Acute postoperative pain management for common facial cosmetic surgeries: a narrative review

Introduction

Facial cosmetic surgery is growing annually within the United States. The American Society of Plastic Surgeons documents 346,384 facial cosmetic surgeries performed in 2022 alone, representing an 18% increase in cases relative to before the coronavirus disease 2019 (COVID-19) pandemic (1). Despite its rise in popularity, certain practices remain inconsistent; pain management regimens after well-understood facial cosmetic surgeries have historically been provider-dependent with little standardization and high variability (2). The management of acute pain is an essential component of patient comfort and surgical outcome, as evidence historically suggests that postoperative pain is commonly undermanaged, with many patients experiencing moderate, severe, or extreme pain after surgery (3). The sequela of this are especially problematic, as this is associated with significant morbidity, such as organ dysfunction, cardiac morbidity, inflammation, uncontrolled physiologic stress response, increased readmission rates, and extended hospital stay (4).

Multimodal analgesia, commonly utilized in cosmetic surgery, refers to the use of several different strategies, medications, or treatments in conjunction to synergistically target nociceptive pathways that govern the pain and acute stress responses (5). Within facial plastic surgery, these may frequently include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, local or regional blocks, and opioid medications, among others (6). Conservative, well-tolerated agents are generally mainstay in the acute setting, with opioid medication solely prescribed as rescue analgesia for breakthrough pain. These surgeries are usually performed on an outpatient basis; thus prescribing surgeons may have little understanding of patients’ true pain requirements postoperatively, which may contribute to variability in prescribing practices (7,8). In light of the recent opioid epidemic, the frequency and degree to which narcotic medications are prescribed has come under scrutiny (9).

In the last several decades, the United States has experienced a dramatic increase in opioid usage, with an increase in opioid-related deaths from 1.4% in 2011 to 4.5% in 2021 with 422,065 unintentional deaths related to opioid toxicity (10). This has been accompanied by a sharp increase in presentations to emergency rooms for non-medical related opioid use, along with a stark increase in patients seeking treatment for addiction to opioid products, which defined the opioid epidemic at the turn of the century (11,12). Yet, opioid abuse remains a relevant issue at present, with over 75% of the 107,000 drug overdose deaths in 2021 alone involving an opioid (13).

While trends in opioid prescription reveal that prescription rates by primary care physicians have declined, surgical patients receive the highest proportion of potent opioids and have experienced increased rates and doses of opioid prescription for opioid-naïve patients (14). In 2021, the American Academy of Otolaryngology-Head & Neck Surgery published its Clinical Practice Guidelines featuring ‘‘Opioid Prescribing for Analgesia After Common Otolaryngology Operations’’ recommending the use of non-opioid multimodal analgesia as first-line pain management for head and neck surgeries (15). Of facial cosmetic surgeries, this guideline only includes recommendations for rhinoplasty, with a wide range of recommended opioid tablets on discharge. Within the facial plastic surgery community, a recent survey of surgeons suggests that there is heterogeneity in prescribing habits and beliefs about postoperative opioid dependence (16). To date, a formal guideline governing post-surgical opioid prescription strategies within the community has yet to be released. Notwithstanding, the otolaryngologic community recently published an evidence-based review that prioritizes NSAIDs and acetaminophen as first-line pain control in multimodal analgesia, with improved efficacy and greater safety profile than opioid regimens, though this does not sub-stratify recommendations by surgery type (17).

As facial plastic surgeons perform a wide variety of surgeries with varying morbidity, the standardization of acute postoperative pain management by intervention type may reduce unnecessary narcotic prescriptions and optimize acute analgesia during recovery. In this narrative review, we examine the latest evidence and trends on acute pain management after several of the most commonly performed facial aesthetic surgeries, namely for rhinoplasty, facelift, brow-lift, blepharoplasty, and hair transplantation surgery (18). In the context of the opioid crisis, the present review allots specific attention to findings on opioid prescription and postoperative opioid utilization where data is available, as well as to examine alternative therapies that may obviate the need for narcotic medication in patients receiving facial cosmetic surgery. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-8/rc).

Methods

The authors performed a focused literature search through the PubMed, Ovid, and Cochrane databases for articles published from January 2008 to December 2023 related to postoperative pain management specific to rhinoplasty, facelift, brow-lift, blepharoplasty, and hair transplantation surgery. The scope of this review was limited to several most commonly performed facial cosmetic surgeries, though this list is not exhaustive for the variety of procedures performed nationally. Literature search was conducted through search engines using key terms, which included a procedure of interest (rhinoplasty, facelift or rhytidectomy, brow-lift, blepharoplasty, and hair transplantation surgery or hair restoration surgery) combined with “postoperative pain” or “opioid” joined using Boolean operators (AND, OR). Literature examined was limited to full-text articles written in English (Table 1). Articles selected included retrospective studies, prospective studies, randomized control trials, and case-reports. Literature surveying both isolated procedures and procedures performed in conjunction were included. Ongoing clinical trials and studies assessing pain after the acute postoperative period beyond 14 days were not included. Titles, abstracts, and full texts were thoroughly screened in addition to associated reference lists to identify primary literature meeting inclusion criteria. A summarization of key information from publications of interest was sorted into relevant themes based on procedure type.

Rhinoplasty

Rhinoplasty is one of the most widely performed surgeries by facial plastic surgeons that has potential for both functional and aesthetic benefits, with 44,503 surgeries performed within 2022 alone (1). Given its common practice, the largest body of evidence exists surrounding acute pain, NSAID efficacy and tolerability, alternative analgesic treatments, and narcotic use in patients receiving this procedure, with less evidence for other procedural types discussed. An aggregate summary of randomized control trials on varying treatment modalities reviewed is represented in Table 2. Rhinoplasty is commonly performed under general anesthesia, though it has been cited that almost all cosmetic surgeries may be performed under local anesthetic, forgoing the risks of general anesthetic (39). In these settings, adequate analgesia may be confirmed with techniques such as processed electroencephalographic monitoring with assessment of real-time electromyographic activity. Surgically, though rhinoplasty may encompass multiple accompanying procedures or refinements (such as an open vs closed approach, the performance of osteotomies, etc.), literature suggests that these variations do not affect narcotic pain use after surgery (8,23,40-42). One prospective study surveying postoperative pain using the visual analog scale (VAS) and opioid usage in both rhinoplasty and septoplasty patients showed no differences between the two in daily pain scores, number of opioid doses, or morphine milligram equivalents (MMEs) (7). Though, rhinoplasty patients were shown to use a significantly larger amount of acetaminophen during recovery (P=0.01). Pain was also shown to be mild after rhinoplasty and most elevated during the two to three days following surgery, regardless of approach or technique (40). Additionally, the performance of turbinate reduction, septoplasty, revision surgery, and cosmetic/functional goal of surgery in this study did not independently influence opioid use after rhinoplasty. The studies examined do not assess pain after extra-rhinologic autologous cartilage graft harvesting (such as conchal or costal cartilage harvest), which are outside the scope of the present review.

Injection of local anesthetic

Rhinoplasty is broadly performed under general anesthesia with the infiltration of local anesthetic medication prior to incision. This is generally done with a mixture of 1 or 2% lidocaine with 1:100,000 epinephrine, although evidence has arisen supporting the use of various mixtures of additional local anesthetics for reducing pain after rhinoplasty. For example, a randomized control trial by Bagatin et al. demonstrates reduced postoperative VAS scores up to six hours and a reduced 24-hour analgesic requirement with the infiltration of pre-incisional local 0.25% levobupivacaine relative to the standard mixture (19). Similarly, citing the analgesic effect of peripheral local ketamine, Şanli et al. published a randomized control trial demonstrating that administration of subanesthetic doses of ketamine (0.50 mg/kg) as an submucosally injected admixture with lidocaine and epinephrine pre-incisionally improved pain scores up to 24 hours postoperatively relative to epinephrine and saline alone (P<0.05) with no need for rescue analgesia (20). Though this was well tolerated, they note that three (10%) of patients receiving ketamine experienced hallucinations 30 minutes postoperatively. While data is promising for infiltrate compositions, more research is needed to compare these agents and delineate superior combinations.

Regional nerve blockade

Literature supports the relationship between pre-incisional regional blocks and pain reduction after rhinoplasty. Sari et al. not only demonstrated that patients receiving either total nasal or complete facial blocks had reduced pain up to two days after surgery regardless of technique, but also that the addition of bilateral infraorbital nerve blocks as part of the complete facial block significantly reduced VAS scores correspondingly (P<0.0001) (21). The antinociceptive effects of pre-incisional infraorbital and/or infratrochlear nerve blocks has been previously examined for septorhinoplasty, with literature demonstrating an associated pain reduction up to two days after surgery (43). Interestingly, Mariano et al. previously highlighted that while infraorbital nerve blockade prior to nasal surgery successfully reduced VAS scores (P=0.047), it did not significantly reduce time to discharge from the recovery unit (44). The sphenopalatine ganglion block has also been shown to drastically reduce opioid use after rhinoplasty (P=0.001) (22). Amongst the studies examined, regional blocks, regardless of technique, appeared to provide significant analgesia, to reduce opioid use, and to have effects that may last for days after surgery relative to controls. With demonstrated benefit and minimal risk, their use in conjunction with other techniques is recommended.

Non-steroidal anti-inflammatory medications (NSAIDs)

NSAIDs are a widely utilized class of cyclo-oxygenase inhibitors that target prostanoid biosynthesis and are known for their anti-pyretic, anti-inflammatory, and analgesic effects (45). Their use after rhinoplasty is frequently utilized as an essential component of multimodal analgesia. Despite the concern for the anti-platelet effects of this family of medications, several subclasses have been shown to be well tolerated without associated bleeding events for patients undergoing this procedure. Of the literature reviewed, ibuprofen, dexketoprofen, and celecoxib represent several NSAID subtypes with promising use after rhinoplasty. Ibuprofen has been shown to provide effective pain control in these patients; a randomized control trial assessing pain control with either 5 mg hydrocodone with 325 mg acetaminophen or 400 mg of ibuprofen after rhinoplasty showed that ibuprofen was non-inferior to the opioid medication in controlling pain in the first day after surgery, and that the NSAID group actually had a lower pain score on postoperative day one (P=0.01) (23). During the study, only five of the 41 patients only taking ibuprofen were escalated to opioids. On day seven, there was no statistically significant difference in pain scores between treatment groups. Moreover, there were no bleeding events reported in this study.

In addition to its utility as a component of postoperative analgesia, pre-and intraoperative use of NSAIDs, notably ibuprofen, prior to or during surgery has been demonstrated to reduce postoperative opioid consumption in rhinoplasty patients. Gozeler et al. published a prospective randomized control trial of 51 patients assessing use of postoperative patient-controlled analgesia with fentanyl in patients who received either a single dose of 800 mg of ibuprofen intravenously 30 minutes before septorhinoplasty or a placebo (24). Within the first 24 hours after surgery, patients who received pre-emptive ibuprofen had a statistically significantly lower rate of total fentanyl consumption (P<0.001), along with reduced rates of nausea and vomiting. Another study by Alshehri et al. compared this approach with an additional group receiving one-time dose of 1,000 mg paracetamol 30 minutes prior to septorhinoplasty, and found that although both of these medications yielded improved VAS scores relative to placebo, the ibuprofen group demonstrated lower VAS scores compared to the paracetamol group up to 12 hours after surgery (P<0.05) (25). Despite the similarity of no bleeding events reported, the authors in this study note that there was no significant difference in nausea or vomiting between groups. Though little research evaluates this approach in rhinoplasty patients, pre-emptive ibuprofen may be a safe and generally well-tolerated strategy for minimizing postoperative pain.

Dexketoprofen, the (S)-enantiomer of ketoprofen with both oral and parenteral formulations and a reduced bleeding risk profile relative to its racemic mixture, is another NSAID that has been studied preoperatively for its analgesic effects in rhinoplasty patients (46). A randomized, double-blind control trial by Ozer et al. showed a significant reduction in pain scores, nausea, and vomiting after septorhinoplasty when compared to controls, regardless of whether or not 50mg of dexketoprofen was administered prior to surgery, after surgery, or split half-wise preoperatively and post-operatively (26). Another group in Turkey reports routine intravenous administration of 50 mg dexketoprofen after rhinoplasty and at 12-hour intervals thereafter (31,32). Celecoxib is another less commonly utilized NSAID whose efficacy has been demonstrated in a variety of acute postoperative settings and has also been implicated in this patient population. A prospective cohort study by Newberry et al. evaluated changes in postoperative opioid consumption after rhinoplasty in patients receiving perioperative oral celecoxib, receiving 200mg of oral celecoxib for five days starting the day before surgery. Their findings demonstrate a 76.2% decrease in milligrams of opioid use (P=0.001) and a 83.4% decrease in the incidence of nausea or vomiting (P=0.02) in the celecoxib treatment group (47). The difference in postoperative bleeding was not significant between groups. These findings fortify the body of evidence that supports the use of various NSAIDS in rhinoplasty patients. However, additional research is needed to demarcate the tolerability and efficacy of other NSAIDs such as ketorolac, naproxen, and diclofenac in this setting.

Gabapentinoids

Alternatively, evidence supports the use of preoperative gabapentin for reducing postoperative pain in a variety of head and neck surgeries, including rhinoplasty (48). Gabapentin is a commonly used neuromodulatory agent that attenuates pain by targeting presynaptic voltage-gated calcium channels (49). Pre-emptive administration of gabapentin has been shown to reduce VAS pain scores within the first 24 hours after a variety of surgeries in the head and neck, and its role in postoperative analgesia for nasal surgery is emerging. In a randomized prospective study, Salama et al. examined the effects of administration of 1,200 mg of gabapentin two hours prior to surgery on anesthetic requirements intraoperatively as well as postoperative analgesic consumption (27). The treatment group was shown to require significantly less intraoperative remifentanil and postoperative tramadol within 24 hours after surgery (P=0.001). In turn, they suggest that such a regimen may reduce requirements for hypotensive anesthetic medications needed to reach blood pressure goals during surgery. Another study assessed pain scores after surgery using this same dosage regimen for patients undergoing nasal surgery (endoscopic sinus surgery or rhinoplasty), and noted significantly decreased rescue analgesic use in the treatment group (P<0.001) (50). However, they observed a more frequent incidence of dizziness in those receiving gabapentin (24% vs. 4% of placebo patients), which is a known side-effect of this medication.

Pregabalin, another gabapentinoid with predictable pharmacokinetics that suppresses pain signaling in the dorsal root ganglia, has also been implicated in patient comfort following rhinoplasty (28). Commonly used for herpetic neuralgia and diabetic neuropathy, pregabalin has well-known uses for neuropathic pain and is structurally related to gabapentin, acting on voltage gated calcium channels to prevent the synaptic release of neurotransmitters (51). Mohammadi et al. demonstrates a double-blind randomized control trial in which the investigators examined postoperative pain in patients that received a single dosage of 75 mg of pregabalin one hour prior to rhinoplasty (28). They found that VAS pain scores were significantly reduced at all time points up to 24 hours after surgery in those who received preoperative pregabalin (P=0.005). This was well tolerated with no significant differences in side effects of nausea, drowsiness, impaired concentration, dry mouth, or constipation between treatment and control groups. This same dosage regimen was assessed by Pourfakhr et al., which revealed lower VAS scores at all time points to 6 hours after rhinoplasty and reduced rescue fentanyl and ibuprofen use in patients that received pregabalin (29).

Alternative preoperative pregabalin regimens have been suggested, with Demirhan et al. assessing the use of patient controlled analgesia and pain scores of patients receiving combined 300 mg pregabalin and 8 g intravenous dexamethasone, pregabalin alone, or placebo after rhinoplasty (30). The use of preoperative pregabalin significantly reduced tramadol use, with total postoperative consumption decreased by 54.5% in the pregabalin alone group and 81.9% in the combination group with dexamethasone compared to placebo (P<0.001 for both). In many of these studies, pregabalin administration was associated with decreased postoperative nausea and vomiting. Despite the tolerability of the medication in these studies, other research suggests that gabapentin is better tolerated than pregabalin with fewer adverse events (52). More research is needed to assess which medication may be more suitable for rhinoplasty patients, and appropriate patient counseling should be exercised. More broadly, evidence suggests that the analgesic effects of gabapentinoids are useful in minimizing pain and opioid use in rhinoplasty patients alongside other metrics of patient comfort.

Perioperative infusion therapies

Several studies highlight the utility of perioperative infusion therapies that possess alternative intraoperative hemodynamic benefit in reducing postoperative pain. Ketamine is a phencyclidine derivative anesthetic agent that acts as an N-methyl-D-aspartate receptor antagonist with analgesic, hypnotic, and amnesic effects that is often used in induction anesthesia. Citing the body of literature that supports its use in postoperative pain control for other domains, Ates et al. demonstrates that patients undergoing septorhinoplasty receiving a low dose (0.5 mg/kg) intravenous bolus of ketamine at induction and then continued at a dosage rate of 0.25 mg/kg/h throughout the operation boasted reduced VAS scores at all postoperative time points relative to controls (P<0.05) (32). Patients receiving ketamine infusions also required significantly less rescue opioid analgesia (P=0.022), with no difference in side effects or incidence of hallucination.

Similarly, intraoperative intravenous lidocaine has been shown in other surgical domains to reduce nausea, vomiting, and postoperative pain, though is most utilized during induction to suppress the hemodynamic response to intubation (53,54). Pharmacologically, lidocaine is a short to moderate acting amide anesthetic that acts to reduce neuronal conduction at voltage-induced sodium channels. Ates et al. investigated the effects of intravenous perioperative lidocaine on postoperative analgesia in a randomized control trial in which 48 patients were randomized to receive either an induction bolus of 1.5 mg/kg lidocaine followed by a continuous infusion of 1.5 mg/kg/h during rhinoplasty and until the end of the first postoperative hour or placebo of the same volume and rate (31). Patients receiving the lidocaine infusion were shown to have significant reductions in VAS scores at all time points up to 24 hours after surgery (P<0.0001) with no difference in side effect profile. Despite its use in a wide variety of surgeries, these effects have not been reproducible for all forms of head and neck surgery (55). Literature suggests that other intraoperative infusions aimed at modulating the body’s physiological response to pain and intraoperative hypotension, such as beta antagonistic infusions, may have the added benefit of postprocedural analgesia. These findings have been demonstrated for rhinoplasty with intraoperative esmolol (P<0.0001), although esmolol has a half-life of nine minutes and the study group only assessed this response up to three hours after surgery (33). With robust evidence supporting the use of intravenous ketamine, lidocaine, esmolol in other surgical domains, they may serve as useful and well-tolerated adjuncts in conjunction with other conservative measures for rhinoplasty.

Opioid use

Despite the efficacy of non-opioid medications and intraoperative techniques in mitigating acute postoperative pain, narcotic medication is still frequently needed by patients during the acute recovery period. Various studies have aimed to specifically define these needs and propose a standardized narcotic regimen to manage acute postoperative pain in rhinoplasty patients, though there exists variability in prescribing practices. Sclafani et al. aims to quantify narcotic requirements by recording the amount of opioid MMEs used by patients after rhinoplasty, reporting that patients used on average 28.7±34.1 MMEs (with 86% of patients prescribed oxycodone 5 mg with acetaminophen 325 mg and 14% prescribed codeine 30 mg with acetaminophen 300 mg) (7). They propose that a regimen involving 71 to 80 MMEs of opioid medication would be sufficient to manage pain in 90% of rhinoplasty patients. Alternatively, Patel et al. published a case-series evaluating postoperative opioid use in 62 patients that underwent rhinoplasty and documented an average use of 8.7 tablets of hydrocodone 5 mg/acetaminophen 325 mg tablets (43.5 MMEs) in the recovery period (40). Marshall et al. proposes the most conservative recommendation of seven pills (35 MMEs) of 5 mg oxycodone or 7.5 mg hydrocodone/acetaminophen 325 mg, with a mean number of 6.15±4.85 pills (30.75±24.25 MMEs) taken within 14 days postoperatively for their cohort of 35 patients (41).

Notably, these studies all prescribed set amounts of opioid following surgery and documented excess remaining opioid medication on follow-up. Regardless of regimen, standardized prescription protocols have been shown to significantly reduce postoperative narcotic use after rhinoplasty. Neighbors et al. implemented a standard protocol synthesizing the available evidence with a base regimen of 650 mg of acetaminophen every 6 hours and oral celecoxib 200 mg every 12 hours with 5 mg immediate release oxycodone tablets for rescue analgesia after rhinoplasty and compared postoperative opioid use to those without standard regimens (56). This led to a 56% decrease in total MME consumption for rhinoplasty patients (P<0.05), with no change in refill requests and an average of 126.6±59.9 MMEs of consumption in the standard group. This supports the notion providers should exercise frugality with narcotic prescriptions after rhinoplasty and adhere to standard prescribing practices, as it has been documented that as little as 1.2% of patients require additional prescriptions beyond what they are prescribed on discharge (8).

Various other modalities for reducing pain have been discussed in the literature, including effective preoperative counseling, postoperative cooling, vibration and pressure treatments, hypnosis, and acupuncture.

Facelift

Facelift, or rhytidectomy is a commonly performed procedure for facial rejuvenation or anti-aging surgery in the head and neck, usually performed under deep sedation or general anesthesia. Pain management after rhytidectomy is an ongoing area of research with much less evidence available than for other procedure types. While there is limited research on pain prescribing practices and narcotic requirements after facelift, one institution reports that surgeons prescribe 13.3±2.9 opioid pills on average after surgery (2). Despite that lack of data on acute pain, patients undergoing rhytidectomy have been shown to have longer recovery times than other facial cosmetic procedures (57). This represents a population for which postoperative pain management is an important consideration, and more research is needed to guide standardization of postoperative prescription. An aggregate summary of randomized control trials on varying treatment modalities reviewed is represented in Table 2.

NSAIDs

Hematoma and hemorrhage are noted complications of rhytidectomy, and research historically demonstrates that the use of aspirin and other NSAIDs is associated with adverse bleeding events for this procedure (58). Nevertheless, COX-2 inhibitors have been known to possess strong analgesic capability in the postoperative setting, and lack the increased risk of gastric ulcer formation, bleeding, bronchospasm for patients sensitive to aspirin, and antiplatelet effects of other NSAIDS (59). Prior evidence suggests that pre-operative NSAID administration may further augment multimodal analgesia for patients undergoing surgery by decreasing the inflammatory response generated by surgery itself. In facial cosmetic surgery, there exists supporting evidence for the role of celecoxib in the treatment of post-operative pain for face-lift patients. Aynehchi et al. demonstrates that patients receiving pre-operative celecoxib (200 mg given the night before and morning of surgery) with post-operative standing regimens (200 mg twice daily for five days) experience improved patient-reported pain scores and reduced postoperative nausea and vomiting when compared to patients in the non-celecoxib treatment group (34). The authors did not report the incidence of hematoma or postoperative bleeding in this cohort.

Ketorolac is another non-opioid NSAID with strong analgesic activity that rivals that of narcotic medications. As its utility in post-operative pain control and opioid use reduction is well demarcated in other parts of the body, ketorolac administration has a similar role in facial plastic surgery (60,61). Specifically, data suggests this may apply for patients undergoing rhytidectomy. Torgerson et al. published a randomized control trial of 140 patients receiving facelift and/or forehead lift at minimum (sometimes with additional procedures in conjunction) who were randomized to receive locally or intramuscularly injected ketorolac intraoperatively, finding that patients with local ketorolac injection required significantly less additional analgesic medication up to 24 hours after surgery (P<0.05) than those who received intravenous administration, with no increased hematoma risk when compared to controls (35). Regardless, those receiving any form of ketorolac, whether locally or intravenously, needed less additional analgesia after surgery than those receiving none at all. This study was conducted by a single surgeon at one center and does not control for the presence of other procedures performed, thus further studies are needed to confirm the safety profile of this medication for facelift specifically.

Alpha-2-agonism

Clonidine, an alpha-2-adrenergic receptor agonist that has been shown to modify the neurohumoral response to tissue injury, has been well described for its use in acute pain management (62). The use of clonidine has even been described for blood pressure reduction during facelift surgery, with one prior report in 1998 documenting a reduced rate of hematoma for facelift patients receiving 0.1 mg of preoperative oral clonidine compared to controls (P<0.05) (63). There are no recent reports examining hematoma risk or other reports to date that evaluate the analgesic properties of clonidine in facelift patients, despite its potential benefit in reducing complications and its uses for acute and chronic pain in other settings.

Longer term, chronic neuropathic pain after rhytidectomy is rare, often multifactorial, and challenging to treat, involving sensations of burning, tightness, allodynia despite an optimal cosmetic outcome. One report in 2006 cites its management with gabapentin (64). Interestingly, one report provides an example of treating chronic focal pain after facelift and browlift surgery with onabotulinum A toxin successfully (65). There are no reports to date that document the need for or efficacy of opioid use in this setting. Chronic pain management after these procedures is out of the scope of this review, and more research is needed to determine best practices in such cases.

Brow-lift

Brow lift is a common facial cosmetic procedure performed with the aims of restoring a more youthful or rested appearance to the upper third of the face by addressing brow ptosis, boasting high rates of patient satisfaction (66). This is performed by either open or minimally-invasive endoscopic approaches, with a recent trend towards minimally invasive techniques (66). Little research has been conducted on postoperative analgesia for brow-lift or whether pain varies based on an open or endoscopic approach. There is an indication that pain is worst immediately after brow-lift surgery and rarely requires additional analgesia beyond 1 week; in a study of 57 patients who underwent endoscopic brow-lift, only 11% noted pain requiring analgesics that persisted greater than 1 week after surgery (57). Similarly, there is a lack of data on standard opioid prescription practices or analgesic regimens following brow-lift, though one institution reported their staff surgeons prescribing 13.3±2.9 opioid pills on average (2). Anecdotally, Richards et al. reports improved pain relief with the administration of liposomal bupivacaine and intravenous acetaminophen towards the completion of the surgery (67). More research is needed to elucidate analgesic prescribing trends, methods for mitigating postoperative pain, and standard regimens for patients receiving this operation, as it may be one of the most painful cosmetic surgeries routinely performed.

Blepharoplasty

Dermatochalasis refers to a condition of skin redundancy of the eyelids characteristic of the aging face, commonly treated by the removal of excess skin through a procedure known as blepharoplasty. This procedure is generally performed under local anesthesia, though many patients identify local anesthetic injection as the most painful part of the experience. A number of factors associated with pain during injection have been previously identified in the literature, including the temperature of infiltrate, depth of injection, amount of solution injected, and size of needle (68). Techniques to minimize local injection and intraoperative pain may render the immediate postoperative period more comfortable (69). However, pain is generally minimal postoperatively; one prospective study of 60 eyelids demonstrated that males and females on average reported pain scores of 3.5 and 2.2 respectively on a ten-point scale in the immediate postoperative period, with peak pain at 4.4 hours after surgery (70). In this study, pain scores did not reach above a score of four in the seven-day postoperative period. Generally, there is a lack of literature on standard postoperative pain regimens, though pain may be treated conservatively. An aggregate summary of randomized control trials on treatment modalities reviewed is represented in Table 2. NSAID is well-tolerated in patients undergoing blepharoplasty, specifically aspirin, as a randomized, placebo controlled study by Winkler et al. demonstrates no increased bruising, bleeding, or hematoma in patients taking low dose aspirin (36). Research on postoperative pain and the standardization of medication regimens after surgery is sparse for blepharoplasty, and more investigation is needed to generate meaningful recommendations. We discuss eyelid cooling, preoperative pregabalin, and opioid use as studied pain reduction options.

Eyelid cooling

Alternative pain minimization techniques such as eyelid cooling are often practiced with the goals of reducing postoperative pain, swelling, erythema, and hematoma during this period where pain may be the worst (37). A randomized control trial assessing these symptoms at varying time points with eyelid cooling administered both immediately postoperatively and throughout the first day demonstrated a successful reduction in pain 1 day after surgery but did not change edema, erythema, or ecchymosis (37). However, only 28.9% of patients indicated that they preferred eyelid cooling after surgery, which may indicate that the application of eye cooling is of only marginal benefit for this procedure with relatively lower pain at baseline. Still, eyelid cooling is of minimal risk and is practiced by many providers, despite the paucity of published evidence.

Preoperative pregabalin

Perioperative pregabalin administration has also been proposed as an effective pain reduction strategy in oculofacial/plastic procedures (38). In a study assessing its perioperative pain management in patients receiving eyelid surgeries, 26 patients were randomized to receive 150 mg of pregabalin 15 minutes to an hour preceding the procedure (38). The authors observed an average of a 5.5-point score reduction in pain scores compared to the control group across all time points (up to 48 hours after surgery) and a consumption of half as much acetaminophen compared to the placebo group. Additionally, this recommendation should be administered with appropriate caution and counseling, as pregabalin has the noted side-effects of dizziness, somnolence, and impaired concentration, amongst others (71). These considerations should be taken into account for all forms of facial cosmetic surgery.

Opioid use

Evidence suggests that these patients do not require a significant amount of opioid medication in the recovery period, and that patients often have leftover pills when prescribed. A surgeon at a single center observed a mean of 2.45 narcotic pain pills (medication not specified) used per patient in the week following surgery (72). In this report, the highest number of pills was consumed within the first 24 hours after surgery. Despite this observation, a study surveying 291 plastic surgeons on opioid prescribing habits revealed that 58% of surgeons report prescribing opioids after blepharoplasty (with an average of 15.4 pills) even though it was the procedure for which they were least likely to prescribe narcotics (73). Mechanisms addressing postoperative pain pre-emptively may find opportunity in reducing this need further.

Hair transplantation surgery

Autologous hair transplantation is a surgical technique for hair restoration common to practice for many facial cosmetic surgeons for various forms of alopecia, most commonly for male androgenetic alopecia. Currently, the most widely performed techniques are follicular unit transplantation (FUT) and follicular unit extraction (FUE). Regardless of technique, this procedure is often performed under local anesthesia in the awake patient. Most of the pain from this procedure arises from local anesthetic infiltration, for which varying techniques have previously been proposed in the literature including the use of ring blocks, pre-infiltrative icing of the surgical site, lidocaine iontophoresis, the application of a eutectic mixture of local anesthetics (EMLA), warming and buffering the local anesthetic agent, and providing vibratory stimulus during injection (74). There is a large gap in literature investigating pain after hair transplantation, with little to no available evidence to date to guide standard postoperative pain management regimens.

In these procedures, donor site pain tends to be the greatest and is often much improved by the morning following surgery (74). Kim et al. suggests that pain after hair transplantation is highly variable, with average pain scores dropping below one on the five-point Wong-Baker pain scale by the second postoperative day regardless of whether FUT or FUE methods were utilized (75). Comparatively, they noted average pain scores to be worse for FUT relative to FUE, at day 1 (2.03 and 1.26 points, respectively), day 2 (1.47 and 0.67 points), day 3 (0.91 and 0.31 points) and day 4 (0.56 and 0.21 points). Aside from the consumption of an oral analgesic immediately after surgery, donor site injection with bupivacaine at the end of procedure and postoperative donor site cooling are other previous anecdotally cited methods for reducing pain from surgery (74). Though pain is minimal after hair restoration surgery, no studies exist to date demonstrating narcotic prescribing patterns or need for rescue analgesia in the recovery period. Further research is necessary to generate evidence to guide standard medication regimens.

Conclusions

Growing evidence in pain management after common facial cosmetic surgeries demonstrates a wide variety of preoperative, intraoperative, and postoperative modalities that reduce acute postoperative pain and significantly improve quality of life. As these surgeries vary widely in invasiveness and morbidity, a tailored and standard approach to pain management may significantly reduce narcotic over-prescription in light of the opioid epidemic. While certain interventions are well studied, large gaps remain in postoperative pain management for the discussed facial cosmetic surgeries. More studies are needed to compare available treatments and to guide the development of standard prescription regimens in these settings.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-8/rc

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