Doi:10.1016/j.jaad.2005.04.016

Daniel S. Behroozan, MD,a and Leonard H. Goldberg, MD, FRCPa,b Tumescentlocalanesthesiawasfirstdescribed (Xylocaine)thatisbuffered10:1with8.4%sodium by Kleinin 1987 when he detailed the infil- bicarbonate. A 30-gauge, .5-in needle on a 3-mL sy- tration of large volumes of a diluted solution ringe is used to inject the anesthetic. Only the tip of of lidocaine with epinephrine into fat before lipo- the needle is inserted into the papillary dermis at suction. The tumescent technique revolutionized approximately a 30-degree angle. The solution is liposuction by eliminating the necessity of general injected slowly to allow diffusion of anesthesia anesthesia or intravenous sedation and the copious within the dermis and not increase the intradermal bleeding that had been associated with liposuction tissue pressure. Care is taken not to inject anesthetic procedures. Since that time, the use of the tumescent technique has been expanded to include other der- Initially, one observes a blanching phenomenon matologic surgical procedures such as hair trans- as a result of mechanical compression of dermal plantation, laser surgery, face-lifts, abdominoplasty, vessels. Further injection of anesthetic solution leads to the elevation of a bleb and peau d’orange as the The benefits of the tumescent technique detailed anesthetic material swells the dermis locally while by Kleinare numerous: optimizing biochemical diffusing laterally (When injecting within the drug efficacy, targeting drug effects in local tissue dermis, as compared with injecting into the subcu- compartments, maximizing drug concentration lo- taneous tissue, there is an elevated level of resistance cally, delaying systemic drug absorption, prolonging that is felt on the syringe plunger.
local and systemic drug effects, decreasing systemic While injecting the anesthetic solution, every drug toxicity, increasing the safe upper limit of drug attempt is made to minimize pain by slow injection, dosage, mechanically expanding a targeted com- using buffered anesthesia, and continual verbal dis- partment, and benefiting from augmented local traction and reassurance to the patient ().
hydrostatic pressure to reduce bleeding.
Additional needle sticks are minimized as the anes- In this report, we aim to describe the use of dermal thetic solution readily diffuses through the dermis.
tumescent anesthesia in cutaneous surgical procedures.
When needed to provide a larger area of anesthesia, It is the authors’ experience that dermal tumescent further injections should be made through already anesthesia produces superior local anesthesia by directly injecting larger amounts of diluted anestheticsolution into the dermis, and also a reduced amount of bleeding intraoperatively and postoperatively.
The technique described above for dermal tu- mescent anesthesia provides the skin surgeon with a temporarily bloodless dermal field and exquisite We routinely use a commercially available solu- anesthesia to perform surgical procedures ().
tion of 0.5% lidocaine with epinephrine 1:200,000 This procedure for the delivery of local dermalanesthesia is a modification of routinely taughtmethods of infiltration of local anesthesia into the From DermSurgery Associates,a and Department of Medicine (Der- matology), University of Texas, MD Anderson Cancer Center.b The use of dermal tumescent anesthesia results in Funding sources: None.
Conflicts of interest: None identified.
lesser amounts of anesthetic solution injected into Reprint requests: Leonard H. Goldberg, MD, FRCP, DermSurgery the dermis compared with when injecting directly Associates, 7515 Main, Suite 240, Houston, TX 77030. into fat to obtain adequate anesthesia. There are several benefits for the surgeon and patient by using this technique. There is immediate mechanical com- 0190-9622/$30.00ª 2005 by the American Academy of Dermatology, Inc.
pression of vascular structures even before the effect of epinephrine takes place. This, combined with the Fig 1. Demonstration of insertion of needle at 30-degree Fig 3. Dermal tumescent anesthesia provides temporarily angle to produce dermal tumescent anesthesia.
bloodless field; 10 mL of local anesthetic solution was usedfor tumescence of each field.
Fig 4. Five minutes of postoperative pressure rather than Fig 2. Dermal blanching and peau d’orange formation as electrocautery is often sufficient for complete hemostasis anesthesia swells dermis locally while diffusing laterally.
more dilute concentration of epinephrine in the Table I. Tips to reduce pain during dermal anesthetic solution, is especially important with elderly patients and those who are more sensitive to the cardiac effects of adrenaline. In addition, using 2. Insert only the tip of the needle initially reduced concentrations of lidocaine and epineph- 3. Use a 30-gauge, .5-in needle on a 3-mL syringe rine allows one to inject more anesthetic solution to maximize tumescence. It should be noted that when 5. Continually distract the patient with verbal reassurance injecting into the dermis, the volume of fluid injected is less than when anesthetic solution is routinely 6. Additional injections should be made through already injected into the fat. We routinely inject an average of 10 mL intradermally for a 1-cm tumor.
Increased tissue pressure caused by anesthetic fluid injected into the dermis compresses bloodvessels resulting in reduced bleeding during surgical necrosis and eschar formation, and potentially de- procedures with less need for electrocautery for creases the likelihood of postoperative infections.
hemostasis. In fact, it is the authors’ experience that It should be noted that in operations below the after surgical or Mohs micrographic surgical exci- level of the dermis, such as excision of lipomas that sions using the dermal tumescent technique, post- may extend and penetrate more deeply, it is impor- operative pressure alone rather than electrocautery tant to follow intradermal injection with subcutane- is often sufficient for complete hemostasis for ous infiltration to provide more complete local wounds (). The lack of need to use excessive anesthesia, although solution from dermal injection electrocautery during routine dermatologic surgical diffuses into the upper fat for some degree of procedures reduces operative time, decreases tissue anesthesia. In addition, for excisional surgeries requiring extensive undermining in the subcutane- In conclusion, we describe a modified form of ous plane, subcutaneous infiltration beyond the area delivery of local anesthesia into the dermis that of initial dermal tumescence site will be necessary.
provides a rapid onset of anesthesia, provides a Yet, for excision and closure of lesions that do not relatively bloodless field in which to operate, and penetrate below the level of the subcutaneous fat, requires decreased absolute amounts of local anes- intradermal anesthesia is sufficient and beneficial in thetic leading to increased ease of performing skin that a decreased volume of anesthetic solution is not lost into the subcutaneous level without benefit tothe patient. Dermal swelling after tumescent injec- tion is lost within minutes, reducing distortion of 1. Klein JA. Tumescent technique for liposuction surgery. Am J tissue during closure or repair. Lastly, it is the authors’ view that intradermal delivery of local anesthesia 2. Namias A, Kaplan B. Tumescent anesthesia for dermatologic leads to a quicker onset and prolonged duration of surgery. Dermatol Surg 1998;24:755-8.
anesthesia. This is likely a result of the fact that most 3. Krejci-Manwaring J, Markus JL, Goldberg LH, Friedman PM, Markus RF. Surgical pearl: tumescent anesthesia reduces pain of of the afferent pain fiber nerve endings in the skin axillary laser hair removal. J Am Acad Dermatol 2004;51:290-1.
are in the papillary dermis and not the subcutane- 4. Klein JA. Tumescent technique chronicles: local anesthesia, liposuction, and beyond. Dermatol Surg 1995;21:449-57.

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