Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review

Abstract

Background Pain management approaches in autologous breast reconstruction have become a topic of great interest in the era of enhanced recovery after surgery protocols, as well as the opioid epidemic. The management of postoperative pain is of critical importance for women undergoing breast reconstruction; however, these protocols have yet to be synthesized and compared in the primary literature. Herein, we present a systematic review of approaches to provide optimal pain control while minimizing narcotic use and its associated potential negative sequelae in autologous breast reconstruction. Methods A comprehensive systematic review of the published literature was conducted using Ovid Medline/PubMed database without timeframe limitations, in compliance with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria were selected for studies reporting objective outcomes of pain modulation in autologous breast reconstruction. Articles for inclusion were stratified based on intervention. Results A total of 101 articles were identified on initial search query. After full-text review and final screening of all articles and review of included studies’ references, 28 studies met the inclusion criteria and were analyzed. Conclusion There continues to be a substantial need for evidence-based guidelines in the plastic surgery literature. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Given the increasing popularity of and access to autologous approaches to breast reconstruction, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized postoperative care.

Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction

“…26 Each modality of an ERAS protocol plays an important role in patients' recovery, and in the case of ketorolac, some treatments can be synergistic in controlling postoperative pain without reliance on opiates. While ERAS protocols can be beneficial in decreasing postoperative opiate utilization, 23 not every institution has implemented formal ERAS protocols. For those institutions, gabapentin and Lyrica can be helpful alternatives to ketorolac for postoperative pain control.…”

“…A multiple linear regression was created to assess the association of different variables that have been shown to affect postoperative pain (BMI, bilateral reconstruction, concurrent mastectomy, ketorolac use, and other NSAIDs including celecoxib and ibuprofen) with MMEs per day. 22,23 Because of the wide distribution of opiate use among the two cohorts, we also split each cohort into tertiles (low, medium, and high users) based on MMEs/day for comparison. Continuous variables were compared using the Kruskal-Wallis test, while categorical variables were compared using Pearson chi-squared and Fisher's exact tests where appropriate.…”

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm

“…However, many of these studies focus on the abdominal donor site (for autologous breast reconstruction), rather than the breast and chest wall, and many only report on ERAS efficacy for acute pain management, rather than long-term neuropathic pain. 32 – 34 …”

“…However, many of these studies focus on the abdominal donor site (for autologous breast reconstruction), rather than the breast and chest wall, and many only report on ERAS efficacy for acute pain management, rather than long-term neuropathic pain. [32][33][34] Gabapentin has also been shown to reduce immediate postoperative pain following mastectomies and other breast surgeries, and is often a component of ERAS protocols. 35,36 In their randomized control trial, Fassoulaki et al found that combining perioperative gabapentin and local anesthesia led to a significant decrease in chronic pain 3 months after surgery, supporting the importance of a multimodal approach to preventing PMPS.…”

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

“…[17][18][19] In a systematic review of 28 studies examining pain management for breast reconstruction, opioid consumption was reduced in all seven studies that included ERP protocols and in eight of nine studies that included TAP or paravertebral blocks. 20 In this systematic review, liposomal bupivacaine, a formulation of the local anesthetic bupivacaine enabling controlled release of bupivacaine for prolonged analgesia, was highlighted for pain management after breast reconstruction. 20 Previous studies investigated liposomal bupivacaine administered as a TAP block (including as part of an ERP protocol) for DIEP flap breast reconstruction, [15][16][17][21][22][23] with some showing reduced opioid consumption versus historical controls.…”