Anesthesia for Facial Cosmetic Surgery

What is the difference between the types of anesthesia used and why is one safer than the other ? The unfortunate consequence under general anesthesia with what happened to Joan Rivers got me thinking on how best to explain this to my patients.

Anesthesia is used to help patients undergo procedures with minimal pain and discomfort and it also allows the surgeon to perform what he/she needs to without interruption. There is confusion out there concerning the different types of anesthesia so hopefully this article will shed a little light on the difference.

General anesthesia (Level 4 anesthesia) is what we are most aware of. It is commonly used in hospitals or certified ambulatory facilities and requires the presence of an anesthesiologist/nurse anesthetist. General anesthesia is the most comfortable for the surgeon as it (usually) puts the patient completely out (the patient cannot be easily aroused)- medications are given to force the patient asleep and muscle relaxants are given to stop the patient from moving. Because of these medications, machines have to be used to take over the patients breathing, so an ‘intubation’ is performed where a breathing tube is placed into the patients airway and is connected to a machine that is set to provide a set number of breaths per minute to ensure adequate oxygenation. The heart rate and oxygen status is continuously monitored and pain medications are given as well. Intravenous fluids are given throughout the surgery to ensure adequate circulation of medication and to help maintain blood pressure.

General anesthesia can be associated with severe nausea afterwards due to the medications administered and since IV fluids are given throughout the procedure, more swelling can be associated with the surgical area after surgery- prolonging recovery from a facelift.

IV sedation also known as conscious or moderate sedation (level 2 anesthesia) is another type of anesthesia where an IV is placed and medications are given intravenously to induce relaxation and to block pain. A breathing tube is not required. These medications can be provided by the operating surgeon- but is often done by a nurse/nurse anesthesiologist/anesthesiologist. It does require a certified facility as well as emergency equipment is needed on hand. Patients have to be monitored closely, as if too much medication is given breathing can be affected- like what happened with Michael Jackson.

Minimal sedation (Level 1) anesthesia combined with a special technique I use for the local anesthesia; is my method of choice. Medication is given orally to help with anxiety and pain but heart and breathing functions are not affected. This is the safest form of anesthesia for patients undergoing facial cosmetic surgery. Medications such as valium are given, along with a pain medication. My patients are easily aroused, and once the local anesthesia is placed- my patients experience minimal discomfort. About half my patients fall asleep during the entire process, a quarter of them dose in and out of sleep and the rest chat with me during the procedure.

Level 1 anesthesia also leads to a quicker recovery as extra IV fluids are not used to maintain blood pressure so there is less swelling associated afterwards, leading to a quicker recovery. There is also significantly less nausea associated after the procedure, resulting in a more comfortable recovery and less swelling as well from the heaving associated with the nausea.

So why doesn’t everyone perform elective facial cosmetic surgery with Level 1 anesthesia? A common reason is that the surgeon is used to performing the procedure a certain way- only under general. Additionally, there are certain older techniques used in facial procedures that are more invasive and require a general anesthesia for patient comfort.

For 99% of my procedures such as facelifts, neck lifts, eyelids and facial fillers- I choose the safer method, to further minimize risk for my patients. It requires a lighter more delicate hand, experience with thousands of facial procedures and awareness of patient comfort; this produces a better patient experience with safer outcomes and excellent results.


Article by Dilip D. Madnani, MD, FACS