Aesthetic plastic surgery is a growing area of medicine. According to data from the
American Society for Aesthetic Plastic Surgery, from 1997 to 2016, there was a 730%
increase in the number of cosmetic procedures performed by plastic surgeons in the
United States of America, representing an amount of 15 billion dollars spent in 13
million of procedures performed in 2016 alone 1. Around the world, these numbers could exceed 33 million cosmetic procedures performed
by plastic surgeons in 2016 2.
Breast augmentation surgery with implant swelled to the first place among the most
frequent operations. This represents a growth of 6.1% compared to 2017 and 27.6% compared
Brazil rose to first place in the world in cosmetic surgery procedures with a total
of 1,498,327 cosmetic plastic surgeries performed, ahead of the United States of America
with 1,492,383. The most popular surgical procedure for women was breast augmentation
surgery, with 1,841,098 procedures performed worldwide. The most popular surgical
procedure for men was the correction of gynecomastia, with 269,720 procedures3.
Regional anesthesia for aesthetic or reconstructive breast surgeries is challenging
for anesthesiologists, not only because of the complex nature of chest wall innervation
and the variety of techniques described as possible to be performed but also for the
constant concern to provide minimal postoperative pain.
Regional blockades decrease the onset of post-surgical chronic pain and decrease opioid
consumption and its known side effects. Enabling rapid recovery and early discharge,
this type of anesthesia can provide a positive experience to patients with reduced
Regional anesthesia techniques are part of a multimodal analgesic strategy. The growing
popularity of ultrasonic-guided regional blockades has profoundly impacted anesthetic
practice, improving some established techniques, and introducing new ones as more
studies have been conducted5. However, in the daily practice of plastic surgeons, anesthetic blocks are not yet
The review of regional blocks guided by ultrasound for anesthesia of cosmetic breast
surgeries is current and relevant because of the growing scenario of this type of
surgery and hospital costs. Anesthetic alternatives that allow reduction of hospital
stay, costs, reduction of the use of analgesic medications that cause constipation,
nausea, vomiting, urinary retention, among other complications, can ensure greater
safety and improve the patient’s experience in the transoperative process.
This work aims to review and compare the most used regional anesthesia techniques
for anesthesia and perioperative analgesia in breast cosmetic plastic surgeries.
The proposed study is secondary and establishes a relationship with articles already
published through the review of clinical studies that investigated the association
of regional anesthetic blocks guided by ultrasound with cosmetic plastic surgeries
of the breasts.
This study does not violate the ethical-legal precepts established by the research
ethics committee of the Federal University of São Paulo because it is an observational
project to review the literature already published.
The project presented was developed with its own resources from the responsible researchers.
To perform this work, articles already published in MEDLINE databases were collected,
using the PubMed portal as a search tool until December 20, 2019.
The research combined terms for breast cosmetic surgeries, regional anesthesia guided
by ultrasound, perioperative anesthesia and postoperative pain. The terms searched
in the MEDLINE/PubMed database were: “regional anaesthesia”,”breast
plane block”,”and spinae
plane block”, “paravertebral
block” and “post operative
The filters added to this database were: articles published in the last five years,
review articles, articles in English and similar articles. The inclusion, non-inclusion
and exclusion criteria of the articles found are listed in Chart 1.
Chart 1 - Study selection criteria.
| Inclusion criteria
|Published in the
last 5 years
|Studies of areas
not related to
of the breasts
Chart 1 - Study selection criteria.
In the MEDLINE/PubMed database, the search for “regional anaesthesia” AND “breast
augmentation” resulted in 27 articles. However, once the filters and criteria and the selection
of the studies were applied, only 1 article was selected for analysis.
The search for “regional anaesthesia” AND “aesthetic
surgery” did not result in any article.
Researched in combination the terms “regional anaesthesia” AND “aesthetic
surgery” AND “breast
augmentation”, a total of 0 articles were found in the MEDLINE/PubMed database.
By researching the terms “serratus
plane block” AND “breast
augmentation” and applying the selection criteria of the studies, a total of 7 articles were selected
Seeking the terms “erector
plane block” AND “breast
augmentation” and applying the selection criteria of the studies, no article met the eligibility
The combination of the terms “paravertebral
block” AND “breast
augmentation” resulted in a total of 5 articles when applying the filters and selection criteria.
The terms “pecs
block” AND “breast
augmentation,” when researched and applying the selection criteria of the studies, originated a total
of 4 articles that were selected for analysis.
The search for “post operative
pain” AND “aesthetic
surgery “resulted in 0 articles.
In the search for the combination of “post operative pain” AND “aesthetic plastic surgery”, a total of 0 articles were found in the MEDLINE/PubMed database.
At the end of the research, the terms sought “post
augmentation “did not result in any article.
In the MEDLINE database, using the PubMed search portal, 16 articles were found with
the criteria described. Of these, two articles were in duplicate, resulting in 14
articles that met the inclusion, exclusion and non-inclusion criteria established
in the methodology.
Of the studies analyzed, the most used ultrasound-guided regional anesthesia techniques
were 5: paravertebral block (PVB) and interfascial blocks (PECS 1 and PECS 2), serratus
plane block (SPB) and intercostal block (IB).
Studies analyzing the analgesia provided by paravertebral block for patients undergoing
breast surgeries concluded that patients presented better hemodynamic stability and
equivalent pain relief compared to thoracic epidural anesthesia6. Studies comparing its immediate and long-term effect demonstrated its superior analgesic
effect at both times, concerning patients who received only systemic analgesia. At
the same time, there was a decrease in opioid consumption and its typical adverse
effects, such as nausea and vomiting, for example4,7.
However, when studying patients up to 12 months postoperatively, sequential analysis
of the most recent trials did not find sufficient evidence that paravertebral block
would be able to avoid long-term chronic pain, in contrast to other meta-analyses
with few studies previouslypresented8. Thus, the studies demonstrated its effectiveness in reducing the intensity of conical
pain and not its potential to avoid it8,9.
Although outside the scope of the present study, it is important to mention the role
of this blockade in reconstructive surgeries. Paravertebral block demonstrated clinically
significant postoperative benefits for patients undergoing reconstructive breast surgery
related to breast cancer. This type of block performed continuously with a catheter
demonstrated more benefits for use in extensive reconstructive thoracic and breast
surgeries, with great potential for chronic pain. However, the use of a catheter is
not superior to single-injection techniques at single or multiple levels4,10. The complications reported using PVB were pleural puncture with pneumothorax, dispersion
of local anesthetic to the epidural space, significant intraoperative hypotension,
and inadvertent puncture of vessels.
Studies comparing PECS 2 with a paravertebral block (PVB) in a single injection at
the T4 level for breast surgeries observed that patients in the PECS 2 group had lower
intraoperative opioid consumption and better postoperative pain control in the first
12 h. They also had better analgesic coverage of the axillary region and less nausea6. However, when the pain scores (visual analog scale-VAS) were evaluated after the
first 12 hours postoperatively, the patients in the PVB group presented less pain.
In addition, the time to request morphine was longer in the PECS 2 group, and overall
opioid consumption was also shorter in this group5,10.
A recent study evaluated the combination of PECS 1 and PVB, comparing it with PVB
associated with sedation in 60 patients undergoing breast surgery with the placement
of subpectoral implants. This combination was made to provide more perioperative comfort.
Pain levels (VAS) were significantly lower in the group treated with the association
of PECS 1 and PVB blocks in the first 8 hours, but not after 24 h. In addition, there
was a reduced need for intraoperative sedation, with no statistically significant
differences concerning postoperative nausea and vomiting11-13.
When compared only to systemic analgesia, PECS 2 showed a reduction in the need for
opioids in the first 24 hours in 13.6 mg of oral morphine, prolonged the first analgesic
request by 301 minutes and reduced the score on the pain score (visual analog scale)
by 0.9 to 1.9 points, on average12. In addition, it impacted the reduction of the incidence of nausea and vomiting,
providing lower postoperative sedation, with a shorter length of stay in post-anesthetic
recovery and hospitalization10. No complications in the execution of this technique were reported14.
PECS 2 was also used as an anesthetic technique associated with dexmedetomidine sedation
without general anesthesia. After 15 minutes of blockade with 10ml between the pectoralis
major and minor muscles, and 20ml between the pectoralis minor and the anterior serratus
muscle, with bupivacaine at 0.25%, sufficient analgesia was obtained to start the
surgical procedure, maintaining only continuous dexmedetomidine. However, its effect
remained for approximately 8 hours, and analgesics were not ordered for one day14.
Comparative studies evaluated superficial serratus plane block (SPB) and PVB in breast
cosmetic surgeries. Lower intraoperative opioid consumption was reported, but the
time for the first analgesic request was longer in the group that received bpv12.
Evaluating intercostals blocks (IB) in subpectoral breast prosthesis placement surgeries,
studies showed that there was no difference in pain scores (VAS) with 1, 3, 6, 24,
48 or 72 hours between patients submitted to IB and those who did not receive IB.
It was also concluded that there was no difference in opioid consumption in the postoperative
period between patients submitted to IB and those not submitted to blockade10.
In the selected articles, no studies were found relating cosmetic breast surgeries
to the blockade of the spinal erector plane following the selection criteria.
The various types of breast plastic surgeries involve the manipulation of different
tissues and surgical incisions. Therefore, the anatomical knowledge of the various
structures involved in each technique is extremely important in perioperative analgesic
Primary augmentation mammoplasty with the inclusion of silicone prosthesis has been
the most performed cosmetic breast surgery globally, in the USA and Brazil3,15, with a frequent trend increasing in recent years. This expressive importance of
the procedure within plastic surgery contrasts with the relative scarcity of studies
found in the present study. Considering the recent development of portable ultrasound
devices and applying the selection criteria described the total of 14 studies found
for final analysis demonstrates the need for greater attention to the theme.
The correlation between the different regional anesthetic blocks and the various access
routes (inframammary, periareolar, transaxillary and even umbilical), plans for prostheses
insertion, and the various types of breast surgeries represents an extensive field
of research still little explored. For example, blocks considered aggressive in the
literature studied and not recommended in cosmetic surgery (such as PVB) may be indicated
in the transaxillary approach, in which the surgical injury of the intercostobrachial
nerve may result in acute and chronic axillary pain10; similarly, surgical dissection for implant insertion between the pectoralis major
and pectoralis minor muscles involves stretching muscle fibers, with the detachment
of their parts attached to the cartilaginous rings of the adjacent ribs, generating
great potential for postoperative myofascial pain and indicating the need for a more
comprehensive blockage. In fact, one of the studies found that 9.5% of the patients
submitted to mammoplasty with submuscular insertion of the implants developed persistent
postoperative pain, from moderate to severe and 38% met the criteria for the diagnosis
of neuropathic pain10.
Other modalities of cosmetic breast surgeries performed, such as mastopexy, reduction
mammoplasty and gynecomastia correction, in which only excess skin and glandular tissue
are removed, and pectoral muscles are spared, have lower pain potential from the perioperative
analgesic point of view10.
In the present study, the five regional blocks commonly associated with breast cosmetic
surgeries represent a wide range of alternatives to the anesthetic techniques traditionally
used, such as epidural and general anesthesia. Since the pioneering introduction of
PVB described by Hugo Sellheim in190516, the incorporation of ultrasound in the performance of regional blocks has represented
the greatest improvement of the techniques, allowing direct visualization of the needle,
anesthetic injection and anatomical structures involved 5. However, despite precise anatomical knowledge and extensive incorporation of ultrasound,
more studies standardizing specific PVB techniques and protocols on direct vision
are still needed. Different approaches to the execution of the blockade were proposed,
but studies considering outcomes of the various approaches seeking a “gold standard”
technique are infrequent. In addition, the heterogeneity of patient selection, different
types of surgeries, techniques, local anesthetics, and adjuvants used for blockades
made it difficult to compare the techniques17.
Moreover, although it is tempting to say that ultrasound-guided blocks offer a lower
risk of complications due to real-time visualization of the needle and local anesthetic
dispersion, there are insufficient data in the literature to support this statement
so far. Thus, they are not infrequent reports in the literature of pleural punctures,
pneumothorax, placement of intrathoracic catheters, inadvertent intrathecal puncture,
and cases of significant intraoperative hypotension in ultrasound guided PVB7. Thus, the use of PVB for cosmetic surgeries has not been recommended as a first
option. Instead, cosmetic breast surgeries should be conducted with other multimodal
analgesia techniques associated with less invasive regional blocks in most patients,
with paravertebral block reserved as an analgesic rescue technique or for patients
at high risk of chronic pain or excessive postoperative pain4.
In addition to PVB, PECS 1, PECS 2, and SPB blocks were the most frequently reported
regional anesthesia modalities in the literature studied, establishing themselves
as effective and less invasive alternatives than BPV17.
The main advantages reported concerning PECS and the blockade of the serratus plane
are the relative ease of visualization and execution of the ultrasound-guided technique.
The superficiality of related anatomical structures, their minimal potential for complications
compared to thoracic epidural and paravertebral block, with sensory block and without
risk of the sympathetic block are often listed advantages. Both PECS and serratus
block have good coverage of the anterolateral region of the thorax, including for
outpatient surgeries, which can also be performed in patients receiving anticoagulation
therapy. However, it is worth remembering that, even infrequent, pneumothorax and
hematoma due to accidental puncture of the thoracodorsal artery are possible complications
to be considered in this type of blockade14,18.
Compared to other blocks, PECS 2 presented clear advantages. Studies show lower intra-
and postoperative opioid consumption, prolongation in the first postoperative analgesia
request, reduction in VAS scores, lower incidence of nausea and vomiting, less intraoperative
sedation with a short stay in post-anesthetic recovery and reduced hospital stay5,6,10,14. Performed in isolation as the only regional block technique, PECS 2 appears in the
literature as the safest and most effective alternative for analgesia in cosmetic
plastic surgery of the breast, and it may even be the only analgesic technique that
can only be associated with sedation. However, it must be considered that PECS 2 effectively
blocks the anterior portion of the chest and breasts and may fail in the lateral portions
of the breasts. Hence the idea of associating the different modalities of blocking.
The association of PVB with PECS 2 as an anesthetic block proved to be an effective
alternative for breast surgery without general anesthesia5,18.
When compared to general anesthesia alone, interfascial blocks were useful in reducing
intra- and postoperative analgesic needs. Both PECS 2 and the association between
PECS 1 and serratus plan blockade proved to be good analgesic strategies for surgeries
involving the anterolateral region of the thorax5,18.
However, because they are a mode of blockades whose efficacy is related to the volume
of anesthetic injected and its dispersion between the planes, the greatest risk associated
with interfascial blocks is local anesthetic poisoning. In addition, they present
a limitation and other techniques of a single injection, restricted duration of the
time of action. It is not yet clear whether the use of adjuvants such as clonidine,
dexamethasone or dexmedetomidine, for example, can prolong the effect of interfascial
blocks as they do on other types of nerve blocks12.
In the studies evaluated, intercostal blocks demonstrated analgesic efficacy equivalent
to infiltration with local anesthetic in the incision, performed intraoperatively
by the surgical team12.
Although thoracic blocks have been widely reported in the literature, it has been
observed that many articles have reported the use of regional anesthesia techniques
in breast reconstructive surgeries and thoracic surgeries. One of the main limitations
found in the present review study was the scarcity of studies correlating the blocks
exclusively to cosmetic plastic breast surgery, in addition to the great heterogeneity
among the studies. Thus, quantitative comparisons were made difficult, leaving gaps
regarding each type of blockage’s efficacy and superiority/inferiority in this specific
modality of breast surgery17.
Most of the evidence produced concerning blocks for cosmetic breast surgery exists
in the form of reports or case series, making it necessary more randomized clinical
trials, well structured, in homogeneous groups, to evaluate each of these techniques.
The different associations of blocks found were conducted without criteria or guidelines
regarding the blocks to be used for each type of surgery, specifically. The need for
standardization of a given technique that demonstrates maximum efficacy was evidenced
after finding the scarcity of studies given the robust universe of aesthetic plastic
This review observed that no blockage effectively covers the entire breast and axillary
region. Therefore, a combination of blocks should be used depending on the incision
site and access route for placement of the breast prosthesis. Currently, with the
scarcity of large randomized well-conducted randomized clinical trials, it is difficult
to determine the superiority of one technique over the other14.
The literature has frequently reported the description of the different types of regional
blocks for analgesia in breast plastic surgeries. In isolation, interfascial blocks
(PECS 1 and PECS 2) are more promising, safe, and easy to perform in aesthetic plastic
surgeries of the breasts than the other modalities of blockages. They promote decreased
opioid use and side effects, reduction in hospitalization time and postoperative recovery.
Furthermore, the association of regional blocks may decrease the use of general anesthesia
and neuroaxis blocks and their complications, allowing surgeries only with sedation
and regional blocks. Despite encouraging prospects, clinical trials and prospective
studies with higher levels of scientific evidence are needed.
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1. Human Clinic, Plastic Surgery, São Paulo, SP, Brazil.
Corresponding author: Leandro Dário Faustino Rua Diogo Jacome, nº 50 - Vila Nova Conceição, São Paulo, SP, Brasil Zip Code 04512-000
Article received: December 18, 2020.
Article accepted: April 19, 2021.
Conflicts of interest: none.