Combining high-concentration topical cream with subcutaneous injections creates a necessary multi-layer pain blockade for effective CO2 Fractional Laser treatment.
While the topical cream reduces the sensitivity of the outer skin layer (epidermis), the subcutaneous injection penetrates deeply into the dermal layers. This dual approach is required not just for patient comfort, but to allow the practitioner to utilize the higher laser energy parameters needed to effectively treat the pathological state of deep scar tissue.
Core Insight: The primary medical justification for this combination is operative freedom. Without the deep analgesia provided by the injection, the practitioner would be forced to lower the laser energy to manage patient pain, potentially rendering the treatment ineffective against deep, structural scarring.
The Dual-Layer Anesthesia Strategy
Addressing the Epidermis with Cream
The first line of defense is a high-concentration topical anesthetic, typically a mixture of lidocaine and prilocaine.
This cream is applied approximately 45 to 60 minutes before the procedure, often under occlusion to increase absorption depth.
Its primary function is to induce surface anesthesia, significantly reducing the initial burning sensation associated with the laser's contact with the skin.
Targeting the Dermis with Injection
Topical creams alone often lack the penetration depth required to fully block nerve conduction in the deep dermis.
Subcutaneous injections deliver anesthetic directly into these deeper layers where the scar tissue often resides.
This step provides comprehensive, long-lasting analgesia that cream alone cannot achieve, ensuring the patient remains comfortable even as the laser penetrates deeply.
The Relationship Between Pain and Efficacy
High-Energy Requirements for Scars
Treating facial scars often requires aggressive settings. Practitioners may need to use pulse energies between 20 and 32 millijoules.
This energy creates Microthermal Zones (MTZs) that vaporize scar tissue and stimulate collagen restructuring.
The energy must be high enough to break down pathological tissue; low energy often yields suboptimal results.
Preventing Involuntary Patient Reaction
The 10,600nm wavelength of the CO2 laser generates significant localized heat and ablative stimulus.
If a patient experiences acute pain, they may move involuntarily or require the practitioner to stop.
By securing total "painless" comfort via the combination method, the operator can maintain a steady hand and precise energy delivery without causing distress.
Understanding the Trade-offs
Complexity vs. Outcome
The "trade-off" here is between procedural simplicity and clinical efficacy.
Relying solely on topical cream simplifies the preparation process and avoids the needle stick of an injection. However, this often results in a "ceiling" on the laser intensity a patient can tolerate.
By skipping the injection, the practitioner effectively trades the patient's deep-tissue comfort for a faster prep time, which often forces a reduction in laser power. This compromise can lead to incomplete scar removal and the need for additional treatment sessions.
Making the Right Choice for Your Goal
The necessity of this dual-anesthesia protocol depends heavily on the severity of the condition you are treating.
- If your primary focus is treating deep or pathological scars: You must accept the combination of cream and injection; this allows the high-energy settings required to restructure collagen deep in the dermis.
- If your primary focus is treating superficial skin irregularities: Topical cream alone may be sufficient, as lower energy parameters are typically used for surface-level texturing.
Ultimately, the combination protocol transforms the procedure from a pain-management challenge into a controlled, high-precision clinical intervention.
Summary Table:
| Anesthesia Type | Target Layer | Primary Benefit | Necessity for Deep Scars |
|---|---|---|---|
| Topical Cream | Epidermis (Surface) | Reduces initial burning & surface sensitivity | High (Initial comfort) |
| Subcutaneous Injection | Dermis (Deep) | Blocks nerve conduction; allows high energy | Critical (Clinical efficacy) |
| Combination | Full Skin Thickness | Complete analgesia for aggressive settings | Mandatory for scar revision |
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References
- Anna Meynköhn, Dimitra Kotsougiani. Fractional ablative carbon dioxide laser treatment of facial scars: Improvement of patients' quality of life, scar quality, and cosmesis. DOI: 10.1111/jocd.13850
This article is also based on technical information from Belislaser Knowledge Base .
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