Anesthesia Management of Skin Cancer Surgery

Owing to increases in life expectancy, the general incidence of skin cancers has increased over the last decade [1, 2]. Consequently, the frequency of skin cancer surgery has also increased. Owing to its cost-effectiveness, safety, and rapidity, the typical form of anesthesia used during skin cancer surgery is local anesthesia [3]. However, anesthesia providers still opt to perform some cutaneous surgeries under general anesthesia [3].

During an analysis of 2,600 head and neck cancer excisions performed over three years in New Zealand, physicians found local anesthesia to produce very high success rates [4]. Patients received “local anesthetic adrenaline infiltration,” consisting of “0.4% lidocaine with 1:125,000 adrenaline” [4]. Despite having tumors of many different depths and sizes, the surgeons managed a tumor clearance rate of 95%, achieving a suitable microscopic margin in each of those cases [4]. Only 6% of patients experienced minor infections or problematic wound healing; 2% required flap revisions [4]. Regardless, none of these complications were readily attributable to the type of anesthesia used to perform the procedures [4].

Another study narrowed its focus to evaluate the success of local anesthesia on facial skin cancer surgery. This subset of skin cancer surgery is especially difficult because surgeons aim to achieve an aesthetically pleasing result [1]. In the 52 analyzed cases, local anesthesia nevertheless produced similar success [1]. Excision of facial tumors under local anesthesia proved quick and cost-effective [1]. Furthermore, it allowed physicians to keep local and systemic toxicity to a medium and maintain anesthesia for an adequate duration, all while allowing them to set the patient’s local and loco-regional facial flaps in an optimal volume and shape for reconstructive surgery [1]. Overall, local anesthesia for facial skin cancer operations appears to be highly successful [1].

However, this is not the case for all operations. Physicians frequently excise keratinocyte skin cancers, consisting of squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), using local anesthesia [5]. General anesthesia has similar rates of positive or close margins during these excisions [5]. And, indeed, general anesthesia may be preferable, depending on how many lesions the patient has. For instance, a case study of a 58-year-old patient with 20 BCCs asked to receive general anesthesia during his excisions to facilitate removing all of the lesions in a single operation [2]. The surgery lasted seven hours but was completed with no subsequent complications [2].

General anesthesia may also be advisable when a patient’s anxiety or inability to remain still threatens the success of the surgery [2]. Because patients are awake during local anesthesia, they may experience stress while witnessing the surgical team’s actions, particularly if excisions occur on a bodily region as sensitive as their face [1]. Recently, studies have focused on ways to reduce stress during local anesthesia, such as by holding the patient’s hand or giving them a stress ball to clench [6]. Unfortunately, neither of these practices proved significantly helpful in the overall population but, depending on the patient, they may help mitigate stress during local anesthesia and, consequently, reduce costs and facilitate a safer operation [6].

If a clear anesthetic method is not evident, the perioperative evaluation can be a beneficial time to analyze all relevant comorbidities and build trust with the patient to thus arrive at an informed decision [7]. In the end, the type of anesthesia used during skin cancer surgery should be chosen by considering the patient’s needs and the physician’s training [2].

References 

[1] A. Bordianu and F. Bobirca, “Facial skin cancer surgery under local anesthesia,” Journal of Medicine and Life, vol. 11, no. 3, p. 231-237, July-September 2018. [Online]. Available: https://doi.org/10.25122/jml-2018-0059. 

[2] A. T. Sampurna et al., “Mohs micrographic surgery under general anesthesia for multiple skin cancer removal,” Journal of the American Academy of Dermatology, vol. 76, no. 6, supp. 1, p. AB171, June 2017. [Online]. Available: https://doi.org/10.1016/j.jaad.2017.04.665. 

[3] D. E. Neal et al., “Local Anesthesia Is Preferred for Skin Cancer Surgery—Results of a Choice-Based Conjoint Analysis Experiment,” Dermatologic Surgery, vol. 46, no. 8, p. 1106, August 2020. [Online]. Available: https://doi.org/10.1097/DSS.0000000000001987. 

[4] M. Z. Ahmed and W. A. McEwan, “Wide Awake Facial Skin Cancer Surgery: A Way Forward for Safe and Economic Skin Cancer Surgery Under Local Anesthesia,” International Open Access Journal of the American Society of Plastic Surgeons, vol. 8, no. 9, p. 66, September 2020. [Online]. Available: https://doi.org/10.1097/01.GOX.0000720632.13357.f8.  

[5] W. McSweeney, M. Leaning, and D. Dastouri, “Keratinocyte Skin Cancers in General Surgery: The Impact of Anaesthesia, Trainee Supervision, and Choice of Reconstruction,” Journal of Skin Cancer, vol. 2021, p. 1-3, April 2021. [Online]. Available: https://doi.org/10.1155/2021/5537273.  

[6] A. F. Yanes et al., “Effect of Stress Ball Use or Hand-holding on Anxiety During Skin Cancer Excision: A Randomized Clinical Trial,” JAMA Dermatology, vol. 154, no. 9, p. 1045-1049, September 2018. [Online]. Available: https://doi.org/10.1001/jamadermatol.2018.1783.  

[7] C. C. Otley, “Perioperative evaluation and management in dermatologic surgery,” Journal of the American Academy of Dermatology, vol. 54, no. 1, p. 119-127, January 2006. [Online]. Available: https://doi.org/10.1016/j.jaad.2005.09.047.