Novel extended-release local analgesic improves post-facial rejuvenati

According to the American Society of Plastic Surgeons, facelifts remain one of the top five cosmetic surgery procedures performed in 2013, likely owed to the major advances in surgical techniques that speed up recovery time and enhance a patient’s overall experience. From microsurgery to mini-lifts, the idea of post-op “downtime” may soon be a thing of the past, if postsurgical pain management protocols can catch up to the significant strides we’ve made on the technical front. Especially in the case of elective surgeries, adequate pain management is vital to a patient’s positive perception towards the surgeon, the practice and the overall procedural outcome. Fortunately, our current pain management toolbox has a vast array of options — ranging from regional anesthesia, deep sedation and non-narcotic analgesics, to long-acting local anesthetics — which may help minimize the need for general anesthesia, narcotics and their associated risks.

Two years ago, we started using a new, extended-release form of bupivacaine (EXPAREL^®) as an adjunct to our standard non-narcotic, peri-operative/post-operative analgesic regimen following abdominoplasty and breast procedures. The product, a liposomal formulation of standard bupivacaine, received FDA approval in 2011 and produces up to three days of analgesia and reduced narcotic requirements with a single dose infiltrated into the surgical site. We’ve successfully treated more than 250 abdominoplasty cases without any medication-related complications and with high patient satisfaction scores.[1] In addition, we were one of 10 sites that participated in a prospective, observational study to assess patient-reported outcomes and ease of use of EXPAREL in patients undergoing abdominoplasty, breast augmentation or reduction, and dual abdominoplasty and breast procedures. The data found that patients who received EXPAREL had low pain scores (average < 4.0 on pain intensity scale of 0 to 10), consumed one-third fewer narcotics than typically expected, and reported > 3.0 on a 0 to 4 Likert scale for satisfaction with pain management.

Case Study

Given the positive outcomes we observed in abdominal and breast procedures, both in the clinical trial and practice settings, we started expanding the use of EXPAREL to outpatient facelifts and endoscopic brow lifts. Our standard pain management protocol for facial procedures involved prescribing hydrocodone/acetaminophen (7.5/325), Demerol (50 mg), or tepentadol (50 mg), one or two pills every three or four hours as needed for pain.

In a recent case involving a 55-year-old female patient, we used EXPAREL as part of a multimodal pain management approach. We performed “omega” pre-auricular and post-auricular with temporal and scalp incisions, and administered IV acetaminophen, remifentanil and hydromorphone intraoperatively, in addition to using one 20 cc vial of EXPAREL (266 mg) diluted with 30 cc preservative-free normal saline to a total volume of 50 cc.

Given that the bupivacaine in EXPAREL is encased in liposomes, it doesn’t disperse as readily as standard bupivacaine. Therefore, the product requires a more meticulous infiltration technique than that used for standard bupivacaine.

Our Infiltration Technique

We used the following infiltration technique to administer EXPAREL for facial rejuvenation with an endoscopic brow lift:

5 cc of EXPAREL injected below deep temporal fascia bilaterally for a total volume of 10 cc (Figure 1)
5 cc at caudal aspect of neck dissection bilaterally (Figure 2)
5 cc as peri-auricular “ring-block” bilaterally (below superficial muscular aponeurotic system [SMAS]) (Figure 3)
5 cc in scalp incisions (temporal and retroauricular) (Figure 4)
Final 10 cc of EXPAREL injected adjacent to the supratrochlear and supraorbital nerves (to provide analgesia for the brow lift portion of the case)

5 cc at caudal aspect of neck dissection bilaterally5 cc of EXPAREL injected below deep temporal fascia bilaterally for a total volume of 10 cc

5 cc as peri-auricular “ring-block” bilaterally (below superficial muscular aponeurotic system [SMAS])

5 cc in scalp incisions (temporal and retroauricular)Post-surgically, the patient received three 50-mg tapentadol tablets and was instructed to take 1 to 2 additional tablets every three hours as needed. Notably, the patient did not report ear discomfort or the 24-hour temporal headache that is typically associated with this type of procedure.

At present, we use EXPAREL in all of our abdominoplasty procedures, many breast procedures, and most of our facial rejuvenation cases for post-operative analgesia. As a result of integrating EXPAREL into our pain management plan for facial procedures, we have been able to successfully reduce the requirements for oral analgesics post-operatively and consequently have noted a significant reduction in the incidence of opioid-related side effects such as nausea, pruritus, constipation, sedation, etc. EXPAREL currently costs up to $299 per vial, and we factor it into the overall cost of the procedure because its value is immediately palpable to patients and measurable to us from the perspective of faster recovery and reduced need for more traditional analgesic methods. In our practice, the integration of EXPAREL has helped our pain management protocol evolve to complement the cutting-edge surgical advances we offer to patients, and enhance the quality and value of overall patient care and service we provide.

Stephan J. Finical, M.D., is a board-certified plastic surgeon in Charlotte, N.C., with 20 years of experience in the plastic and reconstructive surgery fields. Dr. Finical is academically active and has published numerous peer-reviewed articles, with a focus on aesthetic facial surgery, cosmetic breast surgery and body contouring within the field of plastic surgery. Dr. Finical is certified by the American Board of Plastic Surgery and is a member of the American Society of Aesthetic Plastic Surgery (ASAPS) and American Society of Plastic Surgeons (ASPS).

Kevin L. Smith, M.D., is a board-certified plastic surgeon with a private practice in Charlotte, N.C., as well as an associate clinical professor at the University of North Carolina at Chapel Hill. Dr. Smith specializes in aesthetic surgery of the face and breast. He has published papers on in-office anesthetic protocols, wound healing and peripheral nerve surgery. Dr. Smith is certified by the American Board of Plastic Surgery and a member of the ASPS and the ASAPS.

[1] Finical SJ. Evaluation of EXPAREL® On Patient Outcomes and Ease of Use When Administered By InfiLtration in Subjects Undergoing Breast Augmentation Mammoplasty, Breast Reduction, and Abdominoplasty. Presented at: The 46th Annual Meeting of the American Society for Aesthetic Plastic Surgery; 2013 Apr 11-16; New York, NY.