Since its introduction, no therapy has been as effective for rhytid effacement as the CO2 laser. Aggressive CO2 laser resurfacing remains the gold standard for facial-wrinkle treatment. In addition, the selective removal of epidermis and dermis allows for the simultaneous treatment of dyschromias and a variety of benign lesions. Regardless of the success and drawbacks of aggressive CO2 laser resurfacing, there remains a popular push for less aggressive therapies. It is somewhat amusing that the media and the industry are heralding a new claim that the public wants more conservative procedures and will not tolerate extended recoveries. In reality, the public has always wanted conservative procedures, and always will. The push for nonablative and minimally invasive procedures has led to some disappointing results for those who expected CO2-like outcomes. On the other hand, these less invasive procedures have provided patients with increased choices, tailored to their lifestyles and recovery windows. In my practice, laser skin resurfacing remains a popular option. The various choices of treatment include the following:

• CO2 heavy, characterized by aggressive CO2 resurfacing, two to four passes, high fluence, high density, reticular dermal injury, twelve to fourteen days' recovery

• CO2 medium, characterized by a single pass, nondebrided, high fluence, high density, upper dermal injury, eight to ten days' recovery

• CO2 light, characterized by a single pass, nondebrided, low fluence, high density, basilar and superficial dermal injury, six to eight days' recovery

• CO2 ultralight (fractional CO2), characterized by a single pass, nondebrided, low fluence, low density, epidermal injury, four to six days' recovery

Minimally invasive cosmetic surgery has become extremely attractive for patients and cosmetic practitioners. These procedures allow noninvasive correction of a variety of aging problems. They appeal to patients due to the quick result and minimal downtime. The era of lunchtime procedures has truly arrived.

One significant problem that still exists, despite the new technology, is procedural pain. BOTOX, fillers (especially lip), broad band light treatments (BBL), hair removal, radiofrequency skin tightening, vascular lasers, light chemical peels, and lasers are all examples of popular procedures that are painful to patients. Some practitioners adapt the so-called frown and bear it technique, but these clinicians will risk losing patients to a more compassionate doctor. It is very common in my practice for a new patient to present for fillers or other procedures that he or she has been doing traditionally at another office. When these patients realize that they have been enduring unnecessary pain, they usually praise our compassion, stay with our practice, and send their friends. All it takes is one woman at the tennis club telling her friends about her new positive experience, and others will usually follow. This compassion involves many factors, including a calming environment, physical touch, and verbal relaxation by the doctor and staff – and, of course, pain control. Finding the correct mixture of the preceding factors is an unbelievable marketing influence for a practice. We can use dentistry as a model.

INTRODUCTION

One of the biggest advances in the last thousand years of medical history has been the discovery of local anesthesia. Prior to this, patients had to endure excruciating pain with procedures taken for granted today. Even the toughest patient cannot imagine having a tooth extracted or an extremity amputated with no anesthesia. Prior to the late 1800s, one could get drunk or literally bite the bullet, neither of which had any effect on pain. An interesting article appeared about a .50 caliber bullet found at the site of the Battle of Ox Hill. The 21st Massachusetts Regiment had fought at a local cornfield with extreme and horrifying injuries. Yet, they had no medical care. The bullet has molar tooth cusp imprints, reportedly from a patient biting during surgery without anesthesia. Figure 9-1 shows an artist's rendition of the horror and panic of such a battlefield amputation, complete with a bullet between the patient's teeth.

Cocaine was the first local anesthetic to be widely used in surgical applications. In the 19th century, it was reported that the Indians of the Peruvian highlands chewed the leaves of the coca leaf (Erythroxylon coca) for its stimulating and exhilatory effects.1–3 It was also observed that these Indians observed numbness in the areas around the lips. In 1859, Albert Niemann, a German chemist, was given credit for being the first to extract the isolate cocaine from the coca shrub in a purified form. When Niemann tasted the substance, his tongue became numb.