Pectoral Block in Breast Reduction for Pain Control

Overview

A reduction mammoplasty is a commonly performed procedure for patients with symptomatic macromastia. The procedure involves removing breast parenchyma for an overall reduction in breast size and to alleviate patient symptoms, such as back/neck pain, rashes in the inframammary fold, and bra strap indentation. It is well documented in the literature that this procedure has a statistically significant reduction in patient symptoms. Postoperatively, it has been within the norm to prescribe narcotics in order to alleviate post-procedural pain. Recently, however, the research realm has advocated a non-narcotic multimodal pain control (MMPC) approach to minimize narcotic usage. Narcotic use is associated with increased costs in the healthcare system due to reported heightened pain scores for extended duration, constipation, nausea, vomiting, opiate dependence among other factors associated with increased morbidity. The goal of this study is to determine if PECs II (pectoral block type II) block alone is non-inferior to the standard multimodal pain control with narcotics for postoperative pain reduction in breast reduction.

Participants will be initially identified and introduced to the study during preoperative breast reduction consultation in the office. Participants will be contacted via phone for the consenting process, and consented electronically, after their consultation. After completion of the consenting and enrollment process, participants will be entered into a software program will automatically randomize participants into a control group (MMPC including narcotics) and an experimental group (PECs II block, MMPC no narcotics). In the experimental group, participants are informed that additional pain control is not withheld and that a paper prescription for a narcotic will be provided. Participants will be informed to use this paper prescription in the event their pain is not adequately controlled in the experimental group. Participants in the control group will have a paper prescription for a narcotic as well to maintain the study's blindness. Participants will be sent surveys at postoperative days 1, 3, and 7 assessing patient pain control as a primary outcome (PROMIS Pain Intensity Survey) and secondary outcomes: narcotic usage and satisfaction level. If participants do not answer initial survey query after 24 hours, a follow up email or phone call will be completed to obtain the information on the following day. Statistical analysis will be performed on the primary outcome assessing non-inferiority between the two groups at all time points once at least 80 patients have enrolled in the study. Description of PECs II Block: The participant will be administered 20 cc's of local anesthetic (0.25% bupivacaine with epinephrine), with 20 mcg dexmedetomidine and 4 mg dexamethasone added per breast. A total of 40 cc's of 0.25% bupivacaine will be used. This will be performed as a Pectoral II block. "The Pectoral II block is a modified Pectoral I block and can be achieved using a single needle stick. Local anesthetic placement is between the pectoralis major and pectoralis minor as for a Pecs I block and then between pectoralis minor and serratus anterior. The second portion of the procedure will block the anterior cutaneous branches of intercostal nerves 3 to 6, the intercostobrachial nerves, and the long thoracic nerve" (Battista et al). The standard of care injection, whether a nerve block or subcutaneous infiltration typically utilizes only a local anesthetic such as bupivacaine. Multimodal Pain Regimen: Patients are advised to take 1000 mg of acetaminophen every 6 hours and 600 mg of ibuprofen every 6 hours both scheduled and staggered 3 hours apart. If patient weight \<100 kg, oxycodone 5 mg tab PO q6h PRN for pain score 8-10 will be prescribed; disp-10, no refill. If patient weight \>100 kg, oxycodone 10 mg tab PO q6h PRN for pain score 8-10 will be prescribed; disp-10, no refill.