Tumescent Anaesthesia Paper

~

ISSN : 0019- 5154

, ..~

TUMESCENT ANESTHESIA: A USEFUL TECHNIQUE FOR HARVESTING SPLIT-THICKNESS SKIN GRAFT

Sanjay Saraf, Prashant Goyal, Pankaj Ranka

Tumescent anesthesia is now an established technique for regional anesthesia of the skin and the subcutaneous fatty tissue. The unsurpassed simplicity and safety of this procedure have opened up the gates for newer indications. We have employed this technique for harvesting split-thickness grafts in various conditions. We have found that this technique is extremely simple in which large areas can be anesthetized for harvesting split-thickness skin grafts safely. The good passive resistance achieved facilitates easy harvesting of spliHhickness grafts along with minimal bleeding and long lasting pain relief. We found this to be an inexpensive, safe and simple technique with elimination ofrisks and expenses of general anesthesia.

Indian J Dermatol2004; 49 (4):

184-186

Key Words: Tumescent anesthesia, Split-thickness skin graft Introduction The word "tumescent"

is derived from the Latin

"tumidus" meaning swollen.' It is a regional anesthetic technique of the skin and the subcutaneous fatty tissue provided by direct infiltration of large volumes of a dilute local anesthetic. Klein is credited with the first description of this technique which was initially intended to facilitate liposuction.2.3 Subsequently, many disciplines utilized this technique for various indications as per their requirement. The aim of this study was to assess and evaluate its application in harvesting splitthickness skin grafts. Materials and methods This technique was employed for harvesting splitthickness grafts in 19 patients (13 males and 6 females), with ages ranging from 18 to 55 years. The From the Department of Plastic & Reconstructive Surgery, Christian Medical College, Vellore, Tamil Nadu -632004, India. Address correspondence to : Dr Sanjay Saraf, 6-A, Sahnti Priya Nagar, Near Kamla Nagar Hospital, Jodhpur, Rajasthan - 342 002.

Indian J Dermatol 2004; 49 (4)

patients were explained about the procedure beforehand and informed consent was taken. The arbitrary requirement considered was application of split-skin grafts to a healthy granulating wound not requiring any other surgical intervention. Patients excluded from the study were those with sensitivity to lignocaine, with history of cardiac, renal disease or hepatic dysfunction, raw areas more than 10 percent, pregnant women and patients under 18 years of age. The choice of donor site was restricted to the thigh which was shaved and prepared. The area of the donor site was marked as per the requirement. Split-thickness skin grafts were harvested using a Watsons' modification ofHumby's knife. A standard donor site dressing was subsequently done with paraffin tulle, roller gauze and bandage. The solution used for tumescent technique consisted oflignocaine 500 mg/L (0.05%) adrenaline 0.5mg/L (about 1:2,000,000), sodium bicarbonate 10 mg/L, triamcinolone acetonide (Kenacort) 10 mg/L, which was dissolved in 1000 ml ofnOlwal saline. Preliminary anesthesia of each infiltration site was obtained by raising a small bleb utilizing 1 m1of2% lignocaine with adrenaline using a 25 G needle. The amount of

184

""

lr I

Tumescent anesthesia:

tumescent solution infiltrated ranged between 30 and 50 ml depending upon individual case. The maximum safe dose was calculated as per individual requirement and never exceeded 35 mg/kg body weight in accordance with Klein's study.4,5Infiltration was done using a readily available 18 G spinal needle along with a 20 ml disposable syringe. Prior to sta;;ting the procedure, an intravenous access was secured, cardiac monitor and pulse oximeter were attached and emergency medicines rechecked. The indications for skin grafting are listed in Table 1. Table 1 Indications for skin grafting Indication Postburn raw areas Posttraumatic raw areas Others*

No of patients 9 8 2

Total

19

*One leg ulcer. One post-infective raw area

Results Table 2 gives the incidence of pain while harvesting skin grafts. While three patients (16%) experienced no pain, nine patients (48%) experienced mild pain but did not complain while harvesting skin graft. In three patients (16%) the pain was described as moderate, but the operation could be completed without any fmiher local or general anesthesia. Four patients (22 %) complained of severe pain and required general anesthesia for completion of the procedure. The Table 2 Experience of pain while harvesting skin grafts Gradation

Male (%)

No pain

3 (16)

Female (%)

Mild pain

6 (32)

3 (16)

Moderate pain

2(11)

1 (5)

Severe pain

2(11)

2(11)

Table 3 Post-harvest bleeding from donor site Degree of bleeding

Male (%)

Female (%)

Minimal

6 (40)

3 (20)

Moderate

3 (20)

1 (7)

Severe

2 (13)

Indian J Dermatol 2004; 49 (4)

a useful technique for harvesting split-thickness skin graft

tumescent technique was found to be successful in fifteen patients (79%). Subjective and objective features suggestive of toxicity of tumescent anesthesia were not seen in any of the patients. Fifteen patients were evaluated for post split-thjckness harvest bleeding (Table 3). Nine patients (60%) had minimal bleeding while four patients (27%) had moderate bleeding. In two patients (13 %), excessive donor site bleeding was observed but this did not require any active intervention. We observed early loosening of donor site dressing in nine out of fifteen patients with healing underneath in 10-12 days as compared to conventional 15-21days. No allergic reaction was observed nor was there any sign of tumescent solution toxicity. No significant change in blood pressure was detected. The study did not evaluate post-operative plasma level of lignocaine. Discussion Tumescent anesthesia is the subcutaneous injection of a large volume of dilute local anesthetic solution with adrenaline. The unsurpassed simplicity and safety of this procedure have led to its application in a wide variety of surgical procedures.6 With tumescent anesthesia now being a universally accepted technique, we were tempted to apply it for harvesting split-skin grafts which is unarguably one of the commonest operations in plastic surgery. This method of anesthesia, which was originally intended to facilitate liposuction, was first described by Klein.3 Though various concentrations, like 0.05,0.075 and 0.1 % have been described, there is no such thing as a standard tumescent solution. The concentration of infiltrated solution directly correlates with the amount of connective tissue present in the surgical site. Concomitantly, the quantity of infiltrated solution is inversely proportional to concentration. Various studies on the pharmacology of the 0.05% solution document adequate intraoperative safety upto at least 35 mg/kg body weight. Klein4.sand Ostad et aP have reported the safe dose of lignocaine as 35 mg/kg and 55 mg/kg respectively. This is five to eight times the manufacturer's recommended maximum safe dose of

-~

lignocaine with adrenaline. The American Society for Dermatological Surgery in 19978 recommended a maximum dose oflignocaine of 55 mg/kg body weight after multicentric trials. The factors found responsible for safety of tumescent anesthesia include dilute

185 J

Sanjay Sara! et at

solution of lignocaine, a relatively avascular subcutaneous tissue, lipid solubility of lignocaine, vasoconstrictive effect of adrenaline and compression of vasculature from infusion of large volume of solution. The extraordinary safety of this method was demonstrated by the American Society for Dermatological Surgery after evaluation of data of 15,336 patients who underwent liposuction under tumescent local anesthesia.8 The complications of this method were also found to be rare.9 The basic prerequisite for surgery with tumescent anesthesia is that the patient should be in good health, with no impaired cardiovascular, renal or hepatic function. Till date, no data from any study with a sufficiently large sample exists on the incidence of toxic reactions to local anesthetics in tumescent solution. Special precautions with appropriate measures are mandatory in patients with marked myocardial weakness or in patients with known tendency of cardiac anhythmias because of the danger of fluid overloading and proanhythmic effect of local anesthetic. The patients with deranged liver function also need special attention. Psychologically unstable patients, children and very apprehensive patients are also unsuitable for tumescent anesthesia. The only absolute contraindication is a known allergy to lignocaine. Nevertheless, the surgeon should be familiar with the signs and symptoms of lignocaine toxicity and must be adequately equipped to manage it. Tumescent technique has been successfully used by us in harvesting split-thickness skin grafts, which represents a further extension of its growing use. This simple, safe and inexpensive technique provides comfortable anesthesia of large donor areas with sufficient tissue turgor for harvesting uniform thickness split-skin grafts. A minimal donor site bleeding and possibly relatively early donor wound healing seem to be added advantage of this technique.

References 1.

Robertson RD, Bond P, Wallace B, et al. The tumescent technique to significantly reduce blood loss during burn surgery. Bums 2001;27:835- 8.

2.

Klein JA. Tumescent technique chronicles. Local anesthesia, liposuction and beyond. Dermatol Surg 1995;21:449-57.

3.

Klein JA. The tumescent technique for liposuction surgery. AmJ Cosm Surg 1987;4:263-7.

4.

Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993;92: 1085-98.

5.

Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mglkg for liposuction. J Dermatol Surg OncoI1996;16:248-63.

6.

Williams J. Plastic surgery in an office surgical unit. Plast Reconstr Surg 1973; 52:513-9.

7.

Ostad A, Kageyana N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 1996;22:921-7.

8.

American Society for Dermatological Surgery. Guiding principlesfor liposuction.Dermatol Surg 1997;23:1127-9.

9.

Klein JA, Kassarjdian W. Lidocaine toxicity with tumescent liposuction. A case report of probable drug interactions. Dermatol Surg 1997;23: 1169-74.

10.

Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients national survey results. Dermatol Surg 1995;21:459-62.

11. Hanke CW, Bullock S, Bernstein G. Current status of tumescent liposuction in the United States National Surgery results. Dermatol Surg 1996;22:595-8.

--..

Indian J Dermatot2004; 49 (4)

186