The local anesthesia regimen administered prior to surgery is a standard practice for rhinoplasty procedures. However, there is variation in the kind of anesthetic utilized during this time. In our practice, we have used different combinations along with epinephrine which include lidocaine or lidocaine with Marcaine bupivacaine dilutions. Although both are effective at pre-operative local numbing, investigators have seen less reported pain outcomes as perceived by the patient feedback. Therefore, investigators aim to identify specifically the usage of post-operative pain medication with those who had an epinephrine/lidocaine local anesthetic vs. those who had the epi/lidocaine/bupivacaine combination. Patients will be informed about the study and consented for participation. They will be randomized pre-operatively by permuted block assignment to the control treatment (1% lidocaine with 1:100,000 epinephrine) or the study treatment (1% lidocaine with 1:100,000 epinephrine mixed 1:1 with 0.5% Marcaine bupivacaine with 1:200,000 epinephrine) using a predetermined weight-calculated maximum dosage that would be safe for injection of either anesthesia.
As per standard procedure, the patients will be premedicated with a standardized dose of versed if determined necessary by anesthesia. Anesthesia will be induced utilizing weight based dosing of propofol and rocuronium. Intraoperative anesthesia will be maintained utilizing total intravenous anesthesia (propofol, fentanyl/remifentanyl doses). All patients will be given antibiotics (weight based dosing, Ancef or Clindamycin) and 8mg of dexamethasone prior to skin incision. Once anesthesia has been induced, the nose will be injected with local anesthesia as follows: transcutaneous to the bilateral dorsal nasal and the angular neurovascular bundles, transcutaneously along the columella and nasal dorsum, transnasally along the nasal dorsum and ala, the bilateral nasal septum, and the inferior turbinates with a total dose of 10ml's. Topical decongestion and anesthesia will then be obtained with 3 x 0.5cm cottonoids soaked with 4% cocaine placed bilaterally. A standard external rhinoplasty approach will the be performed, and grafting done as necessary. At then end of the procedure, Doyle nasal septal splints will be placed (Reuter-Bivalves if alar grafting performed).
In the immediate post-operative period, pain will be controlled with short acting analgesics (standardized regimen for all patients to be decided with anesthesia team) while in the acute care setting and recorded again as per standard of care. Once discharged from acute care, the patient will be given instructions to control their pain with acetaminophen (1000mg every 8 hours) scheduled during the first 72 hours, then as needed thereafter. They will also be given a prescription for oxycodone (15 tablets) with instruction to take 5mg every 6 hours as needed for breakthrough pain. They will be provided a pain diary for the first 24 hours to record their pain using the Faces scale (ranging 1-10 with 1 being no pain up to 10 being the worst pain ever experienced) at the 1, 2, 4, 6, 12, and 24 hours marks after discharge from surgery. Additionally, they will be asked to keep track of how many pain medications (oxycodone) they took over the first week after surgery. Their pain scores and amount of medication utilized will be recorded upon their follow up visit to the clinic.
