This basal cell skin cancer was excised in our minor procedure room with field sterility under pure local anesthesia by our dermatology Mohs surgeon, Dr. Rob Hayes. He's the one who taught me 17 years ago how to inject local anesthesia so it doesn't hurt at all. I reconstructed this defect in our minor procedure room one week after he excised the cancer. You can see the tie-over dressing on the forehead that he placed. I used a skin graft from the scalp after shaving the scalp and did this all with pure local anesthesia as we do most of our skin grafts. I insert the bevel of the needle just inside the fat and inject until the liquid stops coming back. When the liquid starts inflating the tissues, I stop moving the needle. Did that hurt at all? It won't hurt. I guess not, eh? He didn't feel it at all because I was lucky enough to have my needle tip go in between branches of nerves in the fat. If you don't move your needle at all and you just inflate slowly, you can see the 3 milliliter syringe slowly emptying in real time. You can see the local anesthesia start to form a wheel of tumescent local anesthesia underneath the skin right where the tip of my needle is. I always start where the nerves are coming from and go where they're going to. Even though this is in the vicinity of the supraorbital and supratrochlear nerves, I'm not planning to do a nerve block. I want to block all the nerves, the little nerves, the big nerves. I reinsert where it's clearly numb. All I can feel is your finger pressing a little bit. Right. So you didn't feel anything sharp or nasty there? No. I always reinsert the needle in an area that is clearly tumesced so he never feels needle reinsertion. All this man felt was one poke and that was in the area of the skin graft. He didn't feel anything on the forehead. Notice that I alternate from the left side to the central, to the left side to the central so that I'm reinserting in an area that has had a little time to numb so that when I reinsert I'm guaranteed that he's not going to feel the subsequent needle reinsertions. The goal is that he just feels the first poke. In this case he felt zero on the recipient site and so I scored a hole in zero on the recipient site and on the graft site I scored a hole in one. He just felt the first poke. And so again I alternate from side to side when I inject the local. Then I debride all of the fibrin clot. You were right. That was neat but it didn't hurt a bit. That's good. The procedure was completely painless. He stood up and went home. He was not admitted. We do not have a higher infection rate with our skin grafts since we've started doing them in the minor procedure room but it's much more convenient for patients and the costs are a lot less and the trash to our environment much, much less.

basal cell skin cancer

local anesthesia

skin graft

cost-effective

low infection rates