Permanent Makeup: With or Without Anesthesia?

Responses to pain are highly individual. What may be a gentle discomfort for some could be quite painful for others. Therefore, the decision to use anesthesia for permanent makeup procedures depends on the client's preferences and needs, as well as the recommendations and qualifications of the specialist. In the case of anesthesia administered by micropigmentation professionals, decisions and procedures related to anesthesia are regulated by the laws and health regulations in the respective country. The practitioner must adhere to these regulations, obtain the necessary qualifications, and be licensed to administer anesthesia.

TOPICAL ANESTHESIA

Topical anesthesia is achieved using prilocaine, benzocaine, and lidocaine. Preparations available on the market are often a mixture of two or more of these agents. They do not contain vasoconstrictors, as the addition of such substances would hinder the absorption of the pain-relieving components.

Benzocaine

It is an ester of p-aminobenzoic acid (PABA) and ethanol (ethyl alcohol, C2H5OH). It is known for its rapid action, typically taking effect within 15-30 seconds. The duration of its action is approximately 12-15 minutes. It stabilizes the membrane of nerve cells by inhibiting the flow of ions necessary for the generation and conduction of impulses.

Lidocaine

Lidocaine is an amid-type agent with a benzene ring, metabolized in the liver. It is used for both local and topical anesthesia, recognized as one of the safest anesthetic agents suitable for individuals of all ages. In local anesthesia preparations, it is commonly used as a 2% solution of lidocaine hydrochloride, with or without the addition of adrenaline at concentrations of 1:50,000, 1:80,000, and 1:100,000. Known for its fast onset, lidocaine stabilizes the membranes of nerve cells by inhibiting the flow of sodium ions, crucial for the generation and conduction of nerve impulses. The duration of lidocaine's effect depends on the administration site, dosage, and the addition of vasoconstrictor medications.

Prilocaine

It stabilizes the membranes of nerve cells, inhibiting the generation and conduction of nerve impulses. Compared to lidocaine, it has equivalent strength but offers a longer duration of action, lower toxicity, and undergoes hepatic metabolism more rapidly

Surface Anesthetics Applied to Uninterrupted Skin Areas

These surface anesthetics, often referred to as primary in the beauty industry, typically come in the form of a cream applied to cleansed and disinfected skin. This method allows for the numbing of any pigmented part of the body, such as eyebrows, lips, and eyelids. A common dilemma for novice practitioners is when to apply the cream – before or after the preliminary drawing. If applied before, there may be concerns about the cream's effectiveness, and if applied after, there's a worry it might negatively impact the project.

There's no one-size-fits-all answer to this question. However, it's essential to consider that applying anesthesia after the preliminary drawing may alter the skin's structure – tissues may become swollen and softened under occlusion. There's a significant risk that, despite the numbing, the practitioner might inadvertently tattoo too deeply, leading to client discomfort. The consequences of such work can include scarring, hair loss, uneven pigment absorption, overly intense results, patches, and pigment spreading (photo 1, 2).

LOCAL ANESTHESIA - Mechanism of Action of Lidocaine and Prilocaine

Local anesthetics are characterized by an amide structure. Their mechanism of action involves blocking sodium channels, leading to the inhibition of rapid sodium ion flow and preventing depolarization of the neuron in response to stimuli. In an oil-in-water emulsion preparation, both substances form a eutectic mixture (concentration 2.5%). At room temperature, they are in liquid form, enhancing the penetration of the preparation into the deeper layers of the skin and absorption into the circulation.

After applying the preparation to intact skin, it is absorbed into the skin depths for at least an hour under an occlusive dressing, providing anesthesia to a depth of 2-3 mm, which persists for 1-2 hours after removing the dressing. Initially, there is vasoconstriction, followed by vasodilation.

Other substances included in anesthetics and their effects

Bupivacaine

A long-acting amid-type agent, metabolized in the liver. Its potency and duration of action are four times greater than lidocaine. The addition of adrenaline only slightly prolongs its duration.

Tetracaine

An ester of benzoic acid and a potent, long-acting local anesthetic. It stabilizes the nerve cell membrane, preventing the generation and conduction of electrical impulses. It is characterized by an extended duration of action due to a slower rate of hydrolysis by pseudocholinesterase in the plasma. Tetracaine can be combined with adrenaline.

Local anesthetics also contain vasoconstrictors: adrenaline or noradrenaline. The addition of these substances constricts blood vessels at the application site, reduces drug absorption, lowers the risk of overdose and bleeding, and extends the duration of action.

Contraindications for the use of vasoconstrictors:

• Hyperthyroidism (adrenaline),

• Taking antidepressants (noradrenaline), such as phenothiazines, MAO inhibitors,

• Individuals who have undergone radiotherapy in the face and skull area,

• Individuals who have had a cerebral hemorrhage,

• Children and adults with heart rhythm disorders,

• Children and adults with a chromaffin tumor,

• Individuals with uncontrolled diabetes,

• Poorly controlled hypertension,

• Individuals allergic to sulfites – preservatives in anesthetics with adrenaline contain sulfites.

Treatment in case of toxic symptoms:

• Discontinuation of the anesthetic,

• Increased fluid intake,

• Administration of vasoconstrictor medications,

• Administration of sedatives,

• Application of passive oxygen therapy.

In the event of cardiac arrest, resuscitation measures should be initiated. It's important to note that symptoms of a toxic reaction may not occur simultaneously. The use of anesthesia during a procedure requires vigilance and continuous monitoring by the practitioner.

SECONDARY ANESTHESIA

Applied after the epidermis is disrupted, during the procedure, and typically comes in the form of a gel or liquid. It is advisable to avoid the eye area, so when pigmentation is done on this facial region, choosing a gel and applying it in small amounts is recommended. Prior to administering the agent, a consultation and assessment of the skin condition are necessary. The application procedure is as follows: it is applied for a short period (15-30-60 seconds), then rinsed off, and the pigmented area is thoroughly moisturized. If too much anesthesia is applied or it remains on the skin for too long, the treated area may become very firm, making it challenging to perform the procedure correctly. The individual response to the effect will vary.

After administering anesthesia with adrenaline around the pigmented area, there is vasoconstriction (photo 3). In the case of lips, a side effect of using secondary anesthesia with adrenaline is skin bruising (photo 4). These symptoms usually subside within about an hour after the procedure. Many practitioners use secondary anesthesia with adrenaline at the very end of the procedure to enhance and accentuate the shading of the eyebrows for a better photo. Personally, I do not employ this trick, as I consider it an overuse of the anesthetic.

SUMMARY

During the process of performing permanent makeup, the psychological aspect and technique are crucial factors. Nowadays, practitioners have access to training, advanced technology in devices, and high-quality PMU accessories. All of this largely allows for the avoidance of anesthesia, which, in my opinion, is often overused. I do not recommend beginners to start their work with anesthesia, but rather focus on proper technique and the selection of professional equipment. Skin that has been anesthetized takes longer to regenerate; for example, lip swelling can persist for up to 72 hours. It is significantly more challenging to assess the quality and intensity of color. There are clients for whom performing the procedure without anesthesia seems impossible, and in such cases, the use of a pain relief agent is justified.

BIBLIOGRAPHY

1. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain. 1979;6(3):249-252.

2. Lee HS. Recent advances in topical anesthesia. J Dent Anesth Pain Med. 2016;16(4):237-244.

3. Kühnisch J, Daubländer M, Klingberg G, et al. Best clinical practice guidance for local analgesia in paediatric dentistry: an EAPD policy document. Eur Arch Paediatr Dent. 2017;18:313-321.

4. Nawrot S, Dobrowolska S. Amazink Areola. Medical Pigmentation. Poznań: Amazink Areola; 2019:110-111.

5. https://www.mp.pl/bol/wytyczne/111006,zastosowanie-lekow-znieczuleniamiejscowego-w-leczeniu-bolu-stan-wiedzy-na-rok-2014

6. https://www.mp.pl/pacjent/leki/subst.html?id=1066

7. Guideline on use of local anesthesia for peadiatric dental patients. American Academy of Pediatric Dentistry (AAPD). 2015;32(6):156-162.

8. Grzanka A, Wasilewska I, Śliwczyńska M, Misołek H. Nadwrażliwość na leki znieczulenia miejscowego. Anest Intens Ter. 2016;48(2):135-141.

9. Olczak-Kowalczyk D, Szczepańska J, Kaczmarek U. Współczesna stomatologia wieku rozwojowego. Otwock: Med Tour Press International; 2017:255-259.

10. Krasny K, Wanyura H, Mayzner-Zawadzka E, Kołacz M. Nagłe przypadki w praktyce stomatologicznej: reakcja na preparaty znieczulenia miejscowego. Czas Stomat. 2005;LVIII(2):129-134.

11. Perczak C, Wanot B, Biskupek-Wanot A. Znieczulenie miejscowe przewodowe oraz zasady postępowania z chorym na bloku operacyjnym. Skrypt dla pielęgniarek i studentów pielęgniarstwa. Częstochowa: Wydawnictwo Naukowe Uniwersytetu Humanistyczno-Przyrodniczego im. Jana Długosza w Częstochowie; 2022.

12. Smuda A, Załęska I. Wiedza specjalistów na temat znieczuleń stosowanych w zabiegach estetycznych. Kosmetologia Estetyczna. 2018;7(5):673-581.