Local Anesthesia in Cosmetic Surgery: A Growing Trend
When we think of local anesthesia, common scenarios like dental treatments or minor surgical procedures come to mind, where patients remain awake but pain-free. However, the idea of undergoing a facelift or neck lift with local anesthesia might seem unconventional. Surprisingly, this practice is becoming more prevalent. "Each surgeon has unique methods that contribute to their success," says Dr. Mark Karolak, a board-certified facial plastic surgeon in Wall, New Jersey. "While some surgeons prefer general anesthesia, I'm seeing more colleagues mastering the safe application of local anesthesia."
This trend has been evolving over the past decade, gaining traction among patients who appreciate the numerous benefits of local anesthesia, such as reduced anxiety, physical stress, lower costs, and potentially better cosmetic outcomes.
Beyond facelifts and neck lifts, various other plastic surgery procedures can also be performed under local anesthesia, including mini lifts, brow lifts, eyelid lifts, lip lifts, and rhinoplasty. Procedures below the neck, such as breast lifts, breast implant removals, labiaplasty, and vaginoplasty, can also be conducted under local anesthesia. Liposuction, when performed on smaller areas like beneath the chin or the Buffalo hump, can also utilize local anesthesia.
For some patients, the choice of local anesthesia can be the deciding factor in whether they proceed with surgery. "Many patients are medically unfit for general anesthesia due to blood thinners or other health conditions, making local anesthesia an excellent option," notes Dr. Dilip Madnani, a board-certified facial plastic surgeon in New York City. "For patients who were told they couldn't have a facelift or who avoided it due to anesthesia fears, discovering local anesthesia as an option often leads them to proceed with satisfaction."
Dr. Madnani now performs 80-90% of his surgeries under local anesthesia, including around 150 facelifts annually. "I describe it to patients as similar to dental procedures but more pleasant—we play soothing music, and patients either nap or chat with me," he says. "Once the relaxing medications are administered, patients feel nothing and remain comfortable throughout." This experience is what draws patients like Beth Holmes, 59, who has had four surgeries under general anesthesia and three with Dr. Madnani under local. "I plan to continue with local anesthesia whenever possible; it's a much better experience," she asserts.
Understanding Local Anesthesia
Local anesthesia works at the cellular level to block pain signals, explains Dr. Madnani. "It shuts down pain receptors, so patients feel only slight pressure." Typically, it is injected directly into the skin around the treatment area. Unlike general anesthesia, which affects the entire body, local anesthesia numbs only the specific area. General anesthesia involves a combination of drugs administered intravenously, rendering the patient unconscious and unable to feel anything.
Lidocaine is the most commonly used local anesthetic in plastic surgery. Those familiar with facial fillers like Juvéderm and Restylane are likely aware of lidocaine's effects, often mixed with the filler to reduce discomfort. (Fun fact: Lidocaine and other "-caine" drugs are chemically similar to cocaine, the first local anesthetic.)
Surgeons often combine local anesthesia with oral sedation like Valium to relax patients without putting them to sleep. "Some patients prefer to stay awake, while others want to doze in and out with Valium," says Dr. Karolak. This eliminates the need for intravenous medication. While you may feel a few pinches during the injection, the gradual administration minimizes discomfort. Your surgeon will mark the excess skin and incision sites before injecting the anesthetic, ensuring no distortion affects the procedure's outcome.
The effects of local anesthesia typically wear off within a few hours, according to Dr. Melinda Haws, a board-certified plastic surgeon in Nashville. For Carrie Porter, 63, who had eyelid revision surgery with Dr. Haws, the anesthesia and sedation lasted just long enough for her to leave the operating table, don sunglasses, and have lunch with a friend. "Dr. Haws said I'd have a two-hour window before the anesthesia wore off and it would hurt," she recalls. "By the time we paid the bill, everything had worn off, and I was ready to go home for ice packs and pain pills."
Patients not taking oral medication can even drive themselves to and from the surgery center.
Local vs. General Anesthesia: Anxiety and Cost
A significant factor driving the local anesthesia trend is the high number of patients who either prefer or are unable to undergo surgery under general anesthesia. General anesthesia requires a respirator and breathing tube, which can be a deterrent for many, especially older patients. "Anesthesia is generally safe, but there are additional risks," says Dr. Madnani. "Many older patients are also concerned about cognitive side effects." Even "twilight" sedation, which keeps patients partially conscious, can be off-putting. "A significant portion of my patients would only consider surgery under local anesthesia," says Dr. Karolak.
Take Andrea Filmore, 53, who had a facelift and neck lift under local anesthesia with Dr. Karolak. "Undergoing anesthesia is a genuine fear for me," she says. "At this age, people worry about not waking up." Before her local anesthesia surgery, she had several procedures under general anesthesia, including a hysterectomy and bladder surgery. "I dislike waking up disoriented," she states. "I have no fear of being aware during surgery, so I prefer to be awake."
Choosing local anesthesia also significantly reduces costs. General anesthesia and twilight require an anesthesiologist or CRNA, significantly increasing the final cost. "If I can perform a procedure under local anesthesia, the patient avoids anesthesiologist fees, reducing the overall cost by 10-25% or more," says Dr. Haws. For Beth Holmes, who works as a surgery scheduler for a practice offering "awake" surgery for only a few procedures, cost was a factor. "Three hours of anesthesia would have added $1,500 to my last surgery bill," she says. "I didn't want to pay for anesthesia unless absolutely necessary."
Sarah Billings, 68, was pleased that having her breast implants removed under local anesthesia "significantly reduced the cost." Her general practitioner's support also gave her peace of mind: "She said, 'Go for it—I'm all for you not being under anesthesia.'"
Better Outcomes with Local Anesthesia
For some surgeons, having a patient awake during surgery allows for better results. "It's crucial that facial muscles maintain their tone during surgery," says Dr. Karolak. General anesthesia paralyzes muscles, making them more relaxed than usual. "I want the muscles in their natural state for natural-looking results," he says. Patients can also move their head, smile, or open their eyes, aiding precision. "It's better to perform surgery under local anesthesia because 'you're awake, and I can see you with your eyes open and determine how this will look,'" recalls Carrie Porter.
Being able to sit up is also beneficial. For breast implant exchanges without capsulectomy, Dr. Haws often has patients sit up while sterilely draped, allowing them to look in a mirror and provide input on size changes. "This area can be numbed with a small amount of local anesthetic easily if I'm not working on the breast capsule."
Faster Recovery with Local Anesthesia
Local anesthesia can also expedite the healing process. "General anesthesia causes more swelling due to IV fluids needed to maintain blood pressure," says Dr. Madnani. The breathing tube can also cause throat discomfort lasting several days. Local anesthesia reduces bleeding during surgery, limiting bruising and speeding recovery. "Under local anesthesia, a patient's blood pressure and vital signs are normal compared to general anesthesia or IV sedation, where blood pressure can drop, reducing bleeding," says Dr. Madnani. "It's difficult to manage bleeding during surgery as it's not visible until the patient wakes up and their blood pressure returns to normal."
Local Anesthesia: Not for Everyone
Surgeons offering local anesthesia acknowledge it's not suitable for every patient. "Local procedures require motivated patients," says Dr. Haws. "Some find it too anxiety-inducing to hear, see, and smell the operating room. I strive to be selective to avoid stressing anxious patients or pushing local anesthesia too far." Facial surgery patients need to be comfortable with face injections. "Some patients dislike that," says Dr. Haws.
Despite the close proximity and bright light during surgery, the local anesthesia experience didn't bother Carrie Porter. "It was not at all disturbing," she says. "To me, it was no different from a dentist performing a root canal. The closeness is similar."
During her procedures with Dr. Madnani, Beth Holmes was "relaxed. He guides you through it, so you know what to expect. Nothing is a surprise," she says. "He offers anesthesia, but the right patients can handle this."
From the surgeon's perspective, performing surgery under local anesthesia can be challenging if the patient is anxious or uncomfortable despite numbing and relaxation medications. Surgeons work more quickly and efficiently when patients are fully asleep.
In the right circumstances, local anesthesia is "remarkable," says Dr. John Sherman, a board-certified plastic surgeon in New York City. "The patient gets off the table, and 10 minutes later, after having crackers and water, they walk out the door."
Whether surgery under local anesthesia is always feasible depends on individual circumstances. For example, breast lifts can be done under local anesthesia if the lift volume is small enough to be anesthetized with local anesthetic. "Large volumes do not fare as well as skin-only lifts," says Dr. Haws. Breast implant removals can often be easily performed under local anesthesia if the capsules are not removed.
Local anesthesia can also be used for "simple" rhinoplasty, where bones do not need to be repositioned. Primary breast augmentations and tummy tucks (or "mommy makeovers") are generally not feasible under local anesthesia. "Most performing a full mommy makeover under local anesthesia are physicians who cannot obtain privileges to conduct those surgeries in a surgery center," says Dr. Haws, who would never perform a primary breast augmentation or tummy tuck under local anesthetic. "The amount of local anesthesia needed would make the procedure too risky."
Complications with Local Anesthesia
While local anesthesia may seem harmless, it carries risks. Minor and temporary side effects include bruising, swelling, redness, and itching near injection sites. Lidocaine, developed as a less allergenic form of novocaine, has rare true allergies—discuss this with your surgeon. System toxicity is the primary complication, especially with rapid absorption into vascular areas. "We are cautious about not injecting local anesthetic into vascular areas—using techniques like aspiration and specific needle sizes minimizes this," explains Dr. Madnani.
Surgeons use predetermined doses based on the patient's weight. "If I need an excessive amount to numb the patient, they require general anesthesia for safety," says Dr. Haws. Face and neck surgeries have lower risks due to smaller surface areas and lower overall anesthesia volumes. Many surgeons use a "dilute" local anesthesia solution, further reducing concentration. "Plus, all patients are monitored throughout the procedure, constantly checking vital signs," says Dr. Madnani.
Not all plastic surgeons are willing to perform longer procedures, such as aggressive facelifts, under local anesthesia. "Local anesthesia is remarkable in the right circumstances," says Dr. Sherman. "The patient gets off the table, and 10 minutes later, after having crackers and water, they walk out the door."
