Article Written by Tom Einstein, M.D.

Dr. Einstein is the Head of Anesthesia at the Clavin Center of Cosmetic Plastic Surgery

Welcome to Cosmetic Surgery, Rhinoplasty, Nose Surgery

Anesthesia For Rhinoplasty

           

Rhinoplasty can be done without intubation. The surgeon and the Anesthesiologist work as a team to provide the best possible patient experience.

Anesthesia for Rhinoplasty is a combination of intravenous propofol given by the Anesthesiologist together with local anesthesia injected in and around the nose by the surgeon. The intravenous use of propofol for anesthesia is sometimes called total intravenous anesthesia or TIVA.

Propofol is a gentle, safe, non-opiate medication with rapid smooth action, and quick offset. It is exceedingly unlikely to cause any allergic reaction, and does not cause nausea. In the proper hands, it is easily controlled, and can be used for mild sedation to general anesthesia. It can be used for very short operations, lasting a few minutes, to long procedures lasting many hours.

For cosmetic nose surgery without intubation, the patient is fully monitored for respiratory, heart and cognitive function. The TIVA with propofol is continuously adjusted with the aid of a computerized pump. Initially, enough medication is given to eliminate the discomfort of the local anesthesia injections. The local anesthetic also includes a vasooconstrictor,epinephrine, to eliminate bleeding during the operation. The local anesthetic used is long acting, and the pain relief lasts long after the rhinoplasty is completed. As soon as the nose is numb, the propofol dose is decreased to the minimum required to keep the patient asleep. Since the nose is completely numb, the dose of propofol is usually quite small at this point. The patient continues to breathe naturally, remaining asleep and unaware until the end of the Rhinoplasty procedure. Patients wake up shortly after the TIVA is stopped, and are fully alert, ready to eat drink and ambulate minutes after nose surgery is done. A combination of oral and intravenous anti-inflammatory medications are given before, during and after surgery resulting in minimal swelling and pain after surgery.

General anesthesia with intubation typically involves the use of propofol together with paralyzing drugs and inhaled anesthetic gases. A tube is placed through the mouth into the windpipe. In medical terms, this is called oral endotracheal intubation. The patient depends on the anesthesiologist to help with breathing using a manual and/or powered ventilator for most if not all of the duration of the surgery. Since the patient doesn't move (paralyzing medications are used), the nose does not have to be as thoroughly numbed as in the TIVA technique. There is more likely to be bleeding, and gauze packing is frequently used in the nose and throat. When blood is swallowed patients are also more likely to wake up nauseated. Before patients wake up, they are often given medications to reverse the paralyzing drugs. These medications and intravenous opioid narcotics, and inhaled gases and contribute to a significant incidence of post operative nausea and vomiting. Even in experienced and gentle hands, many patients complain of sore throat, and less frequently, hoarseness and vocal irritation.

TIVA and local anesthesia for rhinoplasty require the Anesthesiologist and the surgeon to work together as a team. The Anesthesiologist needs to monitor the patient closely, both visually and electronically. The surgeon needs to thoroughly and carefully numb the nose with the appropriate propofol dose adjusted constantly by the Anesthesiologist. Once the nose is completely numbed, a few minutes are required for the anesthetic and vasoconstrictor (epinephrine) effect to fully work. At this point the rhinoplasty can proceed with total sedation and minimal medication until the surgery is completed.