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


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

In This Article

Summary and Conclusions

Several effective, evidence-based regional blocks are indicated for abdominal and breast plastic surgery. There is strong evidence for the use of TAP blocks in abdominal-based flap reconstruction and abdominoplasties. TAP blocks should also be used in abdominal wall reconstruction surgeries; however, the supporting evidence is limited (only 1 retrospective study). For breast surgeries, the authors would recommend using PECS and/or PECS II as their primary choice of regional block. Moreover, there is strong evidence for the use of SAP blocks in breast surgeries. The SAP block could be as a primary block or as an adjunct to the PECs blocks. Finally, there is strong evidence that ESPB blocks are effective in reducing post-operative pain and opioid consumption; however, preliminary evidence shows that it is inferior to the PECS II block (Table 1). While any medical procedure has its risks, these plane blocks are relatively safe due to the absence of vital structures in the immediate vicinity. It is important not to exceed the recommended dosage of anesthetic to avoid any anesthetic-related toxicity. We recommend using ropivacaine as the choice of anesthetic. All these blocks can be administered a single dose or as a continuous infusion. For continuous infusions, the authors recommend not exceeding 6–8 ml/hour of 0.2% ropivacaine with 2 ml boluses every 20 minutes, if needed. Furthermore, while previous studies have demonstrated the benefits of liposomal bupivacaine, the current review shows no significant differences in opioid consumption when compared with conventional local anesthetics. Therefore, we recommend future studies to compare the efficacy of liposomal bupivacaine and ropivacaine in the aforementioned plane blocks.

It is important for plastic surgeons to familiarize themselves with evidence-based regional blocks and the important ultrasound landmarks associated with them. This will help them gain the necessary knowledge to administer these blocks themselves (intraoperatively) and ultimately help provide the best post-operative care possible for their patients. Although it is not expected for plastic surgeons to administer ultrasound guided techniques themselves, we believe it is important for them to recognize their efficacy, ease of administration, and safety profile so that they can advocate for their use in their practice/institution. In a quickly evolving field such as plastic surgery, there is a constant drive to provide our patients with the best available care. All the previous blocks are deemed very safe with minimal risk of complications; therefore, we recommend plastic surgeons to perform the block they are most comfortable with, as the evidence shows marginal differences between them in terms of efficacy. Although this article provides practical evidence-based recommendations for a wide variety of regional blocks that could be used by plastic surgeons, it is not an exhaustive list. There are minor differences in technique administration for different surgeries (ex. abdominoplasty versus DEIP flap breast reconstruction), which were not described in this review. Moreover, future studies should compare surgical site infiltration techniques to regional plane block techniques to provide plastic surgeons with evidence regarding their comparative efficacy. Finally, as the domain of pain management continues to evolve, novel blocks such as quadratus lumborum, which demonstrated preliminary evidence of efficacy in abdominoplasties, should be further studied before recommending them to plastic surgeons. Moreover, future studies should compare the efficacy of surgical site infiltration.

To maintain patient safety, communication between surgeons and anesthesiologists is essential. There should be discussion regarding the type of regional block that will performed as well as the maximum local anesthetic dose specific for the patient that would prevent local anesthetic systemic toxicity. In addition, identification and management of potential local anesthetic technique must also be planned.[85] Finally, to attain the maximum analgesic benefits, it is critical that regional analgesia is combined with other non-opioid analgesics (eg, acetaminophen and non-steroidal anti-inflammatory drugs or cyclo-oxygenase (COX)-2 specific inhibitors), unless there are contraindication. These drugs should be administered as scheduled (ie, round the clock). It is necessary to counsel patients regarding the need for non-opioid analgesics to avoid severe pain after block resolution (rebound pain).