What is the recommended anesthesia regimen for a patient undergoing breast augmentation?

Anesthesia Recommendations for Breast Augmentation

For breast augmentation surgery, general anesthesia combined with multimodal analgesia (scheduled paracetamol/acetaminophen plus NSAIDs or COX-2 inhibitors, pre-operative gabapentin, intravenous dexamethasone, and local anesthetic wound infiltration) is the recommended approach, with opioids reserved strictly as rescue medication. 1, 2, 3, 4

Pre-operative and Intra-operative Anesthetic Management

Induction and Maintenance of General Anesthesia

• General anesthesia is the standard approach for breast augmentation, typically using propofol for induction (100-200 mcg/kg/min) combined with remifentanil infusion (0.25 mcg/kg/min) or volatile agents (sevoflurane, isoflurane, desflurane) 1, 5

• For induction through intubation, remifentanil can be administered at 0.5-1 mcg/kg/min, with an optional initial bolus of 1 mcg/kg over 30-60 seconds if intubation occurs within 8 minutes 5

• Volatile anesthetic agents (sevoflurane, isoflurane, desflurane) are safe choices as they are largely cleared by exhalation with rapid clearance and short half-life 1

Multimodal Analgesia Protocol (Essential Components)

Pre-operative medications:

• Gabapentin should be administered pre-operatively to reduce postoperative pain scores and opioid consumption (Grade A evidence), though use caution with high doses in ambulatory patients due to potential dizziness, blurred vision, or sedation 1, 3

• Paracetamol/acetaminophen administered pre-operatively or intra-operatively (Grade B evidence) 1, 3, 4

• Conventional NSAIDs (ibuprofen, naproxen) or COX-2 selective inhibitors (celecoxib) administered pre-operatively or intra-operatively (Grade A-B evidence) 1, 3, 4

Intra-operative medications:

• Single dose of IV dexamethasone provides dual benefits: additional analgesia and reduction of postoperative nausea/vomiting (Grade B evidence) 1, 3, 4

Regional Anesthesia Technique

• Local anesthetic wound infiltration is the recommended regional technique for breast augmentation, using ropivacaine, bupivacaine, or lidocaine (Grade A evidence) 1, 4

• Local infiltration reduces pain scores and decreases rescue opioid consumption, though analgesic effect typically lasts only 6-24 hours 4

• Bupivacaine plus ketorolac may provide superior pain relief at 1 hour postoperatively compared to bupivacaine alone 6

• Local anesthetic infiltration can be added to other regional techniques if used 1, 4

Alternative Anesthesia Approaches (When General Anesthesia is Not Preferred)

Conscious Sedation with Local Anesthesia

While general anesthesia is standard, conscious sedation protocols have demonstrated safety and efficacy in large case series:

• Premedication: Midazolam 0.05 mg/kg IV plus ranitidine 100 mg IV, or diazepam IV 7, 8, 9

• Intraoperative sedation: Midazolam, fentanyl, and ketamine administered by surgeon with circulating nurse monitoring 7

• Tumescent local anesthesia: 25 mL lidocaine 2%, 8 mEq sodium bicarbonate, 1 mL epinephrine (1 mg/mL) in 1000 mL normal saline, infiltrated between pectoral fascia and mammary gland, with 45 minutes allowed before surgery (maximum lidocaine dose 17 mg/kg) 9

• Intercostal nerve blocks at spaces 3-7 at midaxillary line can be added for enhanced analgesia 7

• This approach results in mean recovery times of approximately 50 minutes and postoperative nausea rates of 10-13% 7, 9

Postoperative Analgesia Management

• Continue paracetamol/acetaminophen and NSAIDs/COX-2 inhibitors on a scheduled basis (not as-needed) throughout the postoperative period (Grade A-B evidence) 1, 2, 3, 4

• Opioids should be used strictly as rescue medication only when non-opioid analgesics fail to provide adequate control (Grade B evidence) 1, 2, 3, 4

• The combination of paracetamol with ibuprofen is as effective as paracetamol with codeine but with lower incidence of nausea and constipation 4

• If remifentanil is continued into the immediate postoperative period, start at 0.1 mcg/kg/min and adjust in 0.025 mcg/kg/min increments every 5 minutes, with rates >0.2 mcg/kg/min associated with respiratory depression 5

Critical Pitfalls to Avoid

• Do not administer analgesics "as needed" – scheduled dosing of paracetamol and NSAIDs provides superior pain control compared to PRN administration 3, 4

• Do not rely on opioids as primary analgesia – multimodal non-opioid analgesia should form the foundation of pain management 1, 2, 3

• Do not use aspirin in analgesic doses in breastfeeding women (low-dose aspirin for antiplatelet action is acceptable if strongly indicated) 1

• Avoid ketamine as first-line induction agent if other agents are available, particularly in breastfeeding women, due to limited data on milk transfer 1

• Allow adequate time (45 minutes) after tumescent local anesthesia infiltration before surgical incision for optimal anesthetic effect 9

• Monitor for disproportionate pain postoperatively, as this may indicate infection or hematoma requiring surgical evaluation 2

Considerations for Breastfeeding Women

• All volatile agents, propofol, etomidate, and thiopental are compatible with breastfeeding with no waiting period required 1

• Midazolam can be resumed immediately after recovery from the procedure due to extensive first-pass metabolism 1

• Morphine is the opioid of choice if strong analgesia is required, though single doses are unlikely to cause detrimental effects to the infant 1

• Ibuprofen, diclofenac, naproxen, celecoxib, and ketorolac are all considered safe during breastfeeding 1