The Impact of Tumescent Local Anesthesia on Opioid Use in DIEP Flap Breast Reconstruction

BACKGROUND: The opioid epidemic, which cost over $1.02 trillion in 2017, continues to be a major public health concern. To improve postoperative pain control and reduce opioid misuse, our team implemented tumescent local anesthesia with bupivacaine (TLA) in DIEP flap breast reconstructions at both breast and abdominal donor sites. METHODS: We conducted a retrospective study of DIEP flap reconstructions from 2019-2023, comparing patients who received TLA (tumescent fluid with bupivacaine as TAP, intercostal, and local blocks) to those who received the standard TAP block alone. Unpaired t-tests and Fisher's Exact tests assessed group differences; multivariable regression models evaluated postoperative complications. RESULTS: A total of 481 patients were included: 271 (56.3%) in the TLA group and 210 (43.7%) in the control group. Patients receiving TLA were younger (50.3 vs. 53.7 years; p=0.025), while hormonal therapy (43.8% vs. 34.7%; p=0.047) and prior radiation (52.9% vs. 39.1%; p=0.003) were more common in controls. TLA patients had lower breast hematoma rates (2.2% vs. 6.2%; p=0.033). Linear regression showed reduced inpatient opioid use (29.4 MME lower; 95% CI: -45.29 to -13.45; p<0.001), discharge opioid prescriptions (36.1 MME lower; 95% CI: -58.27 to -13.98; p=0.001), and shorter hospital stays (3.4 vs. 3.9 days; p<0.001). CONCLUSIONS: TLA significantly reduces inpatient and discharge opioid use and hospital stay length without compromising pain control. Further study is needed to evaluate long-term opioid use and refill rates post-discharge.