Re-visiting post-breast surgery pain syndrome: risk factors, peripheral nerve associations and clinical implications

Abstract

Aesthetic and reconstructive breast surgery is among the most common operations performed by plastic surgeons. The prevalence of persistent pain after breast surgery remains underappreciated by plastic surgeons. Post breast surgery pain syndrome (PBSPS) is reported to range between 20-60%. It is the purpose of this paper to revisit chronic pain as a combination of the breast intervention and relate this to the peripheral nerve(s) transmitting the pain message, in order to understand the underlying etiology and to improve breast pain treatment outcomes.

Keywords: Breast surgery; breast pain; nerve surgery; post mastectomy pain.

Figure 1

Anatomical considerations and associated nerves in breast surgery.

Figure 2

Illustration of nerves potentially injured in breast surgery (A), depending on different approaches to implant placement and fat grafting (B), implant location and capsular contracture (C), mastectomy or lumpectomy and/or axillary lymph node sampling or dissection (D).

Figure 3

This is a patient that underwent breast augmentation through a wise incision about 1 year before she presented to our clinic with burning pain over the distribution of her second and third intercostals. Neuromas were found that were excised and buried in the muscle with appropriate outcome as evident by the resolution of her burning pain after the procedure.

Figure 4

This is a patient that had right partial mastectomy and lymph node sampling, followed by simple mastectomy for positive margins about 2 years ago. She was seen in our office for persistent pain over her axilla and inability to raise her arm above the level of the shoulder due to pain (A). A neuroma of the intercostobrachial nerve was found and resected (B) and implanted into the muscle under tension (C) to avoid scarring and neuroma reformation if left at the operative field.

Figure 5

The patient discussed in Figure 4 also had evidence of ulnar neuropathy and numbness along the medial antebrachial cutaneous nerve. The infraclavicular plexus was found to be scarred (A) and neurolysis (B) resulted in resolution of the paresthesias.

Figure 6

This patient presented with significant pain of her left lateral breast (A) following breast reconstruction with submuscular implant placement after breast resection for cancer. On exploration, neurolysis of the intercostal nerves stretched by the muscle pocket was performed (B). Her symptoms resolved after surgery.