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Introduction
CHAPTER 12 Local Anesthesia,
Regional Nerve Blocks, and Postoperative Pain Management
David T. Harvey Emma Elizabeth Harvey
SUMMARY
Local anesthesia is a critical component of dermatologic surgery, and allows
even large flaps to be performed comfortably in an office setting.
If patients unnecessarily undergo painful procedures, or painful anesthesia
injection, this may adversely affect their overall experience and may undermine
their confidence in the dermatologic surgeon.
Beginner Tips
Lidocaine 1% with 1:100,000 epinephrine is the most widely used local anesthetic in
dermatologic surgery.
Lidocaine-allergic patients can usually be treated with either bupivacaine or, for small
biopsies, normal saline or cryoanesthesia.
Patients may complain of an โallergyโ to epinephrine; on detailed history, this is often
related to intravascular injection during a dental procedure, but patient preference should always be respected.
Use physical and mental distraction liberally and always inject slowly when possible.
Expert Tips
For Mohs surgery defects on the lower leg and other high-risk areas, consider adding
dilute clindamycin to the local anesthetic.
0.15 cc of clindamycin 150 mg/mL is added to a 50-mL vial of local anesthetic. Risks,
including allergy, should be discussed with the patient.
Donโt Forget!
Concerns regarding digital block-related necrosis due to the addition of epinephrine
are probably unfounded, though volume should be minimized when possible.
Patients should be warned that temporary paralysis may be seen postoperatively; a
unilateral facial droop is almost always due to anesthetic effect rather than nerve damage.
Pitfalls and Cautions
Buffering bupivacaine with sodium bicarbonate is contraindicated due to the risk of
precipitation.
Be cautious when using off-label or compounded topical anesthetics, as these may lead
to systemic side effects.
Patient Education
Topical anesthetics may be applied at home prior to the procedure, though for most
patients, a slow local anesthetic injection coupled with distraction leads to only minimal discomfort.
Local anesthesia is usually instant, while nerve blocks take several minutes to take
effect.
CHAPTER 12 Local Anesthesia,