Anaesthesia Options & Frequently Asked Questions
Written by Dr. Julian De Silva
What are my options for Anaesthesia?
Anaesthesia is an important consideration when having facial cosmetic or plastic surgery as it plays a role in your comfort, speed of recovery and overall experience. Often our patients have already had experiences of anaesthesia before undergoing cosmetic surgery and have a preference in mind. The two traditional forms of anaesthesia are local anaesthesia and general anaesthesia. Local Anaesthesia takes advantage of using medication to numb specific are of the face only, in contrast to General Anaesthesia where the entire body is unconscious. The third newer type of anaesthesia is called Sedation Anaesthesia, “twilight anaesthesia” or MAC (Monitored Anaesthesia Care). Sedative anaesthesia offers a compromise between the local and general anaesthesia types as the patient has medications that relieve anxiety and make you feel relaxed in addition to numbing the specific are of the face.
What is Local Anaesthesia?
Local anaesthesia means that the medication is applied to only the specific part of your face that is undergoing surgery, this results in numbing of that facial area only, and allows you to remain awake. The area of the face that is anesthetised is usually small and relatively superficial. For some patients oral medications are used to supplement the local anaesthesia by reducing discomfort and inflammation.
Local anaesthesia is useful for shorter procedures as it works quickly and enables a fast recovery after surgery, patients are able to go home soon after the surgery has been completed. Local anaesthesia is effective in numbing the specific area of the face and reducing bleeding, the anaesthesia does sting for 2-3minutes while it begins to have effect. Local anaesthesia is less suited for longer procedures and certain facial cosmetic procedures which are more sensitive, the lower eyelid and nose are more sensitive areas of the face.
Most patients are able to have small procedures under local anaesthesia alone, modern day medications can avoid the need for sedation or general anaesthesia, the advantage being a more comfortable experience and faster recovery.
What is General Anaesthesia?
General anaesthesia differs from local anaesthesia in that your body is completely unconscious, the medications used in general anesthesia are given by a specialist doctor, an anaesthesiologist. The normal protective mechanisms of the body are subdued and a breathing tube is used to protect the airway and maintain breathing. This type of anesthesia has become very safe and is only given in Hospital or Surgical Treatment Centres. The disadvantages of general anaesthesia include a longer recovery that with other forms of anaesthesia, common side effects of the medication are drowsiness and nausea. General anaesthesia requires a medical assessment before surgery to ensure safety is a priority before having surgery.
What is Sedation combined with Local Anaesthesia?
Sedation is also known as “twilight anaesthesia” or MAC (Monitored anaesthesia care). Twilight anaesthesia means that your body is sleepy and relaxed, you are still conscious and able to respond to questions and instructions. Unlike general anaesthesia where you are unconscious and the recovery after surgery is longer. Typically you won’t remember the procedure or the short period of time following it, though you will feel a little euphoric.
Dr. De Silva has a specialist anaesthesiology team that are experts in sedative techniques, that have undergone specialist training and practice only sedation techniques. The sedation used involves a mixture of specialist anaesthetic medications that effectively relieve anxiety, and give patients a comfortable experience that is tailored to the individual. Older sedation techniques use only one sedation medication, the techniques that Dr. De Silva’s team utilise are modern day sedation techniques that enable patients to recover faster after surgery, most go home within 30 minutes of the procedure being complete. In the United States, sedation anaesthesia or twilight anaesthesia has become increasingly used for patients undergoing cosmetic surgery as a safer alternative to general anaesthesia that enables faster recovery.
Sedation does require several instructions to be followed to ensure it is both comfortable and safe:
- You must be accompanied home by an adult who will drive and arrange for responsible supervision for the remainder of the day. We cannot allow you to drive yourself home and advise against taking public transport home.
- Food must be avoided for 6-hours before surgery.
- Water and drinks must be avoided for 2-hours before surgery. Up until 2-hours before surgery drinking small amounts of water is recommended to maintain hydration.
- Patients for an afternoon list should have a light breakfast at least 6 hours prior to the start of the list. Patients with diabetes mellitus should observe their usual morning breakfast. Light Breakfast e.g. A small bowl of cereals with skimmed or semi-skimmed milk. No high fibre cereals such as Weetabix, muesli, bran etc. A slice of white toast with honey, jam, syrup, or marmite but no butter.
- Patients must avoid drinking any alcoholic beverages for 24-hours before and after surgery.
Sedation is a common form of anaesthesia for facial cosmetic procedures in the United States, advanced twilight anaesthesia is popular as it enables faster recovery than general anaesthesia, as has been well documented in the media by celebrities such as Louise Mensch.
What is the best form of anaesthesia for me?
Dr. De Silva uses all three types of anaesthesia dependent on the surgery required and tailors the options to each patient’s specific needs. Smaller procedures that are specific to an area in the face are well suited to local anaesthesia alone. More sensitive parts of the face, involving deeper soft tissues and longer procedures are better suited to sedation anaesthesia or general anaesthesia. In the past most cosmetic surgery in the UK has been performed under general anaesthesia, Dr. De Silva preference is to avoid this deeper form of anaesthesia unless there are good indications for its use. Local anaesthesia combined with sedation is an effective and safe type of anaesthesia that patients find comfortable with a faster recovery time. The best form of anaesthesia is dependent on the surgery you require and Dr. De Silva tailors the anaesthesia to each patient’s specific needs. Dr. De Silva only uses experienced consultant grade anaesthesiologists who specialise in cosmetic surgery anaesthesia, he does not use nurse or non-consultant grate anaesthesiologists.
Why Conscious Sedation?
Conscious sedation is probably the fastest growing area in anaesthesia care, and has become a very effective viable alternative to general anaesthesia for many surgical procedures e.g. dental procedures, plastic and reconstructive surgery, dermatology, endoscopies, bronchoscopies, and liver and renal biopsies. You will come in on the day of surgery and leave the same day usually within one hour after the operation. In addition, there is a significantly lower incidence of side effects with conscious sedation (including low incidence of nausea and vomiting, headaches, sore throats, muscle aches, and pain), and the costs for conscious sedation are much lower compared to general anaesthesia.
What is conscious sedation?
The aim of sedation is to make you comfortable, totally relaxed and safe during a procedure. Administration of the sedatives and analgesia results in you becoming drowsy and sleepy, pain free, and probably amnesic such that you will have very little recollection of the procedure. Communication is possible if necessary during the operation because even though you are completely relaxed and unconcerned, you are not completely unconscious at any point in time. Your vital signs e.g. blood pressure, breathing, pulse rate, etc are monitored throughout the procedure to ensure your safety, and a sedationist will stay with you all the time. Recovery after sedation is much faster than with general anaesthesia. The same applies for the side effect profile e.g. nausea and vomiting, headaches, muscle pains, sore throats, which is much less than with general anaesthesia – in fact very few patients experience any side effects at all. For these reasons patient satisfaction is very high after conscious sedation – a recent survey of the experiences and satisfaction of patients who had sedation show that 99.5% of patients would take sedation again if they have a choice. Conscious sedation is achieved with intravenous agents ( e.g. benzodiazepines, opiates, other sedative/anaesthetics) usually administered into a vein, and/or inhalation agents (e.g. nitrous oxide).
Are there different levels of sedation?
There are three different levels of sedation that are defined and recognized internationally. The three sedation levels recognized in the UK today include:
- Minimal Sedation (or Anxiolysis): This is often referred to as changing the mood of the patient whereby the patient is calmed, responsive to verbal commands, and unconcerned about the procedure.
- Moderate Sedation or Conscious Sedation: This is where the patient is more deeply sedated, becomes drowsy and sleepy (and may even sleep intermittently), is responsive to verbal commands, and calm.
- Deep Sedation: At this level of sedation patients may become unconscious. This level is not allowed in the UK for sedation outside the operating room.
How does sedation differ from general anaesthesia?
The main differences between conscious sedation and general anaesthesia is the level of consciousness, safety, side effects, and cost.
- Level of consciousness: with conscious sedation the patient is drowsy, comfortable, sleepy and relaxed, but remains conscious. Patients can be roused by verbal communication if necessary. With general anaesthesia the patient is completely unresponsive and cannot be roused by verbal communication.
- Safety: with conscious sedation the required dose of drug is low and the patient is still in control of major reflex functions such as breathing. With general anaesthesia the higher doses of drugs renders the patient unconscious who then loses these reflexes which are then maintained artificially. Higher doses of drugs administered with general anaesthesia are associated with higher risks.
- Side effects: due to the lower dose of sedative/anaesthetics the frequency of side effects are minimal when compared to general anaesthesia where the side effect profile is much more substantial.
- Cost: the fact that the recovery period of sedation is much quicker than with general anaesthetic, combined with the fact that sedation does not require hospital settings, means that the cost of sedation is far lower than that for general anaesthesia. General anaesthesia can only be done inside a hospital in an operating theatre.
What is a sedation provider?
A sedation provider service is a dedicated team of sedation practitioners, nurse practitioners and/or nurses who provide sedation. The team concept is an extremely important part of safe sedation practice. There are two types of sedation provider services:
- The dedicated sedation practitioner: here a dedicated sedationist administers the sedation, while the surgeon does the surgery only. The sedation practitioner looks after the well being of the patient from a conscious sedation perspective, which allows the surgeon to focus on the operative procedure.
All sedation practice is closely regulated to the highest professional and ethical standards. All sedation team members and practitioners must have appropriate training in the administration of conscious sedation including monitoring, management, and care of the patient while under sedation. It is also mandatory that sedation practitioners attend regular training updates in knowledge and skills.
Is conscious sedation an option for all patients?
As with any anaesthetic, the suitability of conscious sedation is determined by the patients’ age, health and need, as well as by the procedure being performed. Sedation is not suitable for procedures where general anaesthesia is required. Indications for conscious sedation include:
- Surgery including facial cosmetic surgery and plastic surgery
- Dental procedures
- Very anxious patients – sedation calms the patient and overcomes their fear and anxiety
- Patients who have had a previous traumatic experience – sedation makes it possible to deal with post traumatic stress of the patient relating to medical or dental procedures
- Uncomfortable procedures – sedation relaxes, dissociates and helps comfort the patient
- More complex and prolonged procedures – sedation ensures the patient can remain still yet comfortable for long periods of time
- Procedures in difficult adults and children for procedures that may not be particularly painful, but require them to be very still
Conscious sedation should thus always be evaluated with respect to other available options including local anaesthesia and/or regional anesthesia, local anaesthesia with behavioural management techniques, general anaesthesia, and of course conscious sedation itself. Patients should always be involved in decision making after an explanation of the options available.
What can I eat and drink before sedation?
The general guidelines are as follows, see that you follow these guidelines otherwise your operation may have to be cancelled:
- No solid food for six (6) hours prior to the procedure
- All patients may have clear liquids until two (2) hours before the procedure.
- Diabetic patients will get special instructions as far as food intake is concerned.
All patients receive pre and post-operative instructions explaining what you can and cant do.
Will I be uncomfortable and feel any pain while under sedation?
Even though you are not completely asleep, you will be drowsy, relaxed and pain free during the procedure. The sedative drugs combined with analgesics and local anaesthesia ensures that you will have no pain. The drugs will also contribute towards a pain free period after the operation.
How long will it take for me to recover after sedation?
The recovery time depends on the drugs used, the patient’s individual response to the drugs, and the time spent under sedation. The drugs and doses that are used for sedation have a rapid onset and offset. After the administration of the sedative drugs is stopped, recovery is swift and in most cases less than about 30 minutes, which is the time that you will need to remain at the clinic before being allowed to go home with your escort. The sedation practitioner will carefully monitor you to ensure that you are fit for discharge. Thereafter you may remain drowsy for a few hours, and will be given specific written and verbal instructions on what to do.
What are the side effects of sedation?
As with any medication, the use of sedative anaesthetic agents can result in side effects. However, the incidence of side effects with sedation are very rare and include unintended loss of consciousness, drowsiness, dizziness, shivering (4%), headaches (4%), and post-sedation nausea & vomiting (0.7%).
After sedation is there anything I should avoid?
Elimination of the sedative agents from your body can take up to 24 hours. It is important during this time to rest and recover from the procedure. Therefore, however well you may feel, within that time you should NOT:
- drive a vehicle (insurance will be void)
- cook or use electrical implements
- operate any machinery
- sign important documents, cheques, etc
- look after children
- ride a bicycle, etc
- make important decisions, etc
- use alcohol, sleeping tablets, tobacco, abuse drugs
- perform other complicated tasks or responsibilities
You will not be allowed to drive yourself home, and you will not be able to leave the clinic or facility if there is not a responsible adult that can drive you home and take care of the post-operative recovery period. You should remain in the company of a responsible adult for 12 hours following the procedure.
Who is qualified to give sedation?
Sedation practitioners have all completed undergraduate medical studies and appropriate postgraduate training and qualification in anaesthetics and/or sedations. It is clear that conscious sedation can only be done by those trained AND experienced in how to evaluate and assess the patient, administer the sedative drugs, monitor the patient, and deal with any side effects or situations that may arise. All international and UK guidelines require that conscious sedation practitioners must be appropriately trained and experienced. In addition, practitioners must undergo thorough post graduate training and appraisals to ensure fitness to practice. There are several institutions in the UK that offer training in conscious sedation. According to the American Society of Anaesthesiologists Task Force on Sedation and Analgesia, sedation can be provided by anaesthesiologists as well as non-anaesthesiologists who are appropriately qualified. There are thus three main groups of sedation providers:
- professional sedation practitioners: this group are medically qualified practitioners with extensive postgraduate certification (Diploma, Masters qualification etc), training and experience in conscious sedation. They are usually full time in sedation practice in surgeries, clinics, hospitals, and often travel between facilities to administer sedations.
- operator sedationist: these are practitioners from different sub-specialties that in addition to performing the procedure also administer the sedation.
- anaesthetists: this group are usually qualified anaesthetists/consultants that also administer sedation inside hospitals. They do not do sedations full time, and are a smaller group than those above.
Where can conscious sedation be administered?
Conscious sedation can be done in hospitals as well as outside a hospital or operating theatre setting, including in:
- Medical offices or hospitals with Care Quality Commission regulatory approval.
- Approved facilities with necessary monitoring and emergency equipment and appropriately trained staff.
Conscious sedation should only be performed in an environment where the facilities, personnel, equipment and drugs required to administer, monitor, and manage any complication are immediately available to the same level of care as in the hospital environment.
Am I allowed to take herbal medications before surgery?
Many patients are on herbal drugs for different reasons. It is very rare that they can interfere or cause serious complications with conscious sedation. However it is important that the sedation practitioner knows if and which herbal medication you may be taking. The herbal drugs can influence sedation through interacting with the sedative drugs – some of the herbal drugs have a sedative effect and can potentiate the effect of the sedative drugs; or it can interfere in other ways such as increasing the bleeding tendency. So it is therefore obviously important that you let your sedationist know if you are taking herbal medications, and if possible consider stopping them a week or two before the procedure.
Does medication interfere with sedation?
It is imperative that you advise the sedation practitioner of all the medication you are taking so that this can be factored into your assessment and administration of the sedation. You should continue to take your medications as usual, unless advised otherwise by the sedationist.
- Antihypertensive (high blood pressure) medications: continue taking these as usual.
- Asthma medications: continue taking these as usual and bring your inhalers with you.
- Diabetes medications: it is important that the sedation practitioner gives you guidance here since it may be that you should have a meal, and not take oral anti-diabetic drugs the morning of the operation. You are encouraged to monitor your blood glucose levels before the sedation and bring these with you to the surgery.
- Antidepressants: an increasing number of patients are nowadays on antidepressants not only for the treatment of depression, but also to treat pain. It is of utmost importance that you inform the sedation practitioner of any antidepressants you may be taking, since certain classes of antidepressants can interact with the sedative agents, and it may be required that you stop these for a few days prior to the procedure.
Whatever medication you may be taking it is advisable to bring it to the surgery on the day of the operation to show to the sedation practitioner.
Why am I having sedation?
Conscious sedation is clearly useful for patients who have a fear or anxiety about having cosmetic surgical treatment. Sometimes, the surgeon may request the sedation in order to make the treatment more comfortable for you or to create the optimal working conditions.
What are my anaesthesia options?
You may choose:
- Not to have the treatment
- Have the treatment with local anaesthesia only
- Have the treatment under conscious sedation and local anaesthesia at the surgery
- Have general anaesthesia in a hospital environment
What are the risks and the advantages?
Very rarely you may experience:
- Nausea and vomiting, although very uncommon, may occur.
- Discomfort or bruising at the site of injection.
- Vein irritation (phlebitis), which can last a week and can be painful. This rarely happens when an elbow vein is used (Rare).
- Allergic reaction to any of the drugs used. Allergic reactions to the sedative drugs are extremely rare.
Conscious sedation is a very safe procedure, however, the very rare complications should be mentioned: depressed respiration (slowing or stopped breathing), brain damage, stroke, heart attack or even a fatal outcome. The information that you give us on the attached medical history form will assist us to decide whether you might be at risk to any known complications. Your sedationist is highly experienced in avoiding complications and is trained to deal with unexpected problems.
Will I remember what happened afterwards?
Conscious sedation induces a state of deep relaxation. In over 90% of people the drugs used for conscious sedation produce either partial or full memory loss (amnesia) for the period of time when the drug first kicks in until it wears off. As a result, time will appear to pass very quickly. Consequently, people who remember nothing at all, frequently report that they were “asleep” during the procedure.
Is it necessary to have local anaesthetic as well?
The conscious sedation drugs are given to relax you whilst the local anaesthetic drugs will take the pain away. The local anaesthetic will be administered after the sedation has taken effect.
Will the seditionist be there all the time?
Yes, the sedationist will be at your side all the time. In addition your pulse, oxygen levels and blood pressure are constantly monitored and recorded to ensure your wellbeing.
What drugs are used in sedation?
The most commonly used drug for conscious sedation is Midazolam, which belongs to the same family of drugs as Valium. However, in order to make the injections in the mouth almost painless and also to produce a better quality of sedation your sedationist may choose to add an opiate and/or Propofol or other drugs in controlled and titrated doses. Propofol allows for a much faster recovery but needs a dedicated trained sedationist to be present throughout the procedure. By using multiple medications, lower doses of medications are required resulting in a faster recovery after surgery and fewer side effects.
Older sedation techniques only used a single medication commonly midazolam. Every person has different genetics and physiology and a small proportion of people may be resistant to a single medication. Newer sedation techniques combine multiple medications meaning if you are resistant to a single medication the other medications will compensate, hence less medications are required and reduced side effects.
Will I need someone to go home with me?
Yes, due to the sedative affects of the medication you will need a responsible adult to accompany you home, preferably by car or taxi.
To comply with guidelines and for your own safety we must insist that you have a responsible adult to take you home after your appointment. In the event that you have no escort on the day of the sedation, your appointment may be cancelled and you will be charged in full. If you have no one to take you home we can arrange for a nurse to escort you home and stay with you. This will be at an additional cost and must be pre-arranged and pre-paid at least seven days prior to the appointment.
How long will I be under sedation?
The length of your appointment will depend upon the procedure. There will be a recovery period of 20 – 30 minutes before you are discharged into the care of your escort. The sedative effect of the drugs will gradually wear off during the course of the day. Most patients are well enough to return to their normal activities within 24 hours depending on the nature of their work.
More information on Facial Cosmetic & Plastic Surgery:
- Anaesthesia Options & Frequently Asked Questions
- Sedation & Blepharoplasty/ Eyelid Surgery
- Sedation & Rhinoplasty/ Nose-Reshaping
- Eyelid surgery (Blepharoplasty) Frequently asked Questions
- Nose Re-shaping surgery (Rhinoplasty) Frequently asked Questions
- Facelift (Rhytidectomy) Frequently asked Questions
- How to speed up recovery after cosmetic surgery?
- Minimally invasive surgery