Plastic surgeons usually preform rhinoplasty under general anesthesia, with some surgeons preferring local anesthesia with sedation. Recently, with the increasing demand in office-based procedures, we looked for a simplified approach for simple aesthetic deformities of nose such as wide and boxy tip, mild dorsal humps and simple lateral crural works. Many authors reported simple procedures as alar resection and simple tip work to be done under local anesthesia. In our practice we recorded 104 rhinoplasty operations done under local anesthesia only, with no use of any oral nor IV sedatives.

Patients selection:

A good candidate for this approach is an adult patient with realistic expectations, a good mental stability regarding injections must be considered. Mild cases of dorsal humps, over projected tip, wide boxy tip and alar flaring along with other mild deformities that doesn’t need cartilage graft to repair are considered a good candidate

Anesthesia:

8-12cc of NaCl 0.9% mixed with 3-4ml of Xylocaine 2% and 0.5ml adrenaline injected to the nasal tip and forwarded up to the dorsum and the nasal spine, being aware of the vascular structures, specially the lateral alar arcade. This infiltration is also to guarantee a good hydrodissection. After completing the infiltration, a 10- to 15-minute wait-time before the incision is a must to insure a good homeostasis and a clear field. Nasal packs are placed before making the incision.

Surgical Approach:

I perform all my rhinoplasty procedures under 3.5x loop magnification. With an 11 blade, a complete marginal incision accompanied with transfixion incision is done in each nostril. The incision is extended laterally to insure a good release for the LLC. Dissection of the incision site to separate the LLC from the skin envelope is carried out with sharp curved scissors only for the first 2-3mm, followed by complete dissecting with Metzenbaum scissors up to the radix in cases of dorsal rasping, and restricted to the upper cartilage in cases of tip work only. Care must be taken in dissecting the intra-crural ligaments to insure delivery of the LLC.

After complete release of the LLC and delivering it out, I preform a caudal resection of the LLC in most of the cases leaving 7-8mm. The patient’s satisfaction is higher with this technique. Also, it helps to elevation of the nasolabial angle. Tip definition stitches along with transdomal or intradomal stitches are a must to insure a good aesthetic tip. In over projected tip, I cut and overlap the medial foot plate of each side to decrease its length.

With mild dorsal humps in which rasping is enough and no osteotomies are required, I preform it before the tip work with Joseph nasal rasp. no pain was reported by patients, however presence of mild-to-moderate discomfort associated with the rasping noise was reported. In general, patients are well satisfied with the no pain and mild discomfort associated with the procedure, expressing how they expected it would be more painful and annoying. Alar resections are also done in some patient as aesthetically required.

Post-operatively, I apply Steri-Strip with good compression for 10-15 days, and Vasline gauze nasal packs which are removed after 24-48 hours. Patients are discharged 2-6 hours post-operation with oral analgesic and Serrapeptase.

Results:

In 104 patients, we reported 13 revisions: 5 cases because of under correction; 7 for asymmetry between the 2 LLCs; and one case because of stitch granuloma.

Generally, an excellent patient satisfaction rate was obtained by this technique with good patient selection and simplified surgical approach. This technique is not a replacement for complete rhinoplasty procedures, rather it gives advantages of office-based procedures with limited down time and decreasing the financial costs for the patient and the surgeon. Moreover, the patients recently started to prefer local anesthesia compared to the general anesthesia as they feel it’s safer.

With the newly aesthetic trends and celebrities receiving rhinoplasties, more patients are looking to improve their nasal profile despite the absence of major nasal deformities. This technique provides a good tool to satisfy those patients with no major risk and with reasonable decrease in financial costs.