The significance of safety evaluation of general anaesthesia in paediatrics has been addressed in the past [7]. However, recent epidemiological researches concerning with general anaesthesia-related complications particularly in pediatric skin surgeries were scarce [8]. The available literature usually emphasizing on the usage of general anaesthesia in major operations such as neurosurgery, cardiovascular surgery, and abdominal surgery in adults and children [9]. Little number of articles on the web have addressed the safety of general anaesthesia in pediatric dermatologic surgeries. The available information from the review of the literature shows that morbidity and mortality from general anaesthesia in skin surgeries among children are very rare and clinically insignificant [9,10].

The incidence of post-operative headache as a minor complication related to anesthesia ranges between 2 to 70% [11]. Substantial reasons for this wide range in fallouts are not ostensible [12]. However, short-lived or mild headache may go unremarkable by patient or observer [13]. Our results showed low incidence of headache in spite of patient interviewing. Our study results reported here are a little different from the published literature. However, there was no serious complications or mortalities were noted. The findings of our study are not similar but consistent with the foregoing publications. A multicenter study was done to evaluate the safety and adverse events linked to general anaesthesia in pediatric patients undergoing elective surgeries was conducted as a retrospective review of 270 children between two months and eighteen years old [1]. The complications of general anaesthesia after elective pediatric dermatologic operations were very low and 95%of children did not experience clinically significant complications [14]. An editorial article by Dinulos et al also reported that deep sedation and general anaesthesia are safe and cost-effective approaches to control pain [15]. Under calm and quiet conditions, Dinulos encouraged other surgeons to perform cutaneous surgical procedures on children under general anaesthesia. To report their suggestions, to improve their practice, and to establish recommendations to advance their management.

Another study found that laryngospasm and transient apnea were the most common complications noted, however, the results were statistically insignificant [16]. Our findings did not show any incidents of laryngospasm or apnea. Wound infection was a common complication after skin surgeries, however, it is far away to be classified as a complication related to anaesthesia, it could happen either under general or local anaesthesia [17]. Regarding the appropriateness and timing of the use of general anaesthesia for children in surgical dermatology. Authors and surgeons have settled that general anaesthesia is safe and appropriate for different pediatric dermatologic operations, regardless of the factor of age [18,19]. Especially, Chen who suggested that timely surgical intervention under general anaesthesia will be the best option in children with lesions that; associated with substantial health risks or result in deformity or functional impairment [19]. Also, children who will definitely benefit from early surgical intervention because of the superior cosmetic outcome which will be obtained [20]. Also, in children where the timely surgical correction will positively affect their psychosocial status and self-esteem [15,21].

Fortunately, malignant skin lesions in children are very rare [22,23] . Also, operable skin lesions that may lead to functional impairment are quite infrequent [24]. Dysplastic nevus, congenital nevus, and spindle-cell nevus represent the bulk of the skin conditions which may lead to significant complications if neglected and left untreated [25]. Sebaceous nevus can also turn malignant if left untreated. Excisional biopsies are essential in the diagnosis of such indistinct skin lesions. On the other hand, most of the skin lesions in children are typically benign, in spite of being symptomatic [26]. Symptoms associated, such as; itching pain, growth, or infection. Growth of benign skin lesions in children is usually very slow, however, it may lead to deformation, which is a common complication. All these skin problems can often be treated by surgical interference [27].

Many conditions should be fulfilled first, before the use of general anaesthesia, such as a healthy patient, appropriate choice of surgery, promising outcome, benefits of early surgical intervention in children and right anaesthesia setting [12]. The skin of children is much more pliable, with good healing properties. These advantages allow the surgeon to remove large lesions with primary closure. This makes the skin of children different from the skin of adults [17]. This is clearly shown in the excision of scalp lesions in adults compared with the same procedure in children [15]. The elasticity of the skin in children plays an important role in healing and ease of manipulation than inelastic skin. Inelastic skin in adults sometimes leads the surgeon to perform multiple surgeries, while waiting for better wound healing and skin growth [8].

To avoid postoperative complications such as large scaring, spread scar or wound dehiscence, surgeons should consider an early intervention at a young age [10]. The skin lesion at a young age is not under big tension, so it can be easily closed [14]. When a large skin lesion ought to be removed, in the thigh of a young child. It can be closed primarily without any complications, because of elastic redundant skin and less muscle mass. Similarly, we can avoid surgical complications significantly associated with the usage of skin flaps, tissue expanders or grafts, by early intervention at a young age. All those assistant factors, it is possible to do without them unless you have an older patient with skin lesion under tension [20,21].

In children, sedation is more problematic than in adults because sedation levels are not as obviously distinct [28]. Especially, deep sedation is commonly unclear from general anaesthesia in children. Also, sedation does not provide characteristic airway protection in comparison to general anaesthesia [29]. Repair procedures and large excisions are too painful to be controlled by light sedation. And even small excision with little pain is also difficult to be controlled by light sedation because of the fear and uncooperative behaviour of the child [30]. Especially, if the procedure takes a long duration. Death of children has occurred because the anesthesiologists failed to save the airway in spite of safe sedation [31].

Children go beyond from one sedation level to another with no clear signs, and that increases the likelihood of more risk during the sedation when compared to adults. Moreover, it will be difficult to secure the airway during the procedure done under sedation [32]. Because children have compromised airway due to anatomical variation that makes their airway more prone to obstruction or injury. In addition to the relatively large tongue and small oral cavity which make the procedure of accurate evaluation very difficult. Other factors that make the process of airway protection in children impossible, such as prominent laryngeal and pharyngeal structures, short trachea and neck flexion due to projecting occipital bulge [33].

Sedation may be valuable only in case of minor procedures with short duration provided that, there is an adequate number of well-trained personnel and equipment to ensure the safety and proper management of the airway [30]. On the other hand, procedures concerned with excision and repair should be done under general anaesthesia in the operating room. Generally, the usage of general anaesthesia in pediatric surgeries is favourable and safer than sedation [32].

Trained anesthesiologists ensure the proper position of the endotracheal tube by proper positioning of the patients head, to avoid displacement of the tube in to the right bronchus, or dislodgement. Trained staff, beside their experience of at least 250 pediatric performed cases per year, have shown a lower incidence of anesthesia related complications compared with children treated by non-trained anesthesiologists. Previous literature have shown that the associated comorbidities together with prolonged procedures and lack of trained staff, increased the anesthesia related complications by 300% [21]. The usage of the fast-acting anesthetic agent by inhalation, was associated significantly with low risk of general anesthesia [22]. The ASA (American Society of Anesthesiologists) assesses the probability of severe complications in a fit youngster undergoing general anesthesia due to any reason to be one case per 20,000, a tremendously low risk [24].

Our findings revealed minor anesthesia related complications. And this information offers more evidence that general anesthesia is a safe approach. Provided that there are other precautions should be considered such as appropriate patient selection, well trained staff, full equipped theater, right setting, elective procedures and promising outcome due to early intervention. Relatives must always be directed regarding the probable consequence of these risks. We concluded that general anesthesia is a safe approach to perform pediatric dermatologic surgeries, in well-equipped appropriate setting, proper selection of patient population, between the hands of experienced anesthesiologist.