Enhanced Pain Control after Reduction Mammaplasty with Combination Bupivacaine and Dexamethasone Regional Block: A Double-Blind Randomized Controlled Trial (NCT04919317)

Abstract

eduction mammaplasty is the seventh most common plastic surgical procedure performed worldwide, with over 600,000 cases performed in 2019. 1 Despite its prevalence, pain control following this procedure remains a challenge. 2,3 Preemptive analgesia commonly administered by means of a preoperative modified block of the pectoral nerves (PECS II) 4 or a serratus plane block using bupivacaine has been shown to greatly improve postoperative pain and decrease in-hospital narcotic use. 5 Bupivacaine (0.5%) is relatively cheap in bulk at $0.07/mL, 6 but its actions may Background: There are many approaches to pain control in reduction mammaplasty. Preoperative bupivacaine regional blocks control pain relatively inexpensively ($0.07/mL), but last only 8 hours. A liposomal bupivacaine formulation lasts 72 hours but can be costly ($17.21/mL). Orthopedic and thoracic operations have demonstrated that dexamethasone ($0.44/mL) plus bupivacaine can prolong analgesia. The authors conducted a double-blind, randomized, controlled trial to determine whether dexamethasone plus bupivacaine regional block improves postoperative pain control, reduces inpatient narcotic use, and improves patient satisfaction. Methods: Female patients were randomized into control and experimental groups. Both groups received preoperative modified block of the pectoral nerves: bupivacaine plus saline (control group) or bupivacaine plus dexamethasone (experimental group). Postoperative pain regimens were standardized. Vital signs, pain scores, narcotic consumption, and antiemetic use were recorded throughout the hospitalization. Quality-of-life surveys were distributed at the first postoperative visit.Results: Fifty-one patients completed the study: 25 control and 26 experimental group patients. The experimental group averaged lower pain scores, although there was no statistically significant difference overall or at each 4-hour interval. Postoperative narcotic use was significantly lower in the experimental group (mean, 23.2 oral morphine equivalents versus 36.6 oral morphine equivalents per patient; P = 0.026). There were no differences in 4-hour interval vital signs, antiemetic use, or length of stay. Survey results showed enhanced quality of life in the experimental group, but this was not statistically significant. Conclusions: The addition of dexamethasone to bupivacaine in the preoperative modified block of the pectoral nerves block before bilateral reduction mammaplasty resulted in significantly less narcotic consumption in the hospital. This can be a costeffective adjunct for postoperative pain control.

Emerging Longer-Acting Local Anesthetic Formulations for Plastic Surgeons

“…Through a hypothesized inhibitory effect of dexamethasone on nociceptive pain fibers, upregulation of inhibitory potassium channels, and a regional decrease in blood flow to slow the dissipation of an infiltrated anesthetic, the majority of published randomized control trials in the orthopedic, gynecologic, and general surgery literature have demonstrated promising outcomes associated with bupivacaine-dexamethasone mixtures relative to bupivacaine alone, through prolonged durations of analgesia and decreased opioid consumption. 7 A recent study by Taylor et al was the first in plastic surgery to report on use of bupivacaine-dexamethasone blocks, demonstrating significant reductions in postoperative pain in patients undergoing reduction mammaplasty receiving this formulation in pectoralis nerve blocks. 7 …”

“… 7 A recent study by Taylor et al was the first in plastic surgery to report on use of bupivacaine-dexamethasone blocks, demonstrating significant reductions in postoperative pain in patients undergoing reduction mammaplasty receiving this formulation in pectoralis nerve blocks. 7 …”