When deciding on rhinoplasty, anesthesia is a major concern for most people. Although techniques and safety profiles of anesthesia have advanced significantly over the decades, it still carries a small risk. Almost all major complications associated with facial cosmetic surgery are due to anesthesia-relate issues. The facial cosmetic procedure itself only rarely is the reason for a major complication. Therefore, when selecting the right anesthesia for your rhinoplasty, safety should be the number one concern for you as well as your surgeon. Interestingly, there are various anesthesia options available and you should discuss with your surgeon these different anesthesia techniques. The anesthesia is closely linked to the setting where the rhinoplasty will be performed: doctor’s office, surgical suite or hospital. These various procedure settings also determine patient privacy in comfort.

Below, we discuss the various anesthesia options, their usual settings, advantages and disadvantages of each. The financial aspect should not guide one towards choosing one anesthesia technique over the other.

General Anesthesia for Rhinoplasty Surgery

General anesthesia means that the patient is entirely asleep and not aware of any surroundings. The patient is intubated, which means that a tube is placed in one’s windpipe (trachea) which is connected to a respirator machine. Thereby, all control of breathing function is taken over by this breathing machine and the anesthesiologist who monitors the patient’s vital signs: heart rate, electrocardiogram (ECG), blood oxygen saturation, blood pressure etc. The experienced anesthesiologist uses all these data to decide which inhalation gases and intravenous medications to administer to the patient. Although a definitive study comparing general anesthesia with other modes for rhinoplasty is lacking, many patients alike shy away from general anesthesia and less invasive options instead. The surgeon’s philosophy training, experience and comfort play an important role in his anesthesia preferences but it is fair to say, that most surgeons use general anesthesia for nasal surgery. One of the commonly stated advantages is total patient comfort and protection of the airway in case of bleeding. Bleeding may be more in general anesthesia because inhalation medications can widen blood vessels which increases blood flow to the nose.

Facility: Hospital, free-standing and accredited surgical centers. Some doctors own surgical centers that are accredited for general anesthesia.

Advantages: painless procedure, no memory of the procedure, monitoring of body systems by anesthesiologist, protection of airway by breathing tube.

Disadvantages: most invasive choice of anesthesia; inability to communicate with patient; frequent post-operative nausea and vomiting are side effects of general anesthesia; lung complications possible; prolonged wake-up phase from anesthesia itself – sometimes long hang-over effect; possibly increased blood loss during rhinoplasty surgery; increase in procedure time.

Price: $$$; the operating room and the anesthesiologist often charge separate fees.

Conscious Sedation (“Twilight Anesthesia”) for Rhinoplasty

In twilight anesthesia, the patient is comfortable, does not experience pain and is unaware of its surroundings. Different from general anesthesia, the patient is still breathing spontaneously without a breathing tube inserted. Usually, additional oxygen is delivered through small plastic tubing placed at the lips. The surgeon anesthetizes the nose with local anesthetic solution rendering it entirely numb. The anesthetist follows the patient’s vital signs and delivers the medications through an intravenous. Most of these medications are very short-lived which requires a watchful and experienced anesthetist to ensure enough but not too much relaxing and narcotic medications are administered. Once the medication drip is turned off, the patient regains full consciousness within a couple of minutes ensuring a smooth awakening without coughing and retching. This anesthesia technique requires an anesthesiologist experienced with conscious sedation, a skill usually mastered by specialists working in day-surgery centers. Twilight anesthesia appears to gain popularity with the modern patient and surgeon alike. The concerns with conscious sedation for rhinoplasty are two-fold: First, the patient may be too light and therefore uncomfortable during the rhinoplasty and second, the patient may be too deep and then not able to prevent blood dripping into the windpipe – a reflex present when we are awake. Rhinoplasty surgeons differ in the extent of sedation, some like it rather deep, others prefer a lighter version. Discuss with your nasal specialty surgeon, which anesthesia he prefers and why. Ask, what problems or complications he has encountered in the past and how these issues where dealt with.

Facility: Hospital, free-standing and accredited surgical center.

Advantages: No airway intubation; post-operative nausea and vomiting are rare, quick wake-up; possibly decrease in blood loss during rhinoplasty.

Disadvantages: Requires anesthetist who is experienced with conscious sedation for rhinoplasty; possibly inhibition of airway protection which may lead to lung problems (aspiration).

Price: $$$; the operating room and the anesthesiologist often charge separate fees.

Local Anesthesia with Pre-Medication for Rhinoplasty

In the past, this technique was favored by most busy rhinoplasty surgeons who performed thousands of rhinoplasties this way. Local anesthesia is comparable with the experience at the dentist office. The outer and inner aspects of the nose are anesthetized with topical anesthesia and a mixture of lidocaine and epinephrine; a process that is moderately painful. Once the lidocaine solution is injected into the nose, the region is entirely numb and the procedure can be performed painlessly. Because epinephrine constricts blood vessels and no vessel-dilating anesthesia medications are given, there is usually only minimal oozing. Because one is usually apprehensive before the rhinoplasty procedure, most doctors administer relaxing medications (i.e. Valium or similar) before the procedure, either by mouth or as an injection. Because surgical training happens in hospitals and major operating rooms, most doctors are not comfortable with this local anesthesia technique for nasal surgery but prefer that the patient is entirely asleep. Although basic vital signs are usually monitored during the procedure, the patient is either comfortably awake or snoozing.

Facility: Surgeon’s procedure room, free-standing surgical center.

Advantages: Minimal administration of drugs; no post-operative nausea and vomiting; no recovery from anesthesia; decreased blood loss; faster recovery; decrease in procedure time.

Disadvantages: Requires rhinoplasty surgeons comfortable with this technique; patient will feel lidocaine needle sticks; excluded for major rhinoplasty revision surgery due to prolonged surgery time.

Price: $; fee for procedure room.

What is the Right Anesthesia for your Rhinoplasty?

You should have a thorough discussion with your surgeon about anesthesia options, the doctor’s experience and recommendations. Then, decide whether this is what you are looking for. Again, there is not one right anesthesia technique. The decision should be made between you and your doctor depending on the operative plan. How long does your surgeon need for the rhinoplasty procedure? Are ancillary procedures planed (i.e. chin implantation, neck liposuction etc.)? What facilities are available?

Once all questions are answered and a good plan has been formulated, you will hopefully have a pleasant rhinoplasty experience.

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