Plastic Surgery – Pain and discomfort worse than anticipated?
Written by Mark Domanski, M.D.
The topic of surgical pain and discomfort management frequently arises in online plastic surgery groups and threads so I am going to explore it further.
When I was in medical school, patients with pain received opioids. However, this overly simplistic approach was not comprehensive and had other risks. Thankfully, today’s approach to postoperative pain management is more comprehensive.
As plastic surgeons, we need to thank our colorectal colleagues who developed ERAS, Enhanced Recovery After Surgery. I have adopted several of these elements into my plastic surgical practice.
Before surgery
Before surgery, I will sometimes prescribe a pain medication called Gabapentin (Neurontin). Gabapentin focuses on neuropathic pain and can be taken with a sip of water the morning of surgery. An interesting side effect is that patients report feeling calmer after a single dose.
When applicable, I will encourage carb loading in the two days prior to surgery. We do it for marathons don’t we? I believe this helps recovery.
Evidence shows that many patients can avoid prolonged fasting before surgery – and may be able to drink clear liquids up to 3 hours before anesthesia time. This advice must be altered for patients with delayed gastric emptying, such as those taking GLP-1 medications.
During the procedure
During the procedure, I typically inject a long-acting numbing medication, called Marcaine (bupivacaine) into the surgical area. This will decrease the amount of anesthetic agents patients need during surgery, making recovery easier. Long acting numbing medication keeps the surgical site numb, often for 1 to 2 days – reducing narcotics when patients go home.
At the end of the surgical procedure
At the end of the surgical procedure, I will ask the anesthesiologist to administer a medication called Toradol (Ketorolac). This decreases immediate postoperative pain. Some physicians are concerned that Toradol may increase bleeding risk. However, one of the largest risks for bleeding is high blood pressure. Because patients in pain tend to have higher blood pressure, I believe the benefits of controlling the pain with Toradol outweigh the risks.
After surgery
After surgery, I will recommend a combination of a narcotic, Tylenol, and or ibuprofen for postoperative pain. Many of my patients are able to minimize or even completely avoid narcotics.
In summary
In summary, my approach to managing postoperative pain differs from what I learned in medical school. Instead of using only one medication, I use several to maximize the benefits while minimizing risk. Pain control starts before the day of surgery, and continues until medications are no longer needed.
Sincerely,
