Three types of anesthesia for laser resurfacing are currently practiced. They include straight local anesthesia with topical and/or injected lidocaine (pain reliever) preparations; local anesthetic nerve blocks combined with intravenous (IV) sedation with various agents; or general inhalation anesthesia (GIA).

Drugs like desflurane, sevoflurane, and isoflurane for GIA are triggering agents for the very rare, often fatal syndrome of malignant hyperthermia (www.mhaus.org). Although the risk is low, Dr. Friedberg feels it is unacceptable when the PK technique is a proven alternative.

Since most patients prefer some alteration in their awake level of consciousness for the procedure and it is impractical to bring an anesthesia machine to many office-based practices, it is probably most common to have IV sedation for laser resurfacing -- in combination with lidocaine nerve and field blocks.

Many anesthesiologists favor the combination of propofol and alfentanil (a short acting, synthetic opioid) for IV sedation). Opioids are reported to have a 15 to 40 percent PONV rate which would be very bad for a post-operative patient. The best published PONV rates for an opioid-based technique using two anti-nausea medicines is 8.3 percent. While an 8.3 percent PONV rate is certainly an improvement over 15 to 40 percent it is still unacceptable. The use of opioids (i.e. morphine, Demerol or fentanyl) causes respiratory depression, requiring the use of supplemental oxygen to support the patients' blood level of oxygen. The use of oxygen is a fire hazard in the presence of lasers!

The PK technique has been greatly simplified by the addition of the Bispectral Index® (BIS®) monitor (Aspect Medical System, Inc., Newton, MA - www.aspectms.com). With the monitor's measurement aid, the anesthesiologist knows just the right amount of anesthetic needed by the patient so that the patient receives no more anesthetic than absolutely necessary. In more medical terms, the monitor permits quantification of the safe range of propofol. This is important in helping to prevent the rare occurrence of rare occurrence of hallucinations from ketamine; arguably, the safest anesthetic drug in the anesthesiologist's toolbox. The dissociative state ketamine produces allows the injection of the local anesthetic into a motionless patient. In this way, the injection and the subsequent surgery provide no perceived pain stimulus to the patient. When the propofol infusion is turned off, patients awaken quickly with little discomfort and no PONV. With a rapid return to their pre-anesthetic mental state, patients are able to return home soon after their surgery is completed, with their surgeon's approval.

Bispectral Index® (BIS®) monitor   www.aspectms.com

Details of Dr. Friedberg's innovative PK technique, which provides narcotic-free pain relief, were published in Aesthetic Plastic Surgery 1993; 17:297-300. (No patient's identities were revealed.) The technique is designed to maximize patient safety while creating the illusion of general inhalation anesthesia, i.e. "no hear, no feel." The article has been subsequently cited in twelve peer-reviewed journal articles, and one surgery and four anesthesia textbooks. This is noteworthy because half of all journal articles in print are never referred to in subsequent articles. Several subsequent articles by Dr. Friedberg have also been published.

In the past decade, Dr. Friedberg has worked with more than a dozen different surgeons, on more than 250 laser facial resurfacing patients. Following their procedures, no patients needed postoperative treatment for uncontrolled pain or PONV, which are the two most common causes of postoperative admissions following day surgery procedures.

Dr. Friedberg's most recent publication about PK for laser resurfacing appears in Dermatologic Surgery 1999; 25:569-72.