depress myocardial contractility [7]. Ropivacaine is less cardiotoxic than bupivacaine and may be more beneficial in cases where a large dose of anesthetic is required for a peripheral nerve block [7]. It is the S (−) enantiomer homolog of mepivacaine and bupivacaine. It also has a piperidine ring with a propyl tail. Similar to ropivacaine, levobupivacaine is associated with less cardiotoxicity than bupivacaine and also may be more beneficial when large doses of anesthetic are required for a peripheral nerve block [7]. It is the S (−) enantiomer of bupivacaine.

5.11.1 Topical Anesthesia

There are different formulas for topical anesthesia, which generally exist as an oily substance at room temperature. The oily nature of the compound allows it to be easily spread over the desired area, as well as the ability to penetrate the stratum corneum. Topical anesthesia is generally not utilized during Mohs micrographic surgery.

Summary: Conclusion

•Local anesthesia is a loss in the perception of pain over a small area of the body.

•Regional anesthesia is a loss in the perception of pain in larger anatomical area.

•Two types of local anesthesia exist: aminoamides and amino-esters.

5.12Conclusion

Local anesthesia is a loss in the perception of pain over a small area of the body. Regional anesthesia is also a loss in the perception of pain, but in a larger anatomical

area or region. There are two types of local anesthetic agents, amino-amides and amino-esters, defined by their chemical structures. Both classes achieve their effects by deactivating the sodium channels responsible for the inward flux of sodium during the depolarization phase of the action potential. The net result is an increase in the amount of stimulus required to generate an action potential as well as decreased propagation of any action potentials across the anesthetized neuron. This chapter discussed the history, pharmacology, pharmacokinetics, metabolism, toxicities, chemical structures, as well as the clinical utility of using local anesthetics in localized and regional fashions.

References

1. Drake LA, Dinehart SM, Goltz RW, et al. Guidelines of care for local and regional anesthesia in cutaneous surgery. J Am Acad Dermatol. 1995;33:504–9.

2. Clark DP. Anesthesia. In: Ratz JL, Geronemus RG, Goldman MP, Maloney ME, Padilla RS, editors. Textbook of dermatologic surgery. Philadelphia: Lippincott-Raven Publishers; 1998. p. 31–40.

3. Drasner K. Local anesthetics. In: Stoelting RK, Miller RD, editors. Basics of anesthesia. Philadelphia: Churchill Livingstone/Elsevier; 2007. p. 123–34.

4. Leal-Khouri S, Lodha R, Nouri K. Local and topical anesthesia. In: Nouri K, Leal-Khouri S, editors. Techniques in dermatologic surgery. New York: Mosby; 2003. p. 47–50.

5. Leal-Khouri S, Lodha R, Nouri K. Local and topical anesthesia. In: Nouri K, editor. Techniques in dermatologic surgery. Edinburgh: Mosby; 2003. p. 47–50.

6. Bono R, Rossi G. Local anesthetic techniques. In: Rusciani L, Robins P, editors. Textbook of dermatologic surgery, vol. 1. Padova: Piccin; 2008. p. 61–72.

7. Bernards CM, Artu AA. Hexamethonium and midazolam terminate dysrhythmias and hypertension cause by intracerebroventricular bupivacine in rabbits. Anesthesiology. 1991; 74:89–96.

Summary: Introduction

•Knowledge of cutaneous anatomy is paramount to every Mohs micrographic surgeon.

•Anatomic considerations underlie successful anesthesia as well as surgical approach.

•Appropriate and cosmetically acceptable reconstruction of defects created by Mohs micrographic surgery is rooted in knowledge of anatomic structures and boundaries.

6.1Introduction

Every Mohs micrographic surgeon should possess a solid knowledge of anatomy. Understanding the cutaneous anatomy of the head and neck is essential in directing appropriate anesthesia, reducing postoperative complications and providing for an acceptable cosmetic outcome. Anatomy of the face will be discussed in terms of cosmetic subunits in this chapter.

D. Bolotin • M. Alam (*)

Department of Dermatology, Northwestern University, Chicago, IL, USA

e-mail: m-alam@northwestern.edu

Summary: Scalp and Forehead

•The soft tissue anatomy of the scalp is made up of skin, connective tissue, aponeurotic galea, loose connective tissue, and periosteum.