Minimal Pain Tumescent Local Anesthesia for Wide-awake Forehead Flap Nasal Reconstruction

INTRODUCTION Minimally painful tumescent local anesthesia eliminates the nausea and vomiting of unnecessary sedation as well as the cost and solid waste of unnecessary main operating room sterility.1 The senior author has performed all stages of more than 30 wide-awake (0 sedation) forehead flap nasal reconstructions with field sterility in minor procedure rooms in the hospital and in the office. The purpose of this article is to illustrate with video how to reliably inject minimally painful tumescent local anesthesia for all 3 stages of forehead flap reconstruction. The only discomfort that patients consistently feel is the initial poke of a tiny 30G needle with no further pain during the injection or during the surgery. This article and its videos demonstrate how to turn this operation into a pleasant patient experience. Preparation Tell the patient the local anesthesia will hardly hurt at all, then deliver on your promise. (See Video 1 [online], which shows the marking and the minimally painful tumescent local anesthesia injection technique in great detail for the first stage of a 3-stage forehead flap nasal reconstruction after Mohs excision of a basal cell skin cancer. Patient impressions are included at the end of the video.) (See Video 2 [online], which shows the local anesthesia injection technique for the second stage. This video shows flap elevation off of the nose, sculpturing of the nose and flap, and reinsetting of the flap. Patient impressions are included at the end of the video.) (See Video 3 [online], which shows the minimally painful tumescent local anesthesia injection technique for the third and final stage of flap division, eyebrow reconstruction, and proximal flap contouring and insetting. Patient impressions are included at the end of the video.) (See Video 4 [online], which shows the field sterility setup of the minor procedure room, 2 other cases of accelerated injection and surgery of the first stage of a forehead flap, other patient impressions, and how to inject the inside of the nose with tumescent local anesthesia for a full thickness nasal defect.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"shows the marking and the minimally painful tumescent local anesthesia injection technique in great detail for the first stage of a 3-stage forehead flap nasal reconstruction after Mohs excision of a basal cell skin cancer. Patient impressions are included at the end of the video.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_dxglpozc"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"shows the local anesthesia injection technique for the second stage. This video shows flap elevation off of the nose, sculpturing of the nose and flap, and reinsetting of the flap. Patient impressions are included at the end of the video.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_uonpadyo"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"shows the minimally painful tumescent local anesthesia injection technique for the third and final stage of flap division, eyebrow reconstruction, and proximal flap contouring and insetting. Patient impressions are included at the end of the video.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_b688chgi"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4","caption":"shows the field sterility setup of the minor procedure room, 2 other cases of accelerated injection and surgery of the first stage of a forehead flap, other patient impressions, and how to inject the inside of the nose with tumescent local anesthesia for a full thickness nasal defect.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_iw7dujfx"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}Surgeons can take their time to Doppler the vessels or draw the flap with the patient sitting, because the patient is not sedated. Drawing and local anesthesia injection can be performed before the patient enters the minor procedure room. Perform the procedure with field sterility outside of the main operating room, as is the standard of care for Mohs surgery in the United States with no increased infection rates.2 Provide a pleasant minor procedure room environment with a calm, reassuring manner for a good patient experience. Tips to Almost Pain-free Local Anesthesia Injection of Forehead Flap Nasal Reconstruction Start with a 30G half-inch needle on a 3-mL Luer lock syringe. We prefer 3-mL Luer lock syringes for all nasal injections because of the high injection forces needed to tumesce scarred, tight areas. Small syringes exert larger forces with less effort. Slip-lock syringes blow off the needle and spray the patient (see Video 1–4 [online]). In open nasal wounds such as those after Mohs surgery, start by inserting the first needle tip slowly into the fat so the patient might not feel this first needle poke at all. As soon as the bevel of the needle is in the fat, inject and stop moving when you see clear tumescence (visibly, palpably swollen fat and skin). Inject 2–4 mL slowly before moving the needle at all. If the nasal skin is intact, use sensory noise such as pinching the skin into the needle to decrease the pain of the first poke. Only reinsert the needle in clearly tumesced skin so the patient never feels needle reinsertion, but only feels the first needle poke. Alternate needle reinsertion sites (right to left and back to right, or caudal to distal and back to caudal) to give time for the previous injection site to get numb so all needle reinsertions are painless. In the forehead, start at the eyebrow and work superiorly to tumesce the area of the supraorbital nerve from proximal to distal. In the nose, start tumescing in the mid-dorsum where the skin is distensible. Work your way down to tumesce the less distensible tip. Inject the alae and the columella last, as they are the least distensible and the most sensitive parts. Reinject the alae and the columella just before you start the surgery. They are the areas with the highest blood flow, and therefore, the fastest washout of the local anesthesia. Typical volumes of local anesthesia for the first stage would be 20 mL in the nose and 25 mL in the forehead. We inject 1% lidocaine with 1:100,000 epinephrine buffered with 1 mL of 8.4% sodium bicarbonate added to each 10 mL of local anesthesia. Follow all the other rules of minimal pain tumescent local anesthesia injection.3 Other Tips to Awake Forehead Flap Nasal Reconstruction Epinephrine is safe in awake flap elevation,4 but inject the local anesthesia just outside the cutting line on the forehead to avoid injuring the flap vessels with the sharp needle tip. Inject the local anesthesia at least 30 minutes before the first incision to give ample time for the tumescent epinephrine vasoconstriction to work. This avoids the need for electrocautery. We have cautery available but rarely use it. After local injections, have the patient void to avoid the uncomfortable need to urinate during the surgery. Avoid the uncomfortable needle insertion of unnecessary intravenous lines. We do not routinely monitor the patients, as they are unsedated, but it is an option when it is safer to do so.5 To decrease your complication rate, take advantage of the intraoperative time to educate the awake patient on how to look after the flap and the forehead wound when they get home. The patient can sit up and go home at the end of the procedure. Wide-awake surgery is safer in patients who have medical comorbidities that aggravate sedation risks and complications. DISCLOSURES Dr. Lalonde receives royalties from Thieme Book Publishers and as a consultant for Accurate Surgical & Scientific Instruments, Corp. The other authors have no financial interest to declare in relation to the content of this article.

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