Pectoral Nerve Blocks for Breast Augmentation Surgery

A Randomized, Double-Blind, Dual-Centered Controlled Trial

Yassir Aarab, M.D., M.Sc.; Severin Ramin, M.D., M.Sc.; Thomas Odonnat, M.D.; Océane Garnier, M.Sc.; Audrey Boissin, M.Sc.; Nicolas Molinari, Ph.D.; Grégory Marin, Ph.D.; Pierre-Francois Perrigault, M.D.; Philippe Cuvillon, M.D., Ph.D.; Gérald Chanques, M.D., Ph.D.

Disclosures

Anesthesiology. 2021;135(3):442-453. 

In This Article

Abstract and Introduction

Abstract

Background: Pectoral nerve blocks have been proposed for analgesia during and after breast cancer surgery, but data are conflicted in aesthetic breast surgery. This trial tested the primary hypothesis that adding a preincisional pectoral nerve block is superior to systemic multimodal analgesic regimen alone for pain control after breast augmentation surgery. A second hypothesis is that rescue opioid consumption would be decreased with a long-lasting effect for both outcomes during the following days.

Methods: Seventy-three adult female patients undergoing aesthetic breast augmentation surgery under general anesthesia were randomly allocated to receive a pectoral nerve block versus no block. Both groups received standard care with protocolized multimodal analgesia alone including systematic acetaminophen and nonsteroidal anti-inflammatory drugs. The primary outcome measure was the maximal numerical rating scale in the first 6 h after extubation. Secondary outcomes included intraoperative remifentanil consumption and from extubation to day 5: maximal numerical rating scale, postoperative cumulative opioid consumption and postoperative opioid side effects, and patient satisfaction recorded at day 5.

Results: The maximal numerical rating scale score in the first 6 h was lower in the pectoral nerve block group compared with the control group (3.9 ± 2.5 vs. 5.2 ± 2.2; difference: −1.2 [95% CI, −2.3 to −0.1]; P = 0.036). The pectoral nerve block group had a lower maximal numerical rating scale between days 1 and 5 (2.2 ± 1.9 vs. 3.2 ± 1.7; P = 0.032). The cumulative amount of overall opioids consumption (oral morphine equivalent) was lower for the pectoral nerve block group from hour 6 to day 1 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 31.5] mg, P = 0.006) and from days 1 to 5 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 51] mg, P = 0.002).

Conclusions: Pectoral nerve block in conjunction with multimodal analgesia provides effective perioperative pain relief after aesthetic breast surgery and is associated with reduced opioid consumption over the first 5 postoperative days.

Introduction

Breast augmentation is one of the most popular plastic surgery procedures, with 1,862,506 procedures reported worldwide in 2018.[1] Insertion of breast prosthesis causes major postoperative pain due to surgical dissection, damage to the muscles, and expansion of breast tissues.[2] Indeed, it was ranked the 45th most painful surgical act among 179 procedures in a large, observational, multicenter study.[3]

Postoperative pain is associated with an increase of time spent in the postanesthesia care unit (PACU) or in the ambulatory unit, an increased rate of readmission, dissatisfaction, and significant postoperative nausea and vomiting.[4] Postoperative pain is also associated with a higher risk of chronic pain syndrome and impaired quality of life.[5–7] Then adequate pain control is the cornerstone of postoperative management and may have a substantial impact on morbidity and patient satisfaction.[8] Postoperative pain management after breast surgery traditionally involves intravenous and oral opioids.[9] Several methods including multimodal analgesia and local anesthetic infiltration have been reported to reduce pain and/or opioid use after breast augmentation.[10,11] However, pain control is not always adequately achieved and may cause unwanted side effects.[12]

Recently, the pectoral nerves blocks (PECtoral nerveS blocks I and II [PECS I and PECS II]) were proposed for analgesia during and after breast surgery. These blocks may be more appropriately compared to other regional anesthetic techniques. Indeed, they are minimally invasive with a rapid-spread use.[13] Since the description by Blanco et al.,[14,15] various authors have reported the benefit of isolated or combined PECS I and II blocks for breast cancer surgery, including a recent meta-analysis by Hussain et al.[16] that concluded that pectoral nerve block is noninferior to paravertebral block.[17–20] Evidence for the use of pectoral nerve block for pain control after breast augmentation surgery are still scarce.[21–23] Systemic multimodal analgesia remains the most used regimen.[24–27]

We thought that adding a preincisional pectoral nerve block to a systematic nonopioid multimodal analgesic regimen including acetaminophen and nonsteroidal anti- inflammatory drugs will provide superior pain control after breast augmentation surgery than systemic multimodal analgesia alone with a decrease in rescue opioid consumption and a long-lasting effect for both outcomes during the following days. We therefore undertook the current study to assess the analgesic effect of preincisional bilateral pectoral nerve block for aesthetic breast augmentation surgery, in combination with systemic multimodal analgesia.

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