Plastic Surgery Research Council

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Less is More: A Multimodal Pain Regimen Reduces the Need for Narcotics While Improving Pain Outcomes in Patients Undergoing Autologous Breast Reconstruction
Brian Bassiri-Tehrani, MD, Michael L. Marchese, MD, Itay Wiser, MD, Irena Karanetz, MD, Oren Z. Lerman, MD.
Lenox Hill Hospital, New York, NY, USA.

Purpose:
Enhanced recovery after surgery (ERAS) is a paradigm for improving perioperative care by implementing a series of interventions that decreases hospital length of stay and lowers opioid consumption. In plastic surgery, as in other fields, specific interventions are now routinely performed perioperatively to achieve these goals; namely, multimodal pain management regimens are used. The use of direct injection of liposomal bupivacaine (Exparel) intraoperatively has recently garnered interest due to its long half-life and effectiveness in postoperative pain control, thus minimizing the need for narcotics. This leads to early mobilization, shorter hospitalizations, improved quality of life and patient satisfaction. Direct injection of Exparel to the abdominal wall during abdominally based autologous breast reconstruction is particularly advantageous for early postoperative pain control. This study aims to determine the effectiveness of Exparel in postoperative pain control in patients undergoing abdominally based breast reconstruction measured by patient reported visual analog scales (VAS).
Methods:
In this study, 155 patients underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction. As part of our enhanced recovery after surgery (ERAS) protocol, patients received Ketorolac and Tylenol postoperatively with narcotics used for breakthrough pain. Of the total patients, 115 patients had Exparel directly injected into the abdominal fascia intraoperatively, and the remaining 40 patients had no Exparel injected. Pain scale measuring 1-10 (10=most pain) was used to measure pain in the post-anesthesia care unit (PACU) immediately after surgery, and then every twelve hours thereafter until postoperative day three. Additionally, age, demographics, comorbidities, hospital length of stay (HLOS), pain regimen, opioid consumption and total complications were reviewed in both groups.
Results:
In a multivariate repeated measures test, there was a significant improvement of reported pain as measured by VAS and a shorter HLOS in patients in the group that received Exparel intraoperatively (p<0.001, p<0.05, respectively). In the group that did receive Exparel, the mean VAS score was 2.5 (95% CI=2.111-2.869, SD=0.191), whereas the group that did not receive Exparel, the mean VAS score was 3.6 (95% CI=3.079-4.157, SD=0.272). The HLOS for the Exparel group was 3.7 versus 4.0 in the group that did not receive Exparel (p<0.05). There was a lower rate of use of patient controlled analgesia (PCA) in the group that received Exparel (p<0.05). Both groups had similar rate of use of Ketorolac, age, comorbidities and overall complications.
Conclusion:
Postoperative subjective pain reports measured by VAS scores by patients undergoing DIEP flaps for breast reconstruction were significantly improved with the use of intraoperative Exparel. In addition, there was a statistically significant decreased HLOS and lower rate of PCA use in the cohort that received Exparel.


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