The efficacy of oral celecoxib for acute postoperative pain in face-lift surgery

Oral Sedation Anesthesia Protocol for In-Office Oculoplastic Surgery

PURPOSE

To present an oral anesthesia protocol for in-office oculoplastic surgery and to compare safety outcomes and patient and physician experiences to ambulatory surgery center (ASC)-based surgery with intravenous sedation or general anesthesia.

METHODS

A prospective study was performed on consecutive patients undergoing surgery at an oculofacial plastic surgery practice. Surgery was performed in an in-office setting using our standardized oral sedation protocol or at an ASC with intravenous sedation or general anesthesia. Preoperative and postoperative surveys were conducted by patients and physicians to compare surgical experience, safety, and efficacy of our oral sedation protocol for in-office surgery in the ASC setting.

RESULTS

Two hundred and fifty-three patients (167 in-office and 86 at ASC) underwent surgery between March and November 2022. There was no significant difference in how patients or physicians rated their experience between the 2 locations. A significantly higher proportion of ASC patients would have rather had surgery in-office (34.9% vs. 19.2%; p = 0.006). A significantly higher number of physicians in the office setting would have rather performed surgery at the ASC than the reverse (12.7% vs. 2.3%, respectfully; p = 0.007). There were no safety complications reported in either setting.

CONCLUSIONS

Within our patient cohort, the presented oral sedation protocol provided safe and effective anesthesia for in-office oculoplastic surgery that is comparable to an ASC.

Postoperative Pain and Opioid Use after Facial Feminization Surgery

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population

Objective: To evaluate opioid prescribing patterns among American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members in the Medicare population. Methods: Retrospective cohort study of AAFPRS members in the Medicare Part D Prescriber dataset. Results: From 2014 to 2016, there was a significant decrease in the number of days of opioids supplied per beneficiary (5.9 vs. 4.9 days, p < 0.005), as well as the opioid prescription cost per beneficiary ($14.52 vs. $11.79, p = 0.005). The highest prescription rate was found in the Midwest (20.5%) and lowest in the Northeast (14.0%), however, the difference between geographic regions was not significant (p = 0.11). There was a significant decrease in the number of total opioid days supplied per beneficiary in the South (p = 0.001), Midwest (p = 0.05), and West regions (p < 0.001). There was no significant difference in opioid prescription rate (p = 0.89) or total opioid days supplied per beneficiary (p = 0.26) when states were stratified by age-adjusted opioid-specific death rate. Conclusion: This study demonstrates a national trend toward fewer opioid days supplied and less opioid cost per Medicare beneficiary among AAFPRS members between 2014 and 2016.

Nonopioid Adjuncts and Alternatives

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.

Acute Pain Management Following Facial Plastic Surgery

Facial plastic surgery, including septorhinoplasty, aging face procedures, otoplasty, and oculoplastic procedures, has varying levels of evidence for the management of acute pain after surgery. This article discusses the available evidence in these procedures and discusses the authors' recommendations for the treatment of postoperative pain, with a focus on decreasing the reliance on opioid pain medication.

The Efficacy of Oral Celecoxib Following Surgical Rhinoplasty

Importance: Exploring potential methods of controlling postoperative rhinoplasty pain with non-narcotic medications. Objective: To examine the effects of celecoxib in reducing pain and possible opioid consumption after rhinoplasty surgery. Design, Setting, and Participants: This is a prospective cohort study of 51 consecutive patients who had undergone rhinoplasty surgery between July 2018 and May 2019 by a single facial plastic surgeon. A questionnaire regarding pain medication usage and complications was given to each patient at his or her initial 1-week postoperative visit. Patients were separated into groups based on whether celecoxib had been used perioperatively or not. Main Outcomes and Measures: In addition to demographic information, the following outcome measures were recorded for each group: type(s) of pain medications used, total opioid consumption, refills required, surgical complications, and related analgesic adverse effects. Results: Of the 51 patients included, 17 patients were provided celcoxib. Mean oxycodone-acetaminophen tablets taken in the celecoxib cohort was 4.2 (CI = 2.4-6.1), whereas mean tablets taken among controls was 14.8 (CI = 11.1-18.4) (p = 0.0006). Mean oxycodone-acetaminophen dose taken in the celecoxib cohort was 17.6 mg (CI = 9.0-26.3), whereas the mean among controls was 73.8 mg (CI = 55.5-92.0) (p = 0.0001). Mean total oral morphine equivalents (OMEs) were also reduced with an average of 26.5 OME (CI = 13.5-39.4) in the celecoxib cohort and 110.7 OMEs (CI = 83.3-138.0) in the control group (p = 0.001). Postoperative nausea and vomiting were significantly reduced in the celecoxib cohort versus the control group (p = 0.02). Overall, with the addition of celecoxib, there was a 76.2% decrease in milligrams of opioid use and an 83.4% decrease in incidence of nausea/vomiting. Conclusions and Relevance: Oral celecoxib appears to be effective in decreasing opioid consumption and nausea/vomiting rates after rhinoplasty without increasing surgical complications. Level of Evidence: 2.

Assessment of Persistent and Prolonged Postoperative Opioid Use Among Patients Undergoing Plastic and Reconstructive Surgery

Importance

Although the development of persistent opioid use after surgical procedures has garnered much attention in recent years, large-scale studies characterizing patterns of persistent opioid use among patients undergoing plastic and reconstructive surgery procedures are lacking.

Objective

To assess the prevalence of immediate and long-term postoperative opioid use after plastic and reconstructive surgery procedures.

Design, Setting, and Participants

In this population-based cohort study, patients who underwent 5 classes of plastic and reconstructive procedures (nasal, eye, breast, abdomen, and soft tissue reconstruction) between January 1, 2007, and December 31, 2015, were identified using IBM MarketScan Commercial and Medicare Supplemental research databases. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year preoperatively and postoperatively, had a second anesthesia event within 1 year postoperatively, and filled an opioid prescription within the year prior to surgery.

Main Outcomes and Measures

Analgesic prescription patterns in the immediate postoperative period. The primary outcome was rates of persistent opioid use (opioid prescriptions filled 90-180 days postoperatively). The secondary outcome was rates of prolonged opioid use (opioid prescriptions filled 90-180 days postoperatively and again 181-365 days postoperatively). Explanatory variables included patient demographics, procedure type, and relevant comorbidities.

Results

Of the 466 677 patients who met inclusion criteria, 96 397 (45.3%) were men, and the mean (SD) age was 46.8 (17.7) years. Furthermore, 212 387 (54.6%) of the patients filled prescriptions for postoperative analgesics, with 212 387 (91.5%) of analgesic prescriptions filled being for opioids. Persistent opioid use occurred in 30 865 (6.6%) patients (5.1%-13.5% across procedure classes), while prolonged opioid use occurred in 10 487 (2.3%) patients (1.7%-5.6% across procedure classes). Patients who filled prescriptions for opioids in the perioperative period were significantly more likely to exhibit persistent (odds ratio [OR], 2.87; 95% CI, 2.80-2.94) and prolonged (OR, 2.90; 95% CI, 2.77-3.02) opioid use than those who did not fill perioperative opioid prescriptions, with the greatest odds for persistent use found in patients who underwent breast (OR, 4.36; 95% CI, 4.10-4.63) and nasal (OR, 3.51; 95% CI, 3.30-3.73) procedures. On multivariable logistic regression analysis, independent risk factors for persistent and prolonged opioid use included perioperative opioid use, procedure type, and prior-year mental health (depression and anxiety) and substance abuse diagnoses.

Conclusions and Relevance

Given the significant risk of persistent opioid use after plastic and reconstructive procedures, it is imperative to develop best practices guidelines for postoperative opioid prescription practices in this population.

Level of Evidence

NA.

Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review

With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review

OBJECTIVES/HYPOTHESIS

Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty.

STUDY DESIGN

Evidence-based systematic review.

METHODS

PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included.

RESULTS

Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution.

CONCLUSIONS

Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E200-E212, 2019.

Transition to Nonopioid Analgesia Does Not Impair Pain Control After Major Aesthetic Plastic Surgery

BACKGROUND

Multimodal analgesic protocols are increasingly favored over traditional opioid regimens due to decreased adverse side effects and reduced opioid consumption. Concomitant use of selective cyclooxygenase (COX)-2 inhibitor celecoxib and anticonvulsant gabapentin have been proposed to adequately control acute postoperative pain.

OBJECTIVES

To determine efficacy of postoperative pain control using nonopioid pain regimen vs traditional opioids for all aesthetic plastic surgery procedures.

METHODS

A retrospective chart review was performed on 462 consecutive outpatient plastic surgery procedures by a single surgeon between November 2015 and July 2017. Procedures in the historical control group (n = 275) received traditional postoperative narcotic, hydrocodone-acetaminophen. Patients in the more recent nonopioid study group (n = 187) received a pre-, peri-, and postoperative regimen of celecoxib and gabapentin.

RESULTS

Similar demographic characteristics between the control and study groups were observed: mean age, 39.7 vs 39.5 years; BMI, 24.6 vs 24.4 kg/m2; and ratio of female patients 92.7% vs 92.4%. A significant reduction in rescue analgesia (meperidine 44.6% vs 14.9%, P < 0.001) and antiemetic use (ondansetron 24.2% vs 16.3%, P < 0.05; promethazine 17.0% vs 4.7%, P < 0.001) in postanesthesia recovery unit (PACU) was noted in the nonopioid group compared to the control. The average stay in PACU also decreased in the study group (82 ± 39 min vs 70 ± 22 min, P < 0.001). Both groups reported low numbers of adverse events and need for additional pain prescriptions. These findings were reproducible in the breast subgroup.

CONCLUSIONS

This nonopioid regimen is as effective as traditional opioid use for acute postoperative pain control and decreased recovery time for outpatient aesthetic plastic breast surgeries.

LEVEL OF EVIDENCE 3

Sex differences in innate immunity and its impact on opioid pharmacology

Morphine has been and continues to be one of the most potent and widely used drugs for the treatment of pain. Clinical and animal models investigating sex differences in pain and analgesia demonstrate that morphine is a more potent analgesic in males than in females. In addition to binding to the neuronal μ-opioid receptor, morphine binds to the innate immune receptor toll-like receptor 4 (TLR4), located on glial cells. Activation of glial TLR4 initiates a neuroinflammatory response that directly opposes morphine analgesia. Females of many species have a more active immune system than males; however, few studies have investigated glial cells as a potential mechanism driving sexually dimorphic responses to morphine. This Mini-Review illustrates the involvement of glial cells in key processes underlying observed sex differences in morphine analgesia and suggests that targeting glia may improve current treatment strategies for pain. © 2016 Wiley Periodicals, Inc.

Modified Rhytidectomy that Produces a More Natural Look: Experience with 110 Cases

BACKGROUND

Recognition of the effects of aging on the ear and the mechanisms leading to ear deformity associated with facelift procedures aid in achieving improved aesthetic results. In 2009, the author developed a novel rhytidectomy technique to provide more natural-looking results than those achieved through other facelift procedures, which often result in facial and ear distortion/deformity. This technique is designed to optimize aesthetic outcomes by employing incisions hidden within the ear, autologous fat transfer to restore normally lost facial volume, and absorbable bidirectional sutures, all of which allow less skin removal and shorter, more concealable scars within the inside perimeter of the ear, and thus less-distorted facial contours. In this retrospective study, the author added one important modification to this previously described approach for preventing ear deformity.

OBJECTIVES

The author will show that this modified rhytidectomy technique has many benefits over a traditional rhytidectomy, and it results in a natural-looking facelift.

METHODS

The author modified the original technique to secure the ears in a way that prevents inferior drifting. The modified technique involves the placement of two parallel strands of 3-0 Monocryl sutures under the scalp and over the skull and running from one side of the head to the other side using a 6-inch blunt needle. The absorbable strands are passed from the inferior part of each earlobe-one in front of the ear and the other in back of the ear. The strands are tied with knots under moderate tension under each earlobe, securing the ear back in the anatomical preoperative position. This secures the bottom of the ears and prevents caudal drifting.

DISCUSSION

The use of 360° round-block, inside-the-ear incisions is advantageous. These incisions have much less lymphatic derangement of the skin, because the overall cut is shorter and the skin is not cut as extensively as in other methods that use longer incisions to get rid of more excess skin in facelifts.

RESULTS

This modified rhytidectomy technique has many benefits over a traditional rhytidectomy: the incisions are hidden inside the ears, so there are almost no visible external incisions, and there is no deformity of the ears and earlobes, because the ears do not drift downward. The ear canal is not distorted, there is no hairline distortion, and most importantly, it results in a natural-looking facelift without the commonly seen deformity of any noticeable pulling.

CONCLUSIONS

This modified approach to rhytidectomy achieves natural looking, aesthetically pleasing results.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review

IMPORTANCE

The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction.

OBJECTIVE

To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures.

EVIDENCE REVIEW

PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method.

FINDINGS

The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed.

CONCLUSIONS AND RELEVANCE

Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.