Acetaminophen, Nonsteroidal Anti-Inflammatory Drugs, and Cyclooxygenase-2 Selective Inhibitors

Abstract

Plastic and cosmetic surgery is often performed as an ambulatory procedure, and pain is often mild to moderate. Good pain relief is central to patient comfort and satisfaction. Analgesics used should ensure rapid onset and adequate pain relief lasting a sufficiently long duration with minimal or no side effects. Acetaminophen is well tolerated by patients, efficacious, and associated with only minor side effects, when used in the minimal effective doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are more efficacious, having lower numbers needed to treat compared with acetaminophen, but have several side effects and contraindications. However, when used in the correct doses in healthy patients, NSAIDs are excellent for pain management with one caveat that there is an increased risk for oozing or bleeding. In contrast, cyclooxygenase inhibitors (Coxibs) are equally efficacious as NSAIDs but have the added advantage that they have minimal or no effect on platelet function, and therefore, the risk for bleeding complications is minimal. However, there has been some concern about the risk of vascular events in patients with ischemic heart disease, specifically when using Coxibs, but even some NSAIDs, for example, diclofenac. In conclusion, acetaminophen should be given postoperatively to all patients undergoing plastic surgical procedures. For patients undergoing moderately invasive surgery, the addition of Coxibs to acetaminophen would be an advantage except in the patient with ischemic heart disease where NSAIDs could have a place in management of pain. Side effects and contraindications of NSAIDs, however, restrict their use to the healthy patient with mild comorbidities.

Persistent Opioid Use and High-Risk Prescribing in Body Contouring Patients

“…In this context, consideration of non-opioid pain medications during the perioperative period is critical. Acetaminophen results in improved analgesia when taken in conjunction with narcotics and simultaneously decreases opioid consumption [17] and should be prescribed after plastic surgery procedures [42]. Multiple meta-analyses studying gabapentin and pregabalin concluded that both drugs improve pain control post-operatively and decrease narcotic use with very acceptable risk-benefit ratios [43].…”

Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period

“…48 All patients without contraindications should receive regular acetaminophen postoperatively. 49 Ibuprofen has been shown to have equivalent pain control outcomes to acetaminophen/codeine in oncologic breast surgery. 50 Similarly, 68.3 percent of liposuction patients in a large series had sufficient pain control without use of opioids.…”

“…50 Similarly, 68.3 percent of liposuction patients in a large series had sufficient pain control without use of opioids. 51 COX-2 inhibitors such as celecoxib are associated with a lower bleeding risk than nonsteroidal antiinflammatory drugs 49 and have been shown to reduce opioid requirements in plastic surgery patients postoperatively, 52 although they should be avoided in patients with ischemic heart disease. Preoperative injection of the surgical incision site with local anesthetic has been shown to decrease opioid requirements in breast reduction.…”

Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon

“… 36 NSAIDs are more effective than other adjunct oral medications with lower numbers needed to treat. 37 …”

“… 39 However, there remains no high-level evidence to support their contraindication in most plastic surgical patients, and several large reviews have concluded that there is no difference in hematoma rates associated with NSAID use. 37 , 40 – 42 A recent meta-analysis reviewing 15 studies with 3064 cumulative patients demonstrated no increase in hematoma with the use of several types of NSAIDs across a variety of plastic surgical procedures including breast surgery. 43 In breast and body contouring procedures, Kelley et al reviewed 106,279 patients; among these, 4,924 (4.6%) patients received postoperative ketorolac.…”