Difference between revisions of "Breast reconstruction"
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===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
Regional techniques include thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block. | |||
* Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is | * Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is effective for mastectomy with or without recon, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.<ref>{{Cite journal|last=Calì Cassi|first=L.|last2=Biffoli|first2=F.|last3=Francesconi|first3=D.|last4=Petrella|first4=G.|last5=Buonomo|first5=O.|date=2017-03|title=Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block|url=https://pubmed.ncbi.nlm.nih.gov/28387892|journal=European Review for Medical and Pharmacological Sciences|volume=21|issue=6|pages=1341–1345|issn=2284-0729|pmid=28387892}}</ref><ref>{{Cite journal|last=FitzGerald|first=Simon|last2=Odor|first2=Peter M.|last3=Barron|first3=Ann|last4=Pawa|first4=Amit|date=2019-03|title=Breast surgery and regional anaesthesia|url=https://pubmed.ncbi.nlm.nih.gov/31272657|journal=Best Practice & Research. Clinical Anaesthesiology|volume=33|issue=1|pages=95–110|doi=10.1016/j.bpa.2019.03.003|issn=1878-1608|pmid=31272657}}</ref> | ||
* Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are | * Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are favored for their safety profile and can be combined with PVB for extensive procedures.<ref>{{Cite journal|last=Abi-Rafeh|first=Jad|last2=Safran|first2=Tyler|last3=Abi-Jaoude|first3=Joanne|last4=Kazan|first4=Roy|last5=Alabdulkarim|first5=Abdulaziz|last6=Davison|first6=Peter G.|date=2022-07-01|title=Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy|url=https://pubmed.ncbi.nlm.nih.gov/35499513|journal=Plastic and Reconstructive Surgery|volume=150|issue=1|pages=1e–12e|doi=10.1097/PRS.0000000000009253|issn=1529-4242|pmid=35499513}}</ref><ref>{{Cite journal|last=Matsumoto|first=Marcio|last2=Flores|first2=Eva M.|last3=Kimachi|first3=Pedro P.|last4=Gouveia|first4=Flavia V.|last5=Kuroki|first5=Mayra A.|last6=Barros|first6=Alfredo C. S. D.|last7=Sampaio|first7=Marcelo M. C.|last8=Andrade|first8=Felipe E. M.|last9=Valverde|first9=João|last10=Abrantes|first10=Eduardo F.|last11=Simões|first11=Claudia M.|date=2018-05-18|title=Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/29777144|journal=Scientific Reports|volume=8|issue=1|pages=7815|doi=10.1038/s41598-018-26273-z|issn=2045-2322|pmc=5959858|pmid=29777144}}</ref> | ||
Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics. | |||
==Intraoperative management== | ==Intraoperative management== | ||
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===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
For both implant-based and autologous | For both implant-based and autologous recons, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk). | ||
For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type. | For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type. | ||
After placement of implant or flap, surgeon will typically ask for HOB up 90 degrees to assess symmetry. | |||
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
Latest revision as of 14:27, 22 July 2025
Breast reconstruction
| Anesthesia type | |
|---|---|
| Airway | |
| Lines and access | |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.[1]
Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.[2]
Overview
Indications
Surgical procedure
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | |
| Pulmonary | respiratory compromise can be present if pt had XRT to thorax |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Regional techniques include thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block.
- Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is effective for mastectomy with or without recon, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.[3][4]
- Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are favored for their safety profile and can be combined with PVB for extensive procedures.[5][6]
Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
For both implant-based and autologous recons, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk).
For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type.
After placement of implant or flap, surgeon will typically ask for HOB up 90 degrees to assess symmetry.
Maintenance and surgical considerations
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs.
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.[7]
- Seroma
- Hematoma
- Implant reconstruction:
- Capsular contracture
- Implant malposition / rupture / leakage
- Autologous reconstruction:
- Flap thrombosis can lead to necrosis
- monitoring for flap perfusion is critical in autologous reconstruction
- Fat necrosis
- Hernia
- Flap thrombosis can lead to necrosis
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Indications | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Bellini, Elisa; Pesce, Marianna; Santi, PierLuigi; Raposio, Edoardo (2017). "Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique". BioMed Research International. 2017: 1791546. doi:10.1155/2017/1791546. ISSN 2314-6141. PMC 5742435. PMID 29376067.
- ↑ Gerber, Bernd; Marx, Mario; Untch, Michael; Faridi, Andree (2015-08-31). "Breast Reconstruction Following Cancer Treatment". Deutsches Arzteblatt International. 112 (35–36): 593–600. doi:10.3238/arztebl.2015.0593. ISSN 1866-0452. PMC 4577667. PMID 26377531.
- ↑ Calì Cassi, L.; Biffoli, F.; Francesconi, D.; Petrella, G.; Buonomo, O. (2017-03). "Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block". European Review for Medical and Pharmacological Sciences. 21 (6): 1341–1345. ISSN 2284-0729. PMID 28387892. Check date values in:
|date=(help) - ↑ FitzGerald, Simon; Odor, Peter M.; Barron, Ann; Pawa, Amit (2019-03). "Breast surgery and regional anaesthesia". Best Practice & Research. Clinical Anaesthesiology. 33 (1): 95–110. doi:10.1016/j.bpa.2019.03.003. ISSN 1878-1608. PMID 31272657. Check date values in:
|date=(help) - ↑ Abi-Rafeh, Jad; Safran, Tyler; Abi-Jaoude, Joanne; Kazan, Roy; Alabdulkarim, Abdulaziz; Davison, Peter G. (2022-07-01). "Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy". Plastic and Reconstructive Surgery. 150 (1): 1e–12e. doi:10.1097/PRS.0000000000009253. ISSN 1529-4242. PMID 35499513 Check
|pmid=value (help). - ↑ Matsumoto, Marcio; Flores, Eva M.; Kimachi, Pedro P.; Gouveia, Flavia V.; Kuroki, Mayra A.; Barros, Alfredo C. S. D.; Sampaio, Marcelo M. C.; Andrade, Felipe E. M.; Valverde, João; Abrantes, Eduardo F.; Simões, Claudia M. (2018-05-18). "Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia". Scientific Reports. 8 (1): 7815. doi:10.1038/s41598-018-26273-z. ISSN 2045-2322. PMC 5959858. PMID 29777144.
- ↑ Bennett, Katelyn G.; Qi, Ji; Kim, Hyungjin M.; Hamill, Jennifer B.; Pusic, Andrea L.; Wilkins, Edwin G. (2018-10-01). "Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction". JAMA Surgery. 153 (10): 901–908. doi:10.1001/jamasurg.2018.1687. ISSN 2168-6254.
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