Effect of Operative Plane on Anesthetic Requirements in Tissue Expander Breast Reconstruction Patients

Initially subpectoral, the plane of choice for tissue expander placement in breast reconstruction has evolved over the past decade, with more surgeons moving to prepectoral placement. In making this transition, our institution noted a subjective decrease in the anesthetic requirements of patients undergoing the second stage of their prepectoral reconstruction. Despite this, there is little published literature on the topic. Therefore, our study aims to examine the differences in anesthetic requirements among patients with subpectoral versus prepectoral expanders at the time of exchange to permanent implants.

We conducted a single-surgeon retrospective chart review of all patients undergoing breast reconstruction with tissue expanders from 2017 to 2024. We compared patients with prepectoral tissue expanders to those with subpectoral tissue expanders. Variables collected included perioperative pain medications, sedatives, muscle relaxers, antiemetics, reversal agents, and local anesthetics. Additional data were collected on steroids, diabetes, and hypertension medications and antibiotics used.

A total of 251 patients met the criteria for evaluation, 71 subpectoral and 180 prepectoral. We found that subpectoral patients averaged a statistically significantly higher requirement of fentanyl and hydromorphone in the perioperative period. This group also had a significantly higher requirement of reversal agent and supplementary antiemetic medications. Other medications including those to manage infection, blood pressure, secretions, deep sedation, and awakening did not vary between groups.

We found that patients with prepectoral tissue expanders undergoing exchange to permanent implants have decreased perioperative requirements of pain and antiemetic medications. Although the operative plane of choice in breast reconstruction is a multifaceted decision, we demonstrate that the prepectoral plane results in decreased pain medication burden in the perioperative period. Our study is the first to quantify these differences, allowing evidence-based decisions for patients and physicians.