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Best Practices: Effective Pain Management for Botox Patients

September 17, 2009 |

The IAPAM offers the following  ‘best practices’ for physicians regarding Botox patient pain management, and in support of ongoing botox training and continuing education

As part of a its commitment to aesthetic medicine physicians’, the International Association for Physicians in Aesthetic Medicine (IAPAM) is developing a comprehensive e_report on “Botox Best Practices,” due out this fall.  Through development of this report, the IAPAM has found that here are several aspects of Botox treatment that warrant a separate discussion.  While there is general consensus among physicians regarding ‘best practices’ for: patient consultation, clinical procedures and  post-patient follow-up, interestingly, there are varied opinions surrounding the use of topical anesthetic and ice. The following aesthetic medicine leaders have graciously offered their expertise on the use of topical anesthetic and ice during Botox or similar neurotoxin treatments.

Since first introduced to the medical community in 1989, as a treatment for eye muscle disorders, administering of Botulinum Toxin Type A: Botox and similar neurotoxin injectables, has now become the most popular non-invasive aesthetic medical procedure performed worldwide.  However, as physicians strive to make aesthetic medicine procedures more comfortable for their patients, a “cold hard truth” of sorts has emerged regarding the use of topical anesthetic and ice during injectable procedures.

Through a survey of expert practitioners the following “best practices” for the use of topical anesthetic and ice emerges. 

The critical factor to minimizing discomfort and bruising is technique.  However, based on a patient’s tolerance, topical anesthetic can be used to minimize, but not extinguish, the pain associated with subcutaneous injections.  Ice is generally considered the best tool to minimize bruising.  Other tools in the physician arsenal to minimize pain are size of needle (32 gauge is recommended) and ensuring minimal volume is injected (e.g. dilute the Botox at 2.5 cc per bottle =4u/.1 cc). Finally, for a select group of physicians and patients, ice and topical anesthetic completely take a back seat to a “gentle” hand.

Proponents of Ice and Anesthetic

Dr . Mauro C. Romita, Specialist in Aesthetic and Reconstructive Plastic Surgery in New York, shares that “for Botox I typically use iced gel packs which hold the low temperature well and don’t melt. Further, “they may be able to be chilled slightly colder than regular ice, but ice is already cold enough.” 

“If one leaves the cold pack on long enough the tissue chills very well, so much so, that the patient finds the cold intolerable.  That’s 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.   I use topical  BLT anesthetic (benocaine, lidocaine, tetracaine), with cold packs only in a 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.  The cold usually does this well enough for 90% of my patients.  A minority of patients don’t like the feeling of ice packs and just take the Botox ‘straight’.” 

Moreoever, “ice compresses put the tiny vessels in spasm and make them harder to injure especially in the glabellar area.  Unfortunately, this doesn’t apply so much to the veins at the lateral orbicularis.”
Finally, Dr. Romita offers this final best practice. “I dilute the Botox at 2.5 cc per bottle =4u/.1 cc so the volume injected is minimal. This helps make it more comfortable.”

Dr. Richard Foxx, founder of The Medical and Skin Spa in Indian Wells, also sees the value in the use of topical anesthetic.  Dr. Foxx has “adopted the technique of using a topical anesthetic (and giving it enough time to work)” and afterward, begins the pre-injection consultation. “Whether a repeat patient or a new patient, I apply a topical anesthetic and leave it on for about 15 minutes….then begin injecting.  I ask the patient to move their muscles and then makes appropriate marks with a white pencil.”  Furthermore, prior to injecting Dr. Foxx applies a small packet of ice for 15 seconds or so to each area. 

Gentle Technique Can take the Place of Anesthetic

Dr. Louis DeLuca, a treatment leader in aesthetic medicine and plastic surgery options in Boca Raton, has found that he has been disappointed with topical anesthetic creams and ice application. “I provide my patients with ample warning before each injection.  I touch the area where the injection will be placed and count 1-2-3.  Just like the Pediatrician.  Nobody likes surprises in the doctor’s office.  Over the past five years I have had maybe 1 or 2 patients who have requested ice application,” attests Dr. DeLuca.  “Be gentle with your technique and the patients will have a remarkably comfortable experience.”

Furthermore, rather than using ice to minimize bruising, Dr. DeLuca suggests that these tactics work equally well.  “Avoid superficial veins (particularly around the eyes…the sentinel vein is a nuisance) as this will lead to excessive bruising.  Also, apply direct pressure to the injection sites to minimize post-injection bruising.  This absolutely works!”

Dr. Jennifer Linder, Dermatologist, Chief Scientific Officer for PCA Skin and faculty member of the IAPAM, echoes many of Dr. DeLuca’s insights.  Dr. Linder finds that “talkesthesia” works well, and she recommends, “keep the patient comfortable and relaxed, tell them before you are going to do any thing, and apply pressure near the needle as a distraction.”  “I occasionally use ice to vasoconstrict and for anesthesia.  If you apply the ice to another area with the assistance of a nurse that can also work well as a distraction.  I find most patients do well with cues for relaxed breathing, squeezy balls, tiny gauged needles and 2 cc dilution of Botox.  I rarely use topicals for Botox but I always use it for fillers.”

In Both Camps

Of course many seasoned physicians find the use of anesthetic and ice is entirely “patient dependent.”

For example, Dr. Nathan Mayl, a respected leader in the Fort Lauderdale Plastic Surgery and Cosmetic Medicine field, offers this insight on the companion uses of ice and topical anesthetic. 

“I am actually in both camps regarding how to do Botox as well as other spot treatments. I will use both topical and ice for my admittedly “wimpy” patients. They love it.  However for the average patient I use ice, but in a special way. We place 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).” 

Dr. Douglas S. Steinbrech, renowned plastic surgeon in the Manhattan area, concurs.  “I like to give my patients a variety of options.  Most people prefer ice, while second most common is people requesting anesthetic cream, followed lastly by the “toughies” who don’t want anything.  Some of my patients have a higher tolerance to the needle and a cold sensitivity to the ice which they don’t like.  Also, many busy people don’t want to wait 20-40 minutes for the anesthetic cream to work.”
“I like to use the ice because it is immediate and I find that the topical cream EMLA (Eutectic Mixture of Lidocaine and Prilocaine) takes longer.” Moreover, “the ice causes vasoconstriction of small arteries and veins which diminishes the chance of capillary disruption and subsequent bruising.” 

Dr. Steinbrech also offers this “best practice” to ensure a comfortable experience. Like Dr. Romitra, Dr. Steinbrech finds the “key is small needles. I use 32 gauge, which are tiny,” and minimize discomfort significantly.

Dr. Thomas Sterry, a board-certified plastic surgeon in New York City generously shares his expertise.  “If I’m using Juvederm or Restylane, I prefer to give the patient a block or to mix the product with local anesthesia. For Botox, you can’t do that, and I do want my patients to be as comfortable as possible, so I do have patients who decide to use the BLT topical anesthetic.  I give them an ice pack but I really don’t know how much it helps. What I’ve done that I think has helped my patients to minimize the pain they feel during Botox injections is to dilute it with 1 cc, which means that the volume of the injection is much smaller and much more comfortable and that’s really my answer to the issue of pain. Years ago when I diluted with 4 cc’s, they had four times more product and that much more discomfort.”

Know the Limitations of Both Anesthetic and Your Patients 

The last word goes to Dr. Sterry.  “My experience with topicals for Botox is that they don’t really work and it’s simply because when you’re giving the injection, the needle goes deeper than the cream can penetrate. Having said that, I go patient by patient, and always offer the cream, but I let them know that it doesn’t really make much difference for an injectable. If you’re getting a laser, which is much more superficial, it’s great.  But for an injectable, not so much.”

About the IAPAM (International Association for Physicians in Aesthetic Medicine) 

The International Association for Physicians in Aesthetic Medicine is a voluntary association of physicians and supporters, which sets standards for the aesthetic medical profession. The goal of the association is to offer education, ethical standards, credentialing, and member benefits. IAPAM membership is open to all licensed medical doctors (MDs) and doctors of osteopathic medicine (DOs). Information about the association can be accessed through IAPAM’s website at or by contacting:

Jeff Russell, Executive-Director
International Association for Physicians in Aesthetic Medicine (IAPAM)
1-800-219-5108 x705

Article compiled by Leslie Marshall (, Specialist-Online Media and Research for the International Association for Physicians in Aesthetic Medicine (IAPAM)

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

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