Autologous breast reconstruction using the latissimus dorsi flap remains a widely used and effective technique, particularly for patients who have undergone radiation therapy. This technique offers natural tissue reconstruction with good aesthetic and functional outcomes. However, it requires significant tissue dissection in the back and chest, making it one of the more painful reconstructive procedures. Managing postoperative pain effectively in these patients is critical—not only for patient comfort but also to reduce opioid use, accelerate recovery, and shorten hospital stays.

Historically, pain management in latissimus flap reconstruction has relied on systemic opioids and surgeon-administered local infiltration analgesia. However, these approaches often fall short, leading to inadequate pain control, delayed mobilization, and prolonged hospitalization. As enhanced recovery after surgery (ERAS) protocols continue to evolve, there is increasing interest in integrating regional anesthesia into breast reconstruction pathways. In particular, the use of ultrasound-guided paravertebral block (PVB) and erector spinae plane (ESP) block has gained attention for their potential to provide more effective, targeted analgesia with fewer systemic side effects.

While these techniques have shown promise in implant-based procedures and thoracic surgeries, their impact in the setting of autologous breast reconstruction has remained underexplored. The present study aimed to bridge this gap by examining how PVB and ESP blocks compare to traditional local infiltration analgesia in patients undergoing mastectomy with latissimus dorsi flap reconstruction.

Study objective and methods

This retrospective cohort study evaluated the impact of PVB and ESP blocks compared to local infiltration analgesia on postoperative outcomes in women undergoing mastectomy with latissimus dorsi flap reconstruction.

Participants:

122 patients who underwent surgery from January 2018 to February 2022 were included. Patients were grouped as follows:

• No block (local infiltration): n = 72
• Paravertebral block (PVB): n = 26
• Erector spinae plane block (ESP): n = 24

Patients receiving other block types (e.g., serratus, pectoral, or epidural) or combinations of blocks and local infiltration were excluded.

Techniques:

• PVB: Performed preoperatively at T4, T7, and T10 using a high-frequency linear ultrasound transducer, with 10 mL of bupivacaine or ropivacaine injected per level.
• ESP: Similar level injections deep to the erector spinae muscle and above the transverse process.
• Both blocks included adjuvants (dexamethasone and clonidine) to prolong the analgesic effect.

Outcomes:

• Primary: Postoperative length of stay (LOS) from PACU entry to discharge.
• Secondary: Postoperative pain scores, intra- and postoperative opioid use (measured in morphine milligram equivalents, MMEs), time to first analgesic, and need for postoperative antiemetics.

Key findings

• Length of stay (LOS): Patients who received either a PVB or ESP block had a significantly shorter hospital stay, with a median LOS of 26 hours in both groups compared to 48 hours in the local infiltration group. After adjusting for confounding factors, PVB was associated with a 20-hour reduction in LOS (95% CI 11–30; p < 0.001), while ESP reduced LOS by 24 hours (95% CI 15–34; p < 0.001).
• Intraoperative opioid use: Both regional blocks led to a similar and significant reduction in intraoperative opioid requirements. Patients in the PVB and ESP groups received 23 mg less MME on average compared to those who had only local infiltration (p < 0.001).
• Postoperative opioid use and pain: Although differences were not statistically significant, clinically relevant trends were observed. In the ESP group, only 12% of patients required high-dose opioids postoperatively (> 40 MMEs), compared to 31% in the local infiltration group. Additionally, patients who received a PVB had a 30% lower likelihood of experiencing severe pain (NRS scores of 9–10).
• Antiemetic use and safety: Rates of postoperative nausea and vomiting were similar across all groups, and no block-related complications were reported, confirming the safety of both techniques.

Conclusion

Replacing local infiltration with PVB or ESP blocks significantly reduced hospital stay and intraoperative opioid use in patients undergoing autologous breast reconstruction. While both techniques were similarly effective in reducing LOS, ESP blocks offer a technically simpler and potentially safer alternative to PVB, particularly in settings prioritizing outpatient surgical recovery.

These findings support the integration of regional anesthesia into multimodal analgesic protocols for breast reconstruction and suggest that ESP blocks may be suitable replacements for PVB in appropriate clinical scenarios.

Future research

Future research should focus on conducting randomized controlled trials to directly compare ESP and PVB in autologous breast reconstruction, allowing for stronger evidence of comparative efficacy. Additionally, studies assessing patient-reported outcomes—such as satisfaction, return to daily activities, and the incidence of chronic pain—would offer a more comprehensive view of long-term benefits. Evaluating the cost-effectiveness of ESP, PVB, and local infiltration, particularly in the context of ambulatory surgery, could inform clinical decision-making and resource allocation. Finally, further investigation into single-injection versus catheter-based ESP techniques is warranted, especially for patients with higher pain sensitivity or those undergoing bilateral procedures, to determine the optimal approach for sustained analgesia.

For more detailed information, refer to the full article in RAPM.

Ayyala HS et al. Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction. Reg Anesth Pain Med. 2025;50:339-344.

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