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Presentation

Anatomy and Nerve Block Tips for Lower Extremity Dermatologic Surgery

Description

The talk reviews key lower-extremity anatomy and practical nerve-block tips for dermatologic surgery, emphasizing that understanding where major nerves and vessels lie helps surgeons safely remove tumors without unnecessary fear. It covers the femoral triangle as a proximal danger zone, noting that important structures are generally deep to muscle, while the lateral femoral cutaneous nerve can cause postoperative lateral thigh numbness and the femoral nerve and artery are encountered deeper after muscle is removed. In the distal leg, the popliteal fossa is highlighted as another danger zone, especially because the common fibular nerve is superficial and injury or compression can cause foot drop. For the ankle and foot, the talk explains relationships around the medial and lateral malleoli, including the posterior tibial artery and nerve, superficial peroneal, saphenous, and sural nerves, and the deep peroneal nerve in the first web space. It recommends ankle blocks over straight local anesthesia for comfort, focusing on the four main ankle nerves and adding the deep peroneal nerve when needed. For digital anesthesia, the speaker prefers metatarsal blocks over traditional web-space digital blocks because they preserve collateral circulation better and are easier to perform, and notes that small amounts of epinephrine are safe in digits.

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Conclusions

Deep anatomic knowledge of the lower limb helps surgeons remove tumors more confidently and avoid leaving disease behind due to fear of injury.
In the proximal lower extremity, the major neurovascular structures are generally deep to muscle, so muscle often serves as a useful protective landmark during excision.
The femoral triangle contains important vessels and the femoral nerve, but these structures remain relatively protected beneath the muscular and fascial layers.
The lateral femoral cutaneous nerve is an important superficial sensory nerve to counsel patients about because injury can cause persistent numbness on the lateral thigh.
In the distal lower extremity, the popliteal fossa is the main danger zone, especially because the common fibular nerve is superficial and injury can lead to foot drop.
Even when a superficial nerve is injured or sacrificed during cancer surgery, patients may be helped with counseling, physical therapy, and orthotics.
Around the ankle and foot, the key vessels and nerves lie in predictable positions near the malleoli and beneath specific fascial layers, making anatomy-guided dissection safer.
Understanding the sensory territories of the foot is essential for effective ankle blocks and for avoiding missed anesthesia in the first web space and along the foot margins.
For ankle anesthesia, targeting the superficial peroneal, sural, saphenous, posterior tibial, and deep peroneal nerves provides comprehensive coverage.
Digital and metatarsal blocks can be performed effectively in the foot, and the metatarsal block may be preferable because it better preserves collateral circulation.
Small amounts of epinephrine are considered safe in the digits and may reduce the need for a tourniquet.
Overall, careful anatomy-based planning improves tumor clearance, patient comfort, and procedural safety in lower-limb dermatologic surgery.

Sabotta Clinical Atlas of Human Anatomy