Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

33
Chapter 2  Aseptic Technique
Scrub suits
Scrub suits are made of loosely woven material for comfort,
and serve to reduce bacterial shedding from the skin of surgi-
cal personnel. The perineum is heavily colonized and the
friction generated by walking can liberate bacteria-laden skin
cells into the operating room environment.35 A scrub shirt
tucked into pants that are constricted at the waist and ankles
is an efficient means of reducing perineal dispersal. Wearing
a long-sleeved scrub jacket that snaps closed in the front can
decrease bacterial shedding from the forearms. However,
there are no scientific data to show that wearing scrub suits
rather than street clothes affects the incidence of surgical site
infection.36 Scrub suits serve as personal protective gear but
they are not impermeable to blood or body fluids. While they
add to the overall hygiene of the surgical environment, they
may be considered optional for minor surgical procedures.
For procedures where exposure to body fluid is expected,
such as liposuction, their use – along with impermeable gowns
– should be strongly considered.
Regardless of the apparel chosen, any item of clothing that
becomes soiled during surgery should be changed immedi-
ately. At the end of the day all surgical apparel (including
scrub suits and lab coats that may appear to be clean) should
be placed in a laundry bin – not hung in a locker to be worn
the next day. Pathogenic bacteria and fungi can survive for
extended periods on fabrics, particularly the polyester/cotton
blends that are commonly used for scrub suits and lab coats.37
Cover gowns
Cover gowns are non-sterile, reusable, long-sleeved garments
that cover the front of the scrub suit from the neck to the
knees and tie in the back. They became popular when it was
found that scrub suits, which were protected by cover gowns
when worn outside the operating room, had significantly less
contamination than those that were not.38 Despite the poten-
tial for contamination, there is currently no evidence to link
the use of cover gowns with a lower incidence of surgical site
infection, and neither the CDC nor the Association of Oper-
ating Room Nurses (AORN) guidelines require their use.26,39
Face masks
Face masks were originally designed to limit contamination of
the surgical site from microorganisms expelled by surgical
personnel. The effectiveness of a face mask is defined by its
shape, the materials from which it is made, and the way in
which it is worn. Loose-fitting masks allow up to 40% of
expired air to escape backward past the cheeks and ears, par-
ticularly when sneezing or coughing, and must be tied snuggly
to be effective.40 At the end of each surgery, face masks should
be discarded promptly and not placed in the pocket for future
use, or left dangling around the neck. The inner surface of the
mask becomes contaminated with expired microorganisms
and, once removed, should be handled only by the ties.
There are conflicting data regarding the ability of face masks
to reduce surgical site infection, and their necessity in the
operating room has been questioned. Several clinical studies
found no difference in bacterial counts or wound infection
rates when surgical personnel wore face masks during
surgery.41 It has been suggested that face masks may even
increase the risk for contamination by ‘wriggling’ around on
the face and abrading skin cells into the sterile field.42 Studies
60% isopropanol (NewGer-spray, Biogenetic Labs, Madrid,
Spain) and emollients provides rapid antisepsis with persist-
ent activity at 3 hours.27
Duration and method
Hand scrub solutions can become contaminated and support
microbial growth. To limit this risk, they should be stored in
closed receptacles and either supplied in single-use containers
or dispensed from a foot-operated system.28 The outer sur-
faces of a hand pump frequently become contaminated and
should, therefore, be replaced with a more hygienic system.
Another potential source of contamination is the bacterio-
logical quality of the water used to rinse the skin after com-
pletion of the hand scrub. In one modern operating room,
plumbing manipulations resulted in water flowing from the
surgical sink that was contaminated with Gram-negative bac-
teria and atypical mycobacterium.29 This led to an outbreak
of surgical infections and illustrates that water supplies should
be periodically monitored, particularly after servicing.
Recent studies have refuted the need for the traditional
5–10 minute surgical scrub and suggest that a shorter applica-
tion time may be just as effective. Combining agents that
complement each other can decrease the required duration
of the scrub. For example, an initial 1–2-minute scrub with
chlorhexidine gluconate, followed by an alcohol-based hand
rub, is as effective as a 5-minute scrub with either agent
alone.17,30 While the importance of cleaning under the finger-
nails remains unchallenged, the need to scrub the skin with
a brush has been debated. Keser et al. found that povidone-
iodine had a greater antimicrobial effect when applied with
a scrub brush.31 However, when an alcohol-based product is
used, rubbing the hands together briskly to generate friction
may be as effective as using a scrub brush.22
Fingernails should be kept short to facilitate cleaning, and
artificial nails – which are known to harbor significantly more
microorganisms than natural or polished nails – should not be
worn during surgical procedures.32 There are conflicting data
regarding nail polish and its effect on the surgical hand scrub.
It is generally agreed that nail polish may be worn as long as it
is not chipped or dark in color, potentially obscuring the pres-
ence of subungual debris. Jewelry is known to harbor bacteria
beneath it and to decrease the effectiveness of the hand scrub,
but it is not known whether this sequestration leads to
increased risk for surgical site infection.33,34 Despite the lack
of consensus or scientific data, jewelry and long fingernails
(natural or artificial) clearly limit dexterity, and increase the
risk for glove perforation, and are therefore best avoided
during surgery.
Surgical attire
Surgical attire can be divided into non-sterile and sterile
items, each serving different functions. Non-sterile attire is
designed to reduce microbial shedding from surgical person-
nel and subsequent contamination of the surgical environ-
ment. It consists of a scrub suit, cover gown, face mask, shoe
protection, and hair cover. These items are permeable to
moisture and should be changed immediately should they
become wet with blood or another body fluid.
Sterile surgical attire, such as impervious surgical gowns
and sterile gloves, are designed to maintain a sterile field and
protect personnel from exposure to blood-borne pathogens
during surgery.

34
Part 1  Basic Surgical Concepts
wearer recognizes that a perforation has occurred in only 17%
of cases.48 In this fashion, the aseptic barrier between the
surgeon’s hand and the patient’s wound can be unknowingly
breached for extended periods. Even in the absence of visible
perforation, the hands should always be washed after remov-
ing gloves. Occult glove perforations raise significant concern
for exposure of the surgeon to the patient’s body fluids. This
margin of safety may be increased by the use of thicker ‘tear-
resistant’ gloves or double-gloving.
Despite evidence-based data that these measures reduce
the risk of exposure, most surgeons find that double-gloving
limits their dexterity, and do not use this practice consistently.49
Aside from exposure concerns, there is little evidence that
occult perforations influence bacterial counts on the surgeon’s
hands or on the outside of the gloves.50 These findings should
be interpreted with caution, as they were obtained from
sterile gloves worn over hands that had undergone a traditional
surgical hand scrub using an antiseptic agent with sustained
effect. There are no available studies that evaluate the degree
of surgical site contamination or wound infection rate from
sterile glove perforation without a preceding surgical hand scrub.
Sterile surgical gowns
Sterile surgical gowns are worn as a barrier to fluid and micro-
bial transmission during surgery. They have long sleeves
with elastic cuffs and they maintain the sterile barrier between
the surgical field and the surgeon’s clothes or exposed arms.
They are made from either impermeable material or a water-
resistant, tightly woven fabric, and have been shown to
decrease bacterial counts in the operating room.51 The effect
of contamination via this route, as reflected in the develop-
ment of surgical site infection, is not known. Sterile surgical
gowns are generally not necessary for most dermatologic pro-
cedures, but may be considered as protective gear for liposuc-
tion or other procedures with expected exposure to body fluids.
Preparation of the patient
The man who is stretched on the operating table in
one of our surgical hospitals is in greater danger of dy-
ing, than was the English soldier on the battlefield of
Waterloo.
James Simpson (1811–1870), Scottish surgeon. Cited in:
Glaser H. The road to modern surgery. New York: EP
Dutton & Co; 1962.
Removal of street clothes
Regardless of the scheduled procedure, most hospital-based
operating rooms require that patients remove all of their
clothing, including underwear, and put on a cotton gown. This
empiric practice is based on the perception that street clothes
and shoes may contaminate the operating room environment,
but is not supported by scientific data. Patients in street
clothes disperse the same amount of bacteria as those dressed
in a clean cotton gown, covered with a cotton sheet.35 Infec-
tion rates for same-day surgery are not significantly affected
when patients remain fully dressed.52 Aside from causing
embarrassment, removal of underwear and putting on a min-
imally secured gown allows for increased bacterial shedding
from the perineum into the environment. Therefore, unless
a gown facilitates exposure of the surgical site, or body fluid
spillage is expected, the scientific literature does not support
have found a clear relationship between bacterial contamina-
tion of the surgical field and the volume at which the person
speaks.43 Speaking in a normal tone for up to 30 minutes
without a face mask projects relatively few bacteria. Con-
versely, speaking in a loud tone, even briefly, liberates signifi-
cantly more bacteria – up to 1 meter away – and coughing or
sneezing can propel bacteria up to 3 meters.44 Given these
findings, it is possible that operating in silence without a mask
may provide the least risk for surgical site contamination.
Caution is advised before discontinuing the routine use of
face masks because it is not always known if talking will be
needed during a procedure, or if an unexpected cough or
sneeze will occur. A second consideration is the role that face
masks play in universal precautions. They not only protect
the surgical wound from airborne contamination but also
serve to protect the wearer’s mouth and nose from unex-
pected splashes of blood and body fluids.
Surgical footwear
Footwear worn during surgery should be fluid resistant and
have impervious soles. It should be cleaned regularly and
restricted to use in the operating room environment. These
measures serve to limit contamination of the operating room
floor and protect the healthcare worker from body fluid spills.
If such footwear is not available, paper booties with elastic at
the ankles can be worn over street shoes. These disposable
covers protect the shoes from exposure to blood-borne path-
ogens and add to the overall hygiene of the operating room
environment. However, there is little evidence that their use
directly affects wound infection rates.45,46
Hair covers
The majority of patients and surgical personnel carry bacteria
on the surface of their hair, which may be shed during surgery
and contaminate the surgical field.47 Disposable hair covers
are a convenient and inexpensive means of reducing this
contamination. Of the available varieties, bouffant and hood-
style covers provide maximum coverage and are preferred
over skullcaps that do not cover the hair over the ears or the
nape of the neck.
Surgical gloves
In the winter of 1889–1890 … the nurse in charge
of my operating-room complained that the solutions
of mercuric chlorid [sic] produced a dermatitis of
her arms and hands. As she was an unusually efficient
woman … I requested the Goodyear Rubber Compa-
ny to make as an experiment two pair of thin rubber
gloves with gauntlets … Thus the operating in gloves
was an evolution rather than inspiration or happy
thought, and it is remarkable that during the four or
five years when as operator I wore them only occa-
sionally, we could have been so blind as not to have
perceived the necessity for wearing them invariably at
the operating-table.
Halsted WS. Surgical papers. Baltimore: The Johns
Hopkins Press; 1924.
Surgical gloves provide a second line of defense against poten-
tial contamination from the hand flora of the surgical team.
They also protect surgical personnel from exposure to blood-
borne pathogens. In dermatologic surgery, gloves become
perforated in approximately 11% of procedures, and the

35
Chapter 2  Aseptic Technique
seeks to lower the resident bacterial count as much as pos-
sible and limit rebound growth, but with minimal skin irrita-
tion. On the night before surgery, a preoperative shower with
chlorhexidine gluconate or povidone-iodine has been shown
to decrease wound infection rates, particularly those from
Staphylococcus aureus, and may be considered for procedures
with large surgical fields such as liposuction.55,56 The most
commonly used agents for surgical site preparation are chlor­
hexidine gluconate, povidone-iodine, PCMX, and alcohol-
based products (see Table 2.1). Chlorhexidine gluconate and
alcohol-containing preparations should be avoided in the peri-
ocular area, as they may cause corneal and conjunctival irrita-
tion. Povidone-iodine solution at half strength (5%) is a safe
and effective antiseptic preparation to use in this area. Some
antiseptic agents are mutually inactivating, and if repeated
application is expected (such as during multiple stages of
Mohs micrographic surgery followed by reconstruction), the
same agent should be used for each consecutive application.52
Film-forming iodophor preparations, such as Prevail-Fx
(Cardinal Health, McGaw Park, IL), are partially water
soluble, which makes them fluid resistant and increases their
efficacy. In studies, a 30-second, single application was as
effective as povidone-iodine scrub and povidone-iodine solu-
tion applied in a traditional 5-minute, 2-step scrubbing and
painting.57 However, the film must be removed manually
with soap and water or alcohol, which limits its practicality
for brief procedures.
Draping
Sterile drapes serve to protect the surgical site from micro-
organisms present on the surrounding non-sterile surfaces.
Tightly woven cotton surgical drapes are softer and arguably
more comfortable for patients than disposable impermeable
drapes, but they may absorb fluid during surgery and ‘wick’
bacteria into the sterile field.58 The fabric’s weave may loosen
with repeated washing and may become perforated by
repeated clamping with towel clamps. To limit the risk for
contamination, woven drapes should be chemically treated to
retard water, inspected frequently for wear, and changed
immediately if they should become wet. Alternatives to
woven drapes are disposable plastic and plastic-lined paper
drapes, which are impermeable to moisture and bacteria. The
drawback is that they may be stiff and have a tendency to
shift during surgery.
the need for patients to remove their street clothes before
dermatologic surgery.
Hair removal
While some surgical rituals may be empiric, and not based on
scientific data, they are generally considered sensible, and at
best harmless. One exception to this observation would be
preoperative shaving on the night before surgery and the
erroneous belief that removing hair from the surgical site
decreases the risk for infection. Shaving with a razor in par-
ticular should be avoided, because it causes abrasions which
compromise skin integrity and allow bacteria to flourish. The
time lapse between shaving and surgery plays a key role in
the risk for infection. Seropian and Reynolds found a wound
infection rate of 3.1% in patients shaved immediately before
surgery that was significantly higher than the rate of 0.6%
that occurred in those who were not shaved.53 The infection
rate rose to 7.1% when shaving was done the day before
surgery, and to as much as 20% when performed more than
24 hours before surgery. Cruse and Foord performed a 5-year
prospective study of surgical wounds and found a 2.3% infec-
tion rate in patients who were shaved, 1.7% in patients who
had their hair clipped, and 0.9% in patients whose hair was
not removed from the surgical field by any method.54
From an infection standpoint, it is generally agreed that hair
should be left intact within the surgical field. That being said,
the frustration of attempting to suture on the scalp when hair
is caught with each throw of the knot is well known to sur-
geons who work in this area. If care is not taken, the entan-
gled hair can decrease knot security and can increase the risk
of a foreign-body reaction. One way to avoid this is to secure
the hair away from the field with sterile hair clips, rubber
bands, lubricating gel, or snipped sections from a Penrose
drain or sterile glove (Figs 2.3 and 2.4). If these methods do
not prove sufficient, and removal is required, the hair should
be judiciously clipped at the skin with a pair of scissors or
electric clippers before establishing a sterile field.
Surgical site preparation
The goal of preoperative skin preparation is to lower the risk
for surgical site infection by removing skin debris, dirt, and
transient microorganisms. Like the surgical hand scrub, it
Figure 2.3  Suggested means to limit the need for hair removal.
A sterile glove or Penrose drain may be snipped to create
multiple sterile hair bands.
Figure 2.4  Sterile bands in place to hold the hair away from the
surgical field.

36
Part 1  Basic Surgical Concepts
Steam under pressure (autoclave)
Most office-based dermatologic surgeons use an autoclave,
which is considered the most efficient, economical, and easily
monitored method for sterilizing instruments.67,68 Autoclav-
ing generates pressures of 2 Pascals and temperatures of
121°C that must be maintained for 15–30 minutes depending
on the density of the surgical package. This form of steriliza-
tion is useful for liquids, glass, metal instruments, paper, and
cotton, but should not be used with heat-sensitive plastics or
oils.67 A potential limitation to autoclave sterilization is that
repeated exposure to high humidity may dull sharp cutting
surfaces, particularly the high-grade carbon steel edges of
hair-transplant punches and scalpel blades.
Heated chemical vapor
Sterilization by heated chemical vapor is a low-humidity
method that can be used on sharp instruments, with less
concern for dulling. It has the added benefits of not requiring
a drying phase, and shorter heat-up time than an autoclave.
However, instead of heating with distilled water, this method
uses alcohol and formaldehyde, which necessitates use of
protective gear, adequate ventilation, and safety monitoring.
Dry heat
Dry heat may be used for glass, oils, and instruments that can
withstand prolonged exposure to temperatures of 121–204°C.
As this method is humidity free, it does not dull sharp instru-
ment edges, and has no corrosive or rusting effects on instru-
ments. The most common safety hazard with dry heat
sterilization is burn injury to personnel; so protective equip-
ment must be available and used consistently.
Gas sterilization
Gas sterilization with ethylene oxide or formaldehyde is an
effective method for sterilizing heat-sensitive and moisture-
sensitive instruments. A significant drawback is that ethylene
oxide and formaldehyde are both toxic if inhaled and are
known carcinogens. In addition, gas sterilization requires pro-
longed exposure times and extensive venting systems.65 The
Occupational Health and Safety Administration (OSHA)
requires strict monitoring of these highly toxic gases and,
given its hazardous potential, gas sterilization is rarely per-
formed outside hospital settings.
Chemical immersion
Sterilization by immersion in solutions such as glutaraldehyde
or aqueous formaldehyde may be used for heat-sensitive items.
The most frequently used ‘cold sterilant’ is 2% glutaralde-
hyde, but it is not reliably sporicidal and may be more accu-
rately termed a ‘cold disinfectant.’68 Both glutaraldehyde and
formaldehyde are highly toxic, require immersion for 6–12
hours, and cannot reliably ensure sterility. Once instruments
are removed from the solution they must be handled asepti-
cally, rinsed in copious amounts of sterile water, and dried on
a sterile towel. They cannot be wrapped for storage and must
be used immediately or their sterility is compromised.
New methods
Ortho-phthalaldehyde (OPA) is a relatively new chemical
sterilant that received approval from the US Food and Drug
Environmental cleaning
… the surgeon’s duty under ordinary circumstances is
not to find what are the most dangerous sanitary con-
ditions under which he dare operate, it is rather to dis-
cover the causes of the pestilence and banish them as
far as possible from his field of action. The desiderata
to be secured are a pure air, healthy conditions and
strict cleanliness …
From an address by Sir William Scovell Savory (1879) to
the British Medical Society. Cited in: Elliot IMZ, Elliott
JR. A short history of surgical dressings. London: The
Pharmaceutical Press; 1964.
Microorganisms from both the patient and surgical per­sonnel
are continually shed into the operating room environment via
desquamated skin cells.59 Once dispersed, they eventually
settle onto horizontal surfaces such as the surgical field, floor,
or counter tops. This reservoir can be re-aerosolized from the
passage of feet across the floor and by the breeze generated
from opening the surgical room door.60,61 To limit potential
contamination, doors should be kept closed, the passage of
non-essential personnel should be minimized, and cleaning
and disinfection of surgical rooms should be performed on a
scheduled basis with a quaternary ammonium sanitizer.62,63 It
also follows that all people involved in the break in sterile
technique – the surgeon, patient, and surgical assistant – need
to reprep, or they need to leave the surgical field. Upon
resuming surgery, the surgical site must be reprepared and
draped, and surgeons must don fresh gloves. At no time should
a surgeon leave the surgical suite with contaminated gloves.
Personnel outside of a hospital setting will need to be
instructed in the unique cleaning needs of a surgical room and
the ways in which they differ from routine office cleaning.
There are no current studies that define the frequency and
extent to which environmental cleaning should be carried out.
For brief surgical procedures without fluid spillage, such as
obtaining a Mohs layer, mopping the floor and wiping down
counter tops after each patient is impractical and is not sup-
ported by the literature or the CDC.26,64 Most guidelines
recommend visible inspection of the room in between proce-
dures, and prompt clean up of any visible soiling or discarded
surgical items that may have fallen onto the floor. Terminal
cleaning, including wet vacuuming of the entire floor and dis-
infection of all environmental surfaces with a quaternary
ammonium sanitizer, is recommended at the end of each day
of use.62
Surgical instrument sterilization
Sterilization refers to a chemical or physical process that
completely destroys or removes all forms of viable microor-
ganisms, including spores, from an object. Surgical instru-
ments and materials that come in contact with sterile tissue,
cavities, or the bloodstream must be unconditionally sterile.
Instruments that are sterilized outside of the hospital set-
tings, such as in a physician’s office, are not subject to central-
ized control. It is essential that designated personnel be
thoroughly trained in proper sterilization technique, with the
ultimate responsibility for ensuring its adequacy resting upon
the operating surgeon.65,66 There are several sterilization
methods available, and while some systems are amenable to
use in a physician’s office, others are best suited to a hospital
or industrial setting.

37
Chapter 2  Aseptic Technique
and face the surgical field rather than turning to one side.
Change the face mask immediately if it becomes wet and
discard it at the end of each major procedure, regardless of
its condition. If a face mask is not worn during surgery, intra-
operative talking should be kept to a minimum.
Surgical gloves
Remember that surgical gloves do not replace the need for
clean hands and are considered a second line of defense. While
most surgeons use sterile gloves during suturing of wounds,
non-sterile but clean gloves may be sufficient for routine biop-
sies and the tumor removal stage of Mohs micrographic
surgery.70 Whether sterile or clean, they should be inspected
for tears or imperfections before and during surgery. If they
become perforated, they should be changed immediately.
Double-gloving provides additional protection from perfora-
tion but may limit dexterity and is not 100% effective. A
double-glove puncture indication system (Biogel Reveal,
Regent Medial, Norcross, GA) that shows punctures as
a green color may be considered for high-risk patients or
procedures.
Hair removal
Hair should only be removed if its presence will obscure the
surgical field or hinder proper surgical technique. If hair
removal is deemed necessary, clip it judiciously at the skin
with a pair of scissors or electric clippers before establishing
the surgical field. Hair removal should be limited to the
immediate peri-incisional area.
Surgical site preparation
For procedures with large surgical fields, such as liposuction,
consider having the patient shower the night before surgery
with chlorhexidine gluconate. At the time of surgery, place
the patient on the table in the position in which surgery will
be performed. Remove any visible dirt from the surgical site
with a detergent-based solution and friction. Heavily colonized
areas such as the umbilicus or nasal vestibule should receive
close attention. After a thorough cleansing with a detergent-
containing solution, blot the skin with a sterile or single-use
towel and apply an antiseptic solution that is appropriate
for the location and condition of the surgical site. Use 5%
povidone-iodine solution for surgery around the eye to avoid
irritation. Paint the solution or gel onto the skin in concentric
circles, beginning at the proposed incision site and extending
several centimeters beyond the expected draped perimeter. It
is important to remember that alcohol-containing solutions
are flammable and must be allowed to dry before surgery or
laser procedures are begun.
Draping
Once the skin has been prepared, the drapes should be gath-
ered or folded in a compact manner. They should be held
higher than the surgical table and placed along the perimeter
of the sterile field extending into the periphery. Drapes
should be placed so that they overlap several centimeters of
prepared skin, and once set down they should not be lifted
or repositioned. Woven drapes can be folded to conform to
the size of the surgical field. When possible, apply drapes to
the patient’s head and neck so as to direct the patient’s
expired air away from the surgical field. Woven drapes are no
Administration (FDA) in 1999. When compared to glutaral-
dehyde and formaldehyde, OPA sterilizes much faster (10–
15 minutes) and has superior mycobactericidal and sporicidal
activity.69 It is highly stable, not irritating to the eyes or nasal
passages, and does not require exposure monitoring. Disad-
vantages are that it may stain the skin gray and, as for other
immersion methods, instruments cannot be wrapped for
storage.
 TECHNIQUES AND
OPTIMIZING OUTCOMES
Surgical hand scrub
For minor or short-lived procedures (such as biopsies or elec-
trodesiccation and curettage), the literature does not support
the need for a formal surgical hand scrub, but it is recom-
mended before more lengthy or invasive procedures. Before
beginning the hand scrub, any jewelry on the fingers and
wrists should be removed. Next, wash the hands and fore-
arms thoroughly with a detergent-based solution to remove
visible soiling. Recall that the majority of hand flora is found
under and around the fingernails, so a disposable orange stick
or nail pick will be needed to remove subungual debris and
the fingernails should be kept trimmed (Fig. 2.5). After a
thorough cleansing, rinse and apply a liberal amount of an
antiseptic solution to all the surfaces of the fingers, hands,
and forearms. The effective duration and method of applica-
tion varies with the solution chosen, but should be at least 2
minutes. The arms should be kept flexed at the elbow and
rinsed from the fingertips downward, allowing water to drip
from the elbows. Use a sterile or single-use disposable towel
for drying. Allow any residual moisture to be air dried before
donning surgical gloves. Ideally, the water supply should be
controlled by a foot pedal, which removes the need to man-
ually close a contaminated faucet.
Face masks
For maximum effect, crimp the face mask to fit the contour
of the nose and tie it firmly at the back of the head, so that
it covers the nose and mouth. Should it become necessary to
cough or sneeze while wearing a face mask, step backwards
Figure 2.5  The majority of hand flora is found under and around
the fingernails and a disposable nail pick should be used during
the first scrub of the day to remove subungual debris.

38
Part 1  Basic Surgical Concepts
cut tissue paper without resistance. Any defective instrument
should be set aside for repair. Instruments with moving parts
should be placed into an instrument ‘milk’ that serves as a
water-soluble lubricant and decreases the friction between
opposing surfaces.
Instrument packaging and quality assurance
When the processing method permits, place instruments that
are to be sterilized into individual pouches that can be opened
as needed. Choose a packaging system that assures sterility
until opened, permits identification of the contents, and
resists tears, punctures, or abrasions.72 Instruments with del-
icate tips can be protected with special heat-tolerant tip
guards (Fig. 2.7). The package should be labeled with the
sterilization load number, and a sterilization process indicator,
such as heat-sensitive tape or an insert that turns dark with
heat exposure, should also be in a visible location on the
package. This identifies those packages that have been exposed
to one or more steps in the sterilization process, but does not
verify sterility. The only means of assuring the efficiency of a
sterilizer is to perform quality assurance tests with heat-
resistant Bacillus spp. spores at regular intervals (at least
weekly). The spores’ lack of viability after passing through the
process demonstrates that conditions necessary to achieve
sterilization were met during the cycle being monitored.
Maintaining a sterile field
To limit airborne contamination, cover instruments with a
sterile drape when they are not in use.73 Do not allow sharp
or heavy objects to drop onto the tray where they may per-
forate the sterile field. Instead, they should be presented
directly to the gloved person. To limit splashing that may
compromise the sterile field, dispense solutions by pouring
them slowly into a receptacle that is placed on the edge of
the surgical tray or held by the scrub person.
All devices that enter the sterile field must be sterile or
placed within a sterile barrier. Autoclavable electrocautery
hand pieces are available, but many dermatologic surgeons
longer considered sterile if they become wet and should be
changed immediately.
When working on the fingers, a sterile surgical glove can be
used to create a sterile field (Fig. 2.6). Once the surgical site
is cleansed with antiseptic solution, pull an oversized sterile
glove onto the hand. Then snip and remove the finger of the
glove overlying the affected digit.
Environmental cleaning
At the beginning of each day, equipment, lights, tables, switch
plates, and counter tops should be damp-dusted with a clean
lint-free cloth and disinfectant. Perform a visible inspection
of the room at the end of each procedure and any visible
soiling or discarded surgical items that may have fallen onto
the floor should be picked up and disposed of.
At the end of the day, the entire floor, including the sur-
faces underneath equipment, should be cleaned with a wet
vacuum. Alternatively, a two-mop system may be used,
where the first mop applies the disinfectant solution and the
second mops it up. Only freshly laundered mops should be
used because they are easily contaminated and can spread
bacteria from another location, such as a bathroom, to the
floor of the operating room.
Instrument cleaning and sterilization
It is important to begin with high-grade stainless steel instru-
ments that will withstand repeated use. There should be a
formal protocol that designates the person responsible for
removing all sharp objects, such as suture needles and scalpel
blades, from the surgical tray at the end of each procedure.
Once all the sharps have been removed, the instruments are
taken to the processing area, completely disassembled, and
placed in a pre-soaking solution to soften any adherent debris.
At the end of the day, the instruments are either cleaned
manually or put in a washer/sterilizer. Cleaning must be
meticulous because residual blood, tissue, and other organic
matter may shield microorganisms and affect the reliability of
sterilization methods.71 Irregular surfaces, crevices, or hinged
mechanisms may require ultrasonic cleaning or special brushes.
After cleaning, the instruments are rinsed and inspected for
residual organic debris or surface damage. Forceps and hemo-
stat tips should be exactly aligned, and scissor blades should
Figure 2.6  An oversized sterile glove can be used to create and
maintain a sterile field during nail surgery.
Figure 2.7  Self-sealing sterilization package that allows
visualization of the contents. Note the guard placed over
the delicate tips of the instrument to protect them during
the sterilization process (blue arrow), the clearly identifiable
sterilization load number (green arrow), the heat-sensitive tape
(red arrow) and the technician’s initials (yellow arrow).

39
Chapter 2  Aseptic Technique
 SUMMARY
Most surgical site infections are due to contamination that
occurs during surgery. Common and often overlooked sources
of contamination are the surgical environment, instruments,
and the normal flora of the patient and surgical personnel.
The key to considering any of these sources of infection is
the nature of the potential pathogens – including the ease
with which they are spread from one location to another and
their ability to flourish in broken skin. Indeed, the discovery
that preoperative shaving is associated with a greater infec-
tion rate than leaving the hair intact clearly shows how our
knowledge continues to develop. As the variety and complex-
ity of procedures performed by dermatologists expand, so
will the need to adopt aseptic measures appropriate to each
procedure’s risk for wound infection. This will range from
minimal ones, like the use of gloves and alcohol skin wipes
for a shave biopsy, to full surgical dress and strict asepsis for
liposuction.
use non-sterile hand pieces attached to wall units. Use disin-
fectant to wipe any non-sterile item to be used during surgery
(such as an electrocautery hand piece) and place it in a sterile
covering, such as a proprietary sterile sheath, a sterile surgical
glove, or a Penrose drain (Fig. 2.8) before use.
Surgical technique
Surgical skill does not negate the need for aseptic technique but
the competence with which the tissues are handled is closely
tied to the degree of contamination a wound can overcome. To
assure maximum blood supply to the healing tissue, it must be
handled gently with either a skin hook or toothed tissue forceps,
and unnecessary tension on the wound edges during closure
avoided.74 Hemostasis should be achieved in a manner that
does not compromise blood supply, implant excessive amounts
of suture, or induce unnecessary thermal damage. Electrocau-
tery is an indispensable tool but it must be used judiciously.
Excessive thermal destruction of tissue is associated with an
increased risk for infection.54 Consider bipolar cautery, which
directs current between the tips of the forceps, and produces
significantly less tissue necrosis than monopolar cautery at
comparable energy settings.75 Avoid extensive thermal damage
by tying off large-diameter vessels or muscular arteries. When
possible, use the smallest effective monofilament suture and
limit unnecessary suture, particularly braided silk, which
enhances the virulence of staphylococci 10 000-fold.76
Wound dressings
Wound dressings are an important part of surgical site care.
Ideally a bandage should be placed over the wound while the
sterile field is still in place. The patient is instructed to leave
the dressing undisturbed for at least 48 hours, which allows
a degree of epithelialization to take place and seals the wound
edges from bacterial contamination.77 This does not apply to
blood-soaked bandages, which may enhance bacterial passage.
Saturated bandages should be changed promptly regardless
of the timing.
 PITFALLS AND THEIR MANAGEMENT
As can be seen in this discussion, the use of aseptic technique
is never entirely infallible, particularly in view of the normal
Figure 2.8  A small incision at the edge of the Penrose drain
helps secure it around the sterile electrocautery tip and limits
exposure of the non-sterile hand piece.
Pitfalls and their management
 Removing povidone-iodine after painting the skin to reduce
skin-staining. Povidone-iodine works within minutes but must
be left on the skin to have a persistent effect. It is quickly
inactivated in the presence of blood or sputum. For long
procedures with copious bleeding or around the mouth,
another agent, such as chlorhexidine gluconate, should be
used to prepare the skin.
 Using chlorhexidine gluconate around the eye. Chlorheridine
gluconate may cause conjunctivitis and severe corneal
ulceration. Prepare the ocular area with 5% povidone-iodine
solution.
 Preparing the skin with an alcohol wipe prior to laser surgery
or electrosurgery. Alcohol is flammable and may ignite. Allow
for complete evaporation prior to starting any surgery or laser
procedure. Should a fire occur, smother it with a linen towel.
Do not douse it in water. The alcohol may float on the water
and spread the fire.
 Leaving an alcohol wipe laying on the patient and starting
electrosurgery. This may cause an electrical burn. Start a
habit of discarding alcohol wipes in the refuse receptacle
immediately after wiping the skin.
 Preoperative shaving of the surgical site with a razor. This
should be avoided, because it causes abrasions which
compromise skin integrity and allow bacteria to flourish. Hair
should be pulled away from the field with clips or may be
trimmed with scissors.
flora of human skin and the inability to render it completely
sterile. In the postoperative period, patients should be mon-
itored for surgical site infection and appropriate therapy
should be instituted. Any acute increase in infection rate
should be investigated promptly and appropriate measures
instituted.78 Chapter 6 discusses antibiotic therapy in detail,
and Chapters 7, 8, and 12 give further information on wound
healing, dressings and postoperative care, and drainage.

40
Part 1  Basic Surgical Concepts
15. Cheng SM, Garcia M, Espin S, et al. Literature review and survey com-
paring surgical scrub techniques. AORN J 2001;74:218, 221–224.
16. Wade JJ, Casewell MW. The evaluation of residual antimicrobial activity
on hands and its clinical relevance. J Hosp Infect 1991;18(Suppl
B):23–28.
17. Parienti JJ, Thibon P, Heller R, et al. Hand-rubbing with an aqueous
alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgi-
cal site infection rates: a randomized equivalence study. JAMA
2002;288:722–727.
18. Danziger Y, Pertzelan A, Mimouni M. Transient congenital hypothy-
roidism after topical iodine in pregnancy and lactation. Arch Dis Child
1987;62:295–296.
19. Bantseev V, McCanna DJ, Driot JY, et al. The effects of toxicological
agents on the optics and mitochondria of the lens and the mitochondria
of the corneal epithelium. Semin Cell Dev Biol 2008;19:150–159.
20. Perez R, Freeman S, Sohmer H, et al. Vestibular and cochlear ototoxicity
of topical antiseptics assessed by evoked potentials. Laryngoscope
2000;110:1522–1527.
21. Larson EL. APIC guideline for handwashing and hand antisepsis in health
care settings. Am J Infect Control 1995;23:251–269.
22. Hobson DW, Woller W, Anderson L, et al. Development and evaluation
of a new alcohol-based surgical hand scrub formulation with persistent
antimicrobial characteristics and brushless application. Am J Infect
Control 1998;26:507–512.
23. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings.
Recommendations of the Healthcare Infection Control Practices Advi-
sory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. Society for Healthcare Epidemiology of America/Association
for Professionals in Infection Control/Infectious Diseases Society of
America. MMWR Recomm Rep 2002;51:1–45.
24. Kampf G. How effective are hand antiseptics for the postcontamination
treatment of hands when used as recommended? Am J Infect Control
2008;36:356–360.
25. Kampf G, Ostermeyer C, Kohlmann T. Bacterial population kinetics on
hands during 2 consecutive surgical hand disinfection procedures. Am J
Infect Control 2008;36:369–374.
26. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of
surgical site infection, 1999. Centers for Disease Control and Prevention
(CDC) Hospital Infection Control Practices Advisory Committee. Am J
Infect Control 1999;27:97–132.
27. Herruzo-Cabrera R, Vizcaino-Alcaide MJ, Fdez-Acinero MJ. Usefulness
of an alcohol solution of N-duopropenide for the surgical antisepsis of
the hands compared with handwashing with iodine-povidone and chlor­
hexidine: clinical essay. J Surg Res 2000;94:6–12.
28. Reybrouck G. Handwashing and hand disinfection. J Hosp Infect
1986;8:5–23.
29. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp
Infect 2002;51:79–84.
30. Deshmukh N, Kramer JW, Kjellberg SI. A comparison of 5-minute pov-
idone-iodine scrub and 1-minute povidone-iodine scrub followed by
alcohol foam. Mil Med 1998;163:145–147.
31. Keser A, Bozkurt M, Taner OF, et al. Evaluation of antiseptic use in
plastic and hand surgery. Ann Plast Surg 2005;55:490–494.
32. Hedderwick SA, McNeil SA, Lyons MJ, et al. Pathogenic organisms
associated with artificial fingernails worn by healthcare workers. Infect
Control Hosp Epidemiol 2000;21:505–509.
33. Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, et al. The effects
of test variables on the efficacy of hand hygiene agents. Am J Infect
Control 2004;32:69–83.
34. Salisbury DM, Hutfilz P, Treen LM, et al. The effect of rings on microbial
load of health care workers’ hands. Am J Infect Control 1997;
25:24–27.
35. Bethune DW, Blowers R, Parker M, et al. Dispersal of Staphylococcus
aureus by patients and surgical staff. Lancet 1965;1:480–483.
36. Belkin NL. Use of scrubs and related apparel in health care facilities. Am
J Infect Control 1997;25:401–404.
37. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J Hosp
Infect 2001;48:238–241.
38. Copp G, Mailhot CB, Zalar M, et al. Covergowns and the control of
operating room contamination. Nurs Res 1986;35:263–268.
39. Mathias JM. Sacred cow survey. Use of cover gowns, shoe covers falls to
new low. OR Manager 2000;16:1, 9–11, 13–14 passim.
40. Belkin NL. The evolution of the surgical mask: filtering efficiency versus
effectiveness. Infect Control Hosp Epidemiol 1997;18:49–57.
41. Tunevall TG. Postoperative wound infections and surgical face masks: a
controlled study. World J Surg 1991;15:383–387; discussion 387–388.
42. Schweizer RT. Mask wiggling as a potential cause of wound contamina-
tion. Lancet 1976;2:1129–1130.
43. Schiff FS. The shouting surgeon as a possible source of endophthalmitis.
Ophthalmic Surg 1990;21:438–440.
 REFERENCES
1. Glaser H. The road to modern surgery. New York: EP Dutton; 1962.
2. Lister J. On the antiseptic principles in the practice of surgery. Lancet
1867;2:353–356.
3. Lister J. On the antiseptic system of treatment upon the salubrity of a
surgical hospital. Lancet 1870;1:194–200.
4. Marples MJ. The normal microbial flora of the skin. Soc Appl Bacteriol
Symp Ser 1974;3:7–12.
5. Brook I. Secondary bacterial infections complicating skin lesions. J Med
Microbiol 2002;51:808–812.
6. Altemeier WA, Culbertson WR, Hummel RP. Surgical considerations of
endogenous infections – sources, types, and methods of control. Surg Clin
North Am 1968;48:227–240.
7. National Nosocomial Infections Surveillance (NNIS) System Report,
data summary from January 1992 to June 2002, issued August 2002. Am
J Infect Control 2002;30:458–475.
8. Davies RR, Noble WC. Dispersal of bacteria on desquamated skin. Lancet
1962;2:1295–1297.
9. Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosoco-
mial surgical site infections, 1992: a modification of CDC definitions of
surgical wound infections. Am J Infect Control 1992;20:271–274.
10. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of
surgical site infection, 1999. Hospital Infection Control Practices Advi-
sory Committee. Infect Control Hosp Epidemiol 1999;20:250–278; quiz
279–280.
11. Wahie S, Lawrence CM. Wound complications following diagnostic skin
biopsies in dermatology inpatients. Arch Dermatol 2007;143:1267–
1271.
12. Brewer JD, Otley CC, Christenson LJ, et al. The effects of sirolimus on
wound healing in dermatologic surgery. Dermatol Surg 2008;34:
216–223.
13. Araco A, Gravante G, Sorge R, et al. Wound infections in aesthetic
abdominoplasties: the role of smoking. Plast Reconstr Surg 2008;
121:305e–310e.
14. Kampf G, Kramer A. Epidemiologic background of hand hygiene and
evaluation of the most important agents for scrubs and rubs. Clin Micro-
biol Rev 2004;17:863–893.
Abbreviations and online resources
AORN: Association of Operating Room Nurses ‘Recommended
practices’


CCDR: Canada Communicable Disease Report ‘Hand washing,
cleaning, disinfection and sterilization in health care’

pdf
CDC: Centers for Disease Control and Prevention

‘Guideline for prevention of surgical site infection’ 1999

‘Guideline for hand hygiene in health-care settings’ 2002

FDA: Food and Drug Administration ‘FDA-cleared sterilants and
high level disinfectants’

DeviceRegulationandGuidance/ReprocessingofSingle-
UseDevices/ucm133514.htm
NNIS: National Nosocomial Infection Surveillance

OSHA: Occupational Safety & Health Administration

WHO: World Health Organization ‘WHO guidelines on hand
hygiene in health care’

=Other&template=/CM/ContentDisplay.cfm&ContentFileID
=5682

41
Chapter 2  Aseptic Technique
62. Griffith CJ, Obee P, Cooper RA, et al. The effectiveness of existing and
modified cleaning regimens in a Welsh hospital. J Hosp Infect 2007;66:
352–359.
63. Recommended practices for traffic patterns in the peroperative practice
setting. Association of periOperative Registered Nurses. AORN J
2000;71:394–396.
64. Weber DO, Gooch JJ, Wood WR, et al. Influence of operating room
surface contamination on surgical wounds: a prospective study. Arch Surg
1976;111:484–488.
65. Sebben JE. Surgical preparation, facilities and monitoring. Roenigk &
Roenigk’s dermatologic surgery. New York: Marcel Dekker; 1996.
66. Allen KW, Humphreys H, Sims-Williams RF. Sterilization of instruments
in general practice: what does it entail? Public Health 1997;111:
115–117.
67. Recommended practices for sterilization in perioperative practice
settings. Association of periOperative Registered Nurses. AORN J
1999;70:283–293.
68. Sebben JE. Survey of sterile technique used by dermatologic surgeons. J
Am Acad Dermatol 1988;18:1107–1113.
69. Rutala WA, Weber DJ. New disinfection and sterilization methods.
Emerg Infect Dis 2001;7:348–353.
70. Rhinehart MB, Murphy MM, Farley MF, et al. Sterile versus nonsterile
gloves during Mohs micrographic surgery: infection rate is not affected.
Dermatol Surg 2006;32:170–176.
71. Recommended practices for cleaning and caring for surgical instruments
and powered equipment. AORN J 2002;75:627–630, 633–636, 638
passim.
72. Recommended practices for selection and use of packaging systems.
Association of Operating Room Nurses. AORN J 1996;63:949–
953.
73. Dalstrom DJ, Venkatarayappa I, Manternach AL, et al. Time-dependent
contamination of opened sterile operating-room trays. J Bone Joint Surg
Am 2008;90:1022–1025.
74. Ueno C, Hunt TK, Hopf HW. Using physiology to improve surgical
wound outcomes. Plast Reconstr Surg 2006;117:59S–71S.
75. Ferguson DJ. Clinical applications of experimental relations between
technique and wound infection. Surgery 1968;63:377–381.
76. Edlich RF, Panek PH, Rodeheaver GT, et al. Physical and chemical
configuration of sutures in the development of surgical infection. Ann
Surg 1973;177:679–688.
77. Hochberg J, Murray GF. Principles of operative surgery. Antisepsis,
technique, sutures and drains. Textbook of surgery, 14th edn. Philadel-
phia: WB Saunders; 1991.
78. Gastmeier P, Stamm-Balderjahn S, Hansen S, et al. Where should one
search when confronted with outbreaks of nosocomial infection? Am J
Infect Control 2006;34:603–605.
44. Doust BC, Lyon AB. Face masks in infection of the respiratory tract. J
Am Med Assoc 1918;71:1216–1219.
45. Humphreys H, Marshall RJ, Ricketts VE, et al. Theatre over-shoes do
not reduce operating theatre floor bacterial counts. J Hosp Infect
1991;17:117–123.
46. Weightman NC, Banfield KR. Protective over-shoes are unnecessary in a
day surgery unit. J Hosp Infect 1994;28:1–3.
47. Recommended practices. Surgical attire. AORN Technical Practices
Coordinating Committee. AORN J 1990;51:828, 830, 832 passim.
48. Gross DJ, Jamison Y, Martin K, et al. Surgical glove perforation in der-
matologic surgery. J Dermatol Surg Oncol 1989;15:1226–1228.
49. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection.
Cochrane Database Syst Rev 2006, Issue 2. Art. No.: CD003087. DOI:
10.1002/14651858.CD003087.pub2.
50. Dodds RD, Guy PJ, Peacock AM, et al. Surgical glove perforation. Br J
Surg 1988;75:966–968.
51. Sanzen L, Carlsson AS, Walder M. Air contamination during total hip
arthroplasty in an ultraclean air enclosure using different types of staff
clothing. J Arthroplasty 1990;5:127–130.
52. Woodhead K, Taylor EW, Bannister G, et al. Behaviours and rituals in
the operating theatre. A report from the Hospital Infection Society
Working Party on Infection Control in Operating Theatres. J Hosp Infect
2002;51:241–255.
53. Seropian R, Reynolds BM. Wound infections after preoperative depila-
tory versus razor preparation. Am J Surg 1971;121:251–254.
54. Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical
wounds. Arch Surg 1973;107:206–210.
55. Veiga DF, Damasceno CA, Veiga Filho J, et al. Influence of povidone-
iodine preoperative showers on skin colonization in elective plastic
surgery procedures. Plast Reconstr Surg 2008;121:115–8; discussion
119–120.
56. Hayek LJ, Emerson JM. Preoperative whole body disinfection – a control-
led clinical study. J Hosp Infect 1988;11(Suppl B):15–19.
57. Jeng DK. A new, water-resistant, film-forming, 30-second, one-step
application iodophor preoperative skin preparation. Am J Infect Control
2001;29:370–376.
58. Blom AW, Gozzard C, Heal J, et al. Bacterial strike-through of re-usable
surgical drapes: the effect of different wetting agents. J Hosp Infect
2002;52:52–55.
59. Noble WA. Dispersal of microorganisms from skin. Microbiology of
human skin. London: Lloyd-Luke Ltd; 1981.
60. Ritter MA, Eitzen H, French ML, et al. The operating room environment
as affected by people and the surgical face mask. Clin Orthop Relat Res
1975:147–150.
61. Ayliffe GA. Role of the environment of the operating suite in surgical
wound infection. Rev Infect Dis 1991;13(Suppl 10):S800–S804.

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43
3
Anesthesia and Analgesia
Teresa Soriano MD and David P Beynet MD
Summary box
 Most skin surgery can be performed under local anesthesia,
avoiding the risks associated with general anesthesia.
 Local anesthetics reversibly interrupt propagation of nerve
impulses by interfering with sodium ion influx into peripheral
nerve cells.
 Topical application is particularly effective for mucosal
surfaces because of their enhanced absorption.
 For other surfaces, intradermal or subcutaneous infiltration
are the most commonly used techniques, the former being
more immediate in onset and more prolonged, but also
causing more tissue distortion and pain.
 To anesthetize a large area of skin, a nerve block may be
more appropriate, injecting a small amount at the major
cutaneous nerve trunk that supplies the area, therefore
avoiding the use of potentially toxic amounts of anesthetic.
 Choice of anesthetic and delivery method depends on the
type of surgery planned and patient characteristics.
 Local adverse effects may occur, but allergic reactions are
rare.
 Serious systemic adverse effects can result from inadvertent
intravascular injection, excess amounts, and abnormal drug
metabolism; an awareness of the effects associated with the
different anesthetics is important.
 INTRODUCTION
The expanding field of dermatologic surgery requires the
proper selection and administration of anesthesia to maxi­
mize patient safety and comfort. Because it reliably provides
effective anesthesia and avoids the increased risks of mor­
bidity and mortality associated with general anesthesia,
local anesthesia is preferred for most cutaneous surgical
procedures.
Investigations of local anesthetic agents similar to ones used
today began in the late 19th century. In 1860, Neiman iso­
lated cocaine from the shrub of Erythroxylon coca and noted
its numbing effect on the tongue.1 In 1880, Von Anrep rec­
ognized cocaine’s anesthetic properties after injecting it into
animals and into his own arm.1 In 1884, Koller, influenced by
Sigmund Freud, introduced cocaine into the clinical arena
when he used cocaine as a local anesthetic during surgery for
a patient with glaucoma.1 Soon thereafter, Hall and Halsted
performed the first peripheral nerve block using cocaine.1
However, as the use of cocaine for local anesthesia expanded,
reports of its potential toxicity and addictive effects also
emerged.1
Safer local anesthetics were developed during the past
century. In 1904, Alfred Einhorn synthesized procaine, an
ester of para-aminobenzoic acid (PABA).1 In 1905, Braun
reported the successful use of procaine with epinephrine for
local anesthesia.1 In 1930, a more potent PABA ester, tet­
racaine, was introduced.2 Although both had utility as anes­
thetics, they had the tendency to produce allergic reactions.
In 1943, Lofgren and Lundqvist synthesized lidocaine, an
amide derivative of diethlyaminoacetic acid.2 Its superior
safety and efficacy has led to its widespread use, and lidocaine
has become the prototype of local anesthetics. Subsequently,
other amide derivatives have been developed.
Several local anesthetics with various methods of delivery
are now available for cutaneous surgery. Appropriate, safe,
and effective use of these compounds depends on choosing
the correct compound, understanding its pharmacological
properties, and employing the proper technique of adminis­
tration. Proper use of local anesthesia maximizes patient
safety, minimizes pain, and increases ease of surgical
procedures.
Structure and physiology of anesthetics
Most local anesthetic agents have similar chemical structures,
consisting of three components: an aromatic portion, an inter­
mediate chain, and an amine portion (Fig. 3.1). Modifications
of any of these components can affect the pharmacological
properties of the anesthetic agent. The aromatic end provides
most of the lipophilic properties of the compound. It facili­
tates the diffusion of the anesthetic through membranes,
which correlates to the potency of the anesthetic.3 The
hydrophilic end, usually consisting of a tertiary amine, is
involved in binding within the sodium channel.4 These two
domains are linked with an intermediate chain, consisting of
either an ester or amide, and having a length between 3 and
7 carbon equivalents is necessary for local anesthetic activity.4
Disruption of this chain initiates the drug’s metabolism and
allows for the reversible nature of the anesthetic.4
The differences in the intermediate chain linkage (ester
versus amide) classify local anesthetics into two groups (Table
3.1). They differ in their metabolism and potential for sensi­

44
Part 1  Basic Surgical Concepts
molecular structure and dissociation constant (pKa) of local
anesthetics affect their potency and toxicity.8 Changes in the
molecule’s structure affect lipid solubility and protein binding.
In general, lipid solubility determines the potency of the
agent while protein binding dictates its duration of action.8
For example, the addition of a 4-carbon group to procaine
creates tetracaine, which is more lipid soluble and potent.
Highly protein-bound agents, such as bupivacaine, are tightly
associated with the neural membrane, leading to a longer
duration of action.4 The pKa influences the onset of action of
local anesthetics.8 For the most part, the shorter-acting anes­
thetics tend to have a faster onset of action and less toxicity.
However, peak plasma concentrations depend on various
factors including the concentration of anesthesia, the dura­
tion of infiltration, the site of injection, and the rate of metab­
olism of the agent.9
The pKa of local anesthetics and the hydrogen ion concen­
tration (pH) of the solution and tissue influence the pharma­
cologic activity of local anesthetics.4 Local anesthetics are
weak bases, with a pKa between 7.7 and 9.1. They are usually
prepared as solutions of hydrochloride salts with a pH of
5.0–6.0 to enhance their solubility and stability.4 In tissue,
they exist either as an uncharged base or as a cation, with
their relative proportions determined by the pKa of the anes­
thetic and the pH of the solution.8 The non-ionized base form
can readily diffuse across lipid nerve sheaths and cell mem­
branes while the ionized form can diffuse through the extra­
cellular space and intracellular cytoplasm.8 In general, a lower
pKa correlates to a higher concentration of base and a faster
onset of action.4 Alkalinization of the anesthetic solution
increases the amount of base and the anesthetic’s onset of
action.10 In addition, the pH of the tissue can also affect the
action of local anesthetics. Infected tissues tend to be acidic
and impair the effectiveness of local anesthetics.11
Local anesthetics can cross the placenta by passive diffu­
sion; however, they are generally safe to use during preg­
nancy.12 Studies have shown no maternal or teratogenic
effects from the administration of lidocaine during the first
trimester of pregnancy.13 Lidocaine, etidocaine, and prilo­
caine are labeled pregnancy category B. Because of the poten­
tial of causing fetal bradycardia, bupivacaine and mepivacaine
are labeled category C.13 Local anesthetics can be excreted in
breast milk and result in toxicity to the infant if a large
amount of anesthetic is used.13
Mechanism of action
Local anesthetics act by reversibly interrupting the propaga­
tion of impulses and blocking nerve conduction.8 In the
resting state, the intracellular electric potential is negative
tization.5 Ester-type compounds tend to have a shorter dura­
tion of action because they are rapidly hydrolyzed by plasma
pseudocholinesterases to form metabolites excreted by
the kidneys.5 Individuals with decreased levels of pseudo­
cholinesterase may be prone to the toxic effects of these
agents.5 PABA is a major metabolic product and is responsible
for the higher incidence of allergies with ester-type anes­
thetics.6 Amide derivatives are not readily hydrolyzed. They
are metabolized by microsomal enzymes in the liver and
excreted by the kidneys.5 Individuals with compromised liver
function are more susceptible to the toxic effects of amide
anesthetics.7
The pharmacological properties of common ester and
amide anesthetics are outlined in Tables 3.2 and 3.3. The
Intermediate chain
Ester
Aromatic portion
(hydrophobic)
Amine portion
(hydrophilic)
C
O
R
N
O
1
=
C
O
=
R2
R3
Amide
N
R
N
I
H
1
R2
R3
Ester- and amide-type local anesthetics
Figure 3.1  Basic structures of ester- and amide-type local
anesthetics.
Table 3.1  Local anesthetics
TYPE
GENERIC NAME
SOME TRADE NAMES
Esters
Procaine
Novocain
Tetracaine
Pontocaine
Benzocaine
Hurricane
Chloroprocaine
Nesacaine
Cocaine
(None)
Amides
Lidocaine
Xylocaine
Bupivacaine
Marcaine
Mepivacaine
Carbocaine
Prilocaine
Citanest
Table 3.2  Ester local anesthetics
Duration (min)
Maximal recommended dose
(mg/kg) for adults
ANESTHETIC
ONSET (min)
pKa
WITHOUT
EPINEPHRINE
WITH
EPINEPHRINE
WITHOUT
EPINEPHRINE
WITH
EPINEPHRINE
Procaine
5
8.9
15–30
30–90
10
14
Chloroprocaine
5–6
9
30–60
N/A
10
N/A
Tetracaine
7
8.6
120–240
240–480
2
2
See Table 3.11 for pediatric dosage.

45
Chapter 3  Anesthesia and Analgesia
relative to the extracellular space as a result of an ionic gradi­
ent of sodium and potassium ions. This gradient is maintained
by the cellular membrane, which allows free movement of
potassium, and by Na+/K+ adenosine triphosphatase (ATPase)
pumps. During conduction of an impulse, sodium channels
open and allow sodium ions to move across the membrane
and generate an impulse or action potential. By interfering
with the influx of sodium ions into the cells, local anesthetics
prevent the depolarization of peripheral nerves and subse­
quent nerve conduction.8 The exact mechanism of action by
which local anesthetics interfere with the movement of
sodium ions is unclear. One postulated mechanism involves
the local anesthetic binding to receptors in sodium channels,
and when enough sodium channels within an axon are blocked,
conduction is interrupted.14 The binding site of local anes­
thetics may be at the channel’s pore or on the protein sub­
units within the channel.15,16
Nerve fibers are divided into three main categories: A, B,
and C fibers (Table 3.4).6 A and B fibers are myelinated and
C fibers are unmyelinated. The A fibers are the largest and
are subdivided into four types: alpha, beta, gamma, and delta.
The A-alpha fibers conduct motor impulses, the A-beta fibers
primarily conduct light touch and pressure, the A-gamma
fibers are responsible for joint proprioception, and the A-delta
fibers, which are the smallest of the A fibers, conduct pain
and temperature. The B fibers are preganglionic sympathetic
fibers. The C fibers are the smallest and, like the A-delta
fibers, conduct pain and temperature. In general, smaller
myelinated fibers are easier to block than larger myelinated
Table 3.3  Amide local anesthetics
Duration (min)
Maximal recommended dose
(mg/kg) for adults
ANESTHETIC
ONSET (min)
pKa
WITHOUT
EPINEPHRINE
WITH
EPINEPHRINE
WITHOUT
EPINEPHRINE
WITH
EPINEPHRINE
Lidocaine
<1
7.7
30–120
60–400
5
7
Bupivacaine
2–10
8.1
120–240
240–480
2.5
3
Mepivacaine
3–20
7.6
30–120
60–400
6
8
Prilocaine
5–6
7.7
30–120
60–400
7
10
Etidocaine
3–5
7.7
200
240–360
4.5
6.5
Ropivacaine
1–15
8.2
120–360
Not yet defined
3.5
Not yet defined
Levobupivacaine
2–10
8.1
120–240
Not yet defined
2.1
Not yet defined
See Table 3.11 for pediatric dosage.
Table 3.4  Types and properties of nerve fibers
TYPE OF
NERVE FIBER
MYELINATED
PROPERTY/
INNERVATION
A
alpha
Yes
Motor
beta
Yes
Light touch and pressure
gamma
Yes
Proprioception
delta
Yes
Pain and temperature
B
Yes
Preganglionic sympathetic
fibers
C
No
Pain and temperature
With permission from Grekin RC, Auletta MJ. Local anesthesia in dermatologic sur-
gery. J Am Acad Dermatol 1988;19:599–614.6
Table 3.5  Additives to local anesthetics
ADDITIVE
DOSAGE
PURPOSE
Epinephrine
1 : 100 000 or less
To decrease
bleeding, prolong
anesthesia, reduce
anesthetic toxicity
Hyaluronidase
150 units added to
decrease every 30 mL
of anesthetic
To facilitate drug
diffusion, tissue
distortion with
infiltration
Sodium
bicarbonate
(8.5%)
1 mL (1 mEq/mL)
for every 10 mL of
1% lidocaine with
epinephrine
To decrease pain
with infiltration of
acidic solution
fibers; therefore, pain and temperature sensation may be
eliminated before the loss of vibration and pressure.6 This
translates clinically as locally anesthetized patients may not
feel pain and temperature, but still feel a pressure sensation
during a procedure.6
Additions to local anesthetics
Substances are frequently added to local anesthetics to
augment analgesia and enhance the ease and safety of the
surgery (Table 3.5). Some of these products are commercially
available pre-mixed by the manufacturer.
Vasoconstrictors
Most local anesthetics, except for cocaine, promote vasodila­
tation by relaxation of vascular smooth muscle. This results
in increased bleeding at the operative site and increased dif­
fusion of anesthetics away from the site of injection. Vaso­
constrictors are commonly added to local anesthetics to
decrease bleeding and thereby facilitate the ease of surgery.
In addition, they retard the absorption of anesthetics, which
in turn minimizes the amount of drug injected and decreases
systemic toxicity. By localizing the drug to the field injected,
vasoconstrictors also prolong the duration of the anesthesia.
The added benefit of prolonging the duration of the anesthe­
sia does not seem to hold true for more lipid-soluble, long-
acting agents such as bupivacaine and ropivacaine, which are
already highly tissue bound.8

46
Part 1  Basic Surgical Concepts
for use in peripheral nerve blocks leads to more rapid nerve
blockade.4
Hyaluronidase
Hyaluronidase is an enzyme that depolymerizes hyaluronic
acid, one of the acid mucopolysaccharides present in intercel­
lular ground substance. It is typically prepared in 150 unit
vials. Its addition to local anesthetics facilitates diffusion of
injectable solutions through tissue planes, thereby increasing
the area of anesthesia and minimizing tissue distortion by
fluid infiltration.26 It facilitates undermining in the subcutane­
ous plane by hydrodissection of fatty tissue.27 Clinically,
hyaluronidase may be a useful adjunct in surgery in the peri­
orbital region to minimize the number of anesthetic injection
sites and potential ecchymoses. It may also be helpful in
harvesting split-thickness skin grafts when wider areas of local
anesthesia can be attained with minimal loss of anatomic
contour.28 Uniform dosage recommendations for cutaneous
surgery are not available, but 150 units in 20–30 mL of anes­
thetic have been used.27
Hyaluronidase has disadvantages that limit its use in cuta­
neous surgery. It decreases the duration of anesthesia and
potentially increases the risk of anesthetic toxicity as a result
of increased absorption.27,29 Hyaluronidase contains the pre­
servative thimerosal, which is a contact allergen.28 Because
rare allergic reactions have been reported, preoperative skin
testing has been recommended.27 Hyaluronidase is not rec­
ommended for tumescent liposuction because it does not
augment the degree of anesthesia with the tumescent tech­
nique and increases the rate of absorption of lidocaine, and
therefore the potential for systemic toxicity.29
Other anesthetics
Different local anesthetics are sometimes mixed together to
capitalize on the useful properties of each drug. For example,
a longer-acting anesthetic with a delayed onset of action, such
as bupivacaine, can be mixed with a quicker-onset anesthetic,
such as lidocaine.28 A study that evaluated the efficacy of such
a mixed solution found no difference in onset or duration of
action than with bupivicaine alone.30 The addition of a longer-
acting anesthetic into an operative site previously anesthetized
with a shorter-acting anesthetic may provide more optimal
anesthesia when a prolonged procedure is anticipated.28
 TECHNICAL ASPECTS
Topical anesthesia
Topical application of anesthesia has been particularly effec­
tive on mucosal surfaces, but caution must be taken regarding
increased systemic absorption leading to toxicity. Some prod­
ucts are particularly formulated for application on mucosal
surfaces (Table 3.6). The stratum corneum presents the
major barrier to the delivery of topical anesthesia on intact
skin.31 The development of novel delivery systems has allowed
for increased penetration and greater efficacy of newer topical
agents.32
Cocaine
Cocaine is an ester anesthetic that, unlike other local anes­
thetics, possesses vasoconstrictive properties. Available as a
4% and 10% solution, it is primarily used for intranasal
Epinephrine is the most common vasoconstrictor added to
local anesthetics to enhance efficacy. Although the anesthetic
may have an immediate onset of action, full vasoconstriction
with epinephrine typically requires 7–15 minutes.6 Epine­
phrine is commercially available pre-mixed at concentrations
of 1 : 100 000 and 1 : 200 000 with lidocaine. The optimal
dose of epinephrine has been debated.17,18 However, for der­
matologic surgery, concentrations greater than 1 : 200 000 are
probably not necessary and concentrations greater than
1 : 100 000 are associated with an increased risk for side
effects.19 The maximum dose of epinephrine for local anes­
thesia injected in healthy individuals should generally not
exceed 1 mg (100 mL of 1 : 100 000 solution) over approxi­
mately 8–10 hours, which is the equivalent of 5 half-lives.
However, these parameters can be significantly influenced by
patient age and concomitant health issues which may affect
metabolism.6
Epinephrine is labeled pregnancy category C. Concerns
about the safety of use during pregnancy were raised when
epinephrine was shown to reduce uterine blood flow in exper­
imental animals.12 Decreased placental perfusion can theo­
retically interfere with fetal organogenesis, particularly in the
first trimester. Later in the pregnancy, decreased uterine
blood flow by epinephrine absorption may induce premature
labor. Given these potential risks, it is prudent to postpone
non-urgent procedures requiring the use of epinephrine until
after pregnancy. Some have advocated the use of dilute con­
centrations (e.g. 1 : 300 000) of epinephrine in necessary pro­
cedures during pregnancy.20
To prevent the degradation of epinephrine in an alkaline
pH, commercially prepared lidocaine with epinephrine con­
tains acidic preservatives, such as sodium metabisulfite and
citric acid.21 The resulting acidic solution tends to cause more
pain on injection.22 Freshly mixed solutions of lidocaine with
epinephrine result in a less acidic solution; therefore less
discomfort with injection.21 Freshly prepared anesthetic solu­
tion having a 1 : 100 000 concentration of epinephrine can be
made by adding 0.5 mL of 1 : 1000 epinephrine to 50 mL of
lidocaine. Adding half as much epinephrine in this mix would
give a concentration of 1 : 200 000 epinephrine.
Sodium bicarbonate
The addition of sodium bicarbonate to commercially available
lidocaine with epinephrine reduces the pain on infiltration.23
The pH of lidocaine is around 5.0–7.0. However, the addition
of acidic preservatives lowers the pH of commercially pre­
pared epinephrine and lidocaine solutions to around 3.3–5.5,
thus causing more discomfort with injection. Buffering with
8.4% sodium bicarbonate at a ratio of 1 sodium bicarbonate
to 10 epinephrine 1 : 100 000 or 1 sodium bicarbonate to 15
epinephrine 1 : 200 000 increases the pH, bringing it closer
to physiologic pH, and reduces pain.24 Adjusting the pH of
the solution can affect other pharmacologic properties of
these agents. Epinephrine is chemically unstable in anesthetic
solutions alkalinized by sodium bicarbonate. Neutralizing
lidocaine and bupivicaine solutions containing epinephrine
with bicarbonate decreases the duration of action of epine­
phrine and decreases the shelf life of the mixture.25 In addi­
tion, alkalinization of local anesthetics allows for increased
amounts of uncharged, lipid-soluble base, which more readily
crosses the nerve membrane, leading to a faster onset of
action. Clinically, alkalinization of mepivacaine and lidocaine

47
Chapter 3  Anesthesia and Analgesia
and consistent anesthesia for intact skin surfaces. A lidocaine
5% patch is available that is marketed primarily for posther­
petic neuralgia. Over the past 40 years, mixtures of higher
concentrations of lidocaine have been specially compounded
to achieve topical anesthesia for minor surgical procedures.34
Topical preparations of 30% lidocaine prepared using Acid
Mantle (Doak Pharmacals Co Inc, Westbury, NY) or Velva­
chol (Novartis, East Hanover, NJ) as a vehicle result in
hydrophilic mixtures that hydrate the stratum corneum and
facilitate penetration of lidocaine through the stratum
corneum.34 Over the past decade, topical anesthetics in more
sophisticated vehicles have become commercially available
that allow for better efficacy in reducing pain during superfi­
cial cutaneous surgery (Table 3.7).
EMLA
A widely used agent over the past decade, EMLA (eutectic
mixture of local anesthesia) cream is a 5% eutectic mixture
composed of 2.5 mg/mL of lidocaine and 2.5 mg/mL of prilo­
caine in an oil-in-water emulsion cream. A eutectic mixture
is a formulation that melts at a lower temperature than any
of its individual components. EMLA’s formulation contains
emulsifiers that enhance skin penetration and increase the
anesthetic concentration to 80% in the oil droplets while
maintaining a low overall concentration of 5%, thereby mini­
mizing the risk of systemic toxicity.34 Several clinical trials
have shown its efficacy in alleviating pain during various der­
matologic procedures, including laser surgery, chemical peels,
harvesting split-thickness skin grafts, skin biopsies, and curet­
tage and electrosurgery.32,34
EMLA is available as a cream and a patch. It has a child-
resistant closure that complies with the Poison Prevention
surgery.33 Anesthesia occurs within 5 minutes of application
and lasts up to 30 minutes. The maximum recommended
dose is 200 mg/kg. Potential toxicity, including hypertension,
tachycardia, and arrhythmias, can result from blocking the
reuptake of norepinephrine. In addition, decreased coronary
blood flow can occur, leading to myocardial infarction.33
Dopamine reuptake blockade results in central nervous
system stimulation.33 The risks of adverse events and the
potential for abuse limit cocaine’s anesthetic use over safer
alternative agents.
Benzocaine
Benzocaine is a topical ester anesthetic available as an aerosol
spray, gel, ointment, or solution ranging from 5–20%. It is
commonly used for achieving rapid anesthesia on mucosal
surfaces. Although topical benzocaine can cause contact
sensitization, it is still widely used. The 20% gel known as
Hurricane gel applied with a dry gauze for 30–60 seconds or
Hurricane aerosol spray for less than 2 seconds achieves
anesthesia within 15–30 seconds.34 The anesthetic effect lasts
for about 12–15 minutes. Available as a spray and liquid,
cetacaine is a mixture of 14% benzocaine, 2% butyl aminoben­
zoate, and 2% tetracaine hydrochloride that produces rapid
mucosal anesthesia that lasts for approximately 30–60 minutes.33
Benzocaine-containing preparations should be avoided in
infants because of the risk of methemoglobinemia.35
Lidocaine
Lidocaine, available in a 2–5% gel and topical and viscous
solutions, has been used reliably for topical anesthesia on
mucosal surfaces. However, these compounds are formulated
in conventional vehicles that often do not provide adequate
Table 3.6  Common topical anesthetics formulated for mucosal surfaces
ANESTHETIC
TRADE NAME
CONCENTRATION
(%)
VEHICLE
ONSET OF
ACTION
DURATION
OF ACTION
CLINICAL
USE
Cocaine
4, 10
Solution
1–5 minutes
30–60 minutes
Intranasal
Lidocaine
Xylocaine
2–5
Gel, ointment, topical
and viscous solution
1–2 minutes
15–20 minutes
Oral mucosa
Benzocaine
Hurricane
20
Liquid, gel, spray, swab
<5 minutes
15–45 minutes
Oral mucosa
Benzocaine
combination
Cetacaine
*
Spray, liquid
30 seconds
30–60 minutes
Oral mucosa
Proparacaine
Alcaine
0.5
Solution
20 seconds
15–20 minutes
Ophthalmic
Tetracaine
Pontocaine
0.5
Solution
20 seconds
12–20 minutes
Ophthalmic
*Cetacaine contains 14% benzocaine, 2% butyl aminobenzoate, and 2% tetracaine hydrochloride.
Table 3.7  Common topical anesthetics useful for cutaneous surfaces

48
Part 1  Basic Surgical Concepts
branes for up to 45 minutes. A formulation of 0.5% tet­
racaine, 0.05% epinephrine 1 : 2000, and 11.8% cocaine in
normal saline – termed TAC – has been compounded by
pharmacists for over 20 years for anesthesia and vasoconstric­
tion before repairing superficial lacerations, especially in chil­
dren.36 Its limited absorption on intact skin limits its utility
for other cutaneous procedures. One study found EMLA
cream to be superior to TAC solution for anesthesia of lac­
erations on the extremities.43
Concern over the potential systemic absorption of cocaine
led to the substitution of 4% lidocaine for cocaine (LAT
formulations).34 Tetracaine 4% gel in a lecithin gel base (the
lecithin is thought to enhance penetration of the tetracaine)
is available in the US from compounding pharmacies. Studies
are still needed regarding its efficacy and safety compared to
other available compounds.32 One study showed its effective­
ness in reducing laser-induced pain after a 60-minute occlu­
sion period.42
Amethocaine 4% gel, a preparation with 4% tetracaine
currently not approved for use in the US, is marketed in
Europe as a topical anesthetic that provides more rapid
and longer duration of action than EMLA and can be safely
used in children and adults.32 A study comparing 4% ameth­
ocaine and EMLA for pain relief during pulsed-dye laser
treatments found amethocaine superior to EMLA.44 Adverse
events tend to be transient and include erythema, edema, and
pruritus.32
Other topical agents
Other mixed formulations have been reported to provide
effective topical anesthesia, but further studies are required
to determine their clinical benefits in comparison with other
available agents. The S-Caine patch (Endo Pharmaceuticals,
Chadds Ford, PA) contains a 1 : 1 eutectic mixture of lido­
caine and tetracaine coupled with a disposable, oxygen-acti­
vated heating element. The drug delivery system aims at
utilizing controlled heating to facilitate the anesthetic deliv­
ery into the dermis.32 Similarly, containing a eutectic lido­
caine/tetracaine mixture, Pliagis (Galderma, Fort Worth,
Texas) is a cream containing 7% lidocaine and 7% tetracaine
that dries upon exposure to air to form a flexible film that
can be easily removed. The cream, applied to the face for
20–30 minutes, has been shown to provide rapid, safe, and
effective anesthesia for pulsed-dye laser treatments on the
face.45 In this study, side effects were limited to minimal
erythema; no edema or skin blanching was reported. Cur­
rently, the product has been voluntarily removed from the
market by Galderma due to manufacturing problems.
Compounded topical anesthestic mixtures are also com­
monly used, particularly prior to cutaneous laser procedures
and filler injections. Commonly, they contain different com­
binations and amounts of lidocaine, betacaine, and tetracaine.
In general, these are safe and effective; however, care should
be used when applying a product that has not gone under
extensive Food and Drug Administration (FDA) testing.
There are two well-documented deaths of young women
secondary to compounded numbing creams for laser hair
removal. The women applied the creams (10% lidocaine/10%
tetracaine in one case, 6% lidocaine/6% tetracaine in the
other) to their bilateral legs under cellophane prior to driving
to the appointment. They both had seizures en route, fell into
comas, and ultimately died.46
Packaging Act issued by the US Consumer Product Safety
Commission requiring products containing over 5 mg of lido­
caine in a single package to be child resistant. EMLA is avail­
able as a 30 g tube in retail pharmacies and a 5 g tube in the
hospital setting for inpatient use. EMLA is also packaged as
an anesthetic disc, which contains 1 g of EMLA emulsion,
with an active contact surface area approximately 10  cm2.
Generally, a 60-minute application period under an occlusive
dressing, such as Tegaderm (3M Healthcare, St Paul, MN)
or Saran Wrap (Dow Chemical Company, Midland, Michi­
gan), is needed before the procedure; however, this may vary
depending on the location of the treatment. Effective anesthe­
sia after 25 minutes of EMLA application to the face and
after 5–15 minutes on mucosal surfaces has been reported.32
Increased duration of application over 2 hours has been
shown to correspond to enhanced depth of analgesia. The
depth of analgesia after 60 minutes is 3.0 mm and after 120
minutes, 5.0 mm.34 Because of the risk of methemoglobine­
mia associated with prilocaine, EMLA should be used with
caution in infants.36 Alkaline injury to the cornea has been
seen with EMLA, so the use of EMLA close to the eyes
should be avoided.37
LMX
LMX (Ferndale, Michigan; originally named ELA-Max) is a
more recently developed topical anesthetic containing lido­
caine encapsulated in a liposomal delivery system and is avail­
able without a prescription. The liposomal vehicle facilitates
penetration and provides sustained release of the anesthetic.
In addition, liposomes may enhance the anesthetic’s duration
of action by protecting it from metabolic breakdown.32 LMX
5% is labeled as an anorectal cream indicated for the tempo­
rary relief of local discomfort associated with anorectal dis­
orders. It tends to have a faster onset of action; a 30-minute
application time before the procedure is recommended. In
studies comparing EMLA and LMX 5% used for dermatologic
procedures, both were effective in reducing pain; however,
LMX 5% had a longer duration of action.38 It has been used,
without the need for occlusion, to decrease pain induced
during medium-depth chemical peels and laser hair
removal.39,40 Its use on mucosal or conjunctival surfaces is not
recommended because of the risk of increased absorption and
the potential for irritation of the cornea.34 Moderate amounts,
30–60 g, of occluded liposomal 4% cream in adults showed
no signs of clinical or serum toxicity in a study of 8 healthy
adults.41 In a child weighing less than 20 kg, a single applica­
tion of LMX should be limited to an area of less than
100 cm2.32
Topicaine
Topicaine contains 4% lidocaine in a gel microemulsion
vehicle. Released in 1997, it is an over-the-counter product
approved for pain relief of intact skin.32 The recommended
application time is 30–60 minutes under occlusion. One
study demonstrated its effectiveness in providing anesthesia
for laser treatment after 30 minutes of application.42
Tetracaine
Tetracaine, a long-acting ester anesthetic, is available in a
0.5% solution and is used most commonly for ophthalmic
procedures. It can provide anesthesia to the mucous mem­

49
Chapter 3  Anesthesia and Analgesia
to the epidermis.50 These cooling methods provide some
anesthesia and protect against laser-induced epidermal
thermal injury.
Iontophoresis
Iontophoresis has been used as a method of delivering solu­
tions of lidocaine with epinephrine into the skin without the
pain of needle injections. With this system, an electrical
current draws ionically charged drugs into the skin. The dose
is dependent on the total electric charge delivered. It has
been found useful for cutaneous procedures especially in the
pediatric population.51A study comparing iontophoresis of
lidocaine versus EMLA found iontophoresis to be more effec­
tive in achieving anesthesia.52 Disadvantages of iontophoresis
include additional equipment and learning curve, difficulty in
application to certain regional areas, and limited depths of
penetration of the anesthetic.51,52
Pneumatic skin flattening
There is also some evidence that a relatively new technology,
pneumatic skin flattening (PSF), can help reduce pain in laser
hair and tattoo removal, and intense pulsed light procedures.
With this technology, a vacuum pulls the skin taught and
closer to the light source. It is thought that the pneumatic
pressure on the sensory nerves somehow inhibits the trans­
mission of pain impulses.53 Its applications in other cutaneous
procedures is yet to be determined.
Ophthalmic
Ophthalmic solutions provide safe and effective topical
anesthesia to the mucous membranes of the sclera and the
conjunctiva. They are often useful when placing corneal eye­
shields before periocular surgery and laser procedures.
Common topical eye preparations include proparacaine 0.5%,
tetracaine 0.5%, and benoxinate 0.25%. Rapid absorption and
onset of anesthesia occur within 30 seconds after placement
of one to two drops of anesthesia into the conjunctival sac.34
A stinging sensation may be felt upon instillation of the anes­
thetic drops. The anesthetic effect usually lasts 15 minutes
or longer. An eye patch should be placed until the anesthesia
resolves to prevent inadvertent trauma to the cornea.34 One
study49 showed that tetracaine eye drops cause more pain
than proparacaine eye drops, and proparacaine provided
slightly longer duration of anesthesia than tetracaine (10.7 vs
9.2 minutes). For procedures requiring prolonged anesthesia,
instillation of one drop of proparacaine every 10 minutes for
5–7 doses may be used.
Infiltrative techniques
Local infiltration
Local infiltration of anesthesia that involves the injection of
the anesthetic into the surgical site is the most commonly
used technique in cutaneous surgery. This is administered
either intradermally and/or subcutaneously. Intradermal
injection results in an immediate onset and prolonged dura­
tion of anesthesia compared to deeper injections. However,
it tends to cause more tissue distortion and pain. Subcutane­
ous injection of anesthetics produces less tissue distortion and
pain, but has slower onset and duration as a result of diffusion
and increased absorption.
There have been documented cases of systemic toxicity
even when the compounded cream is applied in the office to
a limited area. Marra et  al. described a patient undergoing
fractional photothermolysis who developed toxic levels of
lidocaine in her serum as well as clinical signs of toxicity after
a 1-hour application of a 30% lidocaine gel to her face.47
There are no strict FDA regulations on compounded creams;
however, they have published several warnings and restricted
certain pharmacies from producing ‘stock’ compounded
creams.46 In general, application of the topical anesthetic
agent under experienced physician supervision to limited
body surface area and for a limited duration can minimize
potential complications.
Cryoanesthesia
Applying cold agents to the skin can be useful in reducing the
pain associated with minor surgical procedures. The place­
ment of ice cubes on the skin is a rapid, inexpensive, and easy
method to minimize the discomfort during needle injec­
tions.48 Topical freezing agents or vapocoolants rapidly cool
the skin and provide enough anesthesia for injections or brief
superficial surgical procedures. Held 10–30 cm (4–12 inch)
from the skin, the refrigerant is sprayed toward the lesion
just until the area turns white. Various topical freezing agents
are available (Table 3.8).49 Care should be taken to protect
the eyes and avoid inhalation of vapor when using these
agents. Cryoanesthesia has the potential risks of causing pig­
mentary alterations and scarring. In addition, some vapocool­
ants, such as ethyl chloride, are flammable.49,50 The concern
about the potential harmful effects of the vapocoolants to the
ozone layer led to the ban of production of hard chlorofluor­
ocarbons in 1996, and the development of more ozone-safe
hydrofluorocarbons.49,50
Various cooling methods to the skin are used with several
laser procedures. These include the application of a cooled
gel, a cold glass window, and other contact cooling devices to
the skin being treated. The delivery of refrigerated air onto
the skin, such as Zimmer air cooling, has also been used suc­
cessfully for many dermatologic procedures including frac­
tional photothermolysis and pulsed-dye laser. Some laser
devices are equipped with dichlorodifluoromethane and
tetrafluoroethane cryogen sprays that deliver transient cooling
Table 3.8  Examples of vapocoolants used for cutaneous
local anesthesia
VAPOCOOLANT
INGREDIENTS
Ethyl chloride*† (Gebauer
Company, Cleveland, OH)
50% dichlorodifluoromethane,
50% trichloromonofluoromethane
Instant Cold Spray† (HL Moore,
New Britain, CT)
10% isopentane, 90% butane
Fluoro Ethyl§ (Gebauer
Company, Cleveland, OH)
75% dichlorotetrafluoroethane,
25% ethyl chloride
Fluori-Methane§ (Gebauer
Company, Cleveland, OH)
15% dichlorodifluoromethane,
85% trichloromonofluoromethane
Frigiderm§ (Delasco, Council
Bluffs, IA)
Dichlorotetrafluoroethane
*Flammable; †ozone safe; §manufacture discontinued, but still available.
With permission from Plotkin S. Clinical comparison of preinjection anesthetics.
J Am Podiatr Med Assoc 1998;88:73–79.49

50
Part 1  Basic Surgical Concepts
Although the basic tumescent solution described by Klein56
contains 0.05% lidocaine, the concentrations of lidocaine and
epinephrine can be tailored, depending on the site and nature
of the procedure (Table 3.9). The safe upper limit of lidocaine
dosage with this technique is estimated to be 55  mg/kg.57
Warming of the tumescent solution before infiltration to
104°F (40°C) and slowing the rate of infiltration have been
shown to reduce pain in liposuction patients.58 The tumescent
technique allows procedures to be performed safely with
minimal blood loss without the risks of general anesthesia, and
its prolonged duration of action provides postoperative anal­
gesia.59,60 Although best known for use during liposuction (see
Chapter 27), the tumescent technique is helpful whenever
large areas are to be treated to obtain adequate and safe
Various techniques can diminish the pain and make local
infiltration of anesthesia better tolerated (see Optimizing
Outcomes box, pages 55–6).52 Providing a calm and comfort­
able environment with the patient reclining, and reassuring
the patient, can diminish fear and anxiety as well as the per­
ception of pain. Patients often feel a ‘stick’ and ‘burning’
sensation associated with the entry of the needle into the skin
and the infiltration of the anesthesia. The use of small-diam­
eter needles, such as the 30-gauge needles commonly used in
cutaneous surgery, minimizes the pain associated with the
initial puncture of the skin.20 The application of topical anes­
thetics, ice, or other cooling devices before the initial injec­
tion may be helpful for children and extremely anxious
individuals.48 Warming lidocaine to body temperature may
also help attenuate the pain with infiltration.35 Providing
counter-irritation by pinching the skin around the needle
entry point can diffuse the pain stimulus.20 As multiple needle
punctures can be painful, re-entering at previously anesthe­
tized areas can further reduce discomfort, especially when
working on larger areas.
Tissue distension with infiltration of the anesthetic pro­
duces pain. Injecting slowly and using only the volume neces­
sary to achieve adequate anesthesia can attenuate the pain
associated with tissue distension.20 The use of smaller-diam­
eter needles also lends to a decreased rate of infiltration with
slow tissue distension and less pain. More recently, compu­
ter-controlled injection devices such as the Wand (Milestone
Scientific) have been developed that control the rate of injec­
tion, and limit patient discomfort.54 In addition, various nee­
dle-free devices have been investigated.55 These systems have
been marketed primarily for dentistry, and their practical
utility in decreasing pain during various cutaneous procedures
is yet to be determined.
Field block
Field or ring block involves the placement of anesthesia cir­
cumferentially around the operative site (Fig. 3.2). It is useful
when direct infiltration into the surgical field is undesirable.
Examples include cyst excisions because injection directly
into the cyst can lead to rupture of cystic contents, and
working with inflamed or infected tissue when local infiltra­
tion may not produce as effective anesthesia in an acidic
environment.5 This technique can also minimize the total
amount of anesthetic required, which is beneficial for proce­
dures involving larger areas that would usually require more
anesthesia via local infiltration.20 To obtain optimal anesthesia
using ring blocks, the anesthetic should be injected into the
superficial and deep planes.20
Tumescent anesthesia
The tumescent technique involves the delivery of large
volumes of dilute anesthesia (usually 0.05–0.1% lidocaine
with 1 : 1 000 000 epinephrine) into subcutaneous fat until
the tissue distends. It has been widely used for liposuction;
hence the name tumescent liposuction, in which as much or
more dilute anesthesia is administered as fat is removed (see
Chapter 27). The anesthetic is typically delivered through
0.5–1.5-mm multiport infiltration cannulas or 18–20-gauge
blunt-tipped spinal needles. To administer the large volumes
typically necessary for liposuction, special pumping devices
aid infiltration.
Field or ring block
Figure 3.2  Field or ring block. Anesthetic is injected
circumferentially around the surgical site. This approach is
useful on any part of the body, especially where a regional
nerve block is not an option, and to treat larger areas.
Table 3.9  Klein’s basic tumescent anesthetic solution
COMPONENT
FINAL
CONCENTRATION
AMOUNT ADDED
TO 1 LITER
NORMAL SALINE
Lidocaine
500 mg/L
50 mL of 1% lidocaine
Epinephrine
0.5 mg/L
0.5 mL of 1 : 1 000 000
epinephrine
Sodium
bicarbonate
10 mEq/L
10 mL of 8.5% sodium
bicarbonate
With permission from Klein JA. Anesthetic formulation of tumescent solutions.
Dermatol Clinics 1999;17:751–759.56

51
Chapter 3  Anesthesia and Analgesia
Nerve blocks on the face
Cutaneous branches of the trigeminal nerve and the cervical
plexus convey sensory innervation from the face (Table
3.10).63 The trigeminal nerve has three main branches: the
ophthalmic, maxillary, and mandibular. These convey sensa­
tion from the face, scalp to the vertex, conjunctiva, oral
cavity, and teeth. Bony landmarks on the face help identify
the location of the main trunk of the cutaneous branches of
the trigeminal nerve (Fig. 3.3). The cervical plexus, a network
arising from the anterior rami of the four superior cervical
nerves, innervates the angle of the mandible, the submandib­
ular area, and the neck.62
Supraorbital and supratrochlear nerve
The supraorbital and supratrochlear nerves are branches of
the frontal nerve, which arises from the ophthalmic (V1)
nerve, and innervate the ipsilateral forehead and frontal scalp
to the vertex. The supraorbital nerve emerges from the
supraorbital foramen or notch, which is on the superior
orbital rim in the midpupillary line. The supratrochlear nerve
lies along the upper medial corner of the orbit approximately
1.5 cm medial to the supraorbital notch (see Chapter 1). Both
anesthesia. Examples are endovenous ablation with lasers or
radiofrequency devices, ambulatory phlebectomy, and face
lifting.
Nerve blocks
Knowledge of the anatomic distribution of sensory nerves of
the head, neck, and hands and feet enables one to anesthetize
large areas of skin using a small amount of anesthesia using a
nerve block. The smaller volume of anesthetic required not
only reduces the risk for toxicity but also decreases tissue
distortion at the operative site. If wide undermining is planned
and hemostasis is needed, a more dilute lidocaine with epine­
phrine mixture can be infiltrated painlessly in the field fol­
lowing the block. In general, nerve blocks cause less
discomfort for the patient given the limited number of injec­
tions, especially during a mucosal approach. They can also
avoid the need for additional sedation or general anesthesia.
In dermatologic surgery, nerve blocks are commonly used on
the face and digits, but can be used to anesthetize other areas,
such as the ears, feet, hands, penis, and lateral thigh.
Because of their usefulness in cutaneous surgery, it is impor­
tant to carefully learn the proper technique for peripheral
nerve blocks to minimize potential adverse effects. For optimal
results, administering nerve blocks requires technical skill and
knowledge of local neuroanatomy. Once analgesia is obtained,
an infiltration of vasoconstrictor at the surgical site or use of a
tourniquet is often necessary because nerve blocks do not
usually provide sufficient hemostasis. Risks include direct
nerve injury leading to dysesthesias and paresis as well as
vessel trauma causing ecchymoses and hematoma formation.54
Amide-type anesthetics are most commonly used for nerve
blocks. As smaller volumes are injected, higher concentrations
of anesthetic, such as 2% lidocaine, may be used to enhance
diffusion of the anesthetic around the nerve.54 Vasoconstrictors,
such as epinephrine 1 : 200 000, may be added to the anesthetic
agent. Epinephrine can have the advantages of slowing absorp­
tion of the anesthetic from the injected site, prolonging the
duration of anesthesia, decreasing the amount of anesthetic
needed, and improving hemostasis.61 The use of epinephrine in
digital blocks has been avoided given the potential risk of vaso­
constrictor-induced ischemia; however, some debate this risk as
theoretical when a proper technique is employed.61,62
Nerve blocks involve injecting anesthesia adjacent to a
nerve or within the same fascial compartment as the nerve
to be anesthetized. Typically, a 1-inch 30-gauge needle is
selected; the smaller-caliber needle tends to be less painful
and allows a slower and more controlled delivery of anesthe­
sia.62,63 As vessels tend to travel along sensory nerves, care
must be taken to avoid injecting into a vessel by aspirating
before injection. Some advocate the use of a 25-gauge needle
for nerve blocks because the smaller-caliber needles may be
less reliable in aspirating blood during inadvertent intravascu­
lar placement.6 After the needle is placed into the desired
area, a small volume of anesthetic is injected and allowed to
diffuse around the nerve. One should take caution not to
inject into the nerve itself, which can cause a neuropraxia
resulting in paresthesia in the distribution of the nerve. Rarely
this can be permanent.63 Peripheral nerve blocks require dif­
fusion into larger-sized nerves, and thus require a longer onset
of action than local infiltrative anesthesia. Usually the block
is effective after 5–10 minutes. The duration of anesthesia
depends upon the anesthetic chosen.6
Table 3.10  Useful dermatologic surgery facial nerve blocks
NERVE
DISTRIBUTION
OF SENSORY
INNERVATION
LOCATION OF
EMERGENCE OF
NERVE
Supraorbital
Forehead, frontal
scalp to vertex
Supraorbital notch
– at superior orbital
rim at midpupillary line
(approximately 2.5 cm
from midline)
Supratrochlear
Mid-forehead,
frontal scalp to
vertex
Above eyebrow,
approximately 1 cm
lateral to midline and
1.5 cm medial to
supraorbital nerve
External nasal
Dorsum, tip, and
columella of nose
At junction of upper
lateral cartilage and
nasal bones
Infraorbital
Lower eyelid, nasal
sidewall, upper lip,
medial cheek, upper
teeth, maxillary
gingiva
Infraorbital notch
– midpupillary line,
approximately 1 cm
inferior to lower orbital
rim and superolateral to
nasal ala
Mental
Lower lip and chin
Mid-height of mandible
in midpupillary line,
approximately 1 cm
inferior to second
premolar
Auriculotemporal
Temporal scalp,
anterior auricle,
lateral temple
Just superior to
temporomandibular
joint at zygomatic arch
Greater auricular
and transverse
cervical
Posterior auricle,
angle of mandible,
submandibular area
Posterior margin of
sternocleidomastoid
muscle at its midpoint
(Erb’s point) (see
Chapter 1)
With permission from Eaton JS, Grekin RC. Regional anesthesia of the face. Derma-
tol Surg 2001;27:1006–1009.62

52
Part 1  Basic Surgical Concepts
Mental nerve
The mental nerve, a terminal branch of the mandibular nerve
(V3), can be blocked as it emerges from its foramen located
approximately 2.5 cm lateral to the midline just medial to
the midpupillary line and midway along the vertical height
of the mandibular bone. The position of the foramen can
vary with the age of the patient. Because the mandible atro­
phies at the alveolar ridge with age, the foramen lies closer
to the upper margin of the mandible in older patients
(Fig. 3.5).62
Blocking the mental nerve provides anesthesia to the ipsi­
lateral chin and lower lip, including its adjacent mucosa and
gingiva.62 Like the infraorbital block, this can be approached
by either the percutaneous or intraoral route (see Fig. 3.4).
Using the intraoral route, anesthetic is injected into the infe­
rior labial sulcus between the lower first and second premo­
lars and injecting 1–2 mL just over periosteum.59
Auriculotemporal nerve
Another branch of the mandibular nerve (V3), the auriculo­
temporal nerve, runs deep and posterior to the temporoman­
dibular joint before it emerges superficially to travel with the
superficial temporal artery. Blocking this nerve as it passes
superiorly across the zygomatic arch provides anesthesia to
the ipsilateral anterior auricle, lateral temple, and temporal
scalp. This nerve block can be achieved by palpating for the
temporomandibular joint with the jaw open and injecting
2–3 mL superior to this joint over periosteum at the zygo­
matic arch.62
nerve blocks can be achieved by entering just lateral to the
supraorbital notch in the midpupillary line and injecting
1–2 mL of anesthetic toward the midline.64
External nasal nerve
The external nasal nerve, a branch of the anterior ethmoidal
nerve, emerges from between the lower border of the nasal
bone and the upper lateral nasal cartilage. Anesthesia to the
skin of the ipsilateral nasal dorsum, nasal tip, and columella
can be obtained by injecting approximately 1  mL of anes­
thetic bilaterally just off the midline after palpating for the
junction between the mobile lateral cartilage and the firm
nasal bones.62
Infraorbital nerve
The infraorbital nerve, the largest branch of the maxillary
nerve (V2), emerges from the infraorbital foramen to provide
terminal branches that innervate the ipsilateral lower eyelid,
nasal sidewall and ala, upper lip, and medial cheek. The
infraorbital foramen is just medial to the midpupillary line
approximately 0.7–1 cm below the infraorbital rim. Blocking
the nerve at its point of emergence can be achieved percuta­
neously or intraorally. With the intraoral approach, the needle
is advanced through the gingival buccal sulcus at the apex of
the canine fossa for about 1 cm, at which point 1–2 mL of
anesthetic is injected just over periosteum (Fig. 3.4).62 The
intraoral route tends to be less painful and the use of a topical
mucosal anesthetic on the mucosal surface before injecting
can further decrease the discomfort of the initial needle
stick.6
A
B
C
Supraorbital nerve
Supratrochlear nerve
Infraorbital nerve
Mental nerve
Supraorbital, supratrochlear, infraorbital, and mental nerve block
Figure 3.3  Location and sensory distribution for nerve blocks. (A) Supraorbital and supratrochlear nerve block. (B) Infraorbital nerve
block. (C) Mental nerve block. (For additional information, see Fig. 1.13.)

53
Chapter 3  Anesthesia and Analgesia
Nerve blocks for the extremities
Nerve blocks are useful for procedures involving the digits
and wider surface areas of the palms and soles.
Digital block
Digital nerve blocks are useful for procedures involving the
nails and phalanges. Two dorsal and two ventral nerves lie
along the lateral aspects of the digits and innervate each digit
(Fig. 3.7). Placement of anesthetic around these nerves at the
base of the digits anesthetizes the finger. The addition of
epinephrine in digital blocks has generally not been recom­
mended because of the risk of vascular compromise. Control­
lable vasoconstriction to achieve an avascular surgical field can
be safely achieved with the proper use of a tourniquet.28
The dorsal approach tends to be less painful than entering
from the palmar or plantar surface (see Fig. 3.7).28 The needle
is placed into the web space at the dorsolateral aspect of the
finger and the anesthetic is slowly deposited. The needle is
partially withdrawn and redirected to deliver anesthesia to
the dorsoventral aspects of the digit. The procedure is
repeated on the opposite side of the digit. A total volume
of 1–3  mL of 2% lidocaine typically provides adequate
anesthesia.28
Although complications from digital blocks are unusual,
care must be taken to avoid digital ischemia. Various factors
that have been reported to contribute to digital gangrene
Greater auricular and transverse
cervical nerves
The greater auricular and the transverse cervical nerves arise
from the cervical plexus and emerge near the midpoint of the
posterior border of the sternocleidomastoid muscle, also
known as Erb’s point (Fig. 3.6). The greater auricular nerve
passes upward toward the ear along the external jugular vein
and innervates the ipsilateral angle of the jaw to the sub­
mandibular area and the posterior auricle.64 Arising approxi­
mately 1  cm inferior to the greater auricular nerve, the
transverse cervical nerve heads in the anterior direction to
provide sensory innervation to the ipsilateral inferior central
border of the mandible and anterior neck. Turning the head
at 45° against resistance to accentuate the landmarks and
injecting into Erb’s point will block both nerves.62
A
B
Intraoral route for blocking
infraorbital and mental nerves
Figure 3.4  Intraoral route for blocking (A) infraorbital and (B)
mental nerves.
Adult
Child
Elderly
Mental foramen
Changing location of mental foramen with age
Figure 3.5  Changing location of the mental foramen with age.
(For additional information, see Fig. 25.3D.)

54
Part 1  Basic Surgical Concepts
of the palmaris tendon and under the flexor retinaculum at
the proximal crease of the wrist crease will block the median
nerve and provide anesthesia to most of the radial side of the
palm.66,67
The ulnar nerve runs beneath the flexor carpi ulnaris tendon
and its insertion into the pisiform bone.67 Flexing the wrist
in a slightly ulnar direction helps identify the flexor carpi
ulnaris tendon.67 Inserting a needle just radial to this tendon
on the proximal crease of the wrist at the ulnar styloid process
and injecting 3–5 mL of anesthetic in the tissue blocks the
ulnar nerve.66,67
The radial nerve lies on the lateral border of the radius just
dorsal to the radial styloid.62 Blocking the superficial branch
of the radial nerve provides anesthesia to the palmar surface
of the thumb.66 Radial nerve block can be attained by infiltrat­
ing 4–6 mL of anesthetic in the area lateral to the radial artery
extending toward the dorsum of the wrist.66 Suboptimal
anesthesia in this area may occur as a result of anatomic
variation of sensory innervation.67
Ankle blocks
Five nerves provide sensory innervation to the foot: four are
derived from the sciatic nerve (the tibial, the superficial and
deep peroneal nerves, and the sural nerve) and one from the
include epinephrine, ring block technique (circumferential
anesthesia), excessive tourniquet pressure, and postoperative
burns from hot soaks to anesthetized fingers.65 Epinephrine
should be avoided in patients with severe hypertension,
peripheral vascular and vasospastic disease, and connective
tissue disease.65 The pressure from the injection of excessive
volumes (more than 8 mL) of anesthetic can also compromise
the vascular circulation.6 Digital blocks should be avoided in
situations that potentially compromise the digital vessels at
the base of the proximal phalanx (i.e. trauma or infection).66
Wrist blocks
Anesthesia to the hand can be achieved by blocking selected
nerves at the wrist level. Wrist blocks are particularly useful
for dermatologic procedures on the palm when multiple
injections can be quite painful. The median and ulnar nerves,
and superficial branch of the radial nerve, provide sensory
innervation to the palm (Fig. 3.8).66
The median nerve is located in the midline of the volar side
of the wrist between the palmaris longus tendon and the
flexor carpi radialis tendon.67 Having the patient place the
thumb and last two digits together accentuates the palmaris
longus tendon, which is almost universally present (Fig.
3.9).59 Injecting 3–5 mL of anesthetic just to the radial side
Sternocleidomastoid
Erb's point
External jugular vein
Greater auricular
nerve
Transverse cervical nerve
Greater auricular and transverse cervical nerves
Figure 3.6  Nerve block of
the greater auricular nerve
and transverse cervical
nerve as they emerge at
the midpoint of the
posterior border of the
sternocleidomastoid muscle,
Erb’s point. (For additional
information, see Fig. 1.33.)

55
Chapter 3  Anesthesia and Analgesia
cutaneously anterior to the medial malleolus, and extends
toward the medial surface of the foot.58 Injecting 3–4 mL of
anesthetic into the subcutaneous tissue medial to the saphe­
nous vein and anterior to the medial malleolus blocks the
saphenous nerve.63
The superficial peroneal nerve, a branch of the common
peroneal nerve, travels along the anterolateral border of the
calf. It arises subcutaneously above the ankle where it divides
into its branches, the intermediate and medial dorsal cutane­
ous nerves, before entering the foot.62 Blocking the superficial
peroneal nerve by injecting 3–4  mL of anesthetic into the
subcutaneous tissue midway between the anterior tibial
surface and the lateral malleolus provides anesthesia to a
major surface of the dorsal foot.63
The deep peroneal nerve supplies a small portion of the
foot, the first web space. The deep peroneal nerve block is
rarely necessary in cutaneous surgery because anesthesia to
this area can be adequately achieved by local infiltration.
 OPTIMIZING OUTCOMES
femoral nerve (the saphenous nerve) (Fig. 3.10).64 The pos­
terior tibial nerve innervates the plantar surface except for
small areas on the lateral and medial aspects, which are sup­
plied by the sural and saphenous nerves, respectively. The
superficial peroneal, sural, saphenous, and deep peroneal
nerves innervate the dorsum of the foot. To achieve a periph­
eral nerve block of the feet requires that the particular nerve
trunks be accessed at the level of the ankle. Blocking all five
nerves (Fig. 3.11) can be performed with the patient supine
and the foot placed on a padded support; however, some
prefer to block the posterior tibial and sural nerves with the
patient prone.
At the ankle, the posterior tibial nerve passes posterior to
the posterior tibial artery between the calcaneal tendon and
the medial malleolus and travels distally deep to the flexor
reticulatum.63 The posterior tibial nerve can be accessed with
the patient supine and with the foot extended and externally
rotated.66 A needle is placed at the level of the upper half of
the medial malleolus, posterior to the posterior tibial artery
pulse and anterior to the calcaneal tendon.63 The needle is
advanced toward the posterior tibia, withdrawn slightly, and
3–4 mL of anesthetic is injected.63
The sural nerve, arising from branches of the common
saphenous and tibial nerves, passes more superficially between
the Achilles tendon and the lateral malleolus as it travels
toward the lateral border of the foot.58 The sural nerve block
is performed with the patient prone.63 A needle is inserted
1–1.5 cm distal to the tip of the lateral malleolus and 3–5 mL
of anesthetic is injected.68
The saphenous nerve, a terminal branch of the femoral
nerve, runs along the medial surface of the calf, passes sub­
A
B
Dorsal digital nerve
Dorsal digital artery
Palmar digital nerve
Palmar digital artery
Paired dorsal digital nerves and arteries
Paired palmar digital nerves and arteries
Digital innervation and nerve block
Figure 3.7  The digit.
(A) Dorsal and palmar
digital arteries and nerves
run together. (B) Dorsal
approach in administering
digital nerve block allows
anesthesia of dorsal and
palmar bundles with one
puncture.
Optimizing outcomes
Techniques to minimize discomfort during the administration of
local anesthesia:
 Reassure the patient.
 Position the patient with head supported, leaning back in a
chair or on the table.
 Use small-diameter (30-gauge) needles.
 Minimize patient viewing of needle and injection.

56
Part 1  Basic Surgical Concepts
Local anesthetics are generally easy and safe to administer;
however, they can cause local and systemic adverse reactions.
Local reactions can occur regionally around the site of admin­
istration. These commonly result from improper technique
or the addition of epinephrine. Allergic reactions to local
amide anesthetics are rare.69 Although idiosyncratic systemic
toxicity can occur at low plasma levels of local anesthetics,
most systemic signs of toxicity are present at increased plasma
levels.69 Systemic toxicity due to local anesthetics primarily
affects the central nervous and cardiovascular systems.
Methemoglobinemia can occur particularly in predisposed
individuals.
Local adverse effects
Regional reactions associated with local anesthetics are often
due to the technique of administration of the agent or the
addition of epinephrine. Tenderness, ecchymoses, and
hematoma can occur, but are seldom of consequence. Epine­
phrine, when added to local anesthetics for its vasoconstric­
tive properties, has been implicated in tissue necrosis,
particularly of the digits.61 Patients with hypertension,
peripheral vascular disease, and vasospastic disease are at
increased risk.61,65 For this reason, it is generally recom­
mended to avoid local anesthetic infiltration of epinephrine-
containing solutions to the fingers and toes. Digital ischemia
A
B
Ulnar nerve
Ulnar nerve
Median nerve
Median nerve
Superficial branch
of radial nerve
Superficial branch
of radial nerve
Ulnar artery
Flexor carpi
radialis tendon
Abductor pollicis
longus tendon
Extensor pollicis
brevis tendon
Palmaris longus tendon
Flexor carpi
ulnaris tendon
Radial artery
Palmar innervation and wrist nerve block
Figure 3.8  The palm. (A) Sensory innervation; (B) nerve blocks
at the wrist.
Pitfalls and their management
 Prevention of digital injury associated with local anesthesia:
n avoid the use of epinephrine especially in patients with
peripheral vascular disease
n use small needles (30-gauge) to avoid vessel injury
n limit volume of anesthetic used to 1–2 mL
n avoid circumferential block of the digits
n block at the level of the metacarpal heads
n do not use digital block if there is infection or trauma of the
proximal phalanx (distal to the injection site)
n ensure bandages are not too constrictive
n counsel patients to avoid postoperative hot soaks.
 Prevention of allergic reactions to lidocaine:
n obtain thorough drug, surgical, and past allergy history
n refer for allergy testing to confirm diagnosis and test for
alternative agents
n use preservative-free solution if paraben allergy present
n use alternative agents when true lidocaine allergy noted:
amide anesthetic, benzyl alcohol, diphenhydramine, or
normal saline (the anesthetic effect of 0.9% saline results
from tissue distention and pressure on nerve endings as
well as the presence of benzyl alcohol preservative)
n consider using conscious sedation or general anesthesia if
concerned that local anesthesia may be inadequate.
 Prevention of methemoglobinemia associated with local
anesthesia:
n adhere to recommended anesthetic dosages
n avoid using prilocaine and benzocaine in patients with risk
factors: age < 3 months; hereditary methemoglobinemia;
glucose-6-phosphate dehydrogenase deficiency;
concomitant oxidant drugs such as dapsone, nitroglycerin,
nitrites, nitrates, phenacetin, primaquine, sulfonamides.
 PITFALLS AND THEIR MANAGEMENT
Optimizing outcomes—cont’d
 Add sodium bicarbonate to neutralize pre-mixed epinephrine-
containing solutions (and use within 24 hours to minimize
loss of vasoconstrictor effect of epinephrine).
 Warm the anesthetic solution.
 Use counter-irritation of adjacent skin.
 Inject and infiltrate anesthetic slowly, deep to more
superficial.
 Use adequate volume of anesthetic only: too much increases
risk of toxicity; too little increases patient discomfort and
bleeding.
 Minimize the number of skin punctures.
 Re-introduce needle at previously anesthetized areas.
 Consider using topical agents (anesthetics, ice, gentle
cryotherapy) before injecting in children and extremely
anxious patients.
 Consider using field or nerve blocks for larger areas.
 Avoid injecting into the nerve during nerve blocks.
 When treating a small child, it may be comforting to parent
and child to enlist the parent’s support in stabilizing the
patient. Consider conscious sedation or general
anesthesia.

57
Chapter 3  Anesthesia and Analgesia
to the eye have been reported with the use of EMLA near
the eyes.37 These manifest as corneal abrasions and ulcera­
tions and require immediate ophthalmologic evaluation and
management.
Accidental thermal burns postoperatively have also been
associated with local anesthesia. Although longer duration of
anesthetic action provides postoperative analgesia, it also
places individuals at risk for accidental thermal burns. Reports
of thermal and cigarette burns to anesthetized areas have
been reported after digital blocks and tumescent liposuc­
tion.72,73 Counseling patients on the duration of anesthesia
before discharge should avoid this potential complication.
Systemic adverse effects
Life-threatening allergic reactions to local anesthetics are
rare.69 Psychogenic attacks and epinephrine reactions should
be differentiated from true allergic reactions.4 Psychogenic
attacks, which frequently manifest as vasovagal episodes,
occur as a result of patients’ response to anxiety, fear of
needles, and/or pain of injection. Increased parasympathetic
can also occur after ring blocks and injection of excessive
volumes of anesthesia even without the addition of epine­
phrine.65,70 Local injections of phentolamine 0.5 mg/mL and
topical application of nitroglycerin have been used to reverse
epinephrine-induced digital vasospasm.61,70 Phentolamine is
an α-adrenergic blocker that competitively blocks both pre­
synaptic (α-2) and postsynaptic (α-1) receptors, producing
vasodilatation and a decrease in peripheral resistance. It is
available in a 5-mg powder and can be diluted in normal
saline.
Paresthesias due to nerve injury can occur, particularly with
peripheral nerve blocks. Nerve injury may result from transec­
tion of the nerve, pressure-induced ischemic injury with
intraneural injection, vascular compromise by injury to local
vasculature, or direct toxicity of injected agents.71 Acute pain
or paresthesias on injection of local anesthetic can signify
intraneural injection and should be avoided.
Inadvertent thermal and chemical burns have been associ­
ated with the use of local anesthetics. To allow for adequate
penetration, EMLA is formulated in an alkaline vehicle
with a pH of approximately 9.4. Alkaline chemical injuries
A
B
C
Flexor carpi
radialis tendon
Radial artery
Median nerve
Flexor carpi
radialis tendon
Proximal wrist crease
Flexor carpi
ulnaris tendon
Flexor carpi
ulnaris tendon
Ulnar artery
Ulnar nerve
Palmaris longus
tendon
Palmaris longus
tendon
Flexor carpi
ulnaris tendon
Palmaris longus
tendon
Flexor carpi
radialis tendon
Landmarks for median and ulnar nerve
Figure 3.9  Landmarks for median and ulnar nerve blocks. (A) The median nerve lies between the palmaris longus tendon and the
flexor carpi radialis tendon. The ulnar nerve runs beneath the flexor carpi ulnaris tendon and its insertion into the pisiform bone.
(B) The tendons can be easily visualized and palpated. (C) Nerve blocks are delivered by insertion of needles at the proximal crease
of the wrist.

58
Part 1  Basic Surgical Concepts
allergen. Cross-reactivity may occur among ester-type anes­
thetics, paraphenylenediamine hair dyes, sulfonylureas, and
thiazides.12 However, there is no cross-reactivity between
esters and amide anesthetics. Methylparaben, an allergen
chemically related to PABA, is a preservative added to anes­
thetics. Reactions to lidocaine may be due to these preserva­
tives and not to the anesthetic itself.69
Mild allergic reactions can be treated with antihistamines
and corticosteroids. Management of anaphylactic reactions
includes the administration of 0.3–0.5-mg epinephrine sub­
cutaneously, basic life support, and transport to an acute care
facility.75
Although uncommon, delayed-type hypersensitivity from
the topical use of ester and amide anesthetics has been
reported. Multiple exposures to increasingly popular over-
the-counter products containing lidocaine may contribute to
topical sensitization to lidocaine.76
There are no specific recommendations on the most reliable
method of testing for suspected allergy to anesthetics.74 The
possibility of reaction to preservatives should be considered.
If there is a clear history of procaine or PABA sensitivity, the
use of preservative-free lidocaine is recommended.74 The use
of patch testing and intradermal skin testing with preserva­
tive-free lidocaine has been suggested as a rational approach.74,76
An alternative in dealing with anesthetic allergy is the use of
other agents for local anesthesia. Benzyl alcohol 0.9%, diphen­
hydramine 1%, and 0.9% saline (which contains benzyl
alcohol) have been used to provide anesthesia for minor cuta­
neous procedures.20,77,78 However, the depth and duration of
anesthesia have been shown to be less with diphenhydramine
and benzyl alcohol compared to lidocaine.77,78 In addition,
diphenhydramine induced more pain than lidocaine,77 caused
tone caused by the stress of injection leads to lightheaded­
ness, diaphoresis, nausea, syncope, bradycardia, and hypoten­
sion. Reassurance and positioning the patient in the
Trendelenburg position typically relieves the patient’s symp­
toms. Symptoms of flushing, palpitations, and malaise related
to the adrenergic effects of epinephrine may be mistaken for
an allergic reaction. Although tachycardia is typically present
in both an epinephrine reaction and an anaphylactic reaction,
blood pressure tends to be elevated with the former and
decreased during anaphylaxis.
The addition of epinephrine poses a risk for potential
adverse reactions in certain clinical settings. Caution should
be taken in using epinephrine in patients taking tricyclic anti­
depressants and β-blockers. The interaction of tricyclic anti­
depressants and epinephrine may lead to hypertension,
tachycardia, and arrythmias.12 Injection of epinephrine-con­
taining anesthetic has been reported to cause hypertension
followed by bradycardia in patients taking propanolol.12 This
is likely a result of unopposed α-adrenergic vasoconstriction.
Epinephrine should be avoided in patients with hyperthy­
roidism, severe hypertension, and pheochromocytoma.
Several reports of allergic reactions, ranging from contact
dermatitis to anaphylaxis, have been described.74 Allergic
reactions occur more commonly with ester derivatives than
amides. Esters are metabolized to PABA, which is a potential
Saphenous nerve
Superficial
fibular nerve
Deep fibular nerve
Sural nerve
Lateral plantar
nerve
Medial plantar
nerve
Sural nerve
Tibial nerve
Saphenous nerve
Sensory innervation of the foot
Figure 3.10  Sensory innervation of the foot.
Extensor hallucis
longus tendon
Anterior tibial artery
Posterior
tibial artery
Posterior tibial nerve
Sural nerve
Fibula
Superficial
peroneal
nerve
Achilles tendon
Deep peroneal nerve
Tibia
Great
saphenous vein
Saphenous
nerve
Ankle block
Figure 3.11  The ankle block. Transverse section of the right
leg above the malleoli to show the location of the sensory
nerves – the sural, superficial peroneal, posterior tibial, and
saphenous nerves.

59
Chapter 3  Anesthesia and Analgesia
Table 3.11  Maximum lidocaine dosages
WITHOUT EPINEPHRINE
WITH EPINEPHRINE
Adults
5 mg/kg
7 mg/kg
Children
1.5–2.0 mg/kg
3.0–4.5 mg/kg
occur until plasma concentrations approach 10  mg/mL.69
Increasing blood levels lead to coma and respiratory arrest.69
Local anesthetics can affect the cardiovascular system.
Transient reactions can occur when using solutions containing
epinephrine. These include tachycardia, diaphoresis, tremor,
headache, elevated blood pressure, and chest pain. Slow
injections and careful aspirations to avoid intravascular injec­
tion prevent rapid systemic absorption of epinephrine. In
healthy patients, increased blood pressure and arrhythmias
do not usually occur if the dose of epinephrine is limited to
0.5 mg (50 mL of 1 : 100 000 dilution).12 However, patients
with underlying systemic diseases, such as hyperthyroidism,
cardiac disease, peripheral vascular disease, and pheochromo­
cytoma, as well as those with anxiety disorder may be more
sensitive to epinephrine.6 The maximum epinephrine dose
recommended for such patients is 0.2 mg.12
Higher toxic blood levels of anesthetics such as lidocaine
lead to vasodilatation, hypotension, and bradycardia, which
progress to cardiovascular collapse and cardiac arrest. Signs
of cardiovascular compromise usually do not manifest until
after signs of central nervous system toxicity.83 Anesthetic
potency directly correlates to the degree of myocardial
depression. More potent anesthetics, such as bupivacaine and
etidocaine, appear to be more cardiotoxic than other anes­
thetics.83 Furthermore, because bupivacaine enters the
sodium channel rapidly, but leaves it slowly, it has a greater
potential to induce serious re-entrant arrhythmias that may
be refractory to treatment.83 The cardiac toxicity of bupi­
vacaine can be more severe during pregnancy, which may be
due to increased progesterone and the adverse effects of
pregnancy on venous return during resuscitation.4
Early recognition of anesthetic toxicity can lead to proper
and timely management. Initial management of allergic and
toxic reactions includes halting the delivery of the anesthetic
and maintaining ventilation and oxygenation. Hypoxia and
acidosis decrease the seizure threshold and contribute to the
cardiodepressant effects of local anesthetics.83 Seizures can
be treated and potentially prevented with thiopental sodium,
diazepam, or propofol.83 Neuromuscular blocking agents such
as succinylcholine may be needed to aid in intubation.83
Hypotension is treated by the administration of fluids; pro­
found hypotension may require vasopressors, such as epine­
phrine, ephedrine, or phenylephrine. Bradycardia and
decreased myocardial contractility may require inotropic
agents, such as epinephrine or ephedrine.77 Bretyllium is used
to treat recalcitrant dysrhythmias. Amrinone can be used
Table 3.12  Lidocaine levels and symptoms of toxicity
LIDOCAINE LEVEL
(mg/ml)
SYMPTOMS OF TOXICITY
1–6
Subjective toxicity: lightheadedness,
euphoria, tongue and circumoral
paresthesia, tinnitus, blurred vision
5–9
Objective toxicity: vomiting, tremors,
muscular fasciculations
8–12
Seizures, cardiopulmonary depression
12–20
Coma, respiratory and cardiac arrest
With permission from Faccenda KA, Finucane BT. Complications of regional an-
esthesia. Incidence and prevention. Drug Saf 2001;24:413–44269 and McCaughey
W. Adverse effects of local anesthetics. Drug Saf 1992;7:178–189.74
skin necrosis in one patient,78 and can potentially be sedating.
Intradermal tramadol and metoclopramide have also been
shown to have local anesthetic properties.79,80 Intradermal
tramadol 5% provided loss of sensation to pinprick, cold, and
light touch 30 minutes after intradermal injection.81 In a
study comparing intradermal 5% tramadol to prilocaine, both
provided similar local anesthetic effect, but tramadol had
significantly increased incidence of local rash at the injection
site.80 Because alternatives to local anesthetics are not ideal,
referral for allergy testing to rule out a true allergy or to
identify a safe anesthetic is recommended.
Systemic toxicity affecting the central nervous and cardio­
vascular systems occurs with higher blood levels resulting
from inadvertent intravascular injection, administering excess
amounts, rapid drug absorption, and abnormal drug metabo­
lism (Table 3.11).69 Delivering anesthesia to a vascular area
results in an increased rate of absorption.69 Rapid absorption
typically also occurs in the mucous membranes. Abnormal
drug metabolism can occur in conjunction with liver disease,
pseudocholinesterase deficiency, and interactions with other
medications.82,83 Amide-type anesthetics are metabolized by
microsomal enzymes in the liver, specifically cytochrome
p450–3A4. Concurrent use of medications that inhibit cyto­
chrome p450–3A4 can potentially result in systemic toxicity,
especially when larger amounts of anesthetics are used
(Box 3.1).83
Signs of central nervous system toxicity to local anesthet­
ics manifest in a concentration-dependent manner (Table
3.12).69,74 Early symptoms of lidocaine toxicity include
drowsiness and circumoral paresthesia. This can progress to
lightheadedness, restlessness, and irritability.74 At higher con­
centrations, muscle twitching, nystagmus, blurred vision, and
confusion appear; seizures and cardiac toxicity do not usually
Box 3.1  Cytochrome p450–3A4 inhibitors
Amiodarone
Benzodiazepines
(midazolam, triazolam)
Carbamazepine
Cimetidine
Clarithromycin
Chloramphenicol
Cyclosporine
Danazol
Dexamethasone
Diltiazem
Erythromycin
Fluconazole
Itraconazole
Isoniazid
Ketoconazole
Methadone
Methylprednisolone
Metronidazole
Miconazole
Nicardipine
Nifedipine
Pentoxifylline
Propofol
Propranolol
Quinidine
Selective serotonin reuptake
inhibitors
Tetracycline
Terfenadine
Thyroxine
Verapamil
Valproic acid
Verapamil

60
Part 1  Basic Surgical Concepts
gested in jaundiced neonates.28 Lastly, given the risk of lido­
caine toxicity and methemoglobinemia, the quantity of
topical anesthetics should be limited to established recom­
mendations (Table 3.13).85
Preoperative and postoperative anesthesia
and analgesia
Perioperative anesthesia and analgesia may be necessary when
performing cutaneous surgical and laser procedures, depend­
ing on the type of procedure and pain tolerance of the patient.
Preoperative discussion regarding the procedure between the
treating physician and patient can alleviate the patient’s
anxiety. However, in particularly anxious patients it is often
helpful to offer preoperative medications to reduce the pain
and anxiety of the patient and to allow for ease of the pro­
cedure for the physician. Benzodiazepines such as diazepam
(2–5 mg) and lorazepam (1–2 mg) are effective anxiolytics.
Analgesic agents such as hydrocodone and oxycodone can be
used prior to procedures as well to increase sedation and to
decrease the pain of the procedure. If any of these agents are
used, consent for the procedure should be obtained prior to
ingestion.
For more extensive anesthesia, such as conscious sedation,
the patient should be placed on monitoring equipment and
resuscitation equipment made available. Intravenous mida­
zolam, diazepam, propofol, and fentanyl are commonly used
agents. Certain circumstances may require general anesthesia
and closer monitoring, thus an anesthesiologist should be
present to administer the medications and monitor the
patient.
Postoperatively, most patients do not need potent analgesic
medication after minor cutaneous procedures. If the patient
does experience discomfort after the procedure, acetami­
nophen or ibuprofen can be used. For more extensive proce­
dures, such as large excisions, ablative laser procedures, and
liposuction, patients may require postoperative analgesia.
Common medications used are oral hydrocodone or oxyco­
done, or intramuscular meperidine given at the time of the
procedure. In addition, longer-acting local anesthestics such
as bupivacaine can be administered at the time of the proce­
dure to give 4–8 hours of local postoperative anesthesia.
 PRACTICAL APPLICATIONS
Local anesthesia for most cutaneous surgery is generally
achieved easily and effectively by local infiltration using 1%
lidocaine with or without epinephrine. When longer proce­
dures are anticipated, longer-acting anesthetics, such as bupi­
when conventional inotropes are ineffective.83 Amrinone is a
phosphodiesterase inhibitor that leads to increased cAMP in
the myocardium and enhanced cardiac contractility. Naguib
et al.83 describe a detailed algorithm showing the treatment
of local anesthetic-induced acute cardiovascular toxicity and
seizures.
Methemoglobinemia, the presence of increased hemoglobin
in the oxidized state instead of the oxygen-carrying reduced
state, can occur following the use of local anesthetics.84 Ben­
zocaine and prilocaine are local anesthetics most commonly
associated with clinically significant methemoglobinemia.
Several reported cases have occurred in infants or young chil­
dren after the topical use of benzocaine to mucosal surfaces,
and more recently after the application of EMLA to the skin.83
Infants and children are at greater risk than adults because
hemoglobin F is more susceptible to oxidation, newborns have
lower levels of reductive enzymes, and the dose tends to be
greater per kilogram of body weight.83 Limiting use to recom­
mended dosages tends to avoid problems; however, suscepti­
bility may increase with glucose-6-phosphate dehydrogenase
deficiency, rare and methemoglobin reductase deficiency, and
concomitant administration of other methemoglobin-forming
drugs, such as sulfonamides and antimalarials.75
Methemoglobinemia presents with a cyanotic appearance
in the skin, lips, and nail beds at methemoglobin levels of
10–20%.75 In addition to the drug history, the presence of
cyanosis without cardiorespiratory disease suggests a diagno­
sis of methemoglobinemia.84 Symptoms frequently do not
occur for 1–3 hours following treatment because methemo­
globinemia is caused by metabolites of the anesthetic.75 Con­
ventional pulse oximeters are usually unreliable in the
presence of methemoglobinemia; therefore arterial blood
gases and methemoglobin levels are recommended.82 Man­
agement depends on the level of toxicity. Methemoglobine­
mia with a level below 30% can usually be managed by
removal of the causative drug, oxygen, and observation.75
Higher levels may need intravenous methylene blue 1–2 mg/
kg as a 1% solution. Methylene blue is contraindicated in
patients with glucose-6-phosphate deficiency. Ascorbic acid
300–1000  mg/day intravenously in three to four doses is
recommended in these patients.84 Hemodialysis may be con­
sidered if symptoms persist.84
Special precautions should be taken when using local anes­
thetics in children. Recommended maximum dosages of lido­
caine for children over 3 years of age are 1.5–2.0 mg/kg for
lidocaine without epinephrine and 3.0–4.5  mg/kg for lido­
caine with epinephrine.85 Because parabens potentially can
displace bilirubin by competitively binding to albumin, the
use of preservative-free anesthetic solutions has been sug­
Table 3.14  Recommended use of EMLA

61
Chapter 3  Anesthesia and Analgesia
anesthesia after using EMLA.35 Topical anesthetics are useful
in minimizing the pain associated with superficial surgical
procedures, laser procedures, filler injections, and chemical
peels. In addition, topical anesthetics are particularly helpful
in performing superficial cutaneous procedures in children.
They also decrease the pain associated with the introduction
of a needle for infiltrative or nerve block administration of
anesthesia.
A combination of the above techniques can be employed
in cutaneous surgical procedures to achieve optimal anesthe­
sia and obviate the need for general anesthesia. Under certain
circumstances, conscious sedation and general anesthesia may
be necessary and must be assessed on a case-by-case basis.
 SUMMARY
The use of local anesthesia is ideal for most cutaneous surgi­
cal procedures. Knowledge of the pharmacologic properties,
potential adverse effects, and different applications and tech­
niques of administration is crucial to the practice of cutane­
ous surgery. With proper use, the available anesthetic agents
provide safe and effective anesthesia and analgesia. Although
local infiltration remains the most commonly used method,
other techniques of drug delivery have expanded the use of
local anesthetics in the field of dermatologic surgery. The use
of nerve blocks, tumescent technique, and topically effective
agents, alone or in combination, has provided optimal regional
anesthesia without the risks of general anesthesia. As the use
of local anesthesia broadens with the emergence of new laser
technology and new surgical techniques, the impetus will
hopefully be present to develop novel agents and delivery
systems with even greater safety, efficacy, and ease of admin­
istration profiles.
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using 30-gauge, 1/2- or 1-inch needles. Larger-diameter
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limited to mucosal surfaces. The development of EMLA and
newer topical agents has extended their application to cuta­
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be applied appropriately for the recommended duration
before the procedure. Insufficient volume and incorrect
application were often found to be the causes of inadequate

62
Part 1  Basic Surgical Concepts
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Cutaneous surgery. Philadelphia: WB Saunders 1994; 105–110.
29. Klein JA. Pharmacology of lidocaine. In: Klein JA. Tumescent technique,
tumescent anesthesia and microcannular liposuction. St Louis: Mosby
2000; 127.
30. Galindo A, Witcher T. Mixtures of local anesthetics: bupivacaine–chlo­
roprocaine. Anesth Analg 1980;59:683–685.
31. Adriani J, Dalili H. Penetration of local anesthetics through epithelial
barriers. Anesth Analg 1971:50:834–841.
32. Friedman PM, Mafong EA, Friedman BS, et al. Topical anesthetics
update: EMLA and beyond. Dermatol Surg 2001;27:1019–1026.
33. Latorre F, Klimek L. Does cocaine still have a role in nasal surgery? Drug
Saf 1999;20:9.
34. Huang W, Vidimos A. Topical anesthetics in dermatology. J Am Acad
Dermatol 2000;43:286–298.
35. Chen BK, Eichenfield L. Pediatric anesthesia in dermatologic surgery:
when hand-holding is not enough. Dermatol Surg 2001;27:1010–
1018.
36. Rincon E, Baker RL, Iglesias AJ, et al. CNS toxicity after topical applica­
tion of EMLA cream on a toddler with molluscum contagiosum. Pediatr
Emerg Care 2000;16:252–254.
37. Eaglstein NF. Chemical injury to the eye from EMLA cream during
erbium laser resurfacing. Dermatol Surg 1999;25:590–591.
38. Bucalo BD, Mirikitani EJ, Moy RL. Comparison of skin anesthetic effect
of liposomal lidocaine, nonliposomal lidocaine and EMLA using 30-minute
application time. Dermatol Surg 1998;24:537–541.
39. Altman DA, Gildenberg SR. High-energy pulsed light source hair removal
device used to evaluate the onset of action of a new topical anesthetic.
Dermatol Surg 1999;25:816–818.
40. Koppel RA, Coleman KM, Coleman WP. The efficacy of ELMA versus
ELA-Mac for pain relief in medium-depth peeling: a clinical and his­
topathologic evaluation. Dermatol Surg 2000;26:61–64.
41. Nestor MS. Safety of occluded 4% liposomal lidocaine cream. J Drugs
Dermatol 2006;5:618–620.
42. Friedman PM, Fogelman JP, Nouri K, et al. Comparative study of
the efficacy of four topical anesthetics. Dermatol Surg 1999;25:
950–954.
43. Zempski WT, Karasic RB. EMLA versus TAC for topical anesthesia
of extremity wounds in children. Ann Emerg Med 1997;30:163–166.
44. McCafferty DF, Woolfson AD, Handley J, et al. Effect of percutaneous
local anaesthetics on pain reduction during pulsed dye laser treatment of
portwine stain. Br J Anaesth 1997;78:286–289.
45. Bryan HA, Alter TS. The S-caine peel: a novel topical anesthetic for
cutaneous laser surgery. Dermatol Surg 2002;28:999–1003.
46. Kaweski S. Plastic Surgery Educational Foundation Technology Assess­
ment Committee. Topical anesthetic creams. Plast Reconstr Surg
2008;121:2161–2165.
47. Marra DR, Yip D, Fincher RF, et al. Systemic toxicity from topically
applied lidocaine in conjunction with fractional photothermolysis. Arch
Dermatol 2006;142:1042–1046.

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Chapter 3  Anesthesia and Analgesia
82. Klein JA, Kassarjdian N. Lidocaine toxicity with tumescent liposuction.
A case report of probable drug interactions. Dermatol Surg 1997;23:
1169–1174.
83. Naguib M, Magboul MM, Samarkandi AH, et al. Adverse effects and drug
interactions associated with local and regional anesthesia. Drug Saf
1998;18:334–335.
84. Coleman MD, Coleman NA. Drug-induced methaemoglobinaemia.
Treatment issues. Drug Saf 1996;14:394–405.
85. Physicians’ desk reference, 57th edn. New Jersey: Thompson PDR; 2003.
86. Keel D, Goldman MP. Tumescent anesthesia in ambulatory phle­
bectomy: addition of epinephrine. Dermatol Surg 1999;25:371–
372.
87. Hanke CW. The tumescent facial block: tumescent local anesthesia and
nerve block anesthesia for full-face laser resurfacing. Dermatol Surg
2001;27:1003–1005.
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surgery, dermabrasion, and soft tissue reconstruction. J Dermatol Surg
Oncol 1992;18:130–135.

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65
4
Instruments and Materials
Melissa A Bogle MD, Valerie T Fisher BS, and Aaron K Joseph MD
Summary box
 A dermatologic surgeon’s skill depends upon knowledge of
basic instrumentation and wound closure materials.
 Investing in the high-quality instruments that are practical for
the range of procedures performed helps the dermatologist
perform procedures with skill.
 Proper maintenance will enhance the longevity of surgical
instrumentation and protect the surgeon’s investment.
 Wound closure materials may be ordered according to the
type, size, length, and color of suture material, as well as the
type and size of the attached needle.
 Surgical excision and repair trays specific to the procedure
can improve the efficiency and safety of office procedures.
 Injury to the patient, surgeon, or surgical personnel can be
avoided by safety procedures that are in a manual and are
rehearsed prior to performing procedures.
 INTRODUCTION
Contemporary dermatology practice incorporates an ever-
increasing number of surgical procedures. Knowledge of the
best equipment and supplies to carry out particular proce-
dures can make a good dermatologic surgeon even better.
Properly organizing the surgical tray can greatly improve the
efficiency and safety of everyone within the surgical suite. In
addition, thorough instrument care will greatly extend the
life of the tools and the investment of the surgeon.
 TECHNICAL ASPECTS
Instruments
Scalpels, scissors, forceps, skin hooks, hemostats, needle
holders, and curettes constitute the basic armamentarium of
the dermatologic surgeon. In general, instruments used for
dermatologic procedures are small, fine, and lightweight,
allowing atraumatic handling of delicate tissues. All instru-
ments are available in various grades of quality. In general, it
is a good investment to use the best surgical instruments that
are practical and affordable for a particular procedure and
ones that suit the individual practitioner’s needs.
Scalpel handles and blades
A scalpel consists of a blade and a handle. Blades are com-
posed of either carbon steel or stainless steel. Carbon steel
blades are sharper but dull fairly quickly with use. Stainless
steel blades, on the other hand, are not as sharp but they will
maintain their sharpness longer than carbon steel blades.1
Scalpel blades are also available with Teflon coatings to
reduce drag when cutting through tissue.2
The two basic types of scalpel handles are the Bard-Parker
#3 handle and the Beaver handle (Fig. 4.1). The Bard-Parker
#3 handle is flat or rounded, and is available with an etched
ruler on the side which is helpful for intraoperative measure-
ments. It is probably the most versatile handle and can hold
a variety of scalpel blades including the #10, #11, and #15
Bard-Parker blades (Fig. 4.2). The #10 blade is wide with a
sharp, convex belly, making it ideal for large excisions on
thick skin such as the trunk. The #11 blade is tapered to a
sharp point and used primarily for incision and drainage or
for cutting sharp angles on flaps. The #15 blade is the most
commonly used blade in excisional surgery. It is shaped like
a smaller version of the #10 blade with the sharpest portion
at the tip. A variant is the smaller #15c blade which is used
when working in areas of thin, delicate skin such as that
around the eye. Turning a smaller blade is useful in small
confined areas like the inner canthus.
The Beaver handle is round or hexagonal, like a pencil, and
it holds a smaller, sharper blade (see Fig. 4.1). It is the handle
of choice for small, delicate work. Standard blades cannot be
used with the Beaver-style handle as the blade is fitted
between two jaws (a collet), which tighten when the handle
is rotated. Like the Bard-Parker #3 handle, a choice of blades
works well with the Beaver system. The two most commonly
used are the #67 and #64 blades. The #67 Beaver blade is
small and curved convexly with a sharp tip similar to the
#15c blade. The #64 Beaver blade has a rounded tip with a
sharp cutting edge which is useful for working in concavities
such as the conchal bowl.
Scissors
There are many types of scissors available to the dermatologic
surgeon. There are choices in the length of the handle (short
or long), the blade (straight or curved, smooth or serrated),
and the tip (sharp or blunt). Each feature affects the utility
of the tool and makes it suited to a particular use. Respectful

66
Part 1  Basic Surgical Concepts
head and neck. It is available with a straight or curved blade
and also with a choice of either two smooth blades or one
smooth blade and one serrated blade (Fig. 4.3). The Gradle
scissor is similar to the iris scissor, except the blades are
curved and tapered to a fine pointed tip. This makes it ideal
for particularly delicate dissection as, for instance, in the
periorbital region. The Westcott scissor is also good for deli-
cate dissection around the eye area due to its sharp, fine,
pointed tip. It is unique in that it operates on a spring system
where the blades come together as the handle arc is squeezed.
The Mayo scissor has an almost 1-to-1 handle to blade ratio
and is used for coarse dissection (Fig. 4.4). The Metzenbaum
scissor is a long-handled scissor that comes in varying lengths,
making it ideal for blunt or sharp dissection in areas that
require long reach. It also comes with either a straight or
curved blade and a sharp or blunt tip (see Fig. 4.4). The
LaGrange scissor is a longer-handled scissor with a strongly
curved tip and a reverse curve on the handle shank. It is used
primarily to harvest hair transplant donor grafts but is also
ideal for removing punch biopsy specimens.
use of the instrument for the purpose that it was designed to
perform will not only enhance a surgeon’s skills but will
protect the scissor blade from dulling and keep the tips in
good alignment. In general, short-handled scissors are useful
for fine work and are probably used the most for delicate
dermatologic surgeries on the head and neck. Long-handled
scissors are ideal in cases where the surgeon must reach under
tissue for a long distance, as occurs in extensive undermining
or freeing up large flaps. Curved blades are ideal for blunt
dissection and allow easy movement around tumors and cysts.
Straight blades are used for gross trimming such as with flaps
or grafts and cutting suture. Adding a serrated edge to the
blade allows for less slipping of the tissue during cutting,
making it particularly useful in areas of thin skin with little
subcutaneous tissue. Finally, sharp-tipped scissors are used
for dissection, whereas blunt-tipped scissors are better suited
to atraumatic undermining and freeing up of flaps such as the
island pedicle.
The iris scissor is a sharp-tipped, short-handled scissor most
often used for blunt or sharp dissection and cutting on the
Figure 4.1  Scalpel handles: (left to right) the Beaver round
knurled handle, the Bard-Parker round knurled #3 handle, and
the Bard-Parker #3 standard handle.
Figure 4.2  Scalpel blades: the Bard-Parker #15 (right), #10
(middle), and #11 (left).
Figure 4.3  Scissors: curved iris scissor with two smooth blades
(left), and straight Strabismus scissors with sharp tips (right).
Figure 4.4  Scissors: the curved Mayo scissor (left), and the
straight Metzenbaum scissor with blunted tips (right).

67
Chapter 4  Instruments and Materials
Skin hooks
Some surgeons prefer the use of skin hooks when manipulat-
ing tissue that is to be sutured or to simulate flap movements,
because hooks are far less traumatic to the epidermis. Skin
hooks come in a variety of models, with single or multiple
prongs, of varying length, sharpness, and curvature. Single-
pronged and double-pronged skin hooks are used most
commonly for stabilizing tissue that is to be sutured, and
for executing flaps and grafts. They may also be used for
planning and removing dog-ear defects and to retract the
wound to give tension when placing buried or running
sutures.
Hemostats
Hemostats are used for hemostasis of bleeding vessels. Their
main use is in clamping off vessels either for electrocoagula-
tion or ligation with suture. Like most instruments, those
used in dermatologic surgery should be fine and lightweight.
Probably the best-suited hemostat for cutaneous surgery is
the Jacobsen hemostat because its fine tip is easily able to
grasp small vessels. It is available in both curved and straight
models.
Needle holders
There are a great variety of needle holders from which to
choose. A general rule is to use a small needle holder with
small needles and a large needle holder with large needles to
avoid needle slippage and damage to both the needle and the
instrument. Apart from size, the jaws of needle holders also
vary; they can be smooth or fine toothed (Fig. 4.7). Smooth
jaws are less damaging to the fine needles and suture used in
delicate procedures. In addition, high-end instruments often
have metal alloy inserts on the working surface of the jaws,
both for protection of the instrument and for secure grasping
of the needle.
Crile-Wood needle holders are long with gently tapered,
blunt tips. They are used primarily when working with larger
suture material (5-0 and larger) in areas such as the back or
scalp. Neuro-smooth needle holders are similar but have
narrow, parallel tips making them ideal for finer suture mate-
Supercut scissors are a relatively new addition to the der-
matologic surgeon’s armamentarium. They are made with a
special sharpening technique such that one of the blades has
a razor edge. They are available as an option for most of the
scissor models discussed above.
Finally, a short discussion of suture-cutting scissors is war-
ranted (Fig. 4.5). While it is not crucial to buy separate scis-
sors only for cutting suture, scissors that are used for cutting
tissue will dull much faster if used to cut suture as well. As
a general rule, fine, sharp, cutting instruments such as iris,
Gradle, or Westcott scissors should never be used to cut
suture. Distinct suture-cutting scissors such as the Northbent
scissor are available with a curved blade and a notch near the
tip of one blade that particularly suits the purpose.
Forceps
Like the majority of instruments used in dermatologic surgery,
forceps tend to be fine and lightweight. Their tips vary from
smooth, to serrated, to toothed. The advantage of serrated
forceps is that they allow firm grasp of tissue. However, they
can easily cause crush injury in delicate areas, which may
hinder optimal wound healing and cosmesis. Toothed forceps
were developed to allow a firm grasp of tissue with reduced
crush injury (Fig. 4.6).
Adson forceps are the most versatile forceps. They have a
relatively broad handle that tapers to a long, narrow tip. They
come in both serrated and toothed models. Brown-Adson
forceps are similar, but have a row of eight or nine tiny teeth
along the length of the tips for enhanced tissue grasping.
Bishop-Harmon forceps are small and delicate with fine tips,
either with or without teeth. They are designed with three
holes on each side of the handle, making them particularly
lightweight and good for delicate work. Jeweler’s (splinter)
forceps are also small and delicate with an extremely fine and
sharp tip. They are best used for grasping small vessels or
retrieving suture fragments. Both the DeJardin and Graefe
cartilage forceps have wide jaws with teeth used for grasping
cartilage.
Figure 4.5  Scissors: general operating scissors for suture
cutting.
Figure 4.6  Forceps: (top to bottom) heavy, smooth, straight
forceps, heavy 1 × 2 toothed straight forceps, and delicate 1 ×
2 toothed straight forceps.

68
Part 1  Basic Surgical Concepts
Miscellaneous instruments
Other instruments that are useful in a dermatologic surgery
suite include: towel clamps, periosteal elevators, bone chisels,
and nail splitters. Towel clips come in conventional or cross-
action models of varying sizes. They are useful for securing
towels during lengthy procedures and for anchoring the elec-
trocautery handle within the surgical field. They may also be
used for holding skin under tension, as with large scalp
wounds. Periosteal elevators and bone chisels are useful when
working on the head and neck for sampling periosteum or
bone thought to be invaded by tumor. In addition, elevators
can be used to aid in nail avulsion procedures.
Wound closure materials
A thorough understanding of suture materials and needles is
essential in dermatologic surgery.3,4 The choice of materials
is dictated by the procedure and the personal preference of
the surgeon. Sutures may be ordered according to the type,
size, length, and color of suture material as well as the type
and size of attached needle. Like suture, needle selection
depends upon the type and location of wound closure as well
as the size of the associated suture material.
Suture
The choice of suture material (Table 4.1) requires an under-
standing of certain descriptive terms. Tensile strength is
analogous to the strength of the suture and is calculated by
dividing the weight necessary to break the suture by its cross-
sectional area. Sutures with larger diameters generally have
greater tensile strengths; however, the type and configuration
of suture material also contributes. Smaller 5-0 and 6-0
sutures are used on the face and neck, while 3-0 and 4-0
sutures are used on the trunk and extremities. Wounds with
a great deal of tension will require 3-0 or 4-0 sutures.
Suture configuration refers to whether it is composed of a
single strand (monofilament) or multiple strands (polyfila-
ment). Polyfilament sutures can be braided to increase the
ease of handling but have a higher incidence of wound infec-
tion.3 This occurs because the braided configuration has crev-
ices that may harbor bacteria in a wound and a high
capillarity that may ‘wick’ bacteria into a wound.
Elasticity refers to a suture material’s ability to stretch (e.g.
with wound edema) and then return to its original form.
Plasticity, on the other hand, refers to a suture material’s
ability to stretch and maintain its new length. Memory defines
the stiffness of the suture and its inherent ability to return
to its original shape after deformation. Sutures with high
memory are generally more difficult to handle and tie. Knot
strength is the force required to cause knot slippage and it
depends on the smoothness and memory of the suture.
Finally, tissue reactivity refers to the body’s inflammatory
response to a given suture material. In general, monofilament
and synthetic sutures have less tissue reactivity than polyfila-
ment and natural sutures.3
The broadest distinction in suture materials is between
absorbable and non-absorbable sutures. Absorbable suture, by
definition, loses most of its tensile strength within 60 days of
placement through either enzymatic digestion or tissue
hydrolysis. Absorbable sutures are used mainly for buried
stitches to close the dermis and decrease epidermal wound
tension. Commonly used absorbable sutures include surgical
rial (5-0 and smaller). The Webster needle holder is short
with narrow jaws so that it is suitable for fine suture work in
small, deep areas. The Castroviejo needle holder has a detach-
able spring handle similar to that of the Westcott scissor and
is used for extremely delicate procedures such as those on
the eyelid.
Curettes
Curettes are used primarily for the treatment of benign or
low-grade malignant tumors and for debulking tumors prior
to Mohs micrographic surgery. They come in many handle
styles with either round or oval heads of varying sizes from
1 mm to 9 mm (Fig. 4.8). The choice of curette is largely
personal preference, but smaller heads should be used for
finer procedures. Furthermore, as with any instrument, care
must be taken not to dull the sharp edge of the curette. A
dull curette will create excessive tissue trauma and a subop-
timal outcome.
Figure 4.7  Needle holders: smooth (top) and fine-toothed
(bottom) variants.
Figure 4.8  Curettes: large (left) and small (right) variants with
oval heads.

69
Chapter 4  Instruments and Materials
through tissue. It has a high tensile strength, minimal tissue
reactivity, and is available in either a white or violet color.
The violet color should be avoided in areas of thin skin where
it may be visible through the closed wound.
Absorbable monofilament sutures include polydioxanone
(PDS) and polyglyconate (Maxon). Polydioxanone (PDS) is
a synthetic polymer of p-dioxanone with a very high tensile
strength and minimal tissue reactivity. It is absorbed much
more slowly than Dexon or Vicryl suture, retaining approxi-
mately 74% of its strength at 2 weeks and not completely
dissolving until 180 days. It is ideal for suturing areas such
as cartilage, where tissue inflammation would cause signifi-
cant discomfort, and it is a better choice for wounds that
may be contaminated because of its monofilament configura-
tion. The main disadvantage of polydioxanone is that it can
be stiff and difficult to work with and tie. Polyglyconate
(Maxon) is composed of glycolic acid and trimethylene car-
bonate and is similar to polydioxanone in terms of tensile
strength. Its main advantage is that it is not as stiff as poly-
dioxanone so that it has greater knot stability and easier
handling.
Non-absorbable sutures are resistant to degradation and
will maintain most of their tensile strength at 60 days after
placement. The most common are silk, nylon, polypropylene
(Prolene, Surgilene), polyester, and stainless steel.
Silk is a natural braided fiber that handles very well and is
easy to tie. It is unlikely to tear tissue and can lie flat in areas
such as mucosal surfaces, around eyelids, and in intertriginous
areas. It has a relatively low tensile strength compared to the
other non-absorbable sutures, retaining only 0–50% of its
original strength at 1 year. The disadvantages of silk are its
high tissue reactivity and increased potential for wound infec-
tion due to the braided configuration.
Nylon is a synthetic polyamide polymer with low tissue
reactivity, excellent elasticity, and high tensile strength. It is
available in a variety of configurations including monofilamen-
tous (Ethilon (Ethicon) and Dermalon (Davis and Geck)) or
gut, polyglycolic acid (Dexon; Davis and Geck Inc, Tyco
Healthcare Group LP, Mansfield, MA), polyglactin 910
(Vicryl; Ethicon Inc, Johnson and Johnson Co, Somerville,
NJ), and polydioxanone (PDS (Ethicon)) and polyglyconate
(Maxon (Davis and Geck)).
Surgical gut is a natural suture made from animal collagen.
It is available plain or treated with chromium salts for
increased strength and decreased tissue reactivity. Both vari-
eties come packaged in alcohol and will break easily if allowed
to dry out. Surgical gut is rapidly degraded in 4–5 days,
making it useful for epidermal approximation of skin grafts,
for tying off superficial blood vessels, or closure of wounds
in children where it may be challenging to remove sutures at
a later date. A fast-absorbing variant also exists which is heat
treated so that it absorbs completely in 2–4 weeks. The dis-
advantages of surgical gut include poor tensile strength, high
tissue reactivity, and poor knot stability. The body’s signifi-
cant inflammatory response occurs because the suture is
broken down by lysosomal proteolytic enzymes as opposed
to hydrolysis.
Absorbable polyfilament sutures include polyglycolic acid
(Dexon) and polyglactin 910 (Vicryl). Polyglycolic acid
(Dexon) is a braided synthetic polymer of glycolic acid and
loses approximately 50% of its strength at 2–3 weeks. It is
broken down by tissue hydrolysis that decreases tissue reac-
tivity and inflammation. Its main use is for buried sutures;
however, it should be avoided in contaminated wounds due
to its braided configuration and higher incidence of infection.
If placed too superficially, the sutures may be transepider-
mally eliminated (‘spit’) before they have a chance to be
completely absorbed. Polyglycolic acid is available in either a
clear or green color, and can be either coated (Dexon Plus)
or uncoated (Dexon-S). The coated variety allows the suture
to pass more easily through tissue. Polyglactin 910 (Vicryl)
is a braided synthetic co-polymer of lactide and glycolide
which is similar to polyglycolic acid but with a lubricant
coating of polyglactin 370 and calcium stearate for easier pull
Table 4.1  Sutures used in skin surgery
ABSORBABILITY
SUTURE (TRADE NAME)
CONFIGURATION
USES
Absorbable
Surgical gut
Virtually monofilament
Rarely used but good for skin graft
closure, tying off superficial vessels,
wound closure in children
Polyglycolic acid (Dexon)
Polyfilament
Buried sutures
Polyglactin 910 (Vicryl)
Polyfilament
Subcutaneous closure, vessel ligature
Polydioxanone (PDS)
Monofilament
Where infection would cause significant
discomfort, e.g. cartilage
Polyglyconate (Maxon)
Monofilament
Subcutaneous closure in high-tension
areas
Non-absorbable
Silk
Polyfilament
Mucosal surfaces, around eyelids,
intertriginous areas
Nylon: Ethilon, Dermalon
Monofilament
Skin closure
Nylon: Surgilon, Nurolon
Polyfilament
Skin closure
Polypropylene: Prolene, Surgilene
Monofilament
Subcuticular running intradermal
sutures
Polyester: Mersilene, Dacron, Ethibond
Polyfilament
Mucosal surfaces
Polybutester: Novafil
Monofilament
Subcuticular running; elasticity
responds well to wound edema
Stainless steel
Monofilament and polyfilament
Tendon repair

70
Part 1  Basic Surgical Concepts
Ethicon and Davis and Geck. Ethicon manufactures for skin
(FS), plastic skin (PS), precision point (P), and precision
cosmetic (PC) needles. The FS is a large, inexpensive, reverse
cutting needle with a triangular body for use on thick skin or
for buried sutures. The PS is also a reverse cutting needle;
however, it is sharper than the FS and good for cosmetic
procedures. The P is similar to the PS but smaller and even
sharper for fine cosmetic work. The PS and P styles both have
an oval body that is flattened on the sides. The PC is a sharp,
conventional cutting needle with a flattened body for less
tissue trauma in delicate cosmetic work.
Davis and Geck manufactures the cutting (CE), plastic
reverse (PRE), skin closure (SC), and slim blade (SBE)
needles. The E designates a 3/8 circle needle. The CE is a
reverse cutting needle comparable to the Ethicon FS needle.
The PRE is a sharp, reverse cutting needle which is ideal for
fine cosmetic work similar to the Ethicon PS and P needles.
The SC is a conventional cutting needle, and the SBE is a
reverse cutting needle with a very thin body. Also available
is the diamond point (DP) needle which has a more
precise tip.
 OPTIMIZING OUTCOMES
It is important to properly care for surgical instruments to
get the maximum longevity and function out of each tool. As
previously stressed, instruments are geared for a particular
use, so using a tool to perform a function outside of that use
polyfilamentous (Surgilon (Ethicon) and Nurolon (Ethicon)).
The monofilament variety comes in black, green, and clear
colors. Its major disadvantage is high memory, causing more
difficult handling and knot tying capabilities. The braided
polyfilament variant is easier to handle.
Polypropylene (Prolene (Ethicon), Surgilene (Davis and
Geck)) is a flexible synthetic monofilament of linear hydro-
carbon polymers. It has good tensile strength, little tissue
reactivity, and a smooth surface allowing it to pull easily
through tissue. This is useful for subcuticular running intra-
dermal sutures. Its plasticity allows it to accommodate tissue
swelling; however, it does not retract once the swelling sub-
sides which can lead to poor wound approximation. The
disadvantages of polypropylene are that its memory and
smoothness can compromise knot security.
Polyester suture is a braided synthetic polyfilament of poly­
ethylene terephthalate. It has minimal tissue reactivity and
an extremely high tensile strength, remaining in tissue indef-
initely. It is available in either a green or white color, and
either uncoated (Mersilene (Ethicon) and Dacron (Davis and
Geck)) or coated with polybutilate (Ethibond (Ethicon)) to
allow for easier pull through tissue. The braided configuration
gives it better handling and knot tying capabilities than nylon
or polypropylene, and it has less risk for infection than silk
because it is synthetic. Polybutester (Novafil (Davis and
Geck)) is a monofilamentous suture composed of polyglycol
terephthalate and polybutylene terephthalate. It combines
the high tensile strength, low tissue reactivity, and easy han-
dling capabilities of polyester with the plasticity and smooth-
ness of polypropylene.
Stainless steel suture is extremely strong and maintains its
strength indefinitely. It is available in monofilament or poly-
filament (twisted or braided) varieties. It is difficult to tie
without breaking and has a tendency to cut through tissue.
Although rarely used in dermatologic surgery, it is a good
choice for tendon repair.
Needles
Needles are designed to carry suture material through the
skin with minimal tissue trauma. The needle itself is divided
into the shank that connects to the suture, the body, and
sharp point. The body of the needle comes in round, trian-
gular, or flattened varieties. Round bodies will gradually taper
to a point and triangular bodies have cutting edges on three
sides. Flattened bodies are designed to eliminate needle
twisting during procedures. Some needles will have ridges
along the body to aid in securing the needle in the needle
holder. The curvature of the needle arc varies, but the most
commonly used in dermatologic surgery are from 3/8 to 1/2
circle.
The needle point is available in three variants: conventional
cutting, reverse cutting, and round with a tapered point (Fig.
4.9). Conventional cutting points are triangular in cross-
section with a cutting edge on the inside of the needle arc.
Reverse cutting points have a cutting edge on the outside of
the needle arc to minimize the risk of tearing through tissue
when placing a stitch. Round point needles have no cutting
edges and are less likely to tear tissue. They are used prima-
rily for suturing fascia, muscle, and aponeuroses.
Different manufacturers have different nomenclature for
needles and identification is not standardized. The most com-
monly used series in dermatologic surgery are those made by
Conventional
Reverse
Round
Needle points
Figure 4.9  Needle points: (left to right) conventional cutting,
reverse cutting, and round.

71
Chapter 4  Instruments and Materials
 PRACTICAL APPLICATIONS
Surgical instruments can be set up on a Mayo surgical stand
with a removable stainless steel tray. The Mayo stand comes
in two styles: an easily maneuverable four-wheeled version
and a two-wheeled version. The stand may be adjusted to the
desired height. Trays should be kept neat and all instruments
should be placed so that needle-stick injuries are minimized.
If needed, two trays can be prepared and sterilized for use:
an excision tray and a repair tray.
The organization of the excision tray is important for safety
and efficiency (Fig. 4.10). At the very least it should contain
a scalpel handle, a ruler, a curette for debulking tumors, tissue
scissors, forceps, and either a marking pen or a cup containing
Gentian violet to delineate tumor margins for Mohs micro-
graphic surgery or excision. The excision tray should also
contain towel clamps for holding sterile drapes if the drapes
are not self-adhering. Sterile gauze, scalpel blades, and Telfa
(Tyco Healthcare Group LP, Mansfield, MA) pads to trans-
port surgical specimens to the laboratory should be added
when the tray is opened. Cotton-tipped applicators are also
useful for hemostasis and the stick can be used for marking
with Gentian violet.
may damage the instrument and shorten its life span. Instru-
ments must also be properly cleaned after use.5
Ideally, all instruments should be placed in a solution with
warm water and a commercially available instrument deter-
gent promptly after use. After soaking, the instruments are
gently scrubbed with a plastic brush to remove foreign matter
and organic debris. An ultrasonic cleaner may be used to
dislodge particulate matter that is not otherwise removed,
but adds to instrument wear and tear.6 The instruments are
then rinsed with water to remove detergent and allowed to
dry completely. If the instruments are not allowed to dry
completely before sterilization they can become stained
from water spots.5 This is also a good time to inspect the
instruments for signs of disrepair. Scissor blades should be
inspected to make sure they do not have nicks or malap-
proximation at the tips. Forceps, hemostats, and needle
holders should also be checked to make sure the tips meet
properly and they are in good working order. If needed,
instruments can be lubricated at the hinge with a water- and
steam-soluble solution such as instrument milk. Oils or grease
should never be used for lubrication as they will turn hard
during the sterilization process and cause the joint to become
stiff.5
There are four main types of instrument sterilization. Dry-
heat sterilization is advantageous because it will not corrode
the instruments; however, the instruments cannot be placed
in the standard paper or plastic packages due to the high
temperatures during sterilization. This creates a problem
when storing the instruments in a sterile fashion for later use.
This type of sterilization is most commonly used for rapid
sterilization of a contaminated instrument needed for a par-
ticular procedure.6 Steam sterilization is the most popular
office method of sterilization. This type of autoclave uses high
temperature and pressure to destroy microorganisms. One
drawback is that steam autoclaves may dull sharp instru-
ments because of the humidity.2 The chemical autoclave is
similar but uses formaldehyde and alcohol instead of distilled
water so there is less dulling of the instruments. The final
type of sterilization is ethylene oxide gas sterilization. The
setup for this type of sterilization is impractical in an office-
based setting, but it is useful for devices that would other-
wise be destroyed by heat or moisture, such as dermabrasion
hand pieces, electrosurgical handles, or wiring. Cold sterili­
zation is not considered adequate for invasive surgical
procedures.6
 PITFALLS AND THEIR MANAGEMENT
Any chapter on surgical instrumentation should include a
discussion on preventing injury to the surgeon, the patient,
or one of the surgical personnel. The first recommendation
when using sharps is to always work away from the surgeon’s
own hand or an assistant’s hand that may be in the field.7
Furthermore, tissue should be handled strictly with instru-
ments such as forceps or skin hooks to avoid unnecessarily
exposing hands to the field. Likewise sharp objects such as
needles or scalpel blades should be handled with another
instrument such as a needle holder or forceps. If a hand must
enter the surgical field when a sharp instrument is present,
for example for blotting tissue, only one hand should be in
the field and the sharp instrument should not be moving at
the same time. All parties should wear properly fitted gloves,
as loose gloves may obscure the field and make it difficult to
Pitfalls and their management
 Keep surgical trays, and the area in which surgery is
performed, well organized and tidy to avoid injury from
instruments.
 Handle instruments correctly to avoid injury.
 Use fitted gloves both for precision and so that the field of view
is not obscured.
Figure 4.10  Mohs layer/excision tray containing a ruler,
stainless steel cup, tissue scissors, scalpel handle, curette, and
forceps.
hold sharp instruments properly.7 The surgical tray should be
kept clean at all times and all instruments should point in the
same direction, away from the surgeon’s hand. Needles or
sharp instruments should not be obscured by gauze pads or
unnecessary items like discarded needle sleeves. Needle
recapping should be avoided.

72
Part 1  Basic Surgical Concepts
Sterile gauze, cotton-tipped applicators, scalpel blades, and
suture should be added when the tray is opened.
 SUMMARY
Knowledge of surgical instruments and wound closure mate-
rials is important to the dermatologic surgeon. The surgeon
should invest in the highest-quality tools available and should
take care to maintain the instruments properly, to optimize
their effectiveness and durability. Likewise, well-planned sur-
gical excision and repair trays will improve the efficiency and
overall safety of surgical procedures.
 REFERENCES
1. Neuberg M. Instrumentation in dermatologic surgery. Semin Dermatol
1994;13:10–19.
2. Weber LA. The surgical tray. Dermatol Clin 1998;16:17–24.
3. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturing
techniques. Semin Dermatol 1994;13:20–26.
4. Campbell JR, Marks A. Suture materials and suturing techniques. In
Practice 1985;7:72–75.
5. Sebben JE. Sterilization and care of surgical instruments and supplies.
J Am Acad Dermatol 1984;11:381–392.
6. Geisse
JK.
The
dermatologic
surgical
suite.
Semin
Dermatol
1994;13:2–9.
7. Trizna Z, Wagner RF. Preventing self-inflicted injuries to the dermatologic
surgeon. J Am Acad Dermatol 2001;44:520–522.
The repair tray should contain roughly the same items as
the excision tray, plus additional specific instruments (Fig.
4.11). The repair tray may also include a needle holder,
undermining and suture-cutting scissors, a variety of forceps,
skin hooks, and a cup with sterile saline for storing skin grafts.
Figure 4.11  Repair tray containing tissue and suture scissors, a
scalpel, skin hooks, a variety of forceps, a needle holder, ruler,
and a stainless steel cup.

73
5
Patient Evaluation, Informed Consent,
Preoperative Assessment, and Care
Parrish Sadeghi MD and Allison T Vidimos RPh MD
Summary box
 Preoperative consultation should include the following
elements: medical, surgical and social history, list of current
medications, thorough physical examination, and explanation
of any proposed procedure.
 Medical conditions may impact outcomes of cutaneous
surgery, including pregnancy, hypertension, and
cardiovascular disease.
 The potential risks, benefits, and alternatives of the proposed
surgical procedure must be adequately discussed in order to
obtain informed consent.
 INTRODUCTION
The preoperative surgical evaluation is often the initial and
perhaps most important encounter between a surgeon and
prospective patient. It is during this critical time that the
physician can adequately assess the patient’s particular
medical problem, motivation for seeking care, and determine
suitability for a particular procedure, as well as discuss rele-
vant underlying health problems. Preoperative evaluations
additionally allow physicians ample opportunity to make
appropriate changes to the patient’s medications and to
explain the various risks, benefits, and alternatives to the
proposed surgical procedure. Patients benefit in many ways:
they have the opportunity to gain a thorough understanding
of the proposed treatment, to have questions or concerns
addressed, and they have an opportunity to consider possible
treatment alternatives. Finally, preoperative evaluations can
help enhance the physician–patient relationship by creating
an open, two-way dialogue.
 TECHNICAL ASPECTS
The consultation area
In general, a clean well-lit area will suffice for most purposes.
Consider replacing the standard bulbs in fluorescent ceiling
light fixtures with full-spectrum bulbs which more accurately
replicate the wavelengths of natural sunlight and better reveal
skin tones. Full-spectrum light bulbs are relatively inexpen-
sive and are readily available from retailers (including Lowe’s
and Home Depot in the USA). A portable overhead light, or
simply a flashlight, is useful for illuminating localized areas of
skin that cause concern.
All consultation rooms should be equipped with a sink,
along with a supply of clean towels and non-irritating facial
cleanser because patients may need to remove their make-up
to allow for adequate cutaneous examination. Mirrors, both
hand held and wall mounted, are essential for allowing
patients to point out particular areas of concern.
A powered examination table is desirable and allows for
comfortable and safe positioning of patients during the phys-
ical examination (Chapter 48). Although the cost of these
tables can be significant, certain discounts and tax deductions
may be available when purchasing at a professional society
exhibit, or under the Americans with Disabilities Act; inter-
ested physicians should consult their tax professional. In
addition, all rooms should be equipped with comfortable
chairs in which patients and their companions can wait before
the consultation.
Consider placing pamphlets detailing the various proce-
dures performed in your office on wall-mounted racks. If
patients will be spending considerable time waiting in the
room, a supply of current magazines is also a nice diversion.
During the initial preoperative consultation, it is important
for the physician to respect and maintain the patient’s privacy.
We have found that an opaque, retractable curtain in all
rooms for patients to change behind is an invaluable fixture.
The consulting physician should attempt to give his/her com-
plete attention to the patient during the visit. Unnecessary
distractions, whether from incoming phone calls, pagers, or
office staff interruptions, should be kept to a minimum.
Components of the preoperative
consultation
The primary goals of the preoperative consultation are to
evaluate, to educate, and to obtain informed consent. While
the exact details of the initial consultation may vary depend-
ing on such factors as whether or not the patient is new to
the practice, the patient’s prior medical knowledge, and par-
ticular medical problem, the overall components of the pre-
operative consultation remain unchanged. The following six
elements should be included in every preoperative consulta-
tion:
• Medical history
• Surgical history with an emphasis on past dermatologic
and/or cosmetic procedures

74
Part 1  Basic Surgical Concepts
romycin base and azithromycin are both pregnancy category
B, and are acceptable alternatives. Category D antibiotics
that are contraindicated in pregnancy include erythromycin
estolate, tetracycline, doxycycline, and minocycline. Ery­
thromycin estolate has been associated with hepatotoxicity
when taken during pregnancy.8 Intrapartum use of tetracy-
cline may result in staining of fetal dental enamel and must
be avoided.9
Hypertension
Blood pressure should be checked during the preoperative
consultation. Elevated blood pressure may be associated with
increased intraoperative and postoperative bleeding and can
complicate the process of wound reconstruction. The use of
epinephrine-containing local anesthetics may lead to vasocon-
striction, which can further elevate blood pressure. The
increased bleeding risk associated with uncontrolled hyper-
tension is perhaps most apparent when working on highly
vascular structures such as the nose and scalp.
Patients with persistently elevated blood pressure, who
have not previously been diagnosed with hypertension, should
be referred to their primary care physician for further evalu-
ation. In our practice, hypertensive patients with a systolic
pressure of greater than 170 mm Hg and/or a diastolic pres-
sure greater than 100 mm Hg are routinely excluded from
surgical procedures until their blood pressure can be further
lowered. Beyond bleeding risk, exacerbation of hypertension
perioperatively may lead to stroke.
Cardiovascular disease
Patients with underlying cardiac disease may have an increased
complication risk during surgical procedures and should be
identified during the preoperative consultation. Special atten-
tion must be given to patients with a history of coronary
artery disease, cardiomyopathy, and cardiac valve disease.
Epinephrine is commonly added to local anesthetic solu-
tions. It is an α-adrenergic agonist and as such has both car-
diostimulatory and vasoconstrictive effects which could tax
the heart in a person with cardiac disease.10 Studies per-
formed in patients with advanced cardiac disease, however,
showed that small volumes of epinephrine-containing anes-
thetics could be given safely without significant adverse con-
sequences.11 Judicious use of epinephrine is nevertheless
advisable in these patients and can be accomplished through
use of highly dilute solutions, such as 1 : 200 000, 1 : 500 000,
or even 1 : 1 000 000.
Various cardiac conditions are associated with an increased
risk for developing bacterial endocarditis following a surgical
procedure. The risk associated with each condition has been
stratified into high, moderate, and low or negligible categories
by the American Heart Association (AHA) (Chapter 6).12
High-risk categories include patients with prosthetic valves,
a previous history of endocarditis, complex congenital cyan-
otic heart disease, and surgically constructed systemic–
pulmonary shunts or conduits. Moderate-risk patients include
those with hypertrophic cardiomyopathy and mitral valve
prolapse with regurgitation. Low- or negligible-risk catego-
ries include people with implanted cardiac pacemakers
and defibrillators, with physiologic heart murmurs, and sur­
gically repaired atrial or ventral septal defects. Coronary
artery stenting is an increasingly popular cardiovascular
procedure and is fairly common among patients undergoing
• Complete medication list including use of over-the-
counter (OTC) drugs, vitamins, and nutritional
supplements
• Problem-focused physical examination (Fig. 5.1)
• Social history
• Detailed explanation of the proposed procedure,
treatment alternatives, and informed consent.
Medical history
The basic components of a medical history include a detailed
accounting of current and past medical conditions, possible
drug or latex allergies, as well as current drug and nutritional
supplement use with special attention to conditions that can
impact the outcome of the procedure. Obtaining a medical
history can be facilitated through the use of preprinted
patient questionnaires, which can be completed at the time
of the preoperative evaluation. A sample questionnaire, as
shown in Figure 5.2, can be further modified to meet the
needs of each practice.
Medical conditions affecting cutaneous
surgery
The underlying health status of each patient should be con-
sidered carefully before any surgical procedure. In fact,
several medical conditions can be identified that may affect
the intraoperative and postoperative success of a given pro-
cedure.
Pregnancy
Pregnancy should always be considered as a possibility in
women of childbearing age. Screening questions for occult
pregnancy should be included in the medical history ques-
tionnaire. Since medications such as local anesthetics and
antibiotics – commonly used in the perioperative setting –
may act as potential teratogens, each should be considered
carefully. Non-emergent surgical procedures should be
delayed until the postpartum period; however, exceptions
will arise. The US Food and Drug Administration (FDA) has
categorized the teratogenic risk of medications using an A to
X rating scale.1 In general, category A and category B medica-
tions can be used safely during pregnancy, while medications
belonging to categories C, D, and X cannot.
Local anesthetics can cross the placental barrier and may
accumulate preferentially in the fetus.2 Potential complica-
tions from use of a local anesthetic during pregnancy include
both fetal bradycardia and central nervous system toxicity.
Lidocaine and prilocaine are listed as pregnancy category B
agents and are the preferred anesthetics for use during preg-
nancy. Furthermore, several studies examining the use of
lidocaine during pregnancy have shown no increase in adverse
fetal events or teratogenicity.3–6 A similar safety profile is
not seen with other amide anesthetics, as intrauterine expo-
sure to both bupivacaine and mepivacaine has been associated
with an increased risk for fetal bradycardia.7 Epinephrine,
which is frequently combined with local anesthetics such
as lidocaine, is pregnancy category C and should be used
cautiously.
Pregnant patients may require antibiotics in the periopera-
tive setting. Appropriate pregnancy class B antibiotics include
penicillin and cefalexin. In penicillin-allergic patients, eryth-

75
Chapter 5  Patient Evaluation, Informed Consent, Preoperative Assessment, and Care
Physical examination
Figure 5.1  Diagrams for use in recording findings of the problem-focused physical examination.

76
Part 1  Basic Surgical Concepts
Ì
Ì
Ì
Ì
HEALTH QUESTIONNAIRE
1
If none, check here
List all current medications (including non-prescription and vitamins):
Name of Drug
Dosage
Route
Frequency
Age:
Occupation:
Why are you seeing the dermatologist today?
Prior treatments used for it?
What part(s) of your body is(are) affected?
How long have you had the problem?
Does it itch?
Has it been infected?
Name of referring doctor:
Have you had it before?
Does it bleed?
Has it formed an open wound?

Does it hurt?
If none, check here
List all medication allergies:
Drug
List hospitalizations for major illnesses and surgeries:
IMPRINT/LABEL
Dermatology health questionnaire
Figure 5.2  A patient health questionnaire.

77
Chapter 5  Patient Evaluation, Informed Consent, Preoperative Assessment, and Care
Signature:
Reviewed by:
Date:
Beeper#:
2
Past personal skin problems:
Abnormal moles
Melanoma
Skin cancer
Psoriasis
Acne
Thick scars or keloid
Eczema or Dermatitis
Other – specify
Family history of skin disease:
Eczema or Dermatitis
Skin cancer
Keloids
Psoriasis
Cancer (not skin)
Abnormal moles
Melanoma
Other – specify
Do you need to take antibiotics before routine dental cleaning?
Yes
No
If yes, why?
Habits:
Alcohol (amount per week)
Tobacco (amount per day)
Aspirin (number per day)
Women only:
Are you pregnant?
Are you trying to become pregnant?
Are your menstrual periods regular?
Date of last menstrual period:
Birth Control method:
Do you have any of the following conditions? if yes, place a check:
Pacemaker
Hepatitis
Anemia
Gout
Artificial heart valve
Other – specify:
High blood pressure
Asthma
Diabetes
AIDS or HIV infection
Thyroid problems
Heart murmur
Artificial joint
Arthritis
Cancer (not skin cancer)
None of the above
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì Yes
Ì Yes
Ì Yes
Ì No
Ì No
Ì No
Ì Not sure
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
/
/
Dermatology health questionnaire (continued)
Figure 5.2, cont’d

78
Part 1  Basic Surgical Concepts
dermatologic surgery. Although no formal AHA guidelines
exist regarding the use of prophylactic antibiotics in these
patients, some authors have advocated antibiotic prophylaxis
for periods ranging from 1 to 6 months after stent implanta-
tion.13 The rationale behind these recommendations is pre-
sumably to allow for complete re-epithelialization of the
implanted stent device. In summary, the exact antibiotic
prophylaxis recommendations for dermatologic surgery are
unclear as official skin-specific guidelines do not exist, leaving
physicians to adapt regimens intended for ‘dental, oral, res-
piratory tract, or esophageal procedures.’
In most cases, a single dose of 2 g of amoxicillin given 1
hour preoperatively is the preferred prophylactic regimen for
bacterial endocarditis.12 In penicillin-allergic patients, alterna-
tives include cefalexin 2  g, azithromycin 500  mg, or clin-
damycin 600 mg given 1 hour preoperatively.12 Patients who
are unable to take medications orally can be given prophylaxis
with either 600 mg of clindamycin or 1 g cefazolin, intrave-
nously or intramuscularly, 30 minutes preoperatively.12
Although the risk of bacterial endocarditis for patients
undergoing dermatologic surgery is exceedingly low, there are
some exceptions. Procedures involving infected or eroded
skin are associated with a significantly higher infection risk
and warrant the use of prophylactic antibiotics. This is par-
ticularly important in both the AHA high-risk and moderate-
risk patients.14 Appropriate antibiotic regimens should
typically provide coverage against Staphylococcus aureus, a
likely pathogen, and include dicloxacillin, cefalexin, and clin-
damycin.14
Patients with implanted cardiac pacemakers and defibrilla-
tors must be identified during the preoperative evaluation.
Electrical currents generated by electrosurgical units may
adversely affect the function of implanted cardiac devices
(Chapter 9).15 In most circumstances, heat electrocautery
(which avoids transfer of current to the patient) is the pre-
ferred method for achieving hemostasis. Disposable electro-
cautery ‘pen’ units are inexpensive and widely available.
Bipolar coagulation (in which small forceps are used to grasp
bleeding vessels) minimizes current transfer to the patient
and has also been advocated.16–18 In patients with automatic
internal cardiac defibrillators (AICDs) it is also recommended
that a magnet is used to inactivate the device just before
coagulation. This can be done relatively easily in the outpa-
tient setting. We recommend that contact be made with the
patient’s cardiologist if that person has an AICD. Often the
manufacturer of the defibrillator will send a technician to
educate and assist the novice at doing this. Advanced Cardiac
Life Support (ACLS) training for physicians taking care of
these patients is essential.
Hepatitis and HIV infection
To minimize exposure risk, all patients treated should be
regarded as potentially infectious and universal precautions
should be practiced. In addition to surgical gloves, appropri-
ate eye wear and protective garments are needed. Offices can
minimize the risk of ‘sharps’ injury by using a scalpel blade
remover or disposable scalpels, placing sharp objects in des-
ignated areas on surgical trays, readily disposing of all sharps
when finished with them, and using double-layered surgical
gloves. Inadvertent fluid exposure to areas such as the eyes
and mouth can be prevented through the use of splash-resist-
ant surgical masks and safety eye wear.
Organ transplantation
Because of the immunosuppressive regimens required to
prevent allograft rejection, these patients may be at increased
risk of postoperative wound infection and delayed wound
healing.14 Some patients may be instructed by their transplant
physicians and internists to take prophylactic antibiotics
before dental or surgical procedures; in these cases, the guide-
lines of the AHA for endocarditis prophylaxis should suffice.12
While not formally supported by AHA guidelines, in our
practice we routinely prescribe prophylactic antibiotics for
immunosuppressed organ transplant patients undergoing pro-
longed surgical procedures (Mohs micrographic surgery, lipo-
suction, laser resurfacing) lasting over 5 hours, as well as those
involving infected or ulcerated skin. Commonly used prophy-
lactic antibiotic regimens in our practice include cefalexin
1 g, dicloxacillin 1 g, or azithromycin 500 mg given orally 1
hour before the procedure
Other prosthetic devices
No specific antibiotic prophylaxis guidelines exist for derma-
tologic surgery in patients with non-cardiac prosthetic devices
(Chapter 6). Such implanted devices include various ortho-
pedic prostheses, indwelling catheters, ventricular shunts, as
well as penile and breast implants.
A comprehensive discussion of the role of antibiotic prophy­
laxis for patients with these devices has been carefully exam-
ined by others,14 and may be found in Chapter 6. In general,
the physician responsible for implanting a prosthetic device
should be consulted in advance of a proposed surgical proce-
dure. In instances where antibiotic prophylaxis is warranted,
it would be reasonable to follow the AHA guidelines for
endocarditis prophylaxis.
Herpes simplex virus infection
A prior history of herpes simplex virus (HSV) infection should
be assessed during the preoperative evaluation. This is espe-
cially important in people undergoing medium-depth chemi-
cal peels, facial laser resurfacing, and potentially for those
undergoing imiquimod treatment around the mouth. Similar
precautions should be taken in patients undergoing extensive
genital procedures who have a history of herpes genitalis.
Various factors experienced during the course of a surgical
procedure, such as tissue trauma and psychological stress, can
precipitate an acute herpetic flare. For high-risk procedures
such as skin resurfacing, appropriate antiviral prophylaxis is
indicated regardless of the historical HSV infection status.
Common regimens for patients undergoing facial resurfacing
procedures include aciclovir 400 mg three times daily, val-
aciclovir 500 mg twice daily, and famciclovir 250 mg twice
daily. Typically, these medications are begun within 48 hours
preoperatively and are continued until re-epithelialization is
complete, generally in 7–10 days.
Inherited bleeding disorders
Patients with inherited bleeding disorders such as hemophilia
A, hemophilia B, and von Willebrand’s disease are at higher
risk for significant perioperative bleeding.19 Consequently,
people with a known or suspected bleeding disorder should
be referred to a hematologist for appropriate preoperative
evaluation and management. Depending on the disorder,
various clotting factors may be given intravenously shortly

79
Chapter 5  Patient Evaluation, Informed Consent, Preoperative Assessment, and Care
Multiple nutritional supplements have also been shown to
have anticoagulant effects, although their impact on derma-
tologic surgery is unknown. Perhaps most notable is vitamin
E, or α-tocopherol, which is often overlooked by both patients
and physicians as a potential anticoagulant. Other common
nutritional supplements with anticoagulant properties include
garlic, ginseng, ginger, ginkgo, St John’s wort, feverfew, and
numerous others (Table 5.1) For a more comprehensive
review, see the article by Dinehart and Henry.23 Alcohol has
also been shown to interfere with platelet aggregation in vitro,
which may result in an increase in bleeding potential.24
Clearly, increased bleeding during the perioperative period
can significantly prolong the course of a surgical procedure,
and increase the risk of postoperative complications interfer-
ing with healthy wound repair. Ideally, use of anticoagulant
medication would be discontinued before initiating a surgical
procedure. However, more recent studies examining the
effect of continued anticoagulant use on the incidence of
postoperative bleeding in patients undergoing dermatologic
surgery have failed to show an increased rate of significant
adverse effects.25,26 In fact, in one study of patients undergo-
ing cardiac surgery, pretreatment with Coumadin not only
failed to increase the risk for bleeding complications but also
was actually associated with decreased intraoperative blood
loss.27 More importantly, however, are multiple reports which
show that discontinuation of anticoagulant before dermato-
logic surgery in patients at risk for thrombotic events has
resulted in an increased rate of perioperative stroke, blind-
ness, pulmonary embolism, and even death.28,29
before a planned surgical procedure. In addition to clotting
factor replacement, meticulous attention to hemostasis is
essential. Where available, physicians should consider using a
carbon dioxide laser in cutting mode to further reduce the
possibility of bleeding.20
Implanted deep-brain stimulators
Deep-brain stimulators are electrical devices implanted into
the thalamus or subthalamus for the treatment of movement
disorders such as essential tremor and Parkinson’s disease.21
Electrical currents generated by electrosurgical devices
including electrodesiccators and electrocoagulators have the
potential to interfere with and adversely affect the function
of these devices.19 Electrocautery, which transfers no current
to the patient, is therefore the preferred method of achieving
hemostasis in these patients.22 Alternatively, the deep-brain
stimulator can be safely inactivated externally by the patient’s
neurologist shortly before the surgical procedure. This will,
however, result in the immediate recrudescence of tremors
in a previously non-tremulous patient, which might interfere
with the planned procedure. In our experience, inactivation
of the deep-brain stimulator has never been necessary as
effective hemostasis of skin and soft tissue defects commonly
encountered in dermatologic surgery can be readily achieved
with electrocautery.
Medications
A comprehensive inventory of both prescription and non-
prescription medication use is an essential component of
the preoperative evaluation. Information derived from the
medication list may reveal undisclosed medical problems,
possible drug interactions, and avoid potential perioperative
complications.
Anticoagulants
Traditional anticoagulants include aspirin, various non-steroi-
dal anti-inflammatory drugs (NSAIDs), Coumadin (warfarin),
heparin, and dipyridamole. Newer derivatives include the
family of low-molecular-weight heparins (LMWHs) such as
Fragmin (dalteparin sodium; Pfizer Inc, New York, NY),
Lovenox (enoxaparin sodium; Aventis Pharmaceuticals Inc,
Bridgewater, NJ), Normiflo (ardeparin sodium; Wyeth-Ayerst
Laboratories, St Davids, PA), and Orgaran (danaparoid
sodium; Organon, Roseland, NJ). LMWHs are indicated for
the treatment of deep venous thrombosis, pulmonary embo-
lism, and postsurgical anticoagulation. These medications offer
heparin-like anticoagulation but with the convenience of sub-
cutaneous dosing. Plavix (clopidogrel; Bristol-Myers Squibb,
New York, NY) and Ticlid (ticlopidine; Roche Pharmaceuti-
cals, Nutley, NJ) are adenosine diphosphate (ADP) receptor
antagonists with powerful antiplatelet effects. Clopidogrel is
approved for preventing thrombotic events in patients with
recent myocardial infarction, stroke, acute coronary syn-
drome, and peripheral arterial disease. The anticoagulant
effect of clopidogrel can be enhanced by the addition of
aspirin, and the two are frequently combined in anticoagulant
regimens. Aggrenox (Boehringer Ingelheim, Ridgefield, CT),
which contains a combination of aspirin and extended-release
dipyridamole, has been recently approved for reducing the
risk of subsequent stroke in people with a history of transient
ischemic attacks or thrombotic, ischemic stroke (Box 5.1).
Box 5.1  Common anticoagulants
Non-steroidal anti-inflammatory drugs (NSAIDs)
Aspirin
Ibuprofen
Anticoagulants
Coumadin
Heparin
Antiplatelet agents
Dipyridamole
Plavix (clopidogrel)
Ticlid (ticlopidine)
Aggrenox (aspirin and extended-release dipyridamole)
Low-molecular-weight heparins (LMWHs)
Clivarine (reviparin)
Fragmin (dalteparin)
Fraxiparine (nadroparin)
Innohep (tinzaparin)
Lovenox (enoxaparin)
Normiflo (ardeparin)
Orgaran (danaparoid)
Factor Xa inhibitor
Arixtra (fondaparinux)
Thrombin inhibitor
Angiomax (bivalirudin)
Argatroban/Novastan
Refludan (lepirudin)

80
Part 1  Basic Surgical Concepts
Table 5.1  Dietary supplements with anticoagulant activity
BOTANICAL
SUPPLEMENT
COMMON USE
MECHANISM OF
ANTICOAGULATION
COMMENTS
Bilberry
Acute diarrhea, diabetic retinopathy
PAI
CS unknown; interaction with aspirin and
warfarin possible
Blackcurrent
Increases micturition, gout, colic, jaundice
PAI
CS unknown; high γ-linolenic acid content
Bladderwrack
Obesity, diseases of thyroid, arteriosclerosis
PAI/FFI
CS not well documented
Cayenne fruit
Gastroprotective agent, muscular tension,
rheumatism
PAI
CS unknown; can reduce salicylate
bioavailability
Celery plant
Diuretic, glandular stimulation, gall and
kidney stones
PAI
CS not documented
Da huang
Laxative, gastrointestinal disorders
PAI
Inhibits thromboxane A2 synthesis, but CS
not demonstrated
Danshen
Cardiovascular and liver disease,
glaucoma, cholesterol
PAI
Documented CS interaction with warfarin
Devil’s claw
Rheumatism, loss of appetite, dyspeptic
complaints
PAI
Documented CS interaction with warfarin
Dong quai
Stabilizes hormonal imbalance, muscular
tension
PAI
Documented CS interaction with warfarin;
NCS in the absence of warfarin
Evening primrose
seed oil
Atopic dermatitis, premenstrual syndrome,
mastalgia
PAI
CS in humans at 3-g daily dose
Feverfew
Migraines, arthritis, fever
PAI
Only slight inhibition of platelet aggregation
documented in patients
Garlic
Antibacterial, antifungal, hypertension
PAI/FFI
Documented CS, especially in high doses or
combined with warfarin
German
chamomile
Inflammatory disease of gastrointestinal
tract
PAI
Probably NCS; coumarin derivatives in
chamomile may be hemostatic
Ginkgo
Cerebral circulation, vertigo, tinnitus
PAI
Documented CS in humans
Panax ginseng
Fatigue, debility, stamina
PAI/FFI
Interactions conducive to bleeding are
produced when taken with warfarin
Horse chestnut
Chronic venous insufficiency, swelling of
legs
PAI
Has a coumarin component, but
anticoagulant activity not well documented
Kava kava root
Sleeping agent, sedative, syphilis,
gonorrhea
PAI
FDA warns of liver damage/failure with kava
kava
Licorice
Gastrointestinal ulcers, bronchitis
PAI
Contains 3-arylcoumarin derivative, CS in
large doses
Meadowsweet
Bronchitis, cough, cold therapy, diuretic
PAI
Not documented, but salicylates could be CS
Papaya
Gastrointestinal complaints, ulcers,
intestinal parasites
PAI
Potentiation of warfarin is documented
Poplar
Hemorrhoids, wounds, burns, pain therapy
PAI
Contains salicylates that may be CS
Red clover
Respiratory conditions, coughs
PPA
Contains coumarin derivatives, but CS not
documented
Sweet clover
Hemorrhoids, blunt injuries, venous
conditions
PPA
CS at high doses; coumarin can be obtained
from sweet clover
Tamarind
Chronic and acute constipation, gallbladder
ailments
Increases bioavailability
Can increase the bioavailability of aspirin and
ibuprofen
Vitamin E
Alzheimer’s dementia, heart disease,
prostate cancer
PAI
May be CS, especially at high doses; can
potentiate effect of warfarin or aspirin
Willow bark
Anti-inflammatory, arthritis, pain therapy
PAI
Anticoagulation not well documented in
patients but may be CS
CS, clinical significance/clinically significant; FDA, Food and Drug Administration; FFI + fibrin formation inhibitor; NCS, not clinically significant; PAI, platelet aggregation
inhibitor; PPA, possible prothrombinopenic anticoagulant.
Reprinted with permission from Dinehart and Henry. Dietary supplements: coagulation and bruising. Dermatol Surg 31:7(Part 2): July 2005.

81
Chapter 5  Patient Evaluation, Informed Consent, Preoperative Assessment, and Care
testing.33 In many cases of suspected amide anesthetic allergy,
the ‘allergen’ is actually not the anesthetic itself, but rather
the preservatives such as para-aminobenzoic acid (PABA),
parabens, or metabisulfite, which are commonly added to the
solutions.33,34 In most instances of suspected anesthetic
allergy, the solution is simply to substitute an anesthetic
belonging to a different class, such as an ester (procaine) for
an amide (lidocaine), as cross-reactivity is not observed. For
patients with documented allergy to parabens, paraben-free
anesthetics are widely available.
Antibiotics
Patients with allergies to oral antibiotics should be treated
with appropriate alternatives. Cephalosporin antibiotics can
usually be given safely to penicillin-allergic patients who do
not exhibit an anaphylactic response to penicillin.35,36 Other
alternatives in penicillin-allergic patients include macrolides
such as azithromycin, clarithromycin, and erythromycin.
Antibiotic allergy may also occur with topically applied
agents. Although most reactions are typically due to neomy-
cin, an aminoglycoside antibiotic, bacitracin allergy has
recently been reported with increased frequency.37 In patients
with suspected topical antibiotic allergy, wounds should be
dressed with petrolatum or Aquaphor ointment (Beiersdorf,
Wilton, CT). Alternatively, Bactroban (mupirocin) ointment
(GlaxoSmithKline, Research Triangle Park, NC), if medically
indicated, can be used safely in patients with either bacitracin
or neomycin allergy.
Latex
Latex allergy is common in medical settings, affecting approx-
imately 12% of all healthcare workers.38 Symptoms may
range from localized urticaria to anaphylaxis.39 Common
sources for allergens include disposable exam gloves, elastic
dressings, and surgical tubing.
Examination glove allergy is generally caused by hypersen-
sitivity to the natural rubber latex molecule. The ‘powder’
present in latex examination gloves has been shown to be an
important vehicle for environmental aerosolization. However,
true allergy to the absorptive agents such as corn starch and
talc, which are used in powdered examination gloves, is
exceedingly rare.
Screening questions for latex allergy should be included in
the preoperative evaluation. Extra pairs of vinyl or nitrile
gloves should be kept in examination rooms for latex-
sensitive patients. Environmental aerosolization of latex aller-
gens may further be minimized through the use of powder-free
latex gloves. Many medical centers have taken a pre-emptive
approach by eliminating latex-containing products from
patient care areas.
Surgical history
Targeted questions can be used to identify patients at high
risk for perioperative complications. Questions relating to the
patient’s previous experience with surgical and dental proce-
dures can help to elucidate these issues. Examples include:
• Have you ever had problems with excessive bleeding?
• Have you ever had problems with scar or keloid
formation?
• Have you ever had difficulty with wound healing?
Based on the above findings, our general recommendations
for anticoagulant discontinuation before surgery are outlined
in Box 5.2.
Non-selective b-blockers
The potential for disastrous complications resulting from the
use of epinephrine-containing local anesthetics in patients
taking non-selective β-blockers is often overlooked. Through
inhibition of vasodilatory β2-adrenergic receptors, non-selec-
tive β-blockers such as propranolol may actually potentiate
the α-adrenergic vasoconstrictive effects of epinephrine
leading to malignant hypertension, profound reflexive brady-
cardia, and even death, when combined with epinephrine.30
In such instances, treatment with intravenous vasodilators
such as hydralazine or chlorpromazine may be appropriate.31
Similar cardiac effects, however, are not observed with the
selective β1-blocker, metoprolol. Despite this, we suspect
there are many patients taking non-selective β-blockers who
receive epinephrine-containing anesthetics in the course of
dermatologic procedures without any adverse effect. The
ultimate significance of this potential interaction in dermato-
logic surgery is therefore unknown and – as some speculate
– idiosyncratic.32 In the event that a medication change is
desired, consultation with the patient’s primary care physi-
cian is essential.
Allergies
A list of medication allergies should be included in the preop-
erative evaluation. In particular, dermatologic surgeons should
pay special attention to patients with possible allergy to local
anesthetics, antibiotics, pain medications, latex, or surgical
wound dressings.
Local anesthetics
True allergy to ester anesthetics is not uncommon and neces-
sitated the development of less allergenic compounds, the
amide anesthetics. True allergy to newer amide local anes-
thetic is generally rare and can be documented through skin
Box 5.2  General recommendations for
anticoagulant discontinuation before
cutaneous surgery
 Discontinue aspirin 10–14 days prior to surgery only for
patients who are taking aspirin for ‘preventive’ purposes,
without a history of coronary or cerebrovascular disease, or
without explicit instructions from their physician.
 Discontinue use of NSAIDs 10–14 days prior to surgery if
using NSAIDs for pain relief. Patients may substitute with
non-aspirin or non-NSAID pain relievers instead (like
acetaminophen or cyclo-oxygenase COX-2 inhibitors).
 Discontinue all nutritional supplements, including
multivitamins, 10–14 days before the surgical procedure.
 Avoid alcoholic beverages for 2 days before the surgical
procedure.
 Continue all other anticoagulant regimens, including
Coumadin, clopidogrel, dipyridamole, and aspirin–
anticoagulant combinations without explicit instructions from
the patient’s internist.