Erector Spinae Plane Block With Selective Use of Adjunct Fascial Plane Blocks for Analgesia in Latissimus Dorsi Flap Breast Reconstruction: A Case Series With Mid-term Follow-Up

Background Autologous breast reconstruction using the latissimus dorsi (LD) flap remains a reliable option in selected patients but is associated with significant postoperative pain involving both the anterior chest wall and the posterior donor site. Optimizing perioperative analgesia while minimizing opioid consumption is a key component of enhanced recovery pathways. Ultrasound-guided fascial plane blocks, particularly the erector spinae plane block (ESPB), have emerged as promising alternatives to traditional neuraxial techniques. Objective This study aims to describe the clinical experience and preliminary outcomes associated with ultrasound-guided ESPB, with or without an adjunct parasternal intercostal plane (PIP) block, in patients undergoing LD flap breast reconstruction as part of a multimodal analgesic strategy. Methods This single-center retrospective observational case series included six adult female patients undergoing elective autologous breast reconstruction with an LD flap between March 2022 and December 2024. All patients received ultrasound-guided ESPB; in selected cases, a PIP block was added based on anatomical considerations. Postoperative pain was assessed using the Numeric Rating Scale (NRS) at rest and during movement up to 48 hours. Opioid consumption, postoperative nausea and vomiting, mobilization, and block-related complications were recorded. Mid-term follow-up at 6 and 12 months was conducted via structured telephone interviews that assessed persistent pain, functional recovery, complications, and patient satisfaction. Results are reported using descriptive statistics. Results All patients achieved low postoperative pain scores, with NRS values of 0 at rest immediately after surgery. Dynamic pain scores remained low during the first 48 hours (median NRS ≤3), and rescue opioid analgesia was required in one patient. No postoperative nausea, vomiting, or block-related complications were observed, and all patients mobilized within 6-12 hours. At 6- and 12-month follow-up, no patient reported persistent pain requiring ongoing analgesic therapy, shoulder mobility was preserved, and overall patient satisfaction was high. Conclusions In this case series, ESPB within a multimodal analgesic approach was associated with favorable acute and mid-term pain outcomes, minimal opioid requirements, preserved shoulder function, and high patient satisfaction following LD flap breast reconstruction. The selective use of adjunct anterior chest wall blocks reflects an individualized, anatomy-driven strategy. These findings support the feasibility of ESPB-centered analgesic pathways in this surgical setting and warrant confirmation in larger prospective studies. These findings should be interpreted as hypothesis-generating rather than confirmatory.