An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery: A Randomized Prospective Study

The Utility of Erector Spinae Plane Blocks in Breast Surgery: A Practical Review

Background

In plastic surgery, breast surgery patients are among the most susceptible to postoperative pain. Amidst the opioid epidemic, healthcare goals seek to optimize nonopioid multimodal pain control by including regional analgesia. The erector spinae plane block (ESPB) is among several regional blocks used in breast surgery. Although the paravertebral block has previously served as the gold standard, new research focused on ESPB may shift standards.

Methods

A comprehensive PubMed review was performed in September 2023 to identify articles related to ESPB use in breast surgery. Non-English and unavailable articles were excluded. Data extracted included publication year, techniques, and outcomes.

Results

Sixty-eight publications were included, of which 31 were randomized control trials (45.6%). Most were published between 2021 and 2023 (n = 40, 58.8%). Most articles that evaluated pain and opioid use suggested that ESPB performed better than nonblocked groups (n = 26, 38.2% of total articles and n = 4, 5.88% of total articles) and performed similarly to other blocks. However, articles that evaluated the pectoral nerve block suggested it outperformed ESPB in these aspects (n = 6 articles, 8.82%). ESPB was shown to be a safe and procedurally short block to perform, effective in the hands of novice providers.

Conclusions

ESPB offers reliable outcomes, improving pain control and decreasing opioid consumption. In turn, this can decrease healthcare costs and patient morbidity.

Quality of plastic surgery Enhanced Recovery After Surgery (ERAS) studies: A systematic review

BACKGROUND

In effort to improve post-operative outcomes, enhanced recovery after surgery (ERAS) protocols have gained popularity. The objective of this systematic review was to assess the reporting and methodological quality of plastic surgery ERAS studies.

METHODS

All plastic surgery ERAS implementation studies, published between January 1, 2020, to November 20, 2023, were included. The primary outcome was reporting quality based on "The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist" (40 points). Secondary outcomes included methodology quality as per ERAS® Society endorsed guidelines (Breast 18 points; Head and Neck (H&N) 24 points).

RESULTS

Fifty ERAS studies were included (breast reconstruction: 29, 58%; head and neck: 7, 14%; craniofacial: 6, 12%; aesthetic: 5, 10%; other: 3, 6%). Average reporting quality was 22.6/40 (56.7%). ERAS protocol elements least adhered to included: patient warming strategy (8/50, 16%), management of post-operative fluids (14/50, 28%), and post-discharge outcome tracking (14/50, 28%). Evaluation of breast methodological quality revealed average compliance of 9.2/18 (51.3%). The least complied with elements included preoperative computed tomography angiography (4/23, 17.4%), intraoperative warming (6/23, 26.1%), and post-operative wound management (2/23, 8.7%). For head and neck studies, average compliance was 9.1/23 (39.6%). The least complied with elements included pre-anesthesia pain medications (1/7, 14.3%), post-operative wound care (0/7, 0%), and urinary catheterization removal (1/7, 14.3%).

CONCLUSIONS

ERAS implementation studies in plastic surgery are highly variable, with overall low reporting and methodology quality. Plastic surgeons should be cautious when adopting published ERAS protocols that do not adhere to the recommended and official ERAS® Society guidelines.

An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay

BACKGROUND

Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery.

METHODS

A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes.

RESULTS

Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery.

CONCLUSIONS

The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

A Comparison of Multimodal Analgesic Regimens for Opioid Reduction in Elective Plastic Surgery: A Randomized Study

This trial aimed to compare the efficacy of a multimodal analgesic regimen with gabapentin to a multimodal nonsteroidal anti-inflammatory drug (NSAID) regimen following cosmetic surgery. This was a prospective randomized study of 106 patients undergoing elective outpatient cosmetic surgery.

Methods

Patients were randomly assigned to a multimodal regimen of postoperative acetaminophen, gabapentin, and oxycodone with an acetaminophen and gabapentin preload or postoperative ibuprofen and oxycodone-acetaminophen protocol without a preload. Data on compliance, number of narcotic pills consumed, duration of analgesic use, pain levels, patient satisfaction, time from incision close to postanesthesia care unit (PACU) admission, and incidence of bleeding-related complications were collected and analyzed.

Results

Patients from both regimens reported equivalent postoperative pain control with the exception of pain in PACU. NSAID patients exhibited a 9.3% higher rate of compliance (P = 0.01), a 6.0% higher rate of satisfaction with pain control (P = 0.04), a 25.2% shorter interval between closure and PACU (=0.01), and an 8.2% lower rate of bleeding-related complications, all of which were statistically significant (P < 0.05).

Conclusions

Both regimens are viable tools in combating opioid overprescription as they both effectively reduce postoperative pain. However, the NSAID protocol resulted in greater satisfaction related to pain management and was more cost-effective by reducing emergence time from anesthesia. As there were no hematomas associated with the use of NSAIDs and a significantly higher rate of compliance, the use of NSAIDs in enhanced recovery after surgery protocols is supported.

Operating in an Opioid Crisis: A Temporal Analysis of Pain Medication Prescribing Practices in Plastic Surgery

BACKGROUND

In response to the opioid epidemic, the United States declared a public health emergency in 2017. We evaluated pain medication prescribing practices among plastic and reconstructive surgeons, assessing pain medication prescription rates and opioid-related mortality both nationally and regionally within the United States.

METHODS

A retrospective analysis of Medicare Part D prescriber data among plastic surgeons from 2013 through 2017 was conducted. Pain medications were categorized as opioid and nonopioid medications. Trends in surgeon prescribing habits were evaluated using the Cochrane-Armitage trend test.

RESULTS

A total of 708,817 pain medication claims were identified: 612,123 claims (86%) were for opioid pain medications and 96,694 claims (14%) were for nonopioid pain medications. Total pain medication claims decreased from 44% of all medications in 2013 to 37% in 2017 (P < 0.001). Opioid medications decreased from 37% of total medication claims to 32% (P < 0.001). The overall opioid prescription rate fell from 1.53 claims per beneficiary in 2013 to 1.32 in 2017 (P < 0.001). Nonopioid pain medications decreased from 7% in 2013 to 6% in 2017 (P < 0.001); nonsteroidal anti-inflammatory drug claims increased by 44%. The prescription rate of nonopioid medications decreased from 2.40 claims per beneficiary in 2013 to 2.32 in 2017 (P < 0.001). An overall increase in opioid-related mortality was observed. Trends in pain medication prescriptions varied significantly among US regions and divisions.

CONCLUSIONS

Plastic surgeons are prescribing less opioids and relying more on nonopioid pain medications. Increased adoption of multimodal pain treatment approaches among surgeons is a likely explanation for this trend in face of the current opioid crisis.