Twilight Sedation Vs General Anesthesia for Septo-rhinoplasty?

I need Septoplasty for medical reasons. I am planning to combine Rhinoplasty with it. One surgeon I consulted said that he uses general anesthesia because he can ensure my breathing continues and the breathing tube ensures that blood from my nose does not get into my lungs.

The other surgeon said that he uses IV Sedation (Twilight sedation) because it is sufficient and because recovery is easy. The anesthesia-nurse said an air-mask prevents blood from entering my lungs. Both said that the anesthetic is administered through an IV. So what's different between the two methods? The drug? The dosage?

Doctor Answers 23

Rhinplasty Under Sedation (twilight) versus General Anesthesia

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You are correct in all the points you make in your question:

1) Anesthesia encompasses many shades of gray; the deeper the sleep, the less you breath, until, ultimately, a breathing tube and ventilator are required. While most physicians would agree that once a patient is on a ventilator it is "general anesthesia", some would argue even patients breathing for themselves in deep sleep may qualify as "general anesthesia" -- just without a breathing tube. There are some IV medications that in moderate doses produce sedation, and in higher doses produce general anesthesia. Propofol is one such drug.

2) Rhinoplasty can be accomplished safely either way - either under general, or under sedation. While a breathing tube does lower the risk of having blood or secretions enter the airway, the depth of anesthesia required to "tolerate the tube" in your windpipe is much deeper than necessary for painless rhinoplasty. It also comes with increased recovery, and the increased risk of the deeper anesthesia itself. Interestingly, bleeding is more frequent and more copious under general anesthesia than under sedation, due to relaxation of the blood vessel walls by the general anesthetic.

3) Recovery is easier under sedation than under general. Fewer drugs + less invasive procedure (no tube) = easier recovery.

As a rule, I prefer twilight for my septorhinoplasty cases. It is certainly more work for the anesthesia provider and surgeon than general anesthesia, but I feel that the risk and recovery profile is better.

Best of luck!

Saint Louis Facial Plastic Surgeon
5.0 out of 5 stars 230 reviews

Most modern surgeons prefer GENERAL anesthesia for septoplasty/rhinoplasty

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Like many areas of medicine, anesthesia has come a long way in recent years. Better and safer drugs and more advanced monitoring technology have really made general anesthesia a much safer and more comfortable approach for patients.

I perform all rhinoplasties and septoplasties under general anesthesia for these reasons. I can be assured that the patient's breathing is adequate, that they're comfortable, and that they won't move unexpectedly.

Besides that, the bleeding during nasal surgery tends to run into the throat. Under sedation, the patient can 1) choke on it, 2) swallow it, which is nauseating, or 3) spit it into the surgical field (and onto me!)...which is also not ideal :-)

I would bet that my anesthesia colleagues would agree with me on all of the above, too.

Hope this helps,


David C. Pearson, MD
Jacksonville Facial Plastic Surgeon

Anesthesia for Rhinoplasty

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Working on the nose is working on the airway.   There is bleeding, although it is a very small amount.   Protection of the airway is important-----meaning that keeping the airway patent----is essential.   To perform any surgery with sedation requires depresssion of the brain---whether it be a little or a lot.   Depressing the brain interferes with the breathing mechanisms:  protective reflexes as well as the rythm and rate of breathing.   To achieve sedation, a doctor or nurse must administer drugs.  These drugs are brain depressors.

General endotracheal anesthesia is still the SAFEST way to achieve this.  NO pain, no feeling of the surgery and absolute protection and secureness of the airway.   To compromise the airway for a cosmetic surgery is not a good idea.   No matter how talented the surgeon is nor how great the anesthesiologist or nurse anesthetist is, the airway is secure, safe with a tube in it.   There is no glitz or glamour to perform rhinoplasty or septoplasty without an endotracheal tube.   In most if not all communities there are "cowboys" who claim great successes from surgery without the "old fashioned" endotracheal tube.   

Ask your surgeon where the highest complication rate of anesthesia on cosmetic surgery is.   The answer across the US is where there was no endotracheal tube anesthesia used.   Almost all anesthesia mishaps occur from loss of the airway.   It is much more difficult to loose control of the airway if there is no tube there protecting it.  There are occasions where there is medication overdose, but more often the problems arise from trying to get away with "not using an endotracheal tube."

The best and safest surgeons use endotracheal anesthesia to perform nasal surgery.   Those surgeons that recommend not using that technique should be questioned why they are choosing not to use one.  Some surgeons claim that it is safer for the patient to breathe on their own without the endotracheal tube.   Patients can breathe on their own with an endotracheal tube.   

Surgeons need to respect the airway.   :-)

Jonathan Berman, MD
Boca Raton Plastic Surgeon
4.7 out of 5 stars 19 reviews

Anesthesia choices in plastic surgery

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The question of whether to use general anesthesia or sedation is common and not only with rhinoplasty but multiple other types of surgeries. What it boils down to is what type of anesthesia the physician is most comfortable with and additionally what types of anesthesia the physician may or may not be licensed to provide. You should check into the certification of the facility where the surgery is going to be performed. Many surgeons like myself to have a fully accredited operating room and will more often use a general anesthesia. Physicians who work in their office may not have full accreditation and use sedation because this is their only option without going to do the surgery at the hospital, which can be expensive for you and for the doctor. The thing to remember is that general anesthesia is implemented by a second person: a nurse anesthetist or anesthesiologist. This requires the plastic surgeon to pay another provider. If the surgeon is providing the anesthesia himself, which is usually sedation, there is no need for a third party to be involved.

Many older surgeons prefer to use conscious sedation as that is how they were trained and they are extraordinarily comfortable and well educated in how to manage patients under twilight anesthesia. If your surgeon is one of these physicians and feels that here she can adequately provide you with a good anesthesia experience and a good clinical outcome, then this is likely a great way to go. Otherwise my recommendation would be to have general anesthesia for an operation such as this. In this case is the physician can concentrate on your rhinoplasty rather than the anesthesia itself which is delegated to a nurse or physician who provides the services and only services on a regular basis.

Twilight anesthesia is safe for Septorhinoplasty

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I commonly use Twilight anesthesia or moderate sedation for all facial surgery. This is a very safe technique and reduces the risks associated with a general anesthetic. The main difference is that with a general, you would have either a breathing tube (endotracheal tube ), a mask, or what is called an LMA. LMA stands for Laryngeal mask airway, which is a tube placed at the back of your throat and blocks fluid from entering your trachea (wind pipe). Obviously, a mask wont work in nasal surgery, so some type of airway must be used in a general anesthetic. With this type, you are much deeper in terms of sedation and may require the tube for helping your breathing.

In contrast, with twilight sleep, you are breathing on your own, and do not require a breathing tube. It is very safe to do a septorhinoplasty under this type of sedation and I have never seen a problem with my patients using this approach. Some surgeons are less qualified or just less comfortable with this approach and may prefer using a general anesthetic.

In my experience of 25 years, I have never seen a problem with sedation for any facial surgery and it remains my first choice, except in children and younger teens who are better off under general for emotional reasons. The risks of a general can be minimized in the hands of an board certified anesthesiologist, but it still carries more risks and side effects than sedation. It also adds to the cost of surgery, and all of this should be considered when making your decision.

Steven L. Ringler, MD, FACS
Grand Rapids Plastic Surgeon
5.0 out of 5 stars 72 reviews

Leave anesthesia method for Septo-rhinoplasty to your trusted surgeon

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The difference is that in twilight anesthesia, YOU do the breathing. the rate and depth of breathing is determined by you. If you slow down, the amount of oxygen will go down, an alarm goes off and the nurse charged with monitoring you will remind you to take a few deep breaths.

In general anesthesia, a machine puts a mixture of anesthetic gas and oxygen through a cuffed tube into your lungs. Your blood oxygen is kept constant by the machine. Once you are asleep, your mouth is opened and a soft flexible tube is placed through the mouth and throat into the trachea (the airway in the neck). After verifying that the tip of the airway is above the tracheal split into a right and left airway (so air and gas goes equally into both lungs) a soft cuff balloon is inflated to keep the airway in place. IT IS THAT CUFF that she referred to. It will prevent any blood from the operation or sudden regurgitation from your stomach from going down the airway and flooding your lungs (ASPIRATION PNEUMONIA).

Both are acceptable and widely used anesthesia techniques. The sedation before both are induced is the same and depends on the preference of the anesthetist / anesthesiologist. Many now use PROPROFOL because as an IV drip it can be easily stopped and the sedation wears off rapidly.

Choose the surgeon you are most comfortable with. The method of anesthesia should be left up to him.

Peter A. Aldea, MD
Memphis Plastic Surgeon

General anesthesia preferred for rhinoplasty

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I greatly prefer general anesthesia for my patients undergoing rhinoplasty. It is clearly the safer way to go. If there is much bleeding in the nasal airway, this could lead to airway issues and aspiration. Performing a rhinoplasty under IV sedation could lead to an airway emergency, and I simply want to eliminate this risk. The disadvantages of general anesthesia are minor, in my experience.

Ryan Greene, MD, PhD
Fort Lauderdale Facial Plastic Surgeon
5.0 out of 5 stars 85 reviews

Twilight Sedation Vs General Anesthesia for Septo-rhinoplasty?

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The answer depends mostly on your anesthesiologist's comfort and skill level with twilight sedation during a nasal procedure which involves some bleeding in the airway.  We prefer general anesthesia in septorhinoplasty, and eschew laryngeal mask airways in any case.  If something goes wrong in any twilight case and/or the airway is lost, the first thing to do is to put a tube in the airway to secure it.  In general anesthesia the airway is secured prior to the procedure.

Ramtin Kassir, MD
New York Facial Plastic Surgeon
4.7 out of 5 stars 179 reviews

Rhinoplasty - General Anesthesia vs I.V. Sedation

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I have used both of these anesthetic techniques with success. Each approach has its pros and cons and sometimes it is the patient's preference and other times it is the surgeon's preference. My personal preference is general anesthesia. The patient's airway is protected and I feel I can work more efficiently. Having said that, it is certainly acceptable to use I.V. sedation and local anesthesia if both the surgeon and patient are comfortable with this approach. Best of Luck

Twilight Sedation vs General Anesthesia

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A twilight anesthesia can be much more dangerous due to the patient slipping into an unconscious state and not being able to breathe on their own with an unprotected airway. Under general anesthesia, the airway is completely protected from collapsing upon itself when sedated too deeply, along with being protected from the actual blood and secretions itself. It is also important to have a board-certified physician anesthesiologist present, during the surgery.

In addition, at the time of the rhinoplasty, when the nasal bones get broken and reset, this is not something you want to have twilight anesthesia for, or be sedated for, since the patient will have recollection and memory of the procedure.

Twilight anesthesia is usually given with narcotics and valium to relax patients, which is given through an intravenous line, while general anesthesia is started with the I.V. and then converted over to the anesthetic gases while the patients are asleep.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.