Can lidocaine with epinephrine be safely used for facial and scalp anesthesia in an adult patient without significant cardiovascular disease, uncontrolled hypertension, hyperthyroidism, or contraindicating medications?

Lidocaine with Epinephrine on Face and Scalp: Safety and Recommendations

Yes, lidocaine with epinephrine can be safely used on the face and scalp for local anesthesia in appropriately selected patients, and is in fact recommended by the American Academy of Dermatology with their highest level of evidence (Level A recommendation). 1, 2

Evidence-Based Safety Profile

The historical concern about using epinephrine in certain anatomical locations has been thoroughly refuted by modern evidence:

• Multiple systematic reviews and randomized controlled trials demonstrate no cases of necrosis when epinephrine is added to local anesthesia for facial and scalp procedures 1, 3
• The American Academy of Dermatology specifically recommends adding epinephrine to local anesthesia for cutaneous surgery on the face and scalp 1, 2
• A comprehensive literature review of 50 historical cases of digital gangrene found that none were associated with commercial lidocaine-epinephrine mixtures, and other factors (older compounds, improper mixing, tourniquets, infection) were responsible 3

Clinical Benefits of Adding Epinephrine

Using epinephrine with lidocaine provides significant advantages:

• Prolongs anesthesia duration by approximately 200% when using concentrations of 1:50,000,1:100,000, or 1:200,000 1, 2
• Reduces bleeding and improves surgical field visualization, which is particularly valuable for facial and scalp procedures where hemostasis can be challenging 2, 3
• Slows systemic absorption of lidocaine, reducing peak blood levels and potential toxicity 4
• Provides faster onset of action (2-5 minutes) with duration of 90-200 minutes 1

Recommended Technique and Dosing

Maximum Safe Doses

• 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) 1, 2
• Children: 3.0-4.5 mg/kg 2

Optimal Concentration

• Use 1:100,000 or 1:200,000 epinephrine concentration - these provide equivalent vasoconstriction and anesthetic prolongation 1, 2
• Concentrations of 1:50,000,1:100,000, and 1:200,000 all have similar clinical effects 2

Injection Technique

• Always aspirate before injection to avoid intravascular administration 5
• Use incremental injections rather than large boluses 2
• Consider buffering with sodium bicarbonate (1:9 or 1:10 ratio) to decrease injection pain 1, 4

Important Contraindications and Precautions

Absolute Caution Required

• Avoid in patients with uncontrolled hypertension, severe cardiovascular disease, or hyperthyroidism 5
• Do not use during or following administration of potent general anesthetic agents due to arrhythmia risk 5
• Avoid in patients taking monoamine oxidase inhibitors or tricyclic antidepressants - may cause severe, prolonged hypertension 5

Relative Contraindications

• Patients with cardiac disease may receive lidocaine with epinephrine, but consultation with their cardiologist is recommended if uncertain 2, 6
• Studies show hemodynamic stability in patients with cardiovascular disease using standard doses, with only minor increases in blood pressure (4.1%) and heart rate (5.1%) 6

Special Hemodynamic Considerations for Scalp

• Scalp infiltration with epinephrine-containing lidocaine can cause temporary hypotension at approximately 1.5 minutes post-injection, followed by potential hypertension 7
• This biphasic response requires monitoring, particularly in neurosurgical settings 7
• The hypotensive episode is temporary but clinically significant 7

Monitoring for Toxicity

Watch for early warning signs of local anesthetic toxicity:

• Circumoral numbness, facial tingling, metallic taste 1, 2
• Tinnitus, slurred speech, auditory changes 1
• Restlessness, anxiety, dizziness, blurred vision, tremors 5
• More severe: seizures, respiratory depression, cardiovascular collapse 5

Critical Safety Measure

• Do not use lidocaine with epinephrine within 4 hours of other local anesthetic interventions to prevent cumulative toxicity 8, 1

Common Pitfalls to Avoid

• Do not exceed maximum dosing - calculate based on ideal body weight, not actual weight if BMI >30 8
• Do not inject rapidly - too rapid infusion increases toxicity risk 8
• Avoid using in areas with compromised blood supply or end arteries, though face and scalp have excellent collateral circulation 5
• Do not use solutions containing crystals; administer through a filter if needed 8

Approved Procedures

The American Academy of Dermatology recommends lidocaine with epinephrine for:

• Skin biopsies, excisions, wound closures on face and scalp 2
• Laceration repair (topical application also effective) 9
• Full-face ablative laser resurfacing 2
• Tissue rearrangements and skin grafting 2
• Follicular unit hair transplantation 2