Post-Operative Pain Management in Rhinoplasty: A Double-Blind, Randomized Controlled Trial

CLINICAL QUESTION

Do non-opioid pain medications offer adequate pain control compared to opioids, following rhinoplasty?

BOTTOM LINE

There was no difference between opioid and non-opioid pain medications in post-operative pain control after rhinoplasty, suggesting that non-opioid medications may offer adequate pain control in rhinoplasty.

BACKGROUND: Opioids remain commonly prescribed after rhinoplasty despite variable use, medication-related adverse effects, and concerns regarding dependence and overprescribing. Evidence supporting non-opioid regimens after rhinoplasty has been limited, although nonsteroidal anti-inflammatory drugs (NSAIDs) have not been consistently associated with increased post-operative bleeding or complications.

STUDY DESIGN: The study was a double-blind, randomized controlled clinical trial. Adults undergoing primary functional, cosmetic, or combined rhinoplasty were assigned to compounded acetaminophen 325 mg–hydrocodone 5 mg or acetaminophen 325 mg–ibuprofen 200 mg, taken as one or two tablets every four hours for five days. All patients received 50 mg tramadol for breakthrough pain.

SETTING: Tertiary facial plastic and reconstructive surgery center

SYNOPSIS: Of 159 enrolled patients, 130 completed the trial, with 65 assigned to each group. Participants had a mean age of 32.1 years, 77% were women, and 68% were white. Mean post-operative pain scores over days zero through five did not differ significantly between the hydrocodone and ibuprofen groups (44.4 versus 40.6 on a 0-100 visual analog scale; P=0.156). Adequate pain control was reported by 94% of hydrocodone–acetaminophen-treated patients and 97% of ibuprofen–acetaminophen-treated patients (P=0.403). Study tablet consumption was also similar. Rescue tramadol was used by 29% of the hydrocodone–acetaminophen group and 23% of the ibuprofen–acetaminophen group (P=0.425), meaning 77% of patients assigned to the non-opioid regimen remained opioid-free.

Itchiness was significantly more frequent with hydrocodone–acetaminophen (22% versus 3%; P=0.001). Rates of nausea, constipation, dizziness, headache, bleeding, and other reported effects did not differ. There were also no between-group differences in periorbital edema, ecchymosis, subconjunctival hemorrhage, or post-operative functional and aesthetic outcome scores, and no serious adverse events occurred.

Limitations of this study include the single-center, single-surgeon design, exclusion of revision cases and patients requiring auricular or costal cartilage grafts, possible selection bias, and use of opioid rescue medication in both groups. Nonetheless, the findings support ibuprofen–acetaminophen as a reasonable first-line regimen after uncomplicated primary rhinoplasty.

CITATION: Kandathil CK, et al. Postoperative pain management in rhinoplasty: a double blind randomized controlled trial. Facial Plast Surg Aesthet Med. 2026. doi:10.1177/26893614261429310.

COMMENT: Why is this interesting? This is a double-blind, randomized controlled trial from multiple institutions that examined the use of post-operative pain medication after rhinoplasty. This showed that there were no differences between opioid and non-opioid pain medication management after this surgery. This may allow surgeons across the country to decrease the need to prescribe opioid pain medication in the right settings.—Ryan Belcher, MD, MPH