Local anesthesia using buffered 0.5% lidocaine with 1:200,000 epinephrine for tumors of the digits treated with Mohs micrographic surgery

Background: Several specialties and textbooks continue to advocate that local anesthesia using epinephrine should not be used during surgery involving the digits. Objective: We sought to assess the association between local anesthesia (buffered 0.5% lidocaine and 1:200,000 epinephrine) injected into digits, comorbid patient conditions, and postoperative complications including ischemia or necrosis. Methods: A retrospective review of all patients presenting for Mohs micrographic surgery in a private practice ambulatory surgery center was performed between October 2002 and January 2009. Patient factors including amount of anesthesia injected; preoperative vitals; history of hypertension, stroke, or circulatory disorders; and presence of anticoagulation were assessed. Results: Three Mohs surgeons' patients were included in the study. No digital blocks were performed; local anesthesia was infiltrated directly into the tumor site. Patients received buffered 0.5% lidocaine plus epinephrine 1:200,000. Of 63 patients presenting for surgery (59 fingers and 4 toes), there were no cases of digital ischemia or necrosis. Approximately one-third had a circulatory disorder or diabetes, and more than half had a diagnosis of hypertension or were taking anticoagulation. The average amount of anesthesia injected was 6.92 mL, with the greatest amount being 25 mL. Limitations: This was a retrospective review with possible overestimation of adverse effects as a result of referral bias of complicated patients to an ambulatory surgery center for treatment. Conclusion: There is no evidence that buffered 0.5% lidocaine with epinephrine 1:200,000 causes ischemia or necrosis when injected into digits. This is true despite a history of circulatory disorders, thrombosis, diabetes, smoking, anticoagulation, or significant preoperative hypertension.