Anesthesia Options for Rhinoplasty
Rhinoplasty can be performed under various depths of anesthesia including local anesthesia, intravenous sedation (also called twilight anesthesia, MAC anesthesia, or IV sedation), and general anesthesia. Each option has advantages and disadvantages, including variations in cost, awareness, safety, and side effects. Because rhinoplasty is considered to be an elective, non-emergent procedure, pre-operative testing is sometimes performed to determine anesthetic suitability. However, the vast majority of rhinoplasty patients enjoy good overall health and can choose from any of the aforementioned anesthetic options. Regardless of the anesthetic option, all rhinoplasty anesthesia is performed in conjunction with local anesthesia (lidocaine mixed with epinephrine) to numb the nose and to reduce bleeding. Few surgeons use local anesthesia alone due to the anxiety and discomfort associated with injecting and operating upon a fully awake patient.
Although many surgeons prefer intravenous sedation for rhinoplasty, in my opinion, this is not the best anesthetic approach for optimal safety, effectiveness, and comfort. Twilight anesthesia relies upon the skillful dosing of powerful anesthetics through an intravenous catheter. Often performed by nurse anesthetists outside the hospital setting, IV sedation must render the patient unconscious and motionless without suppressing respiration (breathing). Although some experienced anesthetists or anesthesiologists are very skilled at achieving just the right dose of anesthetic, in many instances the patient is not rendered fully unconscious, and sudden movements or even a disoriented and combative patient may disrupt the operation. Alternatively, if too much anesthetic is administered, the patient stops breathing. Additionally, bleeding occurs in all rhinoplasty procedures; with the airway unprotected by a breathing tube, blood can be aspirated (inhaled) into the lung, leading to complications. In lengthy surgeries, IV sedation becomes more challenging as sore muscles or a full bladder create an increasingly restless patient. Although less expensive than general anesthesia, I believe the risks, discomfort, and effectiveness of IV sedation make it inferior to general anesthesia.
While many people feel that general anesthesia is more dangerous than IV sedation, I have found the opposite to be true. Because rhinoplasty is comparatively non-invasive relative to abdominal, thoracic, or other types of surgery, the patient only requires enough anesthetic to render them fully unconscious, and therefore both comfortable and motionless throughout the procedure. Longer cases are far better tolerated and the airway is protected from aspiration by the presence of a breathing tube. While a mild sore throat sometimes occurs following rhinoplasty, this is usually from the operation itself rather than from insertion of the breathing tube. Since the dose of anesthetic is comparable to that of IV sedation, aftereffects are generally mild and short-lived, and because painful stimuli are minimized by injecting the nose with lidocaine prior to the incision, narcotics can be avoided, making post-operative nausea or vomiting equally uncommon. Additionally, because respiration is maintained by a ventilator, the depth of anesthesia can be adjusted to keep blood pressure low and thereby minimize bruising, swelling, and bleeding. A motionless and comfortable patient with minimal bleeding translates into far better operating conditions and more favorable surgical outcomes.
Perhaps the biggest reason cited against the use of general anesthesia is fear of post-operative nausea and vomiting. While post-operative vomiting is not only unpleasant, following rhinoplasty, vomiting may dramatically elevate blood pressure levels leading to much heavier facial bruising, swelling, and discomfort. In turn, the surge in inflammation resulting from additional tissue distortion can adversely affect the cosmetic outcome. Although post-operative vomiting cannot be eliminated in all patients, the use of narcotic-free general anesthesia dramatically reduces the incidence of post-operative vomiting. By combining narcotic-free general anesthesia with other medications that suppress nausea, the incidence of clinically significant vomiting after rhinoplasty has almost been eliminated. Surprisingly, the absence of narcotics does not appear to compromise effective pain control as most patients are off pain relievers within 24 hours of surgery. However, in most cases, the reduction in post-operative pain is a consequence of good intra-operative anesthesia care resulting in less tissue trauma.
At the time of this writing, all of my patients receive general anesthesia in the hospital setting by a board-certified anesthesiologist. Based upon the feedback I have received from revision rhinoplasty patients who previously underwent rhinoplasty with either local or intravenous anesthesia, a properly administered general anesthetic is considerably more comfortable with far fewer side effects. In addition, the technical benefits of general anesthesia, such as less bleeding, less patient movement, and less distortion from injected local anesthetic, all translate into better cosmetic outcomes for the patient with fewer anesthesia-related risks or side effects. For that reason, all of my nasal surgery is performed exclusively under general anesthesia by an experienced MD anesthesiologist.