Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial
- Phil Hanwright
- Jul 18
- 2 min read
Updated: Oct 20
Key takeaways
Liposomal + plain bupivacaine TAP block did not lower opioid use vs plain bupivacaine alone after DIEP reconstruction (60.2 vs 66.9 MME; P = 0.47).
Pain scores improved modestly (VAS 3.6 vs 4.3; P = 0.004).
Length of stay (2.2 vs 2.1 days) and refill rates (17 % vs 22 %) were unchanged.
No differences in 30-day complications or flap failures.
Background
Enhanced-Recovery protocols for autologous breast reconstruction already curb narcotic needs. Whether adding the longer-acting liposomal bupivacaine to TAP blocks yields extra benefit remains uncertain.
Objective
To determine if liposomal bupivacaine in TAP blocks reduces postoperative opioid consumption after DIEP-flap breast reconstruction.
Methods
Design: Single-center, single-blinded RCT (Level II).
Setting: University of Virginia, March 2021–December 2022.
Participants: 117 women undergoing unilateral or bilateral DIEP flaps; 59 control (plain bupivacaine + epinephrine), 58 experimental (liposomal + plain bupivacaine + epinephrine).
Inclusion/Exclusion: ≥18 y; no active opioid use or allergy; ERAS pathway adherence.
Intervention: Surgeon-delivered intra-operative TAP block (80 mL control mix vs 100 mL liposomal mix).
Primary endpoint: Total postoperative opioid use in morphine-milligram equivalents (MME) during hospitalization.
Secondary endpoints: VAS pain scores (PACU through 48 h), length of stay, opioid refills, 30-day complications.
Stats: α = 0.05; t-test or Mann–Whitney U; power calculation ≥50 per arm.
Results
Opioids: Mean total MME 60.2 (liposomal) vs 66.9 (control); Δ –6.7 MME; NS (P = 0.47).
Pain: Overall mean VAS 3.6 vs 4.3 (–0.7 points); significant (P = 0.004).
Significant only in 24–48 h window (3.4 vs 4.1; P = 0.02).
Length of stay: 2.2 ± 0.6 vs 2.1 ± 0.4 days; P = 0.55.
Opioid refills: 17 % vs 22 %; P = 0.52.
Complications: No significant group differences in wound issues, thrombotic events, or flap loss (all P > 0.3).
Conclusion
Adding liposomal bupivacaine to TAP blocks improved subjective pain but did not reduce opioids, LOS, or complications versus plain bupivacaine within a standardized ERAS pathway.
Strengths & limitations
Randomized, blinded design within a uniform ERAS protocol.
Powered sample size with contemporary opioid-sparing regimen.
Single institution; potential type II error for opioid endpoint.
Pain scores not site-specific; postoperative outpatient opioid use unmeasured.
Future directions
Cost-effectiveness studies and exploration of alternative long-acting local anesthetics or catheter-based blocks are warranted.
Clinical relevance
For microsurgeons following ERAS, routine liposomal bupivacaine in TAP blocks may not justify extra cost—plain bupivacaine suffices for opioid minimization, though expect slightly higher early pain scores.
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