Monday, January 26, 2009

How to make breast augmentation less painful - Depobupivicaine

One thing that patients frequently ask about when considering undergoing breast augmentation is how much pain and discomfort they'll experience. I think in general, the pain is directly correlated to the surgical technique.

If you could find a video of breast augmentation circa 1975, you'd see a set of instruments like this used:

Those hockey-stick shaped devices are called "Dingman breast dissectors" (after Dr. Reed Dingman, former chief of plastic surgery at Michigan in the 1960's-70's). Basically, they're a lever to mechanically dissect a pocket to place an breast implant into. Breast augmentation in that era consisted of making an incision, shoving one of these instruments in, tearing a pocket out bluntly, and holding pressure until the patient quit bleeding. Sounds great, huh?

Blood around an implant, as we know, is a potent stimulator of capsular contraction, and techniques like this combined with silicone implants of that era probably precipitated many (with a capital M) cases of hardening breast. There is no way to predictably minimize bleeding with blunt dissection, and it should be largely avoided in breast augmentation except when gently refining a previously dissected pocket.

Believe it or not, there are still some surgeons who use that kind of technique when they place implants thru the armpit (transaxillary approach) and belly button ("TUBA" technique). Evidence based medicine and the refinements in surgical techniques described by surgeons like John Tebbetts, Pat Maxwell, and others have clearly shown us ways to get better results, with less bleeding, less inflammation, and softer breasts over the long term.

The key to safe and excellent plastic surgery is precision and planning. As the apocryphal "7 P's" quote from the British military goes:
"Prior Planning and Preparation Prevents Piss Poor Performance". This is particularly true as it relates to long term outcomes from breast augmentation surgery.


The take home message is that more atraumatic technique produces less pain and controlled dissection of the space for the implant under direct vision increases precision and decreases bleeding. We're getting to the point where there are few technical steps to be discovered that will decrease pain much more. Most of available improvement involves intercostal nerve blocks with local anesthetics (which last 6-8 hours), disposable external pulsed electromagnetic field generators (PEMF) (like those made by Ivivi or ActiPatch), or indwelling pain pumps which trickle a local anesthetic in the breast pocket for 2-3 days. They all work, but have limitations due to duration (nerve blocks), external device requirements and costs(PEMF), or potential contamination of the implant from the skin (pain pumps).

I'm currently involved in some phase III FDA trials with breast augmentation on a long-acting local anesthetic that may solve all these problems. It involves bonding a local anesthetic to a fatty lipid molecule which serves to make a very effective sustained release drug. Where normally this drug (marcaine) might last 6-8 hours, when bound to this carrier molecule it lasts up to 3 days.

That is a game changer in post operative pain control IMO. It gives both proven efficacy with long action and no external devices/catheters to pay for. Our most recent patients we've done have have used nothing but tylenol for post-op for pain control, which is pretty amazing for sub-muscular implants.

Study Recruitment for Depo-bupivicaine FDA clinical trial:



Seattle Plastic Surgery on Lake Union said...

Rob, cool write-up on your clinical research...are you using the long-acting local anesthetic for a rib-block or within a pain pump? What is your rib-block technique?


Scott Sattler MD FACS

Anita said...

Hey! I'm wondering do you know what can go wrong with rib removal surgery? I want to get it done when I get older because I really do want a smaller waist.