title: Ischemia of postmastectomy skin after infiltration of local anesthetic with epinephrine: a case report and review of the literature.
abstract: BACKGROUND
  The goals of this study were to review the literature regarding the use of local anesthetic with epinephrine and to report an observation of prolonged ischemia and necrosis in postmastectomy skin.
  
  
  METHODS
  A PubMed literature review was performed and the patient's medical record was reviewed.
  
  
  RESULTS
  Prior skin necrosis with epinephrine use in acral areas was often due to physician or manufacturing overdose. Many large studies have confirmed subsequently epinephrine's safety in acral areas. There are reports of prolonged ischemia in the dermatology literature when used in areas with impaired venous and lymphatic drainage. Our case report suggests that the impaired clearance mechanisms in postmastectomy skin with an underlying implant can lead to ischemia when using local anesthetic with epinephrine.
  
  
  CONCLUSIONS
  The addition of epinephrine to local anesthetic increases the duration of analgesia and provides for a relatively bloodless operating field. In the past many surgeons were reluctant to use it because of concerns about arterial vasospasm and tissue necrosis. However, perceptions have recently changed as large reviews have documented its safe use in acral areas. Based on our review of the literature and this case, epinephrine use may not be appropriate in patients with compromised venous and lymphatic drainage.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA. thartzell@partners.org
authors.forename: Tristan L
authors.initials: TL
authors.lastname: Hartzell
authors.forename: Naveen F
authors.initials: NF
authors.lastname: Sangji
authors.forename: Mary C
authors.initials: MC
authors.lastname: Hertl
mesh_terms: D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects*; D004837:Epinephrine / Q000008:administration & dosage / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000139:chemically induced*; D008408:Mastectomy; D012867:Skin / Q000098:blood supply* / Q000473:pathology*; D012871:Skin Diseases / Q000139:chemically induced*
chemical_list: D000779:Anesthetics, Local; D004837:Epinephrine