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Cosmetic eyelid surgery may be performed under either local or general anesthesia, but there are a number of advantages to using local anesthesia. Be assured that you can comfortably undergo a blepharoplasty without having to contend with the added risks, disadvantages, and cost of a full general anesthesia.
First, a few words of clarification. By local anesthesia, we are referring to local anesthesia with sedation.
Without some sort of pre-sedation, surgery can still be performed successfully, but not without forcing even the most stoic patient to experience unnecessary anxiety and worry. After all, the mere thought of surgery around the eyes is nerve-racking and being fully alert during such a procedure only intensifies your imagination.
Furthermore, the perception of pain is very much influenced by a person's mindset and level of relaxation. An anxious patient is more likely to over-react to even the most minor of unusual or slightly unpleasant sensations.
"With sedation" has a variety of meanings:
The simplest and safest means of administration of "sedative" drugs (here used to include actual sedatives, tranquilizers, and/or narcotics) is via the oral route, and we have found this method to work so well that our bias is most definitely in this direction. Once the pills are administered, a patient can lie back in a comfortable chair in a darkened room and listen to soothing music as he or she drifts away into dreamland. Depending on the dose and mixture of drugs ("the cocktail"), your level of sedation can range from mild to quite deep.
One advantage of oral administration of sedative medications is their relative safety. A rare patient may react to the intravenous administration of sedatives by experiencing respiratory arrest (that is, the complete cessation of breathing). While artificial respiration may generally maintain such a patient until he or she once again resumes breathing, experiencing such a scenario can be scary for both patient and surgeon (Note: Two deaths have occured during the past five years in Florida alone in patients undergoing blepharoplasty under deep intravenous sedation). Oral administration of sedative drugs does not produce such sudden and profound respiratory depression. The onset and progression of the relaxation is more gradual and "natural", like taking a sleeping pill and slowly dozing off.
Yes, this approach takes a little more time, and so most hospitals and surgicenters (where starting times are not all that predictable) prefer the quicker process of having an anesthesiologist shoot the drugs in through an intravenous line. However, especially if your surgery is to be performed in an office operating room and without an anesthesiologist monitoring you constantly, we feel it is best to emphasize sedation safety above all else.
Full general anesthesia is, in our opinion, a matter of overkill. Not only does general anesthesia substantially increase your risk, but it also interferes with your surgeon's optimal performance of the blepharoplasty (as described below). Of course, if a patient elects to undergo simultaneous face lift, rhinoplasty, and liposuction, then general anesthesia may be the most effective or only option. For pure eyelid surgery, though, why face the added cardiovascular and respiratory risks, a longer post-operative recovery, and the added incidence of nausea and vomiting (and just plain feeling crummy)?
Back to local anesthesia. Once a patient has reached comfortable level of relaxation, the eyelids are injected with a local anesthetic (usually lidocaine and/or bupivicaine). Injections given by an experienced eyelid surgeon are usually near painless to mildly irritating. There are a number of tricks that can be employed to minimize discomfort, such as using a tiny needle, injecting slowly, and neutralizing the acidity of the solution just prior to administration. Injection of each lid takes only a few seconds. Patients experience a mild burning sensation not unlike that felt before dental care. Just as a good dentist given near-painless injections, a talented eyelid surgeon with a gentle touch and a caring manner can greatly minimize the unpleasant sensations experienced during injection of the eyelids.
In addition to the factors discussed above, we also favor local anesthesia over general anesthesia for an equally important reason: local anesthesia makes it much easier for your surgeon to avoid an unexpected or undesirable result. Cosmetic eyelid surgery requires a demanding level of exactitude since the margin of error in measured in millimeters. There is nothing more helpful to a surgeon performing blepharoplasty than the luxury of real-time patient feedback. Even a snoring patient can be gently roused by a tap on the cheek and asked to open the eyes or look up or down. Such feedback allows a surgeon to adjust the steps of the procedure to achieve the most precise result.
On the other hand, working on a patient under general anesthesia is like working on a corpse; there is no movement, no muscle tone, no ability to request feedback, and no chance to sit the patient up to evaluate the result in progress. Surgery is instead done using certain "formulas" that may or may not yield an optimal result in any given patient. Surgery becomes a matter of educated "guesswork," and no matter how talented your surgeon may be, sometimes the guess will be wrong.
Under local anesthesia, the chances of significant overcorrection and undercorrection are, in our experience, substantially decreased because your surgeon can more accurately monitor your result as it emerges. Blepharoplasty is not a "stock" operation but one that allows for a great deal of "adjustability." Why forfeit this safeguard?
Most patients undergoing surgery under local anesthesia will note some sensation of pressure, in much the same way that you know a dentist is at work on your teeth even if he isn't hurting you. If true pain is felt, however, your surgeon can readily augment the anesthesia with an additional injection. Just like when you're sitting in a dental chair, you will definitely be able to "think of a better place to be". Once the procedure is over, however, it is unlikely that you will see it as "something to write home about". Putting up with these slight inconveniences is, in our opinion, well worth it.
By the way, don't worry that injections need to given into the eyeball itself. The use of eyedrops alone is sufficient to adequately numb the eye surface.
One last thing. It takes added finesse and consideration on the part of your surgeon to perform a blepharoplasty under local anesthesia because he or she must be constantly aware that you are awake, probably a little nervous, and possibly feeling a few twinges every now and then. Your surgeon may have to pace your surgery a little slower and be a bit more gentle and attentive. All of this is good and to your advantage. If a surgeon expresses firm resistance to performing blepharoplasty under local anesthesia, you may wish to ask yourself whether he or she may, in fact, be inexperienced and/or uncomfortable with the very operation itself.
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