LETTERS GUIDELINES
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction Sir:
W
e read with great pleasure the interesting article by Gassman et al. entitled “Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction,”1 and we congratulate the authors on their thoughtful retrospective study on postoperative pain outcomes following breast reconstruction. Breast reconstruction is becoming increasingly popular and can be associated with considerable postoperative discomfort and pain. We would like to share our experience with postoperative pain control using ultrasound-guided thoracic wall nerve block to overcome this issue. Copyright © 2015 by the American Society of Plastic Surgeons
698e
Fig. 1. A 51-year-old patient undergoing bilateral implant-based breast reconstruction and ultrasound-guided nerve block.
Fig. 2. Sonographic image of infiltration into the interpectoral plane at the infraclavicular level.
This technique was first described by Blanco et al.2,3 and consists of placing local anesthetic into the interfascial plane between the pectoralis major and minor muscles and superficial or deep underneath the serratus anterior muscle. This approach is a practical alternative to both paravertebral and epidural blockade in the management of pain after mastectomy and breast reconstruction. The anatomical site of the block is superficial and the procedure is performed with a linear ultrasound probe (Fig. 1). Once the pectoralis major muscle is identified, the location of the pectoral branch of the thoracoacromial artery between the pectoralis muscles is checked with color Doppler imaging. The lateral pectoral nerve is consistently located adjacent to the artery. We use a 20-gauge needle to infiltrate the interfascial plane with 20 ml of Naropin (APP Pharmaceuticals, Schaumburg, Ill.) 0.375% (Fig. 2). To provide complete analgesia of the lateral part of the thorax, we also perform serratus plane block. We count the ribs until we identify the fifth rib in the
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 5 • Letters midaxillary line; the latissimus dorsi, teres major, and serratus anterior muscles are easily identified by ultrasound overlying the fifth rib. The needle is introduced into a plane with respect to the ultrasound probe from superoanterior to posteroinferior, and 20 ml of Naropin 0.375% is injected. We routinely perform this procedure in our implant-based breast reconstructions (submuscular tissue expander or immediate silicone prosthesis), and we have experienced long-lasting regional anaesthesia, requiring little extra analgesia. The patients who received the nerve block demonstrate a lower mean visual analogue scale score throughout most of their inpatient stay. Total narcotic use is consistently lower in patients receiving nerve block. This is particularly evident immediately after surgery. Furthermore, patients receiving nerve block clearly consume less nonsteroidal antiinflammatory drugs. Moreover, this procedure allows us to place (1) a larger implant underneath the pectoralis major muscle even without acellular dermal matrix and (2) greater initial fill volumes in expander-breast reconstructions with no increase in postoperative pain, with a high level of patient satisfaction. This approach is safe, effective, and easy to perform, and is associated with a low risk of side effects. DOI: 10.1097/PRS.0000000000001657
Stefano Bonomi, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center
Lara Porrinis, M.D. Sara Santambrogio, M.D. Anesthetic Department First Service
Fernanda Settembrini, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center Ospedale Niguarda Ca’ Granda Piazza Ospedale Maggiore Milan, Italy Correspondence to Dr. Bonomi Department of Plastic Reconstructive Surgery and Burn Unit Ospedale Niguarda Ca’ Granda Piazza Ospedale Maggiore, 3 20162 Milan, Italy [email protected]
DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication. references 1. Gassman AA, Yoon AP, Maxhimer JB, et al. Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions. Plast Reconstr Surg. 2015;135:356–367.
2. Blanco R. The ‘pecs block’: A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66: 847–848. 3. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107–1113.
Reply: Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction Sir:
I commend Dr. Bonomi and coauthors for their letter. This work represents observations of a regional anesthetic technique they use in their patient population. They reference a combination of two techniques originally described by Blanco et al., in which local anesthetic is administered with ultrasound assistance in either a subserratus or interpectoral plane (between the pectoralis major and minor). The letter by Blanco et al. in Anaesthesia describes excellent analgesia when preoperatively blocking the interpectoral space despite subsequent exposure during implant or expander insertion.1 The later article by Blanco et al. in the same journal notes that a periserratus depot of anesthetic yields nearly complete hemithorax analgesia for up to 14 hours.2 This work definitely highlights the anatomical considerations important to achieving successful perioperative analgesia. Surgeons must appropriately evaluate patient anatomy before the adoption of these techniques. The operative field after mastectomy and before subpectoral prosthetic insertion affords the surgeon direct access to the anatomical planes roughly described by ultrasound. However, local tissue disruption can potentially limit the accuracy of medication placement and retention. Preoperative, ultrasoundguided analgesia may also potentially limit the total amount of intraoperative anesthetic used and provide critical guidance for a perivascular block such as Blanco’s “pecs block.” However, potential oncologic considerations such as the location of a breast cancer or node may limit constitutive use of preoperative percutaneous blocks. I agree with Dr. Bonomi and colleagues. There is a meaningful role for these adjunctive analgesic techniques. Even in our own population, my coauthors and I have learned that implant-based breast reconstructions are associated with significant patient discomfort in the immediate postoperative period. To address this need, surgeons should look for new methods to expand the available anesthetic techniques. We may argue that as the functional and aesthetic quality of breast reconstruction universally improves, we may look to our patients’ overall experience, including pain control, to improve satisfaction. However, before such techniques can be universally accepted, we should perform objective assessments of patient outcomes and pain perception. DOI: 10.1097/PRS.0000000000001659
699e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction Sir:
W
e read with great pleasure the interesting article by Gassman et al. entitled “Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction,”1 and we congratulate the authors on their thoughtful retrospective study on postoperative pain outcomes following breast reconstruction. Breast reconstruction is becoming increasingly popular and can be associated with considerable postoperative discomfort and pain. We would like to share our experience with postoperative pain control using ultrasound-guided thoracic wall nerve block to overcome this issue. Copyright © 2015 by the American Society of Plastic Surgeons
698e
Fig. 1. A 51-year-old patient undergoing bilateral implant-based breast reconstruction and ultrasound-guided nerve block.
Fig. 2. Sonographic image of infiltration into the interpectoral plane at the infraclavicular level.
This technique was first described by Blanco et al.2,3 and consists of placing local anesthetic into the interfascial plane between the pectoralis major and minor muscles and superficial or deep underneath the serratus anterior muscle. This approach is a practical alternative to both paravertebral and epidural blockade in the management of pain after mastectomy and breast reconstruction. The anatomical site of the block is superficial and the procedure is performed with a linear ultrasound probe (Fig. 1). Once the pectoralis major muscle is identified, the location of the pectoral branch of the thoracoacromial artery between the pectoralis muscles is checked with color Doppler imaging. The lateral pectoral nerve is consistently located adjacent to the artery. We use a 20-gauge needle to infiltrate the interfascial plane with 20 ml of Naropin (APP Pharmaceuticals, Schaumburg, Ill.) 0.375% (Fig. 2). To provide complete analgesia of the lateral part of the thorax, we also perform serratus plane block. We count the ribs until we identify the fifth rib in the
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 5 • Letters midaxillary line; the latissimus dorsi, teres major, and serratus anterior muscles are easily identified by ultrasound overlying the fifth rib. The needle is introduced into a plane with respect to the ultrasound probe from superoanterior to posteroinferior, and 20 ml of Naropin 0.375% is injected. We routinely perform this procedure in our implant-based breast reconstructions (submuscular tissue expander or immediate silicone prosthesis), and we have experienced long-lasting regional anaesthesia, requiring little extra analgesia. The patients who received the nerve block demonstrate a lower mean visual analogue scale score throughout most of their inpatient stay. Total narcotic use is consistently lower in patients receiving nerve block. This is particularly evident immediately after surgery. Furthermore, patients receiving nerve block clearly consume less nonsteroidal antiinflammatory drugs. Moreover, this procedure allows us to place (1) a larger implant underneath the pectoralis major muscle even without acellular dermal matrix and (2) greater initial fill volumes in expander-breast reconstructions with no increase in postoperative pain, with a high level of patient satisfaction. This approach is safe, effective, and easy to perform, and is associated with a low risk of side effects. DOI: 10.1097/PRS.0000000000001657
Stefano Bonomi, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center
Lara Porrinis, M.D. Sara Santambrogio, M.D. Anesthetic Department First Service
Fernanda Settembrini, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center Ospedale Niguarda Ca’ Granda Piazza Ospedale Maggiore Milan, Italy Correspondence to Dr. Bonomi Department of Plastic Reconstructive Surgery and Burn Unit Ospedale Niguarda Ca’ Granda Piazza Ospedale Maggiore, 3 20162 Milan, Italy [email protected]
DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication. references 1. Gassman AA, Yoon AP, Maxhimer JB, et al. Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions. Plast Reconstr Surg. 2015;135:356–367.
2. Blanco R. The ‘pecs block’: A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66: 847–848. 3. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107–1113.
Reply: Comparison of Postoperative Pain Control in Autologous Abdominal Free Flap versus Implant-Based Breast Reconstruction Sir:
I commend Dr. Bonomi and coauthors for their letter. This work represents observations of a regional anesthetic technique they use in their patient population. They reference a combination of two techniques originally described by Blanco et al., in which local anesthetic is administered with ultrasound assistance in either a subserratus or interpectoral plane (between the pectoralis major and minor). The letter by Blanco et al. in Anaesthesia describes excellent analgesia when preoperatively blocking the interpectoral space despite subsequent exposure during implant or expander insertion.1 The later article by Blanco et al. in the same journal notes that a periserratus depot of anesthetic yields nearly complete hemithorax analgesia for up to 14 hours.2 This work definitely highlights the anatomical considerations important to achieving successful perioperative analgesia. Surgeons must appropriately evaluate patient anatomy before the adoption of these techniques. The operative field after mastectomy and before subpectoral prosthetic insertion affords the surgeon direct access to the anatomical planes roughly described by ultrasound. However, local tissue disruption can potentially limit the accuracy of medication placement and retention. Preoperative, ultrasoundguided analgesia may also potentially limit the total amount of intraoperative anesthetic used and provide critical guidance for a perivascular block such as Blanco’s “pecs block.” However, potential oncologic considerations such as the location of a breast cancer or node may limit constitutive use of preoperative percutaneous blocks. I agree with Dr. Bonomi and colleagues. There is a meaningful role for these adjunctive analgesic techniques. Even in our own population, my coauthors and I have learned that implant-based breast reconstructions are associated with significant patient discomfort in the immediate postoperative period. To address this need, surgeons should look for new methods to expand the available anesthetic techniques. We may argue that as the functional and aesthetic quality of breast reconstruction universally improves, we may look to our patients’ overall experience, including pain control, to improve satisfaction. However, before such techniques can be universally accepted, we should perform objective assessments of patient outcomes and pain perception. DOI: 10.1097/PRS.0000000000001659
699e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
