Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Comparative Study of Liposomal Bupivacaine versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction
Jad M. Abdelsattar, MBBS; Judy C. Boughey, MD; Anita T. Mohan, MRCS; Aodhnait S. Fahy, BMBCh, PhD; Whitney J. Goede, PharmD; Prakriti Gaba, BS; Bill Tran, MD; W. Scott Harmsen, MS; Christopher J. Jankowski, MD; James W. Jakub, MD; Tina J. Hieken, MD; Amy C. Degnim, MD; David R. Farley, MD; Karim Bakri, MBBS; Steven R. Jacobson, MD; Valerie Lemaine, MD; Renata L. Maricevich, MD; Michel Saint-Cyr, MD
Mayo Clinic, Rochester, MN, USA.

PURPOSE:
There is an increasing use of immediate breast reconstruction following mastectomy, commonly using tissue expanders. This operation is associated with postoperative pain and nausea and several approaches to optimize pain control and enhance recovery are available. This study compares postoperative pain and nausea between intraoperative local infiltration with liposomal bupivacaine and preoperative ultrasound guided paravertebral block (PVB).
METHODS:
With IRB approval we performed a retrospective review of patients who underwent mastectomy, with immediate tissue expander reconstruction performed by one of two plastic surgeons at our institution between 5/2012-10/2014. We excluded cases with Botox injection, those with both liposomal bupivacaine and PVB and those without either. Liposomal bupivacaine was infiltrated into the pectoralis muscle and skin flap intraoperatively after mastectomy and tissue expander placement had been performed and prior to closure. PVB using bupivacaine was performed under ultrasound guidance preoperatively at T1, T3, T5. Choice between liposomal bupivacaine and PVB was at the discretion of the treating surgeons and anesthesiologist. We compared postoperative pain scores, opioid use and need for antiemetic medications in patients with liposomal bupivacaine to patients with PVB during this study period.
RESULTS:
Of 97 patients undergoing unilateral or bilateral mastectomy with immediate reconstruction using tissue expanders, 52 (54%) had liposomal bupivacaine. There were no statistical differences between the two groups in terms of age, ASA score, BMI, intraoperative expander fill volume, surgeon, operation duration, time in recovery unit and unilateral versus bilateral surgery (all p>0.05). Opioid use in the recovery room was significantly lower in the liposomal bupivacaine group than the PVB group (mean ± SD: 9.1 ± 16.5 vs. 24.2 ± 23.9 morphine equivalents, p<0.001). Fewer patients required antiemetic medication on postoperative day 1 in the liposomal bupivacaine group than the PVB group (12 vs. 19 patients, p=0.044). Day of surgery pain scores were lower in the liposomal bupivacaine group than PVB (mean ± SD: 3.3 ± 1.8 vs. 4.1± 1.5). On multivariable analysis controlling for expander placement (submuscular vs. subcutaneous), liposomal bupivacaine was significantly associated with lower opioid use in the recovery room (p=0.003). Need for antiemetic on postoperative day 1 and day of surgery pain scores were also lower in the liposomal bupivacaine group, trending towards significance (p=0.057, p=0.056 respectively).
CONCLUSION:
Local infiltration with liposomal bupivacaine in patients undergoing mastectomy with immediate tissue expander reconstruction is associated with lower pain scores, opioid requirements and antiemetic use in the postoperative period when compared to paravertebral blocks.


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