Figures 1A . The procedure of rhinoplasty is most frequently performed in the office or outpatient surgery setting under local anesthesia and intravenous sedation. Some surgeons prefer using a general anesthetic. After appropriate administration of intravenous sedation the mucosal surfaces are anesthetized with topical xylocaine with epinephrine. Circumnasal blocks with local anesthesia can be performed.
Some surgeons prefer a mini-dose of ketamine preceding the blocks.
Pretreatment with a benzodiazepam is helpful to prevent side effects of ketamine. There are many variations in technique. The common initial step is exposure of the bony cartilaginous skeleton of the nose. Access to these structures is either through infra- or intracartilaginous incision or through an external approach which elevates the soft tissues off of the bony cartilaginous framework. The procedure is tolerated well by the awake patient who has been prepared both postoperatively and intraoperatively for intraoperative maneuvers such as nasal bone infracture.