What is Exparel?

Exparel is a liposomal bupivacaine pain reliever, or anesthetic, that can be injected into the surrounding tissues of a surgical site intraoperatively (during surgery) to reduce pain for an extended period of time, more so than any other local anesthetics.

Exparel is made by Pacira Pharmaceuticals and was FDA (Food and Drug Administration) approved by clinical trials in 2011.

From a chemistry/biology standpoint, the medication consists of bupivacaine (a well-known anesthetic) contained within liposomes (fat molecules) that slowly release controlled amounts of the anesthetic over time. Therefore, postoperative analgesia is much more easily controlled and the time point from wearing off (unlike lidocaine with or without epinephrine) is extended. The injections of Exparel can be done during many surgical procedures to help with postsurgical pain long after the surgery is complete and considered helpful in reducing the need for opioid pain relievers. It is also suggested that Exparel can help decrease the time needed for a patient to stay at a surgical center or hospital after their procedure.

 

How is Exparel used?

Exparel can be used in orthopedic, plastic, hemorrhoid, and podiatric surgeries to help control postoperative pain. Exparel was first approved for use in pain management in hemorrhoidectomy and bunionectomy procedures, but with its effectiveness and almost negligible side effect profile, Exparel has been used in many other settings:

  • General surgery (like hernia repairs, weight loss surgery)
  • Orthopedic surgery (like knee replacements or knee arthroplasty, hip replacements)
  • Oral surgery (like wisdom teeth extractions and jaw surgeries)
  • Obstetrics/Gynecologic surgery (like hysterectomies, fibroid removals)
  • Plastic and reconstructive surgery

 

What use does it have in plastic surgery?

In plastic surgery, doctors have used it for cosmetic and reconstructive surgeries. Some common examples of surgeries where Exparel might be used are:

  • Abdominoplasties (tummy tucks with or without liposuction)
  • Breast Augmentation, Mastopexy (breast lift) and/or breast reduction
  • Breast reconstruction (in the case of patients undergoing breast cancer surgery)

 

What are the benefits of Exparel use?

Exparel is injected directly at the surgical site, unlike oral pain medications or anesthetics through an IV or a pain pump for long acting pain relief or rescue therapy. The pain after a surgery is usually at its peak for the first several days and Exparel helps keep that pain at bay for those first several days before it wears off.

In the hemorrhoidectomy and bunionectomy studies using Exparel, it was significantly better at reducing pain intensity within the first 12 hours post-op than those who received placebo (normal saline). It was also determined that the method of action being similar to that of unencapsulated bupivacaine HCL, resulted in Exparel having a similar safety monograph.

When considering a breast augmentation or abdominoplasty, the pain levels (or pain scores from 1-10, 10 being the worse imaginable pain) can be more significant than some other cosmetic surgeries in light of the muscles of the chest or abdomen, respectively, being involved in the surgery. Many plastic surgeons in clinical practice have adopted using Exparel regularly for these, and other plastic surgeries, because of its improved recovery time and shortened hospital stays. The medication is touted to last as long as 72 hours post-operatively and therefore can help patients get to the milestone of moving out of bed sooner and decreasing their oral pain reliever use.

 

What are the risks of Exparel use?

In the initial clinical trials of the medication for approval in hemorrhoidectomy and bunionectomy surgeries, investigators found there were no systemic or local side effects of the drug that were different from the already approved bupivacaine HCL control group. The medication is broken down (or metabolized) through the liver, so caution is recommended when a patient has a known history of liver disease.

A clinical study conducted from April 2012 to July 2014 showed no serious adverse effects occur with any of the 17 patients who received Exparel via instillation or infiltration during breast augmentation surgery.

Lastly, the pivotal studies conducted with Exparel noted that following the administration of the medication, the most common side effects were constipation, nausea, and vomiting.

 

Final thoughts on Exparel

With the advent of the opioid epidemic on the United States today, reducing and potentially avoiding opiate use (like morphine or oxycodone) is vital to fighting back on its detrimental impact, especially in the case of elective procedures. Having adequate pain control after a procedure will give patients the ability to move more easily with less pain sooner, and therefore reduce their risks of post-operative complications like atelectasis and blood clots. Should you be planning on a future cosmetic procedure, or any surgical intervention in the future that may require pain medication, discuss with your doctor if Exparel, the extended-release liposomal bupivacaine, could be used for your procedure and if there will be any additional cost if it is appropriate.

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