Exparel - a new, long-acting local anesthetic

Say hello to Exparel. It's a new form of a local anesthetic that's been recently approved by the U.S. FDA. Here's the neat part: a single dose can provide relief for up to 72 hours, which is a big improvement over what we have now.

The product combines the long-acting anesthetic bupivacaine with Pacira's patented DepoFoam, which allows a slow release of the drug. If the price is right, you can expect to see this used a lot in anesthesia pain blocks, as well as outpatient surgery, such as breast augmentations and tummy tucks.

Exparel has been evaluated in 21 clinical studies, with more than 1,300 participants, and has an excellent safety profile. It should add significantly to post-op comfort, and reduce the need for nausea-causing opiate medications.

Better pre-op meds for less post-op pain & nausea

Ask anybody what they worry about when they are thinking of having surgery, and I'm willing to bet that answers like "I'm worried that I'll be in pain or be nauseated" are near the top of the list.

What if I told you that, with improved medications prior to surgery, we could make this a lot better than traditional methods? Interested? You betcha!

Anesthesiologists and surgeons have been doing a lot of research on this area, to determine the best types of drugs to reduce post-op pain. And the answer isn't always "just give more", because the side effects of nausea, vomiting, sedation and respiratory depression from opioids like morphine, fentanyl or demerol can start to become problematic. It turns out that the combination of several different strategies works best. Technically, this is called "multi-modality treatment for postoperative analgesia". (Impress your friends with that phrase!)

Interestingly, a medication used for years as an anti-epilepsy agent, called gabapentin, is a real winner for ambulatory surgery patients. One dose given pre-operatively has been proven in multiple studies to reduce post-op pain, reduce the need for opiate medications post-operatively, and reduce the incidence of nausea and vomiting after surgery.

Also, a non-steroidal anti-inflammatory medicine (NSAID) called diclofenac has be proven to be helpful in reducing post-op pain and swelling. Unlike many other NSAID's, this one doesn't have a significant effect on platelet function, so it's OK to take at the time of surgery.

We're in the process of switching over to this improved pre-op combo. By reducing post-op pain, patients will be obviously have an easier time with their recovery. By reducing the need for strong narcotics, they'll have fewer side effects.

Should be a winner for everyone!

Seromas and plastic surgery

It's medical terminology time. Today's word is "seroma". Read this, and impress your friends with your knowledge!

A seroma is a fluid collection which may show up after surgery. Different than a hematoma, (which is a collection of blood within the tissues) a seroma is typically a watery, yellow-colored fluid pocket that has accumulated in one main area beneath the skin. Seroma fluid looks a lot like the fluid you would see inside a large blister. Seromas are considered a minor complication - more of an annoyance, really - after surgery.

Surgeries in which large dissection pockets are created, such as a tummy tuck, a body lift operation, a mastectomy, or certain types of breast reconstructions have a higher rate of developing these fluid accumulations. It can happen after liposuction, too. Some times the patient just notices the area getting larger without any particular symptoms, sometimes seromas cause a low-grade burning sensation in the area.

We try to prevent these annoying seromas by several methods: compression, use of surgical drainage tubes, or internal "quilting" sutures. Each surgeon has their favorite method, and there is still debate at plastic surgery meetings about which technique is best. For example, the drain tubes used after a tummy tuck help to prevent a seroma from accumulating, allowing the tissue layers to heal back together correctly.

How do you know if you have a seroma? In the classic case, we look for a "fluid wave" during the post-operative check-up. This is where we lightly tap on the skin in one area, and see or feel the skin moving back and forth (like an ocean wave) somewhere nearby. Big seromas can look like a water balloon jiggling beneath the skin. Ultrasound scans can also be used to detect seromas.

The treatment is to aspirate the fluid. Usually this can be easily done with a needle and syringe, and a little local anesthesia. Once the fluid is out, it looks and feels better.

Seromas seem to occur more frequently in our body lift / gastric bypass patients, but can happen to anyone. Fortunately, for most people, after an aspiration or two, they go away and don't typically cause any long term issues.

"A Spoonful of Sugar..."

Yes, it helps the medicine go down, according to the old song. But it turns out that a little sugar - or more properly dextrose in the intravenous fluid - may help to reduce the chance of perioperative nausea and vomiting in surgery patients, and reduces the need for anti-nausea medications.

According to a presentation at the recent American Society of Anesthesiologists 2009 Annual Meeting, in a randomized trial of 56 healthy surgery patients undergoing identical general anesthesia techniques, the group receiving 5% dextrose and Ringer's Lactate in their IV, rather than plain Ringer's lactate, had significantly lower nasuea scores 30 minutes after arriving in the PACU and at discharge, and lower overall nausea scores than the control group.

Those in the dextrose group required half the amount of antinausea medications while in the recovery room, and were able to be discharged sooner. (147 vs 178 minutes) The two study groups were otherwise similar for all other relevant factors: age, anxiety level, weight, previous history of perioperative nausea, previous surgery, nothing by mouth (NPO) status, anesthetic time, preoperative glucose, intraoperative nitrous oxide and narcotic use, and total weight-based fluid volume received.

Of all the things about surgery that patients worry about, having nausea or vomiting after surgery is certainly one that's near the top of the list. This study suggests another easy-to-implement idea. I think this is certainly worth trying for our patients.

Exercise after abdominoplasty

Many patients who have lost significant amounts of weight through either diet, exercise or gastric surgery are very interested to know when they can resume their work-out routines after having a tummy tuck (abdominoplasty). They have made exercise an important part of their lifestyle, and miss it during the immediate postoperative time period.

While there is no scientific paper on this, and each surgeon's recommendations may be slightly different, we recommend a step-by-step return to activities using the following schedule.

3-4 weeks post-op: begin low intensity walking / treadmill / stationary bicycle

8 weeks post-op: may return to work-outs, except for abdominal exercises and activities that require strong twisting motions (e.g. golf, tennis, pilates)

12 weeks post-op: may return to full activities - no restrictions

In my experience from literally hundreds of abdominoplasty patients, we have not seen any problems from this exercise protocol, given an otherwise uncomplicated recovery.