I Want my Nose Shaped Without General Anaesthetic. What is Conscious Sedation with Noseplasty?

The best option for anesthesia for rhinoplasty is indeed General Anesthesia with intubation to help against any blood or secretions going down the throat into the lungs (called aspiration).

Conscious sedation can be tricky as it does not protect your wind pipe and you can swallow and/or aspirate some blood. That can lead to pneumonia. There are a handful of surgeons who can do the rhinoplasty without much bleeding at all and they use conscious sedation. If you want that you must look for a rhinoplasty surgeon who does it routinely under conscious sedation.

Local anesthesia is the third option. You can be awake and the nose can be packed in the back during surgery to avoid any aspiration. It is not a good option for people who are not very healthy or are more anxious than average. The sound of a hammer doing osteotomies can be anxiety provoking.

Regards

Dr. J

Disclaimer: This answer is not intended to give a medical opinion and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case. 

Rhinoplasty with conscious sedation is possible depending what is being done to the nose and how safe it is. Without protection of the airway you will have greater risk. If it is a minimal rhinoplasty it can be done under local anesthesia.

Generally the appropriateness of general anesthesia is dictated by the extensiveness of your surgery and what procedures you will have done.  That being said, there are surgeons that feel completely comfortable performing even complex revision surgeries completely under local anesthesia.  I wouldn't recommend trying to force a surgeon who recommends general anesthesia for you to perform the surgery without it, but as you mentioned, seek a clinic/surgeon that is comfortable with this method instead.  

The debate of whether general anaesthesia or conscious sedation is more appropriate for rhinoplasty essentially hinges on the training and experience of the surgeon and the experience and training of the specialist anaesthetist administering the conscious sedation medication. I emphasise that this is important and you must select your surgeon and he will advise you which technique he is comfortable with.

 

I totally disagree that it is not possible to perform a total block of the pain fibres of the nose.  Obviously a correct technique and experience to do this correctly has to be followed. A total block of the nose is definitely possible and has been performed on thousands of cases and is being performed daily in clinics in England at our clinic in South Africa. Revision rhinoplasty with open approach lasting up to four hours are being performed with conscious sedation without problem. The patients on questioning after surgery reply that they felt no pain, no stress and are very happy and comfortable to recommend the procedure.

I also disagree with the doctors who claim that general anaesthesia is safer than conscious sedation for rhinoplasty. With conscious sedation delivered by a specialist anaesthetist experienced in the technique and with the correct equipment conscious sedation is less traumatic, leads to a quicker post surgery recovery, is more comfortable and is safer than general anaesthesia.

 

The known risks of general anaesthesia are numerous. Ask any specialist anaesthetist and they will enumerate the following risks and negative aspects associated with general anaesthesia.
• Problems and post surgical complications associated  with laryngeal tube usage such as difficulty in inserting the tube, danger of injury to the vocal cords, possibility of voice changes due to tube as a result of excessive compression or irritation of the vocal cords.
• A usual painful  throat post operatively due to the pharyngeal packing which is used for nasal surgery to prevent blood entering the trachea.
• Possibility of damage to dentition by instrumentation of the mouth and jaw in order to insert the laryngeal tube.
• Possibility of aspiration into the lungs of blood or stomach contents (if you happen to vomit) due to the fact that the laryngo-pharyngeal reflexes are ablated by the administration of muscle paralysing medication.
• Possibility of deep vein thrombosis with prolonged anaesthetic.
• Malignent Hyperthermia.
• Recovery of full consciousness after an hour or two of anaesthesia can take quite a long time and you must be carefully monitored in intensive care recovery unit.
• The patients are generally unresponsive for a long time and needs hours to be protected until recovered.

Also be aware that for general anaesthesia your are usually admitted as an in-patient, whereas in conscious sedation you can go home after an hour or two of rest.

None of the above complications occur with conscious sedation.
With conscious sedation understandably and obviously the surgeon must be trained to perform rhinoplasty with nose block and work as a team with the specialist anaesthetist. And obviously care is taken during the surgical technique that blood does not pass into the naso-pharynx. This prevention of blood passing into the nasopharynx is part of the surgical technique of noseplasty but if some blood does enter the nasopharynx the laryngo-pharyngeal reflexes and cough reflexes are intact and aspiration cannot occur and any blood is easily sucked up by your surgeeon. The beauty of the conscious sedation methodology is that there is no pain and no stress or apprehension and you are maintained in a mentally relaxed state and because of the vaso constrictive effect of the nose block, and because your muscular tone and the reflexes are retained, bleeding is minimal. As a matter of fact it is very often (in a closed approach) as little as from a tooth extraction.


At the end of the surgery you walk out of the theatre within 15 minutes as conscious as when you walked in, whereas with general anaesthesia patients have to be wheeled out completely debilitated and overwhelmed by paralysing drugs and medication which takes considerable time to be eliminated from the system.

 

In any event rhinoplasty is a minimally invasive when correctly and expertly performed and when care and the correct surgical protocols are followed. General anaesthetic is ‘overkill’ for such a minimally invasive procedure and exposes patients to risks for a surgically minor, cosmetic, unnecessary and elective procedure.

Dr. J. Calinikos MD FRCS (Edin)
Facial rhinoplasty surgeon
 

It is very important to have your nose performed under general anesthesia for both patient safety and comfort.  When patients are awake under anesthesia it is called conscious awareness.  After their conscious awareness surgery, patients have had nightmares about the surgery, often about when injections were placed in their nose or when their nose bones were being broken.  It is impossible to get the nose completely anesthetized with local anesthesia and it will be a very difficult and painful procedure.  In addition to that the nose does bleed, so it is important to not have a pooling of blood down over the vocal cords since this can get into the lungs and cause respiratory issues during the procedure.  The reason that general anesthesia is used is to protect the airway so that there is no blood pooling in the back of the throat during the procedure and for patient safety and comfort.  The far majority of patients prefer it this way and we have had no issues with general anesthesia in our private practice.

My colleagues comments about safety are incredibly important. However, rhinoplasty can be performed safely under IV sedation. The anesthesiologist or CRNA must be highly experienced in delivering IV sedation and avoiding both under and oversedation. Your plastic surgeon must be able to completely numb your nose as well. Both surgeon and anesthesiologist must work well together and both must be aware of your airway, any potential for bleeding and communicate openly. I hope this information is helpful.Stephen Weber MD, FACS

I perform all rhinoplasty and revision rhinoplasty procedures with deep intravenous (IV) sedation.  The patients do not have to be intubated.  During this procedure, you will not remember anything, and you breathe spontaneously on your own.  A skilled nurse anesthetist or anesthesiologist should feel comfortable with this type of anesthesia if they routinely work with a rhinoplasty surgeon. 

 

There is nothing wrong with using general anesthesia with intubation, but in my experience, it's not needed in the vast majority of cases.

Rhinoplasty surgery is definitely possible under a local anesthetic. Additional sedation can be achieved with preoperative oral medications or IV sedation. These methods of anesthesia depend on the experience and comfort level of your surgeon, as well as having reliable and competent ancillary staff in the operating suite.

With this said, most rhinoplasty patients are more comfortable having general anesthesia.

Thank you for your question. Good luck with your surgery!

 

Gregory C. Park, M.D.

 I have performed Rhinoplasty for 25 years and IMHO, this is ill-advised.  While IV sedation appears desirable, on the surface, the reality is that it is not as safe as a general anesthesia because the airway is not protected.  In the event of bleeding, which Rhinoplasty can do at times even profusely, the blood can be aspirated into the lungs causing pneumonia.  If IV sedation is too heavy, which can occur during the Rhinoplasty, the airway can become compromised from collapse of the oropharynx.  This was the way Rhinoplasty was performed 30 years ago and IMO is not up to the standard of care in the community based upon the above mentioned.  Hope this helps.