Perioperative pain management in facial plastic and reconstructive surgery

Introduction

Pain management is a major concern for many patients who contemplate undergoing facial plastic and reconstructive surgeries. Numerous over-the-counter and prescription pain medications have been used to address this important and universal patient issue. The treatment of acute postoperative pain commonly includes the administration of nonopioid analgesics, opioids, and injectable anesthetics. Over time, the large variety of available medications have led to differences in prescribing patterns and at times, inconsistency in pain management approaches.

Inadequate analgesia negatively affects recovery, length of stay, and quality of life. While many medications provide analgesia, maintaining a judicious balance between the risks and benefits of each pharmacologic modality is paramount in preventing misuse, overdose, or abuse. Opioids have historically been prescribed for many facial plastic procedures, but their potential for abuse and drug diversion rendered increased scrutiny into finding safer and more effective alternatives. Previous studies showed that patients had an increased risk of chronic dependence even after a short-term exposure to prescription opioids. However, most pain management guidelines focus on the treatment of chronic rather than acute postprocedural pain. As such, there is a critical need to examine provider prescribing trends after facial plastic and reconstructive surgeries.

Facial plastic and reconstructive procedures, particularly aesthetic facial surgeries, account for a large number of operations performed in the United States. A comprehensive review of pain management strategies after common surgeries is useful in informing clinical decision-making for providers who perform these types of operations. The purpose of this chapter is to integrate current literature on pain management for common facial plastic and reconstructive surgeries. To mitigate the risk of medication abuse, we propose that all facial surgeons remain vigilant about minimizing opioid misuse and overprescription while maintaining adequate pain control.

Analgesic pharmacology

The head and neck region contains a dense network of nociceptive receptors, which are responsible for high sensitivity and discomfort that patients may experience after facial surgeries. Perioperative analgesics can be classified as topical, local, or systemic; systemic drugs exist in an oral, intramuscular, or intravenous (IV) form. Regardless of the mode of delivery, a comprehensive understanding of pharmacology can guide facial surgeons in selecting the most appropriate modalities for their patients. In this section, we review clinically relevant pharmacology of dermal analgesia, local anesthetics, and systemic medications.