IV Sedation and Local Anesthesia Safe Option for Facelift?

I realise that the purely medical risks are less than general anesthesia, but isn't sedation risky in terms of a possibility, however small, for the patient to actually wake up mid-operation? Or of reaction to the sedation (e.g. restlessness) while actually being operated on? It sounds slightly scary to be semi-conscious during a lengthy, hours long procedure for a facelift. What is your advice, please?

Doctor Answers 16

Anesthesia options for facelift

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I always offer my patients either General Anesthesia or Monitored Anesthesia Care, both with Board Certified Anesthesiology providers, as options for their facelifts. If they do not express a preference, I prefer MAC as the absence of an endotracheal tube certainly expedites the necklift portion. In my practice, I am fortunate to work with exceptionally talented anesthesiologists who "dose" the IV sedation using the usual noninvasive monitors, (blood pressure, electrocardiogram, pulse oximetry). They also use the BIS (brain wave) monitors, which allow them to ensure two important outcomes, namely that patients do not have intraoperative recall (remember painful or frightening events) and have rapid emergence (i.e. wake up smoothly, without nausea) at the end of the case. We have a general anesthesia machine and airway kit but have never had the need to use them.

Patient selection is crucial, as patients should not be "sold" on a technique, rather accept it after full disclosure.Even before the patient arrives, we discuss the operative experience, so they are fully prepared. On arrival, they receive pre-meds, which dove tail into what the anesthesiologists provide. I supplement with local anesthesia +/- nerve blocks, predicated on the patient's weight. Our post-op surveys document safe outcomes and patient appreciation for less intrusive methods. Ultimately, it does depend on matching the patient's needs, the procedure planned and the surgical/anesthesia team. Hope this helps. Good luck.

Orange County Plastic Surgeon
4.8 out of 5 stars 58 reviews

It depends on the surgeon and the surgery.

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We do all of our regular facelifts under general anesthesia combined with local. In that way the depth of anesthesia needs to be much less. We also like to be able to control the airway.

For mini lifts in some patients, I will do them strictly under local after they have taken oral valium. If I use IV anesthesia I ALWAYS have it done by an anesthetist since I only want to focus on my job, not two.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews

Facelifts under local anesthesia is an option in the right hands

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Thanks for posting your question. I have performed thousands of facelifts, neck lifts, mini lifts, blephs, lasers and chin implants all under local anesthesia and oral sedation (valium). Done properly, patients are comfortable and have an easier recovery both mentally and physically. There is an art and science to this local anesthesia technique to acquire a high level of patient comfort. My patients do not even require a narcotic prior or during their their procedures thus reducing nausea caused by narcotics. The risks, both short term and long term, of general anesthesia are eliminated. Please consult with several board certified surgeons experienced in facelifting and also in local anesthesia techniques.

Raymond E. Lee, MD
Orange County Facial Plastic Surgeon
5.0 out of 5 stars 95 reviews

General anesthesia is preferred and is more comfortable for patients

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Respiratory depression and respiratory arrest can occur when patients are partially awake and partially asleep. It is actually safer to be asleep under general anesthesia with a board-certified physician anesthesiologist than it is to be half asleep and half awake. Patient awareness and consciousness of what is going on is a very real issue, so the safest option is to be put to sleep under general anesthetic.

I.V. sedation is my prefered technique for both reasons of safety and comfort

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Virtually all my facelifts for the past 15 years have been done with i.v. sedation and local anesthesia.

There are major advantages:

  • Safer throught the procedure
  • very nfrequent nausea afterward
  • You have the local anesthesia in your tissues so that when the operation is complete there is less pain
  • No distortion of the face from the tubes or masks needed for general anesthesia

Nathan Mayl, MD (retired)
Fort Lauderdale Plastic Surgeon

Anesthesia depends on the comfort of your surgeon

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Dear Jacqui

It is certainly possible to perform a facelift under IV sedation. It is also possible to perform a facelift under just local anesthetic. The choice of anesthetic usually is determined by what the surgeon and anesthesiologist are comfortable with rather than any scientifically mandated requirement.

Surgeons often prefer general anesthesia because it eliminates subjective concerns of the patient. The surgeon is free to do whatever they need to during surgery because patient discomfort is largely out of the equation.

Anesthesiologists prefer general anesthesia because the airway is secure and the anesthesia machine can be used to significantly control and reduce the potential for human errors.

A facelift performed under IV sedation, for the most part, is considered a general anesthesia by the anesthesiologists. They have to work much harder to maintain the appropriate level of anesthesia. Too deep, and they need to step in and ventilate the patient; too light and the patient will begin to shift around.

To my thinking there are advantages to run a case this way but it is an art and it requires a willing artist. Many anesthesiologists seem to ADD and lack the attentiveness to run a case this way. In my experience, nurse anesthetists are much better at this skill.

I perform a number of facelifts in my office under local anesthetic and an oral valium. I have carefully screened these people ahead of time. Generally I have performed prior eyelid surgery on them in the office so I know they will be OK hearing things and can hold still the time it takes to perform surgery. The great advantage of this is minimal drugs in the system so you are not hung over by the anesthesia.

I encourage you to discuss these issues with your doctor. If nothing else, it is a test for how flexible and open your doctor is, which is a good trait to have in a surgeon.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Anesthesia used will vary from Patient to Patient and Surgeon to Surgeon

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Hello Jaqui,

Your question is a very good one and one that I discuss with my patients every day.

General anesthesia, IV sedation and local anesthesia all have their advantages and disadvantages. They are all options worth considering and ultimately the the method used is arrived at by weighing all the important factors in play : safety first, the type of facelift being done, the Patient's medical health and history, the Surgeon's comfort level, the Patient's comfort level, the number and type of additional procedures being done, the setting where the procedure is being done (ie. hospital vs. office based), etc.

I have some Patients who insist on local anesthesia and others who want to be "completely out the whole time". I am very experienced at doing facelifts without general anesthesia and it is my preferred method. However in Patient's who are not comfortable with being awake or whose anatomy requires a more strenuous procedure then certainly general anesthesia becomes a better option.

Bottom line is you should sit down with your Surgeon and go over your concerns with them so that you can both arrive at the technique that will work the best for your case. These procedures are elective and there is always time and room to make them as stress free as possible for the Patient.

Lastly an experienced anesthesiologist who has worked closely with your Surgeon in the past should be able to provide a comfortable experience for you regardless of anesthetic technique used.

Kamran Jafri, MD
New York Facial Plastic Surgeon

Facelift with local anesthesia and twilight sedation

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I have performed well over 2,500 facelifts under local anesthesia with oral sedation for the past ten years. Without doubt it is safe and well tolerated by patients. Compare to the traditional facelift procedures that are performed under general anesthesia, the post operative complications associated with local anesthesia cases are lower and risk of bleeding is minimized. I do not ask my patients to stop their HRT while undergoing facelift with local anesthesia that normally takes less than two hours. The key to a successful facelift procedure using local anesthesia is selection of the right patient by the surgeon and his or her comfort doing these cases.

Anesthesia Used During a facelift - An MD Anesthesiologist can be by your bedside at all times thoughout surgery

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I believe my patients are best served by having an anesthesiologist at ther bedside throughout surgery. It is what I would want for my family or myself. From my perspective as the surgeon, the most important issue is not the form of anesthesia but the credentials and experience of the person who is providing the anesthesia. The options that are available are the following:

An anesthesiologist (board-certified MD)

A certified registered nurse anesthetist (CRNA)

An office nurse (RN) who is responsible for delivering and monitoring IV sedation

Your plastic surgeon (believe it or not) administering sedation themselves or directing another person to do so

In my practice II use experienced, board-certified anesthesiologists (MDs) for the anesthesia care of my patients. One of the many advantages operating in my own Dually accredited surgical suite is that the anesthesiologist is caring for my patient exclusively. The anesthesiologist remains at the bedside of my patient throughout the procedure.

Beyond the issue of the person who is administering your anesthesia, the type of anesthesia really depends on what ‘facelift’ you are talking about, and what risk factors you may have for different forms of anesthesia.
A mini-facelift generally takes one to two hours and can be performed in many patients under relatively light IV sedation. The only unpleasant portion of the procedure in terms of pain is the injection of local anesthesia at the very beginning. So the IV sedation is deeper initially for local anesthetic injection, and then once the entire surgical area is numb then the IV sedation can be lightened.
A full facial rejuvenation surgical procedure (structural fat grafting, High-SMAS face and necklift, browlift, blepharoplasties, etc) may take six hours or more. These procedures can also be performed in many patients under prolonged IV sedation, which is referred to by anesthesiologists as MAC (monitored anesthesia care) anesthesia. To have a long surgery under IV sedation, you ideally should be under the care of an experienced anesthesiologist.
By far the most important consideration from an anesthesia perspective is management (i.e. control of) a patient’s airway. If you can’t reliably provide oxygen delivery and carbon dioxide elimination, then you cannot conduct surgery safely. So experienced, board-certified anesthesiologists insist on some adequate and appropriate means of airway protection. For long IV sedation cases it is customary to pass a nasal airway (once a patient is sedated, of course) which goes in one side of the nose and into the back of the throat and helps to keep a sedated patient’s nasal airway open. It is removed before you wake up.
Some patients will experience airway obstruction when sedated and laying in supine (on your back) position. If your snore heavily, and especially if you have sleep apnea, you are likely to be one of these patients. This in one of the reasons that a good anesthesiologist asks you so many questions before they perform your anesthesia: aspects of your history provide the anesthesia MD significant insight into what to expect and what to be particularly concerned about while you are under anesthesia.
This is important to know: general anesthesia for elective cosmetic surgery, particularly longer cases, is an absolutely reasonable choice. In some patients it is the safest form of anesthesia – as your airway is completely. This is deeper level of anesthesia than IV sedation, and it requires a flexible, soft plastic tiube (either an endotracheal tube or laryngeal mask airway) to keep your airway open as the muscles that keep the airway open when you are awake will be relaxed. If you snore heavily or have sleep apnea, the safest form of anesthesia for you is general anesthesia with an ET tube or LMA.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Anesthesia options for facelift

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Facelift can generally be performed using 3 anesthesia options mainly 1) Local anesthesia with some oral sedation, 2) IV sedation with local anesthesia, 3) General anesthesia. It is best to discuss these options with your plastic surgeon. Not all plastic surgeons will be comfortable with all these options. The options available to you will depend on you and the experience of your plastic surgeon with that anesthesia option and the type of procedure. We have performed facelifts with all the options. Most of our patients prefer local with oral sedation, then IV sedation with local anesthesia, lastly general anesthesia.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.