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Utilizing Tumescent Anesthesia in Office Based Skin Cancer Surgery For Large Lesions Involving Deeper Planes
Peter Smilovits, DDS
Olga Demidova, DO PGY-3
Dr. Jennifer Popovsky, MD, FACMS
Tri-County Dermatology/KCU
Department of Dermatology
Akron/Canton, Ohio
Dermatologic Surgery Center Of Northeast Ohio
Tri-County Dermatology/KCU
Department of Dermatology
Medina, Ohio
Peter Smilovits DDS & Associates, Inc.
Beachwood, Ohio
Abstract
Design
Skin cancer surgeries including MOHS micrographic surgery are commonly performed in the office settings. Office surgery is cost effective, prevents hospital and general anesthesia related adverse events, it is easy to schedule and allows frail patients to be treated safely. During treatment of larger lesions involving deeper planes local anesthesia re-infiltration is commonly necessary. This involves initial patient's report of sharp pain sensation, administration of additional anesthesia, allowing time for anesthesia to work and pain re-assessment. Each event adds 5 or more minutes to total surgery time and usually occurs several times during lengthy operations and the ones involving deeper tissues. Sensation of pain may cause multiple adverse reactions not limited to, vital sign instability, poor patient perception about the procedure or a surgeon, and needle phobia in the future. Relatively painless, safe and efficient procedure is a goal for all surgeons.
Since the initial description by dermatologist Dr. Jeffrey Klein in 1985 tumescent anesthesia was successfully used by dermatologists and other medical specialists performing liposuction, CO2 laser resurfacing, treatment of hyperhidrosis with botulinum toxin, MOHS surgery, skin cancer excisions, scar revisions and other procedures.1,2 Retrospective study was conducted at our institution on 16 operations involving skin excision diameter greater than 12 centimeters squared for which tumescent anesthesia was administered. Surgical cases included melanomas and large basal cell carcinomas. All cases were performed between January 2015 and December Data was collected from anesthesia and adverse effect log. Current literature about safety of local anesthesia was conducted using pubmed.com. Tumescent anesthesia preparation and administration method was written out as a Carepath.
Methods
Tumescent Anesthesia Preparation
1 Liter IV bag of sterile physiologic saline (0.9% NCl)
100-mL 1% plain lidocaine
1-mL 1:1,000 epinephrine
12-mL Sodium Bicarbonate 8.4%
Safe and effective tumescent anesthesia solution consists of 0.1% lidocaine with 1:1,000,000 epinephrine, 1.5  mEq sodium bicarbonate in 1 L of normal saline.3 Slight variations of safe and effective concentrations are used as well.
Figure 2 – Infusion pump with tumescent anesthetic mixture used in our office.
Figure 1 – Equipment:
Infusion tubing, 1L 0.9% NS, short infusion cannula, epinephrine 1:1,000, lidocaine, sodium bicarbonate 8.4%.
Tumescent Anesthesia Administration Method: 
Infiltrate 1.5cc of 1% lidocaine/1:100,000 epinephrine into a small area of skin near distal margin of the lesion
Wait 3 minutes
Using #11 surgical blade make one 2-3 mm stab incision in the previously anesthetized area 
Introduce tumescent anesthesia into the subcutaneous tissue through the stab incision using standard short infusion cannula
The cannula is kept in a deeper plane relative to the lesion and does not pass through the lesion itself (Figure 4).
Infuse solution at slow rate using an infusion pump (Figure 4)
Tumescent Anesthesia Administration Method: 
7. Note tumescence (Figure 4) which should involve:
- Entire area of the lesion
- Margins of excision
- Adjacent areas to be involved in reconstruction
Withdraw the cannula
Allow detumescence to occur (Figure 5)
Whenever feasible, the patient is placed on clean dry towels and is instructed to lay on the site that was infused
Perform desired procedure (Figure 6)
Reassess patient’s pain several times during surgery
Apply compression bandage over the lesion once surgery is completed
Send the patient home 
Figure 3 – Fully assembled pump and cannula in surgeon’s hands.
Figure 4 - Proper cannula positioning and tumescence.
Figure 5 – Detumescence
Figure 6 – Procedure and reassessment
Summary
Conclusion
Pain is a significant obstacle for patients undergoing extensive and lengthy surgery in office settings. Presence of pain during an awake surgery may lead to negative perception about procedure or surgeon as well as vital sign instability and other adverse side effects. Since its invention in 19851,4 tumescent anesthesia has proven to be a safe and effective method of intraoperative pain control2,3.5. Once administered its effects last through a multi hour surgery and into the postoperative period. We believe that tumescent anesthesia could be more widely utilized in certain types of skin surgeries bringing positive experience to both patient and surgeon. Our plan is to continue accessing the patient experience during awake surgery by adding patient post operative questionnaire assessing pain during and after the procedure.
Of the 16 surgery cases performed utilizing tumescent anesthesia there were no anesthesia related adverse events. Maximum amount of lidocaine used in any one case was several times less than the maximum recommended amount according to current guidelines3. All surgeries were at least 2 hours in length and involved large skin excision diameters and deep tissue planes. Tumescent mixture was prepared by auxiliary staff on the day of surgical procedure. Anesthetic was administered by a surgeon in the operating room. Total time from initial administration to first incision was approximately 25 minutes, re-administration was not required, and no anesthesia related side effects were reported. The are variations of preparing tumescent anesthesia solution and administration1,2,4,5. We would like to share our version of solution preparation and administration technique.
References
1. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol Oct;14(10):1124–32.
2. Starling J, Thosani MK, Coldiron BM. Determining the Safety of Office-Based Surgery: What 10 Years of Florida Data and 6 Years of Alabama Data Reveal. Dermatol Surg Feb 1;38(2):171–7.
3. Kouba DJ, LoPiccolo MC, Alam M, Bordeaux JS, Cohen B, Hanke CW, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. Journal of the American Academy of Dermatology Jun 1;74(6):1201–19.
5. Davila P, Garcia-Doval I. Tumescent Anesthesia in Dermatologic Surgery. Actas Dermosifiliogr May 1;103(4):285–7.
4. Klein JA. The tumescent technique for liposuction surgery. Am J Cosm Surg. 1987;1124–32.
Acknowledgements
We would like to thank Sara Burkett, SA/LT of Dermatologic Surgery Center Of Northeast Ohio in Medina, Ohio for assisting with this poster presentation.