The ability to perform some basic surgery is an essential part of a dermatologist’s skills and many GPs now also undertake simple procedures. Up to 60% of referrals to Dermatology may need some surgical intervention.

Preparation Prior to Surgery

Full counselling is essential prior to any surgical procedure to explain why the procedure is necessary, what will be done and possible complications (Table 8.1). This avoids any conflict and potential complaints afterwards.

Pre-operative history should include past medical history and drug history including anti-coagulants and anti-platelets (e.g. warfarin, aspirin) which may need to be stopped prior to surgery.

Basic understanding of anatomy is essential to perform surgery safely, particularly on the face and neck (e.g. branches of the facial nerve and superficial temporal arteries need to be avoided; Figure 8.1).

Local Anaesthesia

1% or 2% lidocaine is used with adrenaline (1 : 80,000 or 1 : 200,000) or without adrenaline. A person weighing 70 kg can have a maximum of 50 mL 1% lidocaine with 1 : 200,000 adrenaline. Adrenaline causes vasoconstriction to reduce bleeding and also increases the duration of the anaesthesia.

Use lidocaine with caution in patients taking non-selective beta-blockers as this can lead to hypertension and reflex bradycardia.

Nerve blocks use less volume and can give effective anaesthesia (e.g. supra/infraorbital). Digital ring blocks for finger anaesthesia usually use plain lidocaine without adrenaline to reduce the risk of ischaemia.

The pain of local anaesthetic injections can be reduced (e.g. in children) with the use of tetracaine gel (Ametop®) used 30 minutes pre-operatively. Other tricks include using 0.5% plain lidocaine without preservative with a small gauge (30 g) needle followed by 1% lidocaine with 1 : 200,000 adrenaline.

Always check the anaesthetic has been effective before starting the procedure!

Side effects of local anaesthetic include accidental injection and toxicity, pain and temporary weakness of muscles (e.g. difficulty raising the eyebrows or closing the eyes after injecting the temple area).

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