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LOCAL ANESTHESIA NOSE.
FOR LOCAL ANESTHESIA Rhinoplasty

We have seen in Part 8, the sensory innervation of the nose now show as technique infiltration of the nose with local anesthesia for rhinoplasty .

is performed with intravenous sedation and control of anesthesiologist.

Topical anesthesia of the nose

Refers to anesthetize the nasal mucosa previously local anesthesia, is used to prevent pain in the nasal mucosa causing local injection into nose and cause vasoconstriction of the mucosa , the solution of cocaine 5% or 2% lidocaine with epinephrine 1/200.00 + 1 ml of adrenaline 1 / 1000 results in decreased size of blood vessels intranasal, therefore, during infiltration and surgery is a bloodless surgical field, ie the normal pink mucosa turns whitish meaning there will be a surgery with very little bleeding because the small blood vessels decreased the diameter of their lights.

Before infiltration, proceed to place buffers embedded into cocaine hydrochloride 5% or 2% lidocaine with epinephrine , plus 1 ml of adrenaline if not available the first solution, a wad of cotton or gauze is placed in the nasal dorsum, nasal root where the anterior ethmoid N. enters the nasal cavity , another buffer is placed in the middle meatus between the inferior turbinate and middle turbinate and gets along all the way back to numb the spheno-palatine ganglion to block nerve branches leaving the ganglion in Meckel and supply the sidewall.

Another buffer septum on your wall medial para reforzar la anestesia de los Ramos nasales internos del N.Etmoidal anterior    y otro en el  piso nasal  para reforzar la anestesia del N. Nasopinoalatino .

Estos tampones embebidos antes de su colocación son exprimidos para no exponer al paciente a grandes cantidades de la solución. Se dejan los tampones unos pocos minutos y se observa su acción vasoconstrictora y se comprueba su acción analgésica de la mucosa.  

LOCAL ANESTHESIA FOR RHINOPLASTY

There are several solutions at various dilutions anesthetic used to numb the entire nose. You use that one is accustomed to using.

So

• anesthetic solution No. 1 : 20 ml of 2% lidocaine with 1/200.000 adrenaline plus 0.5 ml of adrenaline 1 / 1000. Good anesthetic effect, very tachycardic.

• anesthetic solution No. 2 : 10 ml of lidocaine with adrenaline 1/200.000 + 10 ml of saline + 3 cc of prepared solution (9 ml saline and 1 ml of adrenaline 1 / 1000) Good

anesthesia, less tachycardic than the last.

Al infiltrate nose using 1 ml of the solution at each point with 1 ml insulin syringe and needle 27 G , this maneuver prevents injecting a large volume of anesthetic masking the essential reference points for a rhinoplasty and avoiding unnecessary overdose.

• The first point to infiltrate with 27 G needle and syringe for insulin is to block N. Infraorbital terminal branch of maxillary N. whose emergence of infraorbital foramen is approximately one finger and inferior orbital rim in the front of the line half pupil. This point of infiltration that is placed perpendicular to the skin, anestesia la piel  del ala nasal , labio superior , mucosa , encía vestibular mesial del canino , región cigomática ( pómulos ) y párpado inferior .

• El 2º punto, se inyecta profundamente ( subdérmica profunda ) con la aguja encima del periostio  y paralela a la pared lateral nasal   y en la parte externa del ala nasal ya anestesiada con el bloqueo del N. infraorbital 21 G needle toward the nasal root from here is performed retroinyección below and down the side wall of the nasal pyramid and needle emerges at the point of initial entry point with this 2 nd N. Hangs infratrochlear N. branch Nasal or nasociliary and it is so numb the skin from the nasal root to nasal wing, all the way to the base p ared side of the nose.

• The 3rd point is injected with 1ml insulin syringe and needle 27 G, perpendicular to the nasal root to block the branches of N. supratrochlear N.frontal branch being anesthetized glabellar and nasal root again. This maneuver is similar to injection of botulinum toxin to block contraction and procerus muscle hypotrophy.

• E l 4 second point, again using 27 G needle and placed in the skin of the nasal root already anesthetized in the subdermal plane deep ( supraperiostal ) parallel to the base of the pyramid to left nasal wing without exteriorized at that point, retroinyección used again from the wing to nasal root. This infiltration acts on the N. infratrochlear in N. and infraorbital areas are anesthetized nasal root, the side wall of the nose , left nasal wing, upper lip . You can, if necessary to inject as has been done in by 1 point ( block or infraorbital infraorbital )

• The 5 th point, intranasal , retracts, up to a double hook nose the nasal right wing and fed insulin syringe with 21 G needle at a point below the internal nasal valve (where then made the incision intercartilaginous ) and is at the junction of superior and lateral cartilage the septum. The needle is inserted between the alar cartilage and lateral cartilage and passes over the lateral cartilage , the apex of the nasal bones themselves to nasal root and glabella as the need arises , and from that point, a retroinyección to emerge again in the initial entry point. This injection to numb the back nasal cartilage (cartilage top), back bone (nasal bones themselves ) nasal root and glabella . Injection No. 5 blocks to N. anterior ethmoid and its internal and external branch.

If necessary, perform the same shot on the left side.

• The 6 th point can be ignored and goes straight to No. 7 and then to No. 8, which is performed by injecting 1 ml syringe and 21G needle in subseptum to ENA ( anterior nasal spine), or it is injected into base of columella up to the ENA

• The 7 th point injection is 1 ml syringe and 27 G needle in nasal mucosa beginning in lateral cross and addresses cross medial to domus. This point itself is No. 7 bilateral should be done on both sides.

• The 8 th point I prefer to inject into columellar base to the anterior nasal spine

• The last point, No 9 also is bilateral, 21 G needle and syringe of 1 ml be numbed septum is slowly injected into a submucosal plane (between mucosa and septal cartilage ) on your right side wall and progresses by injecting 0.10 ml hydrodissection evidence and controlling heart rate begins to rise because the rapid absorption in this zone of adrenaline contained in local anesthetic solution. It continues to inject metered all along the side wall of septum a length of 4 cm which is the length of the needle 21 G to finish 1 ml total volume which is the syringe. The same maneuver is repeated with the same care on the left side of the septum . Setum area itself, received 2 ml of anesthetic solution.

15-20 minutes are expected to normalize the heart rate, usually with an injection of anesthetic into the space between septal mucosa and septum increases heart rate by approximately 20%. Notice that the solution has produced its e vasoconstrictor defect if it is observed that the mucosa that normally has a pinkish pale features, and predicts a surgery with little bleeding, this is valid for the entire mucosa nasal.

The arterial supply of the septum in part:

• and a half later, comes from the sphenopalatine artery through the internal branch or nasopalatine turn branch of the internal maxillary and this Section of the External carotid .

• anterior and inferior : comes from the Subtabique Artery, a branch of the Facial and that from the external carotid.

• anterior-superior and postero-superior : comes from the anterior ethmoid artery and posterior ethmoid respectively and are branches of the ophthalmic artery and this of the internal carotid

In the span of normalizing heart rate, we proceed to cut the whiskers for improved visualization of intranasal operative field and prevent these hairs are introduced once the wound edges sutured incisions intranasal and act as foreign bodies and produce irritation and scarring folliculitis in intranasal .

point is placed 4-0 in subseptum mononylon to embrace the columella and repaired (sustained Kelly hemostat or forceps mosquito) will serve to give (show) area membranous septum, the area intercartilaginous (bottom edge of the triangular cartilage and cephalic border cuz alarming side-) and medial cross the domus.

Rhinoplasty In part 10, will show how to perform a classical rhinoplasty .