Postoperative Analgesia in Plastic Surgery Procedures

*Daniela Arévalo-Villa, Andrea Figueroa Morales, Roberto de Jesús Jiménez-Contreras and Víctor M. Whizar-Lugo*

#### **Abstract**

Advances in the knowledge of the secondary effects of acute postoperative pain have motivated anesthesiologists and surgeons to pay special attention to its prevention and correct management. Surgical procedures in plastic surgery are very varied and produce postoperative pain in direct relation to the site, type, and extent of surgery, with facial interventions being the least painful (with the exception of rhinoplasty) and the most painful being breast surgery, abdominoplasty, and extensive liposuctions due to the possibility of trauma to peripheral nerves and greater secondary inflammation. The combination of surgeries produces more intense post-surgical pain. There is insufficient data on the frequency and severity of pain after plastic surgery, be it reconstructive or cosmetic. Although opioids have been considered to be the cornerstone in the treatment of postsurgical pain, their use in plastic surgery patients must be carefully evaluated for various reasons that interfere with the results of this type of surgery. Similar to other surgical specialties, multimodal analgesia is now the most appropriate way to prevent and treat pain in these patients. This chapter is a comprehensive review of the management of acute postoperative pain in certain plastic surgery procedures, with emphasis on the multimodal approach.

**Keywords:** plastic, surgery, postoperative, pain, analgesia

#### **1. Introduction**

Postoperative pain (POP) is a subjective phenomenon, without a useful biological function, which varies with several factors such as the patient themselves, type of surgery, experience with previous surgeries, duration and extent of surgery, anesthetic technique, kind of perioperative care, individual characteristics and experiences, fear, and anxiety. The latest global survey from International Society for Aesthetic Plastic Surgery published in January 2023 reports a considerable increase in esthetic surgery worldwide, showing an overall 19.3% increase in procedures performed by plastic surgeons in 2021 with more than 12.8 million surgical procedures and 17.5 million non-surgical procedures performed globally. This equates to an increase of 33.3% over the last 4 years [1]. Paradoxically, the COVID-19 pandemic has increased plastic surgery procedures around the world; although the frequency of scheduled plastic surgery has apparently decreased in many countries, some procedures have increased

as patients have free time for their cosmetic plans [2–5]. The top five most popular surgical procedures remain liposuction, breast augmentation, eyelid surgery, rhinoplasty, and abdominoplasty [1]. This notable increase in plastic surgeries has favored multiple advances not only in the surgical area, but in all anesthetic aspects, including the comprehensive management of POP. With increasing frequency, these types of surgeries are ambulatory or short stay, which tends to make the management of POP even more difficult, especially in the first post-surgical days.

Satisfactory POP management is mandatory for patient satisfaction. In patients undergoing thoracic and abdominal procedures, poor pain management has been related to pulmonary complications, cardiac ischemia, ileus, thromboembolism, and impaired immune function [6]. One of the greatest problems for adequate pain relief is due to inadequate physician familiarity with analgesic options available. Poorly controlled POP has been associated with deficient surgical outcomes, longer postanesthesia care unit stays, poor pulmonary function, and higher readmission rates. The development of chronic pain after surgery, also called persistent postsurgical pain, is also related to uncontrolled acute POP and is recognized as a significant health problem [7]. On the one-day surgery basis, pain is one of the most prevalent problems, being as high as 58% 30 min after surgery in the undeveloped countries and up to 34.7% 48 h after discharge [6].

Up to date, multimodal analgesia is the most effective modality in the management of POP. This chapter reviews the importance of diagnosis, prevention, and timely management of POP in plastic surgery patients.

#### **2. Postoperative pain in plastic surgery**

Postoperative pain in patients undergoing plastic surgery procedures is a problem that has not been resolved and that implies serious management challenges. On one side, these patients are extremely demanding, with little or no tolerance for complications, especially POP. A growing number are tourist patients who have traveled many hours and sometimes thousands of kilometers by train, plane, or car only to be operated in remote places, where another language is often spoken, and customs as well as food are different from their original countries [8, 9]. Transgender and gender diversity patients are a steadily growing group requesting plastic surgery that requires meticulous care in a humanitarian sense, avoiding pejorative comments [10]. These factors produce stressful situations that make the proper management of POP even more difficult. An empathic patient-centered intervention can reduce preoperative anxiety and favor a faster surgical recovery, wound healing, and patient satisfaction.

On the other hand, some plastic surgeons and anesthesiologists do not have enough knowledge and sensitivity to address the timely treatment of POP [11, 12]. If we add the challenges of the current global crisis on the inappropriate and sometimes illegal use of opioids and other narcotics, the problem is even more difficult to address [13].

We did not find sufficient epidemiological data on the frequency and intensity of POP after plastic surgery, although it is known that the most painful procedures are breast surgery, abdominoplasty, extensive liposuction, and combined surgeries. In some studies, it is mentioned that plastic surgery, neurosurgery, orthopedics, and general surgery have the highest prevalence of severe POP varying from 10 to 75% [14–17].
