For plastic surgeons who primarily perform elective esthetic procedures, patient comfort after surgery is of vital importance to patient satisfaction, word-of-mouth referrals, and long-term retention, which all effect the success of the medical spa business overall. After a successful surgical outcome, effectively managing pain and minimizing analgesic-related adverse events (AEs) not only impacts timely recovery, but also shapes the patient’s experience with the surgeon and the practice. In fact, a recent Cedars-Sinai study published in the American Academy of Pain Medicine (AAPM) found that postsurgical pain scores were highly correlated with reports of overall patient satisfaction during hospital stays, underscoring the need for surgeons to optimize treatment of post-op pain.
Ask a patient contemplating surgery to list common concerns and, more often than not, you will find anxiety regarding postsurgical discomfort at the top of the list. Despite this fact, many surgeons remain reluctant to proactively set expectations about the postsurgical recovery period during the preop consultation for fear of increasing that anxiety or dissuading the patient from the undergoing the procedure at all. This can lead to an uninformed patient who may not be aware of the various analgesic treatment options that can help mitigate discomfort and opioid-related AEs during the recovery process.
Pain Treatment Innovation
Until recently, the standard approach to postsurgical analgesia consisted of opioids (intravenous and oral), local anesthetics either infiltrated at the time of surgery or supplied via elastomeric pumps, and nonsteroidal anti-inflammatory drugs (NSAIDs) for breakthrough pain. Opioids, while effective analgesics, are associated with moderate to severe AEs, such as respiratory depression, nausea, constipation and urinary retention, which reduce quality of life, prolong the recovery period, require additional post-op care staff and increase the cost burden on the healthcare system.
Local anesthetics, while safer and more tolerable than opioids, have limitations associated with duration and delivery methods. Traditional local anesthetics administered at the wound site only provide up to eight hours of relief, requiring supplemental or rescue opioids for the crucial few days after surgery. Delivery of local anesthetics via elastomeric pumps has been reportedly associated with safety issues ranging from inconsistent infusion-rate accuracy and clogging and/or leaking of the pump catheter to premature emptying of the medication reservoir and technical pump failure.
In 2011, the U.S. Food and Drug Administration (FDA) approved a liposomal bupivacaine for infiltration analgesia, known as EXPAREL (bupivacaine liposome injectable suspension). Unlike its predecessor standard bupivacaine—which had a six to eight hour duration of action—liposomal bupivacaine claimed analgesic effects lasting up to 72 hours after administration.
Wary of the “new is better” approach to medical treatment, we held off shifting our current pain management approach until we had seen some substantive clinical and practical evidence to support the value and benefit of liposomal bupivacaine for patients. We were then invited, along with six of our esteemed peers from across the country, to participate in a Phase 4, multicenter, prospective, observational study to examine the impact of liposomal bupivacaine in patients undergoing breast and abdominal surgeries—procedures that are associated with significant postsurgical pain and consequent risk of opioid-related AEs.
Boosting Patient Satisfaction
Integrating liposomal bupivacaine into our suite of pain management tools has been transformative for our patients and practice. Having a single-shot, local analgesic do the heavy lifting during the critical few days post-op means cutting back on narcotics, having patients alert and out of bed sooner; which in turn reduces the burden on our post-op care staff who used to actively monitor pain pump functioning and accuracy while tackling opioid- induced GI and GU side effects.
And while the cost of liposomal bupivacaine is higher than some other commonly used analgesics for perioperative pain (e.g., opioids, standard formulations of local anesthetics), in our experience, the incremental cost is typically offset by improved outcomes, such as better pain relief, lower opioid consumption and improved patient satisfaction, therefore resulting in higher retention rates and increased patient referrals.
Not surprisingly, more of our abdominoplasty consultations convert to surgery after we educate them on the benefits of liposomal bupivacaine in improving their postoperative pain. Based on data and our clinical experience, we are optimistic about the potential of new pain treatment options to drive a major shift in the traditional approach to managing postsurgical pain, and we hope our colleagues take the opportunity to experience the value of this game-changing analgesic.