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  • Local anesthesia is a critical component of dermatologic surgery, and allows even large flaps to be performed comfortably in an office setting.

  • If patients unnecessarily undergo painful procedures, or painful anesthesia injection, this may adversely affect their overall experience and may undermine their confidence in the dermatologic surgeon.

image Beginner Tips

  • Lidocaine 1% with 1:100,000 epinephrine is the most widely used local anesthetic in dermatologic surgery.

  • Lidocaine-allergic patients can usually be treated with either bupivacaine or, for small biopsies, normal saline or cryoanesthesia.

  • Patients may complain of an “allergy” to epinephrine; on detailed history, this is often related to intravascular injection during a dental procedure, but patient preference should always be respected.

  • Use physical and mental distraction liberally and always inject slowly when possible.

image Expert Tips

  • For Mohs surgery defects on the lower leg and other high-risk areas, consider adding dilute clindamycin to the local anesthetic.

  • 0.15 cc of clindamycin 150 mg/mL is added to a 50-mL vial of local anesthetic. Risks, including allergy, should be discussed with the patient.

image Don’t Forget!

  • Concerns regarding digital block-related necrosis due to the addition of epinephrine are probably unfounded, though volume should be minimized when possible.

  • Patients should be warned that temporary paralysis may be seen postoperatively; a unilateral facial droop is almost always due to anesthetic effect rather than nerve damage.

image Pitfalls and Cautions

  • Buffering bupivacaine with sodium bicarbonate is contraindicated due to the risk of precipitation.

    Be cautious when using off-label or compounded topical anesthetics, as these may lead to systemic side effects.

image Patient Education

  • Topical anesthetics may be applied at home prior to the procedure, though for most patients, a slow local anesthetic injection coupled with distraction leads to only minimal discomfort.

  • Local anesthesia is usually instant, while nerve blocks take several minutes to take effect.


Local anesthesia is of critical importance in dermatologic surgery. Local anesthesia permits the performance of procedures virtually painlessly through inducing a reversible loss of sensation in a well-circumscribed area of the body. Local anesthetic agents lead to anesthesia by inhibiting excitation of nerve endings or by blocking conduction in peripheral nerves.1 A thorough understanding of local anesthesia is, therefore, important to improve the surgical experience for both patient and dermatologic surgeon.


The biological effects of local anesthetics were first recorded in 1860, when Albert Niemann, a graduate student in pharmacology, isolated cocaine from the plant Erythroxylum coca and recorded the numbing sensation felt when the substance was placed on his tongue.2 Niemann did not initially consider the use of cocaine as a surgical anesthetic. Years later, in 1884, a graduate student in Vienna named Sigmund Freud experimented with the effects of cocaine on himself and animals. Freud published a paper called “Uber ...

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