Chronic pain following abdominal free flap breast reconstruction: a prospective pilot analysis

Long-Term Opioid Use After Free Flap Breast Reconstruction: Incidence and Associated Factors

Background: Opioid dependence can occur in 6% to 10% of patients undergoing breast reconstruction. With the expansion of interdisciplinary initiatives to decrease opioid use after surgery, an updated look at the incidence of and risk factors for prolonged opioid dependence after free flap breast reconstruction is essential. Methods: We retrospectively identified all cases of free flap breast reconstruction completed at our institution from 2017 to 2020. Patients undergoing additional surgery within 120 days of the free flap procedure were excluded. Postoperative opioid prescriptions were identified; prolonged opioid use was defined as the receipt of additional prescriptions 91 to 120 days after surgery. Demographic and perioperative variables were assessed for their relationship with prolonged opioid use by logistic regressions. Results: A total of 732 patients were included in the final analysis; of these, 15 patients (2%) received additional opioid prescriptions 91 to 120 days after surgery (ie, had prolonged opioid use). Univariable associations were identified between prolonged opioid use and intraoperative morphine milliequivalents (OR = 2.3 per 50 units [95% CI, 1.5-3.5]; P < .001), opioid prescriptions 31 to 60 days after surgery (OR = 16.1 [95% CI, 4.0-65.0]; P < .001) and 61 to 90 days after surgery (OR = 89.4 [95% CI, 13.7-584.5]; P < .001), and history of substance use disorder (OR = 8.3 [95% CI, 2.2-31.6]; P = .002), anxiety (OR = 3.8 [95% CI, 1.2-12.1]; P = .023), or mood disorder (OR = 12.7 [95% CI, 1.3-121.3]; P = .027). Conclusion: In our cohort, 2% of patients who underwent autologous breast reconstruction (15/732) had prolonged opioid use. The currently used perioperative opioid minimization initiatives may benefit patients undergoing autologous breast reconstruction.

The Impact of Depression and Anxiety Comorbidities on Acute Postoperative Pain After DIEP Flap Breast Reconstruction

BACKGROUND

Depression and anxiety have a complex association with opioid dependence, though their impact on acute postoperative pain is unclear. The present study investigated the impact of depression and anxiety on acute postoperative pain and opioid requirements following deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

Patients receiving DIEP flap breast reconstruction were retrospectively identified from 2019 to 2023. Patients were classified into the psychiatric comorbidity (PC) group based on a history of depression or anxiety diagnoses, or the control group. Pain (0-10 Numerical Rating Scale [NRS]) scores and cumulative inpatient opioid requirements (in morphine milli-equivalents [MMEs]) were compared between groups. Linear regression analysis assessed the association of psychiatric comorbidities with pain outcomes.

RESULTS

In total, 557 patients were included, of which 11.4% reported a psychiatric history. The PC group was younger (50.0 vs. 52.7 years, p = 0.032) and more frequently reported current marijuana use (15.6% vs. 4.3%, p = 0.001) and former smoking (51.6% vs. 24.5%, p < 0.001). The PC group had higher mean (2.5 vs. 2.0, p < 0.001) and maximum pain scores (8.6 vs. 7.8, p = 0.003) than the control group, which corresponded to higher opioid requirements (256 vs. 223 MMEs, p = 0.041). Psychiatric comorbidities were associated with higher average and maximum pain scores (p < 0.01) while current marijuana use was associated with higher opioid requirements (p = 0.033).

CONCLUSION

Patients with depression or anxiety comorbidities tended to have greater acute postoperative pain and opioid consumption. Marijuana use was also more prevalent, potentially exacerbating pain outcomes, and risk of opioid dependence. These findings will inform patient discussions and targeted interventions to mitigate opioid misuse.

Chronic Pain Following Breast Reconstruction: A Scoping Review

BACKGROUND

Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being.

METHODS

To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed.

RESULTS

The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain.

CONCLUSION

This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.

Characteristics and distribution of chronic pain after mastectomy and breast reconstruction: a long-term prospective cohort study

PURPOSE

Chronic pain following breast surgery is a concern for breast cancer survivors; however, few studies have investigated the localization of persistent postoperative pain. We conducted this study to identify the location of pain following breast reconstruction.

METHODS

A total of 213 Japanese women undergoing mastectomy only or breast reconstruction with a tissue expander/implant (TE/Imp) or a deep inferior epigastric perforator (DIEP) flap were enrolled in the study. Questionnaires related to pain location were sent to patients at the end of postoperative year (POY) 1 and POY 5. Multiple comparisons of the types of operation and cross-tabulation were made between the two time points.

RESULTS

Surveys were completed by 107 of the women. Severe pain in the upper medial breast was significantly more common in POY 1 after DIEP reconstruction than after mastectomy only (P = 0.01), whereas abdominal pain was worse in POY 5 after DIEP reconstruction than after mastectomy only (P = 0.04). Pain in the medial arm and axilla had resolved better after TE/Imp (P = 0.03) and DIEP reconstruction (P = 0.01) than after mastectomy only by POY 5, but the difference between TE/Imp and DIEP reconstruction was not significant.

CONCLUSIONS

These results show that localization of prolonged postoperative pain following breast reconstruction differs depending on the surgical strategy.

Treating Pain and Fat Necrosis after Breast Cancer Surgery with Fat Grafting: Is one Session Enough?

BACKGROUND

Chronic pain after breast cancer surgery is affecting up to 60% of patients, causing significant morbidity to patients. Lately, fat grafting has been applied as a therapy for chronic neuropathic pain.

METHODS

We report a series of eighteen patients, who were treated for pain after breast cancer surgery. Twelve patients had a breast conserving therapy, two a mastectomy and four an autologous flap-based reconstruction. While most presented with neuropathic pain, six patients had fat necrosis in their history. Most patients presented with severe pain (77%) and were treated with fat grafting sessions, performed by water-assisted liposuction.

RESULTS

All patients responded to the interventions; the median number of fat grafting sessions was 2, the median duration of the interventions was 4 months, and the median follow-up period was 56.5 months. The median pain prior to the fat grafting procedure had an intensity of 8 (range 7-9) numeric rating scale points; after the first intervention, this was reduced to 4 (range 2.3-5.8); and after the second intervention, it was down to 2 (range 0.8-3.3). Patients with pain intensities of 4-5 had a good chance of achieving analgesia after one session.

CONCLUSIONS

Fat grafting could be a new treatment modality for symptomatic fat necrosis: complete or partial suction of the necrosis and/or fat grafting around the necrosis to reduce inflammation and pain. Fat grafting proved a valuable tool, reducing pain or even achieving analgesia after breast cancer surgery presenting with a highly favorable risk-benefit ratio.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Factors influencing postoperative abdominal pain in DIEP flap breast reconstruction

Background

Identification of a subgroup of patients with severe postoperative pain is important for adequate pain management for enhanced, fast recovery after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The purpose of this study was to identify factors influencing postoperative abdominal pain in patients undergoing DIEP flap breast reconstruction.

Methods

Consecutive patients who underwent unilateral breast reconstruction using DIEP free flaps from October 2018 to July 2020 were included in this study. Visual analog scale (VAS)-guided postoperative pain scores were documented every 3 hours until 48 hours postoperatively. Factors affecting patient-reported pain scores were analyzed using a linear mixed-effects model. Independent variables included patient characteristics, history of previous open abdominal surgery, and operative factors including the flap size, flap weight, use of a unipedicled or bipedicled flap, number of perforators, timing of reconstruction, and use of a catheter-based subcutaneous plane block in the abdomen. A catheter was placed above the rectus fascia during closure, and analgesics were continuously infused during the 48 hours using an ON-Q Pain Relief System (I-Flow Co., Lake Forest, CA, USA).

Results

Fifty-five patients were included in the analysis. In the linear mixed effect model using multiple clinical variables, the harvested flap weight was significantly associated with the degree of pain (β coefficient =0.157, P=0.008). The pain degrees significantly decreased according to postoperative days (β coefficient =-0.649, P<0.001). The flap type (unipedicle or bipedicle), number of perforators, timing of reconstruction, and history of previous abdominal surgery did not influence pain degrees. The use of subcutaneous plane block did not affect the degree of pain or dose of analgesics used.

Conclusions

A larger flap weight is associated with an increased degree of pain in patients undergoing DIEP flap breast reconstructions. Vigorous pain management might be necessary when a large flap is elevated.

Breast reconstruction after breast cancer surgery - persistent pain and quality of life 1-8 years after breast reconstruction

OBJECTIVES

To assess the long-term outcome of breast reconstructions with special focus on chronic postsurgical pain (CPSP) in a larger cohort of breast cancer survivors.

METHODS

A cross-sectional study on 121 women with mastectomy and breast reconstruction after mean 2 years 4 months follow up. The mean time from breast reconstruction to the follow-up visit was 4 years 2 months. We studied surveys on pain (Brief Pain Inventory, BPI and Douleur Neuropathique 4, DN4), quality of life (RAND-36 health survey), sleep (insomnia severity questionnaire, ISI), mood (Beck's Depression Index, BDI; Hospital Anxiety and Depression Scale, HADS), and a detailed clinical sensory status. Patients were divided into three groups: abdominal flap (Deep inferior epigastric perforator flap, DIEP; Free transverse rectus abdominis flap, fTRAM, and Pedicled transverse rectus abdominis flap, pTRAM), dorsal flap (Latissimus dorsi flap, LD and Thoracodorsal artery perforator flap, TDAP), and other (Transverse myocutaneous gracilis flap, TMG; implant). Clinically meaningful pain was defined ≥ 4/10 on a numeric rating scale (NRS). We used patients' pain drawings to localize the pain. We assessed preoperative pain NRS from previous data.

RESULTS

106 (87.6%) of the patients did not have clinically meaningful persistent pain. We found no statistically significant difference between different reconstruction types with regards to persistent pain (p=0.40), mood (BDI-II, p=0.41 and HADS A, p=0.54) or sleep (p=0.14), respectively. Preoperative pain prior to breast reconstruction surgery correlated strongly with moderate or severe CPSP.

CONCLUSIONS

Moderate to severe CPSP intensity was present in 14% of patients. We found no significant difference in the prevalence of pain across different reconstruction types. Preoperative pain associated significantly with postoperative persistent pain.

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes

BACKGROUND

The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction.

METHODS

We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q.

RESULTS

Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores.

CONCLUSION

System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.

Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways.

METHODS

A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model.

RESULTS

The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86).

CONCLUSIONS

Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.

Physical side-effects following breast reconstructive surgery impact physical activity and function

PURPOSE

To investigate the incidence and severity of physical side-effects experienced by women following breast reconstructive surgery and the effect of these side-effects on physical activity and function.

METHODS

Two hundred and thirty-one Australian women (55 years SD 6.5) who had previously had breast reconstruction surgery retrospectively self-reported the incidence and severity of eight physical side-effects and the perceived effect of these side effects on six physical functions, at three time points after their surgery. The frequency of the combined incidence/severity scores and their impact at the three time points were tabulated and compared using Chi-squared tests. A general linear regression was used to identify characteristics associated with moderate-very high (≥ 5/10) combined incidence/severity scores.

RESULTS

At 6 months following surgery, approximately 50% of respondents reported moderate to very high incidence/severity scores for physical side-effects across multiple body regions, which were perceived to limit their physical function and activity levels. The highest incidence/severity scores were associated with the following: (i) pre-existing physical problems before surgery, (ii) post-operative complications (seroma, infection, necrosis), and (iii) autologous rather than implant-based reconstructions.

CONCLUSION

A large percentage of women reported moderate to severe physical side-effects across multiple body regions following breast reconstructive surgery. These side-effects were perceived to negatively impact both physical function and activity. Early intervention, education and treatment are recommended to alleviate these issues and minimise their negative impact.

Pain after ortho-plastic reconstruction of lower limb injuries: A snapshot study

INTRODUCTION

The incidence of pain after flap reconstruction of complex lower limb injury is poorly reported in the literature, and yet represents a significant source of morbidity in these patients. In our centre (Southmead Hospital, Bristol, England) patients who have had flap reconstruction for complex lower limb injury are followed up at a joint ortho-plastics lower limb clinic run weekly. The aim of this study was to report the incidence of pain in such patients at follow-up in the specialist clinic. The impact of the experience of pain upon the quality of life, and the efficacy of analgesia was assessed these cases.

PATIENTS AND METHODS

This was a cross sectional snapshot study of a cohort of complex lower limb patients attending our lower limb ortho-plastics outpatient clinic between the dates of: 17/5/16 and 28/6/16. Any patient attending clinic with previous flap reconstruction for lower limb injury was asked to complete the BPI (Brief Pain Index) questionnaire, and details regarding their injury and surgery were collected.

RESULTS

There was a 100% response rate, with 33 patients completing the questionnaire. 28 out of the 33 patients (85%) reported ongoing pain. There was no significant relationship between time post operatively and average pain scores (Spearman's Rank R = 0.077), nor was there significant difference by age or gender. Over 25% of the patients with pain were not taking analgesia, however those using simple analgesia (paracetamol, NSAIDS) derived on average over 70% pain relief.

CONCLUSIONS

Pain in a common complication following flap reconstruction for complex lower limb injury reported in 85% of our cohort. This pain does not seem to be correlated with time, gender or age, and responds well to simple analgesia in most cases. This emphasises the importance of asking about pain at follow up, and taking simple measures to improve pain outcomes.

Chronic postsurgical pain following breast reconstruction: a commentary and critique

In line with other major surgeries including breast cancer surgery (BCS), recent studies suggest a striking rate of chronic postsurgical pain (CPSP) following breast reconstruction. This commentary will critically examine evidence for the degree to which the prevalence of CPSP following breast reconstruction is directly attributable to reconstructive surgery. The discussion will trace similarities and distinctions between breast reconstruction and BCS in considering the risk for CPSP, and describe recent advances in the definition of CPSP, highlighting methodological limitations in the general investigation of CPSP, which also characterize the study of CPSP more specifically for breast reconstruction outcome. A convenience sample of relevant studies examining CPSP following breast reconstruction reveals inadequate evidence to support a serious concern for reconstruction-induced CPSP and further that these studies fail to adhere to recommended methodological standards to effectively isolate surgery as the etiology of persistent pain reported by women following reconstructive surgery. Suggestions for future exploration of problematic chronic pain after breast reconstruction are considered.

Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction

BACKGROUND

Chronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction.

MATERIALS AND METHODS

Women (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics.

RESULTS

Nearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years.

CONCLUSIONS

The substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

BACKGROUND

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

METHODS

A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

RESULTS

In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

CONCLUSION

The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Post-breast surgery pain syndrome: establishing a consensus for the definition of post-mastectomy pain syndrome to provide a standardized clinical and research approach - a review of the literature and discussion

BACKGROUND

Post-mastectomy pain syndrome (PMPS) is a frequent complication of breast surgery. There is currently no standard definition for this chronic pain syndrome. The purpose of this review was to establish a consensus for defining PMPS by identifying the various elements included in the definitions and how they vary across the literature, determining how these definitions affect the methodological components therein, and proposing a definition that appropriately encompasses all of the appropriate elements.

METHODS

We searched PubMed to retrieve all studies and case reports on PMPS, and we analyzed definitions of PMPS, inclusion/exclusion criteria, and methods of measuring PMPS.

RESULTS

Twenty-three studies were included in this review. We identified 7 independent domains for defining PMPS: surgical breast procedure, neuropathic nature, pain of at least moderate intensity, protracted duration, frequent symptoms, appropriate location of the symptoms and exacerbation with movement. These domains were used with varying frequency. Inclusion/exclusion criteria and methods for assessing PMPS also varied markedly.

CONCLUSION

To prevent future discrepancies in both the clinical and research settings, we propose a new and complete definition based on the results of our review: PMPS is pain that occurs after any breast surgery; is of at least moderate severity; possesses neuropathic qualities; is located in the ipsilateral breast/chest wall, axilla, and/or arm; lasts at least 6 months; occurs at least 50% of the time; and may be exacerbated by movements of the shoulder girdle.

A review of the literature and discussion: establishing a consensus for the definition of post-mastectomy pain syndrome to provide a standardized clinical and research approach

SUMMARY

Chronic pain presents a management challenge for physicians and patients alike, and post-mastectomy pain is no exception. In this issue, Waltho and Rockwell present a review of post-mastectomy pain syndrome (PMPS) and propose a standard definition that should allow future studies to be comparable. The proposed definition of "post-breast surgery pain syndrome" includes pain after any type of breast surgery that is of at least moderate intensity and comprises neuropathic qualities, that is present in the ipsilateral breast/chest/arm, that lasts longer than 6 months and is present at least half the time. Further work is needed to clarify whether this pain syndrome is in fact driven by neuralgia resulting from the axillary dissection component of breast cancer surgery.

Chronic Postsurgical Pain Outcomes in Breast Reconstruction Patients Receiving Perioperative Transversus Abdominis Plane Catheters at the Donor Site: A Prospective Cohort Follow-up Study

BACKGROUND

Chronic postsurgical pain (CPSP) is a debilitating and costly condition. Risk factors for CPSP after autologous breast reconstruction have not been clearly established. Previously, we demonstrated that transversus abdominis plane (TAP) catheters delivering intermittent local anesthetic reduced postoperative morphine consumption. This prospective follow-up study aimed to (1) compare the incidence of CPSP after autologous breast reconstruction between patients who received postoperative intermittent TAP catheters with bupivacaine or saline boluses and (2) assess the factors that contribute to the development and maintenance of CPSP in this study cohort.

METHODS

Ninety-three patients who underwent deep inferior epigastric artery perforator or muscle-sparing transverse rectus abdominis breast reconstruction were randomized to receive TAP catheters with bupivacaine or saline postoperatively. Subsequently, patients were followed for a year to assess persistent pain, pain severity, quality of life scores, and functional disability at 6 and 12 months after surgery.

RESULTS

Twenty-four percent and 23% of patients reported CPSP at 6 and 12 months, respectively. There were no significant differences between groups (bupivacaine vs. placebo) on pain-related variables, including incidence of CPSP. Patients who reported greater variability in pain scores at rest over the first 48 hours postoperatively were more likely to have CPSP 6 months, but not 12 months, later.

CONCLUSIONS

Acute postoperative pain variability may contribute to the development of CPSP up to 6 months after autologous breast reconstruction surgery. Neither postoperative use of bupivacaine vs. saline in the TAP catheters nor acute pain severity influenced the 6- or 12-month incidence of CPSP.

Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions

BACKGROUND

Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction.

METHODS

Patients undergoing primary implant-based (n = 1038) or flap-based (n = 837) reconstructions from 2004 to 2012 at the University of California, Los Angeles, were evaluated. Postoperative pain was measured using the visual analogue scale, total narcotic use, and number of patient-controlled analgesia attempts. Narcotic dosage was standardized to morphine equivalents per kilogram. The authors modeled postoperative narcotic use, patient-controlled analgesia attempts, and visual analogue scale scores over time using spline graphs for comparison between the two reconstruction methods.

RESULTS

Both total narcotic use and patient-controlled analgesia attempts were higher in the implant-based group throughout the immediate postoperative period. Implant-based reconstruction patients had significantly higher visual analogue scale scores (p < 0.0001) and total narcotic use (p < 0.0001) through postoperative day 3 compared with autologous tissue-based reconstruction patients. When controlling for reconstruction method, bilateral procedures were more painful (visual analogue scale score and patient-controlled analgesia attempts, both p < 0.001). When controlling for laterality, unilateral implant-based and autologous reconstructions had comparable visual analogue scale scores (p = 0.38) and patient-controlled analgesia attempts. However, unilateral implant-based procedures required more narcotic use than unilateral autologous tissue-based procedures (p = 0.0012).

CONCLUSION

Although commonly perceived as a less distressing operation, implant-based breast reconstruction may be more painful during the immediate postoperative hospitalization than abdominally based free tissue transfer.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patient-reported outcome measures in reconstructive breast surgery: is there a role for generic measures?

BACKGROUND

Patient-reported outcomes provide an invaluable tool in the assessment of outcomes in plastic surgery. Traditionally, patient-reported outcomes have consisted of either generic or ad hoc measures; however, more recently, there has been interest in formally constructed and validated questionnaires that are specifically designed for a particular patient population. The purpose of this systematic review was to determine whether generic measures still have a role in the evaluation of breast reconstruction outcomes, given the recent popularity and push for use of specific measures.

METHODS

A systematic review was performed to identify all articles using patient-reported outcomes in the assessment of postmastectomy breast reconstruction. Frequency of use was tabulated and the most frequently used tools were assessed for success of use, using criteria described previously by the Medical Outcomes Trust.

RESULTS

To date, the most frequently used measures are still generic measures. The 36-Item Short-Form Health Survey was the most frequently used and most successfully applied showing evidence of responsiveness in multiple settings. Other measures such as the Hospital Anxiety and Depression Scale, the Hopwood Body Image Scale, and the Rosenberg Self-Esteem Scale were able to show responsiveness in certain settings but lacked evidence as universal tools for the assessment of outcomes in reconstructive breast surgery.

CONCLUSIONS

Despite the recent advent of measures designed specifically to assess patient-reported outcomes in the breast reconstruction population, there still appears to be a role for the use of generic instruments. Many of these tools would benefit from undergoing formal validation in the breast reconstruction population.