From the Guidelines
Lidocaine with epinephrine can be safely used on the face in most situations, contrary to the outdated belief that it should be avoided in these areas. The traditional teaching of "no epinephrine on fingers, toes, penis, nose, and ears" has been largely disproven by modern research, as seen in studies such as 1. When used in appropriate concentrations (typically 1:100,000 or 1:200,000 epinephrine), this combination is safe and beneficial for facial procedures. The addition of epinephrine to lidocaine provides several advantages:
- it prolongs the anesthetic effect
- reduces bleeding at the surgical site
- decreases systemic absorption of lidocaine, potentially reducing toxicity risks. However, caution should still be exercised in patients with severe cardiovascular disease, and the total dose should be limited according to patient weight, with a maximum recommended dose of 7 mg/kg of lidocaine with epinephrine, not to exceed 500 mg total, as recommended in 1 and 1. For facial procedures, concentrations higher than 1:100,000 are generally unnecessary and should be avoided.
The use of lidocaine with epinephrine in facial procedures is supported by guidelines for the use of local anesthesia in office-based dermatologic surgery, which suggest that infiltrative anesthesia is safe and recommended for office-based dermatologic procedures, including but not limited to obtaining a biopsy specimen, excision, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing, as stated in 1. Additionally, the combination of topical and infiltrative anesthesia should be considered as an alternate to sedation or general anesthesia in pediatric patients, as mentioned in 1.
It is also important to note that the safety of small amounts of local infiltrative anesthesia with epinephrine in patients with stable cardiac disease has been demonstrated, and the work group recommends that epinephrine in small amounts is safe for dermatologic surgery in this population, as seen in 1. Furthermore, the addition of hyaluronidase to infiltration anesthesia may be used to enhance diffusion of the anesthetic solution, but its benefits in dermatologic procedures remain unclear, as discussed in 1.
In summary, lidocaine with epinephrine is a safe and effective combination for facial procedures, and its use is supported by current guidelines and research, including studies such as 1, 1, and 1.
From the Research
Use of Lidocaine with Epinephrine on the Face
- Lidocaine with epinephrine is used in local reconstructive procedures such as skin tumor excision and local flap closure, including on the face 2.
- A study measured the effect of subdermal injection of lidocaine combined with epinephrine on cutaneous blood flow in the face and found that the addition of epinephrine resulted in an immediate decrease in cutaneous blood flow 2.
- The use of lidocaine with epinephrine on the face is also supported by a study on drug management in skin surgery, which states that lidocaine 1% with epinephrine 1:200,000 can be used at all sites except the fingers, toes, and penis 3.
- Topical anesthesia with lidocaine and epinephrine has also been shown to be effective and safe for use on the face, with a study demonstrating its effectiveness in adults for larger wounds 4.
Considerations for Use
- The vascularity of different anatomical areas may account for blood flow differences following injection with saline and lidocaine 2.
- Incisions should be delayed for 8 minutes in the face following lidocaine+epinephrine injection to allow maximal benefit to take effect 2.
- There are no significant differences between 1:100,000 and 1:200,000 epinephrine combined with lidocaine in facial injections 2.
- Epinephrine-induced vasoconstriction delays local anesthetic clearance, thus prolonging its effect and enabling a higher maximum dose to be used 3.