Breast reconstruction

Breast reconstruction

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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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.

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.

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

Regional and neuraxial techniques

The most established regional techniques are 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 particularly effective for mastectomy with or without reconstruction, 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.
• 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 increasingly favored for their safety profile and versatility, and can be combined with PVB for extensive procedures.
• Erector spinae plane block is an emerging technique with promising results, but less extensive data compared to PVB and PECS blocks.
• Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.

Intraoperative 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.

Postoperative 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.

• 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

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications