruising is technique.  However,  there are many physicians in the various camps on the issue of anesthesia and cosmetic injectables such as Botox and Dypsort.

The proponents of anesthesia and/or the use of ice assert that using ice around areas that are very vascular for a minute prior to injection (i.e. around the eyes) especially for patients with thinner skin will minimize bruising.

Other physicians choose to adopt the technique of using a topical anesthetic (and giving it enough time to work), and only afterward, begin the pre-injection consultation. Whether a repeat patient or a new patient, these physicians assert that pain is reduced by the application of a topical anesthetic which is left on for 15 minutes or so, before injecting.

Some physicians will also ask the patient to move their muscles and then make an appropriate mark with a white pencil, and then just prior to injecting, they will apply a small packet of ice for 15 seconds or so to each “marked” area. These doctors typically use iced gel packs, which hold the low temperature well, and don’t melt. Also, they may be able to be chilled slightly colder than regular ice. On issue with the use of ice or iced gel packs is that if the physician or his assistant leaves the cold pack on long enough that the tissue chills very well, the patient may find the cold intolerable.

Interestingly, that is the ideal time to quickly inject the Botox, which should only take a few seconds to inject in small volumes. The ice chills the dermis and subcutaneous tissues, which topical anesthetics do not. The cold usually works well enough for 90% of patients, but physicians must be careful, as “ice compresses” put the tiny vessels in spasm and make them harder to inject properly, especially in the glabellar area.

Other proponents of anesthesia use topical BLT anesthetic (benocaine, lidocaine, tetracaine), with cold packs for those very few patients who are extremely intolerant of any discomfort, as it minimizes the discomfort of the 32 gauge needle at the skin level only.

In the other camp, are the physicians who do not use anesthetic creams or ice application. They have found that there are still a minority of patients don’t like the feeling of ice packs or anesthesia, and just take their Botox ‘straight’.”

For these patients, physicians are advised to be gentle with technique and the patients will have a remarkably comfortable experience.

Also, “talkesthesia” works well, and keeps the patient comfortable and relaxed.  For example, explain the procedure to the patient before doing anything, and apply pressure near the needle as a distraction. Most patients do well with cues for relaxed breathing, squeezy balls, coupled with tiny gauged needles and 2 cc dilution of Botox®.

Finally, the majority of physicians find they have patients who do well “in both camps” of practice.

For these physicians, they offer their patients a variety of options. They use both a topical anesthesia and ice for more apprehensive patients, and for the average patient, use ice, but occasionally in unique and special ways. For example, one physician explained that he placed a single half moon shaped piece of ice into the finger of a glove and hold it in place until the patient says ‘cold’. This gives targeted anesthesia and vessel spasm with minimal discomfort (and perhaps less bruising as well).

Some patients have a higher tolerance to the needle coupled with a cold sensitivity to the ice, which they don’t like. Also, many busy people do not want to wait 20-40 minutes for the anesthetic cream to work.

A final recommendation from physicians in “both camps” is to use small needles:  32 gauge, which are tiny, and minimize discomfort significantly.


Botox is a trademarks of Allergan, Inc. Dysport is a trademark of Medicis, Inc. 


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