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TUMESCENT ANESTHESIA: A USEFUL TECHNIQUE FORHARVESTING SPLIT-THICKNESS SKIN GRAFT

Sanjay Saraf, Prashant Goyal, Pankaj Ranka

Tumescent anesthesia is now an established technique for regional anesthesia of the skin andthe subcutaneous fatty tissue. The unsurpassed simplicity and safety of this procedure haveopened up the gates for newer indications. We have employed this technique for harvestingsplit-thickness grafts in various conditions. We have found that this technique is extremelysimple in which large areas can be anesthetized for harvesting split-thickness skin graftssafely. The good passive resistance achieved facilitates easy harvesting of spliHhicknessgrafts 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 anesthetictechnique of the skin and the subcutaneous fatty tissueprovided by direct infiltration of large volumes of adilute local anesthetic. Klein is credited with the first

description of this technique which was initially intendedto facilitate liposuction.2.3 Subsequently, manydisciplines utilized this technique for various indicationsas per their requirement. The aim of this study was toassess and evaluate its application in harvesting split-thickness skin grafts.

Materials and methods

This technique was employed for harvesting split-thickness grafts in 19 patients (13 males and 6females), 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 beforehandand informed consent was taken. The arbitraryrequirement considered was application of split-skingrafts to a healthy granulating wound not requiringany other surgical intervention. Patients excluded fromthe study were those with sensitivity to lignocaine, withhistory of cardiac, renal disease or hepatic dysfunction,raw areas more than 10 percent, pregnant women andpatients under 18 years of age. The choice of donorsite was restricted to the thigh which was shaved andprepared. The area of the donor site was marked asper the requirement. Split-thickness skin grafts wereharvested using a Watsons' modification ofHumby'sknife. A standard donor site dressing was subsequentlydone 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, whichwas dissolved in 1000 ml ofnOlwal saline. Preliminaryanesthesia of each infiltration site was obtained byraising a small bleb utilizing 1m1of2% lignocaine withadrenaline using a 25 G needle. The amount of

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Tumescent anesthesia: a useful technique for harvesting split-thickness skin graft

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tumescent solution infiltrated ranged between 30 and50 ml depending upon individual case. The maximumsafe dose was calculated as per individual requirementand never exceeded 35 mg/kg body weight inaccordance with Klein's study.4,5Infiltration was doneusing a readily available 18 G spinal needle along with

a 20 ml disposable syringe. Prior to sta;;ting theprocedure, an intravenous access was secured, cardiacmonitor and pulse oximeter were attached andemergency medicines rechecked. The indications forskin grafting are listed in Table 1.

Table 1 Indications for skin grafting

Indication No of patients

Postburn raw areasPosttraumatic raw areas

Others*

982

19Total

*One leg ulcer. One post-infective raw area

Results

Table 2 gives the incidence of pain while harvestingskin grafts. While three patients (16%) experiencedno pain, nine patients (48%) experienced mild pain butdid not complain while harvesting skin graft. In threepatients (16%) the pain was described as moderate,but the operation could be completed without anyfmiher local or general anesthesia. Four patients (22%)complained of severe pain and required generalanesthesia for completion of the procedure. The

Table 2 Experience of pain while harvesting skin grafts

Table 3 Post-harvest bleeding from donor site

Degree of bleeding Male (%) Female (%)

Minimal

Moderate

Severe

6 (40)

3 (20)

2 (13)

3 (20)

1 (7)

Indian J Dermatol 2004; 49 (4)

tumescent technique was found to be successful infifteen patients (79%). Subjective and objectivefeatures suggestive of toxicity of tumescent anesthesiawere not seen in any of the patients. Fifteen patientswere evaluated for post split-thjckness harvest bleeding(Table 3). Nine patients (60%) had minimal bleedingwhile four patients (27%) had moderate bleeding. Intwo patients (13 %), excessive donor site bleeding wasobserved but this did not require any active intervention.We observed early loosening of donor site dressing innine out of fifteen patients with healing underneath in10-12 days as compared to conventional 15-21days.No allergic reaction was observed nor was there anysign of tumescent solution toxicity. No significantchange in blood pressure was detected. The study didnot evaluate post-operative plasma level of lignocaine.

Discussion

Tumescent anesthesia is the subcutaneous injectionof a large volume of dilute local anesthetic solutionwith adrenaline. The unsurpassed simplicity and safetyof this procedure have led to its application in a widevariety of surgical procedures.6 With tumescentanesthesia now being a universally accepted technique,we were tempted to apply it for harvesting split-skingrafts which is unarguably one of the commonestoperations in plastic surgery. This method of anesthesia,which was originally intended to facilitate liposuction,was first described by Klein.3 Though variousconcentrations, like 0.05,0.075 and 0.1 % have beendescribed, there is no such thing as a standardtumescent solution. The concentration of infiltrated

solution directly correlates with the amount ofconnective tissue present in the surgical site.Concomitantly, the quantity of infiltrated solution isinversely proportional to concentration. Various studieson the pharmacology of the 0.05% solution documentadequate intraoperative safety upto at least 35 mg/kgbody weight. Klein4.sand Ostad et aP have reportedthe safe dose of lignocaine as 35 mg/kg and 55 mg/kgrespectively. This is five to eight times themanufacturer's recommended maximum safe dose of

lignocaine with adrenaline. The American Society forDermatological Surgery in 19978 recommended amaximum dose oflignocaine of 55 mg/kg body weightafter multicentric trials. The factors found responsiblefor safety of tumescent anesthesia include dilute

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Gradation Male (%) Female (%)

No pain 3 (16)

Mild pain 6 (32) 3 (16)

Moderate pain 2(11) 1 (5)

Severe pain 2(11) 2(11)

Sanjay Sara! et at

solution of lignocaine, a relatively avascularsubcutaneous tissue, lipid solubility of lignocaine,vasoconstrictive effect of adrenaline and compressionof vasculature from infusion of large volume ofsolution. The extraordinary safety of this method wasdemonstrated by the American Society forDermatological Surgery after evaluation of data of15,336 patients who underwent liposuction undertumescent local anesthesia.8 The complications of thismethod were also found to be rare.9 The basic

prerequisite for surgery with tumescent anesthesia isthat the patient should be in good health, with noimpaired cardiovascular, renal or hepatic function. Tilldate, no data from any study with a sufficiently largesample exists on the incidence of toxic reactions tolocal anesthetics in tumescent solution. Specialprecautions with appropriate measures are mandatoryin patients with marked myocardial weakness or inpatients with known tendency of cardiac anhythmiasbecause of the danger of fluid overloading andproanhythmic effect of local anesthetic. The patientswith deranged liver function also need special attention.Psychologically unstable patients, children and veryapprehensive patients are also unsuitable for tumescentanesthesia. The only absolute contraindication is aknown allergy to lignocaine. Nevertheless, the surgeonshould be familiar with the signs and symptoms oflignocaine toxicity and must be adequately equippedto manage it.

Tumescent technique has been successfully used byus in harvesting split-thickness skin grafts, whichrepresents a further extension of its growing use. Thissimple, safe and inexpensive technique providescomfortable anesthesia of large donor areas withsufficient tissue turgor for harvesting uniform thicknesssplit-skin grafts. A minimal donor site bleeding andpossibly relatively early donor wound healing seem tobe added advantage of this technique.

Indian J Dermatot2004; 49 (4)

References

1. Robertson RD, Bond P,Wallace B, et al. The tumescent

technique to significantly reduce blood loss duringburn surgery. Bums 2001;27:835- 8.

2. Klein JA. Tumescent technique chronicles. Localanesthesia, liposuction and beyond. Dermatol Surg1995;21:449-57.

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

4. Klein JA. Tumescent technique for local anesthesiaimproves safety in large volume liposuction. PlastReconstr Surg 1993;92: 1085-98.

5. Klein JA. Tumescent technique for regionalanesthesia permits lidocaine doses of 35 mglkg forliposuction. 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 anesthesiawith a lidocaine dose of 55 mg/kg is safe forliposuction. Dermatol Surg 1996;22:921-7.

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

9. Klein JA, Kassarjdian W. Lidocaine toxicity withtumescent liposuction. A case report of probable druginteractions. Dermatol Surg 1997;23: 1169-74.

10. Hanke CW, Bernstein G, Bullock S. Safety of tumescentliposuction 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 NationalSurgery results. Dermatol Surg 1996;22:595-8.

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