Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Blepharoplasty is a procedure in oculofacial and plastic surgery to modify the eyelid for aesthetic or functional reasons. The anesthetic approach impacts patient comfort, intraoperative precision, and postoperative complications. Contemporary practice reflects a spectrum of strategies for anesthesia management of blepharoplasty, ranging from purely local infiltration to sedation and, less commonly, general anesthesia, with selection driven largely by the extent of surgery, whether the procedure addresses the upper or lower lid, and surgeon preference (Zoumalan and Roostaeian, 2016).
Survey data from 161 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery indicate that monitored anesthesia care is the dominant modality, preferred by 71% of respondents, followed by local anesthesia alone in 21% of cases and general anesthesia in only 8% (Kossler et al., 2017). This preference for sedation over pure local technique was somewhat unexpected among surgeons who are highly experienced with periocular anesthesia, and the authors hypothesized that the high proportion of functional (insurance-covered) cases, in which the additional cost of sedation is absorbed by the payer, may partly explain the trend (Kossler et al., 2017).
Notably, upper lid blepharoplasty is generally performed under local anesthesia or intravenous sedation, whereas lower lid procedures more often require intravenous sedation or general anesthesia, reflecting the greater complexity and discomfort associated with fat repositioning, canthal suspension, and skin-muscle flap dissection in the lower eyelid (Zoumalan and Roostaeian, 2016).
Regardless of whether sedation is used, local anesthesia injection for blepharoplasty was nearly universally utilized by survey respondents. A commonly cited formulation combines 2% lidocaine with 1:100,000 units of epinephrine, buffered with sodium bicarbonate in a 9:1 concentration to reduce the discomfort of injection, with hyaluronidase sometimes added to promote diffusion of anesthetic through the subcutaneous tissue (Zoumalan and Roostaeian, 2016). Epinephrine additionally provides vasoconstriction that limits intraoperative bleeding and improves visualization of the fat compartments and orbicularis muscle.
The technique of local anesthetic delivery itself was the subject of a research study. A randomized, observer-blinded trial comparing blunt-tip and sharp-tip needles for anesthetic injection in upper blepharoplasty found that sharp needles were associated with significantly more bruising and hematoma than blunt needles (25% versus 0% of eyelids) and with higher patient-reported pain scores on a visual analog scale (Yu et al., 2017).
The authors attributed this difference to the tendency of sharp needles to penetrate small vessels inadvertently, whereas blunt needles are more likely to deflect around vascular structures, consistent with earlier animal studies of blunt-needle safety (Yu et al., 2017). These findings suggest that needle selection for local anesthetic administration may meaningfully influence postoperative bruising, patient discomfort, and the need for interventional management of hematoma.
Anesthesia management of blepharoplasty consists of a range of strategies. MAC sedation combined with local anesthesia is the most common strategy, while general anesthesia is reserved for more extensive or combined procedures.
References
- Kossler, A. L., Peng, G. L., Yoo, D. B., Azizzadeh, B., & Massry, G. G. (2017). Current trends in upper and lower eyelid blepharoplasty among American Society of Ophthalmic Plastic and Reconstructive Surgery members. Ophthalmic Plastic and Reconstructive Surgery. https://doi.org/10.1097/IOP.0000000000000849
- Yu, W., Jin, Y., Yang, J., Ma, G., Qiu, Y., Chen, H., Yang, X., Chang, L., & Lin, X. (2017). Occurrence of bruise, hematoma, and pain in upper blepharoplasty using blunt-needle vs sharp-needle anesthetic injection in upper blepharoplasty: A randomized clinical trial. JAMA Facial Plastic Surgery, 19(2), 128–132. https://doi.org/10.1001/jamafacial.2016.1376
- Zoumalan, C. I., & Roostaeian, J. (2016). Simplifying blepharoplasty. Plastic and Reconstructive Surgery, 137(1), 196e–213e. https://doi.org/10.1097/PRS.0000000000001906