Battle of the Blocks: Which Pain Management Technique Triumphs in Gender-Affirming Bilateral Mastectomies?

Abstract

Background: Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds.

Methods: A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques.

Results: The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements.

Conclusion: The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.

Keywords: Analgesic efficacy; Chronic testosterone therapy; Erector spinae plane block; Gender-affirming mastectomy; Non-binary individuals; Pectoral nerve block; Retrospective analysis; Thoracic wall infiltration.

Figure 1

The mean intraoperative morphine milligram equivalent (MME) scores for each group (PECS, ESP, SMA, TWI) with 95% confidence intervals. Each bar represents the average MME score for a group, visually comparing the anesthesia requirements across the different groups. PECS: pectoral nerve; ESP: erector spinae plane; TWI: thoracic wall local anesthesia infiltration; SMA: systemic multimodal analgesia.

Figure 2

Bar graph representing the post-anesthesia care unit (PACU) morphine milligram equivalent (MME) for each group, complete with a legend indicating the mean PACU MME with standard error of the mean (SEM).

Figure 3

The mean pain scores at different time intervals (30, 60, 90, and 120 min) for each group (PECS, ESP, SMA, TWI) along with their 95% confidence intervals allowing for a direct comparison of how pain scores evolve for each treatment group. PECS: pectoral nerve; ESP: erector spinae plane; TWI: thoracic wall local anesthesia infiltration; SMA: systemic multimodal analgesia.

Figure 4

NRS pain scores on postoperative day 2 (POD 2) for the four groups. NRS: numeric rating scale.

Figure 5

The mean interval between arrival to post-anesthesia care unit (PACU) and administration of first rescue dose, with error bars representing the standard deviation for each group.

Figure 6

The average time spent in the post-anesthesia care unit (PACU) by group, with error bars representing the standard deviation for each group.