Anesthesia for Resection of 15 cm Superficial Lipoma

Introduction to Anesthesia Technique

The American Academy of Dermatology recommends the use of local tumescent anesthesia with lidocaine and epinephrine for procedures involving large soft tissues, allowing for safe doses up to 55 mg/kg in patients weighing 43.6-81.8 kg, with evidence level A (I, II) 1, 2, 3.
This dose is significantly higher than conventional local anesthesia, which is limited to 7 mg/kg with epinephrine, making it crucial for a 15 cm lipoma that requires extensive infiltration 4.

The technique of tumescent anesthesia with lidocaine and epinephrine has evidence level A (I, II) for large soft tissue procedures, permitting safe doses up to 55 mg/kg in patients weighing 43.6-81.8 kg, which is sufficient for a 15 cm lipoma 1, 2, 3.
Regional nerve blocks have limited evidence (level C, III) for dermatologic surgery of extremities, based mainly on expert opinion, and comparative studies show equivalent satisfaction between nerve block and local infiltration for soft tissue procedures 5, 2, 6.

The American Academy of Dermatology suggests using lidocaine with epinephrine in a diluted concentration (typically 0.05-0.1% lidocaine with epinephrine 1:1,000,000) for tumescent anesthesia 1, 3.
Warming the solution to 40°C before infiltration (evidence level B, II) can significantly reduce pain during administration 1, 2, 3.

Infiltrating slowly (evidence level C, III) can minimize patient discomfort during administration, and infiltrating both the superficial and deep subcutaneous planes around the lipoma can facilitate dissection 1, 3, 7.

Early signs of toxicity include perioral numbness, facial tingling, slurred speech, metallic taste, auditory changes, and hallucinations, and careful calculation of total dose is necessary to not exceed 55 mg/kg 4, 1.
Having resuscitation equipment and intravenous lipids available is crucial for treating systemic toxicity from local anesthetics 4.

Combining tumescent local anesthesia with peripheral field block can provide additional anesthesia without resorting to formal nerve block 4.
The combination of lidocaine and prilocaine may reduce the risk of toxicity when large volumes are needed, although prilocaine is not approved in the US for tumescent use 1, 3, 7.