What type of anesthesia is recommended for the excision of benign skin lesions with simple closure?

Local Anesthesia is the Standard for Excision of Benign Skin Lesions with Simple Closure

Local anesthesia is the recommended type of anesthesia for excision of benign skin lesions with simple closure. 1

Evidence Supporting Local Anesthesia

The American Academy of Dermatology guidelines clearly recommend local infiltrative anesthesia for office-based dermatologic procedures, including:

• Obtaining biopsy specimens
• Excision of lesions
• Wound closure
• Tissue rearrangement
• Skin grafting
• Cauterization
• Nonablative and ablative skin procedures 1

This recommendation is further supported by FDA labeling for lidocaine, which specifically indicates its use for "production of local anesthesia by infiltration techniques such as percutaneous injection" 2.

Technical Aspects of Local Anesthesia Administration

When performing excision of benign skin lesions:

1. Anesthetic selection:

   • Lidocaine (with or without epinephrine) is the most commonly used agent
   • Maximum safe dose for adults: 4.5 mg/kg of lidocaine without epinephrine or 7.0 mg/kg with epinephrine 1

2. Administration technique:

   • Use the lowest effective dose of anesthetic
   • Aspirate before injection to avoid intravascular administration
   • Use incremental injections
   • Maintain communication with patient to monitor for early toxicity signs 1

3. Alternative options for lidocaine allergy:

   • Ester-type local anesthetics (rare cross-reactivity)
   • 1% diphenhydramine (longer onset, limited efficacy)
   • Bacteriostatic normal saline (0.9% benzyl alcohol in normal saline) 1

Surgical Technique Considerations

For optimal outcomes when excising benign skin lesions:

1. Skin incision placement:

   • Use curvilinear incisions following Langer's lines for best cosmetic results
   • Consider radial incisions at 3 and 9 o'clock positions and in lower breast
   • Place incision over or close to the lesion with adequate size for removal 1, 3

2. Tissue management:

   • Excise the primary lesion with a rim of grossly normal tissue
   • Avoid excessive sacrifice of tissue
   • Maintain meticulous hemostasis to prevent hematoma formation 1

3. Closure technique:

   • Use subcuticular technique for skin closure
   • Preserve subcutaneous tissue with separate closure for improved cosmesis 1

Clinical Relevance and Safety

The clinical accuracy in diagnosing benign skin lesions is generally high (88.6% for lipomas, 72.7% for sebaceous cysts), with an extremely low risk of malignancy (0.33%) in clinically benign-appearing lesions 4. This supports the safety of performing these procedures under local anesthesia in appropriate settings.

Common Pitfalls and How to Avoid Them

1. Anesthetic toxicity:

   • Monitor for early signs: circumoral numbness, facial tingling, slurred speech
   • Prevention: use lowest effective dose, aspirate before injection, incremental administration 1

2. Poor cosmetic outcome:

   • Avoid inappropriate incision placement
   • Minimize excessive tissue removal
   • Consider proper tissue reapproximation techniques 3

3. Hematoma formation:

   • Ensure meticulous hemostasis
   • Avoid drains in the breast or other cosmetically sensitive areas 1

By following these guidelines, excision of benign skin lesions with simple closure can be safely and effectively performed under local anesthesia with optimal cosmetic outcomes and patient comfort.