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.