This was a comprehensive journal article looking at “Safety of Postoperative Opioid Alternatives
in Plastic Surgery: A Systematic Review,” in the Plastic and Reconstructive Surgery Journal back in 2019. We plastic surgeons are always striving to improve care for our patients, and in the face of the opioid epidemic we are always trying to figure out how to control pain better without having some new and exciting complication like bleeding, excessive cost, or other issues.
In this article, they looked at 34 journal articles, which focused on alternative treatments.
- NSAIDS are nonsteroidal medications like ibuprofen. They are great pain relievers, but the issue for plastic surgery cases is their issue with increased bleeding.
- Celecoxib. This is a version of an NSAID, but binds to different receptors, so it has minimal effect on platelets. It may not have the same effect on bleeding risk as other NSAIDs.
- Acetaminophen IV. This is plain old Tylenol, and is a great method for pain control. There is Acetaminophen in most of the opioids we prescribe (Vicodin, Norco, and Percoset). It is not an okay medication if you have liver issues.
- Ketamine. This is an anesthetic that also sedates, causes amnesia (you forget), and reduces pain. It can cause hallucinations, unpleasant dreams, and other effects.
- Gabapentin is an anticonvulsant. It is not allowed in those with kidney issues or who take benzodiazepenes (Valium, Ativan)
- Liposomal Bupivicaine. This is Exparel. It is a numbing agent with time release. It cannot be mixed with lidocaine.
- Nerve blocks. This is where a numbing agent is injected near a nerve to block the pain pathways. The issue with these is that there is a risk of pneumothorax (dropping the lung) and nerve injury as you are generally injecting deeply.
Opioids are the bread and butter of pain control when bleeding is a concern. But they are not without their issues. In addition to the risk of addiction and tolerance over time, they cause nausea, constipation, and respiratory depression.
So what did they find?
I can get into more details in another blog, but after their review, they came up with these recommendations:
- Preoperative IV Acetaminophen or ketamine after procedure
- Superficial T3 to T4 perforator blocks or transversus abdominis plane blocks with Exparel
- Ibuprofen, Ketorolac, or Celecoxib as part of the postoperative pain management.
- Adding gabapentin for longer postop recovery
- Systematic decrease of opioid dose, duration, and refill.
My thoughts?
This is an important topic. I already know that gabapentin has been looked at deeply, and the conclusion now is that if offers no improvement in recovery. I like the idea of IV Acetaminophen but when Vicodin and Percoset contain Acetaminophen, you need to look at the total daily dose of it to avoid damage to your liver. Doing perforator blocks sounds good, but if they have a bigger risk – if in the ribcage for breast surgery procedures you can drop the lung (pneumothorax), and you run the risk of causing bleeding or nerve damage.
The one on here which is truly interesting to me is Celecoxib. As a different kind of NSAID which doesn’t inhibit platelet function, it may not have the bleeding side effects of the others.
Stay tuned.
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