The prospect of pain after a plastic surgery procedure is a key concern that causes patients to hesitate about having surgery. Many surgeons breeze over this aspect of the surgical discussion, as the usual protocol has been pain pills and rest. During my years of practice, I have come to understand the profound significance of poorly managed pain and the adverse results that can occur. My goal is to reduce the use of opiates and give an easy recovery process with a rapid return to daily life. I achieve this via a three phase process: preparation prior to surgery, the surgery itself, and post-operative care. Using this protocol, many of my plastic surgery patients are back to normal within a few days.
- Prior to surgery: Stop taking medications and substances that rev up your liver and increase your resistance to anesthesia – namely, herbal supplements, alcohol, and narcotic pain medications. Also, stop taking substances that increase the tendency to bleed – ibuprofen, aspirin, and fish oil supplements. Focus on hydration and increase your daily aerobic activity (even if it just walking a bit more). This increases your fitness and increases resistance to discomfort.
- During surgery: I practice meticulous minimization of blood loss and minimal tissue trauma during the procedure. I also infuse a long acting numbing agent (Exparel®) that acts to make the entire surgical area virtually pain free for three days after the procedure. This reduces the need for administration of strong opiates, such as fentanyl, during the surgery and reduces the need for oral opiates after surgery. The result is less nausea, less constipation, and a clearer mind. Many patients rate their pain 3/10 immediately after the procedure.
- After surgery: Cold compresses are placed on the surgical site. These are left on for twenty minutes at a time, once every hour while awake for the first evening. Patients are encouraged to eat a light meal the first night and return to their usual diet the next day. Over the counter pain medicines are encouraged for management of pain, and the patient is advised to get up and about the next day.
The result is a fast recovery with a lower chance of problems such as constipation, opioid dependence, and complications such as deep vein thrombosis and pulmonary embolism. In my mind, the real game changer has been Exparel®, which results in a tremendous decrease in immediate post operative pain – the pain that most people remember. Exparel® enables the patient to get through the first three days with minimal pain and has no addictive or mind altering effects. This has cut the need for oral pain medications down to a fraction of what was needed before. Patients who used to need to be hospitalized for pain control can go home and sleep in their own bed the night after surgery.