My 91 year old father needs a skin graft on his nose after mohs surgery. His mohs doctor will do this proceedure using local anesthesia, but most facial plastic surgeons I have spoke with want to do it under general anesthesia. Two questions... 1) is general anesthesia safe for a healthy 91 year old male? 2) Why will the mohs surgeon do it under local, but most plastic surgeons I spoke to do it with general anesthesia? Need t make a decision fast...any guidance is greatly appreciated!
General Anesthesia on a 91 Year Old Patient for Skin Graft After Mohs?
Doctor Answers 9
Mohs Surgery Uses Local Anesthesia
While general anesthesia is overall safe for patients who are healthy, like any medical intervention, it is not without some risk. One of the guiding principles of Mohs surgery is to perform a procedure that is minimally invasive. This translates to all aspects of the procedure including the use of anesthesia. Mohs surgeons use local anesthesia the vast majority of their repairs. Sedation might be considered in a few situations. if the patient cannot sit or lay still for the entire duration of the procedure, or if the patient is extremely anxious and does not feel that they can tolerate the procedure, it is often easier to give the patient a sedative or put them to sleep. Age is not a contraindication to general anesthesia. Many individuals age 75 and up receive it as long as their are no underlying health concerns. However in my practice, I have found that I can perform the majority of my repairs, from skin grafts to forehead flaps for nose repairs, under local anesthesia.
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Skin Grafts and Anesthesia
Most of the time, skin grafts just require local anesthesia. However, in extreme cases, sometimes general anesthesia can be used. Here are your answers:
1. General anesthesia is safe AS LONG AS he is very healthy! He will need to have an EKG before the procedure and be under careful view of the anesthesiologist. For patients who need a large or very in-depth skin graft sometimes it's nicer to be under anesthesia, especially if a patient (and bless them, but many elderly gentlemen get very irritated about how long things take!) if the patient is irritated or impatient.
2. It's not really needed for any purpose other than making the procedure easier for the surgeon. There is no reason the anesthesia will make the procedure better or safer. I will also, although this might not be popular, say that some doctors perform surgeries under anesthesia because a lot more of the cost can be billed and paid by insurance that way. There's the anesthesia, the surgery room, the procedure itself, the post care, etc. You can take something that's a minor, easy, hour or so procedure and bill a lot more money and collect it! Having general anesthesia will require more pre-work for your father, as well he might not feel great and will have to wait at the surgery center for a bit after the procedure should he elect to do it under general anesthesia.
I've been a Mohs surgeon for nearly 30 years and have performed extremely complex and multi-hour, multi-day procedures. I've done less than 50 of tens of thousands of these under general anesthesia, as it's just not needed. I would say he is fine under local and the procedure will be quicker and easier for him and you.
General Anesthesia vs. Local Anesthesia
With regard to the first question, continued advances in general anesthesia have continued to improve its safety. However, the majority of reconstructive procedures after Mohs surgery can be performed safely under local anesthesia. Local anesthesia often seems to be the best option with regards to safety, recovery, ability to continue normal diet and medication regimen, and ability to drive oneself to and from the facility after many procedures. Not to confuse the picture further, but an intermediate option we often use is IV sedation...just like the light sedation often given for a colonoscopy, we can utilize sedation to give the patient an additional level of comfort for sensitive areas or more complex cases. With regards to the second question, doctors' preferences for anesthesia are often based on their training and the complexity of a case. As a dual trained Mohs surgeon and board certified Plastic Surgeon, I have experienced both ends of the spectrum. In my plastic surgery training we performed 90% of our cases under general anesthesia. Now, most of the cases were much larger and complex that Mohs reconstruction, and local anesthesia would not be an option for many. When I went on to do my fellowship training in Mohs surgery with a dermatologist, we did 100% of cases under local anesthesia. Of course, only a handful of cases were anywhere near the magnitude of the standard cases performed in plastic surgery. In my current practice, we perform 98-99% of cases under local anesthesia, 1-2% under IV sedation, and maybe 0.1% go under general anesthesia because of extensive cancer growth. Hope this helps!
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General vs. Local Anesthesia
The ultimate goal is to maximize patient safety. You need a cooperative patient and great nursing to do these procedures under local anesthesia. The anesthesiologist also needs to be present to babysit the patient and to be available in case of an emergency. The risk is generally dictated by the overall health of your father. A preoperative evaluation by the anesthesia staff is probably a wise choice where you will be better educated on the risks and benefits of general vs. local anesthesia.
I can not see any reason why a skin graft on a nose can not be done under local anesthesia. Any plastic surgeon certified by the American Board of Plastic Surgery should be able to do this. I think what you may ask is how large or how extensive is this tumor on my 91 year old fathers nose, does it need MOHS excision, and are there any alternative treatments that could be used.
Unfortunately especially with skin cancers of the nose you can start with what you think is a small problem and end up with a large defect where the reconstruction can become very complicated.
General anesthesia not needed to do a graft
There is no question that general anesthesia has its place when doing larger reconstructive surgeries or for patients who simply cannot sit still for the reconstruction. However, when doing a graft in any patient at any age, general anesthesia is typically not warranted unless there is a very large site that requires repair (in which it would be potentially unsafe to use larger quantities of local anesthesia).
The beauty of Mohs surgery is that both the removal of the cancer and the reconstruction of the defect can be done safely in an outpatient setting using local anesthesia. This limits costs, is less stressful for the patient (one day of surgery rather than two), and is often safer as the risk of general anesthesia is greater than local. Most Mohs surgeons do have access to use of the operating rooms at hospitals but choose to do their reconstructions in their own offices for the reasons above.
I hope your father's surgery goes well.
General anesthesia for 91 year old after Mohs
Most anesthesiologists I have talked to swear that general anesthesia is just as safe as local with IV sedation nowadays. Certainly, the procedure will be more comfortable with some sedation than with local anesthesia only.
Mohs surgery with local anesthesia
Mohs surgery in this patient would be very appropriate using local anesthesia and without general anesthesia. The advantage of this out patient procedure is that the risks associated with general anesthesia in a patient this age are minimized.
Age is not a contraindication to general anesthesia. However, at 91, a thorough preoperative medical clearance is critical. Having said that, except for extreme circumstances (typically a very uncooperative patient) I perform both the Mohs surgery and repair (including skin grafts) in the office under local anesthesia. The differing opinions between plastic surgeons and mohs surgeons regarding local and general is likely a function of comfort and training. As a mohs surgeon our training is in performing both the tumor removal and resultant reconstruction in the office under local. Hope this helps. Please let me know if you have any other questions.
Mohs Surgery under Local Anesthesia
Based on the information you gave, I would recommend doing this Mohs surgery under local anesthesia. One of the reasons your Mohs surgeon wants to use local, and not general anesthesia is because they are dermatologist and not surgeons. They do not have hospital privilages to operate in a hospital / outpatient setting. Since your father is 91, and I assume in relatively good health, local anesthesia is a reasonable option.