When you think of local anesthesia, you might think of dental work or minor procedures, like biopsies and getting stitches, where you’re awake but not feeling any pain. But a facelift or neck lift under local anesthesia? As questionable as it sounds, these days, the answer is, increasingly, yes. “Every surgeon has their own style and techniques that help them achieve the results they’re known for,” says Dr. Mark Karolak, a board-certified facial plastic surgeon in Wall, New Jersey. “Some prefer having their patients under general anesthesia, but I’m seeing more surgeons learning how to use local anesthesia safely.”
It’s a trend that has evolved over the past decade or so, and one that’s catching on with patients, who are enamored with the many benefits of having surgery under local anesthesia—including that it’s less scary, physically taxing, and costly and it may even result in better cosmetic outcomes.
In addition to facelifts and neck lifts, there are a number of other plastic surgery procedures on the local list as well, including mini lifts, brow lifts, eyelid lifts, lip lifts, and rhinoplasty (nose job). Below-the-neck treatments being done under local anesthesia include breast lifts, breast implant removals, labiaplasty, and vaginoplasty. When performed on small areas, like under the chin or the Buffalo hump (a lump of fat at the top of the back between the shoulders), liposuction can also be done under local.
For some patients, this more minimal approach to anesthesia during plastic surgery may even mean the difference between having surgery and not having surgery. “There are many patients who aren’t well enough, medically, to go under anesthesia, whether they’re under treatment with blood thinners or for other medical problems, so this is a great option for them,” says Dr. Dilip Madnani, a board-certified facial plastic surgeon in New York City. “For many patients who’ve been told they can never get a facelift or who would never do one because they want to avoid anesthesia, when they find out that it can be performed under local anesthesia, they proceed—and are very happy with this option.”
Dr. Madnani now does 80–90% of his surgeries under local (including 150 facelifts a year). “I explain to my patients that it’s like having procedures at your dentist but more fun—we have nice music playing in the OR, and patients are either dosing off or chatting with me,” he says. “Once the relaxing medications are on board, patients don’t move, as they don’t feel anything, and they’re kept comfortable through the procedure.” The local experience is something that patients seek him out for. That includes Beth Holmes, 59, who’s had four surgeries with other plastic surgeons under general and three (so far) with Dr. Madnani under local. “I will continue to do as many surgeries under local as I can,” she says. “It’s a much better experience.”
How local anesthesia works
Local anesthesia is a medication that affects the nerves on a cellular level, explains Dr. Madnani. “It shuts down pain receptors so patients don’t feel anything other than a little pressure.” Local anesthesia is usually injected directly into the skin surrounding the treatment area. A key difference between local and general anesthesia is that local numbs the area, while the rest of the body is unaffected. With general anesthesia, patients are given a cocktail of drugs, usually via intravenous injection, that renders them completely unconscious and unable to feel anything.
The most commonly used local anesthesia in plastic surgery is lidocaine. If you’ve ever had facial fillers, like Juvéderm and Restylane, you’re probably familiar with the effects of lidocaine, which is frequently mixed in with the filling material to minimize discomfort felt at the injection sites. (Interesting fact: lidocaine and the other “-caine” drugs are chemically similar to cocaine, the first local anesthetic.)
Often, surgeons use oral sedation, such as Valium, along with local anesthesia to make patients more relaxed and comfortable but not totally asleep. “Some of my patients prefer to be awake, while others want to be relaxed enough that they can fall in and out of sleep, using a medication like Valium that they can take in a pill form,” says Dr. Karolak. This eliminates the need for any intravenous medication. You’ll feel a few pinches when the local is injected, but because the anesthesia is injected slowly, there’s minimal discomfort. Your surgeon will mark the excess skin and incision sites before injecting the anesthetic, so any distortion it creates won’t affect the result of the procedure.
The effects of local anesthesia usually wear off after a few hours, says Dr. Melinda Haws, a board-certified plastic surgeon in Nashville. (There are longer-lasting locals, but they’re often more expensive, she says.) For Carrie Porter, 63, who had eyelid revision surgery with Dr. Haws to remove excess skin after she lost weight, the effects of the local and the sedation lasted just long enough for her to get off of the operating table, don her sunglasses, and grab lunch with the friend who was driving her. “Dr. Haws said I’d have a two-hour window before the anesthesia would wear off and it would hurt like a b**ch,” she recalls. “And by the time we were paying the bill, everything had worn off. I said, ‘Get me home to my ice pack and pain pills.’”
If patients don’t take any oral medication, they can even drive themselves to and from the surgery center.
Related: 6 Plastic Surgery Procedures You Can Do Under Local Anesthesia
Local vs. general anesthesia anxiety
One of the key drivers of the trend toward local is the high percentage of patients who don’t want or can’t have plastic surgery under general anesthesia. To continue normal bodily functions while unconscious, the patient is placed on a respirator and a breathing tube is placed in their throat, since they won’t be able to breathe on their own.
For many patients contemplating elective surgery, especially those of a certain age, these extreme measures can be a deal breaker. “Overall, anesthesia is safe, however, there are added risks,” says Dr. Madnani. “And a lot of older patients are also afraid of the alleged cognitive side affects of general anesthesia.” Even “twilight” (aka IV or conscious sedation), an anesthetic technique that allows patients to be sedated intravenously without completely losing consciousness, turns some patients off. Though most side effects of general anesthesia and twilight are minor and temporary, “a large portion of my patients wouldn’t ever consider having anything done unless it could be performed under local,” says Dr. Karolak.
Take Andrea Filmore, 53. “Going under anesthesia is a real fear for me,” she says. “At this age, people think about that more. They’re not sure they want to go under, because they’re not sure they’re going to wake back up!” Prior to having a facelift and neck lift under local in February with Dr. Karolak, she’d had several surgeries under general, including a hysterectomy and bladder surgery. “I just don’t like waking up, feeling out of it,” she says. “I don’t have the fear of knowing what’s happening during surgery, so I’d rather be awake.”
When she first considered having surgery, Filmore didn’t even realize local anesthesia was an option. “I was thrilled to not need to have an IV setup or be put to sleep,” she says. Prior to her procedure, Filmore was given a sedative, to help her relax, and then injections, to numb the surgical area. During the surgery, she remembers dozing off and then waking back up to chat with Dr. Karolak. Though she’d been fearful about feeling tugging and other sensations, she says she didn’t feel a thing. “At one point during surgery, my back was bothering me, but by then it was almost over.” Afterward, she says, “It was like nothing had happened. I was very alert and felt great.” Two days after her surgery, instead of dealing with the “anesthesia hangover,” which can take several days to fully wear off, Filmore was up and about and visiting with family.
Sidestepping side effects
Going local, where only one part of the body is numbed, carries the least risk of postoperative nausea and vomiting, a side effect of general anesthesia that reportedly affects one-third of surgical patients. The urge to retch after surgery is a reaction that Holmes knows all too well. After past surgeries she’d had under general, she was very nauseous and had to take Zofran, a medication used to prevent and treat post-op nausea and vomiting. “I had to shove those pills down my throat because I didn’t want to bust any stitches and undo the surgeon’s handiwork,” she says.
In addition to reopening incision sites, vomiting after surgery can also lead to increased bruising and swelling, all of which can lengthen the recovery period. Another possible complication, occurring as often as once in every 2,000–3,000 operations requiring anesthesia, is aspiration, when the contents from your stomach move up to your mouth and enter your trachea and lungs. To avoid this, patients are asked to fast for at least eight hours before having surgery under general or IV sedation anesthesia. With local anesthesia, having a light breakfast beforehand—sans coffee, because the caffeine can constrict blood vessels and lessen the effect of the lidocaine—is suggested.
Local anesthesia is less expensive
Though it should never be the primary consideration for any aspect of cosmetic surgery, another major advantage of local anesthesia is the reduced cost. For both general anesthesia and twilight, an anesthesiologist or certified registered nurse anesthetist (CRNA) needs to be on hand, to monitor the patient—something that can add a lot to the bottom line. “Cost varies from market to market, but in my case, if I can perform a procedure under local, that means the patient doesn’t have to pay for an anesthesiologist, which drops the overall cost anywhere from 10–25%, if not more,” says Dr. Haws.
For Holmes, who works as a surgery scheduler for a plastic surgery practice that offers “awake” surgery for only a few procedures (hence one of the reasons she went to Dr. Mandani and paid for surgery that otherwise would have been free), cost was definitely a factor. “To undergo three hours of anesthesia would have added another $1,500 to the bill for the last surgery I had,” she says. “I didn’t want to pay for anesthesia, but even more, I didn’t want to undergo it unless I really needed it.”
Sarah Billings, 68, was delighted that having her breast implants removed last year under local “brought the cost way down.” But having her GP on board really gave her peace of mind: “She said, ‘Go for it—I’m all about you not being under anesthesia.’”
Better results with local anesthesia
For some surgeons, having a patient awake during surgery allows them to deliver better results. “Every surgeon is different, but for me, it’s important that the facial muscles retain tone during surgery,” says Dr. Karolak. During general anesthesia, the muscles are paralyzed and more lax than they would be normally. “When I’m operating, I want the muscles to be in their natural state,” he says. “This helps me achieve natural-looking results.”
It can also be helpful for patients to be able to move their head into different positions, smile, or open their eyes. “It helps me be more precise during the procedures I perform,” says Dr. Karolak. Porter remembers Dr. Haws explaining that it was “better to do her surgery under local because ‘you’re awake and I can see you with your eyes open and know exactly how this will look.’ That made sense to me.”
Being able to sit up comes in handy too. For instance, when patients are doing a straightforward breast implant exchange without a capsulectomy (removal of the scar tissue that naturally forms around the implant), Dr. Haws often sits them up while they’re sterilely draped and has them look in a mirror, to weigh in on the size change. “This is an area I can get numb with a very small amount of local anesthetic quite easily, if I’m not working on the breast capsule.”
Faster healing
Local anesthesia can also give you the jump on healing. “Under general, there’s more swelling from the IV fluids needed to keep your blood pressure up,” says Dr. Madnani. Placement of the breathing tube also has its own set of side effects, including throat discomfort that ranges from mild to severe and that can last for several days post-op.
Local also reduces bleeding during surgery, which limits bruising afterward and speeds recovery. “Under local anesthesia, a patient’s blood pressure and vital signs are basically normal versus under general anesthesia or IV sedation, during which their blood pressure can go low, which decreases bleeding,” says Dr. Madnani. “It’s hard to take care of bleeding that can occur during surgery, as you don’t see it. It only presents once the patient is awake and their blood pressure returns to normal.”
Related: Twilight Sedation: 8 Things to Know
“It’s not for everyone”
Surgeons who offer local anesthesia admit that it’s not for every patient.
“All local procedures require a patient who’s motivated to proceed this way,” says Dr. Haws. “For a few, it’s too anxiety-provoking to hear and see and smell what’s going on in the operating room. I try and be selective, so that I’m not stressing an anxious patient or pushing the limits of local too far.” If having facial surgery, patients also need to be comfortable having injections in their face. “Some patients don’t like that,” says Dr. Haws.
Despite having a light shining on her during the surgery and the surgeon being pretty up close and personal, the local experience didn’t bother Porter. “It wasn’t at all disconcerting,” she says. “To me, it was no different from when the dentist does a root canal. The proximity is pretty similar.”
During her procedures with Dr. Madnani, Holmes was “chilling. He guides you through it, so you know what’s coming. Nothing is a surprise,” she says. “He does offer anesthesia, but the right patients can absolutely do this.”
From the surgeon’s perspective, it can be uncomfortable to perform surgery under local when a person is anxious or uncomfortable even when given all the appropriate medications to numb the area and become relaxed. The surgeon can work more quickly and efficiently when these patients are fully asleep.
In the right situation, though, local “is amazing,” says Dr. John Sherman, a board-certified plastic surgeon in New York City. reports. “The patient gets off the table, and 10 minutes later, after having crackers and water, they walk out the door.”
Whether it’s always possible to have surgery under local also depends on individual circumstances. For instance, when it comes to breast lifts, Dr. Haws says it can be done under local if the lift is a small enough volume that it can be anesthetized with local anesthetic. “Big volumes don’t do as well as skin-only lifts,” she says.
Breast implant removal is another procedure that can often easily be done under local, provided the capsules aren’t also being removed.
Local can also be used for “simple” rhinoplasty, meaning when bones don’t have to be readjusted.
What’s off the list for awake surgery? For many plastic surgeons, primary breast augmentations and tummy tucks (or the combination, known as a “mommy makeover”) are on the no-go list. “Most of those doing a full mommy makeover under local are physicians who can’t get privileges to do those surgeries in a surgery center,” says Dr. Haws, who says she’d never do a primary breast augmentation or tummy tuck under local anesthetic. “The amount of local I’d need would make the procedure too dangerous.”
Complications can happen even with local anesthesia
As innocuous as local anesthesia may seem, it does carry risks.
Minor and temporary side effects of local anesthesia include bruising, swelling, redness, and itching near the site of the injections. Lidocaine was developed as a less allergenic form of novocaine, and true allergies to it are rare—but be sure to discuss the possibility with your surgeon.
System toxicity is the primary complication associated with local anesthesia, and injections of rapidly absorbed local anesthetics into vascular areas heighten the risk. “We’re super-careful about not placing the local anesthetic into vascular areas—there are techniques, such as aspiration and using certain needle sizes, that we follow to minimize this,” explains Dr. Madnani.
To keep within safe parameters, surgeons use predetermined doses that are based on the patient’s weight. “If I need too much to get the patient numb, then they need a general anesthetic, because in those cases, it’s much safer,” says Dr. Haws.
If you’re having face and neck surgery, the risk is lower, since they have smaller surface areas compared with procedures on the body, so the overall volumes of anesthesia are lower. Many surgeons also use a “dilute” local anesthesia solution that further minimizes the concentration of local used during the procedure. “Plus all our patients are monitored throughout the procedure, so we’re checking their vital signs constantly,” says Dr. Madnani.
It’s important to note that not all plastic surgeons are on board with performing longer procedures—such as a facelift, particularly a more aggressive lift, which can take several hours—under local. “Patients who are getting facelifts aren’t 20 years old,” notes Dr. Sherman. “A large percentage of patients age 50 and above who are having facelifts have a medical history.” He points to the possibility of drug interactions that can cause a spike in blood pressure during the procedure that needs to be managed. Though he performs a host of surgeries under local, including otoplasty (ear surgery), the amount of anesthesia for those procedures is “nothing. But with a facelift, you’re getting a load,” he says. The upshot: “For facelifts, I want an anesthesiologist there, for safety reasons.”
This difference of opinion underscores the importance of discussing the risks and benefits of the various type of anesthesia with your surgeon, to determine the best one for you. It’s also important to choose a board-certified plastic or facial plastic surgeon who’s experienced and comfortable using both these techniques—if a surgeon offers only local anesthetic, it’s wise to be wary. If having a procedure under local, make sure the surgery is being done in an accredited facility (it should be accredited by AAASF or AAAASF or Medicare).
In the end, after all, says Holmes, “It’s not just the awake experience, it’s the awake experience with the right doctor.”
