Optimising Local Anaesthesia Techniques in Wide-Awake Skin and Soft Tissue Surgery: A Systematic Review and Meta-Analysis

This study aimed to provide an easy-to-implement guide with the most important techniques for administering local anaesthesia in wide-awake skin and soft tissue surgery, ensuring minimum pain and maximum efficiency. Until December 2024, several databases (MEDLINE, Embase and The Cochrane Library) were used to identify studies with following eligible interventions: needle and injection techniques, additives, communication methods, additional analgesic measures and environmental factors. Studies missing relevant outcomes, peer review, full-text availability or not written in English were excluded. Data extraction and risk of bias assessment (RoB 2 tool) were conducted independently. Meta-analysis was performed in JASP (v0.19.3) using a random-effects model, with mean differences (MDs) as effect measure. Heterogeneity was assessed (τ 2 , Q and I 2 ), and meta-regression explored intervention type as moderator. Out of 48 included studies (3664 patients), 16 were eligible for meta-analysis. All interventions consistently showed pain reduction (MD −1.50, P = .010), and heterogeneity was high ( I 2 = 97.3). Meta-regression did not reveal significant differences between techniques. Techniques like warming, slower injection speeds and cryopreparation showed favourable results, whereas vibration, verbal framing and waiting after epinephrine administration offer promising, low-risk strategies. As wide-awake skin and soft tissue surgery continues to expand in use and scope, this review highlights practical, patient-centred strategies to optimise local anaesthetic injections, ensuring they are no longer perceived as ‘the most painful part of the procedure’.