Minimally painful local anesthetic injection for cleft lip/nasal repair in grown patients

Abstract

Introduction: There has been a recent interest in injecting large body and face areas with local anesthetic in a minimally painful manner. The method includes adherence to minimal pain injection details as well feedback from the patient who counts the number of times he feels pain during the injection process. This article describes the successes and limitations of this technique as applied to primary cleft lip/nasal repair in grown patients.

Methods: Thirty-two primary cleft lip patients were injected with local anesthesia by 3 surgeons and then underwent surgical correction of their deformity. At the beginning of the injection of the local anesthetic, patients were instructed to clearly inform the injector each and every time they felt pain during the entire injection process.

Results: The average patient felt pain only 1.6 times during the injection process. This included the first sting of the first 27-gauge needle poke. The only pain that 51% of the patients felt was that first poke of the first needle; 24% of the patients only felt pain twice during the whole injection process. The worst pain score occurred in a patient who felt pain 6 times during the injection process. Ninety-one percent of the patients felt no pain at all after the injection of the local anesthetic and did not require a top-up.

Conclusion: It is possible to successfully and reliably inject local anesthesia in a minimally painful manner for cleft lip and nasal repair in the fully grown cleft patient.

Video 1.

See Video 1, Supplemental Digital Content 1, which shows how to inject minimally painful local anesthesia for the primary cleft lip and nasal repair in fully grown patients. This video is available in the “Related Videos” section of the full-text article on PRSGO.com or available at http://links.lww.com/PRSGO/A35.

Fig. 1.

First injection: We started injecting under the dermis in the cleft side cheek midway between the infraorbital nerve and the base of the ala. After the needle site was numb, we very slowly injected an additional 2–5 ml without moving the needle at all to anesthetize all involved branches of the infraorbital nerve.

Fig. 2.

Lateral nasal injection: We then angled the needle parallel to and just under the skin. We injected very slowly antegradely as we gradually advanced the needle medially to numb up the lateral nasal sidewall and lateral nasal tip. We were careful to always have at least 1 cm of palpable or visible local anesthesia ahead of the sharp needle tip.

Fig. 3.

Lateral lip injection: We reinserted the needle in numb skin of the lateral lip, injecting slowly ahead of the needle tip, always palpating with our noninjecting fingertips and looking at the skin to be sure the local was expanding the subcutaneous tissue well ahead of the potentially painful needle tip.

Fig. 4.

Nasal tip: We reinserted the needle in the numb lateral nasal tip. When the correct plane between the fat and the perichondrium was infiltrated, the whole nasal tip blanched with 2–3 ml of tumescent local anesthesia.

Fig. 5.

Simonart’s band of the cleft was crossed very slowly as we were getting into a new unanesthetized nerve distribution across the cleft. After the needle tip had crossed the band, we injected 2–4 ml very slowly on the noncleft side without moving the needle.

Fig. 6.

The lateral nasal floor was anesthetized with the needle slowly approaching and finally touching the bone to allow periosteal dissection inside the nose wherever an elevator was to be used, and 3–4 ml was liberally injected to get the whole lateral floor and sidewall below the turbinates.

Fig. 7.

The medial nasal floor and septal mucosa were infiltrated as required, as was the lateral nasal floor. All areas to be dissected were liberally tumesced.

Fig. 8.

Medial lip: We reinserted the needle in the numb skin of the noncleft medial lip to finish tumescing the medial lip, as we had done for the lateral lip.

Fig. 9.

Injection time vs patient number. It can be seen that the injection times were higher early in the week at the front end of the learning curve of injection technique. The first 10 patients had the longest injection times. The last 10 patients had the shortest injection times.

Fig. 10.

Pain score vs patient number. It can be seen that the pain numbers were higher (patients felt pain a greater number of times) early in the week at the front end of the learning curve of injection technique. It can be seen that the pain scores were higher early in the week at the front end of the learning curve of injection technique. The first 10 patients had the highest pain scores (felt pain more times). The last 11 patients (21–32) all scored an eagle (pain score = 2) or a hole-in-one (pain score = 1).