3

CHAPTER 3

Anesthesia in dermatologic surgery

Jose E. Ollague, Marilyn Zabielinski, and Keyvan Nouri
Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine and
Jackson Memorial Hospital, Miami, FL, USA

Local anesthetics
Local anesthetics are drugs used worldwide in minor surgical procedures with the purpose of blocking conduction along peripheral nerves, and thereby inhibiting the
sensation of pain. The rst anesthetic discovered was
cocaine, isolated from coca leaves in 1855 by the German
chemist Frederick Gaedcke. In 1884, Kller rst introduced its uses in ophthalmology, and later that year Hall
used it in dentistry1. Procaine was the rst synthetic
derivative of cocaine developed in 1904 by the German
chemist Alfred Eighorn. Lidocaine was originally produced under the name of Xylocaine by the Swedish
chemist Nils Lfgren in 1943.
They exert their effects by binding reversibly to the fast
voltage-gated Na+ channels located in the membrane of
the postsynaptic neurons. This prevents neuronal cell
membrane depolarization, and, consequently, the propagation of the action potential. The pharmacologic event
interferes with the generation and propagation of the
pain signal2.

Local anesthetic classication

I. Amides
a. Include lidocaine, bupivacaine, levobupivacaine,
etidocaine, mepivacaine, and ropivacaine.
b. Buvicaine is used in long-duration procedures2.
c. They are metabolized by cytochrome P450 3A4 and
should be used carefully in patients with liver disease
or those taking medications that act as an inhibitor of
this microsomal enzyme.

d. Inhibitors include azole antifungals, macrolides,

calcium channel blocker, and protease inhibitors.
II. Esters
a. Include cocaine, chloroprocaine, procaine, and
tetracaine.
III. Lidocaine24
a. Is the most commonly used local anesthetic. Can be
used with or without epinephrine.
b. Epinephrine produces local vasoconstriction which
decreases bleeding and systemic absorption. It also
reduces the pH of lidocaine, which may increase the
pain after injection.
c. Epinephrine can be administered in safe doses of
1.52 mg/kg and 7 mg/kg of plain lidocaine and lidocaine with epinephrine, respectively.
d. The use of lidocaine with epinephrine in the ngertips, the tip of the nose, and the ears is controversial.

Key features
I. Conrm the lesion location with a body map and
outline it with a skin marker.
II. Obtain informed consent.
III. Ask about past medical history, current medications,
and allergies to anesthetics, antibiotics, or antiseptics.
IV. Prepare the surgical site with antiseptic swaps.
V. Select the appropriate anesthetic technique.
VI. Always pull back the plunger of the syringe after
inserting the needle, to ensure that there is no intravascular injection.

Dermatologic Surgery: Step by Step, First Edition. Edited by Keyvan Nouri.

2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

20

CHAPTER 3:

21

Anesthesia in dermatologic surgery

Additives
Epinephrine: decreases bleeding and enhances anesthetic
effect.
Sodium bicarbonate (8.4%): 1 part + 10 parts of
anesthetic, reduces the burning sensation; reduces
anesthetic effect 25%.
Hyaluronidase: better anesthetic diffusion, less tissue
distortion, reduces the anesthetic effect.

Choosing the appropriate

anesthetic technique
I. Topical: for shaves or inltration of anesthetic with
less pain.
II. Inltrative: for shaves, punches, curettage, and excisional biopsies.
III. Nerve blocks: for larger procedures and more sensitive areas.

Instruments
I. Non-sterile gloves
II. Antiseptic swaps
III. Lidocaine (most commonly used) with/without
epinephrine
IV. Syringes (3, 5, and 10 mL)
V. Syringe needles (25, 27, and 30 gauge)
VI. Gauze pads

Step-by-step anesthetic techniques

Topical anesthesia
Topical agent that decreases cutaneous pain sensation3.
Cryoanesthesia: refrigerant sprays (dichlorotetrauoroethane and ethyl chloride)
Topical anesthetic compounds: EMLA, S-Caine Peel,
LMX, and Tropicaine among others.
EMLA
I. Clean and dry the site. Shave the area if necessary.
II. Apply EMLA 13 hours before the procedure. Do not
spread out the cream.

III. Cover with an occlusive dressing, getting a thick

layer underneath.
IV. Write the time of application on the dressing.

Inltrative anesthesia
I. Hold the skin taut, insert the needle in a 10 angle
(intradermal) or a 30 angle (subcutaneous) into the
skin.
II. Inject the anesthetic smoothly.
III. If additional needle sticks are needed, place them in
an already anesthetized area.

Nerve blocks
Classied into ring blocks and peripheral nerve
blocks57.
Ring or eld block
I. Hold the skin taut, insert the needle in a 10 or a 30
angle into the skin.
II. Pull back the plunger of the syringe to ensure that
there is no intravascular injection.
III. Inject the anesthetic smoothly.
IV. Repeat the injection process in a circumferential
pattern around the marked surgical site.
Scalp block
I. Hold the skin taut, insert the needle in a 10 angle into
the skin.
II. Inject small wheals of anesthesia, 5 cm apart from
each other, starting on the mid-forehead.
III. Continue injecting above the eyebrows, follow across
the superior auricular sulcus towards the occiput.
IV. Proceed around the other side of the scalp back to
the starting point, completing the ring.
V. Further injections should be done at the subcutaneous and subfascial level.
Ear block
I. Hold the skin taut, insert the needle in a 30 angle at
the inferior auricular sulcus, next to the attachment of
the ear lobe.
II. Inltrate in the direction of the tragus; withdraw the
needle and redirect it in the posterosuperior direction
along the post-auricular sulcus.
III. Next, insert the needle at the tragus and in a superior
direction. Inltrate along the pre-auricular sulcus.

22

PART 1:

IV. Finally, inltrate along the superior post-auricular

sulcus, completing the ring.

Caution:

Temporal arteries run 1 cm anterior to the

tragus.

Peripheral nerve blocks: higher anesthetic concentrations

(e.g., 2% lidocaine) are recommended

Dermatologic Surgery

Mental nerve block

Anesthetizes lower lip and chin
I. Locate the mental foramen, at the mid-pupillary line,
midway between the alveolar margin and the inferior
border of the mandible (2.5 cm lateral to the facial
midline); press the site with your third nger.
II. Retract the cheek laterally.
III. Insert the needle along the lower gum line between
the two lower premolar teeth; inltrate 12 mL of anesthetic outside the foramen.

Face
Hand and wrist
Supraorbital nerve block
Anesthetizes the scalp and forehead above the eyebrow.
I. Locate the supraorbital foramen in the mid-pupillary
line, along the supraorbital ridge (2.5 cm lateral to the
facial midline).
II. Hold the skin taut, insert the needle perpendicular to
the skin and inltrate the site, generating a papule.
III. Insert the needle into the anesthetized area and
move forward to the bone.
IV. Inltrate 12 mL of anesthetic outside the foramen.
Supratrochlear nerve block
Anesthetizes the glabella, and the forehead and scalp
above it.
I. Hold the skin taut, insert the needle perpendicular to
the skin at the junction of the supraorbital ridge and the
nose root; 1 inltrate the site, generating a papule.
II. Insert the needle into the anesthetized area and move
forward to the bone.
III. Inltrate 12 mL of anesthetic outside the foramen.
Both nerve blocks can be done at the same time, starting from either one and inltrating along the eyebrow
until the other is reached.
Infraorbital nerve block
Anesthetizes lower eyelid, lateral part of the nose, upper
lip, and medial part of the cheek
I. Locate the infraorbital foramen, at the mid-pupillary
line, 10 mm below the infraorbital ridge (2.5 cm lateral
to the facial midline); press the site with your third
nger.
II. Raise the upper lip with second nger and the thumb
of the same hand.
III. Insert the needle at the apex of the canine fossa;
inltrate 12 mL of anesthetic outside the foramen.

Median nerve block

Anesthetizes lateral two-thirds of the palm, ventral side,
and nail beds of the thumb, second, third and half of the
fourth nger
I. Locate the palmaris longus and the exor carpi radialis
tendons.
II. Insert a 27-gauge needle at the proximal wrist exion
crease, between the tendons, in a 30 angle in direction
of the ring nger.
III. Insert the needle until it pierces the fascia; inltrate
5 mL of anesthetic.
Caution:

The radial artery runs lateral to the exor carpi

radialis. tendon.

Radial nerve block

Anesthetizes lateral half of the dorsum of the hand,
dorsum of the thumb, second, third, and half of the
fourth nger
I. Locate the styloid process of the radius.
II. Insert a 27-gauge needle just above the styloid process
of the radius in a 30 angle in medial direction; inltrate
5 mL of anesthetic.
III. Withdraw the needle and redirect, inltrating 5 mL
of anesthetic in a lateral direction.
Ulnar nerve block:
Anesthetizes palmar and dorsal side of fth and half of
the fourth nger, medial third of the palm, and medial
half the dorsum of the hand.
I. Locate the insertion of the exor carpi ulnaris tendon
at the styloid process.
II. Insert a 27-gauge needle transversally, below the
insertion.

CHAPTER 3:

III. Advance the needle until it pierces the fascia; inltrate 5 mL of anesthetic.
Caution:

The ulnar artery runs lateral to the exor carpi

ulnaris tendon.

Digital nerve block

I. Place the patients hand with the palm facing
downwards.
II. Insert a 25-gauge needle perpendicular to the skin
onto the dorsolateral aspect of the base.
III. Advance with the needle until just below the ventral
side; inltrate 1 mL of anesthetic.
IV. As the needle is withdrawn, inltrate 1 mL of the
anesthetic.
V. Repeat the same process on the other side of the base
of the nger.

Ankle
Sural nerve block
Anesthetizes lateral edge of the foot and dorsum of fth
toe.
I. Position the patient prone.
II. Locate lateral edge of the Achilles tendon and the
posterior border of the lateral malleolus.
III. Insert a 25-gauge needle between the two anatomical
landmarks, toward the lateral malleolus.
IV. Advance with the needle, inltrating 510 mL of
anesthetic in a transverse line until the malleolus is
reached.
Posterior tibial nerve block
Anesthetizes the heel, sole and plantar side of the toes.
I. Position the patient prone.
II. Locate medial edge of the Achilles tendon and the
posterior border of the medial malleolus.
III. Locate the posterior tibial pulse behind the
malleolus.
IV. Insert a 25-gauge needle 1 cm behind and above the
pulsating artery toward the tibia in 45 angle.
V. Advance the needle, inltrating 5 mL of anesthetic
until the bone is reached.
Caution:

23

Anesthesia in dermatologic surgery

The posterior tibial artery runs medial to the

nerve.

Saphenous nerve block

Anesthetizes medial edge of the foot.
I. Position the patient supine.
II. Locate the anterior border of the medial malleolus
and the anterior tibial tendon by dorsiexing the foot.
III. Insert a 25-gauge needle 1.5 cm in front and above
the superoanterior border of the medial malleolus.
IV. Advance the needle transversely, inltrating 5 mL of
anesthetic toward the anterior tibial tendon.

Caution:

The great saphenous vein runs anterior to the

nerve.

Supercial peroneal nerve block

Anesthetizes dorsum of the foot and digits, except for the
rst web space.
I. Position the patient supine.
II. Locate the medial and lateral malleoli.
III. Draw a transverse line from the medial malleolus to
the anterior border of the lateral malleolus.
IV. Insert a 4 cm 25-gauge needle at the anterior border
of either of the malleoli.
V. Advance the needle at the subcutaneous level, transversely, inltrating 510 mL of anesthetic toward the
anterior border of the opposite malleolus.
Deep peroneal nerve block
Anesthetizes dorsal aspect of foots rst web space.
I. Position the patient supine.
II. Locate the extensor hallucis longus and the extensor
digitorum longus.
III. Search between the tendons for the anterior tibial
pulse.
VI. Mark the site of the injection.
V. Insert a 27-gauge needle 5 mm lateral to the pulsating
artery, perpendicular to the skin.
VI. Advance the needle until the bone is reached, withdraw the needle 1 mm; inltrate 3 mL of anesthetic.

Caution:

The anterior tibial artery runs medial to the

nerve.

Penile block
I. Position the patient supine.
II. Locate the dorsal supercial penile vein.

24

III. At the base of the penis, insert a 27-gauge needle

lateral to the vein and just below the skin, inject 2 mL of
the anesthetic without epinephrine.
VI. Repeat on the other side of the vein.

Complications
I. Vasovagal response: due to anxiety, producing diaphoresis, dizziness, bradycardia, hypotension, and
syncope.
II. Toxicity: the patient can present with different symptoms depending on the blood concentrations, ranging
from tinnitus, lightheadedness, circumoral numbness
and nystagmus to generalized tonicclonic seizures and
respiratory depression at very high levels.
III. Allergic reaction: rare, less than 1%. Type I (usually
with ester type anesthetics) and IV reactions could occur.
IV. Vascular injury: prolonged bleeding and hematomas can develop. Apply continuous pressure in this
situation.
V. Nerve injury: transient neuritis, paresthesias, or
motor decits can develop. Infection: can occur if aseptic
measures are not taken before starting the procedure.

PART 1:

Dermatologic Surgery

References
1. Suresh, S. (2006). Peripheral nerve blocks. Pediatric Anesthesiology Winter Meeting 2006, Fort Myers, FL.
http://www.pedsanesthesia.org/meetings/2006winter/
manuscripts.iphtml.
2. Hruza GJ. Dermatologic surgery: introduction and approach.
In: Freedberg IM, Eisen AZ, Wolff K, et al. (eds) Dermatology
in general medicine, vol. 5, 5th edn. New York: McGraw-Hill,
1999:311112, 311315.
3. Hruza, G. Anesthesia. In: Bolognia JL, Jorizzo JL, Rapini RP
(eds). Dermatology. New York: Mosby, 2007:223341.
4. Olbritch, S. Biopsy techniques and basic removals. In:
Bolognia JL, Jorizzo JL, Rapini RP (eds). Dermatology. New
York: Mosby, 2007:22701.
5. Scarborough D, Bisaccia E, Schuen W, Swensen R. Anesthesia for the dermatologic surgeon. Int J Dermatol 1989;28:
62937.
6. Lawrence CM, Walker NPJ, Telfer NR. Dermatological
surgery. In: Burns DA, Breathnach SM, Cox NH, Grifths
CEM (eds) Rooks textbook of dermatology, vol. 4, 7th edn.
Oxford: Blackwell Publishing, 2004;78.7, 78.978.10.
7. Gmyrek, R, Dahdah, M. Local and regional anesthesia. (2009).
http://emedicine.medscape.com/article/1831870-overview.