Using Nerve Blocks to Avoid Pain and Narcotics for Rhinoplasty

What if patient pain and narcotics use during and after rhinoplasties could be reduced by 90%? Anil R. Shah, MD, FACS, a facial plastic surgeon in New York, New York, sought to prove that it can be done when he studied the use of a nerve block on 357 rhinoplasty patients, and the results were overwhelmingly positive: All but two of the patients had no pain and did not require narcotics. Dr. Shah, who has authored multiple articles about the nerve block technique,^1,2 presented the findings of the new study at the most recent American Academy of Facial Plastic and Reconstructive Surgery Annual Meeting and Global Aesthetics Conference. Modern Aesthetics® caught up with him to discuss the background and impact of these results.

What about the state of rhinoplasties made you decide to pursue a technique like this?

Of all things, my mother had wrist surgery with a highly esteemed surgeon. When I called her a few days later, I expected her to be on heavy drugs for the pain, but she was out shopping and said she had zero pain. I asked her how that was possible, and she said the doctor had done “a nerve blocky thing.” I thought that was amazing, and I wondered why no one does that for rhinoplasty—especially because research had shown that patients who have more pain tend to be less satisfied with their outcomes from rhinoplasty, and I had observed this in my own practice as well.³ A light bulb went off in my head and I thought, “Why don’t we see if we can use this nerve block to improve the patients’ outcomes and really prevent pain from happening?” It took a bit of trial and error; in the recovery room, I asked patients questions like where their pain was mostly located. It took a few years. Finally, after interviewing large numbers of patients and trying different strategies, I identified a few spots where I could predictably get their pain to go away with an injection. That was when we started the study of our patients. We looked back at 357 patients, and 355 essentially did not have any pain after the rhinoplasty, which is more than 99%.

What was the injection that you used?

It’s a combination of drugs: Bupivacaine mixed with dexmedetomidine and dexamethasone. The combination of all three results in a nerve block lasting for about 3 days.

How did you identify that combination?

Just diving in deep. It is slightly different from what my mother had. I talked to other doctors who do nerve blocks and studied the literature. This seems to be the combination that has the least amount of potential risk with the most potential value.

How much risk is there?

Truly, it’s a field block, not a nerve block, because we are injecting in the area of the nerve—not right into the nerve—and the chance of harming a nerve is extraordinarily low. I tend to be risk averse, so I angle my injection a certain way to ensure I am not at the nerve, just in the area of the nerve. I have not had a single issue with the nerve block in any of my patients, and I have used this for thousands of patients now.

What has the overall impact and value been?

These patients have less nausea and vomiting, and far less pain than those without nerve blocks. They are spending less time in the recovery room. Nausea and vomiting can affect sutures, so this truly improves outcomes as well. Not surprisingly, patients overall have more predictable results and greater satisfaction.

Does it make the surgeon’s job easier in any other ways?

There are certain things that can really get a surgeon into trouble, and one of those things—especially with the Netflix specials—is overprescribing opioids. The amount of opioids you need to prescribe to have a potential fatal outcome is not much. If you prescribe 10 mg of hydrocodone, if the patient takes one or two more pills, they can overdose and die; 20 mg is the overdose amount. I sleep better at night knowing that my patients have less chance of something adverse happening, even if they accidentally take the wrong medication or their timing is off. I’m happy that my patients are both safer and pain-free.

Is there potential for using this strategy for other procedures besides rhinoplasty?

I have begun to incorporate this in other areas—for example, a chin implant. Typically, patients have extreme tenderness for about 24 to 48 hours. With this injection, again, patients are almost pain-free. Otoplasty is another area that’s highly sensitive. The main message here, too, is recovery. If you’re taking narcotics, you can’t drive a car or make life-changing decisions. With nerve blocks, you can work from home or do schoolwork. You don’t need to lose a week of your life, which is important.

Do you envision this catching on with your peers, or do you want to keep this proprietary for your practice?

I want everyone to do this. As surgeons, we sometimes care just about our technical results, and afterward, we just hope the patients do their best and ice. We should take the time to care about what it’s like to have pain, talk to our patients, and keep in mind how dangerous opioids can potentially be. My goal is for fewer opioids to be prescribed and for patients to lose less time and have a much better experience recovering from all sorts of surgeries.

1. Cheung MM-L, Shah A. Minimizing Narcotic Use in Rhinoplasty: An Updated Narrative Review and Protocol. Life. 2024;14(10):1272. doi: 10.3390/life14101272.

2. Schumacher JK, Cristel RT, Talugula S, Shah AR. The Use of Adjunctive Perioperative Nerve Blocks in Rhinoplasty in the Immediate Postoperative Period. Facial Plast Surg Aesthet Med. 2023;25(4):361-362. doi: 10.1089/fpsam.2022.0125. Epub 2022 Sep 14.

3. Gadkaree SK, Shaye DA, Occhiogrosso J, Lee LN. Association Between Pain and Patient Satisfaction After Rhinoplasty. JAMA Facial Plast Surg. 2019;21(6):475-479. doi: 10.1001/jamafacial.2019.0808.