A common and expected question during every plastic surgery consultation is “what will the pain be like”? Although many plastic surgery procedures involve removing skin (tummy tuck, breast lift, face lift, blepharoplasty) which is not particularly painful, they are other procedures which have greater discomfort. Operations which involve bone and muscle manipulation, liposuction, and body contouring surgeries that cover large surface areas are examples of plastic surgery procedures that produce more postoperative pain. And in today’s plastic surgery world, the combination of many procedures in a single operation can take relatively benign procedures into a collective uncomfortable experience.
But regardless of type of number of procedures, the vast majority of plastic surgery patients are going to need some after surgery pain management medication. Even if it is only for a few days, it is always good to have some handy if needed. Pain medications are categorized by the DEA (Drug Enforcement Agency) into five distinct categories known as schedules depending upon the drug’s acceptable medical use and its abuse or dependency potential. The abuse rate is a major determining factor in the drug’s schedule. For example, Schedule I drugs are considered the most dangerous with a high potential for abuse and dependence while Schedule V drugs represent the least potential for abuse. Pain medications in plastic surgery are always either Schedule II or Schedule III.
The most common way to control post-operative pain, despite measures taken during surgery as as the injection of long-acting local anesthetics, is oral opioid medication (narcotics) for mild to moderate pain relief. One common medication that is used is the combination of hydrocodone and acetaminophen, such as Norco, Vicodin and Lortab which can be taken by mouth in doses of 5/325 or 7.5/325 every four to six hours as needed after surgery. Common side effects of these medications are nausea, vomiting and dizziness. Hydrocodone is a Schedule III narcotic which means it can be called in on the phone should an extra prescription be needed.
A very close cousin to hydrodcodone is oxycodone. It is a slightly stronger oral narcotic medication and is well known as Percocet which also contains acetaminophen. It is given in the same dosages as hydrocodone, usually 5/325 or 7.5/325 every four to six hours as needed. It is a schedule II drug that provides stronger pain relief than hydrocodone but also has a higher potential for addiction. Since it is a schedule II narcotic it must be filled by the hand delivery of an actual prescription and can not be called in on the phone to a pharmacy for refills.
Another oralalternative to oxycodone or hydrocodone is Tramadol. This is an oral opioid analgesic that can be taken by mouth 25 to 50mg every four to six hours as needed for pain. Tramadol is said to be just slightly weaker than hydrocodone containing pain relievers. For some patients Tramadol works just as effectively as stronger narcotics. But for other patients it is substantially less effective.
Historically, Tylenol 3 (acetaminophen with codeine) was a common after surgery pain medication but it is used far less today due to other options. Tylenol 3 is often used for pediatric patients who do not require the strength of narcotics such as oxycodone or hydrocodone for pain. Tylenol 3 contains codeine which acts as a sedative as well as acetaminophen for pain relief. It is taken by mouth every four to six hours as needed for pain management. The 3 number refers to the amount of codeine in the drug, there are higher and lower numbers (1 through 4) but 3 is by far the most commonly used.
Often times Promethazine (Phenergan) is provided as well to control postoperative nausea and vomiting. Phenergan does contain codeine which does act as a sedative and can be taken by mouth or given as a rectal suppository in 25mg doses every four to six hours as needed.
Non-steroidal anti-inflammatory drugs (NSAID’s) are considered to be non-narcotic pain relievers. These can be purchased over the counter (ibuprofen, naproxen) or given as a prescription (toradol). Non-narcotics can be taken by mouth every four to six hours as needed for pain relief. These should be taken for mild pain that does not require the strength of a narcotic to treat.
It is important to know any drug allergies prior to choosing the correct pain medication. In addition, helping a patient transition from narcotics to non-narcotics while still effectively managing their pain is also important to avoid dependence and addiction issues.
Dr. Barry Eppley
Indianapolis, Indiana