To analyze the clinical value of propofol and fentanyl combined anesthesia in facial plastic and cosmetic surgery. Methods A total of 72 patients undergoing facial plastic and cosmetic surgery in our hospital from January 2022 to November 2023 were selected and divided into control group and observation group by random number table method, with 36 patients in each group. The control group was anesthetized with propofol during the operation, and the observation group was anesthetized with propofol and fentanyl during the operation. The related anesthesia quality indicators, adverse reactions of anesthesia and postoperative pain were compared between the two groups. Results The anesthesia induction time, spontaneous breathing recovery time, orientation recovery time and tracheal catheter removal time in the observation group were shorter than those in the control group, and the dosage of propofol was less than that in the control group (P <0.05). The incidence of anesthesia adverse reactions in the observation group was 2.78%, compared with 5.56% in the control group, the difference was not statistically significant (P >0.05). The VSA pain scores at 30 min, 60 min, 2 h and 6 h after operation in the observation group were lower than those in the control group (P <0.05). Conclusion In facial plastic and cosmetic surgery, propofol+fentanyl combined anesthesia can effectively improve the quality of anesthesia, accelerate the postoperative recovery of patients, and has good safety.