Paravertebral blockade for day-case breast augmentation: a randomized clinical trial

Bilateral breast augmentation is an increasingly popular day-case procedure. Local infiltration with sedation is routinely used for its ease of application compared with the more complex and potentially riskier paravertebral blockade (PVB). We hypothesized that ropivacaine injected by experienced anesthesia providers into the paravertebral space as a PVB was more effective than ropivacaine injected by the operating surgeon (plastic surgeon) directly into the zone of surgical dissection.

Forty female patients who were ASA physical status I or II and undergoing bilateral subpectoral cosmetic breast augmentation were recruited for participation in a prospective, randomized, single-blind study. Patients were randomized to 1 of 2 groups: ropivacaine via PVB, or surgical infiltration of ropivacaine. In both groups, the surgeon was asked to infiltrate the appropriate area with either saline (PVB group) or ropivacaine (local infiltration group). Both groups were sedated with propofol, titrated to effect. The plastic surgeon was blinded to the solution injected. Data collected included demographic characteristics, intraoperative cooperation scores, recovery room postoperative nausea and vomiting, analgesia use, and visual analog scale pain scores. All patients were asked to complete a preoperative anxiety and quality of recovery questionnaire and to record their pain scores and analgesia requirements on discharge. The outcome measures were (i) intraoperative patient cooperation as assessed by the plastic surgeon, (ii) propofol requirement, (iii) postoperative pain, and (iv) quality of recovery.

Forty patients completed the study. PVB improved intraoperative cooperation (significance of difference P < 0.001, WMWodds = 6.69 with 95% 1-sided confidence interval CI ≥2.85), reduced propofol requirement (significance of difference P = 0.005, WMWodds = 0.35, CI <0.69), and decreased average postoperative pain in the home environment (significance of difference P = 0.007, WMWodds = 0.38, CI <0.73). There were no PVB complications. Only patients from the surgical infiltration group required rescue analgesics (30%, significance of difference = 0.01).

In a limited number of patients, we found that PVB is superior to direct surgical infiltration of ropivacaine for bilateral breast augmentation in same-day surgery. These advantages need to be balanced against the potential risks of PVB, especially in an office setting.