BACKGROUND: Patients undergoing mastectomy and prosthetic breast reconstruction have significant acute postsurgical pain, routinely mandating inpatient hospitalization. Liposomal bupivacaine (LB) (Exparel; Pacira Pharmaceuticals, Inc., Parsippany, N.J.) has been shown to be a safe and effective pain reliever in the immediate postoperative period and may be advantageous for use in mastectomy and breast reconstruction patients.METHODS:Retrospective review of 90 immediate implant-based breast reconstruction patient charts was completed. Patients were separated into 3 groups of 30 consecutively treated patients who received 1 of 3 pain treatment modalities: intravenous/oral narcotic pain control (control),bupivacaine pain pump, or LB injection. Length of hospital stay, patient-reported Visual Analog Scale (VAS) pain scores, postoperative patient-controlled analgesia usage, and nausea-related medication use were abstracted and subjected to analysis of variance and multiple linear-regression analysis, as appropriate. RESULTS: Subjects were well-matched for age (P = 0.24) regardless of pain-control modality. Roughly half (53%) of control and pain pump-treated subjects had bilateral procedures, as opposed to 80% of LB subjects. Mean length of stay for LB subjects was significantly less than control (1.5 days vs 2.00 days; P = 0.016). LB subjects reported significantly lower VAS pain scores at 4, 8, 12, 16, and 24 hours compared with pain pump and control (P < 0.01). There were no adverse events in the LB group. CONCLUSION: Use of LB in this group of immediate breast reconstruction patients was associated with decreased patient VAS pain scores in the immediate postoperative period compared with bupivacaine pain pump and intravenous/oral narcotic pain management and reduced inpatient length of stay.
SUMMARY: This report describes an ultrasound-guided medial and lateral pectoralis nerve block using liposome bupivacaine, performed before the surgical incision, in a patient undergoing submuscular breast augmentation. The anatomic basis and technique are described. This procedure may be offered to patients undergoing submuscular insertion of a breast implant or tissue expander. Advancements in ultrasound guidance allow for more precise anatomic placement of local anesthetic agents. The injection technique used for this procedure resulted in complete relaxation of the pectoralis major, facilitating the surgical dissection and markedly diminishing postsurgical pain and muscle spasms.