Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

Abstract

Background

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

Methods

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients’ satisfaction were systematically assessed with standardized self-assessment questionnaires.

Results

Altogether, 48 patients [median (IQR) age: 30 (36–25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34–2) mg/kg lidocaine and 2.3 (2.5–2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48–4.26) mg/kg/h and 0.27 (0.39–0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43–1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

Conclusions

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-022-03214-w.

Introduction

Over 80% of female patients fear suffering paralysis and pain during general anaesthesia [1]. However, most aesthetic procedures can safely be performed in non-intubated spontaneously breathing patients [2, 3]. Aesthetic procedures under locoregional anaesthesia carry less risk than under general anaesthesia [4]. Sedation is less invasive and less expensive than general anaesthesia. The COVID-19 pandemic raised awareness of a further advantage of sedation over general anaesthesia, which generates potentially hazardous aerosols associated with a risk of transmission of COVID-19 and other infectious diseases to healthcare workers [5].

Perioperative opioid administration is associated with many side effects, such as urinary retention, respiratory depression, postoperative nausea, and dizziness upon ambulating [6]. These side-effects are responsible for delayed hospital discharge and unanticipated admission to the hospital, all of which increase treatment costs [7]. Moreover, the opioid epidemic has highlighted the need for minimizing perioperative opioid medication [8]. Multimodal opioid-sparing strategies are a key component of the enhanced recovery after surgery (ERAS) protocol. The COVID-19 pandemic has been a further incentive to achieve same-day discharges and spare hospital resources.

Solid evidence has been presented underlining the value of regional anaesthesia in breast surgery in decreasing pain scores and cumulative opioid consumption [9]. Intercostal nerve blocks just before waking from general anaesthesia in breast augmentation effectively reduces postoperative pain [10]. However, locoregional anaesthesia techniques in breast surgery are traditionally used for postoperative pain management and not as primary anaesthesia. The aim of this study is to investigate (a) if outpatient breast surgery under sedation, intercostal block, and local anaesthesia can be performed safely with low opioid consumption, and (b) to evaluate the associated recovery, pain, and nausea.

Material and Methods

Patients

This prospective study was approved by the local Ethics Committee (Project No. 144/21). Informed consent for prospective analysis was waived. All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this study. Underage patients and patients requiring revision surgeries within the first week were excluded, as were patients with incomplete self-assessment questionnaires or incomplete clinical study reports.

ERAS Protocol and Anaesthesia

Sedation was done by experienced anaesthesiologists. No routine laboratory screening was done [11]. Preoperative chlorhexidine showering was advised to reduce surgical site infection. All patients were instructed to abstain from solid food 6 h before surgery and clear liquids 2 h before surgery. All patients received 1000 mg acetaminophen and 1000 mg tranexamic acid PO two hours before the surgery as well as dexamethasone 4 mg IV before surgery. No bladder catheter was used unless the surgery was scheduled for more than 4 h. When the surgery was expected to last more than two hours and when breast implants were used cefazolin or clindamycin, in case of penicillin allergy, was administered IV within 60 min of the incision. Warming blankets before, during, and after surgery as well as warmed tumescent solutions were used to prevent hypothermia. The operating room team was composed of two board-certified plastic surgeons, a surgical assistant, a circulating nurse, and a board-certified anaesthesiologist. Routine monitoring was applied, including pulse oximetry (SpO₂), electrocardiogram, and noninvasive arterial pressure. All patients received oxygen 2L/min during the procedures. Propofol was given by a continuous intravenous infusion pump. One-half mg of alfentanil was administered before the intercostal block and during the surgery when the patient appeared to respond to pain stimuli. Postoperatively, patients were recommended preemptive analgesia using acetaminophen 500 mg and metamizole 500 mg alternately every 3 h during the first 48 h. Tilidine/naloxone (50/4 mg) slow-release tablets and dimenhydrinate 150 mg suppositories were prescribed to manage acute pain or nausea. Low-dose postoperative heparin venous thromboembolism prophylaxis was done in patients with a Caprini score of 3 and above. All patients were recommended knee-high compression stockings for 10 days.

Surgery and Locoregional Anaesthesia

All intercostal blocks were performed with ropivacaine 0.375%, 4 mg dexamethasone, and epinephrine (1:100.000). Immediately after sedation, the surgeon performed the intercostal bloc III/IV, IV/V, V/VI, and VI/VII on both sides. Using a 20 ml syringe, a 20-gauge cannula (0.90 × 70 mm) is advanced in a cephalad angulation towards the palpated rib. Once the needle tip impinges on the rib periosteum, it is walked off towards the end of the inferior rib margin. Just underneath the inferior border the needle is advanced 2–3 mm to lie adjacent to the intercostal nerve as previously described [10]. Five milliliters are injected after aspiration to check if the pleura or a vessel was punctured. For hemostasis and local anaesthesia, a solution with lidocaine 0.1% and epinephrine (1:500.000) was injected into the incision sites. For liposuction, tumescent anaesthesia with lidocaine 0.05% and epinephrine (1:1.000.000) was used taking into account the maximum previously described dosage of 45 mg/kg [12]. In the case of fat grafting, 7 ml of 8.4% sodium bicarbonate was added per 1000 ml tumescent solution [13]. Ten minutes after surgery, the patient was allowed to drink and, in the absence of subsequent nausea, also eat. Patients were given permission to be discharged after surgery upon tolerance to food, voiding, ambulation without assistance, absence of intolerable pain, and absence of nausea. Patients were requested to have the assistance of a caregiver at home on the first night. Patients received a discharge letter including postoperative instructions, follow-up appointments, and the surgeons’ cell phone number. The surgeons made a postoperative follow-up phone call on the day after the surgery.

Questionnaires and Clinical Study Reports

Clinical study reports were designed involving all members of the team as easy-to-use data collection forms with sufficient and unambiguous data. The self-assessment questionnaire was developed by a multidisciplinary team consisting of two plastic surgeons, one psychiatrist, and a plastic surgery nurse with knowledge and experience in questionnaire design [14, 15]. The self-assessment questionnaire included 12 items from the validated international pain outcome questionnaire (IPO) [16] and 5 items from the modified Brice questionnaire [17]. The pilot-test data collection forms and questionnaires were developed, ensuring that they provide data in the right format and structure for subsequent analysis, focusing on the clarity and completeness of questions. The precise wording and order of the questions underwent several revisions before field testing. Closed-ended questions were used as much as possible, including “not applicable” and “cannot tell” options where needed. Open questions were strategically used to ensure that all relevant issues were covered and to increase the response rate of the reader [18]. Coding instructions for data extraction were included in the initial design. Responses to open questions were categorized systematically into common themes, coded, and analysed quantitatively. Responses were evaluated to ascertain their completeness and to identify the questions that most often led to default. Interviews were conducted with a small subset of respondents to determine the time taken to complete the questionnaire and to test the understanding of the questions. Primary and secondary outcome parameters and timing of assessments were:

• Structured self-assessment questionnaire for demographic data (gender, age, BMI, comorbidities, medication, and ASA score) completed before the first consultation.

• Clinical study reports with descriptive data regarding surgery and anaesthesia were assessed on the day of surgery by the circulating nurse (total alfentanil and propofol dose per patient, total lidocaine and ropivacaine dose per patient, time required for nerve block and local infiltration, pain on a numeric rating scale (NRS) at 0 h and 2 h after surgery, time to drink, time to eat, time to get dressed, time until discharge, time to void, incidence of postoperative nausea, recovery period until discharge, surrogate for presumed pain, such as agitation during surgery, peripheral oxygen saturation < 90% or conversion to general anaesthesia, postoperative shivering, postoperative hypotensive events (MAP < 65 mm Hg for at least 1 min), unplanned hospital admission).

• Patient-reported postoperative pain and satisfaction with postoperative pain medication and sedation assessed by the international pain outcome questionnaire (IPO) administered the day after surgery, total analgesic, and antiemetic medication in the first 24 h, and quality of sleep on the day of the surgery.

Statistics

Continuous variables are provided as mean ± standard deviation (95% confidence interval) for normally distributed variables as well as median and interquartile ranges (IQR) for non-normal data. All statistical analyses and graphics were performed using SPSS Version 28 (SPSS Inc, Chicago, Illinois, USA). A Spearman’s rank correlation matrix was used to assess correlations between the different parameters. A level of p = 0.05 was considered to indicate statistical significance. A multiple linear regression model was applied to determine differences between the sides, adjusted R² values of ≤ 0.13 were considered indicative for poor, 0.13–0.26 for moderate, and ≥ 0.26 for high goodness-of-fit [19].

Results

A total of 48 patients with a median (IQR) age of 30 (36–25) were included in this study. BMI, comorbidities, medication, and ASA score are presented in Table 1. The most frequent surgery was mastopexy. 69% of the surgeries involved additional procedures, such as liposuction (Table 2). The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48–4.26) mg/kg/h and 0.27 (0.39–0.19) µg/kg/min (median amount of 0.5 mg boli: 3; min.: 0.2; max.: 5) (Table 2).

Table 1.

Demographic data (age, BMI, comorbidities, medication, ASA score)

Age median (IQR)	30 (36–25)
BMI median (IQR)	24 (26 – 22) kg/m²
Sex	39 (81%) women
ASA I	34 (71%)
ASA II	14 (29%)
Comorbidities	No comorbidities: 40 (83%)
	3 (6%) thyroid disease
	2 (4%) arterial hypertension
	2 (4%) asthma
	4 (8%) other
Medication	No medications: 34 (71%)
	8 (17%) hormonal contraception
	3 (6%) Levothyroxine
	2 (4%) antihypertensive drugs
	5 (10%) other

Table 2.

Type and duration of surgery

Surgery type	Total	Surgical techniques	Additional procedures	Procedure time (hours:min) Median (IQR)	Total alfentanil dose per patient (µg/kg/min) Median (IQR)	Total propofol dose per patient (mg/kg/h) Median (IQR)	Postoperative low dose heparin	Postoperative use of drains	Intercostal block and local anaesthesia time (min) Median (IQR)	Total lidocaine dose per patient (mg/kg) Median (IQR)	Total ropivacaine dose per patient (mg/kg) Median (IQR)
Breast augmentation	23	Breast augmentation 7 (30%) Augmentation mastopexy 1 (4%) Hybrid breast augmentation 8 (35%) Implant exchange and mastopexy 1 (4%) Fat transfer 6 (26%)	Liposuction 21 (91%) Dermal suspension flaps 1 (4%) Periareolar skin resection 0 (0%)	02:14 (02:51–01:30)	0.33 (0.52–0.21)	4.96 (5.53–4.38)*	Yes 22 (96%) No 1 (4%)	Yes 10 (43%) No 13 (57%)	15 (16–13)*	22 (39–2)	2.4 (2.6–2.3)
Breast reduction and/or mastopexy	17	Breast reduction and mastopexy 1 (6%) Mastopexy and fat transfer 4 (24%) Mastopexy 11 (65%) Implant removal and mastopexy 1 (6%)	Liposuction 14 (82%) Dermal suspension flaps 5 (29%) Periareolar skin resection 0 (0%)	02:37 (03:13–01:49)	0.27 (0.38–0.20)	5.05 (5.63–4.39)*	Yes 17 (100%)	Yes 5 (29%) No 12 (71%)	22 (26–18)	11 (33–1)	2.2 (2.5–2.0)
Gynecomastia	8	8 (100%)	Liposuction 4 (50%) Dermal suspension flaps 0 (0%) Periareolar skin resection 2 (25%)	01:42 (01:52–01:05)*	0.20 (0.36–0.00)*	2.71 (4.99–0.00)	Yes 6 (75%) No 2 (25%)	No 8 (100%)	11 (12–10)*	20 (36–13)	1.7 (1.9–1.5)
Total/Mean	48	Breast augmentation 7 (15%) Augmentation mastopexy 1 (2%) Hybrid breast augmentation 8 (17%) Implant exchange and mastopexy 1 (2%) Fat transfer 6 (13%) Breast reduction and mastopexy 1 (2%) Mastopexy and fat transfer 4 (8%) Mastopexy 11 (23%) Implant removal and mastopexy 1 (2%) Gynecomastia 8 (17%)	Liposuction 39 (81%) Dermal suspension flaps 6 (13%) Periareolar skin resection 2 (4%)	02:12 (02:51–01:32)	0.27 (0.39–0.19)	4.89 (5.48–4.26)*	Yes 45 (94%) No 3 (6%)	Yes 15 (31%) No 32 (67%)	15 (22–13)*	19 (34–2)*	2.3 (2.5–2.0)

Fat transfers and gynecomastia surgeries were done with intercostal blocks and tumescent anaesthesia in the areas of liposuction without local anaesthesia. All removed implants were ruptured silicone implants. Procedure time includes intercostal block and local anaesthesia time

^*Skewed variable

During the entire study period, no patient dropped out, one was excluded because of incomplete questionnaire, and two due to revision. No desaturation (peripheral oxygen saturation < 90%), hypotensive events, conversion to general anaesthesia, or unplanned hospital admission occurred. In one case an IV access was replaced during surgery. There was one uneventful episode of postoperative shivering after a fat graft of the breast. No risk associated with the intercostal bloc was observed in this series. One patient was excluded because of revision surgery on the first postoperative day, due to a hematoma of approximately 80 ml after submuscular breast augmentation.

Patients were drinking, eating, and voiding within a median (IQR) of 0:45 (1:19–0:25) h and were discharged 2:40 (3:43–1:58) hours after surgery (Table 3). Seventeen percent required once an antiemetic medication (dimenhydrinate) and 38% once used a single opioid medication (tilidine/naloxone slow-release tablets) within the first 24 h. Eighty-three percent of the patients were extremely satisfied with the anaesthesia during the surgery (Table 3). No significant correlation was found between the recovery outcomes (measured in terms of time to drink, eat or void, time to discharge, time to get dressed) and procedure duration (minutes). Likewise, no relevant correlation was observed between the type of placement of the breast implant (submuscular versus subglandular) and the reported pain until the discharge.

Table 3.

Outcome parameters and medication in the 24 h following breast surgery

Surgery type	Time required for nerve block and local infiltration (min), median (IQR)	NRS at 0h, median (IQR)	NRS at 2h, median (IQR)	Time to drink (min), median (IQR)	Time to eat (h), median (IQR)	Time to void (h), median (IQR)	Time to discharge (h), median (IQR)	Time to get dressed (h), median (IQR)	Incidence of dimenhydrinate use, number of patients	Incidence tilidine use, number of patients	Satisfaction with anaesthesia during the surgery (0: extremely dissatisfied, 10: very satisfied), median ± (IQR)
Breast augmentation	15 (16–13)*	1 (2–0)*	2 (3–1)*	0:27 (0:45–0:12)*	1:15 (1:55–0:50)*	1:14 (1:41–0:40)*	3:20 (4:15–2:27)	1:55 (02:41–1:00)	4 (17%)	11 (48%)	10 (10–10)*
Breast reduction and/or mastopexy	22 (26–18)	0 (2–0)	1 (2–0)*	0:34 (0:46–0:15)*	1:03 (1:10–0:34)	0:38 (1:33–0:25)*	2:23 (3:19–1:55)	1:40 (2:01–1:20)	3 (18%)	6 (35%)	10 (10–10)
Gynecomastia	11 (12–10)*	0 (0–0)	0 (0–0)*	0:13 (0:22–0:06)*	1:01 (1:18–0:52)	0:44 (1:01–0:38)*	1:59 (2:19–1:39)*	0:51 (1:28–0:39)*	1 (13%)	1 (13%)	10 (10–9)
Total/Mean	15 (22–13)*	0 (2–0)*	1 (2–0)	0:25 (0:43–0:12)*	1:09 (1:27–0:49)*	0:47 (1:32–0:34)*	2:40 (3:43–1:58)	1:37 (2:13–0:54)*	8 (17%)	18 (38%)	10 (10–10)*

^*Skewed variable

The median intensity of nausea was 0 on a scale from 0 to 10. While in bed or when trying to sleep, patients complained of moderate impairment due to pain (Table 4). Patients slept on average 5 h on the first night after the surgery (Table 5). Patients were very satisfied with the anaesthesia (median: 10; on a scale of 0–10, where 10 means very satisfied) (Table 3). Twenty-nine percent of patients could recall the events related to their surgery. Satisfaction with the anaesthesia did not correlate with amnesia (r_s= 0.198, p = 0.247). 90% of patients did not wish more pain treatment in the first 24 h (Table 6). The median postoperative pain relief was 7 (8–5) on a scale of 0 (no relief) to 10 (complete absence of pain) (Table 6).

Table 4.

Postoperative pain assessed by the international pain outcome questionnaire (IPO) and assessment of adverse effects of anaesthesia

Category		Item	Scale	Median (IQR)
Intensity and frequency of pain	2.1.	The worst pain	(0: no pain, 10: worst possible pain)	6 (8–4)
	2.2.	The least pain	(0: no pain, 10: worst possible pain)	2 (4–1)*
	2.3.	Percentage of time with severe pain	(0%: never severe pain, 100%: constant severe pain)	30% (50–20%)
Activities hindered by pain	2.4.	Movements in bed	(0: no impairment, 10: full impairment)	5 (8–3)
	2.5.	Taking a deep breath or coughing	(0: no impairment, 10: full impairment)	1 (5–0)*
	2.6.	Sleeping	(0: no impairment, 10: full impairment)	4 (8–2)
	2.7.	Activities outside of the bed	(0: no impairment, 10: full impairment)	3 (5–2)
Intensity of	2.8.	Nausea	(0: not at all, 10: severely)	0 (1–0)*
	2.9.	Dyspnea	(0: not at all, 10: severely)	0 (1–0)*

^*Skewed variable

Table 5.

Quality of sleep on the day of the surgery

	Item	Unit	Median (IQR)
2.10.	When did you go to bed on the day of the operation?	(h:min)	22:00 (23:00–21:00)
2.11.	How long did it take you to fall asleep on the day of the operation?	(min)	23 (60–5)*
2.12.	At what time did you get up in the morning after the surgery?	(h:min)	6:30 (7:00–6:00)
2.13.	How many hours did you sleep the night of the surgery?	(h:min)	5:00 (7:00–3:00)
2.14.	How many hours did you spend sitting?	(h:min)	2:00 (3:45–1:00)*
2.15.	How many hours did you spend standing or walking?	(h:min)	1:00 (2:00–1:00)*

^*Skewed variable

Table 6.

Satisfaction with postoperative pain assessed by the International Pain Outcome Questionnaire (IPO)

	Item	Scale	Median (IQR)
2.17	Since your surgery, how much pain relief have you received?	(0: no relief, 10: complete absence of pain)	7 (8–5)
2.18	Would you have liked MORE pain treatment than you received?	(yes/no)	No: 43 (90%)*
2.19	Please mark the number that best shows how satisfied you are with the results of your pain treatment since your surgery	(0: extremely dissatisfied, 10: very satisfied)	9 (10–6)*
2.26	Do you remember anything between going to sleep and waking up?	(yes/no)	No: 34 (71%)*
2.27	Did you dream during your procedure?	(yes/no)	No: 35 (73%)*
2.28	Please mark the number that best shows how satisfied you are with the anaesthesia:	(0: extremely dissatisfied, 10: very satisfied)	10 (10–10)*

^*Skewed variable

Discussion

To the best of our knowledge, this is the first prospective study investigating the safety and the speed of recovery after aesthetic breast surgery with sedation, intercostal block, and local anaesthesia and one of the largest prospective studies on sedation in breast surgery (Table 7). Comparability with previous studies on sedation for breast surgery is limited because of different study designs, different procedures, the use of different sedatives, different total doses and different potencies of analgesics, different nerve block techniques, different anaesthetic agent, and different outcome parameters. The included sample size compares well with previous prospective studies (Table 7).

Table 7.

Comparison of studies on sedation in breast surgery (h: hours)

Reference	Study	Sample size (procedures)	Mean total dose of midazolam iv [range]	Mean total dose of remifentanil (R) or fentanyl (F) [range]	Mean total dose of propofol [range]	Type of nerve block, regional anaesthesia	Type of surgery	Outcome parameters	Results
Santonastaso et al. [56]	Prospective observational case series	50	Not used	Not used	Dose not mentioned	Thoracic paravertebral block with ropivacaine 0.7%	Unilateral quadrantectomy, with or without axillary dissection	Pain on a numeric rating scale (NRS)	NRS 0–3: 90%
								Intra- and postoperative opioid consumption	0%
								Postoperative nausea and vomiting (PONV)	4%
								Rescue analgesia	10%
								Nerve block failure or complications	0%
								Surgeon’s satisfaction (Likert scale)	Indistinguishable from GA: 96%
								Patient’s satisfaction (Likert scale)	Very satisfied: 100%
								Conversion to general anaesthesia	2%
								Onset of chronic pain 6 months after surgery	0%
								Length of hospital stay	Outpatient: 46%
Garreffa et al. [57]	Retrospective chart review	41	Not used	R: 0.1 μg/kg/min	1–3 mg/kg/h	Pectoral nerve blocks with mepivacaine 2%, levobupivacaine 0.5%	Unilateral local Excision or mastectomy for breast cancer	Pain on a numeric rating scale (NRS)	Mean NRS: 3.2 in the recovery room and 2.8 the day after
								Rescue dose of analgesia	20%
								Postoperative nausea and vomiting (PONV)	4%
								Postoperative agitation/confusion	0%
Ceccarino et al. [42]	Retrospective chart review	1541	1 mg before surgery then 0.05 mg/kg	Not used	Not used	Local infiltration of lidocaine 0.1% with 1:100.000 epinephrine 200–600 mL per breast	Breast augmentation Breast reduction mastopexy	Pain on the visual analogue scale (VAS)	Median VAS: 1.8 (IQR: 1–3) after discharge
								Recovery time	150 [120–210] min
								Satisfaction with the anaesthetic technique	Very satisfied: 91.3%
								Conversion to general anaesthesia	0%
Tripathy et al. [58]	Randomized controlled trial	58	Not used	Not used	Not used (Isoflurane inhalation anaesthesia)	Pectoral block over paravertebral block with 0.5% bupivacaine and 2% lidocaine	Unilateral radical mastectomy with axillary resection	Pain on the visual analogue scale (VAS) at rest and with movement above shoulder abduction	Pectoral block VAS at rest at 2 h: 2.2, at 4 h: 2.3
									Paravertebral bloc: VAS at rest at 2 h: 1.2, at 4 h: 1.3
								Post-operative paracetamol consumption in the first 24 h	Pectoral block: 1.2 g; Paravertebral bloc: 1 g
								Postoperative nausea and vomiting (PONV)	Pectoral block: 7%; Paravertebral bloc: 3%
								Surgeon’s satisfaction (Likert scale)	Pectoral block (5/5): 66%; Paravertebral bloc (5/5): 76%
								Patient’s satisfaction (Likert scale)	Pectoral block (5/5): 86%; Paravertebral bloc (5/5): 83%
Pawa et al. [59]	Prospective observational case series	16	1–2.5 mg	F: median 0.8 [IQR 0.0–1.5 (0.0–2.5)] μg/kg	Median: 3.9 [IQR 3.1–5.6 (1.3–15.1)] mg/kg/h	Levobupivacaine 0.5% and lidocaine 2%	Unilateral local excision or mastectomy for breast cancer	Pain on the verbal rating scale (VRS)	VAS at 1 h: 0 [0–1 (0–7)]
								Conversion to general anaesthesia	Conversion to general anaesthesia: 6%
								Surgeon’s satisfaction (Likert scale)	Surgeon’s satisfaction (5/5): 81%
								Length of hospital stay	Outpatient: 75%
Pang et al. [26]	Retrospective chart review	30	0.05 mg/kg	F: 1 μg/kg	4.8–7.2 mg/kg/h	Local infiltration of 214.5 ml (mean) lidocaine 0.2%, epinephrine 1:500.000, 0.084% bicarbonate	Subpectoral breast augmentation via an inframammary incision	Duration to match pre-discharge criteria	Average: 4.7 min ± 3.9
								IV metoclopramide	2.50%
								IV morphine	8%
								postoperative nausea and vomiting	5.70%
Sato et al. [27]	Retrospective chart review	29	Not used	R: 0.005–0.05 μg/kg/min	4.7 ± 1.3 mg/kg/h	Thoracic paravertebral block with ropivacaine 0.5%	Unilateral mastectomy/lumpectomy with sentinel lymph node/ Axillary dissection or simple mastectomy	Pain on the visual analogue scale (VAS) after PACU admission and 24h after surgery	VAS at 0.5h: 4 (0–28); 1h: 5 (0–22); 2h: 2 (0–19); 24h: 1 (0–3)
								Time to drink fluids (min)	Sedation with paravertebral block: 79 ± 34 min
								Time to ambulation (min)	Sedation with paravertebral block: 77 ± 45 min
								Time to voiding (min)	Sedation with paravertebral block: 82 ± 52 min
								Analgesic medication	Sedation with paravertebral block: 21%
								Nausea	Sedation with paravertebral block: 0%
								Antiemetic medication	Sedation with paravertebral block: 0%
								Oxygen supplementation	Sedation with paravertebral block: 0%
Rusciani A, et al. [60]	Retrospective chart review	150	0.05 mg/kg	Not used	Not used	Local infiltration of lidocaine 1% with 1:100.000 epinephrine 400–700 mL per breast	Subglandular breast augmentation	Recovery period until discharge (min)	125 [95 180] min
								Complications	0%
								Conversion to general anaesthesia	0%
Failey et al. [61]	Retrospective chart review	2611	Dose not mentioned	F: Dose not mentioned	Propofol and/or ketamine: Dose not mentioned	Dose not mentioned	Hair transplant Liposuction Blepharoplasty Breast augmentation Facelift Abdominoplasty Rhinoplasty Otoplasty Brachioplasty	Surgical complications	DVT/PE: 0.05%
								Length of hospital stay	Outpatient: 100%
Gart et al. [62]	Retrospective chart review	461	16.6 [7–35]mg	F: 111.5 [50–225] μg	Not used	Local infiltration of lidocaine 0.28%, epinephrine 1:400.000	Breast augmentation Breast augmentation with an additional procedure Implant replacement Implant replacement with an additional procedure	Recovery period until discharge (min)	Breast augmentation: 138 [60–330] min Breast augmentation with an additional procedure: 166 [35–366] min Implant replacement: 149 [21–640] min Implant replacement with an additional procedure: 166 [50–460] min
								Conversion to general anaesthesia	0%
								Surgical complications	Implant infection: 0.9%, hematoma: 0.2%
Colque et al. [63]	Retrospective chart review	132 breast augmentations 39 breast augmentation-mastopexies	5.7 [0.5–11] mg	F: 160.5 [25–300] μg and Ketamine: 19.3 [0–60] mg	Not used	Intercostal and parasternal block with lidocaine 1%, bupivacaine 0.25%	Breast augmentation alone and breast augmentation-mastopexy	Nausea	11.10%
								Length of stay in the recovery room (min)	50.6 min
Eldor et al. [64]	Retrospective chart review	69	5 mg	F: 50 μg	4.5–9 mg/kg/h	Local infiltration of lidocaine 0.44%, marcaine 0.05%, epinephrine 1:180.000	Breast augmentation	Pain on the visual analogue scale (VAS) 2h after surgery	Sedation with local anaesthesia: 3.45 ± 2.57
								Vomiting	Sedation with local anaesthesia: 15.9%
								Recovery period until discharge	Sedation with local anaesthesia: 11.7 ± 6.10h
Rezai et al. [65]	Retrospective chart review	1050	Not used	Dose not mentioned	1.5–6 mg/kg/h	Intercostal and parasternal block with bupivacaine 0.25% and local infiltration of lidocaine 0.18%, epinephrine 1:280,000	Breast augmentation	Postoperative nausea and vomiting (PONV)	0.01%
								Recovery period until discharge	2–3 h
Hasen et al. [2]	Retrospective chart review and questionnaire administered within 24 months of the operation	169	16.1 mg	F: 144 μg	Dose not mentioned	N.M	Facelift Browlift Liposuction Reconstructive breast surgeries	Nausea	Sedation with midazolam/fentanyl: 10.8% Sedation with propofol: 11.8%
								Recall of the operation	Sedation with midazolam/fentanyl: 12.3% Sedation with propofol: 11.4%
Bitar et al. [3]	Retrospective chart review	3625	Dose not mentioned	Ketamine: dose not mentioned	1.5–6 mg/kg/h	Local infiltration of lidocaine 0.25%, epinephrine 1:200.000 Liposuctions Breast augmentations Facelifts Capsulectomies Rhinoplasties Abdominoplasties Mastopexies Scar revisions Skin lesion excisions and others		Postoperative nausea and vomiting (PONV) for more than 24h	0.02%
								Unplanned hospital admission	0.06%
								Conversion to general anaesthesia	0.03%

The administered median dose of alfentanil of 0.27 (0.39–0.19) µg/kg/min compares well with the dose of 0.2–0.4 µg/kg/min previously described for much less invasive breast biopsies [20]. The dose is much lower than 1 µg/kg/min previously administered for lithotripsies [21]. In a retrospective study on various plastic surgery procedures performed under the combination of midazolam and fentanyl, recovery time correlated with the duration of surgery and the total dose of fentanyl [22]. Alfentanil is reported to be 15 times less potent than remifentanil and 2–58 times less potent than fentanil [23]. The low dose and lower potency of alfentanil used in our study may explain why the duration of surgery did not correlate with the recovery time in this study. The sensitivity and specificity of intraoperative slight transient movements as a surrogate of pain are questionable. Attempts to objectively evaluate the intensity of intraoperative pain have shown that there are no good discriminants for distinguishing intraoperative pain in order to titrate opioids [24]. There is strong evidence that opioid-inclusive anaesthesia does not reduce postoperative pain, but is associated with more postoperative nausea and vomiting when compared with opioid-free anaesthesia [25]. Therefore, deeper sedation or additional local anaesthesia may be preferable to higher opioid doses.

The propofol dosage of 4.89 (5.48–4.26) mg/kg/h compares well with previous studies using higher concentrations of ropivacaine or lidocaine for breast augmentation under sedation [26, 27]. Sedation provides general patient comfort and some amnesia for both the block procedure and the surgical procedure [28]. Propofol is the nearest to an ideal agent for sedation during regional anaesthesia, because of its favourable pharmacokinetic profile, with rapid onset and offset and the sedative of choice in regional anaesthesia (see Table 8). Higher infusion rates of propofol produce significant amnesia, opioid-sparing effects, and less postoperative nausea [20]. The sedative and amnesic effects of propofol obviate the use of benzodiazepines, associated with nausea and prolonged recovery [22]. Furthermore, benzodiazepines increase the threshold for seizure, which may result in skipping signs of CNS toxicity of local anaesthetics [29], usually evident before signs of cardiovascular toxicity [30].

Table 8.

Risk and benefits of sedation versus general anaesthesia

	Sedation with nerve block and/or local anaesthesia	General anaesthesia
Pain	Reduced pain scores associated with nerve blocks [38]	Higher postoperative pain scores
Opioid medication	Reduced opioid consumption (Table 7)	Higher request for opioids
Risk of nausea and vomiting	0–16% (Table 7)	45% [66, 67]
Recovery	Faster recovery, early ambulation, ambulatory surgery, ambulatory surgery, and lesser unintended admissions (Table 7)	Slower recovery
Minor movements during surgery	Yes	No
Total procedural times	Time savings: no induction and awakening times [62, 68] Time for intercostal block and local anaesthesia: 15 min	Unclear
Procedural learning curve	Technical ease for plastic surgeons with a steep learning curve	None
Transmission of infectious diseases to healthcare workers	Lower risk of COVID-19 transmission	Higher risk of COVID-19 transmission [5]
Carbon footprint	20% smaller [39]	Greater carbon footprint
Operating room noise	Less noise [69]	More noise
Costs	Fewer costs	Higher costs
Hematoma	Lower risk of hematoma [4, 70–72]	Higher risk of hematoma associated with hypertension during emergence from anaesthesia
Thrombosis	Lower risk of thrombosis [73]	Higher risk [74] of thrombosis associated with relaxation of the calf muscle pump [75]
Infections	Nerve blocks reduce the endocrine catabolic response which may have clinical implications regarding the immune response and the risk of infections [37]	Unclear
Specific risks	Risk of mild toxicity in tumescent Lidocaine anaesthesia: 0.05% [12] Risk of local anaesthetic systemic toxicity for peripheral nerve blocks: 0.08 to 0.004% [34] Pneumothorax: 0.09–0.42% [76, 77]	Airway Complications (dysphagia (43%), pain (38%), coughing (32%), sore throat (27%), hoarseness (27%), laryngospasms, aspiration, damage to the mouth or teeth [78, 79] Urinary retention: 1.4% [80] Hypertension or tachycardia during emergence from anaesthesia: not known Malignant hyperthermia: 1:10,000–1:150,000 [81] Opioid-induced chest wall rigidity (Wooden chest syndrome) [82] Higher risk of postoperative shivering [83]

Nerve blocks with ropivacaine and dexamethasone were administered because of their median duration of 22 h (IQR 18–26) [31], and because dexamethasone reduces rebound pain after nerve blocks [32]. Outpatient patients must be informed of the risks of hematoma and lidocaine intoxication, that may occur in the first 24 h after surgery. Serum lidocaine concentrations peeks at 12 h [12]. Onset of symptoms related to local anaesthetic systemic toxicity (LAST) occurring hours or days after the starting the infiltration have been described [33]. However, the risk of mild toxicity in tumescent lidocaine anaesthesia with liposuction at a dosage of 45 mg/kg has an estimated at 0.05% [12]. The risk of local anaesthetic systemic toxicity for peripheral nerve blocks has been estimated to average 0.08–0.004% [34]. Local anaesthetic systemic toxicity (LAST) predominantly affects patients with underlying cardiac, neurologic, pulmonary, renal, hepatic, or metabolic disease. Considering the ubiquitous use of local anaesthetics in medicine, the 93 cases events of local anaesthetic systemic toxicity (LAST) found in a systematic literature research covering a publication period of 30 years (1979–2009) suggest that the incidence does not justify inpatient monitoring, especially in young and healthy patients. A routine follow-up call by the surgeon 12 h after the surgery and being on call during the first 24 h was deemed adequate to manage the risk of local anaesthetic systemic toxicity (LAST). Although epinephrine does not extend the duration of the block [35], the potential benefit of vasoconstriction slowing resorption rate and decreasing potential toxicity outweighs the risk of exceeding maximum epinephrine doses of 0.13 mg/kg [36]. Nerve blocks reduce the endocrine catabolic response which may have clinical implications regarding the immune response and the risk of infections [37]. Intercostal nerve blocks are as effective as epidural analgesia for thoracic surgery, and they are associated with a decreased complication rate [38]. In our experience the ribs are usually easy to palpate in patients who undergo aesthetic breast surgery, obviating the need for ultrasound. Ultrasound-guided nerve blocks before sedation may inflict additional unnecessary pain, while sterile ultrasound-guided nerve blocks at the operating table add extra time, costs, and waste. The duration of the herein presented anaesthetic procedures compare well with spinal anaesthesia, for example, estimated to take 30–40 min [39]. Anatomical studies have confirmed that blockage of all levels 2–5 partially affected sensation in the nipple-areola complex, suggesting innervation by a nerve plexus consisting of both anterior cutaneous branches and lateral cutaneous branches [40]. The added value of parasternal blocks when using intercostal blocks remains unclear. Tumescence in outpatient breast surgery has been described as safe and effective for pain reduction, thereby facilitating mobilization and reducing the need for oral narcotics [41]. Notwithstanding the type of anaesthesia, the use of epinephrine tumescent solution reduces blood loss, high drainage fluid volumes, bruising, and, most importantly, facilitates visualization [42]. The use of epinephrine tumescent solution may, therefore, contribute to a quick recovery. However, relying solely on tumescence for anaesthesia may require the infiltration of large volumes, impairing the evaluation of skin elasticity in augmentation-mastopexy procedures. Although the incidence of postoperative hematoma of 2.5 percent does not fall outside the normal range, we agree with others that overly aggressive anticoagulation solely based on the Caprini Score needs to be reevaluated [43].

Our study included perioperative strategies used in ERAS protocols to enhance recovery. One gram of acetaminophen before surgery was recommended to further contribute to pain relief [44]. Glucocorticoids were administered since they reduce pain, nausea, and vomiting [45]. By reducing bruising and edema, tranexamic acid may shorten recovery time [46]. Stress-reducing strategies, such as music-induced distraction [47] and shielding the patient from excessive noise were also used. Evidence has been presented that bipolar cautery causes less thermal damage and less postoperative pain compared with monopolar electrocautery [48–50]. Since breast surgery is often combined with liposuction or fat transfer, the use of bipolar cautery also avoids the potential risks of burns associated with wet electrodes. A previous study has described that one out of 10 patients used oral tramadol following the ERAS protocol versus 12 out of 12 during “traditional” postoperative recovery after cosmetic operations performed under general anaesthesia [51]. However, since the study included breast, trunk, and facial surgeries, the comparability remains limited. Tilidine/naloxone 50/4 mg slow-release tablets have the same potency as tramadol but a lower incidence of abuse or dependency [52]. However, our results compare well with the average tramadol consumption of 70.8 ± 15.3 mg in the first 24 h after breast augmentation in 6 patients with postoperative ultrasound-guided erector spinae plane block [53].

This study must acknowledge several limitations. The affective component of pain in humans also makes the simple comparison of pain intensity in different patients liable to error. Pain from areas of liposuction may have biased pain assessment after intercostal block. Pain intensity was only evaluated on the first postoperative days, and not at any other time points. However, because of the median block duration of ropivacaine and dexamethasone of 22 h, we expect the benefits to be most noticeable in the first 24 h [31]. Furthermore, if a patient is going to suffer a narcotic-related event, that event is most likely to occur on the first postoperative day [54]. The focus is always to make the surgery a comfortable experience for the patient with minimal perioperative stress and without rushing the discharge process. In some cases, the patient’s organization of transport arrangements may have delayed the time until discharge. However, differences of 30–60 min until discharge are of limited clinical relevance. Possible confounders for the reported sleep impairment are drains or the supine sleeping position recommended after breast surgery in patients accustomed to the prone sleeping position. The results of a single-institution study may not be applicable to other institutions. Besides, the results of this study may not be applicable to other surgical procedures. The study was not controlled and is underpowered to investigate rare risks, such as DVT, pneumothorax, or toxicity of local anaesthetics. However, a prospective controlled study is not feasible considering the low incidence of this complication and ethically controversial considering the profound empirical treatment difference [43] (Table 8).

The anaesthetic technique contributes not only to patient safety but also to the overall satisfaction of cosmetic procedures. It is imperative that not only the anaesthesiologist but also the surgeon understand the benefits and risks of the various anaesthetic options for cosmetic surgery [7]. The choice of anaesthetic technique for cosmetic surgery varies based on the discretion of the anaesthesiologist, the surgeon, and the patient. The results presented as well as previous studies provide no evidence that breast surgery requires general anaesthesia, i.e., mechanical ventilation. Ultimately it is the plastic surgeon who will be confronted with the patient’s complaints of pain or nausea. In accordance with previous studies, we found that patients not undergoing general anaesthesia most often expect and subjectively experience total unconsciousness [55]. Patients’ overall satisfaction with sedation, intercostal block, and tumescent anaesthesia was high, independently of the presence of recall of intraoperative events. However, sedation and ambulatory surgery are not advised for (a) patients with surgical risk factors, (b) patients who do not live within 1 h from the clinic, (c) emotionally distressed patients, (d) pain catastrophizing patients, (e) patients with low compliance with surgical treatments, and (f) patients with little motivation in being an active participant in their own rapid recovery process. Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. For compliant healthy young patients, the benefits of sedation with a nerve block and/or local anaesthesia for breast surgery largely outweigh the potential risks (Table 8). The results of this study will help the anaesthesiologist discuss the most appropriate type of anaesthesia for patients undergoing aesthetic breast surgery and may help patients have a more realistic expectations about the anaesthesia and the recovery.

Conclusion

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia is associated with minimal intra- and postoperative opioid consumption, fast recovery and a high patient satisfaction.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

No additional external funding was received for this study.

Declarations

Conflict of interest

The authors declare no conflicts of interest concerning the research, authorship, and/or publication of this article.

Ethical Approval

The study was approved by the local Ethics Committee (Project No. 144/21).

Informed Consent

Informed consent was obtained from all participants.