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Minimal Pain Local Anesthetic Injection with Blunt Tipped Cannula for Wide Awake Upper Blepharoplasty


Supplemental Digital Content is available in the text. 1
Operative Technique
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,
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- or available at
PRS Global Open 2017
authors performing an upper blepharoplasty procedure
without sedation,
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-
ing period.
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,
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
Dalhousie University
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 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 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
or available at
... Not infrequently, even though the ocular surface has been anaesthetised with topical anaesthetic prior to the injection, the patient experiences significant pain, likely due to local anaesthetic infiltration resulting in skin stretching and stretching within fascicles of the orbicularis oculi muscle. Additionally, the infiltration of the orbicularis oculi muscle involving the abundant palpebral vasculature not infrequently results in the patient developing a postoperative preseptal haematoma, with associated excessive postoperative lid swelling [7,8]. ...
... • Due to the efficacy of FLAT, patients generally do not need additional sedation and the associated extra medical supportive requirements that may be entailed [8]. ...
... 3-5 14 In general, it is recommended to use small diameter needles and to slowly inject the anaesthetic agent to reduce pain during the procedure. [15][16][17][18][19][20][21] Furthermore, various studies have reported factors that help minimise pain during local anaesthesia, which include the choice of the anaesthetic agent, dilution, buffering, and skin cooling. 22 Anaesthetic injections can also lead to tissue distortion and bleeding, which further distort the anatomical structures, making it more di cult to perform surgery accurately; thus, care should be taken to limit these. ...
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Background: To evaluate the potential benefit of using insulin syringes for local anaesthesia in ptosis surgery. Methods: Sixty patients (120 eyelids) were included in this randomised, fellow eye-controlled study at a university‐based hospital. An insulin syringe was used on one eyelid and a conventional 30-gauge needle on the other. Patients were asked to score pain in both eyelids using a visual analogue scale (VAS) ranging from 0 (no pain at all) to 10 (unbearable pain). Ten minutes after the injection, an observer scored the degree of haemorrhage and oedema in both eyelids on a scale of 0 to 4. Results: The VAS score was 5.17 in the insulin syringe group and 5.35 in the 30-gauge needle group (p=0.264). Ten minutes after the anaesthesia, the haemorrhage score was 1.30 and 1.64 and eyelid oedema score was 1.50 and 1.80 in the insulin syringe and 30-gauge needle groups, respectively (haemorrhage, p=0.045; eyelid oedema, p=0.023). Conclusion: Injecting local anaesthesia using an insulin syringe, compared to conventional 30-gauge needles, significantly reduces haemorrhage and eyelid oedema before skin incision but does not significantly reduce the injection pain. Using insulin syringes also presents fewer complications related to tissue penetration and lesser distortion of anatomical structures compared to conventional 30-gauge needles. We recommend using an insulin syringe for local anaesthesia in ptosis surgery. Trial registration: registry – CRIS / registration number – KCT0005120 / date of registration: 12/06/2020 (retrospectively registered),
... Recently, the wide-awake surgery under local anesthesia without tourniquet and sedation (WALANT) technique could achieve this goal based on the merits of simplicity, good outcomes, and cost-efficiency. This technique has become more and more popular in hand surgeons and has also been accepted by foot and ankle and plastic surgeons [2,3]. The surgeons schedule their work time efficiently as the effect of anesthesia was activated. ...
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Background Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery. Methods From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected. Results All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1. Conclusions Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.
... [1][2][3] With the advent of blunt-tipped microcannulas, the hypothesis that these could cause less damage to tissue infiltration and reduce pain sensation and bleeding, as they presumably cause less damage to surrounding vessels was raised. [4][5][6] Some trials have evidenced that cannulas are efficient in infiltrating hyaluronic acid fillers into very sensitive areas, such as lips, causing minimal to tolerable pain. 4 , 5 Many surgeons have been using microcannulas in their surgical practice to prevent damages to surrounding vessels and nerves while operating. ...
... [1][2][3] With the advent of blunt-tipped microcannulas, the hypothesis that these could cause less damage to tissue infiltration and reduce pain sensation and bleeding, as they presumably cause less damage to surrounding vessels was raised. [4][5][6] Some trials have evidenced that cannulas are efficient in infiltrating hyaluronic acid fillers into very sensitive areas, such as lips, causing minimal to tolerable pain. 4 , 5 Many surgeons have been using microcannulas in their surgical practice to prevent damages to surrounding vessels and nerves while operating. ...
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INTRODUCTION With the emergence of blunt-tipped microcannulas, there is an hypothesis that these could cause less damage and reduce pain compare to conventional sharp needles in eyelid surgery .The purpose is to determine whether a 18G blunt-tipped cannula can be better than a 26G needle. METHODS Prospective, observer-blinded, randomized clinical trial. Conducted from June 2017 to December 2018. 68 patients were randomized to receive local anesthesia injections for upper blepharoplasty. Infiltration via a 26-gauge sharp needle was performed in one side, and, in the other side, infiltration via an 18-gauge stainless-steel blunt-tipped microcannula was used. Numeric rating scale (NRS) of 0 to 10 was used to blindly assess pain in patients receiving anesthesia injections with both needle types. Photographs of the eyelids of each patient were taken in five different periods and used by 3 blinded observers to identify bruise or ecchymoses. RESULTS 136 eyelid operations. There was no statistically significant difference when both groups were compared, however, the average score of pain was higher in patients taking the infiltration via needle (2.85 versus 2.50). Regarding the evaluation on bruising and ecchymoses, the results showed that, in the five periods evaluated, there was no statistical difference in bruising and ecchymosis in the eyelids when taking the infiltration via sharp needle compared with eyelids taking infiltration via (blunt-tipped) microcannula. CONCLUSION The evaluation on the blunt-tipped microcannula showed a lower pain score mean than the sharp needle (2.5 versus 2.85) (p>0.05). There was no statistically difference in the bruising and ecchymosis courses.
Introduction: Pectoral plane (PEC) blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration (LAI) is a simple alternative technique with the same aim. We evaluated both techniques. Mm: In this single-center retrospective study, patients received PEC block (ropivacaine 0.2%, 10 ml PEC I, 20 ml PEC II) or LAI. The primary outcome measure was pain, according to the visual analog scale (VAS), at 24h post-surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours post-surgery, total opioid consumption at 24h, and opioid side effects. Results: 81 were finally recruited: 37 in the PEC group and 44 in the LAI group. Patient characteristics were comparable between the two groups. At 24h post-surgery, the LAI group showed a decrease in pain, with a VAS score of 0.7 vs 1.5 in the PEC group (p = 0.007). There was no difference in VAS between the two groups at 1, 2, 6, or 12 hours post-surgery. The duration of anesthesia was increased in the PEC group with 153 minutes vs 120 minutes in the LAI group (p < 0.001). There was no difference in rescue morphine consumption between the two groups. Conclusions: We found that LAI had a superior analgesic effect at 24h after surgery for dual-plane breast implant augmentation compared with PEC block. These findings are a good indication that the LAI technique is at least as effective as PEC block while being safe, fast, and easy to use.
Full-text available
After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups."
Background: Perceived pain during local anesthesia injections can be effected by the injection sequence. Objective: We sought to compare pain levels during local anesthesia injections during upper lid blepharoplasty (ULB) using 2 surgical sequences. Materials and methods: We conducted a prospective, randomized clinical trial. Patients with ULB were randomized to either have local anesthesia injection followed by ULB in the right eyelid and then in the left (Group A) or to have local anesthesia injection to both eyelids followed by ULB on both eyelids (Group B). Pain was assessed using a visual analog scale (VAS) for pain score of 0 to 10. Results: Forty patients were included and randomized. The mean VAS score in Group A was 2.60 ± 1.84 and 3.30 ± 1.62 (right and left, respectively, p value = .035). The mean VAS score in Group B was 2.55 ± 1.63 and 2.80 ± 1.67 (right and left eyelids, respectively, p value = .258). No intergroup difference in pain was found. Conclusion: Patients having sequential anesthesia during ULB perceived more pain on injection to the second eyelid, whereas patients having local anesthesia followed by ULB perceived the same amount of pain in both eyes. Pain levels in both groups were similar. Local anesthesia injections in both groups were well tolerated.
Learning objectives: After reading this article, the participant should be able to: 1. Describe the fundamental concepts of multimodal analgesia techniques and how they target pain pathophysiology. 2. Effectively educate patients on postoperative pain and safe opioid use. 3. Develop and implement a multimodal postoperative analgesia regimen. Summary: For many years, opioids were the cornerstone of postoperative pain control, contributing to what has become a significant public health concern. This article discusses contemporary approaches to multimodal, opioid-sparing postoperative pain management in the plastic surgical patient.
Learning objectives: After studying this article, the participant should be able to: 1. Process several patient-specific factors before reaching an optimal treatment strategy with appreciation for facial balance. 2. Define the advantages and disadvantages of various hyaluronic acid preparations and delivery techniques, to achieve a specific goal. 3. Perform advanced facial rejuvenation techniques adapted to each facial zone, combining safety considerations. 4. Prevent and treat complications caused by inadvertent intraarterial injections of hyaluronic acid. Summary: The growing sophistication and diversity of modern hyaluronic acid fillers combined with an increased understanding of various delivery techniques has allowed injectable filler rejuvenation to become a customizable instrument offering a variety of different ways to improve the face: volume restoration, contouring, balancing, and feature positioning/shaping-beyond simply fading skin creases. As more advanced applications for hyaluronic acid facial rejuvenation are incorporated into practice, an increased understanding of injection anatomy is important to optimize patient safety.
Full-text available
Introduction: There has been a recent interest in injecting large body and face areas with local anesthetic in a minimally painful manner. The method includes adherence to minimal pain injection details as well feedback from the patient who counts the number of times he feels pain during the injection process. This article describes the successes and limitations of this technique as applied to primary cleft lip/nasal repair in grown patients. Methods: Thirty-two primary cleft lip patients were injected with local anesthesia by 3 surgeons and then underwent surgical correction of their deformity. At the beginning of the injection of the local anesthetic, patients were instructed to clearly inform the injector each and every time they felt pain during the entire injection process. Results: The average patient felt pain only 1.6 times during the injection process. This included the first sting of the first 27-gauge needle poke. The only pain that 51% of the patients felt was that first poke of the first needle; 24% of the patients only felt pain twice during the whole injection process. The worst pain score occurred in a patient who felt pain 6 times during the injection process. Ninety-one percent of the patients felt no pain at all after the injection of the local anesthetic and did not require a top-up. Conclusion: It is possible to successfully and reliably inject local anesthesia in a minimally painful manner for cleft lip and nasal repair in the fully grown cleft patient.
Local anesthesia in plastic surgery is undergoing a revolution. In the last 10 years, significant improvements in technique have permitted surgeons to do more and more under pure local anesthesia to increase patient safety and convenience while maintaining total patient comfort during the injection of the local anesthesia and while the procedure is accomplished. Many procedures which used to require sedation are now being performed without it. This article explores some of the new advances in local anesthesia such as painless blunt-tipped cannula local anesthetic infiltration, decreased pain with sharp needle tip injection, and long-lasting local anesthetics with delayed release from liposomal encapsulation. This article also examines the best evidence of the last 10 years of advances of pain control with local anesthesia.
Local anesthetic injection is often cited in literature as the most painful part of minor procedures. It is also very possible for all doctors to get better at giving local anesthesia with less pain for patients. The purpose of this article is to illustrate and simplify how to inject local anesthesia in an almost pain-free manner. The information was obtained from reviewing the best evidence, from an extensive review of the literature (from 1950 to August of 2012) and from the experience gained by asking over 500 patients to score injectors by reporting the number of times they felt pain during the injection process. The results are summarized in a logical stepwise pattern mimicking the procedural steps of an anesthetic injection-beginning with solution selection and preparation, followed by equipment choices, patient education, topical site preparation, and finally procedural techniques. There are now excellent techniques for minimizing anesthetic injection pain, with supporting evidence varying from anecdotal to systematic reviews. Medical students and residents can easily learn techniques that reliably limit the pain of local anesthetic injection to the minimal discomfort of only the first fine needlestick. By combining many of these conclusions and techniques offered in the literature, tumescent local anesthetic can be administered to a substantial area such as a hand and forearm for tendon transfers or a face for rhytidectomy, with the patient feeling just the initial poke.
Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.
The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2222, 2010.)