Preoperative, Anesthetic, and Postoperative Care For Rhinoplasty Patients

Preoperative,
Anesthetic, and
Postoperative Care for
Rhinoplasty Patients
Ravi S. Swamy, MD, MPH, Sam P. Most, MD*
KEYWORDS
Rhinoplasty Preoperative care
Anesthetic care Postoperative care
PREOPERATIVE CARE Although nasal evaluation is assessed at the

initial visit, it is important to review pertinent find-
An educated patient is more likely to have a posi- ings and get reacquainted with the patient’s anat-
tive perioperative experience. After the initial omy before surgery. The primary concerns of the
consultation and when the surgical plan is com- patient and what he or she hopes to achieve
plete, rhinoplasty patients in the authors’ care through surgery must be paramount. After the
undergo a structured preoperative visit to ensure surgeon iterates and validates these concerns,
that all concerns are addressed, all questions are analysis should begin broadly. After assessing
answered, and the patient and the surgeon have the symmetry and proportions of the nose to
a shared understanding of the goals of the surgery. the face, it is important to evaluate the thickness,
This visit takes place 1 week before the scheduled integrity, and mobility of the skin–soft tissue en-
surgery date. velope in relation to the underlying nasal struc-
All patients fill out a preoperative questionnaire tures, because it dictates what can be
detailing their past medical, surgical, and anes- accomplished intraoperatively.2 Another critical
thetic history, including a list of current medica- factor in assessing the patient is to determine
tions. Patients who are on aspirin or other through careful palpation the inherent strength
medications that may disturb normal platelet func- and support of the nasal tip. A patient who has
tion were told at earlier visits (in collaboration with weak tip support will not tolerate extensive re-
their prescribing doctors) that these medications moval of cartilage but may require the addition
should be stopped 2 weeks before the surgery of supportive grafts and struts to improve the
date. Patients who smoke are asked to avoid tip’s stability and support. Patients who have
smoking and using other nicotine-containing prod- strong tip support can tolerate reduction maneu-
ucts for 4 weeks before surgery because their vers that improve refinement. The size, shape,
effects on wound healing is well documented.1 attitude, and resilience of the alar cartilages can
After the patient completes the questionnaire, be estimated by palpation or ballottement of the
the surgeon reviews the responses and performs lateral crus between two fingers surrounding its
a thorough physical examination, including cephalic and caudal margins. During this assess-
auscultation of the heart and lungs. After address- ment, the surgeon makes the all-important
ing all potential issues concerning the patient’s decision about whether to enhance, reduce, or
general health and well-being, the surgeon can carefully preserve the tip projection that exists
facialplastic.theclinics.com
now focus on the nasal analysis and evaluation. preoperatively.3
Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Road,
Stanford, CA 94305, USA
* Corresponding author.
E-mail address: smost@ohns.stanford.edu (S.P. Most).
Facial Plast Surg Clin N Am 17 (2009) 7–13

doi:10.1016/j.fsc.2008.09.006
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8 Swamy & Most
Just as it is important to recognize the main aes- and a rhinoplasty-specific consent form outlining
thetic concerns of the patient, it is important for the the specific skin incisions that will be used. The
surgeon to highlight and point out the more subtle authors hand-write the specifics of the procedure
findings. If unaddressed, the scrutinizing patient and repeat the goals of the surgery. The patient
may notice these postoperatively, negating an is encouraged to ask questions, and every effort
otherwise positive outcome.4 is made to explain the risks, benefits, and alterna-
Even in cases of cosmetic rhinoplasty, careful tives using terminology that the patient can easily
evaluation and documentation of the nasal airway comprehend. Possible complications are also
and discussion of symptoms of nasal obstruction discussed. Complications rates from rhinoplasty
are addressed in detail. Many cosmetic patients vary between 10% and 15%.4 Complications can
may have underlying symptoms of nasal obstruc- be categorized as aesthetic or functional in nature.
tion that go undiagnosed and may become A candid discussion with the patient regarding the
a source of complaint postoperatively.4 On occa- possibility of a complication is imperative, with the
sion, the use of rigid or flexible endoscopes may acknowledgment that every effort will be made to
yield useful information that could affect surgical correct the complication if it occurs (most compli-
planning.5 cations are correctable).8 The patient should also
Previous to the preoperative visit, standardized be made aware of the temporary swelling, ecchy-
digital photographs from the frontal, base, lateral, mosis, and nasal obstruction in the immediate
and oblique views are taken. These images are postoperative period. An intimate knowledge of
also computer enhanced to simulate surgical the patient’s unique nasal anatomy and accurate
goals. They are excellent communication tools, preoperative analysis are crucial to achieving the
and satisfaction with cosmetic surgery after com- desired long-term postoperative result and to
puter imaging has been documented to be higher avoiding preventable complications.
than in those patients who did not receive imag- After completing the informed consent process,
ing.6 Computer imaging not only facilitates discus- patients are given postoperative prescriptions in
sion about specific goals of the procedure but it advance. Typically, patients are placed on
also helps to uncover any potential unrealistic narcotic medications for pain and prophylactic
expectations of the patient.7 It must be stressed antibiotic for 5 days. The authors do not give their
to the patient that the images represent a means patients a steroid taper. Studies have shown that
to facilitate discussion and to improve their educa- postoperative steroids are not effective in reducing
tion of what can and cannot be accomplished. It is postoperative edema and subject patients to
the surgeon’s responsibility to temper the patient’s undue risk.9–11 Preoperative orders in anticipation
desires to realistic goals. Every effort is made to of surgery are also completed at this visit. There is
reproduce these images, which are used intrao- a standardized work-up of ancillary testing for
peratively. Images are displayed in the operating patients undergoing a procedure under general
suite, and an attempt is made to match the anesthesia (Table 1). Patients meet with the clini-
enhanced images to the patient on the table. A cal nurse to discuss the details of the operative
study by Agarwal and colleagues7 illustrated that day, including the time and location of the surgery,
computer imaging for rhinoplasty patients portrays perioperative diet, and final costs of the
a realistic picture of actual postoperative results; procedure.
however, they state that it is important for the
surgeon to be able to use this modality with discre- ANESTHETIC CARE
tion because the computer images should be
restricted to the confines of the surgeon’s abilities. All patients undergoing rhinoplasty have their
While reviewing the photographic images, it is surgery at an accredited ambulatory surgery cen-
critical to review the goals of surgery and ensure ter and are given the opportunity to meet the anes-
that the issues the patient would like addressed thesiologist preoperatively. All issues regarding
have not changed. During the preoperative evalu- the anesthesia are answered, and a thorough his-
ation, the surgeon must possess a mental image of tory and physical examination is performed.
the potential outcome and the surgical limitations Although this procedure may be repetitive, it
inherent in every individual case. In essence, the allows the anesthesiologist to formulate an appro-
operation is rehearsed as the preoperative evalua- priate plan for anesthesia well ahead of the actual
tion proceeds.4 surgery date. In addition, most patients gain
After the surgical goals are reviewed and the comfort in knowing that all members of the surgi-
plan is mutually understood between the patient cal team share a similar goal of achieving a good
and the surgeon, the patient is given a standard- outcome while placing priority on their safety and
ized medical procedure informed consent form well-being throughout this process.
Preoperative, Anesthetic, and Postoperative Care 9
Table 1
Ancillary test recommendations for patients scheduled for surgical procedures under general anesthesia
Age (y) Male Patients Female Patients

<40 None Pregnancy test
40–49 ECG Pregnancy test, hematocrit
50–64 ECG Hematocrit, ECG
65–74 ECG, hematocrit, blood urea nitrogen, Hematocrit, ECG, blood urea nitrogen,
glucose glucose
>75 ECG, hematocrit, blood urea nitrogen, Hematocrit, ECG, blood urea nitrogen
glucose, chest radiograph glucose, chest radiograph
Data from Feisher LA, Johns RA, Savarese JJ, et al. Miller’s anesthesia. 6th edition. London: Churchill Livingstone; 2005,
p. 2594.
It has been well documented that rhinoplasty to reduce the acidity of the lidocaine, and places
can be performed with local anesthesia and intra- an intravenous line. The anesthesiologist then
venous sedation or with general anesthesia.12 The administers 2 mg of midazolam for anxiolytic
risks of intravenous sedation and general anesthe- purposes and escorts the patient to the operating
sia are well known; therefore, the surgeon and suite. The operating room is kept quiet, and conver-
anesthesia personnel should do what they are sation by the staff is kept to an absolute minimum.
most comfortable executing, keeping patient After properly positioning the patient on the
safety as the principal concern.13 table and ensuring his or her comfort, preoxygena-
The authors advocate an intravenous-only tion by way of facemask begins. For induction, the
general anesthesia using a laryngeal mask for their patient is given 25 mg of fentanyl and 200 mg of
rhinoplasty patients. General anesthesia in the propofol. If the patient has a history of severe
hands of well-trained anesthetists using advanced nausea and vomiting associated with anesthesia,
monitoring and pharmacologic techniques on 4 mg of odansetron is also given. An a2-adrenergic
a healthy patient is safe and effective. With general agonist drug such as clonidine may also be
anesthesia, tighter blood pressure control can be infused because it can reduce anesthetic and
achieved, thereby minimizing intraoperative bleed- analgesic dosage requirements and produce
ing. The authors also believe that the laryngeal sedation and anxiolysis while also decreasing the
mask significantly reduces the risk of aspiration heart rate and blood pressure during anesthesia;
in nasal surgery. Patients are comfortably and fully however, residual postoperative sedation may be
asleep, allowing the surgeon to focus full attention a problem for elderly outpatients.14 After the
on the operation without the distraction of inadver- patient is induced, a short-acting muscle relaxant
tent patient movement and elimination of the such as cisatracurium is given if the patient is
seesaw effect of intravenous sedation.14 expected to be intubated with an endotracheal
tube. As mentioned earlier, the authors prefer the
use of laryngeal mask airway (LMA). Tracheal intu-
The Authors’ Protocol bation causes a high incidence of postoperative
The patient is asked to arrive 2 hours before the airway-related complaints, including sore throat,
scheduled time of surgery and is met by the clinical croup, and hoarseness. One study showed that
nurse who already has an established rapport with the incidence of postoperative sore throat after
the patient. After changing into a surgical gown, the ambulatory surgery was 18% with an LMA versus
patient meets again with the anesthesiologist to go 45% with a tracheal tube.15 Most outpatients
over the plan of anesthesia in the preoperative undergoing superficial procedures under general
holding area. The patient is also given three doses anesthesia do not require tracheal intubation
of 0.05% oxymetazoline nasal spray to each nostril unless they are at high risk for aspiration.16
spaced 10 minutes apart to help with decongestion Compared with tracheal intubation, insertion of
and vasoconstriction. The surgeon arrives to greet the LMA causes minimal cardiovascular
the patent and reviews the surgical plan one last responses and is better tolerated at lighter levels
time. Every effort is made to keep the atmosphere of anesthesia.17 The LMA also prevents the patient
tranquil to reduce patient anxiety. from swallowing blood during the procedure that
The anesthesiologist injects a small amount of could contribute to postoperative nausea and
2% lidocaine diluted 1:1 with sodium bicarbonate emesis. When endotracheal tubes are used, the
10 Swamy & Most
authors place a throat pack to prevent blood from rhinoplasty approach, the columella is injected
entering the esophageal inlet. inferiorly and at its midpoint (Fig. 2A, B). The
After securing the airway, the anesthesiologist authors then insert the needle into the nasal tip
gives the patient a prophylactic antibiotic such as and inject the dome, the medial crura, and surpra-
1 g of cefazolin, or 600 mg of clindamycin for pa- tip region (see Fig. 2C). The authors also inject the
tients who have penicillin allergies. Intravenous cor- alar bases bilaterally to help with vasoconstriction
ticosteroids are routinely administered to reduce of the lateral nasal branch of the facial artery (see
postoperative nausea and postoperative swelling.9 Fig. 2D), followed by injection of the inferior edge
Prior to sterilely cleansing and draping the of the lower lateral cartilages in preparation for
patient, it is important to properly prepare the the marginal incisions (Fig. 3A). Lastly, the nasal
nose for surgery. Fig. 1 illustrates the tools used dorsum is injected subcutaneously through the
in the authors’ typical preparation tray. The use vestibule immediately superficial to the nasal skel-
of a sharp pair of Iris scissors allows the surgeon eton (see Fig. 3B). Less than 5 mL is used because
to cut the vibrissae for improved visualization of any more can cause undo distortion. Cotton pled-
incisions. A 10-mL control syringe with a 1.50-in, gets soaked in 0.05% oxymetazoline are placed
27-gauge needle is used to inject the local anes- bilaterally for continued decongestion and vaso-
thetic. Local anesthetics produce sensory loss by constriction. Although 4% cocaine can also be
blocking excitatory stimulation at the nerve end- used, its cardiotoxic effects are well docu-
ings and by inhibiting conduction in the peripheral mented.19–21 The patient’s face is then prepared
nerve tissue, thereby reducing the amount of gen- and draped in a sterile fashion. The authors prefer
eral anesthetic required.15 Although there are betadine scrub and paint. The first incision is not
many different forms of local anesthetics, the made until at least 10 minutes after injection of
authors prefer 1% lidocaine with 1:100,000 the local anesthetic so that the vasoconstrictive
epinephrine due to its efficacy, length of duration, effects of the epinephrine can take place.
and safety profile.18 The maximum dose of lido- The patient ventilates spontaneously throughout
caine with epinephrine is 5 to 7 mg/kg, which the procedure. For maintenance, the anesthesiolo-
can last up to 3.5 hours.12 First, the septum is gist titrates a propofol drip and gives fentanyl as
injected bilaterally in multiple sites beginning pos- needed for analgesia. Blood pressure and heart
teriorly. When completed properly, hydrodissec- rate are controlled with short-acting b-blockers
tion of mucoperichodrium can be achieved. such as esmolol. It is recommended to maintain
Direct injection into the membranous septum is the systolic blood pressure between 95 to 105 mm
avoided to prevent a false hanging columella Hg to keep blood loss at a minimum, because clear
deformity. The pyriform aperture and nasal floor visualization of the nasal anatomy is essential for
are also infiltrated. When turbinate reduction is a good outcome.
planned, a small amount of local anesthetic can
be injected into the inferior turbinates. For external POSTOPERATIVE CARE
After completion of the procedure, the dressings
are placed and the recovery nurses are notified to
expect the patient shortly. Communication
between the surgeon and the anesthesiologist as
to the end point of the operation is critical to
ensure a smooth emergence. The oropharynx is
gently suctioned with a Yankauer suction catheter.
As the anesthetic is turned off and the patient
becomes more aroused, the LMA is gently
removed. The anesthesiologist is cognizant of the
importance of awakening the patient quietly and
smoothly and the avoidance of traumatic disruption
of the surgical site. The surgeon is present for the
emergence and ensures that the patient is safe be-
fore being moved to the recovery room. It can be re-
Fig.1. Typical instruments used as part of the authors’
preparation tray before the first incision, including
assuring for the patient to see the surgeon in this
Iris scissors, a nasal speculum, 1% lidocaine with immediate postoperative period and hear words
1:100,000 epinephrine, a 10-mL control syringe with of encouragement regarding the surgery.
27-gauge needle, 0.05% oxymetazoline spray, and In the recovery room, attention should be on the
0.5-in 3-in cotton pledgets. patient’s airway. Any mask placed on the patient
Fig. 2. Sites of injection of 1% lidocaine with 1:100,000 epinephrine. (A, B) Sites of injection on the columella.
(C) Injection of the nasal tip. (D) Injection of the alar base.
for oxygenation should be done in such fashion as Patients sit in a recliner at a 45 angle and are
to not place pressure on the nose. The patient’s given clear liquids without carbonation if they are
head is elevated 30 , and cold compresses are not nauseated. An intravenous line remains in
gently placed over the eyes and nose. Care is place until discharge in the event that further anti-
taken to control postoperative pain, hypertension, emetic or pain medication is required.
and nausea as Valsalva can result in epistaxis or During the recovery process, the patient’s care-
bleeding under the septal or nasal skin flaps. Pa- givers are given postoperative instructions and
tients who experience some epistaxis may have contact numbers for the staff and the surgeon.
a folded 4 4 sponge placed under their nose The clinical nurse goes over every detail of the
that is held in place by a surgical mask cut into instructions and ensures that all questions are
a thin rectangular piece. answered. It is most important to address postop-
After the patient is more alert and has stable erative pain because it is frequently the most com-
vitals, the patient is transferred to a secondary mon issue. For those who are most concerned, the
recovery unit and allowed to change into his or authors recommend taking the pain medication as
her clothes. Patients are encouraged to wear but- prescribed every 6 hours for the first 24 hours, and
toned shirts so that they do not have to pull clothes then taking it as needed after that. Patients are
over their head and risk displacing the nasal splint. also instructed to avoid blowing their nose and to
12 Swamy & Most
Fig. 3. (A) Injection of lidocaine along the lower lateral cartilages. (B) Transvestibular injections of the subcutane-
ous plane above the nasal skeleton. Markings of external contour are done before injection.
wipe the nose gently as needed. For minor postop- skin–soft tissue envelope and the underlying
erative bleeding, 0.05% oxymetazoline may be framework. Columellar sutures are then carefully
used sparingly for no more than 3 days. If the removed. Patients will likely have a moderate
patient has continued bleeding, he or she should amount of swelling and should be reminded that
contact the surgeon immediately. The authors rec- it can be almost a year before the final result is fully
ommend that patients avoid nonsteroidal anti- appreciated. Patients should avoid strenuous
inflammatory drugs because they affect platelet physical activity for 2 additional weeks and avoid
function and may lead to epistaxis. Patients are heavy lifting (>10 lb). Patients can expect to
also told to avoid exerting themselves and to limit resume full activity with no restrictions at 6 weeks
bending and lifting anything heavier than 10 lb. after surgery.
Restrictions are gradually lifted during the postop- In the authors’ practice, patients are seen in the
erative period as the patient recovers. Prior to postoperative period at 1 week, 1 month,
discharge, the surgeon meets with the caregiver 3 months, 6 months, and 1 year. Frequent postop-
and the patient to go over the instructions and to erative visits provide positive reinforcement to
address any concerns. Extra time spent in this crit- recovering patients and help to identify those
ical period eases anxiety for the patient and the who may not be satisfied or who have an unex-
caregiver and assists in a quicker recovery. pected outcome.
Patients are also given the time and date for their
postoperative visit.
SUMMARY
The surgeon contacts the patient on the evening
of the surgery to reassure the patient and address The challenges of rhinoplasty are substantial
any additional concerns. It is made clear to the because every patient is unique and achieving
patient that should any issue arise, the surgeon success is multifaceted. A surgeon must not only
or a member of the staff is available at all times. possess a comprehensive set of surgical skills
The first postoperative visit takes place between but also be able to effectively communicate with
postoperative day 5 and day 7. The nasal splint the patient and understand his or her concerns
and columellar sutures are removed at this visit. and desires. Although the surgery itself poses
Great care should be taken to gently remove the considerable challenges and can be a major
tape and splint over the nasal dorsum, which can source of anxiety, the implementation of an
be accomplished by first applying a generous efficient perioperative strategy that can be consis-
amount of adhesive remover such as Detachol tently replicated can reduce trepidation and
(Ferndale Laboratories, Ferndale, Michigan). After amplify success. This article describes the au-
waiting a few minutes, blunt dissection of the nasal thors’ approach to the preoperative, anesthetic,
skin from the overlying splint using a cotton-tipped and postoperative care plan for patients undergo-
applicator avoids any disruption between the ing rhinoplasty. There are many variations in
perioperative planning, with no one correct strat- 11. Kargi E, Hos xnuter M, Babucçu O, et al. Effect of
egy; however, all successful plans must foster steroids on edema, ecchymosis, and intraoperative
open lines of communication and hold the bleeding in rhinoplasty. Ann Plast Surg 2003;51(6):
patient’s welfare in the highest regard. 570–4.
12. Feisher LA, Johns RA, Savarese JJ, et al. Miller’s
anesthesia. 6th edition. London: Churchill Living-
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Preoperative,

PREOPERATIVE CARE Although nasal evaluation is assessed at the

now focus on the nasal analysis and evaluation. preoperatively.3

Facial Plast Surg Clin N Am 17 (2009) 7–13

Age (y) Male Patients Female Patients

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