Perioperative Analgesic Strategy in Breast Reconstruction Surgery: A Narrative Literature Review with Evidence-Gap Analysis for Breast Implant Revision

Five decision domains: analgesic modality, regional techniques, adjuvant pharmacology, risk-stratified communication, and outcome measurement

Collin B. George, pre-medical student ORCID: 0009-0007-8162-6839 Manuscript v8 — repository release 2026.11 (text October 2026; source-currency and accuracy update November 2026)

Educational work by a pre-medical student — not medical advice. Not a clinical protocol, prescription, or patient handout, and not for patient care. See DISCLAIMER.

Review type: Narrative literature review with a documented PubMed search. This is not a systematic review or meta-analysis; no PRISMA reporting standard, formal risk-of-bias assessment, GRADE certainty rating, or data pooling was performed.

Conflict of interest: The author declares no conflicts of interest. Funding: No external funding was received for this work. Data availability: All sources are published and listed in the reference list (also maintained as 06_References.md). No new data were collected.

Abstract

Background: Breast reconstruction surgery raises perioperative analgesic questions across five sequential decision domains: analgesic modality, regional anesthetic technique, adjuvant pharmacology, patient risk stratification and communication, and postoperative recovery measurement. These domains are usually studied separately. The author did not identify a prior review that mapped evidence across all five domains together, particularly with respect to breast implant revision surgery as a procedurally distinct, under-studied subpopulation.

Objective: To describe the scope and nature of published evidence for perioperative analgesic strategies across five decision domains in adults undergoing breast reconstruction surgery, and to describe evidence gaps relevant to breast implant revision surgery.

Sources: A documented PubMed/MEDLINE search (five domain-specific strings), supplemented by targeted retrieval of society guidance and backward reference tracking. The date of the original search was not recorded. When the strings were re-run in October 2026 they did not function as written (several MeSH terms were not recognized and the Domain 1 string returned no records), so sources were identified mainly through guideline retrieval and reference tracking. Sources were selected by a single author; screening counts were not recorded. Fifty-five published sources are cited in this manuscript, including six guideline, consensus or meta-analytic sources added in a November 2026 source-currency update.

Findings: Two meta-analyses of randomized trials in breast cancer surgery report that pectoral nerve (PECS) blocks reduce 24-hour postoperative opioid consumption compared with general anesthesia or systemic analgesia alone. Sun et al. (2020; 13 RCTs, 940 patients) reported a weighted mean difference of −11.88 mg IV morphine equivalents (95% CI −15.50 to −8.26) with very high heterogeneity (I² = 99.5%). Hussain et al. (2019; 14 RCTs, 887 patients) reported a weighted mean difference of −30.5 mg oral morphine (95% CI −42.2 to −18.8) for PECS II versus systemic analgesia and no statistically significant difference versus paravertebral block. These estimates are reported separately and were not pooled by this review. The author proposes, as a hypothesis only, that the measured opioid-sparing effect of PECS blocks may depend on the anesthetic background (for example, propofol total intravenous anesthesia [TIVA] versus volatile anesthesia); the available trials do not allow this to be tested. Meta-analyses support small-to-moderate opioid-sparing effects for dexamethasone, ketamine, alpha-2 agonists, magnesium, and IV lidocaine in mixed surgical populations, with little breast-reconstruction-specific evidence. Communication research documents gaps in informed decision-making and consent-form readability in general medical and surgical settings. Recovery-measurement research documents that recovery instruments vary widely in scope. The selected sources do not establish revision-specific efficacy. This non-exhaustive review cannot establish that no revision-specific studies exist; primary aesthetic augmentation is a distinct population.

Conclusion: The strongest evidence in this literature concerns regional analgesia (meta-analyses of RCTs, with substantial heterogeneity), and the weakest concerns integrated communication and outcome measurement. Conclusions about implant revision are inferences, not established findings, and would need revision-specific trials.

Methodological Note

This is a narrative literature review, not a systematic review. One bibliographic database (PubMed/MEDLINE) was searched, supplemented by targeted retrieval of society guidance and backward reference tracking. A single author selected and summarized sources; screening counts were not recorded and are not available. No formal risk-of-bias assessment, GRADE certainty rating, or meta-analysis was performed. Descriptions of evidence strength use plain study-design terms (for example, "meta-analysis of RCTs" or "single RCT"). All limitations are reported in Section 9.

Source-currency note (November 2026). Several guidance documents cited in earlier drafts have been superseded. The 2020 PROSPECT guideline for oncological breast surgery (Jacobs et al., 2020) is retained as a historical source alongside its 2026 update for major oncological breast surgery (Desai et al., 2026). The Fourth PONV consensus (Gan et al., 2020) is retained as historical alongside the Fifth consensus (Gan et al., 2025). The 2026 ASA guideline on local and regional analgesia for mastectomy (American Society of Anesthesiologists Task Force on Perioperative Pain Management, 2026), the international IV-lidocaine consensus (Foo et al., 2021) and the gabapentinoid meta-analysis by Verret et al. (2020) were added. For the two 2025–2026 updates (Desai et al., 2026; Gan et al., 2025), only abstracts and summaries were reviewed, not the full text. Statements attributed to them are limited to what those abstracts and summaries report.

1. Introduction

Breast reconstruction surgery encompasses immediate and delayed post-mastectomy reconstruction, implant-based reconstruction with tissue expander or direct-to-implant technique, autologous reconstruction, and revision procedures including capsular contracture management, implant exchange, pocket revision, and infection-related explantation with reimplantation. These procedures present perioperative management considerations that intersect five areas of active scholarship: analgesic modality selection, regional anesthesia technique, adjuvant pharmacology, patient risk stratification and communication quality, and perioperative outcome measurement.

The perioperative analgesic literature in breast reconstruction has largely addressed these areas in isolation. The author did not identify a prior review that mapped evidence across all five domains together, examined their interdependence, or described the evidence gap specific to breast implant revision surgery as a procedurally distinct subpopulation. The revision population is relevant because revision procedures are common after implant-based reconstruction, many patients have had prior chest wall radiation, and the psychosocial context of oncology-related revision surgery may create communication and measurement challenges that differ from primary reconstruction or non-oncologic breast surgery.

This review maps evidence across five perioperative analgesic decision domains, summarizes that evidence by domain using plain study-design descriptions, and describes evidence gaps relevant to implant revision surgery. Statements about implant revision are labeled throughout as evidence-gap analysis and inference.

2. Methods

2.1 Review Design

This is a narrative literature review with a documented search. It applies explicit search strings and eligibility criteria but does not include the methods of a systematic review: (1) a single author selected and summarized sources; (2) only one bibliographic database was searched, with supplementary targeted retrieval; (3) screening counts were not recorded; and (4) no formal risk-of-bias assessment, certainty rating, or quantitative pooling was performed. No reporting standard (such as PRISMA 2020) is claimed.

Section 8.5 presents an exploratory narrative observation about whether anesthetic background (propofol TIVA versus volatile anesthesia) might modify the measured opioid-sparing effect of PECS blocks. This is a hypothesis drawn from a reading of published trial abstracts and full texts where available. It is not a subgroup analysis or meta-analysis, and no data were pooled.

2.2 Review Questions

Primary: What is the scope and nature of published evidence for perioperative analgesic strategies across five clinical decision domains in adults undergoing breast reconstruction surgery?

Secondary: What are the evidence gaps and portability implications for breast implant revision surgery in each domain?

Exploratory (hypothesis-generating only): Is there a plausible reason to expect the opioid-sparing effect of PECS blocks to differ between propofol TIVA and volatile-anesthetic backgrounds, and can the published trials address this question?

2.3 Eligibility Criteria

Inclusion: English-language systematic reviews, meta-analyses, RCTs, prospective and cross-sectional studies, and society guidance documents; adults (≥18 years) undergoing breast reconstruction or breast surgery; perioperative analgesic strategy, patient communication, or postoperative recovery measurement in at least one of the five defined domains. Sources from adjacent populations (for example, thoracic surgery, arthroplasty, or general surgical and medical settings) were included where breast-specific evidence was lacking, and are labeled as indirect.

Exclusion: Case reports, case series (<20 patients), editorials, letters, and conference abstracts without full published data; pediatric populations; non-English publications. Exceptions were made for a small number of non-outcome sources, which were included for definitions, historical context or framing and not as outcome evidence. These are the original PECS technique descriptions (Blanco, 2011, a short correspondence item; Blanco et al., 2012), perspective and analysis articles on shared decision-making (Barry & Edgman-Levitan, 2012; Mulley et al., 2012), and an editorial accompanying the gabapentinoid meta-analysis (Kharasch et al., 2020).

2.4 Information Sources and Search Strategy

PubMed/MEDLINE was searched as the primary database, with no lower date limit. Targeted retrieval was conducted for society guidance (ERAS Society, ASRA Pain Medicine, ASA, PROSPECT, and the Society for Ambulatory Anesthesia [SAMBA]). A November 2026 source-currency update repeated this targeted retrieval and added the 2026 ASA guideline, the 2026 PROSPECT update, the Fifth PONV consensus, the Foo et al. (2021) IV-lidocaine consensus and the Verret et al. (2020) gabapentinoid meta-analysis with its accompanying editorial. These sources were identified by targeted retrieval, not by the documented search strings. Backward reference tracking from systematic reviews and meta-analyses was performed. Embase, the Cochrane Library, Scopus, and Web of Science were not searched as databases.

Search strings by domain (as originally documented)

Domain 1 — Analgesic modality: ("breast reconstruction"[MeSH] OR "breast implant"[tiab] OR "mammoplasty"[MeSH]) AND ("opioid-free anesthesia"[tiab] OR "opioid-sparing"[tiab] OR "TIVA"[tiab] OR "propofol"[MeSH]) AND ("pain, postoperative"[MeSH] OR "nausea and vomiting, postoperative"[MeSH])

Domain 2 — Regional analgesia: ("breast reconstruction"[MeSH] OR "breast surgery"[tiab]) AND ("pectoral nerve block"[tiab] OR "PECS"[tiab] OR "serratus anterior plane block"[tiab] OR "nerve block"[MeSH])

Domain 3 — Adjuvant pharmacology: ("breast reconstruction"[MeSH] OR "breast surgery"[tiab]) AND ("ketamine"[MeSH] OR "dexmedetomidine"[MeSH] OR "lidocaine"[MeSH] OR "magnesium"[MeSH] OR "dexamethasone"[MeSH] OR "acetaminophen"[MeSH]) AND ("pain management"[MeSH] OR "analgesics, opioid"[MeSH])

Domain 4 — Patient communication and risk stratification: ("health literacy"[MeSH] OR "shared decision making"[MeSH] OR "informed consent"[MeSH]) AND ("anesthesia"[MeSH] OR "perioperative"[tiab]) AND ("comprehension"[tiab] OR "communication"[tiab])

Domain 5 — Outcome measurement: ("breast reconstruction"[MeSH] OR "breast surgery"[tiab]) AND ("quality of recovery"[tiab] OR "QoR-15"[tiab] OR "patient reported outcome"[MeSH] OR "postoperative nausea"[MeSH] OR "discharge readiness"[tiab])

Search re-run (searched 27 October 2026). The five strings above were re-run exactly as written through NCBI ESearch. Raw responses, query translations and warnings are archived in search-audit-2026-10-27.json. These diagnostics are not screening or study-selection records. Hit counts were: Domain 1, 0; Domain 2, 387; Domain 3, 18; Domain 4, 77; Domain 5, 33. PubMed reported that several quoted MeSH terms were not found as written ("breast reconstruction"[MeSH], "mammoplasty"[MeSH], "shared decision making"[MeSH], "patient reported outcome"[MeSH], "postoperative nausea"[MeSH], and, in Domain 1, "pain, postoperative"[MeSH] and "nausea and vomiting, postoperative"[MeSH]), so those terms did not contribute to the results. The date of the original search, its hit counts and its screening counts were not recorded and are not available. Because the strings did not run as intended, the search should be regarded as non-exhaustive, and sources were also identified through guideline retrieval and reference tracking (see Section 9.1).

2.5 Selection Process

The author selected sources against the eligibility criteria. Screening was not duplicated, and screening counts were not recorded; no flow diagram is presented.

2.6 Data Charting

For each cited source the author recorded study design, population, intervention and comparator, primary outcome domain, outcome instruments used, and key findings as reported in the abstract or, where openly available, the full text. Numerical results reported in this manuscript are taken from the cited publications and can be traced to them. An independent review in November 2026 could not confirm several figures from abstracts alone. These are the Fink et al. comprehension scores (71.4% vs 68.2%), the Sun et al. Egger and Begg P values, the Bowyer et al. count of 11 tools, the Teo et al. and Forsythe et al. sample sizes, and the Hussain et al. side-effect statement. They are understood to come from the full texts and have not been shown to be wrong, but they should be re-checked against the full publications.

2.7 Risk of Bias

No formal risk-of-bias assessment (such as Cochrane RoB 2) was performed. Study-design limitations reported by the source authors are noted where relevant.

2.8 Describing Strength of Evidence

No formal certainty rating (such as GRADE) was applied. Evidence is described by study design and directness to the breast reconstruction population, for example "meta-analysis of RCTs (breast cancer surgery)", "single RCT (thoracic surgery; indirect)", or "author inference".

2.9 Synthesis Method

Sources were summarized narratively by decision domain, giving priority to systematic reviews and meta-analyses. No data were pooled. Where two meta-analyses addressed the same question (Section 4), their results are reported separately because they differ in included trials, comparators, and opioid units.

3. Results: Analgesic Modality — Opioid-Sparing and TIVA-Based Approaches

3.1 Evidence Scope

Sources mapped for this domain are listed in Table 1. They include a breast reconstruction consensus review endorsed by the ERAS Society (Temple-Oberle et al., 2017), the 2026 PROSPECT update for major oncological breast surgery (Desai et al., 2026) and its historical 2020 predecessor (Jacobs et al., 2020), the Fifth consensus guidelines on PONV (Gan et al., 2025) and the historical Fourth consensus (Gan et al., 2020), the Apfel PONV risk score cross-validation study (Apfel et al., 1999), a narrative review of opioid-free anesthesia (Beloeil, 2019), a pharmacology review of dexmedetomidine (Weerink et al., 2017), a systematic review of IV lidocaine (McCarthy et al., 2010), a Cochrane review of IV ketamine (Brinck et al., 2018), ASRA Pain Medicine guidance on local anesthetic systemic toxicity (LAST) (Neal et al., 2018; Neal et al., 2021), and one RCT of opioid-free versus opioid-based anesthesia in mastectomy (Chen et al., 2025).

Table 1. Evidence map — analgesic modality domain. OFA = opioid-free anesthesia; OBA = opioid-based anesthesia; PVB = paravertebral block; LAST = local anesthetic systemic toxicity.

3.2 Principal Findings

The ERAS Society consensus review for breast reconstruction (Temple-Oberle et al., 2017) and the PROSPECT recommendations for oncological breast surgery (Jacobs et al., 2020, historical; Desai et al., 2026, current for major surgery) both describe a multimodal, opioid-sparing framework that combines agents with different mechanisms to reduce reliance on any single drug class, including opioids. The ERAS review recommends anesthetic techniques that decrease PONV and pain; this review did not verify a specific recommendation for propofol TIVA over volatile anesthesia in that document. The evidence base for individual components varies substantially in breast-surgery specificity.

The Apfel simplified risk score uses four predictors: female sex, history of motion sickness or PONV, non-smoking, and postoperative opioid use (Apfel et al., 1999). In breast reconstruction, female sex is nearly universal; the other three factors vary by patient, and postoperative opioid use is directly influenced by the analgesic strategy chosen. The Apfel score was derived in patients receiving inhalational anesthesia for various surgery types and has not been specifically validated in breast reconstruction revision cohorts. The link between analgesic strategy and PONV risk is therefore plausible but has not been evaluated in a controlled trial specific to the revision population.

Consensus PONV guidelines address strategies to reduce baseline PONV risk, including the choice of anesthetic technique. The Fifth consensus (Gan et al., 2025) is now the current statement; the Fourth consensus (Gan et al., 2020) is cited as historical. In a mastectomy RCT in which both groups received a PECS block and propofol target-controlled infusion, opioid-free anesthesia with dexmedetomidine did not improve QoR-15 at 24 hours or postoperative analgesia compared with opioid-based anesthesia, but postoperative adverse events were significantly lower in the opioid-free group, and extubation was slower (Chen et al., 2025). This finding is consistent with the idea that a shared PECS block background limits the incremental analgesic benefit detectable between opioid-free and opioid-based strategies.

Summary — analgesic modality (narrative) Society guidance for breast reconstruction and oncological breast surgery supports multimodal, opioid-sparing perioperative care that includes regional techniques and non-opioid adjuncts. Most supporting evidence comes from breast cancer surgery or mixed surgical populations rather than reconstruction revision, and effect sizes vary across studies and background regimens. The available evidence does not establish superiority over low-opioid conventional approaches for long-term functional outcomes.

3.3 Key Evidence Gaps

No RCT identified in this review evaluated analgesic modality as the primary comparison in elective breast reconstruction revision surgery. Most evidence derives from mastectomy or broader breast surgery populations. PONV estimates come from mixed populations that may not apply uniformly to revision contexts. Long-term functional outcomes are not characterized.

3.4 Evidence Gap — Implications for Breast Implant Revision Surgery

The selected evidence map does not establish analgesic-modality outcomes in breast implant revision; absence of all relevant studies is not demonstrated. The following implications are designated EVIDENCE GAP — ANALYTICALLY INFERRED. The lower PONV associated with propofol TIVA is mechanism-based and not procedure-specific, so it may carry over to revision surgery. No source cited here shows that propofol TIVA itself reduces postoperative opioid requirements. However, revision surgery may involve a lower acute pain burden than primary reconstruction, which could reduce the absolute size of opioid-sparing differences compared with what has been observed in primary reconstruction or mastectomy trials. Prior chest wall radiation, common in post-mastectomy revision patients, may alter regional block efficacy and therefore the background against which any anesthetic-technique differences operate; this interaction has not been evaluated.

4. Results: Regional Analgesia — PECS Block, Serratus Anterior Plane Block, and Related Techniques

4.1 Evidence Scope

Sources mapped for this domain are listed in Table 2. They include two meta-analyses of PECS blocks versus general anesthesia or systemic analgesia alone (Hussain et al., 2019; Sun et al., 2020), a network meta-analysis of regional techniques in breast cancer surgery (An et al., 2023), a SAMBA practice advisory (Ardon et al., 2022), the 2026 ASA practice guideline on local and regional analgesia, which includes mastectomy (American Society of Anesthesiologists Task Force on Perioperative Pain Management, 2026), the 2026 PROSPECT update and its historical 2020 predecessor (Desai et al., 2026; Jacobs et al., 2020), the original technique descriptions (Blanco, 2011; Blanco et al., 2012), individual RCTs in breast cancer surgery (Bashandy & Abbas, 2015; Versyck et al., 2017; Kamiya et al., 2018) and aesthetic augmentation (Aarab et al., 2021), a serratus plane block RCT in thoracic surgery (Kim et al., 2018), a meta-analysis of perineural dexamethasone (Albrecht et al., 2015), and ASRA Pain Medicine LAST guidance (Neal et al., 2018; Neal et al., 2021).

The PECS I block was first described by Blanco in 2011 as an injection in the plane between pectoralis major and pectoralis minor to block the pectoral nerves (Blanco, 2011). The PECS II ("modified Pecs") block, described in 2012, adds a deeper injection intended to block at least the pectoral nerves, the intercostobrachial nerve, intercostal nerves III–VI, and the long thoracic nerve (Blanco et al., 2012).

Table 2. Evidence map — regional analgesia domain. WMD = weighted mean difference; GA = general anesthesia; PVB = paravertebral block; PACU = post-anesthesia care unit; PONV = postoperative nausea and vomiting.

4.2 Principal Findings

PECS blocks reduce early postoperative opioid consumption and pain in breast cancer surgery compared with general anesthesia or systemic analgesia alone. Two meta-analyses address this question and are reported separately:

• Sun et al. (2020; 13 RCTs, 940 patients) reported a 24-hour weighted mean difference of −11.88 mg IV morphine equivalents (95% CI −15.50 to −8.26). Heterogeneity was very high (I² = 99.5%), and the Egger test suggested publication bias (P = .010), although the Begg test did not (P = .161).
• Hussain et al. (2019; 14 RCTs, 887 patients) reported a 24-hour weighted mean difference of −30.5 mg oral morphine (95% CI −42.2 to −18.8) for PECS II versus systemic analgesia, and found PECS II not statistically different from paravertebral block for 24-hour morphine consumption.

The two estimates differ in included trials, comparators, and opioid units (IV morphine equivalents versus oral morphine), so they should not be combined or treated as interchangeable. The direction of effect is consistent across both. The very high heterogeneity means that the effect in any individual patient or protocol cannot be predicted from either pooled estimate, and most included trials enrolled mastectomy rather than reconstruction or revision patients.

The network meta-analysis by An et al. (2023; 100 RCTs, 6,639 patients) found that several regional techniques, including PECS II, paravertebral, serratus anterior plane, erector spinae plane, and rhomboid intercostal blocks and local anesthetic infusion, were each associated with lower postoperative pain, 24-hour morphine consumption, and PONV compared with no block, but the analysis did not detect a statistically significant chronic-pain difference. The authors judged the strength of evidence for their ranking to be very low. The SAMBA advisory (Ardon et al., 2022) recommends PECS blocks over systemic analgesia alone for breast-conserving surgery but could not recommend them over surgeon-performed local infiltration.

Society guidance has ranked these techniques rather than treating them as equal options. The 2020 PROSPECT guideline (now historical) named paravertebral block as the first-choice regional technique for major breast surgery (Grade A). It named PECS block as an alternative to PVB and wound infiltration as an addition to a regional technique (Grade A). For minor-to-moderately invasive procedures such as lumpectomy, it recommended wound infiltration (Grade A) (Jacobs et al., 2020). For mastectomy, SAMBA likewise recommends a PECS block if a patient is unable to receive a PVB (Strength A) (Ardon et al., 2022). Both documents therefore placed PECS behind PVB for mastectomy. Two newer documents are less clear-cut. The 2026 PROSPECT update lists erector spinae plane, PECS, serratus anterior plane and paravertebral blocks and local infiltration analgesia as recommended single-shot techniques for major oncological breast surgery (Desai et al., 2026). This review read only its abstract and summary, so it cannot say whether the update keeps a ranking among them. The 2026 ASA guideline strongly recommends fascial plane blocks or paravertebral block for adults undergoing mastectomy, to reduce pain and/or opioid use in the first 24 hours. It also notes a quality-of-recovery benefit with fascial plane blocks (American Society of Anesthesiologists Task Force on Perioperative Pain Management, 2026). None of these documents addresses implant revision specifically.

4.3 Key Evidence Gaps

Nearly all RCT evidence comes from breast cancer surgery or mixed breast surgery populations. The one RCT in implant surgery identified here studied primary aesthetic augmentation (Aarab et al., 2021). No adequately powered study was identified that evaluated PECS block efficacy specifically in breast implant revision, capsular contracture repair, or pocket revision. Optimal PECS technique parameters (volume, concentration, agent, adjuvant) are not standardized, which likely contributes to the heterogeneity in pooled analyses.

4.4 Evidence Gap — Implications for Breast Implant Revision Surgery

The selected evidence map does not establish PECS efficacy in implant revision; this is not an exhaustive absence claim. The following are EVIDENCE GAP — ANALYTICALLY INFERRED. The PECS II block was originally described with tissue expanders and subpectoral prostheses among its main indications (Blanco et al., 2012), and an RCT in primary aesthetic augmentation found reduced pain and opioid use through day 5 (Aarab et al., 2021); this makes technique portability to implant revision plausible but unvalidated. Prior chest wall radiation, common in post-mastectomy revision patients, may alter fascial plane anatomy, local anesthetic spread, and therefore block coverage. A potentially lower acute pain burden in revision surgery relative to primary mastectomy could reduce the absolute analgesic demand against which block efficacy is measured.

5. Results: Adjuvant Pharmacology and Opioid-Minimizing Pathways

5.1 Evidence Scope

Sources mapped for this domain are listed in Table 3. They include meta-analyses, Cochrane and other systematic reviews, pharmacology reviews, consensus statements, and one large cardiovascular safety RCT across eight adjuvant agent categories. No dosing recommendations are made in this review.

Table 3. Evidence map — adjuvant pharmacology domain. None of the sources in this table evaluated the agent against a contemporary PECS-block-plus-TIVA background in breast reconstruction.

5.2 Principal Findings

Meta-analyses in mixed surgical populations report opioid-sparing effects for dexamethasone, ketamine, alpha-2 agonists, magnesium, and IV lidocaine. The 2020 PROSPECT guideline for oncological breast surgery, now historical, recommended paracetamol, NSAIDs, dexamethasone, and preoperative gabapentin (Jacobs et al., 2020). The 2026 update recommends paracetamol, NSAIDs or COX-2 inhibitors, and dexamethasone; its abstract does not list gabapentinoids among the recommended interventions (Desai et al., 2026; full text not reviewed). The 2020 gabapentin recommendation should not be read as support for routine use. A later meta-analysis of 281 RCTs (24,682 participants) in mixed surgical populations found no clinically significant analgesic effect of perioperative gabapentinoids and more dizziness and visual disturbance, and concluded that the results did not support routine use (Verret et al., 2020). An accompanying editorial argued for revising, if not eliminating, their routine perioperative use in adults (Kharasch et al., 2020). Effect sizes are generally small to moderate, and almost none of the underlying trials were conducted in breast reconstruction. For IV lidocaine, the benefit was concentrated in abdominal surgery and safety and dosing were flagged as unresolved (Vigneault et al., 2011). IV lidocaine is itself a local anesthetic. An international consensus statement regards it as a high-risk medicine and advises that it should not be given at the same time as, or within the period of action of, other local anesthetic interventions such as nerve blocks or wound infiltration (Foo et al., 2021). In a PECS-block or other fascial-plane-block pathway, the issue is therefore avoiding overlap, not adding up doses. Prevention, recognition and treatment of local anesthetic systemic toxicity are addressed in ASRA Pain Medicine guidance (Neal et al., 2018; Neal et al., 2021). No regimen or timing interval is given in this review.

A key interpretive issue across this domain is a possible ceiling effect: the incremental benefit of any adjuvant may be largest when background analgesic coverage is lowest, and smaller when regional block and TIVA already provide substantial coverage. Effect sizes from trials without regional block coverage may therefore not transfer directly to PECS-block-based pathways. In the Chen et al. (2025) RCT, which compared opioid-free with opioid-based anesthesia against a shared PECS block and propofol background, QoR-15 and postoperative analgesia did not differ at 24 hours. This is consistent with, but does not prove, a limited incremental contribution of opioid-free strategies above a PECS-inclusive background. This is an author inference.

5.3 Key Evidence Gaps

This selected-source audit does not establish an optimal lidocaine, magnesium or ketamine regimen for reconstruction/revision with a PECS-inclusive background. It also does not establish the absence of all relevant trials. Bundle comparisons cannot isolate an individual component’s contribution.

6. Results: Patient Risk Stratification and Perioperative Communication

6.1 Evidence Scope

Sources mapped for this domain are listed in Table 4. They include a foundational Institute of Medicine report, an AHRQ systematic review on health literacy outcomes (Berkman et al., 2011), consent-form readability studies, shared decision-making frameworks, a multicenter RCT of comprehension verification in surgical consent (Fink et al., 2010), an integrative review of research-consent comprehension, a breast surgery patient-reported outcome instrument (BREAST-Q), a cross-sectional study of body image during reconstruction, and arthroplasty studies of pain catastrophizing.

Table 4. Evidence map — patient risk stratification and communication domain. IRB = institutional review board.

6.2 Principal Findings: Health Literacy and Comprehension

The Institute of Medicine (2004) frames health literacy as the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. The AHRQ systematic review by Berkman et al. (2011) found low health literacy consistently associated with more hospitalizations, greater use of emergency care, lower receipt of some preventive services, and poorer ability to take medications appropriately and to interpret labels and health messages. These findings come from general medical settings; perioperative-specific outcomes were not the focus.

Consent documents frequently exceed recommended reading levels. Paasche-Orlow et al. (2003) found that consent-form template text provided by IRBs at US medical schools exceeded the schools' own readability standards, and Eltorai et al. (2015) found that invasive-procedure consent forms from Rhode Island hospitals were written at an average 15th-grade reading level.

The post-mastectomy revision population may face compounding barriers: prior oncologic encounters and treatments, the psychological burden of cancer history and body image concerns, and the cognitive-emotional load of a revision encounter that may carry uncertainty about reconstruction success. Teo et al. (2016) found that body image and quality of life vary with the timing and stage of reconstruction. Whether these factors affect comprehension during anesthetic counseling has not been studied directly (author inference).

6.3 Principal Findings: Shared Decision-Making and Preference Verification

The gap between expressed and informed preference is the central communication problem identified by the mapped evidence. Shared decision-making models depend on patients developing informed preferences (Elwyn et al., 2012), and clinicians may misjudge what patients prefer if preferences are not elicited directly (Mulley et al., 2012). Adding a repeat-back step to surgical consent produced a statistically significant but modest improvement in comprehension (Fink et al., 2010), and comprehension deficits persist in research consent despite a range of interventions (Cohn & Larson, 2007). These findings raise questions about whether adequate comprehension is consistently achieved within standard preoperative encounters, particularly for anesthetic option disclosure in oncology-related surgical settings.

Analytical inference (author) A structural tension exists between the goal of shared decision-making, which requires meaningful preference elicitation, and the possibility that patient preferences about anesthetic options may be expressed without adequate understanding of the options. The perioperative-specific literature does not consistently address how to distinguish expressed preference from informed preference under the elevated cognitive and emotional load of oncology-related surgery. This conclusion is drawn by extension from shared decision-making and health literacy research, not from direct study of preference formation in breast reconstruction patients.

6.4 Evidence Gap — Implications for Breast Implant Revision Surgery

The communication and risk stratification evidence reviewed here comes largely from general medical settings, surgical and research consent, and, for pain catastrophizing, knee arthroplasty. The psychosocial complexity specific to post-mastectomy revision surgery has not been directly studied in a communication context and is inferred from adjacent research. No study of pain catastrophizing or preoperative opioid use as risk factors in breast reconstruction populations was identified, and the arthroplasty evidence may not be directly portable.

7. Results: Postoperative Recovery Measurement

7.1 Evidence Scope

Sources mapped for this domain are listed in Table 5: a review of quality-of-recovery measurement (Bowyer et al., 2014), the QoR-15 development and validation study (Stark et al., 2013), two PECS block RCTs using quality-of-recovery outcomes (Kamiya et al., 2018; Chen et al., 2025), a review of ERAS (Ljungqvist et al., 2017), a review of fast-track surgery (Kehlet & Wilmore, 2008), and two breast reconstruction outcome studies (Pusic et al., 2009; Teo et al., 2016).

Table 5. Evidence map — outcome measurement domain. QoR = quality of recovery; NRS = numerical rating scale; PONV = postoperative nausea and vomiting; OFA = opioid-free anesthesia; OBA = opioid-based anesthesia.

7.2 Principal Findings

Bowyer et al. (2014) document that postoperative quality of recovery lacks a universally accepted definition and that assessment tools vary substantially in scope. Standard perioperative metrics such as NRS pain scores, PONV incidence, and discharge criteria capture only part of recovery and do not directly measure cognitive clarity, fatigue, sleep quality, emotional equilibrium, or perceived progress.

Two PECS-block RCTs illustrate the problem. Kamiya et al. (2018) found that a PECS block improved early pain but not QoR-40 on day 1, and the authors suggested that factors such as rebound pain, not captured by early analgesia measures, may explain this. Chen et al. (2025) found no QoR-15 difference between opioid-free and opioid-based anesthesia against a shared PECS block background, despite a significant difference in adverse events. Together these findings suggest that standard recovery instruments may have limited sensitivity to analgesic-strategy differences in this population, although two trials are not proof of systematic instrument failure.

Breast-reconstruction-specific outcome research (Pusic et al., 2009; Teo et al., 2016) shows that satisfaction, body image, and psychosocial well-being are patient-relevant outcomes that vary with reconstruction timing and stage, dimensions not captured by standard perioperative instruments.

Analytical inference (author) In the breast reconstruction revision population, where psychosocial complexity may be elevated and procedures vary widely, the gap between standard recovery metrics and patient-experienced recovery may be larger than in less complex surgical populations. This is inferred from documented measurement limitations in adjacent contexts; no controlled study has tested it in revision populations.

7.3 Evidence Gap — Implications for Breast Implant Revision Surgery

Patient-reported outcome data specific to the acute recovery phase of breast implant revision surgery were not identified. Minimal clinically important difference (MCID) thresholds for QoR-15 and BREAST-Q have not been established in high psychosocial complexity subgroups. A patient-anchored global measure such as the Patient Global Impression of Change (PGIC) could help distinguish instrument failure from treatment failure in apparent non-responders; its use as a co-primary endpoint in breast reconstruction analgesic trials was not identified in this review.

8. Integrated Synthesis

8.1 The Layered Evidence Structure

The mapped evidence suggests that perioperative analgesic planning in breast reconstruction involves a layered decision structure in which each domain's evidence modifies the interpretation of the others. Analgesic modality sets the pharmacological background against which regional blocks and adjuvants operate. Regional analgesia determines the anatomical distribution of analgesia and may create a ceiling that limits the incremental benefit of adjuvants. Adjuvant pharmacology adds opioid-sparing within the space remaining above that ceiling. Risk stratification and communication quality determine whether patients can meaningfully participate in strategy selection. Recovery measurement determines whether any benefit is detectable with the instruments used. This framework is an author interpretation.

8.2 Distribution of Evidence Across Domains

The most robust evidence in this review is for regional analgesia: two meta-analyses of RCTs and a network meta-analysis in breast cancer surgery, with very high heterogeneity and mostly mastectomy populations. Society guidance (ERAS, PROSPECT 2020 and its 2026 update, SAMBA, and the 2026 ASA local/regional analgesia guideline) supports multimodal, opioid-sparing care that includes regional techniques. Adjuvant evidence comes mainly from meta-analyses in mixed or non-breast surgical populations. Communication evidence comes mainly from general medical, surgical-consent, and research-consent settings, with one multicenter RCT of comprehension verification. Outcome-measurement evidence consists of instrument development studies, reviews, and two breast surgery RCTs whose recovery scores did not change. Evidence for predicting risk (for example, the Apfel score or pain catastrophizing in arthroplasty) is generally stronger than evidence that acting on those predictions changes outcomes in this population.

8.3 Cross-Domain Integration

Cross-domain observation — analytically inferred The perioperative literature tends to treat analgesic strategy, patient communication, and recovery measurement as separate research domains. This separation may be limiting in the breast reconstruction revision context. If the ceiling-effect hypothesis in Section 8.5 is correct, the incremental benefit of each additional analgesic component would be smaller when the preceding layers are more effective, a relationship not captured when agents are studied in isolation. A patient who cannot meaningfully participate in analgesic decision-making because of health literacy barriers cannot generate valid preference data for personalizing strategy, and a recovery measure that does not capture patient-relevant dimensions cannot show whether a communication-informed decision produced a valued outcome. Prospective studies that integrate these domains would address this gap.

8.4 Evidence Gaps and Research Priorities

No RCT or adequately designed observational study identified in this review evaluated any perioperative analgesic domain with breast implant revision as the primary population. Three research priorities follow from the mapped evidence: (1) a revision-specific RCT of PECS block against a contemporary propofol TIVA background, with patient-valued recovery outcomes such as QoR-15 and PGIC as co-primary endpoints; (2) controlled studies with pre-specified risk stratification (for example, opioid tolerance, pain catastrophizing, and psychosocial comorbidity) in breast reconstruction; and (3) prospective validation of MCID thresholds for QoR-15 and BREAST-Q in high psychosocial complexity subgroups.

8.5 Exploratory Observation: Anesthetic Background as a Possible Modifier of PECS Block Opioid-Sparing (Hypothesis Only)

This section is a narrative, hypothesis-generating observation. No subgroup analysis, meta-analysis, risk-of-bias assessment, or data extraction for pooling was performed, and none of the numbers below were calculated by the author.

The two meta-analyses in Section 4 report 24-hour opioid reductions of −11.88 mg IV morphine equivalents (Sun et al., 2020) and −30.5 mg oral morphine (Hussain et al., 2019), with very high heterogeneity in the first. Neither publication's abstract reports a subgroup analysis by anesthetic maintenance technique. One possible contributor to heterogeneity is the anesthetic background, but the premise is uncertain. Propofol TIVA is associated with less PONV, but less PONV does not by itself imply lower postoperative opioid demand. TIVA is also often paired with a remifentanil infusion (as in Kamiya et al., 2018). Any modifying effect would have to come from differences in postoperative pain or opioid use between propofol and volatile maintenance, which this review did not evaluate and which no source cited here establishes. This is a hypothesis only.

The individual trials reviewed here can only partly inform it:

Table 6. Trials relevant to the anesthetic-background hypothesis, as reported in their abstracts (and, for Chen et al. 2025, the open-access full text). OFA = opioid-free anesthesia; OBA = opioid-based anesthesia.

These trials do not allow the hypothesis to be tested: only one PECS-versus-no-block trial clearly used a TIVA background, and its opioid outcome was intraoperative. Testing the hypothesis would require either a pre-specified subgroup analysis by anesthetic maintenance technique within an updated meta-analysis, using full-text trial data, or a trial randomizing PECS block versus no block within a propofol TIVA background. If the hypothesis were correct, the observable benefit of PECS blocks in TIVA-based pathways might appear more in early pain intensity and rescue-analgesia use than in large differences in opioid quantity.

Key Interpretations

9. Limitations

9.1 Search Limitations

PubMed/MEDLINE was the only bibliographic database searched. An earlier draft described accessing EMBASE through the Cochrane Library; because the Cochrane Library does not provide a full Embase search, this is not counted as an Embase search here. Embase, the Cochrane Library, Scopus, and Web of Science were not searched. When re-run on 27 October 2026, several MeSH terms in the documented search strings were not recognized by PubMed as written, and the Domain 1 string returned no records, so the documented search did not function as intended. Sources were also identified through guideline retrieval and backward reference tracking. The review is therefore not exhaustive. Any future systematic review would need validated MeSH terms, multiple databases, and recorded screening counts.

9.2 Single-Author Selection

Sources were selected and summarized by one author without duplicate screening, and screening counts were not recorded. This increases the risk of selection bias.

9.3 No Formal Risk-of-Bias or Certainty Assessment

No formal risk-of-bias tool or certainty framework was applied. Strength of evidence is described only by study design and directness, which does not account for individual study quality.

9.4 Exploratory Hypothesis

The anesthetic-background hypothesis in Section 8.5 was not pre-specified and was not tested. It is offered as a question for future research only.

9.5 Ceiling Effects and Portability of Effect Sizes

Much of the adjuvant pharmacology literature evaluates interventions against comparators without the regional block and propofol TIVA coverage used in some contemporary pathways. Effect sizes from these trials may overestimate the incremental benefit of adjuvants in block-based pathways. This is an inference that has not been tested directly.

9.6 Implant Revision Indirectness

Nearly all primary evidence comes from breast cancer surgery, mixed breast surgery, or non-breast populations; the only implant-surgery RCT identified studied primary aesthetic augmentation. No primary evidence specific to breast implant revision was identified. All conclusions about revision surgery are inferred, and the size, and in some cases the direction, of effects in revision surgery cannot be established from the available evidence.

9.7 Author Qualification

The author is a pre-medical student without clinical licensure. Interpretations reflect educational engagement with published sources rather than professional clinical judgment. This manuscript is not clinical guidance and must not be used as such.

10. Conclusion

This narrative literature review mapped published evidence for perioperative analgesic strategies across five clinical decision domains in adults undergoing breast reconstruction surgery and described evidence gaps relevant to breast implant revision surgery.

The most robust evidence concerns regional analgesia: two meta-analyses of RCTs in breast cancer surgery report that PECS blocks reduce early postoperative opioid consumption and pain, with very high heterogeneity and mostly mastectomy populations. The author proposes, as an untested hypothesis, that this effect may be smaller under a propofol TIVA background. Meta-analyses in mixed surgical populations support small-to-moderate opioid-sparing effects for several adjuvants, with little breast-specific evidence. Communication research documents gaps in comprehension and consent-form readability in general and surgical settings, and recovery-measurement research shows that standard instruments may miss patient-relevant dimensions.

No direct evidence on breast implant revision was identified in any domain. Conclusions about revision surgery in this review are evidence-gap inferences, not established findings. Three research priorities follow: a revision-specific RCT of PECS block versus no block against a propofol TIVA background, with QoR-15 and PGIC as co-primary endpoints; controlled studies with pre-specified risk stratification in breast reconstruction; and prospective MCID validation for QoR-15 and BREAST-Q in high psychosocial complexity subgroups.

References

Numbers match the master list in 06_References.md; entries not cited in this manuscript are omitted here, so the numbering is not continuous. Entries 60 onward were added in the November 2026 source-currency update and are numbered after the original alphabetical list so that existing numbers do not change. Entries marked historical have been superseded and are retained for context.

1. Aarab Y, Ramin S, Odonnat T, et al. Pectoral nerve blocks for breast augmentation surgery: a randomized, double-blind, dual-centered controlled trial. Anesthesiology. 2021;135(3):442–453. doi:10.1097/ALN.0000000000003855. PMID 34195767
2. Albrecht E, Kirkham KR, Liu SS, Brull R. Peri-operative intravenous administration of magnesium sulphate and postoperative pain: a meta-analysis. Anaesthesia. 2013;68(1):79–90. doi:10.1111/j.1365-2044.2012.07335.x. PMID 23121612
3. Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia. 2015;70(1):71–83. doi:10.1111/anae.12823. PMID 25123271
4. An R, Wang D, Liang XL, Chen Q, Pang QY, Liu HL. The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: a network meta-analysis. Front Oncol. 2023;13:1083000. doi:10.3389/fonc.2023.1083000. PMID 37056343
5. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693–700. doi:10.1097/00000542-199909000-00022. PMID 10485781
6. Ardon AE, George JE 3rd, Gupta K, et al. The use of pectoralis blocks in breast surgery: a practice advisory and narrative review from the Society for Ambulatory Anesthesia (SAMBA). Ann Surg Oncol. 2022;29(8):4777–4786. doi:10.1245/s10434-022-11724-9. PMID 35428960
7. Barry MJ, Edgman-Levitan S. Shared decision making — the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–781. doi:10.1056/NEJMp1109283. PMID 22375967
8. Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial. Reg Anesth Pain Med. 2015;40(1):68–74. doi:10.1097/AAP.0000000000000163. PMID 25376971
9. Beloeil H. Opioid-free anesthesia. Best Pract Res Clin Anaesthesiol. 2019;33(3):353–360. doi:10.1016/j.bpa.2019.09.002. PMID 31785720
10. Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: an updated systematic review. Evidence Report/Technology Assessment No. 199. Rockville, MD: Agency for Healthcare Research and Quality; 2011. PMID 23126607
11. Blanco R. The 'pecs block': a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66(9):847–848. doi:10.1111/j.1365-2044.2011.06838.x. PMID 21831090
12. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59(9):470–475. doi:10.1016/j.redar.2012.07.003. PMID 22939099
13. Blaudszun G, Lysakowski C, Elia N, Tramèr MR. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116(6):1312–1322. doi:10.1097/ALN.0b013e31825681cb. PMID 22546966
14. Bowyer A, Jakobsson J, Ljungqvist O, Royse C. A review of the scope and measurement of postoperative quality of recovery. Anaesthesia. 2014;69(11):1266–1278. doi:10.1111/anae.12730. PMID 24888412
15. Brinck EC, Tiippana E, Heesen M, et al. Perioperative intravenous ketamine for acute postoperative pain in adults. Cochrane Database Syst Rev. 2018;12(12):CD012033. doi:10.1002/14651858.CD012033.pub4. PMID 30570761
16. Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015;8:21–32. doi:10.2147/JPR.S64730. PMID 25609995
17. Chen J, He L, Shi Y, et al. Effect of opioid-free anesthesia combined with pectoral nerve block on the quality of recovery in patients after mastectomy: a randomized, controlled trial. PLoS One. 2025;20(4):e0320592. doi:10.1371/journal.pone.0320592. PMID 40179095
18. Cohn E, Larson E. Improving participant comprehension in the informed consent process. J Nurs Scholarsh. 2007;39(3):273–280. doi:10.1111/j.1547-5069.2007.00180.x. PMID 17760802
19. Eltorai AE, Naqvi SS, Ghanian S, et al. Readability of invasive procedure consent forms. Clin Transl Sci. 2015;8(6):830–833. doi:10.1111/cts.12364. PMID 26678039
20. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–1367. doi:10.1007/s11606-012-2077-6. PMID 22618581
21. Fink AS, Prochazka AV, Henderson WG, et al. Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial. Ann Surg. 2010;252(1):27–36. doi:10.1097/SLA.0b013e3181e3ec61. PMID 20562609
22. Forsythe ME, Dunbar MJ, Hennigar AW, Sullivan MJ, Gross M. Prospective relation between catastrophizing and residual pain following knee arthroplasty: two-year follow-up. Pain Res Manag. 2008;13(4):335–341. doi:10.1155/2008/730951. PMID 18719716
23. Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020;131(2):411–448. doi:10.1213/ANE.0000000000004833. PMID 32467512. Historical; superseded by reference 63.
24. Hussain N, Brull R, McCartney CJL, et al. Pectoralis-II myofascial block and analgesia in breast cancer surgery: a systematic review and meta-analysis. Anesthesiology. 2019;131(3):630–648. doi:10.1097/ALN.0000000000002822. PMID 31408448
25. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004. doi:10.17226/10883
26. Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F; PROSPECT Working Group. PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2020;75(5):664–673. doi:10.1111/anae.14964. PMID 31984479. Historical for major breast surgery; superseded by reference 61.
27. Kamiya Y, Hasegawa M, Yoshida T, Takamatsu M, Koyama Y. Impact of pectoral nerve block on postoperative pain and quality of recovery in patients undergoing breast cancer surgery: a randomised controlled trial. Eur J Anaesthesiol. 2018;35(3):215–223. doi:10.1097/EJA.0000000000000762. PMID 29227351
28. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189–198. doi:10.1097/SLA.0b013e31817f2c1a. PMID 18650627
29. Kim DH, Oh YJ, Lee JG, Ha D, Chang YJ, Kwak HJ. Efficacy of ultrasound-guided serratus plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: a randomized, triple-blind, placebo-controlled study. Anesth Analg. 2018;126(4):1353–1361. doi:10.1213/ANE.0000000000002779. PMID 29324496
30. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth. 2011;58(10):911–923. doi:10.1007/s12630-011-9560-0. PMID 21773855
31. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292–298. doi:10.1001/jamasurg.2016.4952. PMID 28097305
32. McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery: a systematic review of randomized controlled trials. Drugs. 2010;70(9):1149–1163. doi:10.2165/10898560-000000000-00000. PMID 20518581
33. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients' preferences matter. BMJ. 2012;345:e6572. doi:10.1136/bmj.e6572. PMID 23137819
34. Neal JM, Barrington MJ, Fettiplace MR, et al. The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Reg Anesth Pain Med. 2018;43(2):113–123. doi:10.1097/AAP.0000000000000720. PMID 29356773
35. Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine local anesthetic systemic toxicity checklist: 2020 version. Reg Anesth Pain Med. 2021;46(1):81–82. doi:10.1136/rapm-2020-101986. PMID 33148630
36. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375(26):2519–2529. doi:10.1056/NEJMoa1611593. PMID 27959716
37. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med. 2003;348(8):721–726. doi:10.1056/NEJMsa021212. PMID 12594317
38. Politi MC, Han PKJ, Col NF. Communicating the uncertainty of harms and benefits of medical interventions. Med Decis Making. 2007;27(5):681–695. doi:10.1177/0272989X07307270. PMID 17873256
39. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124(2):345–353. doi:10.1097/PRS.0b013e3181aee807. PMID 19644246
40. Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology. 2013;118(6):1332–1340. doi:10.1097/ALN.0b013e318289b84b. PMID 23411725
41. Sun L, Zhu X, Zou J, Li Y, Han W. Comparison of intravenous and oral acetaminophen for pain control after total knee and hip arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97(6):e9751. doi:10.1097/MD.0000000000009751. PMID 29419667
42. Sun Q, Liu S, Wu H, et al. Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: a systematic review and meta-analysis. Medicine (Baltimore). 2020;99(14):e19614. doi:10.1097/MD.0000000000019614. PMID 32243387
43. Temple-Oberle C, Shea-Budgell MA, Tan M, et al. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery after Surgery (ERAS) Society recommendations. Plast Reconstr Surg. 2017;139(5):1056e–1071e. doi:10.1097/PRS.0000000000003242. PMID 28445352
44. Teo I, Reece GP, Christie IC, et al. Body image and quality of life of breast cancer patients: influence of timing and stage of breast reconstruction. Psychooncology. 2016;25(9):1106–1112. doi:10.1002/pon.3952. PMID 26360810
45. Versyck B, van Geffen GJ, Van Houwe P. Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II. J Clin Anesth. 2017;40:46–50. doi:10.1016/j.jclinane.2017.03.054. PMID 28625445
46. Vigneault L, Turgeon AF, Côté D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58(1):22–37. doi:10.1007/s12630-010-9407-0. PMID 21061107
47. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth. 2013;110(2):191–200. doi:10.1093/bja/aes431. PMID 23220857
48. Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;56(8):893–913. doi:10.1007/s40262-017-0507-7. PMID 28105598
49. Yang L, Du S, Sun Y. Intravenous acetaminophen as an adjunct to multimodal analgesia after total knee and hip arthroplasty: a systematic review and meta-analysis. Int J Surg. 2017;47:135–146. doi:10.1016/j.ijsu.2017.09.011. PMID 28919091
50. American Society of Anesthesiologists Task Force on Perioperative Pain Management. 2026 American Society of Anesthesiologists practice guideline on perioperative pain management using local and regional analgesia for cardiothoracic surgeries, mastectomy, and abdominal surgeries. Anesthesiology. 2026;144(1):19–43. doi:10.1097/ALN.0000000000005790. PMID 41363869
51. Desai N, Dirzu DS, Zolger D, et al.; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. Pain management after major oncological breast surgery: an updated systematic review and procedure specific postoperative pain management (PROSPECT) recommendations. Anaesthesia. 2026 (published online 12 August 2026). doi:10.1111/anae.70313. PMID 42581686
52. Foo I, Macfarlane AJR, Srivastava D, et al. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia. 2021;76(2):238–250. doi:10.1111/anae.15270. PMID 33141959
53. Gan TJ, Jin Z, Ayad S, et al. Fifth consensus guidelines for the management of postoperative nausea and vomiting: executive summary. Anesth Analg. 2025 (published online 14 November 2025). doi:10.1213/ANE.0000000000007816. PMID: identifier unverified
54. Kharasch ED, Clark JD, Kheterpal S. Perioperative gabapentinoids: deflating the bubble. Anesthesiology. 2020;133(2):251–254. doi:10.1097/ALN.0000000000003394. PMID: identifier unverified
55. Verret M, Lauzier F, Zarychanski R, et al. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Anesthesiology. 2020;133(2):265–279. doi:10.1097/ALN.0000000000003428. PMID 32667154

Identifiers for references 60–66 were checked against publisher, society and indexed PubMed listings by web search in November 2026, not by the NCBI ESummary run used for references 1–59. Identifiers that could not be confirmed are marked "identifier unverified".

Supplementary File: Search Documentation

Hit counts are reported as returned by PubMed on the stated date and are not deduplicated across domains. Screening counts (records screened, full texts assessed, and reasons for exclusion) are not available. No PRISMA flow diagram is presented.

Breast Reconstruction Analgesia Review · Collin B. George, pre-medical student · Manuscript v8, repository release 2026.11 · CC BY 4.0. Educational literature review only; not for clinical use.

Earlier releases of this manuscript ended with a 27 October 2026 "source/version update" note. In November 2026 its content was moved into the body: Sections 2.3–2.4, Tables 1–3, Sections 3.2, 4.2 and 5.2, and the reference list.