General Anesthesia Vs. Local Anesthesia in Rhinoplasty

A common concern of patients is which the “best” anesthesia for nose surgery is.

Types of anesthesia

The types of anesthesia that can be used in rhinoplasty are basically 3:

  • Local exclusively
  • Local + deep sedation
  • Local + general anesthesia

Each anesthetic method has its pros and cons.

About local anesthesia

The disadvantages of exclusive local anesthesia are:

  • Pain at the time of anesthetic infiltration
  • Risk of arrhythmias or cardioactive reflexes during infiltration and/or during surgery
  • Pain in some maneuvers (especially in osteotomies)
  • Patient discomfort and intraoperative stress from being awake, listening, and feeling the surgical steps, although there is no pain.
  • Limited time duration, requiring increasing the speed of the procedure, which can lead to leaving unresolved imperfections, compromising the final result.
  • Discomfort for the surgeon

Advantages of exclusive local anesthesia:

  • More economical
  • discharge in one hour (general anesthesia or sedation requires control of at least 3 hours after surgery)

It is false that local anesthesia is without risk. Drugs used in local anesthesia can cause cardiac arrhythmias, as well as stress for the awake patient. We do not recommend the use of exclusive local anesthesia for rhinoplasty procedures, except for a minor touch-up that does not last for more than 30 or 40 minutes.

Local anesthesia with sedation is an alternative to general anesthesia that leaves the patient half asleep but breathing spontaneously through the mouth, generally with oxygen-enriched air.

About general anesthesia

General anesthesia implies that the patient is completely asleep, and control of breathing is the responsibility of the anesthesiologist.

General anesthesia is now used for rhinoplasty surgery in the vast majority of major centers worldwide for several reasons:

  • More peace of mind for the patient and for the surgeon
  • The intervention can be prolonged as long as necessary until the desired changes in the nose are achieved without the "rush" that exists with local anesthesia.
  • The patient's breathing is more assured than with sedation and blood entry into the tracheobronchial tree is prevented. It also prevents the possibility of aspiration of gastric contents.
  • Lower overall risk.

What do we recommend?

In all cases (even with exclusive local anesthesia), it is recommended to perform the procedure in a sanitary operating room and not do it in the office.

Our preference is the use of general anesthesia for the advantages expressed above. Currently, with advances in anesthesiology, it is achieved that the patient is very comfortable in the immediate post-operative period and can withdraw from discharge from the sanatorium in approximately 4 to 6 hours after the intervention in perfect condition.

The use of local anesthesia + deep sedation is an anesthetic alternative that must be used by a well-trained anesthesiologist specialized in this type of technique.

Open Rhinoplasty Vs. Closed Rhinoplasty

Advantages of open rhinoplasty

The advantages of open rhinoplasty are as follows:

Allows better control of the final result

Allows for more appropriate tip treatment

The tip can be strengthened in a more predictable way.

A caveat must be made regarding the technique called Delivery. This is an approach that is similar to the open approach but without making the columellar incision. This variant is used by some surgeons to avoid skin incision. We continue to see the Delivery technique as difficult to deal with symmetry.

Disadvantages of open rhinoplasty

The most important disadvantage of an open rhinoplasty is that the knowledge of the surgical technique by the surgeon requires more training than that required by the closed technique. This forces the surgeon to specialize specifically in this type of surgery.

The control of the tip in open surgery is greater. Some patients state that they have no need to make any changes to the nasal tip because their problem is only on the back (and not the tip).

It is important to clarify that the modifications on the back directly affect the tip. Therefore it is false to believe that if we focus on modifying the nasal dorsum only by closed rhinoplasty and we do not pay attention to the tip, it will not be modified. In most cases, the nasal tip requires some “stabilization,” if not more, to maintain the original position. This stability can be granted through the use of a columellar stem (autologous cartilaginous support, obtained from the nasal septum itself). Therefore, the control of the position, shape, and strength of the nasal tip is basic when facing a rhinoplasty.

The columellar incision is a small 4-mm cut made in the region of the skin called the columella (middle spine of the nose). This incision rarely leaves any noticeable scar, and in the event that such a situation occurs, it can be resolved with a minor surgical retouch.

Tip edema is another event that occurs more frequently after open rhinoplasty than after closed rhinoplasty. The immediate consequence is that the nasal tip looks more rounded. As time passes, this edema resolves, and the surgical result becomes more evident. After 3-6 months, the edema is completely reabsorbed. Likewise, whatever the rhinoplasty technique used, the nose subtly modifies its shape for one or two years after surgery.

Our conclusion

In conclusion, open rhinoplasty offers the surgeon the advantage of being able to provide the patient with a more precise solution both in a complex nose and in a simple hump or crooked nose.…

Post Rhinoplasty Patient Instructions

The following are the instructions the patient receives after nose surgery:

1) Rest for the first ten days—no need to be in bed.

2) Nasal bleeding: it is normal and expected during the first 72 hours. Change the collecting gauze (the one located below the nose) as many times as necessary to maintain hygiene and avoid staining. When the bleeding and secretions stop, you may run out of collecting gauze.

3) Do not blow your nose for the first 15 days because it could cause nosebleeds. Instead, you can breathe in deeply through your nose safely.

4) Plugging: In most cases, we do not use nasal plugging. Inside the nose, two sheets of cellulose (radiographic plate material) are placed to help prevent bruising and internal synechiae. These plates are removed between 2 and 14 days, depending on each case. Likewise, during the first ten days, the nose is quite obstructed by post-operative inflammation, crusts, and discharge (feels similar to a cold). The obstruction gradually subsides. Only after 30 days can the nose be considered completely unobstructed. Edema and bruising increase and peak at 72 hours. 90% is resolved after ten days. The swelling will be more pronounced during the morning hours. Sometimes the whole face swells up to the upper lip and jaw, and it is normal.

5)

To help the reabsorption of bruises and local edema you can use: Local cold under the eyes and between the eyebrows with ice wrapped in compresses (not directly). Use time: The first three days. Therefore it is not recommended.

Chamomile tea: It is known for its local anti-inflammatory effect. It is useful for the first ten days. How to use: Boil a pot with water and prepare the tea with chamomile sachets or with the chamomile flower that is available in herbalists (preferably). Then let stand for a few minutes and add ice to the solution. Apply the embedded cloths to the inflamed region for 30 minutes every 3 hours.

Raising the head of the bed: slightly improves post-operative swelling, but it is not strictly necessary. A splint is placed on the nose in most cases, and it stays for a time between 6 and 15 days. Underneath the splint is adhesive tapes that help contain swelling and reduce edema. After removing the tapes, the skin will be more seborrheic, and it can be cleaned with neutral soap once or twice and use moisturizing and/or keratolytic creams.