Botulinum toxin infiltration for pain control after mastectomy and expander reconstruction.
BACKGROUND
We hypothesized botulinum toxin (BT) infiltration of the chest wall musculature after mastectomy would create a prolonged inhibition of muscle spasm and postoperative pain, facilitating tissue expander reconstruction.


METHODS
An Institutional Review Board (IRB)-approved prospective study was conducted of all patients undergoing mastectomy with tissue expander placement during a 2-year period. Study patients versus controls had 100 units of diluted BT injected into the pectoralis major, serratus anterior, and rectus abdominis insertion. Pain was scored using a visual analog scale of 0 to 10. Wilcoxon rank sum test was used for continuous variables and the chi2 test for nominal level data to test for significance.


RESULTS
Forty-eight patients were entered into the study; 22 (46%) with and 26 (54%) without BT infiltration. Groups were comparable in terms of age (55 +/- 11 years versus 52 +/- 10 years; P = 0.46), bilateral procedure (59% versus 61%; P = 0.86), tumor size (2 +/- 2 cm versus 2 +/- 3 cm; P = 0.4), expander size and volume (429 +/- 119 mL versus 510 +/- 138 mL; P = 0.5). The BT group did significantly better with pain postoperatively (score of 3 +/- 1 versus 7 +/- 2; P < 0.0001), during initial (score of 2 +/- 2 versus 6 +/- 3; P = 1.6 x 10(-6)), and final expansion (1 +/- 1 versus 3 +/- 2; P = 0.009). Volume of expansion per session was greater thus expansion sessions required less in the BT group (5 +/- 1 versus 7 +/- 3; P = 0.025). There was a significant increase in narcotic use in control patients in the first 24 hours (17 +/- 10 mg versus 3 +/- 3 mg; P < 0.0001), initial as well as final expansion periods (P = 0.0123 and 0.0367, respectively). One expander in the BT group versus 5 in the control group required removal (P = 0.13). There were no BT-related complications.


CONCLUSIONS
Muscular infiltration of botulinum toxin for mastectomy and tissue expander placement significantly reduced postoperative pain and discomfort without complications.
Layeeque
Rakhshanda
R
Department of Surgery, Division of Breast Surgical Oncology, University of Arkansas for Medical Sciences, Arkansas Cancer Research Center, and the Central Arkansas Veterans Hospital System, Little Rock, Arkansas, USA.
Hochberg
Julio
J
Siegel
Eric
E
Kunkel
Kelly
K
Kepple
Julie
J
Henry-Tillman
Ronda S
RS
Dunlap
Melinda
M
Seibert
John
J
Klimberg
V Suzanne
VS
D000701:Analgesics, Opioid / Q000627:therapeutic use; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D007902:Length of Stay; D016462:Mammaplasty; D008408:Mastectomy; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control*; D010369:Pectoralis Muscles / Q000187:drug effects; D011446:Prospective Studies; D017568:Rectus Abdominis / Q000187:drug effects; D013035:Spasm / Q000517:prevention & control; D018709:Statistics, Nonparametric; D015626:Tissue Expansion; D015625:Tissue Expansion Devices; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A