Cosmetic surgery: how to treat postoperative pain?

The anesthetist’s mission is to prescribe drugs powerful painkillers, even opiates (morphine) since Kouchner’s painkiller law. I advise against taking them systematically, in order to be able to do a gradation of the painkiller treatment after the act, so as not to immediately switch to the extreme power of these drugs which also have undesirable side effects (nausea, vomiting, drowsiness increased, etc).

Biological reasons for postoperative pain

The causes physical pain are clearly identified. There are three stages of pain production:

• the crossing of the cutaneous barrier, with the section of small nerves sensitive, in fact invisible and subjected to an unfortunate section;
• the transmission via the nervous nets up to the spinal cord then the cerebral bulb of information of distension, traction, compression, during the intraoperative manipulation, sometimes because there is a edema expansive or unexpected postoperative hematoma;
• the alarm interpretation, by the brainfrom pain message the level of cortex, with an automatic repulsive reflex from the continuation of the act; the intensity of the reaction after central decoding is highly variable from one patient to another, depending on the intensity of the painful message, but also on its interpretation; there are stoic patients in front of the painsothers who scream at a simple touch… The anesthetist may have prescribed anxiolyticsthe painful sensation is interpreted as unbearable, thus imposing a General anaesthesia preventive.

The onset of pain postoperative is usually delayed after the operation. Often, plastic surgeons, including myself, use tissue infiltration prior to any incision with a dilute solution of lidocaine adrenaline, the duration of this local anesthesia is four to six hours postoperative.

Because of pain relief lawthe anesthesiologist’s mission is to prescribe painkillers and anti-inflammatories of a power adapted to the operation which is in question, treatment to be taken of course after the intervention and according to what is felt. My recommendations are to use ordinary painkillers (paracetamol 1 gram) to be repeated three times a day at most, but in the event that this treatment is insufficient, the patient, or the patient, is advised to take the most powerful analgesic drugs and anti-inflammatories which potentiate the analgesic drugs – at the cost of a small risk of irritation of the mucous membranes gastric or duodenal. It is recommended to take these tablets in the middle of meals, and to avoid them in case of known peptic ulcer disease.

Evolution of postoperative pain

Postoperative pain related to the procedure can last for a week, gradually easing. Their banal nature means that they are generally well accepted, small sensation of tension, pain when touching the dressing, fatigue of the operated limb or the part of the body concerned. The most painful procedures are:

1. Muscle repair after abdominoplasty.
2. Breast augmentation by prostheses in retro-muscular position.
3. Facelifts at the anchor points of the SMAS (superficial muscular aponeurotic system).
4. The protruding ears cure.
5. The tall liposuction extended to the calves and pegs.
6. Operations relating to joints hands.

On the other hand, blepharoplasties, rhinoplasties, mammaplasties are little or not painful, except for complications or specific emotional fragility. But I would like here to consider the unusual, abnormal pain, which goes beyond the framework of banal postoperative pain.

1. Severing an Important Sensory Nerve Can Lead to Neuroma

This is the case of the section of a nervous branch of the superficial cervical plexus during facelift operations where the surgeon clumsily cuts a very inconspicuous nerve branch, the pains are characteristic because there is a hyperalgic point when it is cut. finger touch through the skin. These neuro-matous pains are difficult to cure. They can impose a revision surgery to bury the neuroma deeper in a muscle. The result is random but sensory rehabilitation can help, action of touching the painful point repeatedly to get used to it. the brain to transform the pain message into a message of painful sensation, but bearable in the long run.

2. Pain concerning spinal transmission

These painful sensations have the characteristic of being increased during changes in the position of the spine. Their improvement involves a postural change, or even rehabilitation through well-oriented physiotherapy. This may be the case following certain abdominoplasties, where a major undermining and tensioning of the rectus abdominis muscles has been performed by a suture that “pulls” in depth.

3. The interpretation of pain at the level of the brain

It varies greatly from one patient to another, some have an excellent tolerance to pain, and master it easily, by a gift of autosuggestion or a serene patience. Other patients cannot tolerate any pain at all, causing hyperactivity, anxiety and even depression. They are all the more poorly tolerated since there is already a depressive state at the start. latent. In these cases, the use of a psychiatrist or psychologist Competent will be essential so that the subject can control his pain until it improves gradually.

This may take several weeks. If improvement does not occur, another cause should be suspected. This can even be a compress or a foreign body forgotten in the wound, imposing after radiological assessment a surgical resumption…

4. A postoperative complication is the most common cause of pain

• Giant or expansive hematoma after breast prostheses or a facelift under tension, which also requires an emergency reoperation.
• Surgical site infection with redness and heatsometimes purulent discharge: a antibiotic treatmentor even a return to the block for cleaning, washing and drainage may be necessary.
• Disunity of the scar, following a suture under too much tension.
• Presence of a foreign body which is being expelled.

In these cases of manifest postoperative complication, the surgeon must be urgently called back so that he can make an inventory and initiate the appropriate treatment, which can go as far as emergency surgery.

In conclusion

The plastic surgery results in very few chronic, unbearable or disturbing painful phenomena. The panoply of therapies is wide enough for an appropriate treatment to be adjusted for each patient, depending not only on the precise cause of the pain but also on the psychology of the person who has to endure it.

The cosmetic surgeon must cross the skin, which is the main organ for perceiving the outside world: the multitude of receptors that dot our cutaneous envelope explains why this creates discomfort which, as a rule, is transient. It is only in the rare cases where there is prolonged and unusual pain that the surgeon will have to look for a precise cause for this suffering which is only exceptionally a total creation of the mind.

Before attributing the suffering vehemently alleged by a patient to a bad state of mind, a patient who is sometimes suspected of being disturbed by the operative trauma, it is necessary to systematically seek a real and physical cause for the pain and which may be increased by dissatisfaction with the result obtained. Indeed, postoperative pain can be the astonishing expression of a negative assessment of the result, which the patient is unable to formulate other than by this mask of the difficulty of telling his surgeon, while there is disillusionment with the result. observed…. Hence the need for the practitioner to combine a large dose of psychology fine to his manual experience to validly interpret these painful signals of a disturbing, if not obsessive nature.

The surgery well-made and successful aesthetics are quickly forgotten in favor of a new joie de vivre.