If you were a patient, would you prefer your local anes-
thetic injector to be a pain-inducing torturer or a magician
who hardly hurts you at all? The purpose of this article is
to help doctors and nurse injectors be the latter. The last
article the senior author wrote on this subject laid out very
reproducible tips and tricks to minimize the pain of local
anesthesia injection.1 Those techniques have enabled many
medical students and residents2 to reliably inject “hole in
one” local anesthesia.3 This means that all the patient feels
is one little sting from the rst poke of a small needle, even
when anesthetizing a large area. The purpose of this article
is also to update injectors on improvements in the hole in
one technique over the last 7 years.
Why is it important to have almost pain-free local anes-
thetic injection and surgery? Because the two main rea-
sons patients feel they need sedation are (1) the possible
pain of local anesthesia injection and (2) the chance that
surgery might hurt because of inadequate local anesthe-
sia. Both concerns can be reliably eliminated by following
the simple tips of this article.4 Avoiding sedation elimi-
nates nausea and vomiting, unnecessary anesthetic risks,
costs, hospital admissions, and the main operating room
environment.5–7 Pure local anesthesia is safer than seda-
tion in patients with multiple medical comorbidities. Wide
awake surgery makes it more affordable and grants access
to millions of the worlds’ poor patients who currently can-
not afford sedative surgery in the main operating room.8
Tumescent means a large enough volume of dilute
local anesthesia that you can see it and feel it inating
all tissues where sharp objects or broken bones will be
Related Digital Media are available in the full-text
version of the article on www.PRSGlobalOpen.com.
Disclosure: The authors have no nancial interest to declare
in relation to the content of this article. This study did not
receive any funding.
From the* Division of Plastic and Reconstructive Surgery, Dalhousie
University, Halifax, Nova Scotia, Canada; and †Division of
Plastic and Reconstructive Surgery, Dalhousie University, Saint
John, New Brunswick, Canada.
Received for publication February 27, 2021; accepted April 8,
Copyright © 2021 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Nadim Joukhadar, MD*
Donald Lalonde, MD, MSC,
Summary: After reading this article, the participant should be able to (1) almost
painlessly inject tumescent local anesthesia to anesthetize small or large parts of
the body, (2) improve surgical safety by eliminating the need for unnecessary seda-
tion in patients with multiple medical comorbidities, and (3) convert many limb
and face operations to wide awake surgery. We recommend the following 13 tips
to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with
sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the
syringe with two hands and have your thumb ready on the plunger before inserting
the needle; (4) use more than one type of sensory noise when inserting needles
into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the
dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the
dermis before moving the needle at all and inject all local anesthetic slowly when
you start to advance the needle; (8) never advance sharp needle tips anywhere
that is not yet numb; (9) always inject from proximal to distal relative to nerves;
(10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert
needles into skin that is already numb when injecting large areas; (12) always ask
patients to tell you every time they feel pain during the whole injection process
so that you can score yourself and improve with each injection; (13) always inject
too much volume instead of not enough volume to eliminate surgery pain and
the need for “top ups.” (Plast Reconstr Surg Glob Open 2021;9:e3730; doi: 10.1097/
GOX.0000000000003730; Published online 4 August 2021.)
How to Minimize the Pain of Local Anesthetic
Injection for Wide Awake Surgery
PRS Global Open • 2021
manipulated. Nerve decompression such as carpal tun-
nel,9 cubital tunnel,10 and lacertus release11 are routinely
performed with wide awake local anesthesia no tourniquet
(WALANT). The results of forearm tendon transfers,12
exor tendon repairs,13,14 tendon grafts,15 and tenolysis16
can all be improved because surgeons can see comfortable
awake patients move the reconstructed tendons during
the surgery. In the head and neck, blepharoplasty,17 rhytid-
ectomy, and skin cancer reconstruction such as forehead
aps can readily be accomplished safely without sedation.
Surgeons can educate unsedated patients during the pro-
cedure to reduce the chances of postoperative complica-
tions.18 Eliminating sedation also simplies and improves
safety in many procedures in emergency rooms.
Minimal pain tumescent local anesthesia injection has
also been used in wide awake internal xation of fractures
of metacarpals,19 distal radius,20,21 elbows,22 clavicles,23 and
ankles.10 When anesthetising long bones for plate xation,
the entire periosteal surface of fracture, screw, or K wire
penetration of the cortex must also be bathed with local
Perhaps the most important reason to avoid unneces-
sary pain with local anesthetic injection and wide awake
surgery is that it is the right thing to do. Here are 13 ways
that work well to achieve the goal.
1. Buffer Local Anesthetic with Sodium Bicarbonate
We prefer to use premixed 1% lidocaine with 1:100,000
epinephrine. However, its pH has been shown to be approx-
imately 4.2, which is roughly 1000 times more acidic than
the body pH of 7.4. This is why it stings when it is injected
without buffer. We add 1.0 ml of 8.4% sodium bicarbonate to
every 10 ml of local anesthetic to decrease the acidic sting.24–27
Refrigerated local anesthetics hurt more than room-
temperature solutions.28 Some British hospitals keep their
lidocaine and epinephrine refrigerated so that it lasts lon-
ger. We store at room temperature and adhere to labeled
2. Use Smaller 27- or 30-gauge Needles
Smaller needles hurt less than larger needles.29–32 We
recommend the use of smaller 27-gauge (0.4 mm) or
30-gauge (0.3 mm) needles for injection, instead of 25
gauge or larger needles. Tinier needles also force the
injector to slow down the local anesthetic injection speed
because of increased resistance. We start most of our injec-
tions with a 30-gauge half-inch needle on a 3-ml syringe,
and then switch to a 27-gauge 1.25-inch needle on a 10-ml
syringe for the rest of the injections.
All hospitals have a designated person who orders
needles from commercial sources. Find that designated
person and ask her to “check the box” that buys 27- and
30-gauge needles the next time she is ordering. The same
goes for ordering premixed lidocaine with epinephrine
instead of plain lidocaine without epinephrine.
3. Immobilize the Syringe with Two Hands and Have Your
Thumb Ready on the Plunger before Inserting the Needle
The senior author has been injected by residents
well over 80 times as the rst volunteer for many local
anesthetic studies. He has felt every little needle move-
ment or wobble until the needle penetration site is numb
(Fig. 4.)33 This is why we immobilize the syringe with
two stabilized hands and have our thumb ready on the
plunger before inserting the needle (Fig.1). We want zero
needle movement in the skin until it is completely numb.
Importantly, the hand holding the syringe should not be
free in the air, where it is likely to move around before the
needle site is numb.
4. Use More Than One Type of Sensory Noise When
Inserting Needles into Skin
Our favorite technique is pinching loose skin up into
the needle instead of inserting the needle down into the
skin (Figs.2–3). (See Video 1 [online], which displays sen-
sory noise. This illustrates examples of pinching the skin
into the needle, inserting needle at mid deep inspiration,
and maintaining pinch till sting is all gone.)
This creates the sensory noises of pinch, movement,
and pressure, which all decrease the volume of the pain
sound that the brain hears. Maintain the pressure of the
pinch until the patient tells you the needle sting is all gone.
We also tell the patients “I will count to 3. When I get to 2,
take a nice deep breath. When I get to 3 try not to move
when you might feel a little sting. If you move, the needle
Fig. 1. Stabilize the syringe with both hands, thumb ready on the
plunger so that the patient does not feel every little wobble of pain-
ful needle movement before the needle entry site is numbed, which
can take up to 60 seconds. Reproduced with permission from Plast
Reconstr Surg. 2013;132:675–684.
Joukhadar and Lalonde • Minimizing Local Anesthetic Injection Pain
might come out and might have to sting you twice because
I need to put it back in.” Inserting the needle at the mid
point of the deep inspiration is good extra sensory noise.
If there is no loose skin, press very rmly with a nger
just proximal to where the needle goes in until the sting is
gone. These simple tricks, along with a 30-gauge needle,
will often result in a “hole in zero” where the patient does
not feel any pain at all with needle insertion.
Other forms of sensory noise include vibration,34
ice,35,36 music, movies, and virtual reality.37,38 Ask patients
to look away because watching the needle insertion may
worsen the patient experience.39 Topical local anesthetics
are effective in the mucosa, but less so in the imperme-
able skin. They may numb the upper dermis, but they take
a long time to work and do not numb the lower dermis
and supercial fat.40 (See Video 2 [online], which displays
sensory noise carpal tunnel surgery injection hole in one.
When there is not a lot of loose skin, like for the rst injec-
tion for carpal tunnel surgery, press very rmly with a
nger just proximal to the needle insertion site and keep
pressing rmly until the patient no longer feels the sting
of the needle entry site.)
5. Try to Insert the Needle at 90 Degrees Perpendicular to
Most skin pain bers are in the dermis. To compare
nerves to trees, the many “leaves” are in the dermis,
Fig. 2. Sensory noise. Pinch the skin up into the needle instead of
pushing the needle down into the skin. Pinch the skin just proximal
(relative to nerve origin) to where the needle enters the skin.
Fig. 3. Good technique. Pinch the skin rmly just proximal to the
needle insertion site. Pinch the skin into the needle instead of push-
ing the needle into the skin. The thumb is ready on the plunger. Both
hands are stabilized to immobilize the needle after entry, so that the
patient does not feel it moving before the needle site is numbed.
Fig. 4. Poor technique. Holding the syringe with only one unstabilized
hand that can move in space has the patient feeling every little side to
side needle movement until the needle site is numb. Needle depth is
also not constant as it keeps moving in and out. The thumb is not ready
to go on the plunger; so the patient will feel the injector move the needle
as he fumbles to get his thumb on the plunger. There is no sensory noise
such as pinching the skin proximal to the needle entry site in this image.
Fig. 5. Do insert the needle perpendicular to the skin to decrease
the number of sensory nerve bers irritated by the needle.
PRS Global Open • 2021
whereas the fewer “branches and trunks” are in subder-
mal fat. The injector is less likely to pierce “pain leaves”
with perpendicular entry into the skin instead of going
in obliquely (45 degrees) or parallel (<45 degrees) across
many leaves of the tree (Figs.5, 6).41,42
6. Do Not Inject in the Dermis, But in Fat Just Below It
Because nerve endings are concentrated in the der-
mis, intradermal injections are more painful than sub-
dermal injections (Fig.7).43 With an open wound such as
a laceration, you can avoid putting the needle through
sensitive skin altogether. Instead of going through the
skin, inject directly into the subcutaneous fat of the open
wound where the trunks and branches of the nerve trees
are, so that you avoid hurting the many nerves in the
skin with transcutaneous needle insertion. As soon as
your needle bevel is in the fat, begin slowly injecting until
you see tissues swell, and then stop advancing the needle
but continue injecting until tissues are very swollen and
7. Inject At Least 2 ml Slowly Just under the Dermis before
Moving the Needle At All (Fig.8)
It takes 15–60 seconds for the needle entry site to get
numb after penetration. Right after needle penetration,
always ask patients to tell you when they no longer feel the
needle in the skin. Until they do, keep it perfectly still like a
mosquito keeps his mouth’s six needle stylets immobile after
they enter your skin. When the needle sting is all gone, you
can inject just a little faster until you get at least 2 ml under
the skin before you even think of moving the needle. A com-
mon mistake is to assume the needle skin is numb and just
start moving the needle soon after you get under the skin.
8. Never Advance Sharp Needle Tips Anywhere That is Not
Do not advance sharp needle tips into areas not yet
numbed (Fig.9). Always use a nger of your other hand
to palpate ahead of the needle tip so that you can both
feel and see where the local anesthesia is swelling the tis-
sue around the needle tip (Fig.10). Always make sure to
have at least 1–2 cm of local anesthesia ahead of where
you are advancing sharp needle point. You never want to
move your sharp needle tip into an area that is not numb.
Move the needle very slowly while injecting antegrade. It
Fig. 6. Do not insert the needle from 45 degrees to parallel to the
skin because it hurts more.
Fig. 7. Do not inject into the dermis because it hurts more.
Fig. 8. Do inject at least 2 ml of local anesthesia slowly into the fat
just below the skin before moving the needle at all. Reproduced
with permission from Plast Reconstr Surg. 2013;132:675–684.
Joukhadar and Lalonde • Minimizing Local Anesthetic Injection Pain
is not necessary to draw back on the plunger as minute
volumes of intravascular lidocaine and epinephrine are
not harmful. Anesthesiologists inject 1 mg/kg of lidocaine
slowly intravenously for pain control in some postopera-
tive patients.44 The intravascular half-life of epinephrine
is only 1.7 minutes.45 You are not likely to inject intrave-
nously in tumesced fat ahead of the needle in any case.
9. Always Inject from Proximal to Distal
Nerves branch in a proximal-to-distal manner. Injecting
proximal to distal increases the likelihood of proximal nerve
blockade.46 However, the goal of tumescent local anesthe-
sia is not to provide large nerve blocks. It takes a very long
time for local anesthesia to be effective in large nerves: up
to 100 minutes for the median nerve at the wrist.47 The goal
of tumescence is to bathe all tissue, including all the little
nerve branches, affected by surgery. The smaller the nerve,
the faster it is numbed. (See Video 3 [online], which dis-
plays injection of a nasal cancer reconstruction forehead
ap with up to 100 ml of 0.5% lidocaine with 1:200,000 epi-
nephrine. The injections demonstrate starting in an open
wound with a 3-ml syringe and a 30-gauge needle, alternat-
ing sites to prevent reinsertion pain, saving the columella
and alar rims for last so that they do not hurt, and injecting
proximal to distal in the forehead.)
10. Use Blunt-tipped Cannulas When Tumescing Large Areas
A sharp needle makes a skin hole entry site through
which you pass a blunt-tipped cannula, which painlessly
glides between nerves and blood vessels through subcu-
taneous fat to anesthetizing large areas more rapidly in
procedures such as forearm tendon transfers, skin graft
harvest from the thigh, and rhytidectomy.48–51 (Figs.11, 12).
When injecting 200 ml for a forearm tendon transfer or a
rhytidectomy, inject the solution from an IV bag with tub-
ing hooked up to a three-way stopcock and a 10-ml syringe.
(See Video 4 [online], which displays cannula injection
showing some of the tumescent injection of 200 ml of
1/4% lidocaine with 1/400,000 epinephrine for rhytid-
ectomy with a 10-ml syringe connected to an IV bag and
tubing with a three-way stopcock. Blunt-tipped cannulas
permit more rapid painless injection of large volume cases
such as these to provide an even better patient experi-
ence. Always reinsert the cannula inside a 1–2 cm border
of clearly tumesced numb skin to avoid cannula reinser-
Fig. 9. Do not advance sharp needle tip into areas that are not num-
bered by local anesthesia.
Fig. 10. Do always see and palpate 1–2 cm of visible palpable local
anesthesia ahead of your sharp needle tip so that you never advance
the needle anywhere that is not numb. Blow slow before you go…
Blow slow before you go…
Fig. 11. Sharp needle tips can traumatize nerves through puncture
Fig. 12. Blunt tip cannulas slide in the fat with a much lower chance
of piercing nerves and blood vessels.
PRS Global Open • 2021
11. When Tumescing Large Areas, Only Reinsert Needles
into Skin that is Already Numb and Alternate Injections
from One Side to Another
You need to reinsert the needle when anesthetizing a large
area such as a cleft lip reconstruction.52 (See Video 5 [online],
which displays injection for simultaneous cubital tunnel
and lacertus releases. The injections demonstrate very lit-
tle movement of the needle as a total of 120 ml is injected
into the anterior and medial elbow for proximal median
and ulnar nerve decompressions. Always alternate sites of
local anesthesia injection with each change of syringe so as
to give time for the local to work at the last area injected.
Always reinsert needles into clearly tumesced skin so
that needle reinsertion does not hurt. Always inject from
proximal to distal.) Always reinsert the needle at least
1 cm inside the safe border of clearly blanched, swollen,
tumesced skin so that you never insert a needle in skin
that is not numb. Patients should never feel pain with the
needle reinsertion. Alternate injecting from one side to
the other of the surgical eld so that needle reinsertion is
less likely to hurt because the last side has had more time
to get numb. (See Video 5 [online], which displays injec-
tion for simultaneous cubital tunnel and lacertus releases.
The injections demonstrate very little movement of the
needle as a total of 120 ml are injected into the anterior
and medial elbow for proximal median and ulnar nerve
decompressions. Always alternate sites of local anesthesia
injection with each change of syringe so as to give time for
the local to work at the last area injected. Always reinsert
needles into clearly tumesced skin so that needle reinser-
tion does not hurt. Always inject from proximal to distal.)
12. Always Ask Patients to Tell You Every Time They Feel
Pain during the Whole Injection Process so That You Can
Score Yourself and Improve Your Technique with Each
Every injection is a learning opportunity. (See Video 6
[online], which displays how to explain to patients about
telling the surgeon each time it hurts during the injection
process, so that we can get better and better with pain-
less injections. The video also shows stabilizing the syringe
with two hands, pinching the skin into the 27-gauge nee-
dle, and sensory noise with pinching the skin into the
needle and deep inspiration at needle insertion time.)
In our practice, if a patient feels pain only once in the
whole injection process, the medical student scores a hole
in one. If the patient feels pain twice, the resident scores
an eagle. If the patient feels pain three times, the lead
author scores a birdie. If we all score ourselves every time
we inject every patient, our inherent desire to improve our
score will drive us to get better and better injectors. (See
Video 6 [online].)
13. Always Inject Too Much Volume Instead of Not
Enough Volume to Eliminate Surgery Pain and the Need
for “Top Ups”
A very common mistake is to not inject enough vol-
ume. The goal is to tumesce all tissues with visible and
palpable local anesthesia at least 2 cm beyond wherever
you will insert sharp objects or manipulate fractures. You
never want to have to add local anesthesia during surgery
because a patient feels pain, any more than you want
patients to wake up during general anesthesia. We use the
extremely safe maximal dosage of 7 mg/kg of lidocaine
with epinephrine. We add up to 150 ml of saline to 50 ml
of 1% lidocaine with 1:100,000 epinephrine when we need
up to 200 ml of volume. We do not need higher concen-
trations than 0.25% lidocaine with 1:400,000 epinephrine,
which provides effective anesthesia for procedures lasting
less than 3 hours.
Patients will truly think you are magical if you take
the time to learn these simple techniques that we easily
teach all our medical students and residents. They will
enable you to almost painlessly tumesce large areas of the
body with local anesthesia for safer surgery without the
Donald Lalonde, MD, MSc, FRCSC
Division of Plastic and Reconstructive Surgery
Suite C204, 600 Main Street
Saint John, New Brunswick
Canada E2K 1J5
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