title: Botulinum toxin infiltration for pain control after mastectomy and expander reconstruction.
abstract: 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.
authors.affiliation: 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.
authors.forename: Rakhshanda
authors.initials: R
authors.lastname: Layeeque
authors.forename: Julio
authors.initials: J
authors.lastname: Hochberg
authors.forename: Eric
authors.initials: E
authors.lastname: Siegel
authors.forename: Kelly
authors.initials: K
authors.lastname: Kunkel
authors.forename: Julie
authors.initials: J
authors.lastname: Kepple
authors.forename: Ronda S
authors.initials: RS
authors.lastname: Henry-Tillman
authors.forename: Melinda
authors.initials: M
authors.lastname: Dunlap
authors.forename: John
authors.initials: J
authors.lastname: Seibert
authors.forename: V Suzanne
authors.initials: VS
authors.lastname: Klimberg
mesh_terms: 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
chemical_list: D000701:Analgesics, Opioid; D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A