Anesthetic Options for Breast Surgery

For most breast surgeries, anesthesia can be provided by various techniques. The choices vary with the type of surgical procedure, your medical history and preferences, and the advice of your surgeon and anesthesiologist. Below is a brief description of anesthetic techniques and how they are usually used. Your surgeon and anesthesiologist can provide more information about each option.

Anesthetic Options

Intravenous Sedation

This is also referred to as Monitored Anesthesia Care, or MAC. It consists of giving sedatives through your intravenous line (IV) or in the breathing mask. The sedatives are used with a local anesthetic that your surgeon will inject into the surgical area to numb the tissues. The level of sedation can be varied to achieve conditions ranging from being able to talk with your doctors to being partially asleep during the procedure. The combination of sedatives and local anesthetic is effective in ensuring your comfort for most minor breast surgical procedures. It is used most commonly for biopsies or the removal of breast lumps.

Regional Anesthesia

This refers to the technique of providing anesthesia to the region of the body where surgery is being performed. Because only the tissues around the site of surgery are made numb, it differs from general anesthesia (see below), in which the entire body is insensitive to pain. To improve patient comfort, regional anesthesia is commonly given with intravenous sedation (see above). Or in some situations, both regional and general anesthesia may be given. In these cases, the regional anesthetic provides long-lasting pain relief after waking up from surgery. The three main kinds of regional anesthetics used for breast surgeries are thoracic epidural anesthesia, paravertebralblocks and intrathecal morphine.

Thoracic epidural anesthesia
Many people are familiar with epidurals in the setting of childbirth, where they commonly are used to relieve the pain associated with labor and delivery. Epidurals are also for a variety of surgical procedures. In contrast to labor epidurals where the catheter is inserted in the lower back, for breast surgery epidurals are placed higher up the back — between the shoulder blades. A tiny catheter is inserted between the bones of the spine into an area called the epidural space, which contains the nerves to be blocked for surgery. Local anesthetic is injected through the catheter, causing the surgical area to become numb. It is insensitive to pain until the effects of the local anesthetic have worn off.

With thoracic epidural anesthesia, pain relief can be prolonged after surgery for as long as the catheter remains in place. As a result, it is most appealing for extensive procedures, such as mastectomies with reconstruction, when a longer hospitalization is required. On occasion, it is also performed for procedures that don’t require hospitalization after the operation. In this setting, because pain will be felt within a few hours of the epidural catheter being removed, another form of pain relief will need to be substituted at that time. This is usually done with oral medication prescribed by your surgeon before your discharge from the hospital.

Paravertebral blocks are another form of regional anesthesia used during breast surgery. Like thoracic epidural anesthesia, this technique involves injecting a local anesthetic into an area of the back where the nerves are located to numb the chest. But there are important differences. Thoracic epidural anesthesia requires the placement of a catheter at a single location in the back. It produces a “block” that usually makes both sides of the chest pain-free but wears off within hours of the catheter’s removal. Paravertebral blocks do not require catheters to be placed in the back. The technique involves a series of injections of local anesthetic at several places along the back of the ribcage. It is given with intravenous sedation. These injections usually “block” only the nerves on the side of the chest where the surgery will be performed. They have the distinct advantage of lasting 18 to 24 hours or more. These are most popular for patients who are having partial or complete mastectomies and are planning to go home on the same day of surgery. The likelihood of being nauseated after surgery is lower with regional anesthesia.

Intrathecal morphine is used in combination with general anesthesia for patients who require mastectomies with flap reconstructions. These patients are always hospitalized after surgery. Intrathecal morphine involves an injection of morphine into the lower back, prior to the administration of general anesthesia. The injection is performed within the spinal fluid (similar to a spinal anesthetic). It is different than a traditional spinal anesthetic, in which the lower portion of the body cannot move for several hours. By contrast, intrathecal morphine does not alter the ability to move the lower body. It provides pain relief lasting 18 to 24 hours or more. Intrathecal morphine can depress breathing for a few hours after surgery. Its use is restricted to people who will be in the hospital after surgery.

General Anesthesia

This remains the most common form of anesthesia provided to people undergoing breast surgery. With this choice, you are completely asleep during your operation. General anesthesia is often combined with a local anesthetic to reduce pain at the incision site. Sometimes, a form of regional anesthesia will be used for this purpose. General anesthesia is started with medicine given in your IV or through a breathing mask. If you have a fear of needles, the IV can sometimes be started after you are asleep. Great improvements have been made in recent years with the drugs and techniques used for general anesthesia. Patients are much less likely to be sleepy after the initial recovery time. Also, there are many new effective approaches to control postoperative problems such as nausea and vomiting. Some day-surgery patients feel well enough to go directly from the operating room to a reclining chair in the recovery lounge. Most day-surgery patients are moved to recovery with minimal discomfort from nausea, vomiting, or pain.

If you are in the hospital overnight after your procedure, pain relief is usually provided by an IV pump called an IV-PCA. This stands for Intravenous Patient-Controlled Analgesia. The nurses in the recovery room will start this pump after surgery and will also teach you how to use it properly. The pump is set so you can receive a certain amount of medicine every five to seven minutes. A physician from the anesthesia department will visit you daily (and is available 24 hours each day) to check on you and be sure you are comfortable.

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