Regional Pain Blocks and Perioperative Pain Control in Patients Undergoing Breast Implant Removal With Capsulectomy
Jacob Katsnelson, MD, David A. Goodman, MD, Brian R. Buinewicz, MD.
Abington-Jefferson Health, Abington, PA, USA.
Background: Breast implant removal constitutes one of the most common plastic surgery procedures performed on an outpatient basis, with demand steadily increasing in recent years due to more patients presenting with safety concerns or symptoms they ascribe to their implants. Postoperative analgesia can be difficult in these patients due to scar tissue surrounding the implant and the potential for extensive dissection during capsulectomy. Previous studies have found that ultrasound-guided regional blocks can provide durable analgesia to patients undergoing breast surgery, but evidence supporting a specific block and applicability to patients undergoing implant removal has been limited. We sought to assess perioperative pain control in patients undergoing implant removal with capsulectomy based on type of regional block and adjunct pain regimen used.
Methods: Patients undergoing breast implant removal with capsulectomy at an outpatient surgical center were included. All patients underwent an ultrasound-guided pain block with combination of either a serratus plane (SP), erector spinae (ES), pectointercostal fascial plane (PIFP), or pectoral nerve block (PECS1). A subgroup of patients who underwent ES+PECS1 block received either preoperative gabapentin or combination of preoperative acetaminophen, celecoxib, gabapentin, and intraoperative ketamine as part of an enhanced recovery protocol. Comparisons were made for postoperative opioid requirement and patient-reported pain on the first postoperative day (POD1) using chi-square analysis. A P-value <0.05 was considered statistically significant.
Results: 302 patients were included. 8.6% of patients underwent an SP block, 4.3% underwent ES+PIFP, and 86% underwent ES+PECS1. 26.8% required opioids in the recovery unit, and 42.5% reported minimal to mild pain on POD1. ES+PECS1 was associated with less postoperative opioid use compared to SP and ES+PIFP (26% vs 35% vs 38%, p<0.001). There was no significant association between type of regional block and level of pain on POD1. In our subgroup analysis, patients who received a combination of preoperative acetaminophen, celecoxib, gabapentin and intraoperative ketamine had lower postoperative opioid requirements compared to those who received preoperative gabapentin alone or no adjuncts (10% vs 12.1% vs 32.4%, p=0.001), and were more likely to report minimal to mild pain on POD1 (p<0.001).
Conclusions: Regional pain blocks offer an effective pain control regimen for patients undergoing breast implant removal with capsulectomy, resulting in low opioid requirements and high patient satisfaction in the postoperative period. Addition of pain adjuncts may further improve perioperative pain control and decrease narcotic requirements, facilitating the development of an enhanced recovery protocol for patients undergoing this increasingly common procedure.
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