The infiltration should begin with a very fine needle, injecting slowly, because rapid distension of tissues is painful. Once the skin has been anesthetized, the fine needle is changed for a longer one or for a cannula. The inner side of an Abbocatt no. 16 or a spinal needle are also very useful.
In general, I infiltrate the whole forehead, face and neck at the beginning of the surgery. This way, when the second or third region is approached, it already has an appropriate vasoconstriction. The infiltration is begun at the facial region where the surgeon will first start. If the surgeon begins at the forehead, this area is infiltrated first.
I start with the face and, in general, I infiltrate 12 cm outside the whole marked area of the face and neck, because the dissection can cross the premarked limits. In the central part of the neck, I infiltrate the skin and the posterior aspect of the central fat so as to facilitate its dissection [11, 12].
With use of 200 ml of the same solution, the scalp is infiltrated first with a long needle in the hypoder-mis underneath the incision line and 2 cm behind the marked line, and deep into the frontal muscle or into the galea. Then I infiltrate the forehead, in the subga-leal plane up to the orbital rim and the nasal dorsum
to assure a better vasoconstrictive effect of the plane to be undermined (Fig. 23.2).
When I finish the infiltration, 15 min has already elapsed and I can start surgery on the region that was firstly infiltrated. I usually begin with the face and then go on with the neck. Before the superficial mus-culo-aponeurotic system dissection, I infiltrate this plane for vasoconstriction and for hydraulic dissection and separation of the planes. The whole surgery takes me 3-4 h. I never have to reinject while I am finishing with the sutures.
A pale color of the skin shows a well-infiltrated area, while an island of reddish skin means an area that has not been infiltrated, such as often happens in postacne scarred skin.
When I have already dissected one side of the face and neck, I introduce two compresses under the skin and I go to the contralateral side, where I repeat the procedure. Then I come back to the first side and I remove the compress slowly while doing the coagulation of the vessels.
I have more than 25 years' experience using local anesthesia for facelift. At the beginning of my practice, I personally did the sedation using a premedication with morphine-prometazine-atropine, but postoperative recovery was not fast. Then I used valium-ket-amine, but later changed to midazolan-fentanyl. For 10 years ago I have had an anesthesiologist in each surgery and he combines midazolan-propofol-fen-tanyl according to the case. He also uses flumazenyl to wake up the patient at the end of the surgery. Using metoclopramide and ondasestron, I have a rate of less than 10% postoperative vomiting.
The argument that after using adrenaline there is a vasodilatation is against the experience of most of facial surgeons. Bleeding does not occur because after some hours of vasoconstriction, the sealing of the sectioned arteries and veins and the clot of the intravas-cular coagulation are firm.
It is often heard that surgeons say they use a tumescent infiltration in the face and neck. As the tumescence is massive, tense, or hard like a ball infiltration and this does not happen on the face and neck, the use of the term tumescence is totally inappropriate for this surgery.
The doses of anesthetic drugs are well tolerated when used much diluted. Big faces and heads need a greater amount of infiltration, while small ones need less. Hydraulic distension of local anesthetics reduces the bleeding and facilitates the undermining.
I routinely use bupivacaine, which gives 3-4 h pain relief after surgery. I have not had a single problem with this drug in my experience of more than 3,000 aesthetic surgeries.
Local anesthesia and deep sedation is a good combination for ambulatory surgery. With local anesthesia, there is no intubation and a low rate of vomiting. With bupivacaine, there are some hours of postoperative pain relief. The cost of anesthesia is also lower.
1. Mottura A.A.: Local Anesthesia in Reduction Mastoplas-ty for Out-patient Surgery. Aesth Plast Surg 16:309-315,
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