Rhinoplasty under general anaesthetic: why it’s the preferred choice

If you’ve spent any time researching rhinoplasty, you may have come across the term ‘twilight anaesthesia’ as the superior alternative to rhinoplasty under general anaesthetic and going fully under. It can sound appealing: less intervention, a quicker wake-up, a lighter experience all round. But for the vast majority of rhinoplasty and septorhinoplasty procedures, it isn’t the preferred option, and it isn’t what Mr Annakan Navaratnam uses for most of his patients.

We spoke to Dr Toby Ashken, consultant anaesthetist at University College London Hospitals (UCLH) and Honorary Clinical Teaching Fellow at UCL, who has worked alongside Mr Navaratnam for many years, about why general anaesthesia is the preferred approach for most nasal surgeries, and what patients can expect on the day.

Twilight anaesthesia isn’t as clear-cut as it sounds

The first thing to understand, Dr Ashken explains, is that twilight anaesthesia is essentially a form of deep sedation, and the line between deep sedation and general anaesthesia is far blurrier than the marketing suggests. “It’s not really a black and white line,” he says. “In practical terms, the key difference is that under general anaesthetic, an airway is secured. Under twilight anaesthesia, it isn’t.”

That distinction matters more than patients might assume. “With twilight anaesthesia, you can’t really guarantee the patient won’t recall anything,” Dr Ashken says. There is also less control over the patient’s blood pressure, which has a direct bearing on the surgical field and can influence the outcome of the procedure itself.

“It’s not to say that there’s no role for deep sedation, but in my opinion, it’s not the optimum approach for rhinoplasty procedures.”

Why the nose makes this especially important

Rhinoplasty and septorhinoplasty present a particular challenge: the nose is both a very small operating area and highly vascular. “Even quite small amounts of bleeding obscure the surgical field and make it harder for Annakan to do the operation technically,” Dr Ashken says. Under general anaesthesia, the anaesthetist has far more control over blood pressure, keeping the field as clear as possible for the surgeon throughout.

These procedures are also more invasive than patients might picture from the outside. Septorhinoplasty typically involves inserting an endoscope into the nose and reshaping the bone and cartilage, which can be traumatic if recalled later.

For context, UCLH, where Mr Navaratnam holds his NHS practice, runs one of the largest rhinoplasty practices in the country, and procedures are done under general anaesthesia as standard. Dr Ashken is clear that this isn’t because twilight anaesthesia is inherently unsafe.

“I don’t think there’s a big distinction between the safety profiles of general anaesthesia and twilight anaesthesia,” he says. “Rather, it’s that twilight anaesthesia sits in more of a grey zone, whereas general anaesthesia is a far more controlled, predictable experience for both the surgical team and the patient.”

There are plenty of operations where Dr Ashken uses deep sedation routinely – often alongside a nerve block, so the patient is comfortable and calm in theatre while the “hard work” of numbing is done by a local anaesthetic. It’s an approach he uses often for hand or elbow surgery, for example. “But that’s quite difficult to do in the nose.”

Longer, more complex procedures need more control

Mr Navaratnam’s operations aren’t always short. “His operations can take several hours,” Dr Ashken explains. “Also, surgery can reveal more complexity than anticipated once underway. For procedures of this length and unpredictability, general anaesthesia gives both the surgeon and the anaesthetist far more control over the patient’s condition throughout the procedure.”

What patients can expect from rhinoplasty under general anaesthetic

For anyone who hasn’t had a general anaesthetic before, Dr Ashken talked us through the process from booking to recovery.

Pre-assessment

Once surgery is booked, patients are contacted by the hospital or clinic’s pre-assessment service. This is usually a form, sometimes followed up by phone or in person, and a nurse will go through details including allergies and any previous experience of anaesthesia.

For Mr Navaratnam’s patients, this is also where any breathing issues linked to septal problems are identified, alongside a general screening for heart, lung, and other health conditions. If anything is flagged, it’s communicated to Dr Ashken, and further tests – such as blood tests – may be arranged to ensure the patient is optimised for anaesthesia.

Before surgery

The hospital provides instructions on arrival time and, critically, fasting. “Having a full stomach under anaesthesia is basically quite dangerous,” Dr Ashken says, and operations will be postponed if fasting instructions aren’t followed, purely for safety reasons.

On the day

Patients are seen by both Mr Navaratnam and Dr Ashken on the morning of surgery. Mr Navaratnam goes through surgical consent, while Dr Ashken talks patients through what to expect and rechecks allergies and medications. Once in theatre, standard monitoring is attached: a blood pressure cuff, ECG dots across the chest to track heart rhythm, and a sensor on a finger for oxygen levels. An intravenous line is placed so that anaesthetic drugs can be administered.

Going to sleep

For approximately 95% of Dr Ashken’s patients, everything is delivered through that IV line – an approach called total intravenous anaesthesia, or TIVA. A mask is still used, but it delivers only oxygen. “I favour TIVA because patients tend to wake up better afterwards, with fewer side effects.” The first medicine typically makes people feel lightheaded, sometimes slightly euphoric; the second brings sleep within about 30 seconds.

Once asleep, Dr Ashken adds a further piece of monitoring – a sensor across the forehead that reads electrical activity in the brain’s frontal region. “This technology has become more widely used over roughly the last decade. It allows us to judge the depth of anaesthesia precisely: not so light that a patient risks becoming aware during surgery, but not so deep that recovery – particularly for older patients – takes longer than necessary.”

During surgery

Dr Ashken remains in the room throughout, continuously monitoring the patient. Rhinoplasty and septorhinoplasty fall into what anaesthetists call shared airway surgery: because the surgical site is the airway itself, the patient’s head is positioned further away from the anaesthetist than in most other operations, and the surgeon’s work can directly affect the airway that’s been secured.

Dr Ashken points to his long working relationship with Mr Navaratnam – built up over many years, since before either of them became consultants – as an important part of managing this safely.

Waking up

As the operation finishes, the anaesthetic is lightened, and patients typically wake within minutes. Most don’t remember the first ten to fifteen minutes afterwards at all, even if they were talking during that time. In recovery, a dedicated nurse looks after each patient one-to-one, offering food and drink (most patients are hungry after fasting) and making sure they’re comfortable and free of nausea before they’re moved to the ward. Mr Navaratnam and Dr Ashken typically check in again later the same day.

Recovery after rhinoplasty under general anaesthetic

Coming round after septorhinoplasty isn’t inherently harder than after other operations, Dr Ashken says, though patients often want to touch their nose because of the cast, and aren’t fully lucid for the first ten minutes or so. Septorhinoplasty is not an especially painful operation, and most patients recover quickly, wake, and return to the ward.

“As a rule, longer anaesthetic times or being unwell before surgery can extend recovery – neither of which tends to apply to Annakan’s patient group, who are often younger, generally well, and back to themselves quickly.”

The success of a rhinoplasty is not solely dependent on surgical skill; it is a collaborative effort where expert anaesthetic planning plays an indispensable role. Mr Annakan Navaratnam has worked exclusively with a small team of consultant anaesthetists for many years. This partnership ensures every aspect of your well-being is managed to the highest standard, directly contributing to a safer procedure, a smoother recovery and, ultimately, a better result.

To find out more about rhinoplasty under general anaesthetic, and what to expect during your operation with Mr Annakan Navaratnam, call +44 (0)203 627 2918 to arrange a consultation.