Ensuring a comfortable aesthetic procedure and a beautiful aesthetic outcome are the cardinal aspects of ensuring patient satisfaction. Lignocaine is the most commonly used local anesthetic, and is known to cause allergies and other adverse effects [1]. The incidence of adverse effects of local anesthetics is generally reported to be 0.1% to 1% [2]. Allergic reactions range from mild symptoms such as urticaria, erythema, and intense itching to severe reactions in the form of angioedema of the lips, tongue, larynx and even syncope [3]. In patients with a documented allergy to lignocaine, alternative methods of anesthesia include the use of alternative local anesthesia, sedation, or general anesthesia. A survey conducted by American College of Mohs Surgery (ACMS) demonstrated that 41% of Mohs surgeons choose bupivacaine in patients with a reported lignocaine allergy [4]. Levobupivacaine, the S enantiomer of bupivacaine, was chosen because it causes relatively low levels of central nervous system and cardiovascular toxicities than those caused by the racemic mixture of bupivacaine (Fig. 1) [5-7].

Figure 1. Levobupivacaine with less cardiotoxicity and neurotoxicity compared with its racemic counterpart bupivacaine. Levobupivacaine is the S enantiomer of long-acting local anaesthetic bupivacaine [6]. Bupivacaine has an onset of 5 minutes, a duration of 2 to 4 hours and a maximum tolerated dose of 2 mg/kg. The addition of adrenaline increases the duration to 3–7 hours and the maximum tolerated dose to 3 mg/kg [7].

Ellanse is a polycaprolactone-based collagen stimulator distributed by Sinclair Pharmaceutical and is ideal for patients who desire a natural aesthetic result through neocollagenesis (Fig. 2). Ellanse has two different preparations: Ellanse S, which has a product longevity of 12 to 18 months and Ellanse M, which has a longevity of 24 months. Ellanse is composed of 30% polycaprolactone microspheres suspended in 70% carboxymethylcellulose gel. The smooth and spherical polycaprolactone microspheres have a diameter of 25–50 μm and are completely bioresorbable. Following injection, the carboxymethylcellulose gel was gradually resorbed within one month, during which time the polycaprolactone microspheres stimulated the formation of neocollagen. Patients were informed that the full aesthetic result would be observed 3 months after injection.

Figure 2. Ellanse M a polycaprolactone-based collagen stimulator that is composed with 30% polycaprolactone microspheres suspended in 70% carboxymethylcellulose gel. It has an aesthetic longevity of 24 months.

The objective of the following case reports was to highlight two cases in which levobupivacaine with adrenaline was used instead of lignocaine in patients with documented lignocaine allergy.

Case 1

A 60-year-old woman was referred to our clinic for nonsurgical rejuvenation. Her aesthetic goals were upper and midface rejuvenation. Her anesthetic history included lignocaine allergy, which was corroborated by the National Electronic Health Record. In addition, she underwent skin prick testing to confirm lignocaine allergy. She was informed of the need for a substitute for the local anesthetic, and agreed to try. Levobupivacaine 0.5 % with 1:200,000 adrenaline was injected to perform the supraorbital and infraorbital nerve blocks.

Observation was conducted for 15 minutes to allow for the onset of the antinociceptive effect of levobupivacaine and to monitor for evidence of an acute allergic reaction. Ellanse M was prepared using 0.2 ml of levobupivacaine and an adrenaline solution. The method of reconstitution was 0.2 ml of 0.5% levobupivacaine and 1:200,000 adrenaline with Ellanse M using a 2-way valve then mixed with 15 stokes to result in a homogenous blend [8].

A total of 4 ml of reconstituted Ellanse M was injected over the forehead, 1 ml to the temples on either side as well as 0.5 ml to the midcheeks. She described that the analgesia was adequate, and a further observation period of half an hour was allowed following the procedure to ensure that the patient had no evidence of an allergic reaction.

Case 2

A 35-year-old woman was referred to our clinic to undergo nonsurgical face rejuvenation with Ellanse after her previous hyaluronic acid filler treatment had dissipated. She wanted to focus on the rejuvenation of the upper part of her face, including the brows, nose, and midcheek augmentation. She was otherwise healthy, and her anesthetic history included facial flushing when a eutectic mixture of benzocaine, lignocaine, and tarozocaine was applied. Furthermore, the patient developed swelling when hyaluronic acid filler premixed with lignocaine was injected. Following the discussion, she agreed to have three syringes of Ellanse M injected for nasal augmentation, brow-lifting, and temple volumization. Levobupivacaine with adrenaline was first injected for analgesia, and the patient was observed for allergic reactions, such as urticaria or breathlessness, before treatment. Ellanse M, reconstituted with levobupivacaine and adrenaline, was injected into the requested area.

On the follow-up in 3 months, there was evidence of brow elevation, nasal elevation, and cheek volumization where ellanse was injected (Fig. 3).

Figure 3. Three months follow up after treatment with 3 vials of Ellanse M reconstituted with levobupivacaine. There is improvement of forehead contours as well as nasolabial folds.

One of the fundamental tenets of patient satisfaction during nonsurgical facial rejuvenation is adequate analgesia and beautiful rejuvenation. Beautiful facial rejuvenation can be achieved with Ellanse, a polycaprolactone-based collagen stimulator that produces natural aesthetic outcomes through the stimulation of neocollagenesis. Lignocaine, an amide-based local anesthetic, is commonly used as a pretreatment agent for analgesia and as an additive to a filler to provide comfort during treatment. A history of documented allergy to lignocaine would prompt the use of an alternative method of treatment, including injection without an anesthetic or the use of alternative local anesthesia such as bupivacaine, light sedation, or even general anesthesia.

Allergic reactions to lignocaine include mainly type 1 hypersensitivity immunoglobulin E (IgE) mediated and type IV delayed hypersensitivity reactions. Type I hypersensitivity reactions are often mediated by the IgE produced by B lymphocytes. Type I hypersensitivity reactions are commonly triggered by local anesthetic components and occur within minutes of exposure [9]. Type IV delayed-type hypersensitivity involves the activation of T lymphocytes (particularly CD4+T cells) that develop later, over hours or days, following exposure to an allergen [10]. This type of reaction to local anesthetics has rarely been reported.

Ellanse biostimulators do not contain premixed lignocaine and can cause discomfort during treatment. This was ideal for our patients because it allowed reconstitution with alternative local anesthesia. The choice of levobupivacaine in this case fulfills three criteria: 1) to provide adequate analgesia, 2) patient safety, and 3) to be used as a reconstitution agent for Ellanse (without causing needle or cannula jam), and to allow the process of neocollagenesis without the

Summary: allergy to lignocaine is uncommon accounting for less than 1% of patients. The use of an alternative local anesthetic agent, such as levobupivacaine, ensures that this group of patients is not precluded from nonsurgical facial rejuvenation with Ellanse. Levobupivacaine is documented to be a safer alternative than its racemic mixture, and it provides a similar reconstitution profile to lignocaine, that is, the absence of needle and cannula jams and documented neocollagenases.

The authors have nothing to disclose.