Tumescent anesthesia as an aid for wide local excision in dermatologic surgery

Received on: 27/04/2010
Approved on: 21/05/2010
This study was conducted at the Department
of Dermatology,Division of Dermatologic
Surgery,Mayo Clinic College of Medicine –
Rochester (MN), USA.
Conflicts of interest: none
Financial support: none

Abstract

Introduction: Local anesthesia is the most common form of anesthesia used in cutaneous surgery. Some patients have comorbidities that put them at risk for general anesthesia.Tumescent anesthesia is the technique of injecting a large amount of dilute local anesthesia into the subcutaneous plane of the skin.Tumescent anesthesia can minimize discomfort, aid in hemostasis, and contribute to the ease of closing large surgical defects that would otherwise be challenging. Objective: To discuss the pros and cons of using tumescent anesthesia in dermatologic surgery. Conclusion: Tumescent anesthesia is a viable option that can aid in cutaneous reconstructive surgery, especially when removing tissue in the deeper subcutaneous fat or fascia.Tumescent anesthesia is also associated with good results and few adverse reactions.

Keywords: ANESTHESIA, SKIN NEOPLASMS, MOHS SURGERY

INTRODUCTION

Local anesthesia has long been the mainstay in cutaneous surgery. Traditional local anesthesia, however, can have certain disadvantages. For example, the reconstruction of larger and complex wounds may be limited due to the recommended safe dosage of lidocaine; namely 3-5 mg/kg lidocaine without epinephrine, and 5-7 mg/kg lidocaine with epinephrine.¹ In addition, older patients may have comorbidities that limit their ability to undergo general anesthesia, thus limiting their options for complex reconstructive surgery.

Tumescent anesthetic technique (TAT) involves injecting large amounts of dilute lidocaine into the subcutaneous compartment of the skin.^2-9 There are various formulations for tumescent anesthesia, however the standard formula is considered to be 1000 ml of normal saline, 50-100 ml of 1% lidocaine, 1 ml of 1:1000 epinephrine, and 12.5 ml of sodium bicarbonate. ¹⁰ Because of the dilute nature of the anesthetic, large amounts can be safely injected without risk of lidocaine toxicity (35 to 55 mg/kg).^2,7 The TAT has been a long established practice in cutaneous cosmetic surgery, and has also been used in soft tissue reconstruction and as a part of Mohs micrographic surgery.^11,12

THE TUMESCENT ANESTHETIC TECHNIQUE

The TAT is the subcutaneous infiltration of large amounts of dilute lidocaine and epinephrine, which causes the surgical site to become swollen, firm, and tumescent, resulting in extensive regional anesthesia of the skin and subcutaneous tissue.^5,13 Dr. Jeffrey Klein described this technique extensively in the outpatient surgery setting, and has demonstrated the safe upper limit of lidocaine used in the TAT to be approximately 35 mg/kg, with other reports showing the upper safety limit to be as high as 55 mg/kg for use during liposuction.^2,7

Depending on the clinical scenario, the tumescent solution may contain anywhere from a 5- to 20-fold dilution of the standard commercially available 1% lidocaine, mixed with epinephrine (1:100,000), and sodium bicarbonate (10 mEq/L) in a physiologic saline solution.5 This solution provides a safe local anesthesia that remains for up to 10 hours after the procedure.⁵

When injecting tumescent anesthesia, an entry point is identified where the cannula is introduced.The cannula is then introduced into the subcutaneous compartment of the skin with the non-dominant hand, while the dominant hand is placed on top of the skin to guide the location of the cannula tip as the anesthetic is being injected.

PROS OF TUMESCENT ANESTHESIA IN DERMATOLOGIC SURGERY

The large volume of dilute epinephrine that is infiltrated into the mostly avascular subcutaneous adipose tissue produces a widespread and prolonged vasoconstriction.^4,5,14 When performing a wide local excision, this produces a significantly less amount of intra-operative bleeding, and reduces the necessity for excessive cauterization.Tumescent anesthesia has also been shown to have an antibacterial effect that may reduce the development of post-operative wound infections.¹⁵

In addition, the stretching of the skin that results from the large volume of tumescent solution introduced at the surgical site can cause an intra-operative acute tissue expansion, which results in an easier approximation of the wound edges in relatively large surgical defects.This tissue expansion means that in many cases tissue undermining becomes unnecessary, resulting in less surgical trauma to the surrounding viable tissue.

Finally, as mentioned previously, the TAT produces an extensive regional anesthesia, both lateral and deep to the surgical site.Thus, wide local excisions that need to extend to fascia – such as in the setting of malignant melanoma re-excisions – have effective anesthesia in the deeper parts of the excision, which causes less discomfort to patients who would otherwise only experience superficial anesthesia.

CONS OF TUMESCENT ANESTHESIA IN DERMATOLOGIC SURGERY

When using the TAT on the distal upper or lower extremities, one should be careful not to introduce too much anesthesia, thus causing a compartment syndrome. In addition, the tissue expansion that occurs during the TAT when operating on an extremity – sometimes around the entire circumference of the limb – may hamper wound closure. Because of these issues, TAT should probably not be attempted on digits.

Also, even though the upper safety limit of lidocaine is very high in the setting of tumescent anesthesia, there has been a report of a fatality due to toxic levels of anesthetics in a 38-yearold female who underwent an outpatient liposuction procedure. ¹⁶

CONCLUSIONS

The TAT has been demonstrated to be a safe and effective tool in the realm of cutaneous surgery.^{4,6,8,9,11,12,14,17-24} The TAT is not only beneficial when used in simple wide local excisions, but can also be a major tool in other forms of cutaneous oncological surgery, such Mohs micrographic surgery.^17,18 This may be particularly beneficial when dealing with large skin cancers that leave relatively large defects on the scalp and face that require complex closures.^11,17,20,21 The TAT has also been used for liposuction, dermabrasion, and even sentinel lymph node biopsy.^{3,4,6,8,12,14,25,26} Other situations in which the TAT has been used include the treatment of a cutaneous schwannoma, and outside of the realm of cutaneous surgery, as an aid in total mastectomies and breast surgery.^22,27-29

In the setting of wide local excision in dermatologic and cutaneous oncological surgery, the TAT can provide excellent hemostasis, exceptional regional anesthesia both lateral and deep to the surgical site, and aid in tissue expansion and closure of otherwise large and difficult defects. Although there are many benefits to using the TAT in cutaneous surgery, care should be taken to avoid the possibility of a compartment syndrome when operating on an extremity. Although there have been fatalities reported due to tumescent anesthesia, one report that examined over 15,000 patients demonstrated tumescent anesthesia to be an effective technique with minimal to no significant risks when performed properly.³⁰

In summary, the TAT is a safe, effective method of obtaining excellent regional anesthesia in the setting of dermatologic surgery with excellent results and minimal complications.

References

1 . Niesel HC, Kaiser H. Dose limits for local anesthetics. Recommendations based on toxicologic and pharmacokinetic data. Reg Anaesth. 1991;14(5):79-82.

2 . Klein JA.Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248-63.

3 . Klein JA.The tumescent technique.Anesthesia and modified liposuction technique.Dermatol Clin. 1990;8(3):425-37.

4 . Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993;92(6):1085-98; discussion 1099-100.

5 . Klein JA.Tumescent technique for local anesthesia.West J Med. 1996;164(6):517.

6 . Namias A, Kaplan B. Tumescent anesthesia for dermatologic surgery. Cosmetic and noncosmetic procedures.Dermatol Surg.. 1998;24(7):755-8.

7 . Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction.Dermatol Surg.1996; 22 (11): 921-7.

8 . Sleth JC, Blatiere V.Tumescent local anaesthesia in dermatologic surgery performed under anticoagulant or antiagregant therapy. Ann Fr Anesth Reanim. 2007;26(12):1078-9.

9 . Sommer B, Sattler G.Tumescence local anesthesia. Improvement of local anesthesia methods for surgical dermatology.Hautarzt. 1998;49(5):351-60.

10 . Meine JG. Local anesthetics. In: Vidimos AT, Ammirati CT, C P-L, editors. Dermatologic Surgery..New York: Saunders Elsevier; 2009. p.49-57.

11 . Coleman WP 3rd, Klein JA. Use of the tumescent technique for scalp surgery, dermabrasion, and soft tissue reconstruction. J Dermatol Surg Oncol. 1992;18(2):130-5.

12 . Goodman G. Dermabrasion using tumescent anesthesia. J Dermatol Surg Oncol. 1994;20(12):802-7.

13 . Welch JD. History of tumescent anesthesia, part I: from American surgical textbooks of the 1920s and 1930s. Aesthet Surg J. 1998;18(5):353-7.

14 . Klein JA.Tumescent liposuction and improved postoperative care using Tumescent Liposuction Garments.Dermatol Clin. 1995;13:329-338.

15 . Klein JA. Antibacterial effects of tumescent lidocaine. Plast Reconstr Surg. 1999;104:1934-1936.

16 . Martinez MA, Ballesteros S, Segura LJ, Garcia M. Reporting a fatality during tumescent liposuction. Forensic Sci Int. 2008;178(1):e11-6.

17 . Acosta AE. Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol. 1997;133(4):451-4.

18 . Do DV, Kelley LC.Tumescent anesthesia: evolution and current uses.Adv Dermatol. 2007;23:33-46.

19 . Eichhorn K, Renner R, Frithjof Haustein U. Sentinel node biopsy in melanoma of the trunk and the extremities in tumescent local anesthesia. Dermatol Surg. 2004;30(2 pt 2):253-6.

20 . Fincher EF,Gladstone HB.Dual transposition flaps for the reconstruction of large scalp defects. J Am Acad Dermatol. 2009;60(6):985-9.

21 . Gladstone HB, Stewart D. An algorithm for the reconstruction of complex facial defects. Skin Therapy Lett. 2007;12(2):6-9.

22 . Kim BJ, Choi CW,Moon SE, Huh CH. Cutaneous schwannoma treated by tumescent suction technique. Int J Dermatol. 2006;45(10):1267-8.

23 . Pasta V, Urciuoli P, Macrina N, Amabile MI, Chiarini S, Maturo A, et al. Advantages and limits of tumescent anesthesia in outpatient surgery. G Chir. 2009;30(3):112-6.

24 . Perez M.Advances in dermatologic surgery.Dermatol Clin.1997;15(1):9-18.

25 . Klein J.The two standards of care for tumescent liposuction.Dermatol Surg. 1997;23(12):1194-5.

26 . Klein JA. Post-tumescent liposuction care.Open drainage and bimodal compression.Dermatol Clin. 1999;17(4):881-9, viii.

27 . Carlson GW.Total mastectomy under local anesthesia: the tumescent technique. Breast J. 2005;11(2):100-2.

28 . Palmieri B, Baitchev G, Grappolini S, Costa A, Benuzzi G. Delayed nipplesparing modified subcutaneous mastectomy: rationale and technique. Breast J. 2005;11(3):173-8.

29 . Shoher A, Hekier R, Lucci A Jr. Mastectomy performed with scissors following tumescent solution injection. J Surg Oncol. 2003;83(3):191-3.

30 . Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients.National survey results.Dermatol Surg.1995;21(5):459-62.