TUMESCENT ANESTHESIA : A USEFUL TECHNIQUE FOR HARVESTING SPLIT-THICKNESS SKIN GRAFT Sanjay Saraf, Prashant Goyal, Pankaj Ranka ‘Tomescent 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 splicthickness grafts in various conditions. We have found that this technigue is exirer simple in which large areas can be anesthetized for harvesting splicthickness skin safely. The good passiv ciliates easy haxvesting of split-thickness prafis along withminimal bleeding and long lasing pain relict, We found this to bean inexpensive, sifeand simple technique with elimination of risks and expenses of general anesthesia, jstance achieved £ Indian J Dermatol 2004; 49 (4) : 184-186 Kes Words : Tumescent anesthesia, Split-thiekness skin graft Introduction The word “tumescent” iy derived trom the Latin “mids” meaning swollen Itis a regional anesthetic technique of the skin and the subcutaneous futty tissue provided by cireet infiltration of large volumes of a dilue local anesthetic. Klein is credited with the first description ofthis technique which was initially intended. (o facilitate liposuction. Subsequently, many disciplines utilized this technique for various indications as per their requirement. The aim of this study was to assess and evaluate ils application in harvesting sp thickness skin grafts. Materials and methods This technique was employed for harvesting split- thickness grafts in 19 patients (13 males and 6 females), with ages ranging from 18 t0 55 years, The From the Depariment of Plastic & Reconstructive Surgery, Christian Medical College, Vellore, Ramil Nadu -622004, India. Address correspondence to : Dr Sanjay Sara}. 6-A, Salunti Priya Noga Near Kamla Nagar Hospital, Jodhpur Rajasthan - 342 002, Indian J Dermatol 2004, 49 (4) paticnts were explained about the procedure beforehand. and informed consent was taken, The arbitrary requirement considered was application of split-skin grafts to @ healthy granulating wound not requiting, ‘vention, Patients excluded fiom any other surgical in the study were those with sensitivity to lignocaine, with history of cardiac, renal disease or hepatie dysfunction, raw areas more than LO percent, pregnant women and patients under 18 years of age. The choice of donor site was restricted to the thigh which was shaved and prepured. The area of the donor site was marked as per the requirement. Splitthickness skin grafts were harvested using a Watsons’ modification of Humby"s Knife. A standard donor site dressing was subsequently done with paraffin ule, roller gauze and bandage. The solution used for tumascent technique consisted of lignocaine 500 mg/T. (0.05%) adrenaline O.Sma/t. (about 1:2.000,000), sodium bicarbonate LO mpfl.. triamcinolone acetonide (Kenacort) 10 mgJT., which was dissolved in 1000 ml of normal saline, Preliminary anesthesia of each infiltration site was obtained by raisinga small bleb utilizing 1 ml c2% lignecaine with adrenaline using @ 25 G needle. The amount of 184Tumescent anesthesia irmescent solution infiltrated ranged between 30 and 50 ml dependingupon individual case. The maximum safe dose wascaleulated as per individual requirement and never exceeded 35 mg/kg body weight in accordance with Klcin’s study.** Infiltration was done, using 2 readily available 18 G spinal needle along with 220 ml disposable syringe. Prior to starting the procedure, an intravenous aweess w monitor and pulse oximeter were attached and emergency medicines rechecked. The indications for skin gralting are listed in Table secured, cardiac Table 1 Indications for skin grafting Tadication Noot patients Postburn raw areas Postirauratic raw areas 8 Others 2 Tout 2 * One leg uleer. One postinisetive raw area Results Table 2 gives the incidence of pain while harvesting skin grafts, While three patients (16%) experienced no pain, nine patiemts (48%) experienced mild pain but did nor complain while harvesting skin graft, In three paticnts (16%) the pain was described as modera but the operation could be completed without any further local or general anesthesia. Four patients (22%) complained of severe pain and required general anesthesia for completion of the procedure. The ‘Table? Experience of pain while harvesting skin grafts Gradtion Male (%) Female (%) No pain 3416) : ‘Mild pain 6032) 3116) ‘Moderate pain aay 19) Severe pain 2a) 1) Table 3 Post-harvest bleeding from donor site Degree ofbleeding _Male(%) __ Female (%) Minimal 6140) 3(20) Moderate 3 (20) 10) Sever 213) Indian J Bermatot 2604; 49 (4) ee eatin estas ue for hanvesiing split: Jickwess skin graft tumescenit technique was found to be suecessfia) 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-thickness harvest bleeding, (Table 3). Nine patients (60%) had minimal bleeding, while four paticats (27%) had moderate bleeding. two patients (13%), excessive donor site bleeding was observed but hisdid 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 2s compared to conventional 15-21 days. 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 otevaluate post-operative plasima level of lignocaine. Diseussion anesthesia is the subcutaneous injection of a large volume of dilute loca! anesthetic solution with adrenaline. The unsurpassed sienplicty and safety of this procedure have led to its application ina wide variety of surgical procedures.® With tumescent anesthesig now being a universally accepeed technique, we were rempted to apply it for harvesting splitkin grafts whieh is unarguably one of the commonest ‘operations in plastic surgery. This methodof anesthesia, ly intended to facilitate Fposuction, wes first described by Klein.’ Though various coneentrations, 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 onthe pharmacology of the 0.05% solution document adequtate intraoperative safety upto at least 35 melk body weight. Klein** and Osiad et a have reported the sale dose of lignocaine as 35 mgikg and 55 mgfkg respectively. This is five to eight times the manufacturer's recommended maximum safe dose of lignocaine with sdrenaline. The American Society for Dermatological Surgery in 197° recommended @ maximum dose of lignocaine of 55 mg/kg body weight which was origit afier multicentric tals, The factors found responsible for safety of tumescent anesthesia include dilute 185Ss Senjary Saraf erat 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. he complications of this method were also found to be rare.? The basic prerequisite for surgery with tumescent anesthesia is Ghat the patient should be in good health, with no impaired cardiovascular, renal or hepatic Function, Hill date, no data from any study with a sufficiently large sample exists on the incidence of toxie reactions (0 local anesthetics in tmescent solution. Special precautions with appropriate measures are manclatory in patients with marked myocantial weakness ot in palients with known tendency of cardiae arrhythmias because of the danger of fluid overloading and proarthytamic 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 aamescent anesthesia. The only ubsolute contraindication is a known allsrgy tolignocaine, -vertheloss, the surgeon should be familiar with the signs and symptoms of lignocaine toxicity and must be adequately equipped to manage it. Tumescent technique bas been suecesslully uscd by us in harvesting split-thicknoss skin grafis, which represents a further extension of its growing use, This simple, safe and inexpensive technique provides comfortable anesthesia of large donor areas with sutficient dssue 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. Indian J Dermatol 2004; 49 (4) References 10, IL Robertson RD. Bord P, Wallace B, era, Tae tumeseent lechnique to significantly reduce blood loss during, bura surgery. Burns 2001;27:835-8, Klein JA, Tumescent technique chronicles. Loesl anesthesia, liposuction and beyond. Dermatol Surg 1995;21: 449.57, Klein JA. The tumescent technique for liposuction surgery. AmJ Cos Surg 19874:263-7 Klein JA. ‘Tumescent technique for local anesthesia improves safety mm large volume liposuction, Plast Reconstr Surg 1993,92: 1085-93 Klein JA. Tumescent technique for regional anesthesia permits lidveaine doses of 35 mgfkg for liposuction.J Dermatol Surg Oncol 1996:16:248-6'. Williams J. Plastic surgery in an office surgical unit Plast Reconste Surg 1973: 52:513.9, Osta A. KageyanaN, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mgvke is sale for Fposuction. Dermal Surg 1996;22:921-7, Amesican Society for Dermatological Surgery, Guiting Frinciplesforliposuction, Dermatol Surg 199723:1127-9. Klein JA, Kassarjdian W. Lidocaine toxicity with tumescent liposuction. A ease report of probable drug, interactions. Dermavol Surg 1907:23:1 169-74, Hanke CW, Bernstein G, Bullock 8. Safety aftumescent Liposuction in 15,336 patients national survey results, Detunatol Sury 1995:21459-62, Fanke CW. Bullock S, Bernstein G, Current status of tumescent Liposuction in the United States Nationat ery estlts, Dermatol Surg 1995;22:595-8. 186