The VivAer Treatment: Procedure Technique & Anesthesia Protocol

[Gopi Shah MD]
So when you actually perform it, when you have the stylist or the paddle, where do you put it?

[Mary Ashmead MD]
Right? So that's the most important part. So I do, there's lots of different ways to do this. Some people use a headlight. I still use the scope because that's how I've examined the patient. And that's what I'm used to. So I will lay them down in a normal position. Like I'm doing sinus surgery. I lay them back. Other people will do this upright, which I think if you're using a headlight, most people will keep the patient upright. And then if you're using a scope, I think it's a little simpler, a little easier to lay them down. And you're holding this stylist against that little scroll area where those tissues come together. And so you're putting this inside of the nose and then you're lifting up and out. I've actually started holding some pressure on the outside, to model and hold that cartilage. So it starts to bend the way that we want it to. So we want to go from concave to convex work. We're trying to make millimeter changes. We're not trying to make big changes. I'm trying to make small changes and to hold that stylus out. So there is a heating period. Again, that's temperature control to 60 degrees, and then there's a cooling period and you hold that position. So you're holding this inside, you're lifting up and out and, and compressing a little bit on the outside to change and mold that cartilage. And so once that cooling position is complete, then you remove it. I go back in with the camera and I watch exactly where I came out and then I move slightly farther down. So we march our way down that internal valve. And it's usually three to four treatments per side. Depending on their specific anatomy, it's usually three to four of these cycles and you kind of see these little railroad tracks of where you've treated. And so you look and you see any move it just slightly down below, and then you repeat. Then you hold it out and then we can press slightly, heating cycle, cooling cycle. And each cycle is 30 seconds. So we're not talking long periods of time here. Usually it was about six or seven minutes from start to finish. Numbing is a whole other thing which we can talk about, but the actual procedure is about six to seven minutes to do. And that includes walking everybody through it and, and keeping everybody comfortable, so marching through. And then, and then going to the other side and doing the same thing on the other side.

[Ashley Agan MD]
And you're looking with a scope to make sure you're, you know, kind of not overlapping and treating, you know, accidentally treating the same area. You're kind of, you know, you start at the top and then you get it in position. Then you take the scope out and use that hand to hold pressure.

[Mary Ashmead MD]
I do that. Sometimes. So I have trained my medical assistant to help with that lateral pressure. I have taken the scope out if I really know exactly where I want it to be, and I really want to kind of hold the other opposite sides. But she can do that too. You can do it both ways to make sure that you're getting the best outcome, but I do like to place it with the scope. You want to make sure you're not going into the bony aperture, so you kind of would make sure you're not, on that bone to one, it's just not going to work there. Or you’re just causing extra swelling that you're not going to be gaining from so that you're in that right place where that valve is. You're kind of straddling that area, working your way down and then either pulling the scope out and holding or, training an assistant to do that for you. You can do it either way and there's data to say that you don't necessarily need to hold the outside. What I found is that when I don't, the patients think that I'm trying to turn their head. And so we talk about it, you know, there's a lot that I walked through with the patient while they're numbing on kind of what to expect. It's going to feel like I'm trying to pull your head over to the side. I'm not, I'm just trying to hold this area open. I found that when I'm holding lateral pressure like that, it turns that off a little bit in the patient's mind. Oh, I don't need to turn my head. They're not, she's not trying to move me or trying to gain some space there.

[Ashley Agan MD]
And I mean, we've been talking for a while, but I feel like I can't let you go without at least touching a little bit on what your anesthesia protocol is and what you like to use for anxiolytics for patients who want something. And I mean, cause it sounds like you're able to offer quite a bit in the office, which is great. it's so much more efficient for your time and for the patient's time and for recovery. And I mean, I feel like if you can, the more you can do in the office, the better.

[Mary Ashmead MD]
I agree and patients like it too. Because there's about at least a third of patients that we set up for something in, or say no and they don't get scheduled. Because they don't decide for whatever reason, but office procedures people are generally game for that. So I think that's important. Anesthesia for VivAer is really important. It can make or break how your case goes. Not necessarily the anxiolysis, that is a very personal decision, but the topical is extremely important. So thinking about anxiolytics, I use halcion or Triazolam, I will generally use a pretty low dose. I use 0.125 which is very low. I use 0.125 and I say, this is kind of like a half a glass of a margarita. We can talk about that or wine to see, just to give them a sense of how they respond. And so, the people who are more sensitive than medications, we do really low doses. The people who are like, oh, that's no big deal for me. I'm like, okay, well, let's take two. and I'll give you a third that if you're still feeling anxious, when you come in, we'll, we'll take another because we'll have time for that to kick in. So it's a little bit faster on and off, than kind of the more traditional Valium, if I'm going to be doing a longer case.

I will use Valium sometimes. So I use translate I'm I generally will do, Phenergan more for a cough suppressant. But sometimes for nausea, we're going to take, a Tramadol at the same time. So a low dose of a Tramadol low dose of Phenergan. Also, it makes them a little bit sleepy for those anxious people, it can be really helpful. Especially if I'm going to be needing to do a spheno-palatine block. Sometimes that medicine can leak out. Then they have this kind of cough reflex and Phenergan helps with that too, to some extent. So we offer it, but it's, so it's probably about 60, 40 in my office. 60% want to take something and have a driver and 40% say no I’ll be fine with straight local.

[Ashley Agan MD]
And do you have them and do you have them take it before they come in?

[Mary Ashmead MD]
I do. So I have them take that. So I have a whole text message that goes out. Ideally, it's about a week before, but in practice, it's probably more like three days or so that goes over medications. So we've already talked about this whole thing in the clinic, but it may have been a few weeks, sometimes a little bit longer. “Hey, here's a reminder on what we talked about with those medications”. And so I generally have them take them about 45 minutes to an hour before they even come in. And then it's about a 20-minute numbing protocol. So it's plenty of time for those things to work, plenty of time for those things to work. So they come in and then we start with the topical numbing. So this is not like a turbinate reduction or a posterior nerve ablation where you can rely on a nerve block heavily. You really need to get the topical right. It's pretty important for VivAer here and you're within the nose to do this. Well, I use a 4% topical compounded tetracaine lidocaine gel that I get from one of my local pharmacies in a little tub, and I will make a little arch out of a pledget. Usually, it's about half of the pledget of the normal standard links. It's a little bit shorter than that. I tailor it to the size of the person's nostril. So I actually will look with a scope and see, okay, is this a little bit larger? And maybe I'll do about half. If its a small little nose. I'll make it more like a third of that kind of standard pledget size. And then I will put on my gel. I do sometimes put a little bit of Afrin, just my normal Afrin, lighter cane to moisturize it more than anything else, but ring it out a little. And then I put a layer, a little thin layer of my gel on the side with the, with the lines. so that I know not to waste the gel. You don't need it. You don't need it on the inside of that art. She just needed it on the outside.

So little thin layer. And then I fold it into the arch with a pair of bayonets. I use bayonets for this. I use micro alligators for placement farther in the nose. So if we're doing swell bodies or turbinates, you numb those up and how you normally do. I use lidocaine. I will spray those people beforehand, too. If we're doing something farther back, whether it's a septoplasty or swell bodies or turbinates. I will spray those people and then place a normal. Horizontal vertical you've oriented pledget in the usual location. But then for the valve, with this arch that I placed with a bayonet, it's a little bit off center. You want the lateral portion to come all the way down to the floor. You want it to come all the way down to get that whole side of the nose. And then as this comes in medially, you really have to tuck it in up medially at the septum, right? So you have to get way up there. It doesn't need to come all the way down the septum side, cause we're not really generally doing a whole lot there, anteriorly at the septum, but it really needs to get all the way up there into that little crease. So I'll use my bayonets or sometimes I'll use an ear curate really to make sure it gets all the way up there in that corner. And you want to have good tissue opposition of that pledget. So if you just put in something kind of straight in the nose, normal way, it's not going to get along the edge, right? It's not going to get that whole area numb and they're going to be uncomfortable. So that's why I use this archway. Other people will use a cotton ball and that's another way to do it too. So take a cotton ball that kind of fits in that area, kind of coated on the outside with gel and put that in the nose. But then they're totally blocked, which is fine. But it's a little bit more comfortable if you use the arch, they have a little space to breathe, so they're not just completely nose closed off. Cause I let them sit there for about 15-20 minutes. I'll usually go see another patient. We'll have a post-op or a CT scan review or something else that I'll schedule at the same time. So all a mile, my someone else will be rooming that patient getting the scan pulled up and I'll be getting, the patient num, and so get that arch placed all the way up and I will actually go back and check it about 10 minutes later and make sure it hadn't, hasn't fallen down to make sure it's really coating that outside. I also put a little bit outside. I learned this from Dr. San McClurg, we were at a conference together. About putting a little bit on the outside. There's this extra little nerve that comes in, laterally. So that bottom edge that last third or fourth treatment along that line, sometimes they feel that a little bit more. And so there's lots of ways to address that.

One is just to let the topical sit there longer at least 20 minutes, or you can put a little bit of your BLT cream or something else that you use the tetracaine works to, out at that nasal crease laterally. And that we'll get that last little part. You can also use an infraorbital block for that. I haven't really needed that, but some people rely on that. I have an extra syringe in the room in case I need to, and you don't have to go all the way infraorbital. But just a little sublabial to that area. So I have something on hand for that if I have trouble and it's uncomfortable, or if I maybe rushed a little bit was drying and maybe they only sat for 10 minutes. And they're feeling that last little spot, and that's just normal lidocaine with epinephrine. You don't necessarily need the epinephrine. I try to avoid it in that, in the office. If I don't think I need it, because it just adds a little bit of that adrenaline effect to an already kind of nervous patient. And so unless I'm going to be doing something that I really needed to stick around for awhile. I'll use plain lidocaine if I have it around.

[Ashley Agan MD]
And you're cutting the pledget in half or third. Is that right?

[Mary Ashmead MD]
Yeah. So, yes to make that little arch or a little rainbow. It's about half to two, a third of the normal length. So they sit there and I tell them, your teeth may go numb. They may not. Don't worry if they do, don't worry if they don't, but just so you know, this might happen. Cause otherwise they kind of, “Hey, my teeth went numb.” It's okay. Don't worry about it. And once as I'm kind of putting those pledgets in. I'm going to walk them through everything that we're about to do. Okay. We're going to move. So right now I have a staging room while my main procedure room is getting turned over. My goal is to have two separate rooms that I can just kind of go back and forth, but not there yet. We're going to move down to the procedure room. It's a big, comfortable chair. When I lay you backwards, room lights are going to be on. Have some music. You can bring your own headphones if you want to, but I let them know it's going to be about 10 minutes. I do generally put a little gauze pad over their eyes for most of my procedures. You don't have to do that. Everybody's different. I tell them, I'm going to put this here. My light's really bright. if you don't want it there, we can take it off. I know some other doctors who will do this in the normal exam room, just because that's where their patients have been and they're comfortable there. $specially if we're, if it's just a straight VivAer, there's nothing else, you know, no turbinates in the septum, just, very anteriorly. So it's going to be five minutes in and out. And that's great.

My chairs are more comfortable in my procedure room, so I like that they're comfortable. And I have blankets because our room is cold and you try to make it comfortable. And spa-like for them, you know, “Alexa play spa music”. You can only, you can only listen to so many pan flutes though, and it starts to grate on you. I used to let the patient choose what they wanted to listen to. Except I had one patient choose Christmas music, and it was a really long case that we were doing. And I really regretted that decision. And so now we try to just have something on that's unobtrusive, but just something else to kind of take their mind off of it.

And so we move into the procedure room and I lay them down and we put the gods over the nose and I have the lights down and I'm looking with my scope and I have it up on my big screen. So their extra person can kind of see what they're doing or see what I'm doing and seeing what's happening. And then I use a little one CC syringe, just a little TB syringe with a short 30 gauge needle with just some lidocaine. And you're going to put this right where you're going to be placing your wand, your paddle. And so you don't have to get all the way up to the tip with that needle. Usually it's about, I don't know, a fourth of the way down first little, little injection. You have to stay really superficial. You don't want to go too deep with this. and when you're using a headlight, I think it's a little bit easier to know exactly how far in your wall. You have more of a global picture, but when you're using a scope, I have found it's a little easier for me to get a little too deep. And so I'll put that 30 gauge in and I'll pull it back a little bit before I inject. You want to see a very small little bleb, you want to see a very small little bleb just in that mucosa, because that helps with transduction of the energy. So you actually want, even if they're totally numb, you still want it to. You're not really relying on this for anesthesia. It's a small amount. I use about 0.2 to 0.3 per side. It's a very small injection and you want to see this in bleb out just a little bit, and it will kind of push up towards that corner. And then I'll come down about three or four millimeters and then I'll come down about three or four millimeters and I'll make a second one. And it's usually just those two little injections and I'll save if I need more, a little bit farther down. but again, we're not relying on this for anesthesia.This is just making that little extra bit of, of, blebbing within the mucosa so that we can get this energy where we need to go. So you want, you want that to be there just very small amounts though, cause you don't want to be too much. Cause then it won't, you'll have too much depth to get through. And that's why I like using the one CC syringe. you know, you're not going to put it in too much. I used to use a three or a five. It was harder to have as much control as I wanted to get just that little bleb. And that's why I use the 32. Not necessarily for just patient comfort. They're already numb there. I just want to be very specific about where this is going.