Anesthesia for rhinoplasty: A summary of clinical considerations, therapeutic modalities, outcomes, and future directions

Rhinoplasty is a challenging operation that requires optimal surgical conditions for its success. Stability of hemodynamics - particularly, permissive hypotension – allows for greater visualization of the surgical field, and thus, has been a key pillar in navigating anesthetic considerations. While there are multiple modalities that reduce mean arterial pressure (MAP), it remains unclear how these compare with respect to post-operative outcomes. A literature review, using the PubMed database, was conducted using the following terms: "rhinoplasty," "anesthesia," and "permissive hypotension." Inclusion criteria included randomized control trials (RCTs), prospective / retrospective cohort reviews, case series, patients undergoing cosmetic rhinoplasty, and presentation of an objective post-operative outcome. Initial review yielded 301 articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of 47 studies for analysis. Articles studied the impact of various physical operating room conditions, multiple analgesic medications, general anesthetics, local nerve blocks, steroids, vasoactive agents, and anti-fibrinolytic agents. Outcomes during the intra-operative period (i.e. MAP, SBP, and bleeding) and post-operative period (i.e. ecchymosis, edema, pain, narcotic requirement, and recovery time, surgeon satisfaction) were measured. Our investigation presents foundational knowledge of various analgesic, vasoactive, steroid, nerve blocks, as well general and local anesthetic agents, utilized for achieving permissive hypotension in rhinoplasty. We hope to leverage such knowledge to 1) develop a standardized anesthetic protocol for rhinoplasty, 2) study its associated clinical outcomes within an institutional cohort; and 3) ultimately, encourage closed-looped communication among the anesthesia and plastic surgery teams to optimize outcomes.