Opioid Overuse

The economic and social impacts of the opioid epidemic are staggering. In 2018 alone, opioids were involved in 46,802 overdose deaths, which accounts for 69.5% of all overdose deaths. The rapid rise in overdose deaths in the past 2 decades coincides with the expansion of opioid prescribing for pain control in the 1990s. Deaths related to prescription opioids were more than 4 times higher in 2018 compared with 1999. Estimates of the economic consequences of the opioid epidemic surpass $95 billion per year.

Plastic surgery is not spared from this crisis. Recent studies reveal that plastic surgeons performing outpatient procedures often prescribe almost double the amount of opioids that are consumed by patients postoperatively. Excessive prescribing can set up patients for unintentional overdose or diversion of unused pills, with documented incidences of both nonfatal and fatal prescription-related opioid overdoses in the plastic surgery literature. ^, Even when used appropriately, reliance on opioids for pain control has significant side effects, including nausea, vomiting, constipation, pruritis, and respiratory depression.

Enhanced Recovery Protocols

Enhanced recovery after surgery (ERAS) pathways increasingly are advocated as multidisciplinary, multimodal tools to reduce hospital length of stay, decrease total costs, reduce postoperative morbidity, and, importantly, reduce opioid consumption. ^, For breast reconstruction surgery, consensus guidelines from the ERAS Society outline 18 elements of preoperative, intraoperative, and postoperative care for optimization, including recommendations for multimodal management of preoperative and postoperative pain control. Such measures have demonstrated efficacy in reducing hospital stay, decreasing opioid use, and enhancing patient experience for both autologous and implant-based breast reconstruction patients. Although there is little literature describing ERAS protocols for cosmetic breast surgery, the principals outlined by efforts in reconstructive breast surgery provide a valuable framework for enhancing patient care for these cases. Ambulatory breast procedures, in particular, where patients have limited postoperative supervision, could benefit from ERAS protocol implementation.

Regional Blocks

Local anesthesia has a long tradition of utility in plastic surgery. The most common anesthetic agents are lidocaine and bupivacaine, either plain or in mixture with epinephrine, to reduce bleeding and to prolong the duration of efficacy. Frequently used for pain control in emergency room and clinic procedures, innovative methods with local injections led to the advent of wide-awake plastic surgery. This development eliminates the risks of sedation or general anesthesia for many patients undergoing cases traditionally performed in the operating room.

The introduction of liposomal bupivacaine expands on these benefits. Bupivacaine in this formulation diffuses from within a lipid-based vehicle over the course of 48 hours to 72 hours, providing long-lasting pain relief. Either bupivacaine with epinephrine or liposomal bupivacaine can be administered as a regional block. Although the Food and Drug Administration differentiates blocks from local infiltration, the concept is the same: infiltration of local anesthetic into a targeted area to affect a specific nerve or group of peripheral nerves in order to provide anesthesia to a specific dermatome. These blocks are useful for the plastic and reconstructive surgeon. For example, multiple studies have demonstrated the utility of the transverse abdominus plane block in reducing postoperative pain in both abdominal wall reconstruction and cosmetic abdominoplasty patients.

Several regional blocks have been described to reduce pain during breast surgery. The sensory innervation of the breast consists of 3 components: medial innervation from the anterior cutaneous branches of intercostal nerves I to VI, lateral innervation from the lateral cutaneous branches of intercostal nerves II to VII, and superior innervation from the supraclavicular nerves. Regional blocks for breast surgery target these end nerves.

Paravertebral Block

In the thoracic paravertebral (TPV) block, local anesthetic is injected into the space where the thoracic spinal nerves emerge from the intervertebral foramina, immediately lateral to the intervertebral foramina. Anatomically, the TPV space is defined anteriorly by the parietal pleura, posteriorly by the superior costotransverse ligament, medially by the vertebrae, and superiorly and inferiorly by the ribs. Because this affects the spinal root and sympathetic chain, the TPV block acts as a sensory, motor, and sympathetic block within multiple dermatomes.

Studies demonstrate that breast reconstruction patients who undergo a TPV block experience reduced pain and reduced opioid consumption as well as less nausea and vomiting, compared with patient managed with general anesthesia alone. Complications of TPV block include hypotension, vascular puncture, pneumothorax, and epidural spread. With increasing body mass index, the probability of block failure increases, limiting the patient population for whom TPV block is indicated. Given the potential complications, it is recommended that TPV blocks be administered only by experienced anesthesiologists under ultrasound supervision.

Pectoralis Nerve I and II Blocks

The pectoralis nerve (PECS) I block involves infiltration of local anesthetic into the interfascial plane between the pectoralis major and minor muscles, anesthetizing multiple branches of the medial and lateral pectoral nerves. This motor blockade acts to relax the pectoralis muscle fibers, thus alleviating pain associated with muscle tension and spasm. This modality is limited in that it does not provide significant sensory blockade.

The PECS II block adds to the PEC I with infiltration above the serratus anterior muscle at the level of the third rib, with the intention of blunting the intercostobrachial, long thoracic, pectoral, and intercostal nerves III to VI. The addition of the PECS II block has been shown to reduce postoperative pain, nausea, and vomiting in breast surgery patients compared with general anesthesia alone. This method also is performed under ultrasound guidance. Complications include risk of intravascular injection, pneumothorax, and winged scapula. ^, Additionally, although effective for intercostal nerves III to IV, it seems to be less reliable for levels V to VI (L.I., senior author observation).

Proximal Intercostal Block

Proximal intercostal (PIC) nerve blocks have been described for various breast surgery indications as well as for pain control during thoracic procedures. ^, Under ultrasound guidance, local anesthetic is injected into the second and fourth intercostal spaces, providing sensory block to the intercostal nerves. Breast surgery patients who underwent PIC blocks had lower opioid consumption compared with general anesthesia alone and, in 1 study, patients were able to undergo breast surgery with PIC block and sedation alone, reducing the risks associated with general anesthesia. Hypothetical risks include vascular puncture and pneumothorax.

Limitations

Although regional blocks have demonstrated promising improvement in patient care and specifically reduction of postoperative pain and opioid use, there are limitations to their use, especially in the ambulatory surgery and office-based settings, where aesthetic procedures are performed most commonly. The TPV block, PECS I and II blocks, and PIC blocks all require the presence of an anesthesiologist trained in regional anesthesia as well as availability of ultrasound equipment. These procedures require additional time in either the preoperative area or in the operating room. Risks of intravascular injection and pneumothorax also may limit use of these blocks in the hands of an inexperienced provider.