Intraoperative Local Anesthesia and Opioid Use in Enhanced Recovery After Surgery-based Breast Reduction

Abstract

Background:

Opioids have traditionally been the mainstay of postoperative pain management, but their side effects and potential for dependence have prompted increased focus on opioid-sparing strategies. This study evaluates the impact of intraoperative local anesthetic techniques on postoperative opioid use and time in the postanesthesia care unit (PACU) among patients undergoing bilateral breast reduction.

Methods:

A retrospective review was conducted for 199 patients who underwent bilateral breast reduction between July 2017 and December 2022 was conducted. Patients were grouped based on the intraoperative analgesic adjunct received: pectoralis nerve block I/II (n = 17), liposomal bupivacaine (n = 83), immediate-release bupivacaine (n = 62), or no local anesthetic (n = 37). The primary outcomes were opioid use in the PACU, measured in morphine milligram equivalents (MMEs), and time to discharge from the PACU, measured in minutes.

Results:

Use of anesthetic adjuncts was significantly associated with opioid consumption in PACU as compared with the control (P < 0.05). Patients who received immediate-release bupivacaine showed the lowest mean opioid use (mean = 1.96 mg MME, SD = 2.80 mg MME), whereas those with no anesthetic adjunct had the highest (mean = 4.42 mg MME, SD = 4.63 mg MME). Use of an anesthetic adjunct was not statistically associated with time in PACU.

Conclusions:

Intraoperative local anesthetics are a valuable component of multimodal analgesia in breast reduction surgery. Immediate-release bupivacaine was shown to be associated with significantly lower opioid use in the PACU. This strategy could be considered as an adjunct in the enhanced recovery after surgery pathway for breast reduction surgery.

Takeaways

Question: Does use of intraoperative local anesthetic decrease opioid use and time in the postanesthesia care unit among breast reduction patients, and is there a difference among the local anesthetic options?

Finding: The immediate-release bupivacaine group presented with the lowest mean value of morphine milligram equivalent (MME) use (mean = 1.96 mg MME, SD = 2.80 mg MME), whereas the control group showed the highest mean value of MME use (mean = 4.42 mg MME, SD = 4.63 mg MME).

Meaning: Immediate-release bupivacaine was associated with reduced opioid use in the postanesthesia care unit and may serve as a simple, effective adjunct within the enhanced recovery after surgery pathway for breast reduction surgery.

INTRODUCTION

The opioid epidemic in the United States has drawn attention to the role of surgical care in contributing to persistent opioid use.^1,2 Historically, opioids have been the cornerstone of postoperative pain management, but their side effects are associated with increased healthcare costs, prolonged hospital stays, and diminished patient outcomes.³ Alarmingly, 6%–9% of opioid-naive patients undergoing body-contouring procedures, such as breast reduction, develop new, persistent opioid use postoperatively.²

In response, enhanced recovery after surgery (ERAS) protocols have been developed and widely implemented across surgical disciplines to promote faster recovery, reduce length of stay, and improve overall surgical outcomes.^4,5 ERAS programs emphasize a multimodal, opioid-sparing analgesic strategy, early mobilization, minimal fasting, and standardized anesthetic techniques to improve postoperative recovery without increasing complications.⁶

Within the field of plastic surgery, the ERAS Society has published comprehensive guidelines outlining best practices to optimize perioperative care for breast reconstruction.⁶ These recommendations include the use of multimodal analgesia, regional anesthesia or nerve blocks, and perioperative strategies that reduce opioid exposure and improve recovery trajectories.^6–15 Meta-analyses support these guidelines, demonstrating that ERAS protocols in breast reconstruction are associated with reduced opioid use, decreased length of stay, and improved patient satisfaction.^16–18

Despite this growing body of evidence in breast reconstruction, there remains a paucity of literature examining ERAS implementation in other breast-related procedures—particularly reduction mammaplasty. Although breast reduction is commonly performed in an ambulatory setting, it involves significant soft tissue manipulation and can be associated with moderate to severe postoperative pain. However, standardized ERAS pathways and the routine use of intraoperative local anesthetics or regional blocks in this population are not well delineated.

The primary objective of this retrospective review is to evaluate the impact of intraoperative local anesthetic adjunct use on early postoperative opioid consumption and postanesthesia care unit (PACU) discharge times in patients undergoing bilateral breast reduction (BBR). An additional goal is to build upon the existing ERAS framework by contributing data relevant to breast reduction surgery, an area with limited representation in the current ERAS literature.

METHODS

ETHICAL APPROVAL

This study was approved by the St. Joseph’s University Medical Center institutional review board. A retrospective chart review of all patients who underwent BBR between July 2017 and December 2022 was conducted. Patients were de-identified using the “safe harbor” method in accordance with Health Insurance Portability and Accountability Act guidelines.

Study Design and Data Collection

This retrospective cohort study included patients who were 18 years or older, had no history of opioid use disorder, and underwent primary BBR in an ambulatory surgery setting. A total of 199 patients met the inclusion criteria.

Surgical and Perioperative Protocol

All procedures were performed by 1 of 3 plastic surgeons participating in the study. Patients were managed according to a standardized ERAS protocol designed to minimize postoperative nausea and vomiting, prevent intraoperative hypothermia, and promote early mobilization. The multimodal opioid-sparing analgesic regimen included scheduled acetaminophen (325 mg every 4 h), nonsteroidal anti-inflammatory drugs—ibuprofen (800 mg every 8 h), celecoxib (200 mg every 12 h), or naproxen (250 mg every 12 h)—gabapentin (300 mg every 8 h), and oxycodone (5 mg every 6–8 h as needed), unless contraindicated.

Data Collection and Variables

Patient charts were reviewed, and a database was created capturing demographic and perioperative variables, including age, weight, body mass index, race, postoperative opioid consumption (measured in morphine milligram equivalents [MMEs]) in the PACU, and the time (in min) to discharge from the PACU.

Patients were categorized into 1 of 4 groups according to the intraoperative local analgesic adjunct received. Due to the retrospective design, group allocation was nonrandomized and based on surgeon preference and institutional availability. All patients underwent surgery in either the main operating room or the same-day surgery center and were managed under standardized nursing protocols.

Based on prior evidence supporting their efficacy in breast surgery, pectoralis nerve block (PECS) I/II were included as part of the analgesic strategy. Immediate-release bupivacaine was analyzed as a cost-effective, short-acting option, whereas liposomal bupivacaine was evaluated for its prolonged analgesic duration (72–96 h), supporting an opioid-sparing recovery. Both formulations were analyzed as distinct variables. Four comparison groups were assessed:

• PECS (n = 17): Received a PECS I (local anesthetic injected between the pectoralis major and pectoralis minor muscles) and/or PECS II (PECS I plus a second injection between the pectoralis minor and the serratus anterior muscles) using either liposomal bupivacaine or immediate-release bupivacaine. Blocks were administered under ultrasound guidance by an anesthesia provider.

• ●EXP (n = 83): Received 20 mL (266 mg) of liposomal bupivacaine (Exparel) injected into the pectoral fascia under direct visualization by the surgeon with skin infiltration for hemostasis.
• ●BUP (n = 62): Received 100–150 mg (2–2.5 mg/kg) of immediate-release bupivacaine injected into the pectoral fascia under direct visualization by the surgeon, with skin infiltration for hemostasis.
• ●None (n = 37): Did not receive any intraoperative anesthetic adjunct as control.

Statistical Analysis

The primary outcomes were opioid consumption (MME) and PACU discharge time (min). Statistical analyses were performed using the Mann-Whitney U test, the Student t test, Pearson correlation, analysis of variance (ANOVA), and permutation ANOVA, with opioid use and PACU time as dependent variables. A P value of less than 0.05 was considered statistically significant.

To further analyze potential confounding factors, the following surgical factors were recorded: pedicle type (medial, superomedial, or inferior), resection weight per breast (in grams), resection pattern (wise, vertical, yin-yang, or snowman), nipple graft use (yes or no), history of breast reduction (yes or no), and whether liposuction was performed during the procedure (yes or no) (Tables 1–4).

Table 1.

Anesthetic Adjunct and Race Distribution

Anesthetic Adjunct	Race (Count)
	Asian	Black	Hispanic	Middle Eastern	Other	White
PECS	0	4	6	0	0	7
EXP	3	21	35	6	6	12
BUP	1	14	31	1	0	15
None	0	9	20	0	1	7

Table 4.

Categorical Distribution Among Different Anesthetic Adjuncts

Category	PECS	EXP	BUP	None
Nipple graft
Yes	1	1	7	4
No	15	82	55	33
Redo procedure
Yes	2	2	2	2
No	15	81	60	35
Liposuction
Yes	0	6	4	0
No	16	76	58	37
Pedicle type
Medial	0	2	0	0
Inferior	5	0	16	23
Superomedial	12	81	46	14
Resection pattern used
Snowman	0	4	0	0
Vertical	6	21	12	19
Wise	10	58	48	18
Yin-Yang	0	0	2	0

Table 2.

Continuous Variable Distribution Among Different Anesthetic Adjuncts: Mean and SD for Age, BMI, and Weight

Anesthetic Adjunct	Age Mean, y	Age SD, y	BMI Mean, kg	BMI SD, kg	Weight Mean, kg	Weight SD, kg
PECS	32.76	11.86	32.85	4.43	82.70	11.72
EXP	36.06	12.28	33.70	17.32	84.10	16.08
BUP	38.87	14.96	31.84	5.73	82.51	17.64
None	39.65	13.78	33.79	11.40	83.22	20.33

BMI, body mass index.

Table 3.

Continuous Variable Distribution Among Different Anesthetic Adjuncts: Mean and SD for Weight of Tissue Resected From the Left and Right Breast and Operation Length

Anesthetic Adjunct	Left Breast Mean, g	Left Breast SD, g	Right Breast Mean, g	Right Breast SD, g	Operation Length Mean, min	Operation Length SD, min
PECS	952.26	343.15	972.74	421.54	184.06	42.29
EXP	983.06	418.76	983.30	426.05	161.43	31.41
BUP	766.19	482.67	760.42	494.07	168.73	39.25
None	748.97	736.38	782.54	711.76	191.57	53.69

RESULTS

Morphine Milligram Equivalents

A total of 199 patients met the inclusion criteria and were stratified across 4 anesthetic groups. Demographic and operative characteristics were comparable across cohorts. Bivariate analysis (Table 5) revealed that anesthetic adjunct category (P < 0.05) and anesthesia provider (P < 0.05) were significantly associated with opioid use. Additionally, opioid use was significantly correlated with breast tissue resection weight (left and right breast, P < 0.05) and resection pattern (P < 0.05). In contrast, patient demographics (age, body mass index, weight, race), intraoperative variables (use of nipple graft, revision surgery, liposuction), and operative time were not significantly associated with opioid use.

Table 5.

Bivariate Analysis on MME and Time in PACU Time

	MMEs	Time in PACU, min
1. Age	P = 0.06	P = 0.26
2. BMI	P = 0.89	P = 0.61
3. Weight	P = 0.45	P = 0.51
4. Race	P = 0.61	P = 0.42
5. Provider	P < 0.05	P = 0.35
6. Anesthetic adjunct	P < 0.05	P = 0.35
7. Pedicle type	P = 0.10	P = 0.61
8. Weight of tissue resected from left breast, g	P < 0.05	P = 0.47
9. Weight of tissue resected from right breast, g	P < 0.05	P = 0. 65
10. Type of resection pattern used	P < 0.05	P = 0.29
11. Nipple graft	P = 0.20	P = 0.77
12. Redo breast reduction	P = 0.24	P = 0.43
13. Liposuction	P = 0.34	P = 0.49
14. Operation length	P = 0.61	P < 0.05

Bolded findings are statistically significant, represented by P < 0.05.

BMI, body mass index.

After adjusting for resected tissue weight, the use of an anesthetic adjunct remained significantly associated with opioid use (P < 0.01). In the adjusted ANOVA model evaluating intraoperative analgesic adjuncts across the 4 groups, patients in the immediate-release bupivacaine (BUP) group had the lowest mean opioid use, measured in MMEs (mean = 1.96 mg MME, SD = 2.80 mg MME), whereas the control group that received no anesthetic adjunct had the highest mean opioid use (mean = 4.42 mg MME, SD = 4.63 mg MME). The adjusted difference in opioid use between the immediate-release bupivacaine and control groups was statistically significant (P < 0.01).

Time in the PACU

Operation length was significantly associated with time spent in the PACU (P < 0.05). The remaining variables listed in Table 5 were not significantly associated with PACU time. Notably, the use of an anesthetic adjunct was not statistically significant in relation to PACU time (P = 0.35). PACU duration by anesthetic group is summarized in Table 6. The control group demonstrated the shortest mean PACU time (mean = 78.92 min, SD = 52.62 min), followed by the immediate-release bupivacaine group (mean = 85.21 min, SD = 64.01 min) (Tables 5, 6).

Table 6.

MME and Time in PACU Among Anesthetic Adjunct Groups

Anesthetic Adjunct	MME Mean	MME SD	Time in PACU Mean, min
PECS	3.53	3.69	103.24
EXP	2.64	3.08	96.65
BUP	1.96	2.80	85.21
None	4.42	4.63	78.92

DISCUSSION

This retrospective analysis evaluated the impact of intraoperative local anesthetic adjuncts on postoperative opioid consumption and recovery time in the PACU among patients undergoing BBR. These findings contribute to the growing body of evidence supporting the integration of intraoperative pain management strategies within ERAS protocols, particularly in the context of breast reduction.

Among the 4 anesthetic strategies assessed—no local anesthetic (None), immediate-release bupivacaine (BUP), liposomal bupivacaine (EXP), and PECS I/II administered by anesthesia providers (PECS)—the immediate-release bupivacaine group demonstrated the most favorable outcomes. This group required the lowest mean opioid doses in the PACU, a difference that remained statistically significant after adjustment for resection weight and resection pattern, both independently associated with opioid use.

The inclusion of both immediate-release and liposomal bupivacaine reflects their distinct pharmacological and economic profiles. Immediate-release bupivacaine provides a short-acting, cost-effective option well suited to ambulatory procedures, although its duration may not extend beyond the immediate postoperative period. Liposomal bupivacaine, by contrast, offers prolonged analgesia lasting up to 72–96 hours, theoretically aligning with efforts to reduce opioid use during the early recovery phase but at substantially higher cost. Because duration, cost, and availability are critical considerations in developing ERAS pathways, both formulations were analyzed separately. Despite its shorter duration, immediate-release bupivacaine achieved comparable or superior opioid-sparing effects in the early postoperative period, supporting its practicality and value in outpatient breast reduction surgery.

The “provider” variable was significantly associated with opioid use, potentially reflecting differences in block technique, infiltration method, or dosing among anesthesiologists and surgeons. Interpretation of this finding is limited by the retrospective design. Future prospective, protocol-driven studies could better delineate whether such provider-level variability meaningfully influences clinical outcomes.

Although the control group demonstrated the shortest mean PACU time (78.9 min), followed closely by the immediate-release bupivacaine group (85.2 min), no anesthetic adjunct was statistically associated with a reduction in PACU duration. These differences are likely influenced by nonclinical factors—such as anesthesia workflow, nursing availability, and bed turnover—which commonly impact PACU efficiency, particularly in high-volume tertiary care centers. This observation likely reflects the retrospective, nonrandomized design of the study and the absence of a standardized perioperative protocol. Importantly, the lack of any delay in discharge among patients receiving anesthetic adjuncts supports their safe inclusion within ERAS pathways.

These findings support previous literature highlighting the benefits of multimodal analgesia in minimizing opioid exposure following surgery. Immediate-release bupivacaine, a widely available agent, offers a meaningful short-term benefit and aligns with ERAS objectives. Our results reinforce the value of intraoperative local anesthetic use—particularly immediate-release bupivacaine—as a straightforward and effective adjunct to enhance recovery after breast reduction surgery. This is especially pertinent in ambulatory surgical settings, where minimizing narcotic use and promoting timely discharge remain key priorities.

LIMITATIONS

Although this study provides evidence supporting the short-term benefits of intraoperative local anesthetics in patients undergoing BBR, several limitations must be acknowledged. First, the retrospective chart review design inherently limits control over data collection and group assignment. As a result, the 4 anesthetic groups were not evenly distributed. These anesthetic groups were determined by individual provider preference and institutional availability at the time of surgery, rather than standardized protocol.

Second, the assessment of postoperative pain was limited to the immediate recovery phase during the patient’s stay in PACU. Although this allows for evaluation of short-term outcomes, it does not capture the potential benefits of longer acting agents such as liposomal bupivacaine, whose analgesic effects may extend well beyond the PACU period. Additionally, patient-centered outcomes—such as functional recovery, satisfaction, anxiety, and distress—or PACU-specific metrics—such as anesthesia team workflow, nursing availability, and bed turnover—were not measured.

Future research should use a prospective, randomized, protocol-driven design to minimize confounding. Standardizing anesthetic regimens, provider participation, and surgical setting (eg, same-day surgery centers) would enhance internal validity. Extending follow-up into the outpatient period would allow for a more comprehensive assessment of postoperative opioid use and analgesic effectiveness beyond the immediate recovery phase. Such an approach would also clarify the longer term effects of intraoperative anesthetic techniques on pain control, functional recovery, and overall patient well-being.

CONCLUSIONS

This retrospective study supports the incorporation of intraoperative local anesthetics as a valuable component of postoperative pain management in BBR procedures. Among the 4 anesthetic adjuncts evaluated, immediate-release bupivacaine was associated with the lowest opioid consumption in the PACU. These findings are consistent with the objectives of ERAS protocols, which aim to minimize opioid exposure and enhance patient recovery. Although the study is limited by its retrospective design and short follow-up period, the results underscore the importance of anesthetic selection in multimodal analgesia. Prospective, randomized trials are needed to confirm these outcomes and further explore the efficacy of extended-release formulations in improving long-term pain control.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.