Dermal analgesia

A commonly used topical analgesic in facial plastic surgery is the eutectic mixture of local anesthetics (EMLA) cream. EMLA cream is a water and oil emulsion mixture that contains 2.5% lidocaine and 2.5% prilocaine. EMLA cream has been shown to provide pain relief on intact and nonintact skin, making it useful for a variety of applications including chemodenervation, skin grafts, and laser treatments. ^, The onset, depth, and duration of analgesia are dependent on the timing of medication application. EMLA cream should ideally be applied to the targeted area for at least 1 h before the procedure. This medication can achieve a penetration depth of 3–12 mm and lasts for up to 2 h. Inadequate analgesia occurs secondary to insufficient application or short waiting time for the medication to achieve its maximal effect. The side effects of EMLA include local allergic reactions or sensitivity, but this medication is generally well tolerated. Topical lidocaine alone or in combination with benzocaine and tetracaine may also be considered, which can be supplied in a variety of concentrations and formulations. However, the surgeon should be aware of the potential for adverse outcomes in some compounded products with high anesthetic concentrations.

Local anesthetics

Local anesthetics are another modality for delivering perioperative analgesia. The biochemical structures of local anesthetics determine their potency, duration of action, and metabolism. In facial surgery, local anesthetics can be used to block branches of the trigeminal nerve to provide regional anesthesia. Regional nerve blocks are a powerful tool for pain control and are frequently utilized for in-office procedures, such as laser resurfacing, cutaneous surgeries, or hair transplant. Fig. 4.1 demonstrates the distribution of head and neck cutaneous nerves and potential sites of local anesthetic injections. Furthermore, dilute epinephrine solutions of 1:100,000 or 1:200,000 concentrations are frequently mixed with local anesthetics to provide vasoconstriction on top of analgesia, which can prolong the duration of action.

Cutaneous innervation of the face and scalp and potential sites of head and neck regional anesthesia.

Reproduced under creative commons license from Davies T, Karanovic S, Shergill B. Essential regional nerve blocks for the dermatologist: part 1. Clin Exp Dermatol . 2014;39(7):777–784.

Toxicities of local anesthetics have the potential to be greater than those of topical agents. Systemic toxicity is dose-dependent and relates to cardiovascular side effects and neurotoxicity, including arrhythmias, convulsions, coma, and central nervous system depression or collapse. Additionally, local adverse effects, such as injection site pain, nerve injury, burning, intravascular injections, or tissue necrosis, have all been reported. Before using an injectable anesthetic, it is imperative that the surgeon be mindful of the maximal dosing and drug-specific side effects. Examples of pharmacologic characteristics of commonly used local anesthetics are provided in Table 4.1 .

The process of injecting local anesthetics can cause discomfort and distress to the patient. Various methods to reduce injection-related pain have been proposed, including the application of ice, cool air, and vibration devices. Nestor et al. demonstrated the efficacy of a contact cooling device in alleviating pain and ecchymosis after small gel particle hyaluronic acid dermal filler injections. Similarly, vibrotactile devices have been used for decreasing injection-related pain in many office-based procedures. Although the underlying physiology is incompletely understood, vibration devices are thought to reduce pain by stimulating large nerve fibers and suppressing pain stimuli transmitted by small A-δ and C nerve fibers. At the time of anesthetic injections, the operator simply applies the vibratory stimuli in an area adjacent to the target area for needle injections. Several studies confirmed the effectiveness of vibration devices, such as the Buzzy device and Vibration Anesthesia Device, in reducing needle- or injection-associated pain for adult and pediatric applications. ^,

Systemic analgesics

Systemic medications are available in oral or IV forms and include a variety of over-the-counter and prescription analgesics, such as acetaminophen, nonsteroidal drugs, and narcotics. Over-the-counter acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) are typically first-line medications in this category due to their high tolerability, ease of access, and safety profile. Both acetaminophen and NSAIDs are available in the IV form, although their use is limited to the perioperative setting due to a need for IV access. From a side effect perspective, acetaminophen can cause hypersensitivity, hepatotoxicity, and metabolic derangement. Similarly, excessive NSAIDs can lead to nephropathy, gastrointestinal bleeding, or cardiovascular compromise. NSAIDs also decrease the formation of prostaglandins and thromboxane A2 and can lead to platelet dysfunction. Thus, the use of NSAIDs in a postsurgical setting remains controversial and will be further discussed later in this chapter.

Opioids are commonly prescribed as an adjunct to over-the-counter medications. There is a large variety of opioids available for prescription use, ranging from oxycodone to hydromorphone and opioids that are combined with acetaminophen. Morphine milligram equivalent (MME) is a standardized measurement to approximate the amount and potency of different types of opioids and can be calculated as a product of dose, quantity, and opioid-specific conversion factor. Common side effects of opioids include reduction in gastric motility leading to bloating, nausea, vomiting, and sedation, which can lead to cardiopulmonary depression and collapse.

In addition, opioids have the potential for abuse and can lead to drug diversion. Prescription opioid use has contributed to the rising opioid epidemic in the United States. Studies have shown that postsurgical opioid prescription, even for a short course, can be associated with conversion to long-term dependence. ^{, ,} More recent studies demonstrated a general trend of overprescription by clinicians, and as such, there has been a nationwide push to examine prescribing patterns of opioids after all surgical procedures. ^,

Contemporary strategies for managing postoperative pain focus on reducing opioid prescriptions and advocacy for a multimodal pain treatment regimen, including the use of nonopioid analgesics, injectable anesthetics, topical medications, and a combination of these options. ^{, , ,} This approach has been shown to increase patient satisfaction and reduce narcotic use in a large variety of surgical procedures. ^, In the following sections, studies on pain after common facial plastic and reconstructive surgeries are discussed in the context of each operation.

Septorhinoplasty

Rhinoplasty and septoplasty are two of the most commonly performed operations by facial surgeons. Establishing clear management guidelines is important and has been the subject of numerous studies. For these operations, nonopioid medications have been shown to decrease or even eliminate the need for opioids among some patients. Nguyen et al. conducted a systematic review on nonopioid analgesic use after septorhinoplasty and concluded that of all the modalities studied, local anesthetics provide highly effective analgesia and were associated with decreased pain scores and lower rescue analgesic consumption. Although some local anesthetics have short half-lives and rapid clearance, their effects were found to extend beyond the duration of action for up to 24 h. ^, The utility of local anesthetics in facial surgeries is further supported by the American Society of Anesthesiologists practice guidelines. Thus, they remain a workhorse for pain control among patients who undergo septorhinoplasty.

Acetaminophen and NSAIDs are also highly effective for providing postoperative analgesia. In several randomized controlled trials, NSAIDs use after septoplasty was shown to decrease pain and consumption of rescue analgesics. ^, In another randomized control study of 150 patients who underwent open septoplasty with concurrent rhinoplasty, Celik et al. studied patients who received IV paracetamol versus IV ibuprofen and concluded that IV ibuprofen provided more analgesia than paracetamol in the first 12 h after surgery. All of these studies considered bleeding as a potential complication due to the platelet-altering effect of NSAIDs; however, none reported an elevated incidence of hematoma or other bleeding-related complications. ^, The safety of acetaminophen and NSAIDs were further established by the American Academy of Otolaryngology—Head and Neck Surgery Clinical Practice Guideline, which advocated the use of acetaminophen and NSAIDs as first-line agents for pain after rhinoplasty and septoplasty.

Opioids were commonly prescribed after septoplasty and rhinoplasty. However, recent studies actually suggested overprescription and underutilization of these medications. In a case series of 62 patients undergoing a combination of open septoplasty, open rhinoplasty, and endonasal rhinoplasty, Patel et al. (2018) demonstrated that patients used a median of 8.7 out of 20–30 hydrocodone-acetaminophen tablets prescribed. Patient age, sex, septoplasty or turbinate resection, use of osteotomy, or a history of prior rhinoplasty was not associated with the number of opioid tablets used. In this study, only one patient underwent endonasal rhinoplasty. Postoperative pain between the open versus endonasal approach was not specifically queried. In another retrospective study, Rock et al. reported similar findings in a cohort of 75 patients and noted that the mean number of opioids consumed after septorhinoplasty was 14.7 out of 42.4 tablets prescribed. Sex, procedure performed, use of nasal splints, or surgeon was not associated with the number of opioids prescribed. In a prospective study, Scalafani et al. (2019) demonstrated that most patients experienced only mild pain for 2–3 days. About 90% of their patients required fewer than 11 opioid tablets. The total MMEs were compared and found to be similar between septoplasty and rhinoplasty. In this study, both open and endonasal techniques were included, but the authors detected no differences in MME, opioids consumed, or pain scores between the open or closed approaches. Based on their data, Scalafani et al. concluded that pain control after septorhinoplasty would require 10–11 opioid doses of sufficient potency, or an equivalent of 71–80 MMEs.

The abundance of literature on septorhinoplasty extended to other less commonly used modalities. One randomized control trial evaluated electro-acupuncture and morphine as adjunctive methods of pain control for septoplasty. This study did not identify differences in pain scores or consumption of rescue opioid medications, but they reported a reduction in nausea and vomiting in the electro-acupuncture group compared to morphine users. Additionally, two studies evaluated the use of dexamethasone as an adjunct to local anesthetics and gabapentin. ^, These studies demonstrated decreased pain and rescue analgesic use with steroid administration with no increases in side effects, though further prospective, controlled trials examining the efficacy of steroid administration as a pain control modality should be conducted.

Facial rejuvenation

In contrast to the breadth of studies on postoperative pain after septorhinoplasty, there are considerably fewer publications on pain management following facial rejuvenation. Facial rejuvenation procedures include an array of operations such as upper and lower blepharoplasty, brow lift, volume augmentation procedures, and cervicofacial rhytidectomy. In periorbital facial rejuvenation, postprocedural pain is generally reported as mild and managed by acetaminophen and/or NSAIDs. ^, In a study by Henrici, Clemens, and Tost, the application of EMLA cream to the eyelid before upper blepharoplasty was also shown to lower postoperative pain. Similarly, Wei et al. evaluated preoperative use of a single dose of 150 mg pregabalin in patients undergoing upper eyelid surgery and showed lower pain scores in treated patients compared to controls. In that study, patients who were treated with pregabalin consumed less acetaminophen in the first 48 h after surgery. In oculoplastic and orbital surgeries, information on opioid prescription had been limited until recently. A study in a cohort of 2660 patients who underwent oculoplastic and orbital surgeries demonstrated that the average MME of prescribed opioids was 73.2 for brow lifts, 64.7 for blepharoptosis repair, and 71.9 for upper blepharoplasty, but the authors did observe a decrease in prescribed opioids over time. This study also evaluated other procedures and concluded that soft tissue surgeries in the periorbital region had lower MMEs than orbital surgeries. This study did not specifically examine patient use of opioids or the adequacy of pain control.

For patients undergoing cervicofacial rhytidectomy, pain can be more significant due to a greater extent of tissue dissection. In a prospective randomized trial of 140 patients, Torgerson et al. investigated intraoperative ketorolac for analgesia following cervicofacial rhytidectomy. In this study, patients who received local injections of ketorolac into the surgical field required less pain medications than those who had an intramuscular ketorolac injection and controls who received injectable anesthetics alone. Two patients in the control group developed a hematoma requiring surgical evacuation, while none of the 115 patients in the local ketorolac group developed bleeding complications. Aynehchi et al. evaluated the use of celecoxib in 50 patients undergoing deep-plane rhytidectomies. In their study, patients who were treated with preoperative and postoperative celecoxib reported less pain compared to controls. No studies to date have examined postoperative pain between various rhytidectomy techniques.

Cutaneous reconstruction

Cutaneous reconstructive surgeries are another type of operation commonly performed by facial surgeons. Cutaneous reconstruction of defects from skin cancers is most commonly achieved through tissue rearrangement and local flaps. Because the reconstructive approach can vary depending on the size and location of the defect, patients often experience different amounts of discomfort.

In general, pain after cutaneous reconstruction is mild. A study from 2010 showed that only 7% of patients who underwent Mohs micrographic surgery consumed postoperative opioids. Limthogkul, Samie, and Humphreys corroborated with these findings in 158 patients and concluded that the majority of patients did not require prescription analgesics. Another subsequent study showed that opioids were prescribed to a minority (34%) of patients undergoing Mohs surgery; furthermore, 35% of patients did not consume any opioids that were prescribed to them. In general, patients undergoing cutaneous procedures may be expected to do well with a combination of acetaminophen and NSAIDs, and at least one randomized controlled trial supports this approach.

Several studies showed that the type of reconstruction for Mohs defect may be predictive of opioid prescriptions. Harris et al. identified increased odds of receiving opioid prescriptions in patients who underwent Mohs closure using local flaps compared to healing by secondary intention. They also concluded that young age, female sex, and use of full-thickness skin graft for closure were associated with increasing pain scores. Firoz et al. found that patients who had full-thickness skin grafts and local flaps had higher mean pain scores and greater narcotic prescription use than those undergoing linear repair or healing by secondary intention. These findings were redemonstrated in a study by Brahe et al. Skin graft reconstruction of cutaneous defects portends a large extent of tissue dissection as well as a secondary donor site, which may contribute to increased postoperative pain. Prospective studies on analgesic requirements after Mohs reconstructive techniques are needed to understand the extent and severity of postoperative pain, as well as narcotic prescribing patterns after these reconstructive procedures.

Facial trauma

Maxillofacial fractures account for over 400,000 emergency room visits annually in the United States. The management of pain after repair of facial trauma is an area of active investigation. A recently published study by Lapidus et al. shed light on opioid prescribing and use in postsurgical facial trauma patients. In this large retrospective cohort of 20,191 patients who underwent repair of facial fractures, a majority of patients (78.6%) filled opioid prescriptions; within the subgroup of patients who filled their prescriptions, a majority (58.7%) also went to complete a refill of an opioid-containing medication. In this analysis, patients who suffered from nasal, naso-orbito-ethmoid, and Le Fort fractures most commonly filled their prescriptions. The authors also evaluated the appropriateness of opioid prescriptions and found that 39.3% of their cohort received inappropriate prescriptions characterized by overlapping opioid prescriptions, high morphine equivalents, or concurrent use of opioids and benzodiazepines. Prior substance use, mental health disorders, number of procedures performed, and prescription of tramadol were associated with increased odds of opioid prescription refills.

Another recent study by Som et al. evaluated opioid use among adolescent patients seeking repair of facial trauma and similarly identified high percentages of opioid prescription and use. In this study, older age, comorbidities, and multiple fractures were associated with persistent opioid use. Interestingly, their analysis identified that the rates of potentially inappropriate opioid prescribing differed based on the analgesic medication, with oxycodone, propoxyphene, and less commonly prescribed opioids being associated with higher odds of inappropriate use.

Despite the high rates of opioid use identified in the previous studies, overall narcotic prescribing trends for facial trauma repair in the United States have remained stable. In a study by Shah et al. the authors assessed opioid prescribing trends for craniofacial trauma between 2006 and 2016 and identified relatively unchanged rates of opioid prescriptions, with 13.4% of all patient visits receiving opioid prescriptions. Younger age (ages 18–44) and lower face trauma were associated with increased rates of opioid prescriptions, while there were no significant differences across geographical regions, ethnicity, or sex. Nonetheless, opioid prescription and use after trauma are substantially higher in comparison to other facial plastic and reconstructive surgeries discussed earlier. Future studies are needed to more accurately identify predictors of poor pain control and risk factors for inappropriate use in this patient cohort.