Tumescent local anesthesia: Technique benefits reconstructive skin cancer surgery

Key Points

Alvaro E. Acosta, M.D., chief of the department of dermatology and oncology at the National Cancer Institute of Colombia, and associate professor at the National University, has utilized tumescent local anesthesia (TLA) more than 1,500 times while performing reconstructive skin cancer surgery. He says this type of anesthesia can greatly benefit surgeons as well as patients.

"Numerous older patients who suffer from cutaneous malignancies also often have additional health problems which make them high-risk candidates for general anesthesia.

"Tumescent local anesthesia has made it possible to increase the total dose of lidocaine five- to sevenfold, up to 35 to 50 mg/kg, without resulting in toxic levels of lidocaine or negative side effects among patients," Dr. Acosta says.

TLA is readily used in Mohs micrographic surgery, skin flap and graft surgery, in sentinel node biopsy and in breast surgery. It has also become popular in arthroscopies, phlebectomies, in the debridement of venous ulcers and when surgically treating axillary hyperhidrosis - and its indications are expanding.

"I almost exclusively use TLA in my patients when performing skin cancer surgeries. Each patient receives the same TLA solution, which consists of 100 ml of 0.9 percent sodium chloride and 10 ml of 1 percent lidocaine with epinephrine - 1:200,000, and 1 mEq of sodium bicarbonate. I add the active substances of the TLA solution to the saline solution just before injection," Dr. Acosta tells Dermatology Times.

Dr. Acosta says that, due to the blunt dissection of the subcutaneous tissues that the hydrodissection effect of TLA can achieve, surgical procedures become far less traumatic. There is far less intra-operative bleeding to worry about - also due to the addition of epinephrine - which provides the surgeon with a far better surgical view, facilitating surgical reconstruction and "stress-free" environment.

"Extensive areas in and around the operative field can be anesthetized painlessly and without side effects. Another major advantage of TLA is its long-lasting postoperative analgesia, up to 18 hours post-operatively," Dr. Acosta says.

The vast majority of patients - 98 percent - do not complain of postoperative pain. According to Dr. Acosta, the few patients who do complain of moderate pain may have been influenced by stress and not by the complexity of the surgery or the inadequacy of the TLA. He says the tumescence edema resides approximately eight hours post-operatively in 80 percent of all patients. To date, none of his patients have reported adverse reactions.

However, Dr. Acosta says caution must be taken when performing this type of anesthesia. Due to the tumescent effect of TLA, skin tension lines are unrecognizable immediately following infiltration, and there is relatively high skin tension at wound closure.

There is also an increase in the local swelling intra-operatively and postoperatively, which can cause a distortion of the surgical field and may be a cause of bother to the surgeon.

"In my experience, if the proper precautions are taken pre-operatively, and especially in the hands of an experienced surgeon, TLA is problem-free, and these difficulties can be easily overcome," Dr. Acosta says.