Analgesic considerations in facial plastic and reconstructive surgery: a review

Introduction

Proper analgesia has been a constant challenge for surgical providers since the advent of anesthetic techniques. From early iterations of distracting stimuli, systemic agents with alterations of consciousness, and more modern medical anesthetics, a quest to perform surgical interventions in a safe and tolerable manner is a never-ending challenge of the surgical professions. Each sub-specialty within the umbrella of surgery has their own specific considerations when it comes to proper analgesia and ways to tailor the various resources available to their patient’s specific needs. This review will focus on the analgesic needs of the facial plastic surgery patient population and the varied procedural use of each.

The field of facial plastic and reconstructive surgery has many unique characteristics. As a subspecialty within the field of otolaryngologic surgery, its practitioners are experts in the anatomic complexities of the head and neck. Early practitioners arose around the end of the 19^th century, and the field of facial plastic surgery grew until it was incorporated under the umbrella of otolaryngology in the late 20^th century (1,2). Issues that are addressed by these providers include the span of aesthetic concerns to functional deficits, particularly in relation to the special senses. The face is also the predominant vehicle through which one presents themself to the world, facilitating a heightened degree of importance. Facial plastic and reconstructive surgeons have a specific focus on aesthetic concerns, whether posttraumatic, congenital, or acquired in nature. These often include an underlying functional component, whether that be nasal breathing, oral competency, cancer reconstruction, dental occlusion, or other significant needs. It is the role of the facial plastic surgeon to harmonize and balance these concepts when caring for this patient population.

Facial plastic surgery shares many objectives with plastic surgery, which is a separate specialty that originally arose from the field of general surgery. Practitioners of plastic surgery have a broader range of focus on aesthetic and reconstructive concerns of the entire body. However, many anesthetic principles detailed in this review apply broadly to providers who perform a similar range of procedures. Included in this may be oculoplastic surgeons, trained similarly in ophthalmology with additional sub-specialization in rejuvenating and reconstructive procedures of the eyelids and upper face.

While there is great diversity in practice, the most common procedures performed by a facial plastic and reconstructive surgeon include rhinoplasty, rhytidectomy, blepharoplasty, and genioplasty (2). Several of these procedures may be performed either awake with the adjunct of local anesthesia or in a traditional surgical setting under general anesthesia. Many facial plastic surgeons often offer aesthetic or therapeutic non-surgical treatments such as chemical peels, lasers, and injectables that have their own degree of discomfort or pain that must be anticipated by the patient and provider. Due to the variety and diversity of procedures within the scope of facial plastic and reconstructive surgery, a discussion is warranted regarding options for procedural and post-procedural pain control. This can be grouped into pain management with and without the use of systemic agents for pain control (Table 1).

Pain management without the use of systemic analgesics

In-office and minimally invasive procedures are an ever-increasing portion of facial plastic surgery practice (2). Common treatments include neuromodulator injections, filler injections, microneedling, laser therapy, and some surgical procedures. There is significant interest in optimizing pain management for these procedures as patients are aware during interventions and the procedures are often repeated at regular intervals. Specific interventions offered by facial plastic surgeons that rely on local analgesia include surgical procedures such as facelift, blepharoplasty, post-Mohs reconstructive procedures, and other small tissue transfer interventions. The patient’s specific anatomy and goals are considered when the decision is made to offer a procedure awake in lieu of performing under deeper sedation or general anesthesia. Some may have significant comorbidities that preclude the recommendation to undergo general anesthesia, others may have a preference to avoid. Patients undergoing self-paid cosmetic treatments may also want to avoid the costs associated with a general anesthetic and may consider the more cost-effective option in their decision making. It is critical to have a shared decision-making model when determining the best and safest option for patients. The most common in-office pain management interventions include use of distracting stimuli, topical anesthetic application, and injection of local anesthetic through local infiltration or nerve blockade.

Distraction stimuli

Distracting stimuli is an increasing area of research regarding the gate-control theory of pain. While practitioners may use a variety of techniques, one commonly utilized and backed by research is the use of a vibratory wand. Studies with injections of local anesthesia and intralesional triamcinolone showed a statistically significant difference in reduced pain ratings with application of vibratory wand compared with placebo (device applied with no vibration) (3,4). The literature differs when it comes to injection of botulinum toxin. When a group of patients undergoing injectable therapy with botulinum toxin A underwent pretreatment with unilateral ice therapy, unilateral vibratory wand, or both therapies on opposing sides, there was no statistically significant difference between these techniques and no analgesia. This suggests that Botox injections may not always have significantly painful effects (5). Another study showed less injection pain with vibration than control in a split face study with 86% of patients preferring vibration in future treatments (6). Similar techniques have been used including vapocoolant spray, which has been shown to similarly decrease pain scores by 59% with neurotoxin injections and 64% with filler injections (7). When vibration was used in patients undergoing dermal filler injections, a statistically significant pain reduction was appreciated in addition to a 95% preference for vibration analgesia for future injections (8). Alternatively, patients may be offered cryoanesthesia in the form of ice pack application or cold sprays. In laser therapies, some devices have cooling tips built into laser administration (9). This can be a low-risk alternative or adjunct to other analgesic methods.

Other forms of distraction stimuli are areas of ongoing research within the facial plastic surgery community. In a randomized controlled trial by Ortega et al., adding music for pain management during nasal bone fracture reduction showed significant decreases in systolic blood pressure, anxiety, and pain (10). Other disciplines have extensive research on use of virtual reality for pain management; recent systemic reviews have found significant decreases in pain and anxiety with use, particularly in the pediatric population undergoing a variety of medical procedures (11,12). For certain patients, mindfulness and other relaxation techniques may also be incorporated with varying results. Further studies may be warranted to evaluate the effectiveness of these interventions on the facial plastic surgery population (13).

Topical anesthetics

Topical local anesthetics are widespread in their use across surgical disciplines for analgesia. Common agents utilized include esters such as procaine and chloroprocaine, and amides such as lidocaine, prilocaine, or the longer lasting bupivacaine and ropivacaine. Important considerations include maximum dosing ability of utilizing these anesthetics for systemic toxicity, which can be mitigated by combining administration with epinephrine (14). Topical application of local anesthetic improves patient tolerance of many procedures in facial plastic surgery. There are a variety of forms of topical analgesia available with some being Food and Drug Administration (FDA) approved [e.g., eutectic mixture of local anesthetics (EMLA), LMX-4, and topicaine] and others being compounded through specialty pharmacies [benzocaine, lidocaine and tetracaine (BLT) and lidocaine, epinephrine, and tetracaine (LET)] (Table 2). The most utilized is in the form of an emulsion of lidocaine and prilocaine (EMLA), which can take effect up to 3 mm depth at 60 minutes and 5 mm depth in 120 minutes (9). The penetration and efficacy of most topical anesthetics can be increased by occlusion of the area after application (15). Other FDA approved forms include 4% lidocaine only formulations for use in patients with prilocaine sensitivity. Lidocaine only formulations have a quicker onset of 5 minutes but a shorter duration of action (14). Duration of action can vary greatly among patients based on vascularity of the area injected, type of anesthetic used, and inclusion of epinephrine. Another commonly used topical anesthetic is a compound of 20% benzocaine, 8% lidocaine, and 4% tetracaine (BLT). BLT can be a stronger topical anesthetic as it has higher concentrations of anesthetics than those found in FDA approved products; however, these higher concentrations have also been associated with increased concerns for toxicity.

Regarding efficacy of different topical anesthetics, a comparison study showed no difference between EMLA and 4% lidocaine when used prior to Nd:YAG laser (16). Microneedle application has also been shown to increase its analgesic efficacy (17). Topical anesthetics may be utilized in any procedure or intervention that targets the epidermal or dermal layers of the skin. For compounds containing multiple anesthetics, the effect of the different anesthetics is additive. Procedures that often utilize these therapies include laser treatments, dermabrasion, microneedling, and chemical peels. These can have a considerable amount of periprocedural discomfort and thus require a significant ability to offer anesthesia to the entirety of the treatment area, commonly the face, neck, and/or chest.

Although use of topical anesthetics is common in most aesthetic practices and typically thought to be a safe procedure, there are risks associated with this intervention. First, there is a risk of systemic absorption and systemic toxicity which can result in significant morbidity and even death (18). For facial application, the systemic absorption of lidocaine has been quantified and found to be considerable for formulations including EMLA, LMX-4, topicaine, and BLT (19,20). For each anesthetic, there are guidelines regarding the safe limit of mg/kg that can be administered; these should be followed at all times. Another potential complication from application of topical anesthetics is local reaction with risk of dermatitis, allergic reaction, and potential hyperpigmentation. Generally, ester type anesthetics have a higher association with dermatitis and allergies.

Local injection infiltration anesthesia

Local injection anesthetics are widespread in their use across surgical disciplines for analgesia. Common agents utilized include esters such as procaine and chloroprocaine, and amides such as lidocaine, prilocaine, or the longer lasting bupivacaine and ropivacaine (Table 2). Each has a unique onset, duration, and risk profile that must be considered when selecting an anesthetic agent. Lidocaine with epinephrine is the most commonly used anesthetic in the surgical setting with an onset of 2–8 minutes and duration of effect lasting an average of 4 hours (21). Local anesthetic is injected in standard fashion along the surgical planes and the patient is responsive if they can feel the area of anesthetic fade or if the surgical manipulation affects nearby tissues that have not been anesthetized.

The risks associated with the choice to utilize local anesthesia include the patient being more aware of the surgery being performed, specifically experiencing pressure or tugging sensations, apparent sounds or smells of surgical instrumentation, and the immediate awareness of any undesired complication. Patients need to be educated and consented on the risks involved in an awake procedure. Proper injection technique is paramount when attempting to reduce discomfort with anesthetic injection. Local anesthetic is often buffered with sodium bicarbonate to reduce the burning sensation and normalize the pH (22,23). Keeping the solution at room temperature, using smaller gauge needles, and inserting the needle at 90 degrees perpendicular to the skin can also mitigate the pain of injection. It is also important to inject proximal to distal beneath the dermis and minimize any additional movements of the needle (22,24). The size of syringe plunger also impacts the patient’s experience with larger plungers creating higher pressures and increased pain at the site of injection. Careful weighing of the pain of repeated injections with the pressure experience with larger syringe volumes must be balanced to reduce discomfort with injection.

Prior to injection of local anesthetics, counseling on the risks is appropriate. Risks of utilizing a topical anesthetic include the ability to induce an allergic reaction or the discomfort of the numbing sensation. Ester local anesthetics are associated with a higher incidence of allergic reactions due to one of their metabolites, para-amino benzoic acid (PABA). Additionally, the local anesthetic compound itself can cause a burning sensation due to its acidic nature. Important considerations include balancing maximum dosing ability of utilizing these anesthetics with the risk for systemic toxicity. The risk of systemic toxicity can be partially mitigated by combining administration with epinephrine (14). Using large doses may increase the risk of local anesthetic toxicity (25). Signs of toxicity include tinnitus, metallic taste, and circumoral numbness, which can lead to lightheadedness, change in affect, and eventual lethargy (9,26). Patients should be questioned about a history of reaction or allergy to local anesthetics prior to application and close monitoring of total dosage should be implemented.

Local nerve blockade

For more involved procedures, a blockade of local nerves may be considered for pain reduction (27,28). Many targets have been proposed, including occipital nerves, branches of the trigeminal nerve, and branches of the cervical plexus for procedures that encompass the face and neck. This has been studied intensively in the nasal surgery population with significantly reduced postoperative pain, decreased opioid requirements, and increased satisfaction scores (27). In a study of pediatric scalp nevus excision, a nerve block targeting the specific innervation of the area of excision reduced postoperative pain but did not affect emergence agitation (28,29). Continuous wound infiltration of a long-acting local anesthetic may also be considered for highly painful procedures where postoperative pain control is difficult to achieve to reduce pain and use of breakthrough analgesics. This was demonstrated to be significantly efficacious in microtia patients after costal cartilage harvest (30).

Tumescent analgesia

Another form of local injection anesthesia to consider is tumescent anesthesia. Tumescent anesthesia involves the infusion of a solution containing dilute lidocaine and epinephrine into the targeted areas undergoing surgery. This technique causes the targeted tissue to become firm and swollen, hence the term “tumescent”. The lidocaine serves as a local anesthetic, numbing the area, while the epinephrine constricts blood vessels, reducing bleeding during surgery. The typical concentration of lidocaine ranges from 0.05% to 1% within the tumescent solution. For tumescent, guidelines often suggest a maximum dose of 35–55 mg/kg of lidocaine (31). This higher dosage of lidocaine that can be safely utilized allows for anesthesia over a larger area than may be possible with standard local injection anesthesia. Additionally, tumescent provides prolonged anesthetic effect lasting up to 18 hours post-procedure; this ensures extended pain relief after the procedure, enhancing patient comfort and satisfaction during the critical post-operative period (32). With fat harvesting or liposuction, a potential space develops where the fat is removed and the tumescent fluid will face resorption, thus patients must often wear a compressive garment to protect against dead space development or seroma formation.

Cannula injection

Various injectable treatments include the use of cannula rather than needle injections which warrant special consideration. These have a larger bore and often use a previously inserted needle site to break through the skin to distribute a product, commonly dermal filler and fat injections. Cannulas are a safer distribution than needle tip with reduced rates of vascular infiltration; this is of particular concern in the face with potential endpoints of skin necrosis and blindness (33). They also allow the use of a single port of entry into the area of product distribution under the skin rather than repetitive needle puncture sites. The area of insertion is often numbed both topically and with local infiltration. Filler products may incorporate premixed lidocaine and fat injections will also contain remnants of tumescent analgesia (11). Patients may still be discomfort with cannula placement that may invite use of distraction techniques and other adjuncts.

Systemic analgesia

In many cases, local anesthesia is insufficient for adequate analgesia for many surgical procedures of the face and neck. In certain patients, a degree of anxiolysis is necessary and a certain level of immobility to ensure a safe and satisfactory outcome. While pain may be controlled with local or topical infiltration, the degree of invasiveness of the procedure may require reduced awareness on behalf of the patient. Due to the proximity of the operative field to the airway and other critical structures, oxygen use and fire safety must also be taken into consideration. A multi-disciplinary approach is critical when involving levels of analgesia with close collaboration with anesthesia providers. In addition, some patients with lasting post-procedure pain, particularly in the case of intensive surgical reconstruction, may benefit from the involvement of pain specialists when chronic pain may arise as a comorbidity or a result of a surgical intervention. There are several levels of systemic analgesia that may be offered to the patient with respective levels of awareness and responsiveness to stimuli ranging from minimal to generalized sedation. Levels of awareness can be classically categorized using the Ramsey scale, which details eight characteristics of arousability translating to anxiolysis [2–3], moderate sedation [4–5], deep sedation [6], and general anesthesia [7–8] (34). The Richmond Agitation-Sedation Scale (RASS) was developed to assess the degree of sedation in critical care units, ranging from +4 (agitation) to 0 (alert and calm) to −5 (unarousable) (35). Regardless of choice and degree of sedation used, patients benefit from systemic analgesia peri- and post-procedure in all cases during which lasting pain is expected.

Minimal sedation

Minimal sedation is generally defined as complete consciousness of the patient with the primary goal of anxiolysis. Patients are awake but relaxed and interactive, or a 2–3 on the Ramsey scale. This is commonly achieved by using benzodiazepine medications to calm the patient, provide an amnestic effect, and lessen the impact of procedural pain; however, these medications do not reduce pain. Patients must be counseled on the side effects of benzodiazepines, particularly the risk of sedation, and are required to refrain from driving the day of the procedure. The use of diazepam in conjunction with oral analgesics and intramuscular ketorolac reduced the need for local infiltration anesthesia in patients undergoing CO₂ laser resurfacing with topical anesthetic (9). Of note, concomitant usage of lidocaine and diazepam may increase risk of toxicity due to its inhibition of CYP3A4, thus use of alternate medications such as lorazepam and a thorough understanding of drug interactions is paramount when introducing additional agents.

Conscious sedation

Varied definitions of conscious sedation exist in the literature, but it exists as a scale ranging from moderate to deep sedation under monitored anesthesia care (MAC). Under moderate sedation, patients are arousable and responsive to commands but may be in a reduced state of awareness and thus tolerate more discomfort. Patients maintain appropriate respiration and do not require ventilatory support (36). These patients would be a 4–5 on the Ramsey scale and a RASS −1 through −3 (sustained eye contact, brief eye contact, or eye opening without contact) (35). Deep sedation translates to reduced awareness to touch and manipulation but responsiveness to repeated or painful stimuli at a Ramsey 6 or RASS −4. Conscious sedation may be an appropriate option for patients or providers desiring some degree of reduced awareness without the need for total immobility or generalized anesthesia. This is often carried out with anesthetic agents such as dexmedetomidine and ketamine (37,38). It is also associated with lower rates of postoperative nausea and vomiting (39). A survey of patients undergoing MAC versus general anesthesia for reduction of nasal bone fractures noted neither a difference in pain nor postoperative satisfaction of patients (40).

Risks, however, include a lack of airway protection, fire risk with cautery, oversedation, and hypotension with heavy doses of anesthetic agents. These patients may need intermittent respiratory support and more intensive anesthesia monitoring and care. It is often implemented for surgical procedures with greater pain and discomfort during which patients would not tolerate awareness. It is critical to maintain close vigilance when caring for patients under deep sedation as they do not have a formalized subglottic airway and thus need to maintain a carefully titrated level of sedation that does not reduce their respiratory drive.

Generalized analgesia

Deeper sedation to a Ramsey 7–8 with complete lack of arousability may be desired for surgical procedures if a patient is not an ideal candidate or does not want to have the procedure performed under lighter anesthesia. This can include the extent of surgical resection necessary to perform, the degree of expected discomfort during the procedure, or surgeon preference. Defects that include sensitive structures such as the nose, orbit, and oral cavity are often more likely to be performed with a degree of sedation. The ability to manipulate the head of the patient safely is a common indication for a secure subglottic airway in the facial plastic surgery patient. Of particular concern when using general anesthesia is the common phenomenon of rebound hypertension when the patient awakens from surgery. This carries a specific risk of hematoma formation, which can be of particular concern during and following a facelift operation. This is an uncommon but persistent occurrence in the literature (41,42). Careful mitigation of intraoperative hemodynamics and proper analgesia during the case can reduce the risk of postoperative hypertension and adverse complications. In addition, facial plastic surgical patients include young, female, and lower body mass index demographics, which correlate with a higher risk of postoperative nausea and vomiting (43,44). This can be a risk factor for the development of postoperative hypertension and lead them to a higher risk of subsequent complications.

Post-procedure analgesia

Postprocedural pain is often minimal and can be controlled with over-the-counter analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Acetaminophen has wide tolerability and, except patients with altered liver metabolism, can be recommended in almost all cases of post-procedural pain with minimal side effects and ease of access over the counter. Use of NSAIDs intraoperatively has been shown to decrease need for additional opioid analgesia (45). Some providers exercise caution with the use of NSAIDs due to a theoretical concern for increased risk of bleeding; however, aspirin use did not demonstrate a higher risk of postoperative complications in prospective study (46). In a review by Cramer et al., a regimen of acetaminophen and ibuprofen demonstrated was more efficacious at reducing pain than acetaminophen and oxycodone (47).

Nonetheless, a significant portion of the population with nephrological limitations or a history of gastric procedures may not be able to utilize this category of analgesic agents. In this case, or in the case of significant postprocedural pain, opioid medications may be offered to patients for short-term mitigation of their pain. Risks of opioid dependence must be discussed with patients prior to prescription. A cohort study of plastic surgery patients noted an opioid prescription fill rate of 54.6%, and a rate of persistent use among 6.6% and prolonged in 2.3% (48). It has also been shown to be less effective than opioid-free regimens in the pediatric population. In a case series of patients undergoing rhinoplasty, patients only used 40% of the prescribed dose of hydrocodone-acetaminophen, with 74% consuming 15 or fewer tablets from prescriptions of 20–30 tablets (49). Clinical practice guidelines from the otolaryngology literature include identifying risk factors for opioid use disorder, using nonopioid medications first line, and counseling patients pre- and post-procedure on pain duration and tapering opioid usage (50).

Postprocedural pain may be more significant when patients undergo procedures with general anesthetics considering the selection bias within the cohort that is recommended to undergo general anesthesia. This may include patients with more extensive procedures in sensitive areas expected to correlate with more postoperative pain. However, pain control protocol is often the same regarding the recommendation of NSAID and/or acetaminophen with the addition of a short course of opioid agents in some cases. A tailored discussion of pain control should be undertaken with each patient preoperatively to ensure a safe and customized plan with appropriate expectations.

Patient satisfaction

A thorough discussion of analgesia must include the subjective experience of the patient. Numerous studies have sought to define and quantify the pain experience, with several validated pain scales existing to help translate the inherently subjective experience (pain scale). Patient satisfaction, however, has not been demonstrated to correlate with pain severity. It is much more intricately linked with the patient’s perception that their care team responded to their requests for analgesia and that their experience was validated (satisfaction). All of the aforementioned techniques may reduce the pain experienced, but if the patient did not feel validated in their experience, their satisfaction may be lower and the impact of pain may be more negative. It is critical to have a thorough discussion with patients prior to performing any invasive procedures to ensure comprehension of the expected pain experience and tools available to mitigate and address their concerns. Patients who undergo anesthesia must be properly informed of the risks and benefits of administration, and patients who receive prescriptions for analgesic medications must also understand the risks of administration. Proper postoperative surveillance will also ensure safe use of prescription pain medications and either satisfactory resolution of pain or referral for specialized chronic pain care.

Conclusions

Analgesic management in facial plastic surgery involves a variety of techniques, and careful decision-making regarding appropriate anesthetic usage is paramount. The pain of many surface or injectable treatments can be managed or minimized with the use of topical and infiltrative anesthetics, with adjunct in certain cases of distraction stimuli. Important consideration must be given to the safe usage of local anesthetics with careful attention to maximum dosing and potential adverse reactions. The patient and surgeon may collectively decide when procedures may be done under a local anesthetic or may necessitate either sedation or general anesthesia. In either case, patients often receive adequate analgesia from over-the-counter anti-inflammatory agents with occasional supplemental use of opioids. A thorough understanding of the discipline of facial plastic and reconstructive surgery allows for proper and tailored analgesic care of this patient population.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-23-33/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-23-33/coif). The authors have no conflicts of interest to declare.

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