Blepharoplasty Under Local Anaesthetic or Asleep: Which Is Right for You?

Will I be awake during eyelid surgery? It is one of the first questions people ask about blepharoplasty, and the honest answer is that it depends on what you are having done. Removing excess skin from the upper eyelids is commonly done under local anaesthetic, with you awake and comfortable. Lower eyelid surgery, and operations that treat both lids or combine eyelid surgery with something else, are usually done with you asleep.

This guide explains what blepharoplasty under local anaesthetic actually feels like, when sedation or being asleep makes more sense, and how the choice affects safety, preparation and recovery. If you are not yet sure which operation you need, our guide to upper vs lower blepharoplasty explains the difference, and our article on TIVA anaesthesia explains how being asleep works at our hospital.

Is Blepharoplasty Done Under Local or General Anaesthetic?

Both are used. The NHS describes blepharoplasty as an operation that can be done under local anaesthetic or with you asleep.^[1] In practice there are three options:

• Local anaesthetic: you are awake, and the eyelids are numbed with an injection.
• Local anaesthetic with sedation: medicine makes you drowsy and relaxed, and the eyelids are still numbed with local anaesthetic.
• Asleep: you are fully unconscious for the whole operation. When people search for blepharoplasty under general anaesthetic, this is what they mean. At Centre for Surgery, being asleep means total intravenous anaesthesia (TIVA), given entirely through a drip by a consultant anaesthetist, with no anaesthetic gases.

Which one suits you depends on which eyelids are being treated, how much work is needed, whether anything else is being done at the same time, your general health, and how you feel about being awake. This is how it usually works at our Baker Street hospital:

If you would prefer to be asleep for upper eyelid surgery, TIVA can be arranged. It adds a consultant anaesthetist and a separate anaesthetic charge, which is set out in your written quote. Our blepharoplasty cost guide explains how the anaesthetic affects the price.

Can You Be Awake During Eyelid Surgery?

Yes. Upper blepharoplasty under local anaesthetic is routine in the UK, and many people are surprised by how manageable it is. This is what usually happens:

1. Marking. Your surgeon marks the skin to be removed while you sit up with your eyes open, so the new crease and the amount of skin are judged with gravity acting on the lids.
2. Numbing. Your surgeon may use numbing drops or cream first. A very fine needle then places local anaesthetic, usually lidocaine with a small amount of adrenaline to reduce bleeding, just under the eyelid skin. This stings for a few seconds on each side.
3. Surgery. Within a few minutes the eyelids are numb. Your eyes stay closed under a sterile drape. You will feel touch, pressure and gentle pulling, and you may hear the surgeon talking, but you should not feel sharp pain. If you do, tell your surgeon and more local anaesthetic can be given.
4. Checking. Your surgeon may ask you to open and close your eyes so they can check the height of the crease and that the lids close fully.
5. Finishing. The skin is closed with fine stitches, ointment is placed in the eyes and cold compresses go on. After a short rest you go home with your escort.

The injections are the part most people remember. In a 2021 randomised trial in Dermatologic Surgery of 40 people having upper eyelid surgery under local anaesthetic, average pain scores for the injections were 2.6 to 3.3 out of 10, and the injections were well tolerated.^[2] Experiences vary, though. In another trial, people who had no numbing cream before their injections rated them at about 6.7 out of 10 on average, and a numbing gel applied an hour beforehand lowered that.^[3]

Surgeons have several ways to make the injections more comfortable. In a trial of 288 patients, buffered local anaesthetic, which is less acidic, hurt less than standard solutions.^[4] In a 2015 comparison, lidocaine was less painful to inject than prilocaine.^[5] Injecting slowly, using a very fine needle and talking you through each step all help too.

Does Blepharoplasty Hurt?

The operation itself should not hurt. Under local anaesthetic you feel the injections and then pressure, and under TIVA you feel nothing at all. Even when you are asleep, your surgeon still places local anaesthetic in the eyelids, so you wake up comfortable.

Afterwards, most people describe their eyes as tight, puffy and gritty rather than painful, and simple painkillers are usually enough. Our own pain audits show that combining TIVA with local anaesthetic keeps the need for strong painkillers to a minimum, often to none at all. Swelling and bruising usually peak around days three to four and then settle.

Pain that gets steadily worse, swelling that makes the eye bulge, or any change in your vision is not normal after eyelid surgery. Call your surgeon straight away on the direct number you are given for the first 24 hours, or the clinic after that. If you cannot reach us, go to your nearest A&E or call 999, because these can be signs of bleeding behind the eye, which needs urgent treatment.

What Is Blepharoplasty Under Sedation?

Sedation sits between being awake and being asleep. Medicine given through a drip, or sometimes as a tablet, makes you drowsy and calm, and you may remember little of the operation. You keep breathing for yourself, and your eyelids are still numbed with local anaesthetic, so sedation is an addition to local anaesthetic rather than a replacement for it.

Sedation can suit people having upper eyelid surgery who are nervous about being fully awake. It works best for shorter operations: our guide to twilight sedation explains why it is less suitable once an operation runs well beyond an hour. With sedation you need to fast beforehand, just as you would before TIVA, and you will feel drowsy for the rest of the day.

When Is Eyelid Surgery Done Asleep Under TIVA?

At Centre for Surgery, lower eyelid surgery and combined operations are done with you asleep under TIVA. There are good reasons for this:

• Lower eyelid surgery works deeper. It treats the fat pads that cause eye bags, often through an incision inside the lid, and it is closer to the eye. You need to be completely still for longer.
• Combined operations take longer. Treating both lids, or adding a brow lift or a mini facelift, can take several hours, which is too long to stay comfortable awake.
• Revision surgery. Correcting a previous operation can be less predictable, so being asleep is often the better choice. Our revision blepharoplasty page explains more.
• Your preference. Some people simply do not want to be awake for any surgery near their eyes, and that is a reasonable choice.

With TIVA, a consultant anaesthetist gives propofol and a short-acting painkiller continuously through a drip in your hand or arm, and monitors you throughout. No anaesthetic gases are used, so most people wake quickly and clear-headed. Your surgeon still uses local anaesthetic in the eyelids, which reduces bleeding during the operation and keeps you comfortable afterwards. Our guide to anaesthesia for cosmetic surgery shows which anaesthetic is usually used for other operations.

Is It Safer to Have Blepharoplasty Awake or Asleep?

For healthy adults, both are safe when they are given by an experienced team in a properly equipped hospital. The more useful question is what could go wrong with eyelid surgery in particular, and how the anaesthetic plan helps prevent it.

The most serious eyelid-specific complication is bleeding behind the eye, called orbital haemorrhage. A 2004 survey of 269,433 cosmetic eyelid operations in Ophthalmic Plastic and Reconstructive Surgery found it in about 1 in 2,000 cases, with permanent loss of vision in about 1 in 22,000. Most bleeds happened within three hours of surgery, and they were linked with high blood pressure, aspirin taken around the time of surgery, vomiting after surgery and physical exertion.^[6]

That shapes how we look after you, whichever anaesthetic you have:

• Your blood pressure is checked before surgery and kept steady during it.
• You stop aspirin and anti-inflammatory painkillers two weeks before surgery, unless a doctor prescribed them (see below).
• Your anaesthetist aims for a smooth wake-up without coughing, straining or sickness.
• You rest in our recovery suite with a nurse watching your eyes before you go home, and you avoid bending, lifting and exercise in the first days.

Feeling sick after an anaesthetic matters for eyelid surgery, because vomiting raises the pressure around the eyes. A 2018 meta-analysis of 229 randomised trials and 20,991 patients in BMC Anesthesiology found that keeping patients asleep with propofol, as in TIVA, made sickness after surgery 39% less likely than using anaesthetic gases. Patients also had slightly less pain on waking and were more satisfied.^[7] The risk of sickness is also higher in women, non-smokers, people who get travel sick and people who need strong painkillers afterwards. In one study, it rose from 10% with none of these factors to 79% with all four.^[8] Under local anaesthetic alone there is no anaesthetic sickness to worry about, which is one reason it suits upper eyelid surgery so well.

Being awake has its own demands. You need to lie still for about an hour and cope with the injections, and some people find the idea harder than the reality. Being asleep means fasting, an anaesthetist and a longer stay in recovery, and you will be tired for the rest of the day. Our article on the risks of blepharoplasty covers the other possible complications.

Local Anaesthetic or TIVA for Blepharoplasty: Side by Side

Your surgeon will recommend an approach at consultation, and you are welcome to say which you would prefer. Our article on surgical vs non-surgical blepharoplasty covers the alternatives if you are not ready for surgery at all.

How Do You Prepare for Blepharoplasty Under Local Anaesthetic or TIVA?

• Smoking and vaping: stop at least four weeks before surgery and stay stopped for four weeks afterwards, because nicotine slows healing. Our article on smoking and cosmetic surgery explains why.
• Aspirin and anti-inflammatories: stop them two weeks before surgery. If a doctor prescribed your aspirin, don’t stop it without speaking to them and your surgeon first. Your surgeon will also go through any other medicines and supplements at your pre-operative assessment.
• Fasting: for upper eyelid surgery under local anaesthetic alone, you do not need to fast. For sedation or TIVA, have no food for 6 hours before surgery and only clear water up to 2 hours before.
• Your eyes: take out contact lenses, come without eye make-up and bring your glasses.
• Getting home: arrange a responsible adult to take you home and stay with you for the first 24 hours. We cannot discharge you without one.
• Driving: do not drive for at least 72 hours after upper eyelid surgery under local anaesthetic, and for longer after lower or combined surgery under TIVA. Our guide on driving after blepharoplasty has the detail.
• Time off: most people are back at desk work in 7 to 10 days, once bruising can be covered.

UK day-surgery guidance from the Association of Anaesthetists and the British Association of Day Surgery supports operations like this as day cases for most healthy adults, with clear written instructions and an escort home.^[9] Our general guide to preparing for plastic surgery covers the rest of the checklist.

What Happens on the Day of Your Eyelid Surgery?

You arrive at our hospital at 95–97 Baker Street and meet your surgeon, who is the same consultant who assessed you at consultation. They go through the plan and your consent again, and mark your eyelids with you sitting up. If you are having TIVA, you also meet your consultant anaesthetist, who checks your health and answers any questions.

After the operation you rest in our recovery suite, looked after one-to-one by a recovery nurse, usually for one to two hours after TIVA and for less time after local anaesthetic alone. Your vision will be blurry from the eye ointment, which is normal. You go home the same day with written instructions, and you have your surgeon’s direct number for the first 24 hours.

Recovery After Local Anaesthetic and After TIVA

After local anaesthetic alone you will feel alert, and the numbness wears off over the next few hours. After sedation or TIVA you will feel tired for the rest of the day. From then on, recovery is the same:

• Rest with your head raised and sleep on your back on two pillows for at least the first week.
• Use cold compresses for the first 48 hours, 20 minutes on and 20 minutes off.
• Expect swelling and bruising to peak around days three to four.
• Stitches that need removing come out at about one week, and dissolvable stitches go on their own.
• Avoid exercise for about four weeks, and avoid eye make-up until your surgeon says the incisions have healed.

Our full blepharoplasty recovery guide has the week-by-week timeline, and our articles on blepharoplasty scars and dry eyes after blepharoplasty answer the questions people ask most in the first weeks.

Frequently Asked Questions

Why Choose Centre for Surgery for Eyelid Surgery?

Eyelid surgery at Centre for Surgery is performed by GMC-registered surgeons with oculoplastic training, at our CQC-regulated hospital at 95–97 Baker Street, which has been caring for patients for over 10 years. The surgeon who assesses you at consultation is the surgeon who performs your operation. When you are asleep, your anaesthetic is TIVA given by a consultant anaesthetist, and almost all of our operations are day cases. You can see our results in our blepharoplasty before and after photos. We recommend a two-week cooling-off period before any surgery, and we publish our clinical outcomes and patient safety data.

Finance is available through Chrysalis Finance, subject to status. See our finance options page for details.

Phone: 020 7993 4849 | Address: 95–97 Baker Street, Marylebone, London W1U 6RN
Contact us to schedule a consultation

References

1. NHS. Eyelid surgery. nhs.uk
2. Ohana O, Ayala-Haedo J, Anagnostopolous A, Lee WW. Local anesthesia injection in upper blepharoplasty surgery: a side at a time or both sides at once? A prospective randomized study. Dermatologic Surgery 2021;47(2):241–244. doi:10.1097/DSS.0000000000002718
3. Sun H, Mei Y, Zhu L, et al. Efficacy of 4% tetracaine gel and lidocaine-prilocaine cream in reducing local anesthetic injection pain in upper eyelid blepharoplasty: a randomized, single-blinded, controlled trial. BMC Ophthalmology 2024;24(1):530. doi:10.1186/s12886-024-03799-7
4. Vasović DD, Karamarković M, Stojičić M, et al. Buffered versus nonbuffered local anesthetics and local pain scores in upper eyelid blepharoplasty: randomized controlled trial. Ophthalmic Plastic and Reconstructive Surgery 2023;39(6):602–605. doi:10.1097/IOP.0000000000002442
5. Pool SM, Struys MM, van der Lei B. A randomised double-blinded crossover study comparing pain during anaesthetising the eyelids in upper blepharoplasty: first versus second eyelid and lidocaine versus prilocaine. Journal of Plastic, Reconstructive & Aesthetic Surgery 2015;68(9):1242–1247. doi:10.1016/j.bjps.2015.04.021
6. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthalmic Plastic and Reconstructive Surgery 2004;20(6):426–432. doi:10.1097/01.iop.0000143711.48389.c5
7. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC Anesthesiology 2018;18(1):162. doi:10.1186/s12871-018-0632-3
8. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91(3):693–700. doi:10.1097/00000542-199909000-00022
9. Bailey CR, Ahuja M, Bartholomew K, et al. Guidelines for day-case surgery 2019: guidelines from the Association of Anaesthetists and the British Association of Day Surgery. Anaesthesia 2019;74(6):778–792. doi:10.1111/anae.14639