In plastic surgery, there are many procedures that can be performed using local instead of general anesthesia. Not only can this help mitigate health care costs, but precious operating-room resources can also be directed to areas of greater need. Common procedures that can be performed under local anesthetics include skin grafts and local flaps. However, as not all patients are suitable for local anesthesia, careful patient selection is necessary to maintain the standard of care. This article describes the detailed surgical approach to using local anesthetics for skin grafts and local flaps.
Key points
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Health care resources are limited, and surgeons must adopt evidence-based and efficient practices for improved patient outcomes.
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Use of local anesthesia for skin grafts and local flaps can be an excellent alternative to general anesthetics.
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Appropriate patient selection for the use of local anesthetics is imperative to maintain safety and the standard of care.
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Many factors influence the success of local anesthesia, including method of injection, type and volume of solution, needle characteristics, and how the local anesthetic is injected.
Introduction
In Canada, as in other jurisdictions, expenditures in health care are coming under scrutiny because of their tremendous burden on the system. For instance, in Ontario, Canada’s largest province, health care consumes about 40% of the provincial budget. Over the last 30 years it has been recognized that significant waste occurs in the delivery of health care, estimated to be about 50% in the United States, 25% in Canada, and 20% to 40% on a global basis. The cost and waste in health care continues to increase despite finite resources. This predicament has required all stakeholders in the health care team, including surgeons, to take innovative and prudent steps to manage resources and reduce costs while allowing for long-term competitive advantage. One of the most sought-after and cost-consuming resources in a hospital setting is the operating room. As surgeons we assume the role of not only being the gatekeepers of operating room but also the managers, responsible for its most efficient use. Expectations to reduce surgical waiting times have challenged us to reevaluate the decision to perform most procedures in the main operating room (MOR).
In plastic surgery, many common procedures such as skin grafts and local flaps can be performed safely and easily in the ambulatory setting under local anesthetic (LA). In the authors’ geographic region, the notion of performing “complex” procedures in the ambulatory minor procedure room (MPR) began with carpal tunnel release (CTR) more than 30 years ago. At that time, the senior author (A.T.) was faced with the same dilemma: long waiting times arising from limited space in the MOR, or performing the CTR in a less formal environment, namely the MPR. Subsequently, as no significant issues were identified in the latter, this gradually became the standard of care. The procedure can be completed with only one attendant nurse without requiring blood work or intravenous infusion. Furthermore, on completion of the procedure the patients are discharged home within minutes, substantially reducing the amount of time spent in the recovery room. This approach bypasses the unnecessary and sometimes adverse complications associated with general anesthesia, such as nausea and vomiting. A recent cost-effectiveness analysis showed that, if performed in the ambulatory setting, CTR would be 4 times cheaper and 2 times faster than if completed in the MOR.
An increasing demand for cost-effective and efficient health care services continues to challenge surgeons to deliver the same quality of care, but more efficiently. For instance, the concept of using LA for minor procedures can be broadened to include skin grafting and local flaps, a practice that in the authors’ institution is more commonly performed in the MPR than the MOR. Skin grafts and local flaps are often required after excision of lesions such as basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). The purpose of this article is to outline the surgical approach to skin grafts and local flaps using LA.
Although the goal of this issue of Clinics is to encourage clinicians to consider the use of LA alone in a minor-procedure setting, it behooves us all to be reminded that many of the patients who require skin grafts and flaps are elderly. The elderly population is not only increasing as a percentage of the whole population but also has higher number of comorbidities that need attention, for example, end-stage renal failure, congestive heart failure, and aortic stenosis. This group of patients is better served in the MOR with anesthesia standby ( Box 1 ).
Candidate for Main Operating Room
Multiple comorbidities requiring anesthesia support
Needle phobias
Psychiatric population
Pediatric population
High anxiety
Inability to tolerate lengthy procedure
Introduction
In Canada, as in other jurisdictions, expenditures in health care are coming under scrutiny because of their tremendous burden on the system. For instance, in Ontario, Canada’s largest province, health care consumes about 40% of the provincial budget. Over the last 30 years it has been recognized that significant waste occurs in the delivery of health care, estimated to be about 50% in the United States, 25% in Canada, and 20% to 40% on a global basis. The cost and waste in health care continues to increase despite finite resources. This predicament has required all stakeholders in the health care team, including surgeons, to take innovative and prudent steps to manage resources and reduce costs while allowing for long-term competitive advantage. One of the most sought-after and cost-consuming resources in a hospital setting is the operating room. As surgeons we assume the role of not only being the gatekeepers of operating room but also the managers, responsible for its most efficient use. Expectations to reduce surgical waiting times have challenged us to reevaluate the decision to perform most procedures in the main operating room (MOR).
In plastic surgery, many common procedures such as skin grafts and local flaps can be performed safely and easily in the ambulatory setting under local anesthetic (LA). In the authors’ geographic region, the notion of performing “complex” procedures in the ambulatory minor procedure room (MPR) began with carpal tunnel release (CTR) more than 30 years ago. At that time, the senior author (A.T.) was faced with the same dilemma: long waiting times arising from limited space in the MOR, or performing the CTR in a less formal environment, namely the MPR. Subsequently, as no significant issues were identified in the latter, this gradually became the standard of care. The procedure can be completed with only one attendant nurse without requiring blood work or intravenous infusion. Furthermore, on completion of the procedure the patients are discharged home within minutes, substantially reducing the amount of time spent in the recovery room. This approach bypasses the unnecessary and sometimes adverse complications associated with general anesthesia, such as nausea and vomiting. A recent cost-effectiveness analysis showed that, if performed in the ambulatory setting, CTR would be 4 times cheaper and 2 times faster than if completed in the MOR.
An increasing demand for cost-effective and efficient health care services continues to challenge surgeons to deliver the same quality of care, but more efficiently. For instance, the concept of using LA for minor procedures can be broadened to include skin grafting and local flaps, a practice that in the authors’ institution is more commonly performed in the MPR than the MOR. Skin grafts and local flaps are often required after excision of lesions such as basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). The purpose of this article is to outline the surgical approach to skin grafts and local flaps using LA.
Although the goal of this issue of Clinics is to encourage clinicians to consider the use of LA alone in a minor-procedure setting, it behooves us all to be reminded that many of the patients who require skin grafts and flaps are elderly. The elderly population is not only increasing as a percentage of the whole population but also has higher number of comorbidities that need attention, for example, end-stage renal failure, congestive heart failure, and aortic stenosis. This group of patients is better served in the MOR with anesthesia standby ( Box 1 ).
Candidate for Main Operating Room
Multiple comorbidities requiring anesthesia support
Needle phobias
Psychiatric population
Pediatric population
High anxiety
Inability to tolerate lengthy procedure
Treatment goals and planned outcomes
The treatment goals of using LA for skin grafts and flaps can be divided into surgeon-oriented and patient-oriented goals ( Box 2 ).
Surgical Goals
Optimize patient safety
Maintain standard of care
Strengthen physician medical competencies
Minimize operative time
Reduce surgical wait times
Patient Goals
Patient education
Avoid complications associated with general anesthetics
Shorten hospital stay
Mitigate anxiety
Screen for needle phobia
Patient Selection
The primary surgical objectives are to ensure patient safety and maintain the standard of care. A foremost important safety measure is to identify patients who are suitable for procedures with LA, whether in the MPR or MOR setting (see Box 1 ). Patients who benefit from having their procedures done in the MOR are those with multiple comorbidities, and carry a higher perioperative risk. These patients often require the assistance of an anesthesiologist to help monitor their status during the procedure. Although LA can still be used, the MOR setting is safer because it allows anesthesia staff to be on standby in case of emergencies. Another cohort for which the MOR would be more appropriate is patients with needle phobia and certain psychiatric conditions. The assumption is that they cannot tolerate the length of the procedure and would generally benefit from light sedation or general anesthesia in the MOR. Pediatric patients, in particular, may have high levels of anxiety during procedures done using LA. It is well known that most young children do not even tolerate a simple dressing change without sedation. Hence, it is imperative to understand that pediatric patients will require sedation or general anesthesia for most procedures. By being able to recognize which patients are suitable for the MPR or MOR, the surgeon appropriately triages patients and maintains the standard of care.
Surgeon-Oriented Goals
Another surgical goal is to strengthen the surgeon’s medical competencies, particularly the managerial role. In 1996, the Royal College of Physicians and Surgeons of Canada adopted the CanMeds roles: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. These roles were implemented to allow the specialist to develop the skills and abilities for better patient outcomes. By using LA, in the MPR the need for sedation or general anesthesia is eliminated. Effectively reducing MOR requirements, this translates into more cases being completed in a specified time frame and a reduction in the surgical wait times. In addition, as most of these cases can be done in the MPR, the surgeons can allocate operating-room resources for patients requiring more extensive procedures. Placing the surgeon in control of the operating room (a finite resource) will foster important managerial skills targeted at improving patient outcomes.
Patient-Oriented Goals
In addition to surgeon-oriented goals there are patient-oriented goals. The main objective for the patient is centered on education, emphasizing the advantages of LA over sedation or general anesthesia. The one major benefit for patients is the avoidance of possible complications such as those related to intravenous insertion (eg, extravasations) or reactions to the general anesthetic (eg, intubation-related adverse events or postoperative nausea and vomiting). The other advantage of using LA is that it gives patients the opportunity to enter and leave the hospital without altering their level of consciousness. The patients resume their usual activities as soon as possible. If sedation or general anesthesia is required; however, they will need to spend more time recovering and possibly be admitted for observation. For instance, after general anesthesia, patients with moderate to severe forms of obstructive sleep apnea are usually admitted overnight to monitor oxygen saturation. The premise is that the effects of the general anesthetic may prevent them from being able to protect their airway during sleep time. By educating the patient on the numerous benefits of LA, the treatment is aimed at reducing any unwarranted anxiety about being awake. It should be noted that patients should be initially screened for uncontrolled anxiety or needle phobias by asking them how they react to the needle from the dentist. If a true phobia exists, consideration can be given to intervention in the MOR under LA with an anesthetist on standby.
Preoperative planning and preparation
The preoperative planning should focus on preparing the patient and the ambulatory setting for the intervention. In the case of skin grafts and skin flaps, this includes obtaining informed consent and explaining the risk and benefits of the procedure. The patient’s weight and any known allergies should be noted. To guarantee proper organization of the ambulatory setting, a MPR equipped with an operating-room table or equivalent and lighting is required. A nursing staff member is needed to help during the procedure and with patient monitoring. Equipment required includes, but is not limited to: oxygen saturation monitor and blood-pressure cuff; sterile surgical equipment; cautery and silver dermatome for small skin grafts, or a Zimmer dermatome for larger ones. If the surgery is planned in the MOR with an anesthetist on standby because of a patient’s significant medical conditions (eg, congestive heart failure or end-stage renal failure), similar equipment is required; however, the surgeon will have the assistance of additional staff members.
Patient positioning
For most procedures the patient can be in supine, lateral decubitus, or prone position. It is imperative to apply an oxygen saturation monitor and blood-pressure cuff. The operative site is prepped and draped in the usual standard fashion. For split-thickness skin grafts (STSG), the ipsilateral thigh is generally chosen as the donor site. If needed, hairs from the thigh may be clipped before the procedure. For full-thickness skin grafts (FTSG), donor sites such as the groin, neck, or proximal forearm are chosen based on recipient-site characteristics.
Procedural approach
Major Steps for Injecting Local Anesthetics
Choice of local anesthetic
The first step is to choose an LA. Several factors influence this decision, including:
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Desired onset of action
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Anticipated length of procedure
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Volumes necessary for adequate anesthesia
Lidocaine has faster onset (within seconds) but shorter duration of action (1.5–2 hours). Conversely, bupivacaine has slower onset (within minutes) but longer duration of action (3–6 hours).
In certain situations it may be advantageous to use a mix of both fast-acting and long-lasting LA. When only small volumes of LA (eg, grafts and flaps on finger tips) are required, the use of 2% lidocaine, rather than the commonly used 1% concentration, may also be used for faster onset of action.
Lastly, additives to the LA should be considered. Epinephrine, a common premixed additive, has vasoconstrictive effects that provide local hemostasis and restrict vascular absorption. Bicarbonate, which can also be added to preparations, increases the pH of LA and helps to reduce tissue irritation with injection.
Safe volumes
The maximum dosage of LA should be calculated before administration. This dosage differs based on the LA, its concentration, and the patient’s weight ( Table 1 ). For example, for a healthy adult patient who weighs 60 kg, the maximum allowable dosage of lidocaine without epinephrine is 60 kg × 4 mg/kg = 240 mg. If 1% lidocaine is used, it contains 1 g of lidocaine per 100 mL of solution, and therefore 24 mL of this solution can be safely administered. If the operative site is larger and a greater amount of volume is required to achieve anesthetic effect, the solution may be diluted to meet requirements or alternative techniques other than infiltrative anesthesia may be considered (see later discussion). Either sterile normal saline or water can be used to dilute standard concentrations in a syringe or small intravenous bag. Dilute solutions are particularly useful for local anesthesia of large skin graft donor sites.
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