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ISSN : 0019- 5154 ,

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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

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

This technique was employed for harvesting split-
thickness grafts in 19 patients (13 males and 6
females), with ages ranging from 18 to 55 years. The
From the Department of Plastic & Reconstructive Surgery,
Christian Medical College, Vellore, Tamil Nadu -632004,
India. Address correspondence to : Dr Sanjay Saraf, 6-A,
Sahnti Priya Nagar, Near Kamla Nagar Hospital, Jodhpur,
Rajasthan - 342 002.
The solution used for tumescent technique consisted -
oflignocaine 500 mg/L (0.05%) adrenaline 0.5mg/L ""
(about 1:2,000,000), sodium bicarbonate 10 mg/L,
triamcinolone acetonide (Kenacort) 10 mg/L, which
was dissolved in 1000 ml ofnOlwal saline. Preliminary
anesthesia of each infiltration site was obtained by
raising a small bleb utilizing 1 m1of2% lignocaine with
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
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.8 The complications of this
method were also found to be rare.9 The basic
prerequisite for surgery with tumescent anesthesia is
that the patient should be in good health, with no
impaired cardiovascular, renal or hepatic function. Till
date, no data from any study with a sufficiently large
sample exists on the incidence of toxic reactions to
local anesthetics in tumescent solution. Special
precautions with appropriate measures are mandatory
in patients with marked myocardial weakness or in
patients with known tendency of cardiac anhythmias
because of the danger of fluid overloading and
proanhythmic 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 tumescent
anesthesia. The only absolute contraindication is a
known allergy to lignocaine. Nevertheless, the surgeon
should be familiar with the signs and symptoms of
lignocaine toxicity and must be adequately equipped
to manage it.
Tumescent technique has been successfully used by
us in harvesting split-thickness skin grafts, which
represents a further extension of its growing use. This
simple, safe and inexpensive technique provides
comfortable anesthesia of large donor areas with
sufficient tissue 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 Dermatot2004; 49 (4)
References
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