Aesth Plast Surg

https://doi.org/10.1007/s00266-023-03831-z

ORIGINAL ARTICLES BREAST SURGERY

Pain Levels Following Cosmetic Breast Surgery and An Easy-To-

Use Pain Treatment Algorithm for Plastic Surgeons
Nuray Camgoz Eryilmaz1 • Tolga Eryilmaz2

Received: 14 September 2023 / Accepted: 19 December 2023

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2024

Abstract prevention is crucial following aesthetic breast surgeries. It

Introduction The purpose of this study was to examine the not only helps to reduce hospital stays but also aids in
degrees of pain experienced following various breast cos- patient recovery, facilitates a quicker return to daily
metic surgery procedures and to evaluate the existing pain activities, and enhances patient satisfaction. To achieve this
treatment methods. objective, it is advantageous to utilize a practical pain
Materials and Methods Patients who underwent subpec- treatment algorithm that is readily applicable.
toral breast augmentation, mastopexy, or breast reduction Level of Evidence III This journal requires that authors
between 2017 and 2022 were evaluated retrospectively. A assign a level of evidence to each article. For a full
total of 90 patients were randomly selected, with 30 description of these Evidence-Based Medicine ratings,
patients in each group. The visual analog scale (VAS) was please refer to the Table of Contents or the online
used to assess pain levels. The data were analyzed using Instructions to Authors www.springer.com/00266.
the statistical program SPSS 22.0 (IBM Corp., Armonk,
NY, USA). Keywords Breast surgery
Pain levels
Patient
Results The subpectoral breast augmentation group satisfaction
VAS
exhibited the highest recovery VAS score. Postoperative 1,
2, 4, 6, 12, and 24-h VAS values were higher in the breast
augmentation group than in the breast reduction and mas- Introduction
topexy groups. No statistically significant difference
observed between mastopexy and breast reduction in terms The three primary surgical procedures conducted for aes-
of VAS scores during the evaluation periods. Statistically thetic purposes on the breast include breast augmentation,
significant higher VAS scores were observed for subpec- mastopexy (commonly known as a breast lift), and breast
toral breast augmentation at all times compared to the reduction. The demand for cosmetic breast surgery remains
preoperative period. consistent and steadily growing. The rising number of
Conclusions Subpectoral breast augmentation is associated breast augmentation procedures necessitates a constant
with higher levels of postoperative pain compared to breast assessment of postoperative outcomes and complications.
reduction and mastopexy. Effective postoperative pain Pain is a critical determinant of patient satisfaction
following surgical procedures. Patients who have under-
gone aesthetic breast surgery frequently exhibit discomfort
& Tolga Eryilmaz about pain. It is well established that injuries to soft tissues,
[email protected] ischemia, and inflammation are the three primary causes of
1 pain following breast surgery [1]. Studies indicate that the
Department of Anesthesia and Reanimation, Gazi University
School of Medicine, Ankara, Turkey incidence of postoperative pain following non-cancerous
2 breast surgery ranges from 21 to 50% [2]. Postoperative
Dr. Tolga Eryilmaz Plastic Surgery Clinic, Neorama Is
Merkezi, Yasam Caddesi, 4th Floor, No:13, Bestepe, Ankara, pain lengthens hospital stays, increases the need for anal-
Turkey gesics, and increases hospital expenses. Moreover,

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inadequate postoperative pain management poses a poten- Data Collection and Postoperative Analgesia
tial for the development of chronic pain [3]. Postoperative Administration
chronic pain, defined as pain lasting at least three months,
has been reported in numerous breast surgical procedures, The pain levels were evaluated using the visual analog
such as breast augmentation, reduction mammoplasty, scale (VAS) (0 = no pain, 10 = worst possible pain).
mastectomy, and reconstructive mastectomy [2]. Blinded third-party personnel recorded VAS scores at
The purpose of this study was to examine patient pain various time points: preoperative intravenous access, in the
levels following various surgical procedures performed on postoperative recovery unit (PACU), and at 1, 2, 4, 6, 12,
the breast for aesthetic reasons and to assess the current 18, and 24 h after surgery. All patients were given 1 g of
approaches being employed to maintain patient pain levels intravenous paracetamol for analgesia in the PACU.
as low as possible. Patients with a VAS score of 3 or higher following surgery
were given additional analgesia. Analgesia was not
administered if VAS B 2 or if the patient refused pain
Materials and Methods medication. In the first 24 h following surgery, patients
with a VAS score of 3–5 were given dexketoprofen 50 mg
A retrospective evaluation was conducted on patients who IM as rescue analgesia. Ketorolac infusion was delivered
underwent subpectoral breast augmentation, mastopexy, or via intravenous patient-controlled analgesia (PCA) in
breast reduction surgeries performed by the same surgeon patients with VAS [ 5.
from 2017 to 2022. The study employed specific exclusion
criteria, which encompassed individuals who fell into the Statistical Analysis
following categories: heavy smokers, individuals who did
not cease smoking for one month before and after the A power analysis was conducted on a study that included a
surgery, those who habitually used painkillers, individuals total of 90 patients, with 30 patients in each of the three
who experienced prolonged pain following prior surgeries, groups. The analysis revealed that the study had a power of
individuals with rheumatological or systemic diseases, 84.6%, using an alpha value of 0.05 and a confidence
individuals diagnosed with breast cancer, individuals who interval of 95%. The study data were analyzed using the
encountered post-surgical complications, individuals with a Statistical Package for the Social Sciences (SPSS) 22.0
history of previous breast surgery, individuals who under- (IBM Corp., Armonk, NY, USA) statistical program, and
went revision surgeries, and individuals who underwent p \ 0.05 was considered statistically significant. The data
combined procedures involving non-breast surgeries per- are displayed in the form of mean ± standard deviation
formed concurrently. (SD), minimum, maximum, n, and percentage (%). Fol-
After the patients who met the criteria for inclusion in lowing descriptive statistics, the Kolmogorov–Smirnov test
the study were categorized based on whether they under- was used to determine whether a normal distribution was
went subpectoral breast augmentation, mastopexy, or present. Since p [ 0.05, it was determined that the data
breast reduction, a total of 30 patients were randomly distributions for all three categories were not significantly
chosen for each group. The groups created were as follows: different from the normal distribution. Normally dis-
Group 1 for subpectoral plane breast augmentation, Group tributed data were represented as mean ± standard devia-
2 for mastopexy, and Group 3 for breast reduction. tion, while other data were expressed as the median
In Group 1, all patients underwent primary breast aug- (25–75%). To determine whether the difference between
mentation in the subpectoral plane. Round breast implants the groups was statistically significant, an analysis of
were used in all cases. The average volume of breast variance (ANOVA) was utilized. The homogeneity of the
implants was 382.83 (210–560) ml. In Group 2, patients variances was determined based on the Levene test results.
underwent a superior pedicled short-T scar mastopexy Tukey’s test, one of the post hoc tests, was used to deter-
procedure. Patients in Group 3 underwent a superomedial mine which groups were responsible for the difference. A
pedicled breast reduction procedure. In each group, a total general linear model repeated measures analysis was uti-
of 20 ml of 2% lidocaine with 1:100,000 epinephrine were lized to analyze repeated data (VAS values) within the
infiltrated prior to the incision into the pectoral plane in same group. The Wilks’ Lambda test yielded statistically
order to provide preemptive analgesia, and 20 ml of 0.5% significant results. The paired samples t-test was used to
bupivacaine was infiltrated into the same area before the determine which time intervals were responsible for the
closure in order to provide postoperative analgesia. significant difference.

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Results Discussion

The patients in the subpectoral breast augmentation group Constant evaluation of postoperative results and compli-
had a lower mean age than those in the breast reduction and cations is necessary due to the rising number of aesthetic
mastopexy groups, and this difference was statistically breast surgeries. Pain is one of the most crucial factors
significant (p \ 0.05). A statistically significant difference influencing patient satisfaction following surgery. Patients
in operation time was observed among all three groups (p\ often express their discomfort regarding pain following
0.05). Breast augmentation was the shortest procedure, aesthetic breast surgeries. Inadequate perioperative pain
while breast reduction was the longest (Table 1). management has negative effects, including prolonged
In terms of preoperative VAS values, there was no recovery time, delayed return to normal daily activities,
difference between the three groups. The most sobering and decrease in patient satisfaction [4].
VAS score was found in the breast augmentation group. Postoperative pain following breast prosthesis insertion
The statistical significance between sobriety VAS scores is primarily attributed to surgical dissection, muscle dam-
was due to the difference between breast augmentation and age, and enlargement of breast tissues. During subpectoral
mastopexy (p = 0.04). The breast augmentation group had breast augmentation, the surgical procedure involves the
higher VAS values at 1, 2, 4, 6, 12, and 24 hours postop- separation of the pectoralis major muscle and its attach-
eratively than the breast reduction and mastopexy groups ments to the ribs in order to create space for the implant.
(p \ 0.001). There was no statistically significant differ- Therefore, the primary source of pain after subpectoral
ence observed between mastopexy and breast reduction breast augmentation is myofascial pain, which is trans-
surgeries in terms of VAS scores during the evaluation mitted by the pectoral nerves [5].
periods. A statistically significant difference was observed Studies indicate that the sensation of pain is initiated by
in the VAS values at 1, 2, 4, 6, 12, 18, and 24 h after the process of neuronal sensitization within the pain path-
awakening when comparing the Group 1 VAS scores with way. This sensitization can be central or peripheral [6].
the preoperative period VAS scores (p \ 0.05). The VAS During surgical tissue damage, cytokines and pros-
values were consistently higher at all times compared to the taglandins are produced. This increases inflammation and,
preoperative period. A statistically significant difference consequently, the excitability of central neurons in the
was observed in the recovery, 1st hour, and 24th hour VAS spinal cord that transmit pain signals [7]. Extreme stimu-
values when comparing Group 2 VAS scores with preop- lation of peripheral afferent fibers occurs during surgery.
erative period VAS scores (p \ 0.05). Compared to the This stimulation is diminished but not prevented by general
preoperative period, recovery and 1st hour VAS values anesthesia [8]. Conventional analgesic protocols typically
were greater, while 24th hour values were determined to be involve the administration of intravenous and oral nar-
lower. When the VAS scores of Group 3 were compared to cotics. However, relying solely on systemic opioids is
the VAS scores of the preoperative period, there was a inadequate for effectively inhibiting nociceptive neurons
statistically significant difference between the recovery, and preventing central sensitization [9]. The excessive use
18th, and 24th hour VAS values (p \0.05). While sobering of opioids carries various risks, including nausea and
VAS values were greater than those of the preoperative vomiting, disorientation, respiratory depression, urinary
period, 18th, and 24th hour values were lower. Table 2 retention, ileus, constipation, sleep disturbance, altered
contains the statistical findings. mental status, tolerance development, and the potential for

Table 1. Demographic data of

Group Mean SD Minimum Maximum P*
patients
Age (years) 1 31.46 6.36 22 43 \ 0.001
2 36.8** 4.83 27 46
3 38.93** 9.24 21 56
Duration of operation 1 62 5.95 50 70 \ 0.001
(min.) 2 135.66 19.72 110 210
3 157.33 20.11 120 210
SD standard deviation
*p \ 0.05: Significance level with ANOVA test
**p \ 0.05: Compared with Group 1

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Table 2. Comparison of the

Evaluation period Group Mean SD Minimum Maximum P*
groups according to pain levels
(VAS scores) Preoperative 1 3.30 2.50 1 10
2 2.43 1.86 1 10
3 3.03 2.4 1 8
Recovery room 1 6.60a 3.05 1 10 0.04
2 4.53**a 3.22 1 10
3 5.13a 3.26 1 10
Postoperative 1st hour 1 6.86a 2.59 1 10 \ 0.001
2 3.76**a 2.82 0 9
3 4.20** 3.28 0 10
Postoperative 2nd hour 1 6.40a 2.52 1 10 \ 0.001
2 3.03** 2.25 0 8
3 3.23** 2.59 0 9
Postoperative 4th hour 1 5.96a 2.49 0 10 \ 0.001
2 3.30** 2.70 0 9
3 3.23** 2.59 0 9
Postoperative 6th hour 1 5.36a 2.31 0 10 \ 0.001
2 2.36** 1.75 0 6
3 2.46** 1.99 0 7
Postoperative 12th hour 1 5.03a 2.20 0 8 \ 0.001
2 2.03** 1.49 0 6
3 2.46** 1.81 0 6
a
Postoperative 18th hour 1 4.66 1.86 1 8 \ 0.001
2 1.90** 1.56 0 6
3 2.13**a 1.71 0 6
Postoperative 24th hour 1 4.50a 1.79 1 8 \ 0.001
2 1.53**a 1.45 0 5
3 1.80**a 1.58 0 6
VAS visual analog scale, SD standard deviation
*p \ 0.05: Significance level with ANOVA test, ** p \ 0.05: Compared with Group 1
a
p \ 0.05: Compared with preoperative value

abuse. Due to the aforementioned factors, it is recom- provide the most effective pain relief possible. Different
mended that other analgesic applications, such as nons- pathways can be targeted using drugs with distinct mech-
teroidal anti-inflammatory drugs (NSAIDs), and local anisms of action. This method of postoperative pain man-
anesthetics be used rather than opioids in order to limit the agement is preferred over singular approaches [10].
amount of opioid consumption [10]. Nonsteroidal anti-in- A suitable method for reducing post-injury pain is to
flammatory drugs possess the capacity to exert their effects avoid peripheral and central tenderness. Preemptive anal-
both centrally and peripherally. The local inflammatory gesia is the administration of analgesia prior to painful
response that arises as a consequence of damage is stimuli in order to reduce the intensity of pain [12]. On the
diminished, leading to a reduction in peripheral sensitiza- basis of this principle, it is indicated to administer a local
tion. Consequently, this reduction in peripheral sensitiza- anesthetic prior to the incision for optimal pain prevention;
tion results in a decrease in the processing of spinal however, the efficacy of lidocaine in infiltration solution on
nociception [9]. By decreasing peripheral and central sen- postoperative pain is controversial. Although there have
sitivity, it effectively decreases postoperative pain and the been reports stating that the addition of lidocaine solution
overall amount of opioids needed [11]. Multimodal anal- to the infiltration solution significantly reduces pain for up
gesia has become standard clinical practice in recent years to 18 hours after surgery, there have also been reports
in order to avoid peripheral and central stimulation and to suggesting that it does not have a significant effect on
manage postoperative pain. This approach involves the use postoperative pain [13–15]. Our study found that the use of
of various combinations of analgesic drugs in order to local anesthetic infiltration immediately before the incision

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and during the closure of the incisions did not effectively comparable to morphine [18]. Ketorolac administered
provide preemptive analgesia. This was evident from the intravenously after surgery has been shown to be less
high VAS scores observed in the first few hours after the effective than ketorolac administered intraoperatively
surgery. Hence, it is crucial to administer an effective pain toward the end of surgery. Ketorolac has been reported to
prevention treatment following the surgery. increase intraoperative bleeding if administered before
In the present study, it was ascertained that following primary hemostasis is established. Nevertheless, there is
breast reduction and mastopexy procedures, patients currently no evidence indicating any bleeding complica-
experienced a greater prevalence of moderate pain, which tions linked to the administration of ketorolac once
was found to be well-tolerated. Conversely, after subpec- hemostasis has been achieved. For these reasons, it is
toral breast augmentation surgery, pain was shown to be usually given toward the end of the surgery [19, 20]. We
more severe and necessitated the administration of sup- believe that administering ketorolac through intravenous
plementary analgesics. Following breast reduction and patient-controlled analgesia (IV-PCA) at the end of the
mastopexy procedures, NSAIDs should be used to treat surgery and during the recovery period is a suitable option,
mild-to-moderate pain. It has been observed that NSAIDs particularly for managing pain after subpectoral breast
are generally sufficient for pain management after these augmentation surgery.
surgical procedures. However, the use of NSAIDs alone Despite implementing various pain control measures, it
did not effectively relieve pain after subpectoral breast is possible that pain management may still be inadequate
augmentation surgeries. Therefore, patients undergoing and result in undesirable side effects. Consequently, pec-
subpectoral breast augmentation required additional anal- toral nerve blocks (PECS-1 or 2) have been recently rec-
gesics for pain relief. In order to facilitate the process, we ommended for pain management after breast surgery and
believe that implementing a user-friendly and practical are becoming an increasingly essential technique after
pain treatment algorithm would greatly assist plastic sur- breast augmentation. Pectoral nerve block anesthetizes the
geons specializing in aesthetic breast surgeries (Fig. 1). pectoralis muscles, numerous branches of the intercostal
The combination of intravenous NSAIDs and opioids for nerves, and the long thoracic nerve by providing analgesia
pain management after surgery has been shown to have to the medial and lateral pectoral nerves [21–23]. Because
several benefits. These include reducing the amount of of this, we believe that pectoral nerve block should be the
opioids needed, improving pain relief, and decreasing method of choice for postoperative pain management,
postoperative symptoms such as nausea, vomiting, and particularly if the anesthesiology team at the center where
sedation. Ketorolac is the most commonly preferred subpectoral breast augmentation surgery is conducted has
NSAID for this purpose [16, 17]. Furthermore, it has been experience with pectoral nerve block.
demonstrated that ketorolac can produce analgesic effects
Fig. 1. Algorithm for pain
treatment after breast surgical
procedures

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Conclusions American Society of Anesthesiologists Task Force on Acute Pain

Management. Anesthesiology 116:248–273
11. O’Hanlon DM, Thambipillai T, Colbert ST, Keane PW, Given
To ensure an easy recovery process, minimize hospital HF (2001) Timing of pre-emptive tenoxicam is important for
stays, and enhance patient satisfaction, it is crucial to postoperative analgesia. Can J Anaesth 48:162–166
implement effective pain prevention measures following 12. Woolf CJ, Chong MS (1993) Preemptive analgesia–treating
postoperative pain by preventing the establishment of central
aesthetic breast surgeries. These measures aim to support
sensitization. Anesth Analg 77:362–379
patients in their recovery journey and facilitate a quicker 13. Christie BM, Kapur S, Kempton SJ, Hanson SE, Ma Y, Rao VK
return to their daily routines. We believe that a practical (2017) A Prospective randomized trial comparing the effects of
pain treatment algorithm that can be easily implemented lidocaine in breast reduction surgery. Plast Reconstr Surg
139:1074e–1079e
will be useful for this purpose (see Fig. 1).
14. Danilla S, Fontbona M, de Valdés VD, Dagnino B, Sorolla JP,
Israel G, Searle S, Norambuena H, Cabello R (2013) Analgesic
Declarations
efficacy of lidocaine for suction-assisted lipectomy with tumes-
cent technique under general anesthesia: a randomized, double-
Conflict of interest The authors declare that they have no conflicts of
masked, controlled trial. Plast Reconstr Surg 132:327–332
interest to disclose.
15. Chen IC, Kang YN, Wang HJ, Chiu WK, Chen C (2022) The
efficacy of local anesthesia for postoperative pain control in
Statement of Human and Animal Rights All procedures performed
breast augmentation surgery: a systematic review and network
in studies involving human participants were in accordance with the
meta-analysis of randomized controlled trials. Aesthetic Plast
ethical standards of the institutional and/or national research com-
Surg 46:1106–1115
mittee and with the 1964 Helsinki Declaration and its later amend-
16. Gan TJ, Daniels SE, Singla N, Hamilton DA, Carr DB (2012) A
ments or comparable ethical standards.
novel injectable formulation of diclofenac compared with intra-
venous ketorolac or placebo for acute moderate-to-severe pain
Informed Consent For this type of study, informed consent is not after abdominal or pelvic surgery: a multicenter, double-blind,
required.The data required for this study were collected by retro- randomized, multiple-dose study. Anesth Analg 115:1212–1220
spectively reviewing patient follow-up forms. 17. Marret E, Kurdi O, Zufferey P, Bonnet F (2005) Effects of
nonsteroidal antiinflammatory drugs on patient-controlled anal-
gesia morphine side effects: meta-analysis of randomized con-
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