Surgeons and anesthesiologists are finding new and better ways to alleviate the pain and PONV associated with such major cosmetic procedures as abdominoplasty, breast augmentation and major liposuction. This is welcome news in cosmetic surgery, where comfort runs a close second to desirable results when it comes to happy patients. Here's a sampling of the latest in helping cosmetic surgery patients recover more comfortably.

Pain reduction strategies
Cosmetic surgeons say that, in some cases, refining the surgical approach can lessen pain, and that targeting analgesics to the exact source of pain can help alleviate pain more effectively than ever before.

• Refined surgical approaches. When it comes to liposuction, Bruce E. Katz, MD, with the Mount Sinai School of Medicine and JUVA Skin and Laser Center in New York, says his comparative studies of the right and left flanks on the same patients show that powered liposuction can reduce intraoperative pain by as much as 45 percent over manual liposuction while reducing post-op pain, ecchymosis and edema by about one-third.

"When you're using a manual cannula, you cannot keep your hand aiming in one direction," says Dr. Katz. "The powered, reciprocating cannula is much more exacting and creates a lot less side-to-side tissue trauma and torque on the tissues."

Dr. Katz, who performs powered liposuction using tumescent (lidocaine) anesthesia in sedated but aware patients, says the powered cannula is especially beneficial for eliminating intraoperative discomfort around the sensitive peri-umbilical area. He also says that the reduced bruising, along with a hastened recovery period, leaves many patients with the perception of an improved cosmetic result. To further improve comfort, Dr. Katz also administers nitrous oxide to help patients tolerate the sting of the local lidocaine injections. The power liposuction machine costs about $12,000, he adds.

During his breast augmentation cases, Peter T. Pacik, MD, a board-certified plastic surgeon in private practice in Manchester, N.H., says overstretching of the pectoralis major muscle, which he achieves by temporarily overfilling implants intraoperatively, helps reduce post-op pain.

"In our population of 500 augmentation patients, there has been a statistically significant reduction in post-op pain after intraoperative stretching," says Dr. Pacik, whose controlled study will soon be published. "Intuitively, one might think this would increase pain, but expansion helps prevent post-op spasms because it stretches the muscle."

Dr. Pacik says his extensive research also shows that, contrary to conventional wisdom, the type of dissection (blunt versus sharp) and procedure duration have no effect on post-op pain. "It has always been my opinion that a careful, meticulously performed operation during which we maintain control over bleeding will help minimize pain, no matter how long it takes," he adds. "It is known that blood in tissues causes pain."

Finally, adds Bruce A. Mast, MD, a board-certified plastic surgeon in private practice with Accent Physician Specialists, PA, in Gainesville, Fla., staples hurt more than sutures. While most surgeons know this, some continue to use staples, he says.

• Targeted analgesia. During breast augmentation, placing a local analgesic directly into the implant pocket can reduce post-op pain. In one recent controlled, double-blind study, the combination of ketorolac 30mg and bupivacaine 150mg reduced post-augmentation breast pain more effectively than either agent alone. In his practice, Dr. Pacik places an indwelling catheter under each implant so patients can self-administer bupivacaine boluses for up to three days post-operatively. He says patients prefer the intermittent bolus to continuous flow catheters because they like the control, and because the intensity of post-augmentation pain is highly variable from patient to patient. In addition, he says, this approach costs just $10 versus the estimated $200 cost of each continuous infusion system.

The catheters help about 90 percent of patients to experience effective pain relief, yet Dr. Pacik still recommends evaluating each patient's pain profile individually and adding analgesics if needed. His research shows that sternal pain, caused by the stretch of the pectoral nerve, is fairly common and requires adjunctive narcotics.

"It took me more than 200 patients before I started asking where the pain was, and I did so only because one patient told me it felt like an elephant was sitting on her chest," he explains. "It was sternal pain, and our data now show that narcotics work much better for sternal pain than the catheter." Dr. Pacik says pectoral nerve stretching can also cause clavicular pain, and that intercostal nerve irritation can cause pain along the sides of the chest. He has yet to determine the cause of interscapular pain, which also occurs in these patients.

Local analgesic infiltration appears to improve patient comfort in abdominoplasty patients as well. "I insert catheters over top of the dissection and allow the analgesic to flow over the tissues," says Dr. Pacik. "I wasn't sure this would work because the medication simply comes out the suction drains, but it has shown to be effective." Dr. Mast agrees: "One of the very real, tangible things you can do is inject a long-acting local anesthetic into the skin around the abdominoplasty incisions," he says. "We usually use 0.25 percent bupivacaine without epinephrine because the epi could inhibit the blood supply to the skin flaps."

PONV reduction strategies
When it comes to reducing PONV in cosmetic surgery patients, practitioners tend to be branching off in two directions. Those who continue to administer general anesthesia and IV narcotics are focusing on refined anti-emetic regimens that better offset the nausea induced by these agents, and many are also using local analgesia to reduce the inhalational requirement - a technique some call light general. Others are eliminating inhalational agents altogether by using IV conscious sedation regimens coupled with significant local analgesia.

• Refined anti-emetic regimens. The incidence of PONV among all patients receiving any sort of prophylactic antiemesis is still 22 percent, and cosmetic surgery patients are at high risk. Female gender, plastic procedures, breast procedures, general anesthesia and opioid use are all risk factors for PONV.

To bring the PONV rate down, cosmetic surgeons and anesthesiologists are experimenting with various prophylactic regimens, and refined multiple-drug regimens that target the vomiting reflex at numerous sites appear to be helping. In their comparison of several regimens, Robert Lee Steely, MD, and his colleagues at Christus St. Joseph Hospital in Houston, Texas, found that one regimen in particular was a clear winner. The regimen consists of ondansetron 4mg IV at induction (with a second dose just before extubation in cases longer than four hours), metoclopramide 10mg IV after induction and promethazine 25mg IV before extubation. Facial surgery patients also receive dexamethasone 10mg IV at the beginning of the case. All patients also receive liberal IV infusions to ensure hydration and gastric suctioning at the end of the case to eliminate gastric distention, secretions and blood. This regimen reduced their overall PONV rate in plastic surgery patients to 3 percent.

• Conscious sedation. While there are many ways to approach conscious sedation in the plastic surgery patient, many anesthesia practitioners rely on propofol as a basis. Many believe that propofol, in and of itself, has some antiemetic properties. In one retrospective review of more than 3,600 plastic surgery patients who received a conscious sedation regimen consisting of midazolam, propofol and a narcotic, just 0.2 percent had "protracted" nausea and vomiting.

Not everyone uses propofol, however. In another, more controlled, 153-patient study of abdominoplasty patients, Zol B. Kryger, MD, and his colleagues at the Northwestern University Feinberg School of Medicine in Chicago used a medazolam/fentanyl combination in lieu of a propofol-based regimen. They found that just three patients (2 percent) required an overnight stay in the hospital due to PONV.

Still, these approaches do not eliminate the need for PONV-inducing narcotics, in part because aware patients need protection against the pain of the local anesthesia injections. To solve this dilemma, Barry Friedberg, MD, an office-based anesthesiologist in Corona del Mar, Calif., recommends his propofol-ketamine technique, in which ketamine injected immediately after propofol induction produces a mild dissociative state and some limited analgesia, thereby allowing the surgeon to inject local anesthetic with little or no narcotic. Dr. Friedberg's research in 1,200 plastic surgery patients shows that this approach results in an about 1 percent incidence of PONV overall, with no hospital admissions for PONV or pain.

Best of both worlds?
There is another anesthesia approach that can significantly reduce both pain and PONV in cosmetic surgery patients: regional anesthesia.

In his practice, Don Siwek, MD, with William Beaumont Hospital's South Oakland Anesthesia Associates in Royal Oak, Mich., says regional anesthesia has made a world of difference for his breast augmentation and abdominoplasty patients. Dr. Siwek performs bilateral paravertebral blocks with ropivacaine for these patients, with the augmentation patients typically receiving a higher block (T2 through T7) than abdominoplasty patients (T5 through T10). These patients often receive propofol infusion or light general, which Dr. Siwek says translates into "half a MAC" of anesthetic agent, with no narcotic requirement.

"With the propofol infusions, patients are much more awake afterwards and we avoid PONV, which is particularly notable in breast augmentation patients who tend to experience high PONV rates," he says. Dr. Siwek also notes the importance of placing subcutaneous local anesthetic before performing these multiple-injection blocks to ensure patient comfort and of prescribing an NSAID to target the inflammatory pathway. The blocks cost these patients more money (about $300 in some facilities), but are well worth the investment, he says.

Comfort is key
Whatever the approach to helping their patients recover more comfortably from surgeries, cosmetic surgeons and anesthesia practitioners appear to be making real strides in their efforts to make their patients more comfortable. "The two biggest fears of these patients are waking up sick and waking up with pain," says Dr. Siwek. "It is a big advantage when we can get them out of the hospital and comfortable in their own home."

Bibliography
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Kryger ZB, et al. The Outcome of Abdominoplasty Performed under Conscious Sedation: Six-Year Experience in 153 Consecutive Cases. Plastic and Reconstructive Surgery. 2004;113:1807.
Mahabir RC, et al. Locally Administered Ketorolac and Bupivacaine for Control of Postoperative Pain in Breast Augmentation Patients. Plastic and Reconstructive Surgery. 2004;114:1910.
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