Anaesthesia for facial plastic surgery


No facial cosmetic surgery is compulsory. Infact I spend considerable time trying to dissuade patients from undergoing surgery if I think a non-surgical alternative will achieve a similar result. Why? this seems on odd thing for a facial plastic surgeon to do! The answer lies in safety, there is no completely risk free surgical procedure. Sure, all risks can be minimised with correct preparation, meticulous technique, and diligent post operative care, but those risks never become 0%.

The greatest risk of any cosmetic surgical procedure is, in my opinion, the anaesthetic. General Anaesthesia is also a significant causal factor in some of the more common “surgical” complications such as bleeding, infection and pain. I will explain more on this shortly.

The UK is in the minority in the western cosmetic surgical world in that general anaesthesia is the default norm. As a country we have been slow to adopt twilight anaesthesia for cosmetic surgery (local anaesthetic and sedation) which is common place across Europe and the United States. It is for this reason that I travelled abroad for the majority of my cosmetic surgical training. I wanted to remove a significant risk factor from my surgery and the UK based training couldn’t offer that. My surgery, without exception, is performed under local anaesthetic or twilight sedation.

Conventional techniques vs Dominic Bray's techniques

What Is Twilight Sedation?

The definition of twilight is ‘the period between night and day when peace pervades’. This is a perfect description of twilight surgery. You are neither wide awake or out cold. You are relaxed, comfortable and peaceful. Asleep but not anaesthetised. The twilight state is achieved with one injection through a drip in the arm. Latest generation sedatives are fast acting, predictable, easily metabolised and have no hangover effects. When combined with very specific local anaesthesia delivered in a methodical and meticulous way, the whole face can be numbed and you are blissfully unaware of your procedure(s). There are common misconceptions of twilight sedation. Patients often say to me “I would rather be asleep”, “I don’t wan’t to be aware”, I don’t want to feel anything” or “ I don’t want to remember it”. All of these are markers of twilight sedation.

Twilight sedation has every benefit of general anaesthesia without the breathing tube, muscle paralysis, continuous infusion of toxic drugs or postoperative hangover and sickness.

Advantages of Twilight sedation

I believe that on every conceivable parameter: procedure, safety, recovery, outcome, experience and cost; day case local anaesthetic facial surgery is preferable to general anaesthetic inpatient surgery.

Let’s take facelifting by way of an example. Conventionally, patients undergo facelifting under general anaesthesia. This means they must arrive at the hospital starved from the night before. Even if their surgery is at midday they need arrive and be seen early in the morning as the team will have other cases before theirs. Stress hormones are therefore circulating. The patient is taken to an anaesthetic room where they are put under by gas or injection. A tube is then placed between the vocal cords so that a machine takes over breathing. This tube is irritating to the voice box so paralysing agents are given to block muscle movement (including the facial muscles). The anaesthetist then infuses medication to artificially lower the blood pressure, control discomfort and sickness and maintain anaesthesia. The surgery is then performed whilst the patient lies flat and motionless. Often an electronic facial nerve monitor is used to confirm the location of the facial nerve during dissection. Upon waking patients’ have a sore throat from the breathing tube and commonly a headache. They may also cough which dramatically increases the pressure through cauterised blood vessels in the facial tissues. This is compounded by nausea and sickness from the anaesthetic agents.. These factors, coupled with a rising blood pressure, which is normalising after being artificially lowered for surgery, and raised naturally from stress hormones and discomfort, cause bleeding into the tissues. This is why placement of plastic drains is commonplace despite being an infection risk. They are there to collect this oozing. The face is also wrapped in a tight compression bandage to restrict the swelling.

This artificially induced comatose state for operating on the most dynamic and expressive part of our body was anathema to me.

I realised if I could remove the requirement for general anaesthesia, it followed that there would be no requirement for breathing tubes, paralysing drugs, prior starvation, blood pressure management and/or surgical drains. It also meant that I could talk to my patients throughout, ask them to smile or raise the brow for real time facial nerve monitoring and even sit them up mid case to assess the vector of facelift. It also meant that all surgery could be performed as day case so no inpatient admission was necessary. I devised a protocol for full facelifting under local anaesthetic and sedation. The key to this technique is methodical and meticulous local anaesthesia. I use a very dilute mixture of local anaesthetic agents which are carefully infiltrated under the skin . This achieves two things. Firstly, complete numbness of the surgical field so no pain is experienced before, during or after surgery and secondly the volume of water infiltrated starts the gentle dissection of tissues before I have even made an incision. The solution literally lifts the skin off the underlying tissue. This process makes the dissection part of the facelift much less traumatic and with less surgical dissection, post operative pain is greatly reduced. My patients need nothing more than paracetamol after a full face and neck lift. Infact, as I write, the last few patients have had to be persuaded to take paracetamol even though pain free! My anaesthetists were initially sceptical, they had seen MACS facelifts and mini-facelifts under local anaesthetic in the UK but not full SMAS face and neck lifts. They are now converts and they believe this technique will be the gold standard in time.

Anaesthetic colleagues

I only work with two specific consultant anaesthetists. I have chosen them not only for their professionalism and expertise but also their bedside manner and care. They are present soley to ensure my patients’ comfort. I would be happy for them to anaesthetise myself or any member of my family.