Wide Awake Facial Reconstruction: A Literature Review, Cost Analysis, and Practical Guide.

Background: General anesthesia (GA) has been the standard for complex facial reconstructive surgery but is associated with perioperative risks and increased resource consumption. Wide awake facial reconstruction (WAFR), performed under local anesthesia (LA)/regional anesthesia (RA), offers an alternative that avoids these limitations. Nonetheless, WAFR remains underreported, and best practices are not well established. Methods: A literature review was conducted to identify studies involving WAFR, from which data were analyzed. Additionally, the costs of performing forehead flap reconstruction using LA/RA were compared with those under GA. Finally, a practical guide was developed to highlight key strategies for optimizing patient comfort. Results: Thirty studies involving 1249 patients and 1262 flaps were included. Forehead (n = 443, 35.1%) and nasolabial (n = 387, 30.7%) flaps were the most frequently implemented. Minor (n = 126, 10.0%) and major (n = 34, 2.7%) complications were uncommon. Most patients expressed minimal to no pain during surgery and were consistently satisfied with their experience. No conversions to GA were required. The total cost of performing a forehead flap using WAFR is considerably lower when compared with GA ($1280.03 versus $6646.74; difference: $5366.71). Conclusions: WAFR is a safe, well-tolerated and effective alternative to facial reconstruction under GA. Advanced procedures, such as loco-regional flaps, can be successfully performed under LA/RA. This approach also improves access to revision surgery, a key factor in achieving the best possible final outcomes. The avoidance of GA significantly reduces healthcare costs. Further research is needed to incorporate patient-reported outcomes and expand the role of WAFR across diverse techniques.