Breast Surgery Under LocalAnesthesiaSecond-stage Implant Exchange, Nipple FlapReconstruction, and Breast Augmentation

Dimitri J. Koumanis, MD, FACSa,*, Alex Colque, MDb,Michael L. Eisemann, MDc, Jenna Smithd

KEYWORDS

� Breast reconstruction � Local anesthesia � Nipple � Areola � Nipple-areola complex (NAC)� Star flap � Implant exchange � Silicon breast implant

KEY POINTS

� Local anesthetic as an alternative to general or monitored anesthesia care (MAC) has been used forthe past 30 years.

� Several health risks associated with general anesthesia/MACs are not present with local sedation,providing a safer option for the patient as well as the surgeon.

� When attempting to perform surgery under local anesthesia, consider the patient’s desires andtolerance to being awake for the procedure. If anxiety is associated with the procedure or the nee-dle, intravenous sedation is added to the anesthetic plan. A neurologic assessment of the breastmound area is performed, evaluating for light touch and pressure as well as pain.

� The star flap and the tattoo method for nipple-areola complex reconstruction, in conjunction withthe Keller Funnel sizer to tissue expander exchange to silicon implant performed under local anes-thesia, allow a single-site wound and minimal stress, time, and financial burden to the patient, butprovide optimal aesthetic results and psychological benefits.

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INTRODUCTION

As of 2011, more than 93,000 patients were under-going breast reconstruction. Of those 93,000 pa-tients, two-thirds of the procedures were implantbased.1 More than 60,000 of these patients werepostmastectomy breast reconstructions.2

Implant-based reconstruction is more frequentlyperformed in 2 stages,with the first tissue expanderstage performed immediately after the mastec-tomies. Results for implant reconstruction havebecome reliable and have even improved in thesetting of radiation therapy in certain instances.3

Although performing the first stage of recon-struction usually requires general anesthesia, the

a Capital Area Plastic Surgery of New York, 377 Church Sttice, 21675 E.Moreland Boulevard,Waukesha,WI 53186, UHouston, TX 77030, USA; d Private Practice, Glens Falls H* Corresponding author.E-mail address: jkoumanis@yahoo.com

Clin Plastic Surg 40 (2013) 583–591http://dx.doi.org/10.1016/j.cps.2013.08.0010094-1298/13/$ – see front matter � 2013 Elsevier Inc. All

second stage seemsmore amenable to performingthe procedure under local anesthetic, which canbe performed with small incisions with the tech-niques to be described in this article. Breastaugmentation, which is more involved comparedwith second-stage breast implant reconstruction,has been shown to be performed successfully un-der local anesthetic.4

Reconstruction of the nipple-areola complex(NAC) is most frequently associated with breastcancer and, consequently, mastectomies, and it isalso indicated inburnor traumadeformities, compli-cations of reduction mammaplasties, and congen-ital or developmental disorders.5 Increase in case

reet, Saratoga Springs, NY 12866, USA; b Private Prac-SA; c Private Practice, 6550 Fannin Street, Suite 2119,ospital, 100 Park Street, Glens Falls, NY 12801, USA

rights reserved. plasticsurgery.th

eclini

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numbers over the years has led tomany techniquesbeing developed and revised to accommodate theaesthetic objectives of a nipple-areolar reconstruc-tion. The unique texture and color of theNACmakesdevelopinganalternative challenging.Since first be-ingdocumentedbyAdams6 in1949, the reconstruc-tionof theareolahashistoricallybeenaccomplishedvia the nonoperative side sharing techniques, graft-ing from other sites, NAC saving or banking, derm-abrasion, and tattooing. Some of these have beenused in conjunction with ultraviolet light to facilitatebetter pigmentation. Reconstruction of the nipplehas been achieved through grafting, centrally basedflaps, subdermal pedicle flaps, internal nipple pros-theses, or autogenous implants.5 Although skingrafting in conjunction with areolar tattooing canprovide an aesthetically pleasing result, it requiresa skin graft to be harvested, which in turn producesan additional donor site wound. As an alternative,star flaps in combination with tattooing can providean equally aesthetically pleasing result without theneed for an added site wound.Local anesthetic as an alternative to general or

monitored anesthesia care (MAC) has been usedfor the past 30 years4 and provides many benefitsto the patient. Several of the health risks associatedwith general anesthesia/MACs are not present withlocal anesthetic, providing a safer option for the pa-tient as well as the surgeon. In addition, as anoutpatient procedure with no sedation, patientscan go home immediately following the procedure,as opposed to general anesthesia/MACs withwhich the patients must recover from the anes-thetic gasses in the postanesthesia care unit(PACU). Furthermore, patients are not required toabstain from the consumption of food or beveragesafter midnight on the night before their procedure,which alleviates the need for an additional changein the patient’s routine. Patients benefit financiallyfrom the procedure being performed under localanesthesia as well. The costs to the patient aresignificantly less because an anesthesiologist isnot necessary for the procedure; recovery in thePACU after stage 1, 2, or both is not necessary;and the only anesthetic is a local medication.In breast reconstruction, it is therefore feasible

to perform tissue expander exchange to perma-nent breast implant and third stage nipple flapreconstruction under local anesthesia with suc-cessful and reliable results. In our practice this isthe usual method.

TREATMENT GOALS AND PLANNEDOUTCOMES

Treatment goals for restoring the NAC and ex-changing sizers for silicon implants are commonly

the same regardlessof thesurgeon’s technique.Po-sition, size, shape, texture, pigmentation, perma-nent projection, scar position, and symmetry areessential components for aesthetically pleasing re-sults. The end result must be created in a way thatallows patients to readily incorporate the changeinto their healthy body images. This concentrationon the optimization of psychological benefits hasbeen shown to have a positive influence on theoverall recovery course of women undergoing post-mastectomy breast reconstruction.7

TISSUE EXPANDER EXCHANGE TOPERMANENT BREAST IMPLANTPreoperative Planning

The patient is marked in the preoperative holdingarea with a surgical marker. We use an existingscar to make the incision and generally excisethe scar with 1-mm margins in order to provideclean tissue for the subsequent closure. Patientsare given 1 dose of prophylactic antibioticscovering gram positives, unless the patient hashad a previous infection, in which case we referto previous cultures to guide our choice of antibi-otics. A recent analysis study that searched theliterature for antibiotic regimens using 1 dose pre-operatively, at 24 hours, and greater than 24 hoursshowed no significant difference between 24 hoursand greater than 24 hours of antibiotic use aftersurgery. One dose was associated with higherinfection rates.1 However, the literature lacks anyrandomized trials to answer this question andmost plastic surgeons continue to justify theirantibiotic protocols based on their training andexperience.

Patient Positioning and Procedure

Patients are placed on the operating room table inthe supine position with their arms extended outon arm extensions and wrapped with gauze wrapsto facilitate sitting the patient up during the proce-dure to look for symmetry. A chlorhexidine skinpreparation is used and, if the procedure requiresonly a small incision and a simple exchange from atissue expander to a permanent implants, a smallamount of 1% lidocaine with 1:100,000 epineph-rine mixture is injected into the incision line anddeeper as the surgeon dissects down toward themuscle and capsule/acellular dermal junction. Ifconcomitant revisions of the breast flaps areneeded, intravenous sedation and intercostalblocks can be injected, as described by in a recentstudy.4 The blocks are injected into the intercostalspaces 3 to 7 with a 1% lidocaine and 0.25% bu-pivacaine with 1:100,000 equal parts mixture. Thismixture is injected at the midaxillary line and the

Breast Surgery 585

lateral border of the sternum if needed. Because ofthe added toxicity of both mixtures, we calculatethe dose at 4 mg/kg, erring on the lower end forsafe dosing.

The breast pocket is entered at this junction,which can typically be identified preoperativelyby palpation with the patient flexing the pectoralismuscle. The tissue expander is deflated with a#15 blade over suction tubing and removed fromthe pocket. A minimal incision is used in orderfor the silicone gel implant to be inserted intothe breast pocket. The size of the silicone gelimplant is ascertained with silicone gel sizers. Inour practice, we have been using the Keller Funnelto introduce the implant into the breast pocket.This funnel allows us to use a smaller incisionper implant size. The funnel has standardizedmarkings that represent a specific diameter open-ing of the funnel (Fig. 1). The funnel end is cut ac-cording to the implant size that the surgeon isplanning to insert into the breast pocket. Alongwith changing gloves when handling the implant,and triple antibiotic wash of pocket, implants,and the funnel, a reduction in bacteria load andcapsular contracture rates has been reported.8,9

The incision is closed using a multilayer closure,and Steri-Strips and sterile gauze dressings arethen applied.

NIPPLE-AREOLA RECONSTRUCTIONPreoperative Planning and Preparation

Several techniques have been described in nipplereconstruction, including nipple sharing tech-niques, local flaps, and grafts.10–13

In our practice, we almost always use the modi-fied star flap as described by several investiga-tors.14,15 It has offered consistent results andsatisfactory outcomes without the need for skinor other tissue grafts and the morbidity that canbe associated with those methods. The star flapis also a flap that is easily executed under local

Fig. 1. Keller breast implant funnel.

anesthetic conditions, circumventing the need forgeneral anesthesia and its associated higher costsand potential morbidity (nausea, vomiting and soforth).

When attempting to perform any operation underlocal anesthetic, we consider the patient’s desiresand tolerance to being awake for the procedure. Ifthere is some anxiety associated with the proce-dure or the needle, intravenous sedation is addedto the anesthetic plan. In addition, a neurologicassessment of the breastmound area is performed,evaluating for light touch and pressure as well aspain. Many patients have decreased or little sensa-tion in this area because of the previous mastec-tomy and reconstructive procedures.

We begin our planning of the modified star flapreconstruction with several key measurementsbased on specific anatomic points. The supraster-nal notch, the midclavicular line, and the infra-mammary fold are all marked or taken intoconsideration when placing our nipple. Most ofour nipple measurements are within the meridianof the breast and form close to an equilateral trian-gle in relation to the sternal notch, the nipples oneach side, and the lines connecting both nippleson the horizontal. The patient is involved in the finaldecision of the nipple position by asking her tolook into a mirror with us and comment on theplacement of the circles we have drawn. If it is aunilateral, the native nipple is used as a referencepoint. We typically do our mastopexy or reductionsymmetry operations in the second stage of animplant breast reconstruction when performingthe exchange from tissue expander to permanentimplant. The native nipple has therefore settledto a more stable position.

The 3 limbs of the flap are drawn, with the lateraland medial limbs having 2-cm lengths and a 1-cmto 1.5-cm width at their bases. The inferior limb isdrawn shorter, to about 1.5 cm, with a width of2 cm at the base as well (Fig. 2). The inferior limbcan sometimes be referred to a superior limbdepending on the direction of the blood supplyto the flap. As described by Gurunluoglu and col-leagues,16 the horizontal or vertical scar is incor-porated into the flap design so that the limbmaking up the cap of the nipple flap is the onethat may cross a preexisting scar. A vertical scarincorporation means that the star flap is designedmedially or laterally, and an inferior-based orsuperior-based flap in relation to a horizontal mas-tectomy scar.

Patient Positioning and Procedure

Once on the operating room table, the patient isplaced in the supine position and chlorhexidine

Fig. 2. Modified star flap design with a superior-based pedicle.

Fig. 3. Close-up of immediate postoperative result ofnipple star flap.

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skin preparation is applied and our sterile field issecured. A single preoperative prophylactic doseof intravenous antibiotic is given if the reconstruc-tion is associated with an implant.Local anesthetic is prepared with a 1% lidocaine

with 1:100,000 epinephrine mixture. If the patienthas sensation to the skin involved, we add 1 mLof bicarbonate for every 9 mL of lidocaine drawninto our 10-mL syringe. Because nipple flap sur-gery encompasses a small surface area and littlelocal anesthetic is used, we add 0.25% bupiva-caine at the end of the procedure for longer-acting analgesia. However, if we are doing a largerarea because of breast flap revisions, we do notuse bupivacaine because of its lower lethal dosecalculations compared with lidocaine (maximumdose 2–3 mg/kg bupivacaine with epinephrine vs5–7 mg 1% lidocaine with epinephrine). Animalstudies have also shown that mixing the two localanesthetics has an additive toxicity, making calcu-lations of toxic levels more difficult.17 In addition,cardiotoxicity related to bupivacaine is generallyunresponsive to resuscitation efforts accordingto some animal studies.18,19 Therefore, we tendto use lidocaine instead of bupivacaine in proce-dures requiring large volumes of local anesthetic.If our calculations bring us anywhere near toxic

doses of local anesthesia use, we opt for generalanesthesia.The skin incisions are performed with a #15

scalpel blade and are raised with sufficient subcu-taneous thickness and kept thickest when dissect-ing near the base of the pedicle. The medial andlateral flap limbs are set with an interdigitatingpattern to form the cylindrical base of the flap,whereas the inferior limb makes up the superiorcap of the flap. We use 5-0 chromic sutures tosew the limbs together. The donor site is under-mined full thickness just above the pectoralis mus-cle fascia and the defect is closed in 2 layers with3-0 Monocryl for the deep dermal stitches andrunning or interrupted 4-0 nylon stitches to closethe skin defect. The base of the flap is securedto the skin and closed off with 5-0 chromic inter-rupted sutures as well (Fig. 3). We then dress theflap and its donor areaswith Xeroform strips 1 layerthick and a nipple protective cup as a dressing(Fig. 4). We keep the dressings light without any in-crease in complications, including infection.Approximately 3 to 6 months after the nipple

reconstruction is complete, the patient is readyfor nipple and areola tattooing. We use a profes-sional medical tattoo artist to perform the tattoos.The artist is capable of recreating the small three-dimensional nuances of the female areola, in-cluding the areolar glands and the transitionalnature of areolar tissue to regular skin. In addition,a good tattoo artist can use shading to accentuatethe nipple from the areola and improve the appear-ance of projection. A satisfactory outcome can beobtained with these techniques, removing theneed for areola skin grafts (Figs. 5 and 6).

Fig. 4. Nipple flap dressed with Xeroform and nippleprotecting cup.

Fig. 6. Postoperative result of bilateral implant breastreconstruction with modified star nipple flap and are-ola/nipple tattoos.

Breast Surgery 587

BREAST AUGMENTATIONPreparation and Operative Method

Breast augmentation methods under local anes-thesia were described by Colque and Eisemann.4

The study was of 171 patients who underwentbreast augmentation, all subpectoral, some withmastopexy. The procedures were all performed inan outpatient operating room in an office settingaccredited by the American Association of Accred-itation of Ambulatory Surgery Facilities. Patientswere placed in the supine position and intravenous

Fig. 5. Final nipple flap and tattoo of areola.

sedation, directed by the surgeon, was started with1 mg of midazolam, 50 mg of fentanyl, and 10 mgof ketamine. Appropriate additional doses weretitrated to comfort by the circulating nurse, asdirectedby the surgeon. Patients’ vitals andoxygensaturation were monitored throughout the case.

The local anesthetic consisted of a 1:1 solutionof 0.25% bupivacaine and 1% lidocaine with1:100,000 epinephrine. Lateral ribs 3 to 7 weremarked at the midaxillary line and the intercostalspaces correspondingwith those ribswere each in-jected with 2 mL of the anesthetic solution (Figs. 7and 8). The lateral margin of the sternum was alsoinjected with anesthetic solution, providing a lateraland medial block to the breast (Fig. 9).

The incisional approach was either inframam-mary or periareolar, depending on the patient’spreference. Varying amounts of local anestheticsolution were also injected into the operative fieldif patients experienced intraoperative pain. The

Fig. 7. Ribs 3 to 7 are marked at midaxillary lines forthe lateral intercostal blocks. (Reprinted fromColque A, Eisemann ML. Breast augmentation andaugmentation-mastopexy with local anesthesia andintravenous sedation. Aesthet Surg J 2012;32:304;with permission.)

Fig. 8. Injection of 1:1 anesthetic solution of 0.25%bupivacaine and 1% lidocaine with 1:100,000epinephrine solution, 2 mL in each intercostal space.(Reprinted from Colque A, Eisemann ML. Breastaugmentation and augmentation-mastopexy withlocal anesthesia and intravenous sedation. AesthetSurg J 2012;32:305; with permission.)

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results of 2 patients undergoing a breast augmen-tation and a breast augmentation-mastopexy un-der local anesthesia are shown in Figs. 10 and 11.

Outcomes, Potential Complications, andManagement

Surgical complications for breast reconstructioninclude infection, hematoma, flap necrosis, andcapsular contracture. Unlike clean, elective sur-gery, breast reconstruction infection rates canexceed 20%. These rates are mainly attributed tothe presence of prosthetic devices and drains.Preventative measures taken to avoid infectioninclude diligent aseptic technique, the use of anti-biotics,1 and the Keller Funnel. The Keller Funnel isa medical device consisting of rip-stop nylon and a

Fig. 9. Injection of 0.25% bupivacaine and 1% lido-caine with 1:100,000 epinephrine to the lateral sternalborder. (Reprinted from Colque A, Eisemann ML.Breast augmentation and augmentation-mastopexywith local anesthesia and intravenous sedation. Aes-thet Surg J 2012;32:304; with permission.)

hydrophilic inner coating. The function of thedevice is to reduce the amount of handling andskin contact between the implant, the surgeon,and the patient. The no-touch technique is in-tended to limit the potential for parenchymacontamination. Bacterial contamination was 2times less likely with the Keller Funnel comparedwith the standard digital insertion technique.8

Even though the cause of capsular contractureis not implicit, there is a correlation betweencapsular contracture and bacterial infection.Capsular contracture has long been, and remains,one of the commonly reported complications inboth aesthetic and reconstructive breast surgery.9

Adams and colleagues20 conducted a study ofoptimal broad-spectrum antibacterial coveragefor the organisms that are most frequentlyresponsible for implant contracture and infection.The analysis established that a combination ofpovidone-iodine, gentamicin, and cefazolin pro-vided optimal coverage.20 To date, the use oftriple-antibiotic irrigation has been clinically asso-ciated with low incidence of capsular contracturecompared with other published reports.9

Anesthetic complications are also of signifi-cance. General anesthesia affects the entirebody and presents the potential for aspiration,allergic reactions, increased blood pressure,increased heart rate, damage to teeth and lips,swelling of the larynx, nausea and vomiting,delirium, infection, heart attack, stroke, malignanthyperthermia, systemic toxicity, or (on extremelyrare occasions) death, but locally infiltratedanesthetics are distributed only to the operativelocation, alleviating most of the potential risksassociated with general or MAC anesthesia.Although risks associated with locally infiltratedanesthesia are minimal, local anesthetic’s abilityto cross the blood-brain barrier presents an ab-sorption risk that can, in rare cases, lead tosystemic reactions. In the presence of extremelyhigh levels, coma, respiratory arrest, cardiacarrhythmia, hypotension, and cardiovascular col-lapse are possible. Prevention measures can beachieved through heart rate, blood pressure, andelectrocardiogram monitoring, as well as anawareness of suggested dosing, frequent syringeaspiration for blood, and an initial test of a smallsample dose. If systemic toxicity develops, localanesthetic injection should be stopped andoxygenation and ventilation should be maintainedto resist hypoxemia, hypercarbia, and acidosis,because the presence of these increases systemictoxicity.21–24

Regarding the safety and efficacy of breastaugmentation (with or without mastopexy) Colqueand Eisemann4 were able to show that the

Fig. 10. An 18-year-old woman is shown (A) before and (B) 10 months after primary breast augmentation with360-mL saline implants (Allergan, Inc; Irvine, CA). (Reprinted from Colque A, Eisemann ML. Breast augmentationand augmentation-mastopexy with local anesthesia and intravenous sedation. Aesthet Surg J 2012;32:303–7;with permission.)

Fig. 11. A 40-year-old woman is shown (A) before and (B) 6 months after breast augmentation-mastopexywith 339-mL silicone gel implants (Allergan, Inc; Irvine, CA). (Reprinted from Colque A, Eisemann ML. Breastaugmentation and augmentation-mastopexy with local anesthesia and intravenous sedation. Aesthet Surg J2012;32:306; with permission.)

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Table 1Cost analyses of local versus generalanesthesia for a 2-hour nipple-areolareconstruction (the table shows the amountsthat were billed to insurance companies)

Local (US$) General (US$)

Operating room 2668.00 2817.00

Patient care unit 0.00 873.00

Medical supplies 489.00 710.00

Anesthesia 0.00 900.00

Total 3157.00 5300.00

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operation can be performed successfully with alidocaine/bupivacaine solution using intercostalblocks and surgeon-directed sedation. In thebreast augmentation–only group (n 5 132), theaverage 1% lidocaine/0.25% bupivacaine with1:100,000 epinephrine mixture used was 79.6 mL(range, 25–120 mL) and, in the breast augmenta-tion/mastopexy group, it was 90.9 mL (range,45–144 mL). Average operating room time was63.8 minutes and 134.7 minutes respectively foreach group. There was some slight nausea (be-tween 10% and 12.5%) across both groups andthere were no deaths, no hospital admissions,and no serious complications in either group,underscoring the safety and efficacy of thisapproach. The investigators avoided propofol asa sedative and the need for anesthesiologist ornurse anesthetist services. This cost reduction issignificant for the patient.A cost analysis of our nipple-areola reconstruc-

tion under general versus local anesthetic, takinginto account operating room, recovery room(PACU), medical supplies, pharmacy, and anes-thesia fees, showed a local anesthetic proceduralcost of US$3157 and a general anesthetic proce-dural cost of US$5300; a difference of US$2143(Table 1).

SUMMARY

Breast reconstruction can be performed safelywith local anesthesia, providing the patient withminimal discomfort, minimal complications, anda financially beneficial option. Utilization of thestar flap method in conjunction with tattooingsuccessfully provides optimal aesthetic resultswithout the need for an additional donor site.When tissue expander to silicon implant exchangeis part of the operative plan, use of triple antibioticirrigation as well as the Keller Funnel is recom-mended to decrease both infection and capsularcontracture. Breast augmentation and breast

augmentation-mastopexy can also be performedsafely and with good results under local anestheticin a private operating room setting, with somesedation directed by the operative surgeon. Allother operative conditions, including sterility andsound operative surgical techniques, should bethe mainstay of any practice.

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