I’m always learning. This month’s Aesthetic Surgery Journal September 2024 had a pull-out section on how to optimize pain control after surgeries, of major importance- how to use DIFFERENT ways to address pain, to make it safer. I love this. I think it is important to come at pain from different directions, as for some people one medication works way better than another, and you minimize side effects if you take less of any one thing.
This article was about tummy tucks in particular, as abdominoplasties continue to be one of the most painful surgeries we do as plastic surgeons. Unlike when I started my practice, now most of our patients go home the same day. How I treat tummy tuck pain control has evolved with time. I used to use a pain pump that dripped numbing medication internally, but switched to Exparel so my patients don’t need to deal with more tubes and reservoirs.
My current regimen:
- I love Exparel, an injection I do into the rectus muscle sheath during surgery to help numb the area (the muscle is what hurts).
- I use Celebrex, an NSAID which unlike ibuprofen and other NSAIDS, does not increase the risk of bleeding.
- I love Tylenol.
- I believe in muscle relaxants and narcotics too- but I really try to minimize use of things you can get a tolerance to and can impair you. Narcotics are the worst for side effects. They can constipate (and bloating is super painful after abdominoplasty, and you don’t want to strain to have a bowel movement), make you feel nauseous, make you feel out of it, and build a tolerance. We as surgeons try to not prescribe opioids or limit it as much as we can.
So what did this article say? “Multimodal Pain Control in Abdominoplasty: A Systematic Review and Algorithm of Optimal Pain Management.” This was a review of the literature, which found 32 studies with 2451 patients looking at different pain regimens. All studied showed less narcotic use.
What were the basic things they found?
- NSAID (specifically celebrex, which does not increase bleeding risk). They recommend this pre surgery, postop in recovery, and postoperatively
- Acetaminophen (tylenol). They recommend this preoperatively as well
- gabapentin. Can be given perioperatively
- dexamethasone. Intraoperatively or post operatively.
- local and regional anesthesia. This is done on almost all surgeries, as local anesthesia doesn’t allow your body to mount a pain response (when we cut), which has been shown to decrease postoperative pain. It also has epinephrine for the skin injections, which keeps the anesthetic working longer and reduces bleeding. In the article, it stated local anesthetic “improves postop nausea and vomiting, reduces pain scores, opioid usage, and length of hospital stays.
- catheter pain pumps
- ultrasound guided nerve blocks. The optimal site of nerve block is an “area of active research”, though the most common currently is the transversus abdominis plane, shown to reduce opioid usage, length of stay in hospital, and pain scores.
They strongly advocate for “multimodal” pain regimens- that means coming at the pain from many different ways- as the best. They talk about progressive tension sutures helping with post op recovery (which I do, but not sure how that helps with recovery other than less fluid formation so less swelling?). They even talk about a time of a “completely painless abdominoplasty.” Love their inspiration, but not sure I can see that for a long time… And I don’t think pain is all bad. A little pain keeps you from doing things you shouldn’t. It’s a gentle reminder that your body is healing.
They end with a sample regimen, most of which I already do.
My thoughts?
Speaking to the choir. There is an ERAS protocol- “Enhanced Recovery After Surgery”-used in reconstructive surgery, and most of the tenets here are similar. I have read data that gabapentin does not help, so I do not use that. I also do not do an ultrasound guided block, and I prefer Exparel over a catheter pain pump. But I do follow most of the other recommendations.
Am I sad they didn’t have much to add to what I do? No! I’m thrilled that I’m on top of it. The beauty of being a doctor blogger- being up to date. 🙂