SABAH, MALAYSIA Warta Kerajaan Tambahan Pertama Diterbitkan dengan Kuasa Jil. XLIX] KOTA KINABALU, KHAMIS, 25. JULAI 1996 [No. 2 Kenyataan-kenyataan berikut adalah ...
Report CopyRight/DMCA Form For : Local Anesthesia For Cosmetic Procedures Intech
12 Clinical Use of Local Anesthetics, intermediate chain and amine group hydrophilic The intermediate chain connects the. aromatic group to the amine group It is also the basis of local anesthetic classification as. either esters or amides Table 1, Ester anesthetics are metabolized via the plasma enzyme pseudocholinesterase Hydrolysis. is rapid and the by products are excreted in the urine. Amide anesthetics are metabolized primarily by the liver They should be used with caution. in patients with liver disease 3, For detailed discussion on pharmacology of local anesthetic agents kindly refer to the. related chapter in this book,Duration Available,Group Generic name Trade name of Concentration. anesthesia,anesthesia,Lidocaine Xylocaine Rapid Moderate 0 5 1 0 2 0. Mepivicaine Carbocaine Rapid Moderate 1 0 2 0,Bupivicaine Marcaine Slow Long 0 25 0 5 0 75. Etidocaine Duranest Rapid Long 0 5 1 0,Procaine Novacaine Rapid Short 0 5 1 0 2 0. Tetracaine Pontocaine Slow Long 0 1 0 25, Table 1 Common Local Anesthetics Used in Dermatology2 4. 1 4 Combination of Local anesthetics and adrenaline5 6. Many times local anesthetic is administered along with vasoconstrictor like adrenaline with. beneficial results This combination offers following advantages. 1 Decrease anesthetic absorption and systemic toxicity with improved efficacy and. smaller amounts required, 2 Prolonged duration of action almost doubled especially with lignocaine and procaine. 3 Less bleeding at operative site especially useful on vascular areas with better. visualization of operative field, Adrenaline may potentially induce adverse effects Therefore its use must be carefully. considered in patients with heart disease and those patients concomitantly taking. blockers 7,www intechopen com,Local Anesthesia for Cosmetic Procedures 13. Symptoms Treatment,Central nervous system, Lidocaine Drowsiness circumoral Intravenous diazepam oxygen. numbness tingling of tongue,metallic taste diplopia. blurred vision tinnitus,slurred speech muscle,twitching shivering seizure. respiratory arrest,Epinephrine Nervousness tremors. Cardiovascular system,Lidocaine Progressive myocardial Cardiopulmonary. depression prolonged resuscitation oxygen,conduction time vasopressors. arteriovenous block intravenous fluids,bradycardia vasomotor. depression hypotension,hypoxia acidosis, Epinephrine Tachycardia palpitations Vasodilators hydralazine. chest pain hypertension clonidine sublingual,nifedipine. Lidocaine Urticaria angioedema Antihistamines subcutaneous. anaphylaxis epinephrine oxygen steroids,Psychogenic. Cold compresses on forehead, Vasovagal response and neck Trendelenburg position. fan patient ammonia ampule, Table 2 Adverse Effects of Lidocaine with Epinephrine8. 2 Types of local anesthesia for cosmetic procedures. 2 1 Topical anesthesia9, Topical anesthesia is the surface application of a LA to the skin or mucous membrane by. means of a spray spreading of an ointment Lidocaine 2 jelly EMLA cream or. iontophoresis of lidocaine can allow one to perform simple procedures such as shave. biopsies electro cauterization of epidermal growths or superficial laser surgery Topical. www intechopen com,14 Clinical Use of Local Anesthetics. anesthetics can also provide surface anesthesia to permit painless insertion of a needle. especially in children and on painful areas such as the nose lips and genitalia 10. 2 1 1 Mucosal agents, Topical anesthetics agents are useful on mucosal surfaces include cocaine 4 benzocaine 5. 20 tetracaine 0 5 and lidocaine 2 5 jelly ointment lidocaine 10 aerosol etc. 2 1 2 Cutaneous agents, Creams for producing an anesthesia on intact skin creams of lidocaine 30 or EMLA. eutectic mixture of local anesthetics have to be applied for variable period of time 30min. to 2 hours according to the composition of the EMLA This EMLA has to be applied. under occlusion for its optimum effect The list of commonly available topical anesthetic is. given in Table 3, Special delivery techniques for topical anesthesia. Iontophoresis11, The introduction of various ions into the skin through the use of electricity has been. increasingly used to provide pain relief in outpatient procedures It uses an electric. current to overcome some of the barriers of the skin and assist the penetration through. the movement of ions into the skin via sweat glands hair follicles and sebaceous. Iontophoresis can be used to deliver chemicals to both superficial and deeper layers of. Advantages are,1 It avoids pain associated with injections. 2 It prevents the variation in absorption seen with oral medications. 3 It bypasses first pass elimination, 4 Drugs with sorter half life can be delivered directly to the tissue. Disadvantages are, 1 Discomfort and erythema at the site of iontophoresis secondary to pH changes. 2 There is also potential of skin irritation and burn. Laser assisted delivery of Topical anesthetics, A research in 2003 indicates that a single pass of the Er YAG laser wave length 2940. nm enhanced the absorption and penetration of lidocaine by disrupting the stratum. corneum 12, Although this technique may not be adequate for invasive procedures it may minimize. pain and discomfort for more superficial cutaneous procedure such as hypodermic. needle insertion This is a well known fact that reapplication of topical anesthetic after. first pass of ablative lasers produce quicker and deeper anesthesia. Interest in laser assisted drug delivery was reemerged after advent of fractional lasers. Narrow but deep vertical channels of ablation into skin created by fractional CO2 laser. were used to successfully deliver a drug methyl 5 aminolevulinate MAL to a uniform. depth into skin 13 The absoption was uniform and full thickness indicating drug. delivery from lateral walls of the tunnel Currently trials are under progress to use this. method to deliver local anesthetic agent to skin,www intechopen com. Table 3 Drugs used for topical anesthesia14,www intechopen com. Application Occlusion FDA,Anesthetic Ingredients Vehicle Advantages. Dose required approved, Betacain LA Lidocaine Vaseline 60 90 No No Anecdotal. Prilocain ointment reports of,Dibucaine rapid onset. LMX 4 Liposomal 60 No Yes Liposomal,Lidocaine delivery. long duration,LMX 5 5 Liposomal 30 No Yes Rapid onset. Lidocaine of action,EMLA 2 5 Oil in water 60 Yes Yes Proven. Lidocaine efficacy and,2 5 safety,Prilocain profile. Tretracaine 4 Lecithin gel 60 90 Yes No Anecdotal,gel Tretracaine reports of. Gel rapid onset,Amethocaine 4 40 60 Yes No Rapid onset. Tretracaine prolonged, Topicaine 4 Microemulsion 30 60 Yes Yes Rapid onset. Lidocaine Cost effective, S Caine 2 5 Oil in water 30 60 No Phase III Unique. Lidocaine clinical delivery,2 5 trails system,Tretracaine. 16 Clinical Use of Local Anesthetics,Needle less Dermajet. This is a needleless pressure injection syringe for the intradermal infiltration of drugs in. a soluble state This technique achieves almost painless tissue infiltration with a high. velocity microspray in single or multiple doses of 0 1 cc to a depth of 2 to 5 mm. without actual contact with the site of injection A fine jet emitted under great pressure. punctures the tissue without coring with a minimum amount of trauma raising. instantaneously a well defined pinpoint wheal Besides giving local anesthesia this. mode of drug delivery is useful in intralesional steroid injection in case of keloid and. hypertrophic scar in mass vaccinations15 etc,Microporation. Iontophoresis applies a small low voltage typically 10 V or less continuous constant. current typically 0 5 mA cm2 or less to push a charged drug into skin or other tissue. In contrast electroporation applies a high voltage typically 100 V pulse for a very. short s ms duration to permeabilize the skin 16 Low frequency ultrasound is also. used as sonoporation,2 2 Infiltration anesthesia9, This is the most commonly used method of anesthetizing the skin It consists of injecting the. anesthetic agent into the tissue to be cut The injection may be intradermal when the. anesthesia is almost immediate or into the subcutaneous tissue when the anesthesia is. usually delayed and has a shorter duration However an intradermal injection is more. painful The pain of a LA injection into the skin can be reduced by adding freshly prepared. sodium bicarbonate 8 4 solution to the LA solution in a 1 10 dilution Local pain can also. be reduced by injecting the drug slowly while pinching the neighboring skin to distract the. patient The infiltration may distort the operative site this can be minimized by gentle. massage after the injection,2 3 Field blocks, A field or ring block is a variation of infiltration anesthesia The LA agent is placed around. the operative site anesthetizing the nerve fibers leaving from the area A ring block is useful. when direct needle entry into a lesion such as a cyst is not desirable The LA has to be. placed in both superficial and deep planes Start injecting from proximal to distal end This. also limits the amount of LA needed to anesthetize the operative site This is a particular. advantage when a large area has to be anesthetized. 2 4 Peripheral nerve blocks, A nerve block involves placing the local anesthetic solution in a specific location at or. around the main nerve trunk that will effectively depolarize that nerve and obtund. sensation in the area of sensory distribution of that particular nerve In dermatological. surgery the commonly employed nerve blocks are for the digits and for the central face. because both areas are painful to anesthetize using local infiltration Peripheral nerve blocks. are difficult to perform and complications include laceration of the nerve intravascular. injection of LA and hematoma formation may occur,www intechopen com. Local Anesthesia for Cosmetic Procedures 17, Advantages of nerve blocks include the fact that a single accurately placed injection can. obtund large areas of sensation without tissue distortion at operative site. Disadvantages of peripheral nerve blocks include the sensation of numbness in areas other. than the operative site and the lack of hemostasis at the operative site from the. vasoconstrictor component of the local anesthetic injection. Since many nerves are accompanied by corresponding veins and arteries pre injection. aspiration should always be performed to prevent intra vascular injection Use of local. anesthetics with vasoconstrictors will prolong anesthesia. 3 Sensory nerves and respective dermatomes of face and their block. 3 1 Fig 1a and 1b Sensory innervations of face and neck area. Trigeminal nerve, Often referred to as the great sensory nerve of the head and neck the trigeminal nerve is. named for its three major sensory branches The ophthalmic nerve VI maxillary nerve. V2 and mandibular nerve V3 are literally three twins trigeminal carrying sensory. information of light touch temperature pain and proprioception from the face and scalp to. brainstem The main branches of the trigeminal nerve supply sensation to the well defined. and consistent facial areas,www intechopen com,18 Clinical Use of Local Anesthetics. 3 2 Anatomic arrangement of facial foramina, Successful nerve block anesthesia is largely dependent upon knowing the position of the. nerve foramina The surgeon can take advantage of the alignment of the major facial. foramina as they relate to a vertical line through the mid pupillary line with the eye in the. primary position of natural forward gaze,3 3 Common nerve blocks17. 1 Supraorbital nerve, The supraorbital nerve exits through a notch in some case a foramen on the superior. orbital rim approximately 27 mm lateral to the glabellar midline This supraorbital. notch is readily palpable in most patients After existing the notch or foramen the nerve. traverses the corrugator supercilii muscles and branches into a medical and lateral. portion The lateral branches supply the lateral forehead and the medial branches. supply the scalp,2 Supratrochlear nerve and Supraorbital. The supratrochlear nerve exits a foramen approximately 17 mm from the glabellar. midline and supplies sensation to the middle portion of the forehead The infratrochlear. nerve exits a foramen below the trochlea and provided sensation to the medial upper. eyelid canthus medial nasal skin conjunctiva and lateral lacrimal apparatus. When injecting this area it is prudent to always use the nondominant hand to palpate the. orbital rim to ensure that the needle tip is exterior to the bony orbital margin To anesthetize. this area the supratrochlear nerve is measured 17 mm from the glabellar midline and 1 2. mL of local anesthetic is injected The supraorbital nerve is blocked by palpating the notch. and or measuring 27 mm from the glabellar midline and injecting 1 2 mL of local. www intechopen com,Local Anesthesia for Cosmetic Procedures 19. anesthetic solution The infratrochlear nerve is blocked by injecting 1 2 mL of local. anesthetic solution at the junction of the orbit and the nasal bones. Fig 2 Supra orbital nerve block,3 4 Infraorbital nerve block. This block is one of the most commonly utilized facial blocks in order to anesthetize the. upper lip and upper nasolabial fold for injection of fillers Obviously a bilateral block must. be performed to achieve anesthesia on both sides of the lip. The Infraorbital nerve exits the Infraorbital foramen 4 7 mm below the orbital rim in an. imaginary line dropped from the midpupillary midline The anterior superior alveolar nerve. branches from the Infraorbital nerve before it exits the foramen and thus some patients will. manifest anesthesia of the anterior teeth and gingival if the branching is closed to the. foramen Areas anesthetized include the lateral nose anterior cheek lower eyelid and. upper lip on the injected side This nerve can be blocked by intraoral or extraoral routes. To perform an Infraorbital nerve block from an intraoral approach fig 3 topical anesthesia. is placed on the oral mucosa at the vestibular sulcus just under the canine fossa between the. canine and first premolar tooth and left for several minutes The lip is then elevated and a. inch 30 gauge needle is inserted in the sulcus and directed superiorly towards the. Infraorbital foramen Bending the needle at 45 degree angle upward can facilitate the needle. insertion The needle needs only to approach the vast branching around the foramen to be. effective It is important to use the other hand to palpate the inferior orbital rim to avoid. injecting superiorly the orbit 2 4 mL of 2 lidocaine is injected in this area for the. Infraorbital block and the palpating finger can feel the local anesthetic bolus below the. Infraorbital rim confirming the correct are of placement. The Infraorbital nerve can also be very easily blocked by the transcutaneous facial approach. and may be the preferred rout in dental phobic patients fig 4 A 32 gauge inch needle is. used and is placed through the skin and aimed at the foramen in a perpendicular direction. Between 2 and 4 mL of local anesthetic solution is injected at or close to the foramen Again. www intechopen com,20 Clinical Use of Local Anesthetics. the other hand must constantly palpate the inferior orbital rim to prevent inadvertent. injection into the orbit Care must be taken in this approach to avoid superficial vessels that. may cause noticeable bruising, A successful Infraorbital nerve block will anesthetize the Infraorbital cheek the lower. palpebral area the lateral nasal area and superior labial regions as shown in figure. 3 5 Zygomaticotemporal nerve block, Two uncommon facial local anesthetic blocks are the zygomaticotemporal and. zygomaticofacial nerves This may assist the injection of fillers in facial rhytides on the lateral. temporal and lateral canthal areas or in the malar areas These nerves represent the terminal. www intechopen com,Local Anesthesia for Cosmetic Procedures 21. branches of the zygomatic nerve The zygomaticotemporal nerve emerges through a foramen. located on the anterior wall of the temporal fossa This foramen is actually behind the lateral. orbital rim posterior to the zygoma at the approximate level of the lateral canthus. To orient for this injection it is necessary to palpate the lateral orbital rim at the level of. the frontozygomatic suture which is frequently palpable With the index finger in the. depression of the posterior lateral aspect of the lateral orbital rim inferior and posterior. to the frontozygomatic suture the operator places the needle just behind the palpating. finger which is about 1 cm posterior to the frontozygomatic suture The needle is then. walked down the concave posterior wall of the lateral orbital rim to approximate level of. the lateral canthus After aspirating 1 2mL of 2 lidocaine is injected in this area with a. slight pumping action to ensure deposition of the local anesthetic solution at or about the. foramen Again it is important to hug the back concave wall of the lateral orbital rim with. the needle when injecting, Blocking the zygomaticotemporal nerve causes anesthesia in the area superior to the nerve. including lateral orbital rim and the skin of the temple from above the zygomatic arch to the. temporal fusion line,3 6 Zygomaticofacial nerve block. The zygomaticofacial nerve exits through a foramen or foramina in some patients in the. inferior lateral portion of the orbital rim at the zygoma If the surgeon palpates the junction. of the inferior lateral portion of the lateral orbital rim the nerve emerges several millimeters. lateral to this point By palpating this area and injecting just lateral to the finger this nerve is. successfully blocked with 1 2mL of local anesthetic Blocking this nerve will result in. anesthesia of a triangular area from the lateral canthus and the malar region along the. zygomatic arch and some skin inferior to this area. 3 7 Mental nerve block, The mental nerve exits the mental foramen on the hemimandible at the base of the root of. the second premolar many patients may be missing a premolar due to orthodontic. extraction The mental foramen is on average 11 mm inferior to the gum line There is. variability with this foramen but by injecting 2 4 mL of local anesthetic solution about 10. mm inferior to gum line or 15 mm inferior to top of the crown of the second premolar tooth. the block is usually successful In a patient without teeth the foramen is often times located. much higher on the jaw and can sometimes be palpated This block is performed more. superiorly in the denture patient As stated earlier the foramen does not need to be entered. as a sufficient volume of local anesthetic solution in the general area will be effective By. placing traction on the lip and pulling it away from the jaw the labial branches of the. mental nerve can be seen traversing through the thin mucosa in some patients The mental. nerve gives off labial branches to the lip and chin. Alternatively the mental nerve may be blocked through the skin of the cheek with a facial. approach aiming for the same target, When anesthetized the distribution of numbness will be the unilateral lower lip to the. midline and laterally to the mentolabial fold and in some patients the anterior chin and. cheek depending on the individual furcating anatomy of that patient s nerve. www intechopen com,22 Clinical Use of Local Anesthetics. As mentioned earlier sometimes patients may perceive pain despite bilateral nerve block in. the upper or lower lips When injecting fillers in the lower lip and bilateral mental nerve. blocks are not totally effective a supplemental infiltration of several milliliters of local. anesthetics region of the mandibular labial frenulum can assist the block. Anesthesia for aesthetic lip augmentation17, Although in theory a bilateral Infraorbital block should anesthetize the entire upper lip. some patients may still perceive pain for various anatomic or sometimes psychological. reasons It is recommended that the injection of 1 0mL of local anesthetic solution in the. maxillary labial frenum This can also be performed in the lower lip labial frenum area to. augment bilateral mental blocks,3 8 Digital nerve block9. This is commonly performed nerve block by dermatosurgeons for nail surgeries acral. vitiligo correction multiple verrucae on fingers etc. Each digit is innervated by two dorsal and two ventral branches of nerve as follows. Fingers Radial and ulnar nerves on dorsal surface,Median and ulnar nerve on palmar surface. Toes Peroneal nerve on dorsal surface,Tibial nerve on planter surface. Rarely Saphenous nerve on dorsal aspect of great toe. Two methods exist for achieving a digital block viz ring block and metacarpal metatarsal. head technique anesthetizing the nerves before they enter the digits Ring block is more. commonly used in day to day practice,Ring block, The 0 5 1 mL of local anesthetic without adrenaline is injected with the help of 26 gauge. inch needle at the dorsolateral margin of the desired digit at the level of webspace The. needle is advanced further across the dorsal aspect of the digit and the anesthetic solution. injected in superficial subcutaneous and then deep plane close to the bone It is then. withdrawn up to the insertion point and rerouted along the palmar surface in a similar. manner and after depositing 0 5 1mL the needle is completely removed The hand is turned. over and needle inserted at the palmar medial surface at level of webspace of the same digit. It is pushed across laterally and solution injected withdrawn to insertion point redirected. medially to complete the block,Metacarpal metatarsal head technique. The needle is introduced in the space between the heads of the metacarpals metatarsals. proximal to the webspace and perpendicular to skin It is advanced in a similar direction. towards the palmar plantar aspect of the hand foot till it reaches the subcutaneous level. The local anesthetic solution is then injected thus blocking the digital nerves at the level. before they enter the digit The needle is withdrawn and the procedure repeated on the. other side of the respective metacarpal metatarsal head. www intechopen com,Local Anesthesia for Cosmetic Procedures 23. Since the blood supply to digits is by terminal arteries adrenaline should not be mixed. with local anesthetic The volume injected to produce block should not exceed 8mL as. larger volume can produce mechanical compression on vasculature results in ischemia. and digital necrosis, Sometimes the anesthesia achieved is unsatisfactory the reason for this could be failure to. infiltrate the local anesthetic close to bone where nerve lies or failure to anesthetize adequate. length of the nerve Both causes can be avoided by using higher concentration solutions. Reducing the pain of local anesthesia10, The introduction of needle and infiltration of anesthetic are many times very painful and may. provoke intense anxiety and can lead to an unpleasant surgical experience for the patient. The pain experienced during the administration of local anesthetics may be attributed to the. needle puncture of the skin tissue irritation from the solution and tissue distention from. the infiltration, To minimize pain physician should be reassuring distracting patients through conversation. or slightly vibrating the skin may decrease their perception of pain For extremely anxious. patients mild sedation with a benzodiazepine may be helpful. Explanation of procedure,a Reducing the needle prick pain18. Use of mild sedation, Use of topical anesthetic cream can be helpful to minimize pain. Use of small diameter needle can be less painful compare to larger diameter needle. Longer needle should be used when anesthetizing large areas to avoid multiple. Use of long acting local anesthetic helps to avoid repeated pricks if procedure is. more time taking, Slow introduction of needle introduction of needle through accentuated pore on. face reinsert needle in an area already anesthetized are other way to reduce the. pain associated with needle prick, b Reducing the pain associated with tissue distension. Slow injection of anesthetic solution only required amount to be injected inject into. subcutaneous fat use of field block being injecting the drug proximally and. advanced distally produce anesthesia distal to needle tip reducing the pain of. advancing injection needle,c Reducing the pain due to tissue irritation. The tissue irritation from local anesthetics is primarily due to the acidity of the. anesthetic solution The anesthetics are acidified to increase their solubility as well as. their chemical stability To decrease irritation produced by local anesthetics the. solution may be buffered through several means, Mix lidocaine with adrenaline with plain lidocaine in equal part. Mixed plain lidocaine 10 mL with adrenaline 0 1mL The subsequent solution is. lidocaine with adrenaline but at same pH as plain lidocaine. Add sodium bicarbonate to the anesthetic solution lidocaine with adrenaline. sodium bicarbonate in 10 1 to increase the pH of local anesthetics to near tissue. fluid levels 19,www intechopen com,24 Clinical Use of Local Anesthetics. 4 Tumescent anesthesia20, This is a technique of local anesthesia which involves the subcutaneous injection of large. volumes of dilute LA in combination with adrenaline and other agents is used for. dermabrasion skin grafting rhinophyma correction liposuction and hair transplant. procedures most common being liposuction The plasma concentrations may peak more. than 8 12 hours after infusion Clinicians are advised to exercise great caution in. administering additional local anesthesia by infiltration or other routes for at least 12 18. hours following the use of this technique,4 1 Tumescent fluid Composition21. Normal Saline 1000 cc,Lidocaine 2 50 cc,Adrealine 1 1000 1 cc. Sodium bicarbonate 8 4 10 cc,Effective concentration of lidocaine 0 1. Safe up to 55 mg kg according to the American Academy of Dermatology guidelines of. care for liposuction,4 2 Advantages20 21, 1 The injection is almost painless as it is placed subcutaneously where the lax tissue is. easily distensible, 2 It pushes up or stretches the skin and the area to be operated and provides a cushioning. effect to deeper structures so less chance of their damage. 3 Provides very good hemostasis due to large volume of anesthetic compresses the. subcutaneous vasculature, 4 It causes hydrodissection at subcutaneous layer and provide safer plane for dissection. like in donor strip harvesting in hair transplantation due to volume of anesthetic. injected and also helps to preserve the dermal tissue architecture since injection is. placed at deeper level, 5 Smaller quantity of actual anesthetic agent is required for desire action which reduces. the possibility of systemic side effects, 6 Prolonged area of several hours duration occurs as a result of a reservoir effect of local. anesthetic, 7 The addition of adrenaline increases the duration of action5 while sodium bicarbonate. helps to adjust the pH of the formulation to a level very close to that of the tissue fluid. which reduces the tissue irritation and pain during the injection of Tumescence. anesthesia, 8 Elimination of general anesthesia hospital operating facilities and hospital overnight. stays also result in a favorable impact on costs when this technique is employed. 4 3 Disadvantages20, 1 Since the prepared solution is placed subcutaneously there is more diffusion in this. highly distensible compartment and faster absorption through this vascular tissue. 2 Onset of anesthetic action takes 10 15 minutes due to time taken to penetrate the dermal. nerves from deeper plane,www intechopen com,Local Anesthesia for Cosmetic Procedures 25. 4 4 Calculation of maximal tumescent technique lidocaine dose for 70 kg liposuction. 55mg kg 80kg 4400 mg,If 0 1 lidocaine solution is used then. 4400 mg 1mg L 4 400 L,4400 mL of 0 1 solution,4 5 Tumescence infiltration technique. Tumescent fluid is infiltrated in tissue either by a syringe with needle or by infusion. Skin is gently numbed by infiltration of same tumescent solution at places of anticipated. adits Small access openings are made to insert infusion canula attached either to a lure. locked syringe or infusion pump Tumescent fluid in infiltrated till the skin shows pallor. Rate of infusion should be slow to avoid discomfort due to rapid stretching of skin. Tumescence solutions concentration volume used for various body areas21. volume of tumescent,Area Lidocaine mg L Lidocaine mg. Solution ml,Jowels 25 75 1250 30 95,Chin and Neck 50 150 1250 60 190. Male breast 400 1400 1250 500 1750,Upper arms 500 1200 1000 500 1200. Male flanks 500 1100 1000 500 1100,Waist 400 1000 1000 400 1000. Hips 600 1200 750 450 1080,Abdomen upper 500 1200 1000 500 1200. Abdomen lower 600 1500 1000 600 1500,Medial thighs 800 1500 750 600 1125. Lateral thighs 400 1300 750 300 975,Knees 200 400 750 150 300. Discomfort during the infusion may be due to21,Too high infusion rate decrease the rate. Advancing an infusing cannula too rapidly consider slower advancement consider. needle infusion or initiating infusion with needle prior to using infusion cannula.
17-Feb-2020 2 Views 8 Pages
SABAH, MALAYSIA Warta Kerajaan Tambahan Pertama Diterbitkan dengan Kuasa Jil. XLIX] KOTA KINABALU, KHAMIS, 25. JULAI 1996 [No. 2 Kenyataan-kenyataan berikut adalah ...
17-Feb-2020 2 Views 28 Pages
Previously: putting business skills into finance. Now: put finance skills into the business. CFO driving the sustainable business model agenda. Reporting data revealed to stakeholders in . real time Communicating the impact of the enterprise to . Financial, Social, Economic, and Fiscal stakeholders Finance creating an environment for external
17-Feb-2020 2 Views 20 Pages
SABAH, MALAYSIA Warta Kerajaan Tambahan Pertama Diterbitkan dengan Kuasa pp p- Jil. LI] KOTA KINABALU, KHAMIS, 23 JANUARI 1997 [NO. 1 Kenyataan-kenyataan berikut ...
17-Feb-2020 4 Views 45 Pages
development, career coaching, vocational rehabilitation, career constructing, and life designing (Savickas,2015a). Guidance Compared to Counseling For the purposes herein, I wish merely to differentiate between the practice of vocational guidance based on scores and life-design counseling based on stories. Vocational
17-Feb-2020 2 Views 70 Pages
SABAH, MALAYSIA Warta Kerajaan Jil. LXIV] [No. 20KOTA KINABALU, KHAMIS, 21 MEI 2009 Kenyataan-kenyataan berikut adalah diterbitkan atas perintah Tuan Yang
17-Feb-2020 3 Views 514 Pages
RegistrationId Name Father Name DOB Category Marks Obtained 12th Total Marks 12th %age 12 2017721120 KAWALJIT SINGH IQBAL SINGH 12-Dec-1992BC 766 100 766.00
17-Feb-2020 2 Views 72 Pages
2 DRIVING RECORD EXAMPLES CERTIFIED COURT PRINT DRIVING RECORD This is a certified court print that includes convictions for traffic crimes, commercial driver license ...
17-Feb-2020 3 Views 16 Pages
Spring-Security using spring-boot and JDBC Authentication 4 Hello Spring Security 7 Securing application 7 Running Secure web application 9 Displaying user name 9 Logging out 10 Chapter 2: Spring Security config with java (not XML) 11 Introduction 11 Syntax 11 Examples 11 Basic spring security with annotation, SQL datasource 11
17-Feb-2020 3 Views 22 Pages
36 The Bilingual Brain immersion schools, and bilingual nannies are very popular among monolingual parents. Not only is this trend apparent in everyday life, there ...
17-Feb-2020 3 Views 10 Pages
Professor Petitto, The Bilingual Brain, page 1 of 10 The Bilingual Brain Professor Laura-Ann Petitto PSYD25 Winter Term 2011 University of Toronto Scarborough