Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica.
Hello and welcome. Dr. Stephen Mulholland here in Toronto, Canada. Welcome to Plastic Surgery Talk and another installment of our podcast series. This podcast is an interesting topic. It’s on the use of nitrous oxide in aesthetic medicine. Really, it could be about how to manage pain successfully. Pain, not paying. P-A-I-N, pain, patient discomfort in the outpatient aesthetic setting, optimally. So do you have a lot of word-of-mouth referral for comfortable treatments and recurring revenue?
So, today’s podcast is on nitrous oxide, Pro Nox specifically, was one of the biggest vendors in the U.S. and in North America for outpatient clinic. Nitrous oxide. There’s also Nitron Ox and some other vendors as well. So laughing gas. Nitrous oxide and its use in aesthetic medicine. If you find these podcasts entertaining, educational, informative, please share them, sign up, and comment.
So what is Pro Nox? Pro Nox is a manufacturing trade name for nitrous oxide, or laughing gas. Laughing gas has been around in dentistry for 30 years. They cause a lot of pain, dentists. Everybody doesn’t like a dentist. So you don’t want to be viewed as a dentist. You’re an aesthetic physician, aesthetic technician. You want people to tell their friends that it was a painless experience, that tattoo removal, or that energy-based device or that injectable. So the use of laughing gas has been one of the most important additions to my business and my practice I think I’ve made in many, many years. So Pro Nox is laughing gas. Laughing gas is nitrous oxide. Nitrous oxide helps minimize the perception of patient discomfort during an aesthetic treatment.
How does nitrous oxide or Pro Nox, laughing gas, work? Quite simple. Nitrogen is about 9% of the atmosphere that we breathe in every day. When we increased the percentage of nitrogen in our inspiratory gases, in this case we’re talking 50% nitrous oxide. Many dental components and systems use up to 80%. At 80%, nitrous oxide becomes an anesthesia and there are regulatory issues around that, particularly in my practice and your practice. The Pro Nox that I’m advocating, the nitrous oxide or laughing gas, content mixture is 50%. 5-0. At 50%, it’s considered an analgesic. Depending on the state, and virtually every state and province are the same, you can legally drive after eight to 10 minutes of Pro Nox, or nitrous oxide.
So how does nitrous oxide work? You increase the percent of inspiratory gas to about 50%. After about six to eight breaths or one minute, and as a deep breath, hold it and then breathe out. So slow, deep breaths. After six to eight deep breaths, it releases. The nitrous oxide goes from the lung into the bloodstream, bloodstream to the brain, and it releases a sudden surge of endorphins. These are the chemical neurotransmitters in your brain of well-being. The two neurotransmitters that are released, a tremendous surge of well-being, are serotonin and dopamine. So this surge of well-being, of euphoria, washes over the patient whilst they’re getting an energy-based treatment like a tattoo removal, or laser resurfacing, or laser hair removal, or Botox, or filler, or your pre-freezing prior to a surgical treatment.
These experiences then, which are viewed as painful by the hypothalamus, they get corticated. The higher brain with all this serotonin, dopamine goes ah, be quiet hypothalamus, I can hear this pain. I know it’s there, I hear you, but I don’t care. So it creates a disassociation, a euphoria, sense of well-being during discomfort. It’s a very pleasant experience for patients who otherwise would be in a significant amount of discomfort in a lot of cases. It induces a chemical release of natural neurotransmitters of well-being, serotonin and dopamine. That’s what nitrous oxide does. The beautiful thing about it, once you stop inspiring or breathing in the nitrous oxide, within about eight minutes the effect is washed out. Patients are back to their baseline and they can drive home.
So who’s a good candidate for Pro Nox, for laughing gas, for nitrous oxide during your procedure? Well, any patient coming into your clinic who’s medically well, who has no signs or symptoms of metabolic diseases that are in control, like liver failure or heart diseases or uncontrolled respiratory illnesses. Medical illnesses that would not make them a great candidate for cosmetic treatment in the beginning. So medically well patients who are having what is an uncomfortable or painful procedure. Injectables are common, energy-based device are common, freezing for a local anesthesia, face lift, or liposuction. Common indications for modulation of pain, and they understand that there are slight risks and side effects to the nitrous oxide, but not many. These are the great candidates. Those that are going to have a procedure that has some degree of discomfort and you want to take that discomfort and make it a pleasant experience. I call it fun pain. Turning the procedure into fun pain to the use of nitrous oxide. That’s a good candidate.
How’s Pro Nox, nitrous oxide, administered? Well, it comes in a very convenient carrying module on wheels. A tiny module with two little canisters. It’s a mixture of oxygen and nitrogen oxide. 50/50 mixture of 50% oxygen, 50% nitrous oxide. The suppliers of these medical gases are medical gas supplier companies, and those are available in every market. They come in small sizes that slide nicely into the little portable unit on wheels. The regulators hook into a modulator that creates flow, and then the patient simply breathes through a one-way tubing, or obturator. Sort of like they’re snorkeling. They’re swimming in the water, they breathe in, out, in and out through the same tube. There’s the white intake tube, the pink exhalation tubing. The excalation tubing goes to the floor or a scavenger, so there’s no risk of nitrous oxide to the staff or the surrounding ambient region.
It’s in a very portable unit. There’s two mechanisms for inspiration. A mask, which you the patient could use if they’re having a body procedure, let’s say liposuction or a body procedure where local anesthetic is being required, or they’re having a body laser procedure like an energy-based device or a fractional technology.
What are the procedures you can use this? Well let’s divide them into injectables and non-injectables. Injectables, Botox, soft tissue fillers, Sculptra, any kind of injection technique. It’s great for that. Nitrous oxide, laughing gas, as an outpatient Pro Nox is great for injectables. Energy-based devices, lasers, radio frequency devices, laser resurfacing with fractional technology like fractional CO2 or fractional RF with high fluids. That can be uncomfortable, and Pro Nox, or nitrous oxide, is perfect for that. Energy-based devices such as laser hair removal. There can be a real snap or sting to laser hair removal that some patients find uncomfortable. Pro Nox, or nitrous oxide, laughing gas, is perfect for that. Energy-based devices such as laser hair removal. That can be snap, you’re uncomfortable, and it works beautifully for that. Fat destruction through thermal technologies such as sculpture is good for that energy-based device.
So any energy-based device in your practice that has discomfort associated with it, or local anesthesia leading up to it such as the miraDry, which is a microwave use to ablate excess sweating. There’s a local anesthesia for that. Nitrous oxide will decrease the discomfort of the local anesthesia. So energy-based devices, injectables, and leading up to and during a surgical procedure into local. Those are the main indications and procedures during which I found the use of nitrous oxide, or laughing gas, to be invaluable in modulating patient discomfort and making the procedure fun.
What are the benefits of Pro Nox or nitrous oxide? Well, there’s two benefits. One is to the patient, and two is to the practice. First, the patient’s perception is one of euphoria, one of well-being in the face of pain, which is an odd sensation. They feel not altered consciousness as in they’ve been smoking marijuana or some substance that changes cognition. They feel euphoria and well-being, but it’s their same brain. They just feel separated from the pain. The pain is over here. The hypothalamus. They’re thinking about the pain or other things and it’s separated from the pain. So it’s a sense of well-being in the presence of disassociated pain. Uncomfortable procedure that might be ranked as a seven or eight out of 10 by the patient, will be ranked a two or three when they take the nitrous oxide. So the benefit is the patient’s perception. Very few side effects. Patients can drive home right away, and you know there’s really no contra indications, in essence.
The benefits to the practice are huge. Number one, patients find that your technique is painless and they tell patients. So more word-of-mouth referrals from patients who are telling other patients the use of this Pro Nox, or this laughing gas, was an awesome addition to the experience of discomfort making you the provider they want to see. So word-of-mouth referral.
Retention. Patients are more likely to come back for an uncomfortable procedure like miraDry where they need to treatments, or subsequent laser tattoo removal treatments, or fractional treatments, ongoing maintenance injectables when the fear of the pain or the anxiety anticipation of pain is removed. So patient variables, better experience, practice variables. Better outcomes in terms of perception discomfort, and better retention and referral. Ambassadorship when you are the painless practice.
Pro Nox sounds great. This laughing gas sounds great, but are there any side effects or risks that we got to know about? Well, there are some rare syndromes, particularly for the liver, metabolism, where if they’re in fulminant liver failure insufficiency or they have a pulmonary disease such as cystic fibrosis or COPD, they’re not great candidates for treatment anyway and they might want to avoid an inhalational like nitrous oxide. But virtually every healthy, well, cosmetic medicine patient is a candidate for nitrous oxide.
What are some of the side effects? In rare instances, perhaps one in 20 or 5%, patients will experience a little lightheadedness, perhaps a little nausea. They might get a bit of vasovagal from the experience of the nitrous oxide, and that may actually be related to the injectable anyway. But those that have reported side effects in generally, you remove the nitrous oxide, bring the legs up, head back, cool compresses and the sense of nausea or lightheadedness tends to dissipate as they wash out the nitrous oxide is six to eight minutes.
So some limited side effects that generally are self-limiting and go away as the nitrous oxide washes away. In my experience, there’s probably even less than one in 20 or less than 5%. Virtually everybody finds it an enjoyable experience. Sometimes it can be very powerful and patients exercise what I call self-administered Pro Nox. They take a few breaths, remove it, and they can take another puff or two when whatever I’m doing gets uncomfortable again. So it’s titrated to patient levels of euphoria and well-being. You don’t want to force them to breathe the nitrous oxide through the entire procedure. Self-directed, patient administered helps minimize over nitrous oxide in the brain, creating too much euphoria and the side effects that can occur.
What is the cost of Pro Nox to you, the patient who’s getting this treatment? Different physician practices do different things with this. Some just include it as part of the treatment. Generally, these tend to be practices that are generally more expensive. They’re charging more because they perhaps have a better or a more expensive reputation in the market. You’ll find that the cost of the Pro Nox is part of the treatment. Some practices prefer to break out the cost of the Pro Nox. So there’d be cost of the treatment whether it be Botox of soft tissue filler or laser hair removal or a PicoSure, Picoway, and lighten, Picosecond laser tattoo removal, or a fractional laser resurfacing.
There’s the cost of the procedure and some practices break down the items of the costs associated with the treatment. They might charge for the topical anesthesia. They might charge you for the Pro Nox individually. Most practices charge between $50 and $70 per treatment for the analgesic effect of the Pro Nox. So about 50 bucks U.S., different if you’re a non-U.S. market for Pro Nox, as an additional cost to the treatment. You as the consumer can decide, you know what, that 50 bucks for the pain relief was more than worth it. Again, some practices with higher price points to their procedures will tend to bundle it within the treatment itself. So you can see either way. Paying per treatment in addition to the treatment service fee, or rolled into the treatment service fee. Both models are acceptable and it depends on the practice that you pick.
When sourcing out a physician, what do you look for? A clinic or provider? Well, you want to make sure they have a great reputation on for whatever you’re doing. Whatever injectable you’re doing, Botox, filler, or energy-based device treatment, laser hair removal, tattoo removal, fracture resurfacing. Any cosmetic surgery procedure, liposuction physician, facelift surgeon. Make sure they’re good at what they do. Then of course they modulate and cover off on pain and discomfort.
The more modern and up-to-date practices are going to be incorporating nitrous oxide increasingly. I’ve done it for quite a long time and it has become a mainstay and addition to local anesthesia for discomfort. Make sure that Pro Nox is part of their treatment offering, or call the clinic. If you know your doctor well, reach out to them and ask them why haven’t they included in nitrous oxide into the management discomfort? You’ve read online that this is a great technique, and I think you can help them. They might not even know about it. Help them bring something great into their practice. So research your physician or provider on the basis of the quality skills outcome. Before and after, has a photo gallery, lots of testimonials, no medical malpractice lawsuits, litigation and of course their approach to pain and discomfort, and hopefully nitrous oxide, Pro Nox, laughing gas, is a part of that equation.
Thank you for joining me again, Dr Stephen Mulholland, here in Toronto, Canada on Plastic Surgery Talk. For another installment of our podcast series, this was on laughing gas. Nitrous oxide, Pro Nox, the largest brand name, and how we have incorporated that into our aesthetic practice and how you, the consumer, can benefit hugely from the perception of discomfort. You can create fun pain during those treatments and services that right now may be uncomfortable. You can render them, dare I say enjoyable? A fun pain. A fun experience. A way to modulate discomfort in the name of aesthetic beauty and enhancement. If you’ve enjoyed these podcasts, this one in particular, please share, sign up, and comment.