Analgesic Management in Plastic Surgery: A Multimodal Approach

Effective postoperative pain control in plastic surgery uses multimodal analgesia—combining agents with different mechanisms to maximize relief while minimizing opioid use and side effects.

Analgesic Classes and Roles

Class	Agents	Role	Key Considerations
Non-opioid oral	Acetaminophen 1g q6h, NSAIDs (celecoxib 200mg q12h, ibuprofen 600mg q6h)	Foundation; scheduled around-the-clock	Avoid NSAIDs if bleeding risk, renal impairment, peptic ulcer; celecoxib preferred for COX-2 selectivity
Opioids	Oxycodone 5-10mg, hydromorphone 2-4mg, tramadol 50-100mg	Breakthrough/severe pain	Shortest duration, lowest dose; bowel regimen; risk of sedation, respiratory depression, dependence
Local Anesthetics	Lidocaine 0.25-0.5%, Bupivacaine 0.25% (with/without epinephrine)	Infiltration, field blocks	Duration: lidocaine 1-2h, bupivacaine 4-8h; max dose limits
Regional Blocks	PEC I/II, serratus plane, erector spinae, TAP, femoral, fascia iliaca	Extended coverage (12-24h+ with liposomal bupivacaine)	Ultrasound-guided; reduces opioid need; catheter for continuous infusion
Adjuncts	Gabapentin/pregabalin, dexamethasone, ketamine (low-dose IV), magnesium	Neuropathic component, opioid-sparing, anti-inflammatory	Gabapentinoids: sedation, dizziness; dexamethasone: hyperglycemia

Protocol Example (Abdominoplasty)

• Preop: Acetaminophen 1g + Celecoxib 400mg + Gabapentin 300mg PO.
• Intraop: Bilateral TAP block with liposomal bupivacaine 266mg + dexamethasone 8mg IV.
• Postop: Scheduled acetaminophen 1g q6h + celecoxib 200mg q12h x 3-5 days; oxycodone 5mg q4h PRN breakthrough.

Individualization

Regimen tailored to procedure magnitude, patient comorbidities, opioid tolerance, and recovery goals (e.g., ERAS protocols).