A total of 859 patients presenting for outpatient rhinoplasty were divided into two groups that received intravenous sedation of midazolam 0.1 mg/kg either with or without ketamine 0.4 to 0.5 mg/kg immediately prior to conduct of the local anesthetic injections and surgery. Additional midazolam was given intraoperatively as needed. No patient received narcotic either as premedication or intraoperatively. Patients were evaluated by the surgeon on their response to the injections and surgery, and patients were given a questionnaire 1 week postoperatively to examine their response to and recall of the procedure. Scoring by both the surgeon and patients revealed that the great majority of patients in both groups had adequate "sedation." Patients from both groups related a high degree of satisfaction (> 90 percent) with the technique of sedation. The differences between the two study groups achieved statistical significance only on 4 of the 12 parameters investigated. Those who had received only midazolam were less likely to vocalize during the surgery or to experience the procedure as being of undue duration. Those who had also received ketamine had a lesser chance of remembering the local anesthetic injections (11.1 versus 19.8 percent) and a lesser likelihood of being dissatisfied with their surgical experience (3.3 versus 7.4 percent). In conclusion, the use of an opioid-free sedative technique of intravenous midazolam was highly successful in meeting the needs of both patients and surgeons. The addition of a single preblock dose of intravenous ketamine to intravenous midazolam sedation for rhinoplasty does not improve intraoperative conditions for the surgeon in terms of patient behavior.(ABSTRACT TRUNCATED AT 250 WORDS)