Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons

Evidence and Techniques

Hassan ElHawary, MD, MSc; Girish P. Joshi, MBBS, MD, FFARCSI; Jeffrey E. Janis, MD, FACS

Disclosures

Plast Reconstr Surg Glob Open. 2020;8(12):e3224 

In This Article

Abstract and Introduction

Abstract

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Introduction

The last several years witnessed a significant increase in opioid-related overdose deaths in the United States.[1] Due to the fast, and often effective, analgesic effect of opioids, they are frequently used as method of post-operative pain control.[2] Regional/local analgesic techniques are an important component of a multimodal analgesic strategy, with the aim of reducing opioid requirements and opioid-related adverse events.[3] This change parallels quality improvement initiatives and the Enhanced Recover After Surgery pathways implemented in many hospitals in North America.[4,5]

In recent years, there has been an increasing trend toward administration of interfascial plane blocks [eg, transversus abdominis plane (TAP) blocks, pectoralis (PECS I and II) blocks, serratus anterior plane (SAP) blocks, and erector spinae plane blocks (ESPBs)].[6] These blocks are purported to be technically easier and safer, and are amenable to be administered by surgeons.[7] Due to the broad breadth of plastic surgeries and the wide array of anatomical locations that plastic surgeons operate on, an extensive number of regional analgesic techniques have been investigated within plastic surgery.[8,9]

To that end, the goal of this practical review is to present clinically-relevant, evidence-based recommendations of the most commonly used regional blocks in abdominal and breast plastic surgery. Specifically, the review will focus on interfascial plane blocks that can be performed directly by plastic surgeons. The review will highlight the technique, indications in plastic surgery, analgesic efficacy, as well as potential complications or challenges associated with these blocks. The ultimate aim of this review is to facilitate their use by plastic surgeons and trainees and gain a widespread use to improve perioperative pain relief, while reducing opioid requirements. Of note, surgical site infiltration techniques are outside the scope of this review.[10]

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