Episode 39: Sunday April 11

One of the most common concerns for plastic surgery patients is pain after their procedure. In the year 2021, what are the best ways to manage post-operative pain? Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic discuss different, including nontraditional, methods to optimize pain management while minimizing narcotic use. Effective pain control is a critical component of great surgical outcomes. If you ever worried about pain management after surgery, this episode is a MUST WATCH

Full Transcript (download PDF here)
2021.04.11 Post Operative Pain Management
Dr. Salvatore Pacella: [00:00:00] Good morning, everybody. Welcome to our podcast. I'm joined here by Dr. Sam Jejurikar in Dallas and Dr. Sam Rhee and Paramus New Jersey. I am, of course, Dr. Sal Pacella from San Diego and today's topic. We're going to be talking about a. A unfortunately, a necessary evil in surgery. We're talking about postoperative pain and how to manage it, what to do, what our strategies are.
We think it's a really important topic for our patients because it it'll definitely cut through some myths and also highlight on some facts related to pain. So prior to going into that, I just want to go over a show. Disclaimer, this show is not a substitute for professional medical advice, diagnosis, or treatment.
This show is for informational purposes, only treatment or results may vary based on the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon and other qualified healthcare professionals. With any questions you may have regarding a medical care, never disregard professional medical advice, or delay seeking advice because of something in the show.
This sort of reminds me this week they were on HBO. They replaying Rocky, rocky two and Rocky 10 and whatever. And one of my favorite lines from Rocky was clubber Lang. Remember Mr. T a reporter asked them, what's your prediction for the fight against Rocky Balboa? You know what his answer was?
Dr. Sam Jejurikar: [00:01:27] Pain.
Dr. Sam Rhee: [00:01:34] That's an awesome, 
Dr. Sam Jejurikar: [00:01:36] it's funny you bring that up because I've found myself just going to Rocky for watching training scene montages all week. It is very true though. I it's a similar story. One of, we, we always seem to have a Michigan theme to this and our esteemed chairman while we were there, who was a gruff man from upstate New York after he'd become chairman.
He I remember he, his practice being one of reconstructive to being an aesthetic surgeon, all of a sudden, because he was a chairman at the university of Michigan and patient came in after a facelift. And as the residents, we blindly followed along the attendings to every room. Lady was complaining about postoperative pain.
He looked at her frustrated for a few minutes and ultimately just grumbled that her surgery hurts and walked out of the work. And I had to, and I, it and talked to her for about five to 10 minutes to try to clarify that. So it's true though. I know Dr. Rhee is gonna to lead us through a discussion, but this is a really, I think, a really salient topic because we all know that surgery hurts.
And we also know that we have an opioid crisis in the United States. And so how we navigate that, Dr. Rhee hunt, what are your approaches to this? 
Dr. Sam Rhee: [00:02:41] That is a very true, I think I try to keep it simple. I probably am not as advanced as some providers are in terms of alternative medications and forms of treatment.
I find that. A majority of patients for me do really well on a fairly basic postoperative pain management regimen, but some have extreme issues one way or the other either because of what they bring to their lives beforehand or their own personal. Just idiosyncrasies and it really does help to have more treatment protocols and other medications in your armamentarium.
And I know that you Sam and have a lot of experience working with different protocols. And so that's something that I'm interested in hearing.
Dr. Salvatore Pacella: [00:03:28] Okay. 
Dr. Sam Rhee: [00:03:29] I'm going to keep this simple so that we can keep our discussion fairly open. Obviously we could classify postoperative pain management into three broad categories, systemic, which affect the entire body regional, which affect part of the body and then topical or local, which, are basically directed analgesics specific to an area. And any comments about how you feel about these three different modal treatment categories?
Dr. Salvatore Pacella: [00:03:58] Yeah. couple of comments, I think we by nature of our discipline operating all over the body the pain we induce post-operatively, sometimes can be actually quite predictive based on the type of surgery and the body origin of surgery. Okay. So for example when I do breast reconstruction surgery, we're oftentimes maneuvering a lot of muscle.
Okay. And muscle by nature hurts when it's divided or injured. And so if you've ever had a Charlie horse from riding on your Peloton bike, Dr. Jejurikar that, that pain, it's really intense. And so my postoperative regimen really concentrates on things that, treat inflammation and muscle pain as opposed to treating the the noninflammatory aspects of pain.
Other places of the body, such as the face, to be honest with you, it can't. Th don't really induce a tremendous amount of pain, or what I see is oftentimes facial surgery, the pain is rather great the first day or two after surgery, and then wanes, whereas breast surgery tends to do this.
And so in the face, I tend to use a tremendous amount of ice, a tremendous amount of non non traditional methods to reduce swelling. Yeah, go ahead guys. 
Dr. Sam Jejurikar: [00:05:07] I think when you think about systemic approaches to pain a lot of it comes down to societal expectations for pain. And what I mean is, if you think back to when we were residents, it'd be very common for us to go into the residents' lounge at the university of Michigan.
And there would be a. A drug rep that's there who was pitching their latest wares. And when we were training, one of the big things was long acting opioids. There was this push towards oxycodone use, which of course there's been a ton of lawsuits about, but with that came the general expectation for patients that they could have pain.
After or they could have surgery and not have any significant pain afterwards. And I think that's very much a unique United States phenomenon. When you look at the rest of the world, when you look at Europe in particular, the expectation has always been, even when you have an operation, like a hysterectomy or not, or a C-section, you have narcotic pain medication while you're in the hospital.
And then you go home, you utilize nonsteroidal, anti-inflammatories predominantly utilize some muscle relaxation, but in general, Th the expectation was that you would have some pain after surgery. And in some ways, if you think about it guys, particularly for these big muscle operations, like you were talking about South, if patients have pain after surgery, not overwhelming pain, but pain that is that they're responsive to, it helps guide their activity level.
They know what not to do and what to do. So one of the big conversations to have with people is. You know what I am very concerned about your pain afterwards. I want your pain to be manageable afterwards, but I don't want you to believe that you're not going to have pain. Because with this idea that we're going to block all of your pain afterwards, you're going to overuse narcotic pain medications.
You're going to have all of the short term side effects that go along with it and you're going to have addiction issues. So from a holistic standpoint, I think. One of the biggest change that's happened in my practice in the last five to 10 years is the recognition that you are going to have some pain afterwards and pain is actually important for you not to overdo it after your surgery.
Dr. Salvatore Pacella: [00:07:06] That's an excellent point. And it's I think many patients approach the concept of pain is like pregnant. You're either pregnant or you're not, you either have pain or you don't want to get to the point where I don't have pain. And so I've found it very helpful to talk about pain in a gradient, use one to 10, say.
Obviously 10 out of 10 pain would be the worst. We don't want you there. That's that's terrible, but it's not possible to have zero out of 10 pain. If we could live somewhere in the three to four range, you know that's a place we have to shoot for not zero. So really important.
Dr. Sam Rhee: [00:07:36] When I hear both of you guys speak, I think the most important top points you guys, both outlined one is Expect that there might be some pain and that cultural expectation as Sam pointed out and it is very cultural. It's very American is and it's different when you go to other countries is, being completely pain-free after an operation.
Is a foreign concept or should be. And that's where the explanations that you guys both engage in with your patients is very important. So obviously counseling them beforehand, what to expect is very helpful so that they are not surprised by what they encounter after the surgery. And then as Sal said, and I think this is very important as plastic surgeons, where we operate makes a big difference in terms of the amount of pain we patients will experience and what they.
And how it's managed. I do agree that opioid use is a major issue in this country. And I do remember Sam when I was a resident, just like you, the Oxycontin rep was there. And that was when we started prescribing a lot of it for a lot of patients. And maybe our education at that time.
Wasn't so great in terms of managing post-operative pain. And I know that my. Experience and my learning over there. Yeah, like you said, the past 10 years has really helped me a lot. And I think we need to keep up on it as providers to help make sure that we provide our best for our patients. Let me move on to the next screen.
So let's comment first, as Sam said, the nonsteroidals The most common ones. I just listed a couple we can comment on is Toradol or couture, lack acetaminophen or Tylenol or ibuprofen Motrin. And there are many others out there. What do you guys think? 
Dr. Salvatore Pacella: [00:09:16] Yeah I I'm a huge fan of couture lack or Toradol.
Particularly in these muscle type surgeries, that's just exactly what I was going for with the anti-inflammatory medication. This is an exceptionally powerful anti-inflammatory and when I'm doing a big, large breast cancer reconstruction, it is huge in my armamentarium. Now the one thing I'm I approach with a little bit of trepidation is because it's an NSAID.
Toradol can lead to this is a little controversial, but co Toradol can, depending on who you ask the anesthesiologist, the surgeon toward all can lead to a little bit of postoperative bleeding. So I usually do not start this until the day after surgery all evaluate my patients and make sure we're not having a hematoma or any sort of bleeding issue.
And then start that. And it's almost magically improve their pain level. 
Dr. Sam Jejurikar: [00:10:05] Now, what do you think Dr. Pacella about these class two? Nonsteroidals like Celebrex, for instance it comes only in an oral form, so it's not potentially as, as strong as the IB or I am forms of a Toradol that you're thinking of.
But have you noticed in your practice bleeding issues from those types of medications? Yeah 
Dr. Salvatore Pacella: [00:10:22] so good question. There is my understanding of bit of data yeah. In the anesthesiology literature about Celebrex and its improvement in not only post-operative pain, but not having an effect on bleeding.
And I have the benefit of working very closely with a lot of orthopedic surgeons that I that are in my group or practice and Celebrex as part of their normal preoperative treatment ahead of time. And afterwards I've been hesitant to use it because of that being an inset category.
But in, in the several times I have I haven't noticed a ton of difference to be honest with you in their pain. 
Dr. Sam Jejurikar: [00:10:54] What about you, Dr. Rhee? Have you used Celebrex at all? 
Dr. Sam Rhee: [00:10:57] I don't. I usually don't have a problem with either a Toradol, or, Motrin or any other types of oral NSAIDs I think.
There have been a few patients that have had a significant. Reflux or guests riotous or some other issues. And then sometimes I'll perf you know, prescribe an alternative form of a Cox two inhibitor, like Celebrex. But I don't find that much better. What do you think? 
Dr. Sam Jejurikar: [00:11:21] What will you just let me ask you one question. So I've been, I've used Toradol as a patients and I've prescribed it in a delayed manner frequently for patients. And I agree with everything. Dr. Pacella said, it's an incredibly powerful medication that is very effective. I've been reluctant to use it immediately postoperatively. And as you both of you gentlemen know usually the day of surgery and the first day afterwards tend to be the most painful days for patients.
So in those patients I have used Celebrex. I use it for all of my breast augmentation patients. Part of our protocol that try to get people back to work and like within, two or three days or even one or two days after breast augmentation involves using Celebrex and having them take it
daily for or twice daily for two weeks postoperatively. And I've used it on probably hundreds of patients. I haven't identified a higher incidence of hematoma related to it. I feel comfortable. I haven't really broadened it to using it in other patient populations, just because as we talked about other things that are out there at a certain point, you can only prescribe a certain number of medications to people before they get overwhelmed.
So I've only really restricted it to breast surgery, but I've been happy with it. 
Dr. Sam Rhee: [00:12:25] Does your institutions use a lot of the IV form of Tylenol or the acetaminophen? Because here the hospital is very into it and they've used it a lot. They feel like it helps tremendously. And I'm not sure I feel that way though.
Dr. Salvatore Pacella: [00:12:38] My, my hospital there the pharmacy division is very. Conscious of patient outcomes from a cost perspective and from a, from an outcome perspective. And they have not found a cost benefit to IB Tylenol. 
Dr. Sam Jejurikar: [00:12:54] I would agree with both of what you guys have said in the hospitals where patients are saying we've used Ofirmev or the IV form of acetaminophen.
I've heard a lot about the cost involved with that, but when you look it up, it's about $10 a dose. It's not prohibitive at all. It's more expensive than narcotics, but it's not ridiculously priced. Most of what I do is outpatient surgery. So there's not really a role for IV pain medication.
But but I have found it to be highly effective when people are spending the night.
Dr. Salvatore Pacella: [00:13:23] Now, let me ask you both of you gents. Okay. So let's say you use a a secondary medication like this for pain. Tell me, give me an example of what you would prescribe your average breast augmentation. On your 
Dr. Sam Jejurikar: [00:13:34] prescription. For Celebrex, we will give them a hundred milligrams tablets.
They'll take it twice a day and they'll take it for 15 days. Post-operatively we started the day of surgery. And and a lot of times I'll find that probably 40 or 50% of my patients will report that they never take any narcotics between between some of the regional stuff. That doctor reason it gets you next to with D pivot cane blocked that, and that we might do in the chest wall and Celebrex, the narcotic use is very well.
Dr. Salvatore Pacella: [00:14:01] But, and then you're giving them an additional narcotic medication 
Dr. Sam Jejurikar: [00:14:05] or, yeah, give it to them as a backup. I don't want patients to feel like they don't have something. Should they have breakthrough pain, but they do have narcotic medication. So how many would you say you give them how many hydrogens those are prescribed?
We prescribed Tramadol. Which it's 50 milligram tablets and we in the state of Texas, I don't know if it's like this everywhere. We're restricted to a one week prescription. So they get 28 pills. 
Dr. Sam Rhee: [00:14:25] Let's move on to narcotics since we're talking about them now. Probably the most popular pain medication or analgesics that physicians use.
And like we said, there's a huge issue with opioid addiction in this country. Yeah, let's talk a little bit about how we use our opioids in our patients. Post-op 
Dr. Sam Jejurikar: [00:14:42] In, in my practice there's and I think you guys would agree with this. There's obviously a recognition that opioids are the strongest class of pain medication that's out there.
And oftentimes we'll see people preoperatively who are worried that they're not going to get adequately treated for their pain. So there is a role for opioids and everybody. But again, pretty much everything I do at this point can be done as an outpatient or with an overnight stay. I have almost no role in my practice for IB narcotics.
The side effects are substantial particularly in. In combination with body contouring surgery, where there's a restriction of of the ability to take deep breaths. I get worried about the potential respiratory side effects that go along with it, but I will give patients oral narcotic pain medication for breakthrough pain.
Should they need it? And for bigger body contouring surgeries, of course. 
Dr. Salvatore Pacella: [00:15:31] W what strikes me is just How incredibly unpredictable, these narcotic medications can be in different various people. From the Latin, the word narc and AR C is to sleep or to dream. And so you would think that when you take these medications, they're the respiratory depressants. Obviously they make you relaxed. They make you sleep, but in a good population of patients, They don't sleep very well. They actually get quite wired up taking these. Some people have tremendous nausea and vomiting.
Others have none. And so I agree with you, Jen. So I just try to minimize or stay away from this. As much as you can, for the average, breast augmentation surgery, or minor plastic surgery, I may get patients 20 tabs really trying to rely on insets more than anything. Oh, I get myself into a little bit of a challenge with some of the larger inpatient.
Hospital cases, we do such as breast recon or abdominal wall reconstruction, and we really have to bump our pain regimen up to oxycodone. And it's, we've got to watch patients a little closer 
Dr. Sam Rhee: [00:16:32] my own personal, I agree with Sal. I I think there's a tremendous variability in terms of how patients their, the side effects that they experience with narcotic pain medications. I, my typical, for example, for a breast dog is I will send them home with 600 of ibuprofen, every eight hours, a standing, just to, I don't want them to.
Wait for the pain. I want them to just take it on a standing basis. And then for breakthrough, I'll have them take a half or one Percocet every six hours to start. I have found enough people complained about the Vicodin the hydrocodone for either it was inadequate or they.
Had a lot of nausea with it that it seemed at least for my population, that the per the oxycodone seemed to work a little bit better. I don't prescribe more than 10 at a time. And if they need more than that, I really. Bring them in and I really figure out what's going on here with that. I don't, I've never had anyone or it's very rare that anyone needs to take more than about 10 in my practice, 
Dr. Sam Jejurikar: [00:17:41] even for a larger body contouring operation.
Yeah. No, 
Dr. Sam Rhee: [00:17:44] but that's different. I'm talking about breast dog. I'm talking about breasts daughter. Yeah, obviously bigger body contouring may require more. But I still start with 10 and I will prescribe as needed just so I can keep track of it myself. I think for the body contrary, the problem is that a lot of them will develop constipation.
So we're on a very. Pretty strict anti constipation regimen, right from the get-go. That seems to be an issue with some of these patients that I've tried to keep it simple that way. I know that there are a lot of other options that Tramadol I've thought about for awhile as well. I don't know what your experience with that is.
I would like to 
Dr. Sam Jejurikar: [00:18:16] hear that, I think I think we're all saying the same thing. We find opioids to be unnecessary, evil in our practice. There is some role for it to varying degrees, the bigger the operation, the more you generally need it, but patients do better. The sooner they get off of it, Tramadol or Altram on this slide are is Kind of the weakest of the opioids.
And it's oftentimes not enough for people that have had bigger operations or at least they perceive it not to be enough. But again, I tend to err on the side of under-treating a little bit, I'd rather not eliminate the pain, but knock it down in terms of intensity so that they can be more responsive to it because pain does get better reasonably quickly after surgery.
You just have to give the body time to let the inflammatory process resolve. 
Dr. Sam Rhee: [00:18:56] Sometimes I will. They take these medications, particularly opioids, not because of pain as much as. Difficulty sleeping or resting. And in those cases I will prescribe alternatively, some Ambien, which I think is a reasonable alternative for some patients.
But it's individual it's on a case by case basis. And you have to address.
Dr. Sam Jejurikar: [00:19:18] Yeah, I think No. We're going to talk a little bit more about some alternative medications. I think as we can introduce more non-narcotic medication into the regimen, the, hopefully our reliance on narcotics becomes less than medications. Like Tramadol may become more effective 
Dr. Sam Rhee: [00:19:31] yeah, multimodal.
So you have a, can use less opioids strength. If you combine it with something else. Absolutely. Let's. I didn't have a separate regional slide, but let's talk about some regional Protocols and treatments that are 
Dr. Sam Jejurikar: [00:19:42] available. I think what we all probably do for both breast and body contouring procedures are blocks in the abdominal wall.
For instance, if you're doing a tummy tuck, it's really common to do a transverse apron, neurosis, plain block, or a tap block. And very commonly now it's being used as a liposomal form of of, bupivacaine, which is called XPRL. For patients it's a local anesthetic that lasts approximately 72 hours.
And the surgeon can inject it in a plane in the abdominal wall so that it spreads somewhat diffusely the way I generally, and I use this Almost all of my tummy tucks at this point. And generally we'll explain it to patients is it's not gonna take away your pain. But it's going to make your pain controlled with other medications.
And I have noticed that after tummy tucks still pretty much everybody takes some degree of narcotic pain medication, but the duration of time, which they're doing it and the amount they're taking have gone down tremendously.
Dr. Salvatore Pacella: [00:20:35] I I agree with you. Unfortunately my, at my institution expert panel has a very limited Usage they've only used, they only use it in in GI surgery rectal surgery actually because literature has demonstrated a cost benefit to it. There's actually very limited studies in plastic surgery using it.
At for improvement of pain. Now that doesn't mean that it doesn't work. It just means that there's no studies. And oftentimes, being at a larger institution like myself every product every drug has to go through a process. So we haven't been able to use it at my facility, but I do use pain pumps all the time, particularly in tummy tucks.
And I've, I found this to be a game changer. It is a little bit cumbersome and just for our audience out there what is a pain pump? It's a round device that looks like a balloon and it's attached to a catheter, a little tiny metal catheter that can be placed exactly at the surgeon's discretion.
So oftentimes with tummy tucks, we're going to sew up the abdominal wall. The muscles of the abdomen and I'll actually snake this catheter right behind that repair. And what it does is it gives a three-day dose of something called Marc Haine directly to the site. So at the site of most intense pain, this narcotic is being continually delivered over three days.
And I've had, I've found that to be really impressive with my postoperative pain control. I don't know what you got.
Dr. Sam Rhee: [00:21:54] So just for me, I I do offer expert will which is also the lyposomal form of Mark cane. As an upcharge, I have found in my personal experience that it does work a little bit longer than just injecting like a broad field block with Mark cane before you close. But it's, to me, it's Like maybe another day's worth of if that and for the upcharge, if patients ask me, I say, for what it offers, I'm not sure it's really going to be so much of a difference in terms of your activity level, because most patients who are body contouring patients have drains.
I do encourage them to get out of bed and mobilize. But they're not running marathons and they're not, doing anything particularly crazy. And so for the activity level that they're engaging in, I don't, I, in my personal experience, I don't know how much that, that upcharges worth for the patient.
And I've asked patients pretty extensively with, or without the expert role and their activity level and pain. For me seems to be the same. And as Sam says, they're all taking some degree of narcotic pain medication anyway. I'm not sure I would have to really look at it carefully to see what sort of difference I'm seeing in terms of pain pumps.
I use, I did use them a while back. I found them cumbersome and that was the thing about them. And. They have so many different models and, do you use the reusable ones or the disposable ones or this type? And once I had a disaster with one that just got. Dislodged, and it was a nightmare.
And once I had one negative experience with it, I just said F it
Dr. Salvatore Pacella: [00:23:33] basic. It is definitely a, there's definitely a learning curve and an annoyance curve, 
Dr. Sam Rhee: [00:23:39] for sure. Yeah. And so maybe I just didn't stick with it, but that's where I stopped. 
Dr. Sam Jejurikar: [00:23:44] Yeah, I think pain pumps are definitely effective. I agree. I just largely stopped using them when XBRL became available eight or nine years ago.
And and much like Sam, I have the ability to offer it to patients with an additional upcharge, but I have I would say I have seen in in a. Okay. Majority of patients fruit pain, not necessarily increased activity level. Imagine if you're having a tummy tuck, you're not going to be walking blocks, but I had a patient as week, for instance, who took one hydrocodone after a tummy talk.
And then I just talked to her yesterday. She was taking no other pain medication of any kind. There, there is definitely in some patients, a huge benefit. 
Dr. Sam Rhee: [00:24:22] So let's talk about different other medications that might not necessarily be considered analgesics. Or non traditional methods of pain management. 
Dr. Sam Jejurikar: [00:24:30] Gabapentin or Neurontin is part of the eras protocol, which for the people out there, it's the early recovery after surgery protocol, which has been really been popularized at, for general surgery operations.
It's something that I have started using for my patients as well, where there, in addition to the narcotic and nonsteroidal medications, we've talked about, we'll prescribe Around the clock schedule of Gabapentin three times a day. And it's again, an alternative way to basically just diminish sensitivity of your sensory nerves.
And I found this to be a very useful adjunct. It doesn't eliminate the need for narcotic pain medication, but it has lessons in nature tremendously.
I, in terms of cannabis, it's illegal in the state of Texas, so we can't prescribe it, but you guys may have more experience with that. 
Dr. Salvatore Pacella: [00:25:16] Yeah. That's a good question. So 
Dr. Sam Jejurikar: [00:25:18] I'm of course in 
Dr. Salvatore Pacella: [00:25:18] California.
We have many patients, we will have a discussion about cannabis and I will say, cannabis has. A component of what's called CBD, which is a cannabinoid oil and THC, which is the stuff that makes you high and want to eat. Cheetos. So you know, this, the CBD component with a little tincture of THC, I think if you're looking the pain literature out there and anesthesia, that is a really good combination for people that have chronic pain, but don't, it doesn't necessarily have any literature related to.
Acute pain. So what I tell patients is I don't have a problem with you using cannabis. I just don't want it smoked vaporized because it can cause necrosis of the skin just like any smoking. So 
Dr. Sam Rhee: [00:26:07] edibles are fine. So I, it is not legal, still in New Jersey just was. It is for medical use, but I don't I'm, you have to be a pretty, there are a lot of hoops to jump through if you want to be able to prescribe it.
So I don't specifically prescribe it, but I, as Sal does, I have a lot of discussions with patients who ask about it because they themselves do consume it either for medical reasons or otherwise. And they ask whether or not they can take cannabis after their surgical procedures. And I generally feel okay about it.
I think anecdotally, it seems like the patients who do take cannabis have much, much less opioid use pretty much zero in everyone that I know that has taken cannabis. Plus they don't their pain perception is less and again, pain is a very personal. Experience. So maybe the, just the fact that they feel that they're taking something to address the pain, obviates the need for other pain medications, such as opioids.
It's a tricky situation. I don't know, but I certainly am not opposed to it. Obviously the vape and smoke is not a good thing, not good. But I will be very interested as Cannabis becomes more widely available to see how that can be introduced as part of a postoperative pain regimen.
As Sam said, any kind of multimodal pain, operative pain, postoperative Rhee pain regimen is very helpful. I'm very interested in I'm going to probably after this talk start introducing Neurontin into my practice and I want to see how that goes. I think there probably is a very good role for that.
I haven't used anything such as the pulse electron electromatic fields or prednisone postoperatively. I don't feel like those are very. I don't see how I could work those into my practice, but but definitely the cannabis and Gabapentin, I might start working on 
Dr. Salvatore Pacella: [00:27:53] that. And just to be clear in California, although it is legal, both for recreational and medicinal use I do not prescribe it.
My. Narcotic license is a federal DEA license and it's still illegal federally. Sorry, patient 
Dr. Sam Jejurikar: [00:28:09] before you
could just walk into the store and buy it though, right? 
Dr. Salvatore Pacella: [00:28:18] I won't discourage you from using 
Dr. Sam Jejurikar: [00:28:20] it. So the scenario in California for Dr. Coachella's patients is you're going to go to the pharmacy and they're going to say, they're going to, or you're going to go to your dispensary. And you're going to say, I don't have a prescription for Dr.
Pacella, but they'll do that.
So we've had Dr. Pacella out of it 
Dr. Salvatore Pacella: [00:28:41] for two. 
Dr. Sam Jejurikar: [00:28:43] Exactly. Yeah. I also have any experience either with pulse electromagnetic fields. And for viewers out there, prednisone is a powerful anti-inflammatory, but it is thought to have some association with wound healing complications. So we do have some trepidation using it, particularly after bigger body contouring surgeries right away after surgery, I will use it.
When for postoperative swelling and body country stuff, maybe two or three weeks postoperatively, I'll use it somewhat aggressively in facial aesthetics surgery as well, but that's more to help the swelling.
Dr. Sam Rhee: [00:29:12] I think that a is a really awesome summary of most of the major aspects of post-operative pain management. Obviously everyone should be talking to their own provider, as you can tell, we all have our different approaches to this. And some of it is. What we do in our surgeries as well. The, the techniques that we employ in our surgeries also lend themselves to different.
Yeah. Recovery methods as well and how we manage postoperative pain, but just, it's pretty obvious that as providers, we give a lot of thought to pain management, how we can help our patients best. And as you can see, it's an ongoing evolving field and we'll probably in a couple of years revisit this topic and have different.
Thoughts and protocols at that point as well. 
Dr. Salvatore Pacella: [00:29:54] Awesome. One last one last question for you guys, actually for Dr. Jejurikar. When you said you were watching and incorporating the Rocky for montage training the, was that the Ivan dragon? 
Dr. Sam Jejurikar: [00:30:06] Yeah. That's when Rocky. So this is after Apollo creed has died.
He's in Russia for the Epic showdown with Drago and you have the split images going back and forth with Drago training, with all of the latest technology and getting shot up with stuff and Rockies, just, chopping wood, pulling sleds, and there's incredible inspirational music. That's your jam?
My God. Yeah, I could watch that on repeat while eating Doritos and drinking beer grapes. So it's fantastic. 
Dr. Salvatore Pacella: [00:30:39] Yup.
Dr. Sam Jejurikar: [00:30:43] Take care.