General Anesthesia on a 91 Year Old Patient for Skin Graft 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. 

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!

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.

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. 

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.