The economics of pain after cosmetic surgery

Every year, the same report comes out in the press about the number of people who are not opposed to cosmetic plastic surgery (80%) and the number of people who would have the surgery performed were it not for economic factors (40%). Plastic surgeons know that as encouraging as these numbers may be for the future of their profession, the real reason most people don’t have surgery is fear of pain. Can there be plastic surgery without pain?

Brains and pain

The human brain has many frailties and, as has been exquisitely delineated in the recent bestseller Thinking, Fast and Slow by Daniel Kahneman, is particularly lazy and gullible. Our brains essentially function most of the time at the level of the village idiot if left to their own devices. It is only when our “higher brain” kicks into gear that we actually have an incentive or drive to get out of bed and leave behind the lives of gluttony and sloth to which our “lower brain” condemns us.

It is the higher brain function that lays the groundwork for a healthy individual with no physical ailments to undergo plastic surgery and suffer discomfort for the higher gain of an improved physique. In short, having cosmetic surgery is the smart part of your brain working, and you are smarter if you have cosmetic surgery! (I love what words can do).


Decreasing the level of pain after surgery is an integral part of the whole cosmetic surgery experience.  In the past, I have written about how our brains deal with pain.

Now, Exparel, a new formulation of an old medicine, appears to allow a decrease in post-operative pain and a more pleasant recovery. For years, many plastic surgeons, such as myself, have been injecting Bupivacaine (Marcaine) along patients’ incisions to decrease pain. Bupivacaine is a type of local anesthetic like Lidocaine or Novocaine that numbs the area it is injected into. The pain nerves just stop working for variable amounts of time: 1-3 hours with Lidocaine and 4-8 hours with Bupivacaine. The new formulation is Bupivacaine wrapped up in a Depo-Foam lipid-based delivery system. The Depo-Foam system can be thought of as a bunch of balloons, each holding some amount of the drug, which allows for a sustained and slow release of the drug. In the case of Exparel, the effect of the injection of Bupivacaine is extended by up to 72 hours! One injection and three days of no pain at the incision is remarkable.

The drug is injected like all other local anesthetics, and its effects are well known and documented. Most plastic surgeons are very familiar with it, having used in in breast augmentations, tummy tucks and facelifts. The advantage of less local pain is that the cosmetic patient will need less narcotic medication for pain relief. That means less feeling groggy and weird, less constipation and a faster return to normal activities and movement, which is the best way to recover from surgery.

Economics of cosmetic surgery pain

I am ready to sign on, but wait, one last question: how much does it cost? And here, as with many other health-related situations these days, it comes down to the dollars and economics of it all. One vial of Exparel costs $285.  One vial of Bupivacaine costs $5.  Even if my cosmetic patients do not need that much narcotic medication, they would only save $20-30. That still leaves a $250 cost difference for the Exparel. Hospitals and surgery centers will not buy it because the pain relief of the drug is for after the surgery—the patient has been discharged from their care and the post-op pain is the cosmetic patient and plastic surgeon’s problem. Patients may be reticent to pick up an extra fee for  pain relief when, after all,  the current medications give relief, though it may differ in feel and duration.

So, maybe it is economics that holds many patients back from having cosmetic surgery after all.