Everything You Need To Know About Twilight Anesthesia

Written by Cameron Craven, MD, FACS, Board Certified Plastic Surgeon on February 20, 2014 59 Comments

twilight anesthesia

Some patients are hesitant to undergo cosmetic surgery strictly because of the need for general anesthesia. Indeed general anesthesia does have its downsides, such as the need for breathing assistance (ventilation), nausea-related side effects, and increased costs.  There is an alternative to general anesthesia called twilight anesthesia.

What is twilight anesthesia?

Twilight anesthesia is an anesthetic technique that uses mild doses of drugs to block pain, reduce anxiety, and provide a temporary memory loss, thus enabling patients to feel comfortable during and after surgical procedures. With twilight anesthesia a patient is sedated but remains conscious in what’s commonly referred to as a “twilight state”. The patient is sleepy but still responsive and able to follow direction or communicate with their surgeon. Typically, a local anesthetic that’s applied to the surgical site is used in conjunction with twilight anesthesia to ensure a pain-free experience for the patient.

The drugs used in twilight anesthesia are similar to those used in general anesthesia, but the doses are lower. Specific drugs commonly used include: fentanyl, valium, ketamine, midazolam, or nitrous oxide (laughing gas). These drugs can be reversed quickly, so the patient can be woken up in a matter of minutes.

How does twilight anesthesia differ from general anesthesia?

The primary difference between general and twilight anesthesia is the degree of consciousness of the patient. In general anesthesia patients are put in an induced coma making them completely unconscious; resulting in the loss of control of reflexes and the autonomic nervous system. While under general anesthesia patients breath with the help of a ventilator as their normal muscular functions may become impaired making it necessary for breathing tubes and a ventilator to be used.

In contrast twilight anesthesia patients remain semi-conscious and ventilation is not required.

Is twilight anesthesia better than general anesthesia?

Overall, twilight anesthesia has many benefits compared to traditional techniques including:

  • Ventilation is not required
  • Quicker average recovery times
  • Reduced anesthesia based side effects like nausea and vomiting
  • Reduced risk of complications
  • Lower general cost

However your plastic surgeon will review your medical history to determine if twilight anesthesia is right for you.

What procedures can be done under twilight anesthesia? 

Twilight anesthesia can be used during many popular plastic surgery procedures.  Some of these include:

Cameron Craven, MD, FACS

Cameron Craven MD, FACS is board certified by the American Board of Plastic Surgery. Dr. Craven specializes in the full spectrum of cosmetic surgery including breast augmentation, liposuction and body contouring, facial rejuvenation, laser surgery, eyelid surgery, and rhinoplasty, as well as reconstructive surgery for skin cancers.

59 Responses to “Everything You Need To Know About Twilight Anesthesia”

  1. Avatar Thiago says:

    Interesting, I’d never heard of twilight anesthesia before, but it does sound like it’s got some distinct advantages over general anesthesia. Honestly, I can’t remember my one and only anesthesia experience. I was pretty much out.

  2. Avatar Lyle says:

    Excellent post. I absolutely appreciate this website.
    Stick with it!

  3. Avatar Ginnie says:

    I had Twilight sleep yesterday during my Blepharoplasty procedure. I think it has great benefits but I did feel a little more pain than I would have liked. I moaned a little and my doctor said, “sorry! Sorry!” But did not put me under any further and did not numb me any more. Time seemed to go quickly. Soft music in the background was pleasant and I found myself humming along in my head. I do remember almost all of the procedure. The positive comments the doctor and staff were making eased my mind and I felt confident in their care. I think I would have liked to have been a little more asleep yet the flip side of it was the immediate wakefulness and no nausea or dizziness. I would choose this route again.

  4. Avatar Maryann says:

    I had a procedure to use a laser to I guess zap a dead vein in my right leg. I was given Twilight. It did absolutely nothing for me. They gave nome maximum but had nor effect at all. I had to bear the pain for one hour which was a nightmare! How could this happen?

    • WD Staff WD Staff says:

      I’m sorry to hear that Maryann, do you know what specific drug was used? Did your provider try an alternate topical form?

      Some individuals do react differently to different forms of anesthesia, sometimes to the point where the form of anesthesia is rendered ineffective.

  5. Avatar joshua says:

    Hi guys yesterday i had done radio frequency done to my lower back i had the twlight sedation and works i didnt feel a thing and woke up in recovery wondering if it was all over. Still in abit of pain but that should ease in the coming weeks

  6. Avatar Jo says:

    Hi I am having an upper and lower eyelift surgery, I have been recommended just having a local anaesthetic, but think with my nerves I will go for twilight……….hope it works!!

    • WD Staff WD Staff says:

      Hi Jo, it may sound startling but depending on the specific procedure local anesthesia can be a good choice. However, being for many people being fully awake during a surgical procedure is unnerving. I would definitely recommend asking your surgeon if you can undergo the procedure using some form of twilight anesthesia. Thank for reading our blog and sharing your story!

  7. Avatar Jacob T. says:

    Twilight anaesthesia can be the best option for those who feel anxiety from local anaesthesia. I know there are some side effects of general anaesthesia & therefor it is not suggested for every surgical procedures. I thanks to you for sharing information about twilight anaesthesia.

  8. Avatar Victoria says:

    I had twilight sedation this morning and it was like being overly drunk, I don’t remember much except at one point I remember great pain and moaned and cried.

    Afterwards I began being coherent and would be upset and cried frequently over small things. I really wanted a frosty and cried to my boyfriend proclaiming I needed one since my throat was dry.
    I think I had fallen asleep during my procedure except for the painful portion I remember which didn’t last long. I have no memory of much, except it’s like a broken dream I can’t put back together.

  9. Avatar Lawes says:

    Thanks a lot, I appreciate it!

  10. Avatar Kendra says:

    next month I am undergoing a surgical procedure and my doctor recommended twilight anesthesia since I was nervous about the out come of the normal anesthesia. I would definitely like to use the twlight instead but I have heard it’s likely to cause you to feel a lot of pain and discomfort during your procedure. How commen is it for a patient to experience this while undergoing twilight anesthesia?

  11. WD Staff WD Staff says:

    Hi Kendra, thanks for reading our post!

    When done correctly, patients who undergo twilight anesthesia should not feel any pain during their procedure. An experienced anesthesiologist will administer an appropriate amount of medicine which is also usually accompanied by a local anesthetic. The combination of both twilight and local anesthesia make it very rare for patients to experience pain.

    I hope that helps and you have a speedy recovery!

    WD Staff

  12. Avatar stan says:

    Excellent post. Very useful information particularly the last part 🙂

  13. Avatar Anderson says:

    Great post!

  14. Avatar Patti says:

    I had upper eyelid surgery 5 days ago. Twilight anesthesia was used. I was anxious but they gave me just a little in my iv and I started to get relaxed, then on to the table and I was out like a light or so I thought. I thought I was sleeping and drempt about riding white horses– very pleasant and did not feel a thing. woke up and put my clothes on and left the office (husband driving). Dont remember a thing even about the drive home though. Dr. assistant told me later that she saw me and I recognized her and was very sweet to her. I don’t remember talking to anyone! I thought I was sleeping. Glad I had that over general or just novocaine. Cant figure out how I could be asleep dreaming about horses and still awake and responsive? that’s weird!

    • WD Staff WD Staff says:

      Hi Patti, glad to hear that your procedure went well! Depending on the type and amount of medication used patients may experience different levels of memory. It’s not uncommon for patients to appear fully responsive during the procedure (i.e. following specific instructions from providers) but later have no memory of the same period.

  15. Avatar Dakota says:

    Im going to have twilight and i am very worried i will feel pain and become loopy (like i cant contoll my thoughts or what i say) im going to have a chin implant please help

    • WD Staff WD Staff says:

      Hi Dakota, many patients feel some apprehensive prior to undergoing twilight anesthesia. So you are definitely not alone!

      I would recommend that you reach out to your provider to discuss the specifics of your procedure: what type of medicine would be used? Who is administering the anesthesia (and what credentials to they have)? Finally, your surgeon should be able to tell you exactly what to expect in terms of feeling.

      You can also read about the experiences of other patients who have undergone twilight (see Patti’s comment for example).

      I hope that helps!

      WD Staff

  16. Avatar Andy says:

    I’m a smoker going in for teeth extraction using twilight..there were not any complications!

  17. Avatar Ellen says:

    I had internal radiation for cervical cancer using versad? and general intravenously. I was spoo anxious that it overrode the drugs. Can I recommend something stronger than versad? The procedure took 3hours of TOTAL anxiety.

    • WD Staff WD Staff says:

      Hi Ellen, We are sorry to hear about your experience. However, we cannot provide any further information or recommendations without actually administering care. We definitely encourage you to discuss these issues freely with your current physicians, they may have alternate methods which may help.

      WD Staff

    • Avatar Ciara says:

      So number one your oncologist should have discussed with you before hand which medication they would be using and fully explained it. Number two, versed is widely used for children. It’s used for sedation/anxiolytic for procedures they want kids to be awake for because it’s safe, easy to reverse & keeps them awake while also sedating them & reducing anxiety. While your radiation is painless it’s no wonder versed easily let your anxiety overload you. Most of all though…you should have been being monitored. Even though the specialist decided to strangely use versed…no matte their choice of anxiolytic and/or sedative they should have been closely monitoring you. This is why you’re given the medication via IV. Both for ease of delivery, quick delivery to your system…but also so they continuously have easy access to both increase/add to your dosage and/or reverse the process if needed. The moment they saw your anxiety taking over they should have given you an additional dose or different medication. They should have discussed your history of anxiety with you and what’s worked in the past. Don’t get me wrong, they can’t always predict how you will react and it’s not always realistic that they can help you achieve a completely anxiety free treatment session. However, knowledge is key. Make sure you fully know your doctor; their experiences, credentials and especially if they have an bias opinions regarding drug therapies. Then you should discuss which drug therapy they plan on using for you, if it’s a mixture-what’s in it & how much they’ll be giving you. Don’t be afraid to ask them what the back up plan is if it doesn’t work & you start having a panic attack. It would be a good idea to find a good therapist as well that help you with some good techniques for reducing anxiety. As corny as that sounds; having panic attacks like this can lead to you wanting to skip treatments and having more severe anxiety attacks during treatment in the future. My suggestion is make sure you’re prepared; be knowledgeable of your specialist, their plan for you, their back up plan & that you fully understand what to expect through the whole process. Have several techniques planned in your head as well of techniques you’re going to do if you do feel anxiety coming on. Sorry for your experience. It sounds like you were left in the dark a little, which can unfortunately cause the worst panic of all. Good luck & remember…you control what’s done to & put into your body! Make sure you’re part of that plan and fully on board!

  18. Avatar FH says:

    Would it be possible to do Thermage, several areas in one session, with twilight sedation? I’m pain intolerant to begin with, and while I know the cooling tip and spray have made it less painful, those aren’t options for me as I have a rare condition called cold urticaria. Contact with cold, even washing my face with cold water, causes me to swell. I’m willing to travel.

    • WD Staff WD Staff says:

      Hi FH,

      With the condition that you reference, cold urticaria, you may not be an ideal candidate for Thermage. However, Ultherapy could work for you. For Ultherapy treatments, we can prescribe an oral medication to help you relax prior to the treatment and would also administer a topical numbing cream. Our patients are generally very comfortable with this combination.

      We hope that helps! Please give us a call if you have any questions.

      WD Staff

      • Avatar FH says:

        Thank you for your response! I’ve heard Ultherapy can be very painful for some people, and my pain tolerance is quite low. Do you offer the option of twilight sedation if doing multiple Ultherapy areas in one session? Also, do you accept patients from outside the area?

        • WD Staff WD Staff says:

          Hi FH, No problem, thanks for reading our post and submitting your original question! We do accept patients from outside areas, please contact us at 512.328.3376 and one of our patient coordinators will be able to discuss further.

          WD Staff

  19. Avatar Shelly says:

    Yesterday I was inquiring about a tummy tuck. I asked what type of anaesthetic this particular office used. They told me that use Twilight. My last experience with Twilight was not good. I had a cardiac ablation done and although I don’t remember anything about it my doctor had to give me full anaesthetic during the procedure because he said I was kicking and moving around too much during the procedure. Because of this the last surgery I had done I asked for full anaesthetic which they obliged me with even though the procedure definitely didn’t call for it.
    Because of the doctor telling me I kicked a lot I’m a little paranoid to have any plastic surgery done without full anaesthetic but I know there’s more risk involved. Still I would almost rather take the risk then to be awake and feel my abdominal region being torn open buy a scalpel. That particular office only does twilight so I was not a candidate for them.
    With my anxiety I just can’t imagine not being fully sedated for a tummy tuck. Is this something plastic surgeons are doing moving forward now?

    • WD Staff WD Staff says:

      Hi Shelly, we’re sorry to hear about your experience with twilight. There are many benefits with twilight in general, so its use is expanding in nearly all areas of surgery.

      However, in your case it sounds like there are some sound benefits in using general anesthesia. We would encourage you to find a different provider who is willing to perform the procedure under general anesthesia. You should discuss (in detail) your previous experiences under twilight and your overall concerns and only move forward with a procedure if you feel comfortable with all variables (including the anesthetic used).

      Thanks for reading our post and sharing your experience with our readers!

      WD Staff

  20. Avatar Kelli says:

    I had twilight anesthesia for my chest tube insertion procedure. I hallucinated for most of the procedure but I started to wake up toward the end when they had some complications. It was an experimental tube and they just couldn’t get it in quite right. They had to take me to radiology so they could take x-rays as they finished the procedure and that’s when the meds really started to wear off. Once in radiology, doctors aren’t allowed to administer any medication so I went through the remainder of the procedure with very little medication. I remember everything and I could feel the tube being pushed through my chest. It’s safe to say it hurt like a b****! However, if I hadn’t come across this complication I think the twilight anesthesia would have done the job just fine. The hallucinations were a little frightening but thankfully it was no where near a scary dream or nightmare. I would recommend this over general anesthesia, despite my painful experience, because it was much less scary than the surgery I had with general anesthesia a few days later.

    • WD Staff WD Staff says:

      Hi Kelli, Thanks for reading our post and submitting your comment. We’re sorry to hear about your experience, but I think your story will be helpful to others while they are in the process of considering twilight vs. general anesthesia.

      Thanks again for reading and submitting your comment!

      WD Staff

  21. Avatar Sarah says:

    I have a surgery on the 6th of July and I’m beyond scared and nervous even for an adult. It’s for the abscess on my tooth and my doctor says I’ll be under twilight anesthesia but reading these comments I want to be fully asleep. Any advice?

    • WD Staff WD Staff says:

      Hi Sarah, I think the best advice we could give you is to contact the surgeon before the date of your surgery to discuss any concerns you may have. It’s always best to talk to your provider to see if this form of anesthesia is best.

      We do have patients who opt for general anesthesia and after discussing the matter we proceed in that direction.

      WD Staff

  22. Avatar Shelby says:

    Hello all. After reading a few posts, I just wanted to share my twillight sleep surgery. I have had two in the last five months to repair my crushed finger and then again to repair my trigger finger. I had twilight anaesthesia both times and it was amazing. I don’t remember anything and I woke up from both almost instantly. My last one I actually sat up and moved myself off the surgery table and told all the surgery staff thank you. All in all, I have had general, but if at all possible, I will only use twilight.

  23. Avatar Judy says:

    I am going to be going for a Tummy Tuck Revision and they are going to be using Twilight sedation. I want to make sure I am asleep and dont feel anything. What questions should I ask as far as the type of medications and sedation they are using to make sure that I do not feel anything or wake up?

    • WD Staff WD Staff says:

      Hi Judy, thanks for reading our post and submitting your question. You’ll definitely want to ask about the surgeons past experiences with patients under the same form of anesthesia. You can ask what specific medications would be used and then do some self-research. Also who will administer the anesthesia (and what training do they have)? Are there any “contingency plans” in the event of something going incorrectly?

      As long as you are seeing a board certified surgeon with experience performing abdominoplasty using twilight sedation you should be fine. However, it’s always good to ask these questions and independently vet the responses.

      Good luck with your procedure and we wish you a speedy recovery!

      WD Staff

  24. Avatar Jeremy says:

    I have had Twilight Sedation twice in the past month (spinal injections). My experience with it was very good. I do not remember any of the procedure from the time I laid down on the table, until in the recovery room.
    I did, however, fail a drug test a couple of days later. I tested positive for Ketamine and Phentanol ol. They insisted that it was not from the procedure. But it had to be, as I am absolutely not a drug user. My advice, make the anesthesiologist give you something beforehand with everything that he us putting into you. One little oversight by some *** can mess up your life, job, insurance, etc…

  25. Avatar Christina says:

    I had twilight sleep once & only once during a wisdom teeth extraction with the help of novicane. It didn’t do anything to ease my pain whatsoever, I felt absolutely everything & was fully conscious. I felt every slit, crush, & extraction that dentist did. At some point because I was screaming so much the dr yelled “give her more drugs!” It put me asleep for a few mins & I woke up tied up, & woke up because I was still feeling everything. General anesthesia only makes you nauseous the 1st time they use it on you & it’s really not that bad. I’ll pay the extra money not to feel anything.

  26. Avatar Victoria says:

    I’m able to have my wisdom teeth pulled (upper ones only) and they told me that all they can do for me is give me this twilight amnesia. I’d prefer to be put to sleep instead because I’m not comfortable knowing what’s going on in my mouth and having teeth pulled…some of you experienced no pain and some of you guys did…I just want to know if that’s just you guys or am I not gonna feel anything either. This is my first time getting teeth pulled and first time using twilight.

  27. Avatar Cheryl says:

    I have had twilight sedation several times and it was great. Don’t remember anything and then just woke up feeling rested. But This time I’ll be having it for a blepharoplasty and i”m scared. My Doctor said they will wake me up toward the end so that I can respond to commands that will enable him to measure correctly. He said I will feel the pinch of the sutures. I’m less concerned about the pain and more about the anxiety. I don’t do well in these situations. I’m afraid I’ll get so anxious I won’t stay still. He said if that happens they give you more anesthesia. I need clarification of what it means when he says “wake me up”. Does that mean make me coherent so I can answer but still retain the relaxation of whatever drugs they administer? Help!

    • WD Staff WD Staff says:

      Hi Cheryl, Thanks for reading our post and for submitting your great question! You are correct, it sounds like your surgeon will elevate your level of consciousness to a point where you can follow specific commands (which often helps the surgeon complete the procedure and provide better results). When done correctly, twilight sedation allows for the patient to be reactive, while still remaining relaxed and blocking pain. More than likely you will actually not remember the interactions in question at all after your procedure is done!

      We definitely encourage you to speak with your surgeon more about these concerns, they will be able to advise you fully on the process which will hopefully give you even great peace of mind!

      Thanks again for reading!

      WD Staff

  28. Avatar DH says:

    Is there a known reason why twilight anesthesia doesn’t work on some people? I’ve had three foot surgeries over the past two years (two Achilles repairs and one for a torn ligament and dislocated bone), and twilight anesthesia wouldn’t work on me for any of them. They ended up using general anesthesia for the last two. For the first surgery, I was vaguely aware of what was going on the whole time and I fully woke up 3/4 of the way through (luckily, they used a nerve block behind my knee to numb my leg, so I couldn’t feel any pain). They asked me if I wanted to go back to sleep or if I was okay. I said I was fine and talked to the anesthesiologist about travel for the rest of the surgery. They ended up putting me out with general anesthesia for the last two when it became clear that the twilight anesthesia wasn’t effective (I was having a conversation with a nurse about books…they kept asking me if I felt sleepy yet, and I never did).
    I’m a very healthy, active person in my early 30’s. I’m usually pretty resistant to a lot of medication though for some reason. Why does this happen to some people and not others?

    • WD Staff WD Staff says:

      Hi DH,

      Thanks for reading our post and submitting your great comment. I’m sorry to hear about your experiences. While its not common, there are reports of ineffectiveness in some individuals. There are certain medical issues which might make it less effective for some individuals but it sounds like you did not have any previous “red flags” (otherwise your anesthesiologist would have just recommended shying away from twilight). But it is possible for some individuals to be resistant to twilight, and instead require general anesthesia.

      WD Staff

  29. Avatar Julie says:

    7 days ago I had Outpatient foot surgery with the Twilight sedation. I ended up being admitted and had to stay in the hospital for 2 1/2 days for severe Nausea and Vomiting. I was given 3 different nausea medications via I.V.’s. Nothing was working. I couldn’t even take a sip of water and keep it down. I have had surgeries in the past but with General Anesthesia and never had a problem. So I’m wondering what went wrong with this Twilight anesthesia? I am 52 years old, don’t smoke, don’t drink, Vegetarian and not over weight.

  30. Avatar Hilary says:

    I had twilight sedation for a bone marrow biopsy earlier this month and it had no effect on me, even though I’ve had success with it in the past for kidney biopsy. The experience was very stressful and I feel confused about it and anxious about needing future procedures and having the same experience. You’ve answered similar comments stating simply that some people are resistant to it- can you go into why that is, physiologically? I would really like to know more and I imagine I’m not alone.

  31. Avatar Kathryn says:

    Wow! Last time I had heard about Twilight Anesthesia was when I was a young labor and delivery nurse. Patients could be found standing in the sinks or on the beds, confused, crying. You name it. Once again I hear that my Gyn was using it ON ME this morning for an outpatient procedure that was too painful to be done in the office. YIKES! Thankfully, I came across this site. I honestly can’t remember being awake at all. Guess they got it right. But I must say, I despised it’s use in the 70’s!

  32. Avatar Anna says:

    TIVA (Total IV Anesthsia) is the best…with Propapol drip. As most, I also could never tolerate the nausea, vomiting and dizziness that follows a General inhalation Anesthsia. After much research, and questioning what are the alternatives, I felt armed and ready to present my preferance for TIVA to my surgeon. My reasons were and are valid, to avoid organ tissue saturation of inhalation gas chemicals. Fortunatly, I had a surgeon who listened to my concerns. Why more doctors aren’t using this makes no sense….one argument I learned, is traditional Gas inhalation Anesthesia is less expensive. I say, sorry my internal organs are worth any added expense. A family doctor friend years ago said, to question what does not feel right. Ask, ask and expect an intelligent answer not just a non answer. And if necessary, ask the question, “would you settle for that for your family loved one?” I actually asked that of a doctor….and shortly thereafter, fired him. That’s right, I said, “fired.” We hire doctors to give us medical service. We hire a mechanic to fix our cars, contracture to repair our homes….and fire them, if they do not keep our best interest priority and do their very best for us.

  33. Avatar layla says:

    Very helpful post, great job!

  34. Avatar Krise says:

    Great information, this was even more helpful than my doctors explanation!

  35. Avatar Kate says:

    Can a patient have twilight anesthesia for Liposuction on hips and thighs and was recently diagnosed with early Parkinson’s which is under control with medication and 71 years old and in good health with no blood pressure problems?

    • WD Staff WD Staff says:

      Hi Kate,

      Thanks for the great question. As always, we recommend seeing a board certified plastic surgeon for an in-person assessment and discussion on options based on your health history.

      I spoke with Dr. Craven and he indicated that he would probably do the procedure just using local anesthesia (not twilight anesthesia). However the surgery should only be performed if there is a clear benefit.

      We hope that helps!

      WD Staff

  36. Avatar Airelavameadiabilgar says:

    I had an Endoscopy yesterday and it was horrible It was with Twilight sedation and I felt every horrible minute of it. I slept for two days after the procedure and could not eat for for three days due to swollen lips and pain in my stomach and esophagus. I also have pain my joints and back. All I can say for Twilight Sedation is NEVER AGAIN!!!!!!!

  37. Avatar Ann says:

    Am going to have a colonoscopy the 17 of Dec. They say I will be under twilight, I’m really nervous, any suggestions?

  38. Avatar MarthaPap says:

    I recently had a mini-facelift under twilight anesthesia and local numbing. It worked really well. I was still awake but did not feel a thing. Exactly what I was hoping for as I was scared to go under general anesthesia.

  39. Avatar Kristin says:

    Very good facts. Appreciate it!

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