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TUMESCENT ANESTHESIA: A USEFUL TECHNIQUE FOR
HARVESTING SPLIT-THICKNESS SKIN GRAFT

Sanjay Saraf, Prashant Goyal, Pankaj Ranka

Tumescent 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
split-thickness grafts in various conditions. We have found that this technique is extremely
simple in which large areas can be anesthetized for harvesting split-thickness skin grafts
safely. The good passive resistance achieved facilitates easy harvesting of spliHhickness
grafts 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 patients were explained about the procedure beforehand


and informed consent was taken. The arbitrary
The word "tumescent" is derived from the Latin requirement considered was application of split-skin
"tumidus" meaning swollen.' It is a regional anesthetic grafts to a healthy granulating wound not requiring
technique of the skin and the subcutaneous fatty tissue any other surgical intervention. Patients excluded from
provided by direct infiltration of large volumes of a the study were those with sensitivity to lignocaine, with
dilute local anesthetic. Klein is credited with the first history of cardiac, renal disease or hepatic dysfunction,
description of this technique which was initially intended raw areas more than 10 percent, pregnant women and
to facilitate liposuction.2.3 Subsequently, many patients under 18 years of age. The choice of donor
disciplines utilized this technique for various indications site was restricted to the thigh which was shaved and
as per their requirement. The aim of this study was to prepared. The area of the donor site was marked as
assess and evaluate its application in harvesting split- per the requirement. Split-thickness skin grafts were
thickness skin grafts. harvested using a Watsons' modification ofHumby's
knife. A standard donor site dressing was subsequently
Materials and methods done with paraffin tulle, roller gauze and bandage.

This technique was employed for harvesting split- The solution used for tumescent technique consisted -
thickness grafts in 19 patients (13 males and 6 oflignocaine 500 mg/L (0.05%) adrenaline 0.5mg/L ""
females), with ages ranging from 18 to 55 years. The (about 1:2,000,000), sodium bicarbonate 10 mg/L,
triamcinolone acetonide (Kenacort) 10 mg/L, which
From the Department of Plastic & Reconstructive Surgery,
was dissolved in 1000 ml ofnOlwal saline. Preliminary
Christian Medical College, Vellore, Tamil Nadu -632004,
anesthesia of each infiltration site was obtained by
India. Address correspondence to : Dr Sanjay Saraf, 6-A,
Sahnti Priya Nagar, Near Kamla Nagar Hospital, Jodhpur, raising a small bleb utilizing 1 m1of2% lignocaine with
Rajasthan - 342 002. adrenaline using a 25 G needle. The amount of

Indian J Dermatol 2004; 49 (4) 184


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

tumescent solution infiltrated ranged between 30 and tumescent technique was found to be successful in

lr 50 ml depending upon individual case. The maximum


safe dose was calculated as per individual requirement
fifteen patients (79%). Subjective and objective
features suggestive of toxicity of tumescent anesthesia
I and never exceeded 35 mg/kg body weight in were not seen in any of the patients. Fifteen patients
accordance with Klein's study.4,5Infiltration was done were evaluated for post split-thjckness harvest bleeding
using a readily available 18 G spinal needle along with (Table 3). Nine patients (60%) had minimal bleeding
a 20 ml disposable syringe. Prior to sta;;ting the while four patients (27%) had moderate bleeding. In
procedure, an intravenous access was secured, cardiac two patients (13 %), excessive donor site bleeding was
monitor and pulse oximeter were attached and observed but this did not require any active intervention.
emergency medicines rechecked. The indications for We observed early loosening of donor site dressing in
skin grafting are listed in Table 1. nine out of fifteen patients with healing underneath in
10-12 days as compared to conventional 15-21days.
Table 1 Indications for skin grafting
No allergic reaction was observed nor was there any
Indication No of patients sign of tumescent solution toxicity. No significant
Postburn raw areas 9 change in blood pressure was detected. The study did
Posttraumatic raw areas 8 not evaluate post-operative plasma level of lignocaine.
Others* 2

Total 19 Discussion

*One leg ulcer. One post-infective raw area


Tumescent anesthesia is the subcutaneous injection
of a large volume of dilute local anesthetic solution
Results with adrenaline. The unsurpassed simplicity and safety
of this procedure have led to its application in a wide
Table 2 gives the incidence of pain while harvesting variety of surgical procedures.6 With tumescent
skin grafts. While three patients (16%) experienced anesthesia now being a universally accepted technique,
no pain, nine patients (48%) experienced mild pain but we were tempted to apply it for harvesting split-skin
did not complain while harvesting skin graft. In three grafts which is unarguably one of the commonest
patients (16%) the pain was described as moderate, operations in plastic surgery. This method of anesthesia,
but the operation could be completed without any which was originally intended to facilitate liposuction,
fmiher local or general anesthesia. Four patients (22 %) was first described by Klein.3 Though various
complained of severe pain and required general concentrations, like 0.05,0.075 and 0.1 % have been
anesthesia for completion of the procedure. The described, there is no such thing as a standard
tumescent solution. The concentration of infiltrated
Table 2 Experience of pain while harvesting skin grafts
solution directly correlates with the amount of
Gradation Male (%) Female (%) connective tissue present in the surgical site.
Concomitantly, the quantity of infiltrated solution is
No pain 3 (16) inversely proportional to concentration. Various studies
Mild pain 6 (32) 3 (16) on the pharmacology of the 0.05% solution document
Moderate pain 2(11) 1 (5)
adequate intraoperative safety upto at least 35 mg/kg
body weight. Klein4.sand Ostad et aP have reported
Severe pain 2(11) 2(11) -~
the safe dose of lignocaine as 35 mg/kg and 55 mg/kg
respectively. This is five to eight times the
Table 3 Post-harvest bleeding from donor site manufacturer's recommended maximum safe dose of
Degree of bleeding Male (%) Female (%) lignocaine with adrenaline. The American Society for
Minimal Dermatological Surgery in 19978 recommended a
6 (40) 3 (20)
maximum dose oflignocaine of 55 mg/kg body weight
Moderate 3 (20) 1 (7)
after multicentric trials. The factors found responsible
Severe 2 (13) for safety of tumescent anesthesia include dilute

Indian J Dermatol 2004; 49 (4) 185

J
Sanjay Sara! et at

solution of lignocaine, a relatively avascular References


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of vasculature from infusion of large volume of technique to significantly reduce blood loss during
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interactions. Dermatol Surg 1997;23: 1169-74.
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