**1. Introduction**

Plastic surgery has become increasingly done over the last decades. The surgeon and patients become aware of the importance of postoperative pain control. This has occurred in part in an attempt to improve the patient experience and satisfaction. However, pain remains a major patient concern. Most patients who undergo cosmetic surgery do not report pain during the immediate postoperative period. However, most patients who underwent liposuction combined with or without other surgical procedure report pain after surgery. Pain is unpleasant sensory and emotional experience associated with tissue injury [2]. Postoperative pain is mainly derived from acute tissue manipulation during the surgical procedure. In fact, a recent study documented that 30–80% of patients undergoing outpatient surgery encountered moderate-tosevere postoperative pain. The characteristics of pain that should be evaluated are onset, location, irradiation, type of pain, duration, and pain-related behavioral responses [2–4].

cyclooxygenase (COX)-2 inhibitors with opioids, and alpha-2-delta modulators (gabapentin and pregabalin) with opioids, N-methyl-D-aspartate (NMDA) antagonists ketamine and magnesium, also alpha-2-agonists clonidine and dexmedetomidine with opioids. Combination of central neuraxial analgesia through epidural with NSAIDs proved favorable by suppressing

Pain Management in Plastic Surgery http://dx.doi.org/10.5772/intechopen.79302 103

There are several systemic analgesic protocols to relieve postoperative pain in plastic surgery, but the IV administration of opioid and nonopioid analgesics is the most used. In the following paragraphs, each one of these managements is described, being possible for the combina-

Postoperative pain management for ambulatory patients usually is treated with NSAIDs. This type of analgesics is the most important treatment for nociceptive pain. These kind of patients may also need a short-acting opioids such as hydrocodone, oxycodone, and acetaminophen. In immediate postoperative pain management, we prefer to use short-acting opioids rather than long-acting ones. However, if the patient is already on long-acting opioid before surgery, it is more appropriate to continue the long-acting opioid with combination of short-acting

Intravenous (IV) injection drugs that are commonly used as postoperative pain management are opioids (morphine and oxycodone). They are given based on patient's need, usually for every 2–4 h. This condition can become a burden for both nurse and patient when the ratio between nurse and patient is low. NSAIDs also can be given intravenously for a short period,

Patient-controlled analgesia (PCA) was used since 1971. PCA is one of the pain management techniques using a programmable pump intravenous device. The machine is put at patient's bedside and connected to the IV line than contains a bag of premixed opioid solution. The patient can self-administer analgesic on demand by pressing the button connected to the PCA machine. The demand dose is already determined by the physician. The machine will lock for the amount of time before it can send another demand dose (lockout period), so it can protect the patient from overdosing. PCA device can also release the drug at a low-dose continuous infusion rate [3]. There are several advantages of PCA such as painless route to deliver opioid, give accurate analgesia, help the nursing staff in patient's pain control, and ensure the medication level compared with intermittent bolus injection or continuous IV infusion of opioid. PCA is used when the patient cannot take oral medication either in preoperative or

stress response and suppressing pro-inflammatory factor [4–9].

**2. Systemic analgesia**

**2.1. Oral administration**

opioid for postoperative pain [3–9].

**2.3. Intravenous patient-controlled analgesia (PCA-IV)**

**2.2. Intravenous bolus injection**

1–2 days [5, 7, 9, 11–13].

tion of the different alternatives of analgesia.

Along with this increased awareness of the importance for pain management, a variety of newer analgesics modalities designed to reduce pain have arrived on the scene. In the era of health care reformation, it is important to consider that pain management techniques can contribute to the overall value of care that is delivered to patients.

#### **1.1. Concept of multimodal pain management**

Treatment for each type of plastic surgery and resulted pain requires a specific approach and must be individualized to the patient. There are three main techniques for acute postoperative pain management: systemic analgesia, regional analgesia, and local/topical analgesia. Systemic analgesia can be given through intravenous injection, oral or rectal route, intramuscular, and skin patch. Regional analgesia technique can be divided into neuraxial analgesia and peripheral nerve block. Currently, pain management through intravenous injection or continuous neuraxial and peripheral nerve blocks is more controllable and safer since the invention of pain pump, which commonly use the principal of patient-controlled analgesia. Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), mild analgesics, local anesthetics, etc., are all valuable in the multimodal pain management [4–6].

Nausea, vomiting, constipation, somnolence, etc., are well-known adverse effects of opioids. Although these effects may seem minor to some, they can lead to significant complications following certain types of plastic surgery, for example, face-lift hematoma following nausea and vomiting, pulmonary complications from respiratory depression, and even thromboembolic phenomena from bed rest following prolonged opioid use. In fact, a recent study documented adverse side effects in 17% of patients due to opioids. Most importantly, multimodal pain therapy including pharmaceutical agents mentioned above, long-acting local anesthetic preparations, and pain pumps may in large part replace isolated narcotic treatment of postoperative pain. This approach has been documented to increase patient satisfaction and reduce both opioid use and the incidence of nausea and vomiting in a large variety of nonfacial esthetic procedures. Although this multimodal treatment seems to have significant benefits, postoperative dosing becomes more complex, and adverse drug interactions and drug overdose become more likely [1–10].

There are some combinations that is proven to have a good effect in multimodal analgesia, such as paracetamol and NSAIDs, paracetamol with opioids, nonselective NSAIDs or selective cyclooxygenase (COX)-2 inhibitors with opioids, and alpha-2-delta modulators (gabapentin and pregabalin) with opioids, N-methyl-D-aspartate (NMDA) antagonists ketamine and magnesium, also alpha-2-agonists clonidine and dexmedetomidine with opioids. Combination of central neuraxial analgesia through epidural with NSAIDs proved favorable by suppressing stress response and suppressing pro-inflammatory factor [4–9].
