The Operation Day – Surgery and Anesthesia
Dr. Portuese feels that it is important to meet with the patient to go over the Rhinoplasty / Nasal Surgery in fine detail again so that both the surgeon and the patient understand the plan. At this time, any last minute minor modifications to the surgical plan of action for the rhinoplasty can be discussed. If routine medications need to be taken (such as blood pressure pills, etc.), they can be taken with a small sip of water. The anesthesiologist will ask about certain medical conditions, food allergies, latex allergies or any allergic reaction to anesthesia. Patients are then brought into the formal operating room. An intravenous line is started, usually in the right hand, and a sedative is given to relax the patient.
Then the anesthetic is given to put patients to sleep with propofol. Once asleep, a small breathing tube called an LMA (laryngeal mask airway) is inserted on top of the vocal cords and is left in place for the surgery.
Patients are breathing on their own under a general anesthesia and there is no recollection of the procedure. Anesthesia is now much safer than it was many years ago due to improvements in technology, the anesthetics and the monitoring agents used during the surgery. There is also a local anesthetic placed inside the nose to prevent any bleeding. To ensure the patient’s complete safety, the physician anesthesiologist monitors the patient’s vital functions the entire time the anesthesia is being administered in the Seattle Rhinoplasty Surgery Center. While Dr. Portuese concentrates on making the refinements to the new nose, the physician anesthesiologist focuses on the patient’s anesthesia and the equipment monitoring heart, breathing, oxygen, and circulation levels. The monitors that are employed are EKG, which is heart tracing, blood pressure cuff to monitor blood pressure during the procedure, pulse oximeter, which measures oxygen concentration in the blood stream, and a ventilator monitor, which is usually monitoring the patient’s own breathing and respirations. Carbon dioxide and temperature monitors are also used during the surgery to closely monitor for the patient’s safety.
THE DAY OF THE SURGERY – OVERVIEW
The surgery will take 1 – 2 hours depending upon the complexity of work being done. During the procedure, the preexisting characteristics of the nose will determine the length of the procedure. The rhinoplasty usually involves the sculpting or reshaping of the nasal bones, upper lateral cartilages (middle 1/3 of the nose), and lower lateral cartilages (the tip). Sometimes a septoplasty is performed to improve the functionality and airflow dynamics through the nose along with a turbinate surgery if needed for improvement of airflow. Reshaping of the septum and other tissues inside the nose address functional breathing issues. Sculpting and reshaping of the bridge of the nose most of the time involves reduction and shaving down the bone and cartilage of the nasal dorsum. Occasionally an augmentation or building up of the bridge is required if too much has been taken down in the past or if there has been a traumatic injury. The bridge of the nose consists of both bone and cartilage, with the bone being on the top portion and the cartilage being the lower 2/3 of the nose. During the rhinoplasty procedure itself, the excess in convexity of bone and cartilage is removed with an osteotome or a rasp (an instrument similar to a file). Once the dorsal hump has been removed, the lateral sidewalls need to be narrowed. Otherwise, an open roof deformity will present itself and will need to be closed. The open roof deformity is closed with osteotomies in a very controlled manner, making very small and fine cuts in the nasal bones and reshaping the nasal sidewalls to create a more natural shape. To augment the height of the bridge of the nose during a rhinoplasty, Dr. Portuese may be required to add some cartilage from the nose. On a rare occasion, he will use an alloplastic or synthetic material. This is usually done if there is no cartilage left on the inside of the nose or if the patient requires a very large augmentation such as an Asian rhinoplasty. Dr. William Portuese prefers to use the patient’s own natural tissues and usually will use cartilage from the septum. On the rare occasion that there is no cartilage left over in the septum, he may also have to use a piece of cartilage from the ear. To correct a crooked nose, the bones have to be realigned by making fine small cuts in the nasal bones with an osteotome and realigning and straightening the nose bones. The cartilage usually follows suit with the nose bones and then a cast is applied. When patients awake in recovery, the nose is relatively numb, however most patients experience some form of mild burning and congestion. Some patients experience a headache, but that usually subsides with a couple of mild pain relievers in the first few hours after the surgery.