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Pain After Breast Surgery: Etiology, Diagnosis, and Definitive Management
Laurence T. Glickman, MD1, Eric H. Williams, MD2, Lee Dellon, MD Ph D3, Justin M. Broyles, MD4, Sammi H. Tuffaha, MD5, Taylor A. George, BS6.
1Long Island Plastic Surgical Group, Garden City, NY, USA, 2The John Hopkins University School of Medicine, Baltimore, MD, USA, 3The Dellon Institute for Peripheral Nerve Surgery, Baltimore, MD, USA, 4Department of Plastic and Reconstructive Surgery The John Hopkins School of Medicine, Baltimore, MD, USA, 5Department of Plastic and Reconstructive Surgery TheJohns Hopkins School of Medicie, Baltimore, MD, USA, 6The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Breast procedures are amongst the most common surgeries performed by Plastic Surgeons. The prevalence of post-operative, persistent pain remains unknown. Our experience has been that persistent post-operative breast pain is related to intercostal nerve trauma. The purpose of this article is to increase awareness of this problem and to describe the diagnostic and management strategies for patients with post-operative breast pain.
Methods: A retrospective analysis of the patients of four surgeons involved with peripheral nerve surgery was done. This cohort contained 10 patients stratified according to the index surgical procedure: implant based reconstruction (7), reduction (1), augmentation(1), and mastopexy (1). Outcomes were assessed with a numerical analog score. Physical examination demonstrated painful trigger points along the pathway of one or more intercostal nerves. Prior to surgery, each patient improved > 5 points after a diagnostic Xylocaine/Marcaine local anesthesia block of the suspected intercostal nerves. At surgery, one or more intercostal nerves were resected and implanted into adjacent muscles.
Results: At a mean of 16.5 months, there were 6 excellent, 1 good, and 3 had self-reported poor results. Intercostal nerves resected included the intercostal-brachial (5 patients), 3rd (10 patients), 4th (6 patients), 5th (9 patients), 6th(7 patients), 7th (1 patient). Multiple intercostal nerves were resected as follows: 2 nerves (6 patients), 3 nerves (1 patient), 4 nerves (1 patient), 5 nerves (1 patient). There were no post-operative complications.
Conclusions: Intercostal neuromas can be the source of breast pain following breast surgery. The same clinical and diagnostic approach can be used in patients with breast pain as in patients with upper or lower extremity pain.

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