Bilateral Reduction Mammoplasty
Patient phenotype
Mostly female, 30-60, BMI often elevated, large pendulous breasts causing back/neck/shoulder pain. Insurance-covered for medical necessity (pain + dermatologic complications) vs. cosmetic.
Procedure
Wise pattern incision, removal of glandular tissue + skin, repositioning of nipple-areolar complex (preserving blood supply). Bilateral, ~2-4 hours. Outpatient or 1-night stay.
Anesthetic plan
GETA. Multimodal analgesia (PECS block + ESP block + local infiltration). PONV prophylaxis (high-risk female + opioid use). Aim for outpatient discharge.
Setup
- ·Standard ASA + temp
- ·Two PIVs
- ·Type & screen (rarely transfused but possible)
- ·PECS or ESP block kit + ultrasound
- ·Forced air warmer
- ·DVT mechanical prophylaxis
Biggest concerns by phase
PONV high-risk profile
Female + non-smoker + history of motion sickness/PONV + opioid use + breast/abdominal surgery. Apfel commonly 4. Multimodal: scopolamine patch pre-op, dex 4-8 mg + ondansetron 4 mg + droperidol 0.625 mg + propofol-based maintenance.
Standard induction + multimodal opioid-sparing
Standard induction. Maintain opioid-sparing technique throughout. Lidocaine 1.5 mg/kg bolus + 1-2 mg/kg/hr infusion shown to reduce opioid need 30-50%.
Regional analgesia — PECS block or ESP block
PECS II block (local between pec major + pec minor + serratus) covers anterolateral chest. ESP block (paravertebral T2-T6) covers similar with simpler technique. 20-30 mL of 0.25% bupivacaine bilateral.
Positioning + airway in obese patient
BMI often elevated. Ramped position for intubation if needed. Arms abducted < 90° to protect brachial plexus + give surgical access.
Heat loss + duration
Long case + large surgical area exposed = heat loss. BAIR upper body, warm fluids, avoid hypothermia.
Outpatient discharge with regional
Effective regional → minimal opioid → safe outpatient discharge. PADSS score + driver. Counsel on ice, drains (if used), pain expectations, return for hematoma signs.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-year-old female, BMI 38, history of severe PONV with prior anesthetic. Bilateral reduction mammoplasty. Walk me through your PONV prophylaxis + analgesia plan.
What an examiner probes for
- ▹Pre-op: scopolamine patch + oral aprepitant if available
- ▹Intraop: dex 8 mg + ondansetron 4 mg + droperidol 0.625 mg + TIVA propofol
- ▹Avoid N₂O
- ▹Regional: bilateral PECS or ESP blocks
- ▹Multimodal: APAP, NSAID (if surgeon agrees), gabapentin 300 mg, lidocaine infusion
- ▹Postop: scheduled APAP/NSAID, breakthrough opioid only
Sources
- ASRA regional
- Miller's Ch 71
- Apfel PONV scoring
Anatomy reference
Sourced reference images. 4 matches for "breast chest thoracic skin".
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