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The need for improving pain control for all patients

Article-The need for improving pain control for all patients

When I was a kid I used to dread going to the dentist. Fortunately, I've been blessed with good teeth all my life; so it wasn't that frequent dental appointments had sensitized me to the experience — it was purely and simply the fear of pain.

My parents, survivors of the Great Depression, watched every penny, and I believe to this day that they chose our dentist based on fees, not skills or ability to develop an effective rapport with patients — especially children. On the rare occasions when I had to see my parents' choice for a family dentist, I knew, even as a 5-year-old, that the experience would be painful because procedures would always be done without anesthetics!

It is from that childhood perspective that I've come to recognize the need for improving pain relief for all patients, including cosmetic surgery patients. Patients bring many life experiences to the cosmetic surgeon. The unspoken fear of pain or anxieties they may have about undergoing cosmetic surgery are extraordinarily difficult to assess even during the most comprehensive preoperative consultation. Some patients might express some anxiety, a few might describe their concerns about pain, but I've learned most won't say anything at all, unless they are specifically asked.

I believe that there are a number of important steps that should be taken to ensure that every patient is given the opportunity to have as pain-free a cosmetic procedure as possible.

Effective preoperative consultation

The consultative appointment allows the physician time to evaluate the patient physically and emotionally, provide a detailed description of the procedure and develop an appropriate level of rapport with the patient.

I have found it extremely beneficial to actually ask the patients about their level of anxiety or concern about pain that they anticipate during or after the planned procedure. This allows the development of a well-conceived plan to possibly use a preoperative anxiolytic agent.

Options in anesthetics

Since a number of cosmetic procedures are being performed today using only topical anesthesia, a technique about which most patients may have no prior experience or knowledge, care must be taken to explain to patients how these agents work and how they are applied.

  • Tumescent anesthesia — The advent of tumescent anesthesia for liposuction and other procedures has allowed many cosmetic procedures to be performed with the patient completely awake and alert. Yet it is a new enough procedure that many patients will be unfamiliar with it. As a result, it is important to discuss this technique in detail with the patient preoperatively so he or she can understand how it is administered, its benefits and postoperative requirements.
  • Local anesthetics and nerve block anesthetics — These have been used for many years and yet many patients fear the pain from their use the most. For that reason, I always teach my residents to inject these agents slowly and carefully since that will reduce the pain that comes from too rapid an injection.

Systemic intraoperative pain relief

A number of agents can be safely administered during a cosmetic procedure to provide pain relief.

Whether the choice is an anxiolytic agent, sedative or narcotic depends on the type of procedure being performed and the emotional status of the patient. The cosmetic surgeon must be familiar with the appropriate use of a variety of different agents in order to customize the management for each patient.

Postoperative care paramount

Depending on the type of procedure performed, postoperative pain relief may consist of nothing more complicated than having the patient reduce physical activity, rest with his or her head (or other operative site) elevated and use compression dressings.

Non-narcotic pain medications may be all that is required to provide pain relief for some patients while others may require true narcotics to relieve their pain. The most important thing to remember in effectively managing postoperative pain and achieving complete pain relief is that whatever technique is used, it must be individualized to meet the particular needs of each patient. There is no formula in pain control that will work in every circumstance.

I believe that achieving effective pain control in the cosmetic patient has not been fully addressed. In California, the state licensing board has recently required all licensed physicians to complete a special course in pain management in order to qualify for license renewal.

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