Lidocaine with Adrenaline for Sebaceous Cyst Excision
Yes, you should use lidocaine with adrenaline (epinephrine) for sebaceous cyst excision—it is safe, effective, and provides superior hemostasis and prolonged anesthesia compared to lidocaine alone. 1
Why Lidocaine with Adrenaline is Recommended
Vasoconstrictors like epinephrine play a critical role in dermatologic surgery by slowing anesthetic mobilization, prolonging its effect, reducing peak blood levels, and providing hemostasis—all essential for clean excision of sebaceous cysts. 1
Key Benefits for Sebaceous Cyst Excision:
Prolonged anesthesia duration: Epinephrine extends lidocaine's action by approximately 200% regardless of concentration (1:50,000,1:100,000, or 1:200,000). 2, 3
Superior hemostasis: Provides better surgical field visualization and reduces bleeding during dissection of the cyst wall, which is particularly important for complete removal and preventing recurrence. 4
Reduced systemic toxicity: Vasoconstriction limits systemic absorption, reducing peak blood levels of lidocaine. 1, 4
Faster onset: Lidocaine with epinephrine achieves anesthesia within 2-5 minutes. 4
Recommended Technique
Use the lowest effective concentration of epinephrine (typically 1:100,000 or 1:200,000) to provide adequate pain control and vasoconstriction. 1, 3
Dosing Guidelines:
Maximum safe dose for adults: 7.0 mg/kg of lidocaine with epinephrine (for a 70 kg adult, this allows up to 490 mg or 49 mL of 1% solution). 4, 3
For sebaceous cyst excision: Most procedures require far less than the maximum dose—typically 3-10 mL of 1% lidocaine with epinephrine is sufficient. 4
Pain Reduction Strategy:
- Add sodium bicarbonate to buffer the solution (1:9 or 1:10 ratio of bicarbonate to lidocaine with epinephrine) to decrease injection pain—this is a Level A recommendation. 1, 2, 4
Safety Considerations
Anatomical Location Safety:
The historical dogma that epinephrine causes necrosis in areas with "end arteries" has been thoroughly refuted by extensive research. 1, 5
Multiple systematic reviews and randomized controlled trials have demonstrated no cases of necrosis when using lidocaine with epinephrine on digits, ears, nose, hands, and feet—all areas previously considered contraindicated. 1, 2, 4
Over 250,000 procedures on digits and extremities using lidocaine with epinephrine have been reported without resulting necrosis. 5
Sebaceous cysts commonly occur on the scalp, ears, face, thorax, and scrotum—all locations where lidocaine with epinephrine is safe and recommended. 6, 7
Special Populations:
Patients with stable cardiac disease: May receive lidocaine with epinephrine (Level B recommendation); consult cardiology if uncertain about tolerance. 1, 3
Pregnant women: Small amounts appear safe, but postpone elective procedures until after delivery; if urgent, delay until second trimester when possible. 1, 3
Safety Precautions:
Aspirate before each injection to avoid intravascular administration. 3
Use incremental injections and continuously assess the patient for early signs of toxicity (circumoral numbness, facial tingling, metallic taste, auditory changes). 4, 3
Avoid using within 4 hours of other local anesthetic interventions to prevent cumulative toxicity. 4
Common Pitfalls to Avoid
Do not avoid epinephrine based on outdated concerns about digital or facial necrosis—this is an "urban legend" that has been definitively disproven. 5 The only documented case of finger tip gangrene occurred in a patient with Raynaud's syndrome, not from epinephrine itself. 5
Exercise caution only in patients with infected cysts or areas with severely compromised circulation—in these rare situations, consider plain lidocaine. 5