Intraoperative Techniques for the Plastic Surgeon to Improve Pain Control in Breast Surgery

Multimodal Pain Control in Abdominoplasty: A Systematic Review and Algorithm of Optimal Pain Management

The procedure with the highest rate of opioid prescription in plastic surgery is abdominoplasty. Additionally, plastic surgery patients are at a particularly elevated risk of becoming opioid-dependent. The main objective of this study was to perform a systematic review and create an algorithm for a multimodal pain regimen specific to patients undergoing abdominoplasty. A systematic search of the research literature was performed to summarize the prevailing understanding of multimodal pain control in the management of abdominoplasty. The initial search yielded 448 articles. Sixty-eight manuscripts were identified for full-text review. The effectiveness of current strategies was evaluated by way of pain scores, opioid usage, and length of stay, as well as other measures of physical function such as time to early mobilization. In 32 studies involving 2451 patients, the efficacy of different pain regimens during abdominoplasty was evaluated. Among nontraditional, opioid-sparing analgesia, efficacy of treatment interventions for improved pain and decreased opioid usage was found inall studies. Among local infusion studies, efficacy of treatment interventions for improved pain and decreased opioid usage was found in 78% of studies. Last, among regional block studies, efficacy of treatment interventions for improved pain was found in 87%, with 73% efficacy for decreased opioid usage. Multimodal pain regimens in abdominoplasty have the potential to play an important role in opioid-sparing practices in medicine by incorporating nonopioid pain adjuvants such as nonsteroidal anti-inflammatory drugs and transversus abdominis plane blocks in the preoperative, perioperative, and postoperative periods.

LEVEL OF EVIDENCE: 2

Regional Pain Blocks and Perioperative Pain Control in Patients Undergoing Breast Implant Removal With Capsulectomy

Background

Demand for breast implant removal is on the rise, with more than 36,000 explants performed in 2020, an increase of 7.5% from previous years. Postoperative (PO) analgesia is an important consideration in this patient group due to scar tissue surrounding the implant and the potential for extensive dissection during capsulectomy.

Objectives

The authors sought to compare perioperative pain control between three different types of ultrasound (US)-guided regional anesthetic techniques in patients undergoing implant removal with capsulectomy.

Methods

The authors reviewed all patients who received an US-guided block and underwent breast implant removal with capsulectomy at their outpatient surgical center over a 2-year period. They compared intraoperative (IO), PO opioid requirement, and patient-reported pain on the first postoperative day (POD1) between 3 different block techniques using chi-square analysis. A P-value of <.05 was considered statistically significant.

Results

A total of 352 patients were included. Twenty-six patients (7.4%) underwent a serratus plane (SP) block, 13 (3.7%) underwent an erector spinae combined with pectointercostal fascial plane (ES + PIFP) block, and 313 (88.9%) underwent an erector spinae combined with pectoral nerve (ES + PECS1) block. ES + PECS1 was associated with less IO and PO opioid use compared with SP and ES + PIFP (1.9% vs 19.2% vs 61.5%, P < .001 for IO, 26.8% vs 34.6% vs 38.5% PO, P < .001). The ES + PECS1 block was associated with mild pain on POD1 compared with the other 2 regional block techniques (P = .001).

Conclusions

Regional pain blocks, and specifically the ES block, offer effective pain control for patients undergoing breast implant removal with capsulectomy, demonstrating high patient satisfaction in the PO period with low opioid requirements.

Level of Evidence 3

Intraoperative Interpectoral and Subserratus Nerve Blocks in Breast Augmentation Surgery

An essential component in ambulatory breast augmentation surgery is good analgesia. The demographic undergoing this operation is usually fit, low risk with few comorbidities. These patients do not require long-term hospitalization and do not want to spend excessive time in the hospital for financial reasons. Opiate analgesia can have significant side effects such as nausea, vomiting, and sedation. Reducing volumes of postoperative opiates allows faster ambulation and discharge from day surgery. We have developed two targeted nerve blocks that the operating surgeon can apply in minutes under direct vision, not requiring imaging. Anecdotally, we found that these targeted nerve blocks reduced opiate requirements and allowed accelerated discharge and faster return to normal activities. We conducted a prospective randomized, double-blind trial to test this theory.

METHODS

Twenty patients were randomized into saline (n = 10) or ropivacaine adrenaline solution (n = 10). The operating surgeons and anesthetists were blinded to the solution. All patients were closely followed up, and morphine equivalents were accurately recorded. Follow-up pain scores were recorded using the Overall Benefit of Analgesia pain questionnaire.

RESULTS

The ropivacaine nerve blocks significantly reduced opiate requirements postoperatively (P < 0.05). Pain scores were significantly decreased in the study group (P < 0.05). There were no side effects attributable to the nerve blocks.

CONCLUSION

Intraoperative targeted nerve blocks significantly reduce postoperative opiate requirements in breast augmentation surgery resulting in faster recovery and higher patient satisfaction.

Moving Toward Opioid-Free Breast Surgery: Regional Blocks and a Novel Technique

Perioperative pain control is of increasing importance as awareness regarding the risks of under-controlled pain and opioid abuse rise. Enhanced recovery protocols and multimodal analgesia, including regional blocks, are useful tools for the plastic surgeon. The thoracic paravertebral block, pectoralis nerve I and pectoralis nerve II blocks, and proximal intercostal blocks are 3 described methods that provide regional anesthesia for breast surgery. The widespread use of these methods may be limited by the requirements for ultrasound equipment and anesthesiologists skilled in regional blocks. This article describes a novel technique of the intercostal field block under direct visualization that is safe and efficient.

Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon

Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.

Analgesic Use Following Bilateral Breast Reduction

The opioid epidemic in the United States resulted in 42,000 deaths in 2016, 40% of which involved a prescription opioid. It is estimated that 2 million patients become opioid-dependent after elective, ambulatory surgery each year. There has been increased interest in quantifying the need for postoperative narcotic pain medications for a variety of surgical procedures. However, studies have been limited. We sought to quantify the analgesic usage after one of the most common operations performed in plastic surgery, bilateral breast reduction.In this prospective, observational study, sequential breast reduction patients were contacted by telephone on the evening of postoperative days 3 and 7. Patients were queried as to which analgesic medications were used on the day of the phone call. Data relating to dosage, frequency, and satisfaction with pain control were sought. Patients taking chronic narcotics, postoperative complications requiring surgical intervention, and those unable to be reached after multiple attempts were excluded.Complete data were obtained for 40 patients. Narcotic prescriptions were written for oxycodone, hydromorphone and tramadol, with the number prescribed ranging from 0 to 20 tablets. The median total number used was 6 tablets. Eighty percent of patients used a total of 10 tablets or less. Fifty percent of patients were using only nonnarcotic analgesia by postoperative day 3. Patient-reported satisfaction with pain control was overwhelmingly positive, with 95% being either somewhat satisfied or very satisfied with postoperative pain control. Of those taking any medication on postoperative day 3, only half were using a nonsteroidal anti-inflammatory drug (NSAID) as part of their pain regimen.The number of tablets prescribed after breast reduction surgery varies considerably, and there is no consensus regarding the appropriate number to prescribe. Currently, few patients use all the medication prescribed to them, indicating a high rate of overprescribing. The overwhelming majority are satisfied with their pain control. Most patients use less than 10 tablets of narcotic pain medication after surgery. Acetaminophen is widely used as an adjunct but NSAIDs remain underutilized. Based on these data, we recommend that breast reduction patient's pain is best managed with acetaminophen, NSAIDs, and expectation management.