We present our increasing experience using blunt
tipped ﬁller cannulas for local anesthesia inﬁltra-
tion to minimize pain and bruising during upper
lid blepharoplasty. Avoiding injection pain enables the pa-
tient to enjoy the beneﬁts of wide awake surgery without
the inconveniences of sedation. We present educational
videos on how to perform the local anesthetic inﬁltration
using blunt tipped cannulas, the blepharoplasty proce-
dure itself on a wide awake patient, and a video on the
patient's perspective of wide awake blepharoplasty.
Upper lid blepharoplasty is typically performed using
local anesthesia with or without sedation.1 Many surgeons
still prefer to use sedation to decrease patient discomfort
with the local injection and the procedure. We present
our increasing experience2 using blunt tipped ﬁller can-
nulas for local anesthesia inﬁltration to minimize pain
and bruising. Avoiding injection pain enables the patient
to enjoy the beneﬁts of wide awake surgery without the
inconveniences of sedation. We have performed over 30
upper lid blepharoplasties with this technique.
We used a blunt tipped cannula for painless local an-
esthesia inﬁltration (see video, Supplemental Digital
Content 1, which displays blunt tipped cannula for painless
local anesthetic inﬁltration technique for wide awake up-
per lid blepharoplasty, http://links.lww.com/PRSGO/A433).
• A 30-gauge needle is used to inject 0.25–0.5 ml of
local at the lateral most extent of the planned skin
• Firmly pinching the entry site skin distracts the pain
nerves stimulated by the needle poke. We have observed
that needles hurt less if the skin is pinched into the nee-
dle rather than pushing the needle into the skin.
We numb both lateral eyelids with this initial bleb of lo-
cal. We then insert a 20-gauge needle in the ﬁrst numbed
side to make a skin hole in which we easily insert the blunt
27-gauge 1.5 inch ﬁller cannula (see video, Supplemental
Digital Content 2, which displays the authors using a blunt
tipped cannula for local anesthesia inﬁltration, http://
• The cannula slides through fat unless it becomes ob-
structed by ligaments, in which case we back up and
bypass the obstruction by heading in a slightly differ-
ent direction. Unlike sharp needle tips, cannulas do
not lacerate nerves and vessels. They therefore de-
crease pain and bruising.
• We use buffered room temperature local anesthesia,
slow inﬁltration, and encourage patient feedback.3
• We routinely use 3–6 ml of 1% lidocaine with
1:100,000 epinephrine buffered 10 ml:1 ml with
8.4% bicarbonate and a small amount of bupivacaine
per side. We add 1 ml of 0.05% bupivacaine with
1:200,000 epinephrine to 10 ml of the lidocaine/
bicarbonate mixture in a 10 ml syringe.
Wide awake upper blepharoplasty procedure (see
video, Supplemental Digital Content 3, which displays the
From the Department of Surgery, Division of Plastic Surgery, Dal-
housie University, Saint John, NB, Canada.
Operative Technique Video Articles
© 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society
of Plastic Surgeons. All rights reserved.
Minimal Pain Local Anesthetic Injection with
Blunt Tipped Cannula for Wide Awake Upper
Daniel Mckee, MD; Don Lalonde, MD
Disclosure: The authors have no ﬁnancial interest to declare
in relation to the content of this article. The Article Processing
Charge was paid for by the authors.
Supplemental digital content is available for this
article. Clickable URL citations appear in the text.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This is
an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Plast Reconstr Surg Glob Open 2017;5:e1310; doi: 10.1097/
GOX.0000000000001310; Published online 4 May 2017.
Video Graphic 1. See video, Supplemental Digital Content 1, which
displays blunt tipped cannula for painless local anesthetic infiltration
technique for wide awake upper lid blepharoplasty. This video is avail-
able in the “Related Videos” section of the Full-Text article on PRSGlo-
balOpen.com or available at http://links.lww.com/PRSGO/A433.
PRS Global Open • 2017
authors performing an upper blepharoplasty procedure
without sedation, http://links.lww.com/PRSGO/A435):
• Waiting 30 minutes after the injection of the local
anesthetic before starting the surgery is important.
Half an hour of waiting has been shown to produce
one-third the blood loss of waiting only 7 minutes.4
The patient may go to the restroom during this wait-
• We use surgical procedure time to educate the fully
alert patient and give them postoperative instruc-
tions to decrease complications.
• Bipolar cautery hurts less than monopolar cautery.
• Fat pads can be anesthetized by injecting more local
with either sharp needles or blunt cannulas.
• The patient sits upright during surgery to ensure a good
result against gravity when ptosis repair is required.
Patient satisfaction is high with wide awake blepharo-
plasty (see video, Supplemental Digital Content 4, which
displays a patient’s perspective after undergoing wide
awake upper blepharoplasty, http://links.lww.com/PRSGO/
• Avoiding sedation provides many patient beneﬁts in
addition to considerably reduced cost.5
• They do not suffer the inconveniences of intrave-
nous insertion, preoperative testing, postoperative
nausea and vomiting, and extra time in a recovery
room. They simply get up and go home as they do
after a dental procedure.
• They do not need to fast or change medication
schedules, which is particularly helpful in diabetics
or patients with comorbidities.
Daniel Mckee, MD
Suite C204, 600 Main Street
Saint John, NB E2K 1J5, Canada
The patient provided written consent for the use of her
1. Friedland JA, Lalonde DH, Rohrich RJ. An evidence-based
approach to blepharoplasty. Plast Reconstr Surg. 2010;126:
2. Lalonde D, Wong A. Local anesthetics: what’s new in minimal
pain injection and best evidence in pain control. Plast Reconstr
Surg. 2014;134(4 Suppl 2):40S–49S.
3. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local
anesthesia injection. Plast Reconstr Surg. 2013;132:675–684.
4. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay be-
tween epinephrine injection and incision to minimize bleeding.
Plast Reconstr Surg. 2013;131:811–814.
5. Lalonde DH, Price C, Wong AL, et al. Minimally painful local an-
esthetic injection for cleft lip/nasal repair in grown patients. Plast
Reconstr Surg Glob Open. 2014;2:e171.
Video Graphic 3. See video, Supplemental Digital Content 3, which
displays the authors performing an upper blepharoplasty proce-
dure without sedation. This video is available in the “Related Videos”
section of the Full-Text article on PRSGlobalOpen.com or available at
Video Graphic 4. See video, Supplemental Digital Content 4, which
displays a patient’s perspective after undergoing wide awake upper
blepharoplasty. This video is available in the “Related Videos” section
of the Full-Text article on PRSGlobalOpen.com or available at http://
Video Graphic 2. See video, Supplemental Digital Content 2, which
displays the authors using a blunt tipped cannula for local anesthe-
sia infiltration. After numbing the area, create an introducer punc-
ture with a large gauge needle, then introduce the cannula through
this hole. The tumescent uid injected (blue) should extend beyond
the planned surgical incisions (red). This video is available in the “Re-
lated Videos” section of the Full-Text article on PRSGlobalOpen.com
or available at http://links.lww.com/PRSGO/A434.