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Patrick K. Sullivan, MD
Kyoung C. Kim, MD
Fred Burgess, MD*

Department of Plastic Surgery
*Department of Anesthesia (Pain Management Center)
Brown University School of Medicine
Rhode Island Hospital, Providence, Rhode Island

ABSTRACT

Many individuals are so afraid of pain, nausea, and vomiting that they choose not to have facial rejuvenation surgery.

Goals:

  1. Eliminate intra operative and postoperative pain.
  2. Eliminate nausea and vomiting.

M&M: 108 patients underwent rhytidectomy surgery by senior surgeon (PS). A comparison was done of 3 groups:

  1. 50 patients had lidocaine and epinephrine mixtures used for nerve blocks for surgery done with I.V. sedation only.
  2. 15 patients received the above with supplemental bupivacaine (Marcaine) blocks with or without rofecoxib {Vioxx}.
  3. 43 patients studied prospectively had:
    1. An oral cox-2 inhibitor (rofecoxib {Vioxx}50 mg po) administered 24 hours before surgery and QD for 7 days thereafter.
    2. Field and nerve blocks followed by the injection of a levobupivicaine/clonidine mixture along incision lines and specific sensory nerve pathways prior to closure.

Analgesic and anti-emetic consumption was recorded for each patient in each group.

Results:

Group three patients required significantly fewer analgesics compared to the other groups as well as less anti-emetics. Furthermore, the average score (0 – 10) for pain, headache, anxiety, nausea, and vomiting for group three was less than 1 for each category.

Discussion:

Studies have shown (S(-) enantiomer) levobupivicaine to have the same potency as the (R(+) enantiomer) bupivacaine but with a longer duration of 17 hours and a lower risk of cardiovascular and central nervous system toxicity. The addition of Clonidine to levobupivicaine prolongs the peripheral nerve block by 30 – 50%. Prescribing a cox-2 inhibitor (rofecoxib) one day prior to surgery gives a systemic blockade of the normal pain pathways providing analgesic and anti-inflammatory properties without bleeding problems.

Increased knowledge of:

  1. The pharmacological manipulation of afferent nerve pathways.
  2. The anatomic location of key sensory nerves that we can effectively block for a prolonged period has enabled us to dramatically decrease postoperative pain, nausea, and vomiting in our patients.

INTRODUCTION

Pain is something we should prevent if possible. All plastic surgeons want to have their patients be as comfortable as possible after facial rejuvenation surgery. Many perspective rhytidectomy patients are reluctant to even pursue facial rejuvenation because of fear of postoperative pain. Given recent advances in pain management we knew that new medications were available. We carefully studied the sensory nerve pathways in the face and neck using magnification in order to learn about the significant variability of the nerves. (Pantaloni, Sullivan, Plast. Recstr. Surg. 105: 2000) our rhytidectomy pain management strategy has evolved to a multimodal approach that has given us the ability to significantly reduce and in some patients eliminate postoperative pain after rhytidectomy. The treatment includes the use of intraoperative nerve blocks with a levobupivicaine/clonidine solution and pre operative oral Vioxx that continues for seven days. This prospective study evaluates the efficacy of this multimodal regimen. Furthermore, a retrospective comparison is performed with other regimens used by the same surgeon in the past.

MATERIALS AND METHODS

The vast majority of facial rejuvenation procedures performed include forehead rejuvenation, extended SMAS rhytidectomy, and platysmaplasty under MAC anesthesia. The anesthetic protocol for rhytidectomy used by the anesthesiologist at our institution has remained essentially unchanged over the interval of our study and involves the use of intraoperative intravenous midazolam, propofol, fentany, and ketamine. In addition, decadron, droperidol, reglan, and demerol are administered at the onset of the case. Lastly, zofran is given just before the end of the procedure.

The patient is further anesthetized by the surgeon with a combination of 1% xylocaine 1:100,000, ½% xylocaine 1:200,000, and ¼% xylocaine 1:400,000 in the scalp and forehead region then eventually in the lower face and neck over a period of time during surgery. The field block includes local infiltration of lidocaine with epinephrine solution in the scalp, forehead and lower face and neck regions.

Postoperatively, orders are used and have remained unchanged throughout the duration of this study. However, minor alterations in medications are made if warranted by the patient’s allergies or request.

Our strategy has evolved to better optimize pain control. First was the additional use of bupivacaine, which was selectively infiltrated at key areas to block the great auricular nerve, the lesser occipital nerve and the auriculotemporal at the end of the case.

Subsequently, bupivacaine was changed to a levobupivicaine and Clonidine mixture. Furthermore, an oral COX 2 inhibitor was added to the regimen starting one day prior to surgery.

This study included three groups of patients who underwent facial rejuvenation by the surgeon.

Group 1: 50 patients had lidocaine and epinephrine mixtures used for field blocks for surgery done with I.V. sedation.

Group 2: 15 patients received the same field blocks with supplemental bupivacaine (Marcaine) blocks with or without rofecoxib.

Group 3: 43 patients studied prospectively had:

  1. An oral cox-2 inhibitor (rofecoxib 50 mg po) administered 24 hours before surgery and QD for 6 days thereafter.
  2. Field blocks followed by the injection of a mixture of ¼% levobupivicaine and .5 mg of Clonidine along incision lines and specific sensory nerve pathways prior to closure.

The medical records were evaluated to determine the analgesic consumption of each patient in each group. For group 3, a prospective study was conducted to evaluate postoperative pain control with the use of a patient rating system. The morning following surgery, each patient was asked to rate his or her pain using a scale of 1 to 10. This survey also inquired about nausea, vomiting, anxiety, and headaches. All postoperative analgesic, anti-emetic, and anxiolytic consumption was compared for each patient in the three groups. (Fig 1)

RESULTS

A comparison of the average total of all postoperative analgesic, antiemetic and anxiolytics consumption throughout the overnight hospital stay is shown in fig 2.

Fig 2.

MSO4
(mg)
Demerol
(mg)
percocet
(tabs)
vicodin
(tabs)
tylenol
(mg)
zofran
(mg)
droperidol
(mg)
compazine
(mg)
Restoril
(mg)
vioxx
(mg)
Ambien
(mg)
Group 1 157.20 1.21 0.10 196.55 0.83 0.15 4.31 5.95
Group 2 121.15 1.21 0 50 0 0.10 3.46 1.15
Group 3 0.14 46.55 1.10 0 44.83 0.83 0.09 0.03 2.07 8.62 0.18

Analgesics Consumption
Groups 1 and 2 averaged a higher requirement for opioids compared to group 3.

Patients who received the levobupivicaine/clonidine and Vioxx combination required less analgesics (both opioids and nonopioids) compared to the other groups.

Antiemetic Consumption
The incidence of nausea and vomiting in group 3 was also deceased as indicated by the lower requirement of anti-emetics.

Anxiolytic Consumption
Anxiolytic usage throughout the overnight hospital stay was decreased.

Patient Rating Group 3
The morning following surgery, the patient’s in-group 3 were surveyed and asked giving a rating (scale 0 to 10) for pain, headache, nausea, vomiting and anxiety. The average score for each category was less than 1. (Fig3) Specific numbers as follows:

Fig 3. Patient rating on scale of 0 to 10

PAIN HEADACHE ANXIETY NAUSEA VOMITING
0.70 0.89 0.79 0.51 0.13

DISCUSSION

Inadequate postoperative pain control after rhytidectomy can cause unnecessary discomfort for the patient resulting in distress and even a prolonged hospital stay. However, despite a vast arsenal of potent narcotics, patients may still suffer unnecessarily due to the delay of medication administration and time lag for peak effect. Furthermore, most narcotics are associated with adverse reactions such as nausea and sedation contributing to more anxiety.

Therefore, the ideal strategy in pain management is to preemptively eliminate intra and postoperative pain. Consequently, we have developed a multimodal approach to induce preemptive analgesia with presurgical use of a Cox 2 inhibitor then specific sensory nerve blockade with levobupivicaine combined with Clonidine. The combined effect outlasts the local anesthetic and decreases pain and opioids use. Although bupivacaine is widely used, the dose related toxicity has decreased its popularity. Studies have shown (S(-) enantiomer) levobupivicaine to have the same potency as the (R(+) enantiomer) bupivacaine but with a lower risk of cardiovascular and CNS toxicity. Furthermore, it has a longer duration of 17 hours and provides a preferential sensory block over motor.

The addition of Clonidine to levobupivicaine prolongs the peripheral nerve block by 30 – 50%. Clonidine has utilized for over the past two decades in the treatment of hypertension. Only recently has this alpha 2-agonist been shown to have a role in the management of pain. While Clonidine produces analgesia through a central mechanism, it also has been shown to inhibit the release of noradrenaline at terminal nerve fiber endings. Clonidine decreases the body’s release of adrenaline that increase blood pressure, heart rate, and anxiety. Centrally, pain control works by preventing the pain signal’s transmission to the brain.

Prescribing a cox-2 inhibitor (rofecoxib) one day prior to surgery gives a systemic blockade of the normal pain pathways providing analgesic and anti-inflammatory properties without bleeding problems.

SUMMARY

Through this multimodal approach, the postrhytidectomy patient’s discomfort during the first 24 hours is greatly reduced. This in turn reduced the requirement for narcotics thereby avoiding much of the side effects of opioids. In general, these patients described a comfortable, restful experience during the hospital stay.

Selective nerve blocks are done in key areas, the anatomy of which we have previously described in addition to the dissections we have done involving the variable branching pathways of the lesser occipital nerve, the great auricular nerve, and the auriculotemporal nerve. Other descriptions have been done of the later nerves.

Patrick K. Sullivan, MD, is Associate Professor of Plastic Surgery, Brown Medical School.