Plastic Surgeons and Dermatologists Weigh In on Pain Management Post-Plastic Surgery

Cotton Codinha

Plastic surgery can hurt. Large-volume liposuction, tummy tucks, breast augmentation, and the like. Depending on the procedure, you could be in for an uncomfortable couple of days. Up until recently, many plastic surgeons didn’t give as much thought to prescribing narcotics like Vicodin, Percocet, and oxycodone to address the issue and maintain a level of comfort for patients. But as the country grapples with an opioid epidemic that claimed tens of thousands of lives last year alone, doctors who perform cosmetic procedures are taking a closer look at pain management.

"Ten years ago, when I was doing liposuction, I would send a patient home with a prescription for 10 Percocet," says Cheryl Karcher, a New York City dermatologist. "And that was considered a little bit by most doctors’ standards then." But in the past six years, Karcher has not prescribed a single narcotic for liposuction patients. “I use so much local anesthetic during the procedure, and then Tylenol is plenty [after that]," she says. "If you ask my patients, you won’t get one single complaint."

In Karcher’s opinion, writing that Percocet prescription just isn’t worth the risk. "You never know who has that genetic predisposition for addiction. If there’s a family history, there’s a larger chance of the patient having the genes for addiction," she says. “You can give opioids to plenty of patients that take them, it kills the pain, and then they never take them again. But [some] are going to take them and say, ‘Oh, my God, this makes me feel so much better. I’m going to take more.’ You never know who that’s going to be. I didn’t know. I had no clue."

About 10 years ago, Karcher became addicted to opioids after they were prescribed to her following several orthopedic surgeries. She has been in recovery since 2010 (and is still a board-certified dermatologist).

While Karcher is passionate about not prescribing narcotics to her patients, she recognizes that, as a dermatologist, the recovery from the procedures she does is less intense than more invasive procedures that plastic surgeons perform. In that field, narcotics are often prescribed for controlling pain after major operations like large-volume liposuction and tummy tucks — and narcotics can be necessary.

But when possible, some plastic surgeons are finding alternatives and using anti-inflammatories, local anesthetics, and numbing medications to attack different pain pathways. In some cases, patients are demanding it. "For the first time ever in my practice, I will have people say, ‘I have had several friends die of an opioid overdose. Please do not prescribe me any pain medication,’" says Melissa Doft, a plastic surgeon in New York City. “When I was in training, you rarely heard that.”

As reducing narcotics use becomes a greater priority, innovations are happening. “There are some things that plastic surgeons can do to really decrease the narcotic requirements for a lot of plastic surgery procedures and get patients off them a lot quicker,” says Jeffrey M. Kenkel, a plastic surgeon in Dallas. Things like Experal. “It has completely changed recovery for patients,” he says. “It’s a drug that contains the longer-acting numbing agent bupivacaine and binds to fat molecules in a microscopic honeycomb. We inject it at the surgical incision site and in some cases use ultrasound to place it exactly where the nerves are. It dissolves over the course of 72 hours.”

Of course, not every effective alternative needs to be revolutionary. "People pooh-pooh Tylenol," says New York City-based plastic surgeon Adam Kolker. "But it’s extraordinarily effective, especially when taken in frequent doses." He tells patients to take it after even major surgeries like breast augmentation. Often he’ll also use an anti-inflammatory steroid called Decadron intravenously during surgery, with intravenous Tylenol to help reduce pain later.

Kenkel’s presurgery pain-management plan always includes Celebrex, an anti-inflammatory arthritis medication and pain reliever, and a nerve medication called Lyrica. The first is taken the day before surgery, and the second several hours before and for four to five days afterward. “That covers a lot of patients’ discomfort,” says Kenkel.

Before taking out a prescription pad, doctors are also being more vigilant about screening patients for a history of addiction. But as Karcher learned, often it’s not possible to see drug dependency coming. For those who suffer from addiction or have a family history of it but for whom surgery necessitates narcotics, there are pain management and addiction therapists who can help monitor behavior when taking a small, controlled prescription, says Doft. But that requires self-awareness and prescience that aren’t always there.

Unfortunately, as the future of pain management rolls slowly forward, the rates of opioid abuse in the U.S. are climbing steadily, with no abatement in sight. The magnitude of the problem cannot be overstated. “People are dying from opioid overdose every day,” says Karcher. “The equivalent of an airplane full of people. Every day.”

But at least in the world of postoperative care, there is some hope for a narcotic-free future. "As we have a better understanding about pain receptors, we hope to have more products we can inject into the surgical site for pain management," says Kenkel. "We may even see sutures that are laced with certain types of growth factors and pain relievers that will deliver medication right at that microscopic level within the incisions. I think we’re going to see a lot of innovations in pushing pain control away from narcotics."

They won’t come a moment too soon.

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Originally Appeared on Allure