The Use of Intercostal Nerve Blocks for Implant-Based Breast Surgery

Abstract

Sir: Postoperative pain following breast surgery has been a significant problem and the subject of extensive research for its prevention and management.1 Over the past two decades, there has been considerable interest in the use of intercostal nerve blocks for the management of pain following breast surgery. However, most studies have focused on oncologic breast surgery,2,3 except for Cooter et al., who showed the use of nerve blocks for breast augmentation procedures.4 A recent meta-analysis by Tahiri et al.5 compared several studies and showed that, in general, the use of intercostal nerve blocks has led to significantly improved postoperative parameters (e.g., analgesic consumption, reduced amounts of nausea and vomiting) and has led to increased patient satisfaction and reduced length of hospital stay. We demonstrate the use of intercostal nerve blocks in 57 consecutive patients undergoing bilateral implant-based breast surgery. After institutional review board approval, data were gathered for all patients undergoing breast surgery with the use of intercostal nerve blocks. Informed consent was obtained from the patients. All blocks and breast procedures were performed by a board-certified anesthesiologist and board-certified plastic and reconstructive surgeon, respectively. After positioning the patient, 2 to 4mg of intravenous midazolam was administered for sedation. Blocks were administered using a 25-gauge ⅝- to 1½-inch needle at the anterolateral chest wall at the midaxillary line, at each level from T2 to T9 bilaterally. Each intercostal nerve was infiltrated with 2ml of a solution containing 0.25% bupivacaine with 1:200,000 epinephrine. A total of 78mg of bupivacaine was administered, and no aspiration of blood or air was noted. Monitored anesthesia care was provided for the duration of the procedure. Fifty-seven patients underwent implant-based nononcologic breast procedures consisting mainly of bilateral augmentation mammaplasty (n = 42), followed by bilateral implant exchange with capsulectomy (n = 11), bilateral augmentation mammaplasty with mastopexy (n = 2), bilateral implant removal with capsulectomy (n = 1), or bilateral augmentation mammaplasty with blepharoplasty (n = 1). All patients were women, with a mean age of 35 years. Mean operative time was 74 minutes and mean time from the conclusion of the operation to discharge was 116 minutes. None of the patients was converted to general anesthesia. There were no complications related to the intercostal nerve blocks or surgery. Intraoperative and postoperative drug use was tabulated (Table 1). All patients received fentanyl and midazolam intraoperatively, and antiemetics. Postoperatively, only 44 percent of patients received intravenous fentanyl, 14 percent received acetaminophen-oxycodone, and 12 percent of patients received antiemetics.Table 1: Intraoperative and Postoperative Drug UseImplant-based nononcologic breast surgery can be safely performed with the use of intercostal nerve blocks without the need for conversion to general anesthesia. The lack of general anesthesia also leads to decreased consumption of postoperative narcotics and antiemetics. Although a limitation of this study is that there was no postdischarge survey of patients’ use of narcotics, all patients were given a prescription for 30 tablets of acetaminophen-oxycodone (325mg/5mg). No refills were requested. DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.