Just got off the phone after doing a major tummy tuck on a patient.
“How are you doing?”
“Great!” “I’ve walked around a bit, had some Gatorade, and am watching TV.”
“How many pain pills have you taken? Is your pain controlled well?”
“I haven’t taken any pain pills.” This is 8 hours after major surgery, with getting into the car, a car ride, getting into the house, walking around in the house to go to the bathroom and living room. To have a tummy tuck and not need any medications after – and this is *not* because of anesthesia, the agent we use for that is long gone- is revolutionary.
So why is this so important? Tummy tucks (also known as abdominoplasty) were traditionally admitted to the hospital for an overnight stay when I first started my practice twenty years ago. Now, almost none of my patients stay overnight. Why did they stay overnight? It wasn’t because of bleeding or fluid issues or some other medical thing.
It was for pain control.
- Pain control is important so you feel comfortable. Ouch.
- Pain control is important because if you are in pain, you don’t get out of bed and walk around. There is an association between pain control and DVT risk. Those in pain —>move less—-> higher DVT rates.
- Pain control is important for tummy tucks because when your belly hurts you don’t take deep breaths. Not breathing deeply increases your rate of atelectasis (where your lungs don’t open fully), which can lead to fevers and ultimately pneumonia.
- If you are in pain it can raise your blood pressure. Higher blood pressure means increased bruising and risk of bleeding.
- Walking after surgery can help move your bowels faster. If you are in pain, you don’t walk as much, and your risk of constipation is higher. Once you are passing gas or have a bowel movement you can eat real food.
Why do tummy tucks hurt? It isn’t the big scar. It is from the muscle repair, where we fix the diastasis (fancy way of saying muscle separation) which occurs after pregnancy or major weight change.
I started using implantable pain pumps years ago (the onQ pain pump). These pumps had two little catheters which I placed during surgery which released numbing medication slowly over the course of three days. They worked well, but it was another thing to deal with after surgery (there were tubes and a bulb you wore in a super fashionable fanny pack).
Then Exparel came around. It is an injection I do at the time of surgery, where the numbing medication is wrapped in liposomes to allow a slow release of the numbing medication over the course of three days. There is a lot of data indicating if you never allow your body to mount a pain response, your pain levels overall are significantly lower.
What have I seen?
Since starting Exparel a few years ago, I have many patients who take almost no pain medication after or significantly reduced amounts. They are happier and more mobile. They take less narcotic pain pills, which is great- narcotic pain pills can 1. constipate you and 2. are addictive.
The negative? The only negative I have found is the cost- Exparel is pricey (At this time about $350). But I think worth it given all the positives. I do have some patients who still need a traditional dose of pain pills and muscle relaxants after tummy tuck even with the Exparel, so it isn’t foolproof. Everyone has different levels of pain tolerance. But after doing so many of these before and after Exparel, I am truly a fan.