How is bleeding controlled during rhinoplasty?

Bleeding the enemy of the surgeon during a rhinoplasty.  I take steps before going to surgery to prevent bleeding.  I have a list of medications and foods I have all of my patients stop taking 2 weeks before surgery.  Before going back to surgery, I have patients ice their nose to slow the blood flow to the nose.  

 

In surgery, the throat is packed with gauze to prevent blood from running down into the stomach or in the trachea.  At the end of the case, the stomach and throat is suctioned cleaned to remove any blood that may be in that location.

 

During surgery, the nose is injected with medication to prevent bleeding and I keep the blood pressure low during the surgery.  With these maneuvers  I typically have very little bleeding during a rhinoplasty in my office in Charlotte.  

The answer to this question really depends on what type of anesthesia that is used to perform your rhinoplasty.  I typically use general anesthesia and we place a packing in your mouth and throat to prevent you from swallowing any blood.   We also pass a tube into your stomach while your asleep to remove any additional blood.  If you are not having general anesthesia, the packing is not used although the tube in the stomach may be passed depending upon your surgeon and anesthesiologist.

Other than that bleeding is controlled as it would be in any other surgery through cauterization and use of medicines that cause the blood vessels to clamp down preventing blood from leaking. 


Best of luck with your surgery.

Good question which patients rarely ask. The nose is very vascular, which means there are many blood vessels. Therefore it is important to control this blood flow prior to any surgery so the surgeon can see what he/she is doing. The first thing we do is decongestant the nasal membranes, which shrinks the blood vessels in the mucosa and decreases blood flow. Then we inject the nose with local anesthesia which contains  epinephrine, which contracts all the blood vessels and reduces bleeding to a minimum. Once this takes effect we can make incisions and perform the alterations needed to change the shape of the nose. Bleeding is therefore minimal, and rarely an issue. After surgery the medications wear off, and a slow oozing for the first 1-2 days is normal.

Most of the control of bleeding occurs before the surgery even starts. It involves placing a decongestant throughout the nose to shrink the blood vessels and decrease any inflammation in the nose. Once this is done, I then inject Lidocaine with epinephrine which provides anesthesia to the area in addition to further decreasing the size of the blood vessels.  Doing this in a very systematic manner will decrease the overall bleeding during the surgery. Additionally, meticulously dissecting the tissues also greatly minimizes bleeding. 

In our surgery center, rhinoplasty is performed under general anesthesia with total protection of the airway so that patients do not have aspiration of blood into their lungs.  Once the patients are placed under general anesthesia, an injection of Lidocaine with epinephrine is placed inside the nose, numbing both the nasal bones, the septum, and the turbinates.  In addition to that, Afrin is given to the patients to help shrink the membranes and decrease the bleeding.  Both of these drugs decrease bleeding in the nose during the procedure.

Usually, most of the bleeding is controlled through the injection of medications, just prior to surgery, that shrink the blood vessels. If this is done appropriately, bleeding will be minimal. Some suction and packing is used. Usually, under general anesthesia, a cuffed endo tracheal tube is used so that fluid does not enter the lungs. Even then, aspiration is a real risk. If the patient is just under sedation, he/she swallows most of the liquid trickling into the back of the throat.

 

These are all good questions and should certainly be discussed with your plastic surgeon at the time of your consultation.  Bleeding is obviously a risk in all surgery and this includes nasal surgery.  The degree of risk is related to how extensive the procedure is and the techniques used in performing the operation.  Suction is certainly necessary to allow for clear visualization of the nasal structure and an electrocautery is used to control bleeding.  The nose is also injected prior to surgery with a lidocaine / epinephrine solution to make the blood vessels shrink down in size.  The procedure is done under general anesthesia and a protected airway is vital to prevent any blood from being aspirated into the lungs.  If you are having only a cosmetic rhinoplasty post operative bleeding is unusual.  If you also require a septoplasty there are many methods used to prevent bleeding including internal suturing and the use of nasal packing.  Modern nasal packing is much different than what was used years ago and sometimes it is left in for only a day or two.  In many cases it is not necessary to use packing at all.  This generally makes the patient more comfortable since you can breath through your nose.   If a turbinectomy is performed for nasal airway obstruction then packing is usually necessary since this tissue is very vascular and can bleed without the compression from the packing.  We try not to let blood drip down the back of your throat after surgery since this can cause nausea and vomiting.  I hope that this answers your question.  

good questions. The first and most important method is injection of the nose with a vasoconstricting agent, usually lidocaine with epinephrine. This causes the vessels to constrict and limit bleeding. The second is proper incisions and dissection. Performing rhinoplasty in the correct tissue plane is an almost bloodless procedure. Suction is used. If a patient has general anesthesia I will also place a throat pack while they are asleep to prevent any blood from going into their stomach. It is removed before they awaken. Occasionally some cautery is required. Afterwards the split provides compression.

Aspiration is typically not a risk because it is something that a rhinoplasty surgeon carefully controls. The first step is to prevent bleeding from occurring. This is achieved by proper injection of local anesthetic containing epinephrine which minimizes bleeding. The second step is to operate in the proper tissue planes which are typically bloodless. The final step is to use careful cautery to stop any bleeding that does occur. We also typically place small cotton pads in the nose to soak up any bleeding before it reaches your airway. Rhinoplasty is very safe in experienced hands.Stephen Weber MD, FACS

Hi

First off I agree with Dr. Papel that the bleeding is usually minimal but only in good surgical hands with good meticulous technique.  Sloppy surgical technique creates significant bleeding.  Use of local anesthetic with epinephrine as well as decongestants like Afrin or Cocaine create constriction of the blood vessels which minimize bleeding.  The patient's blood pressure is also usually kept low during General Anesthesia if safe with a systolic pressure of about 90 which also minimizes bleeding.  Ultimately good surgical dissection in the proper area of the nose minimizes bleeding.  This is something that good surgeons will know how to do well and poor ones will not.  Use of cautery is kept as a last resort to minimize scar tissue formation.  With all this, some patients will and do bleed more than others.  We also check labs before hand to make sure the patient does not have a bleeding disorder.