Post-Augmentation Pain

[Winged Scapula]

For PRS, the bane of most of you is the decubs.

For me, its breast pain. Obviously, at the start of my practice I cannot refuse to see benign breast disease and see a few patients each week with mastalgia. For most its likely dietary or hormonal or related to structural things like large cysts or fibroadenomas.

However, I have a few who claim to have never had breast pain until they had augmentation. In some cases the complaints started immediately post-op and in one, resulted in removal of the devices. In others, it took months and persists years later. Examination and imaging are always normal of course. I assume its due to ICB involvement if there is no obvious device abnormality.

Have any of you found good success with NSAIDs or other medical treatments/interventions? Operating for pain is not satisfactory and I generally refuse to do it, knowing it won't help, especially if I don't have a definitive source.

But I feel like I need to solve this problem for these patients...perhaps its an impossible task.

Any good suggestions from your experiences? Sent one to pain mgt without any resolution (but she refused a nerve block).

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[MOHS_01]

I'll admit ignorance here -- what kind of pain are they describing? Pressure, ache, pinpoint, etc? Or is this your typical crazy don't want to be middle age symptoms (and anyone who has ever really spent time in clinical medicine knows what I am talking about). Does it have any correlation with pre-post size change? Perhaps it is some sort of neurpraxia secondary to stretch.

Have you tried compression +/- heat packs or may consider something along the lines of neurontin or elavil if you believe that it is neuropathic.

Best of luck -- the closest thing that I have had to deal with is scalp pain after a significant flap reconstruction, and it is unsatisfying as well.

 

[Winged Scapula]

The pain descriptions are all over the place.

One would not describe it as pain, only pressure. She corrected me every time I called it pain.

Another said it was a stinging. Yet another "like a razor".

At least one is crazy but she actually had some chest wall asymmetrical swelling. Her I think I have figured out...I think she is spasming and relaxants are helping (plus her pain ran from the scapula to the chest wall and down onto the breast). Others may be crazy as well, but I try not to assume that at least not initially.

Generally by the time they see me, their PCP and PRS have written them off and they've tried heat packs, NSAIDS, etc. I have not tried Neurontin because frankly I'm not a pain doctor and prefer not to get involved in treating someone with chronic pain.

One of them I was convinced had some sort of ICB neuroma as the pain was at the extreme lateral position of her scars (these are post mastectomy so they have the typical scars associated with that). Sent her to see Pain Mgt...finally on second visit she tells him it only hurts when she lifts the skin and tissue off the chest wall. I don't know what to make off that except as related to scar tissue.

The pre and post stretch is a real phenom but it doesn't make sense to me as most of them did not complain when the tissue expanders were placed.

OTOH, for those who are not post-mastectomy and are simple cosmetic augs, I suppose that could be the case but you would think the pain would be immediate and not have an onset years later.

I admit I'm stymied and hate to think they're crazy or miss something. But maybe its nothing I can do anything about.

 

[droliver]

Pain, usually occasional, is not that uncommon after breast augmentation.

I wasn't taught this, but I think pain after augmentation or reconstruction with implants are usually due to interaction of the capsule around the implant with the surrounding intercostal nerves. You can get traction on these nerves from the capsule which is what usually is what I think people are complaining about IMO. Higher grade capsular contracture can be particularly painful from traction.

At the lateral edge of the pocket you create for the implant, the intercostal perforator in that area can come out as far anterior as the midclavicular line or as far posterior as the mid axillae. I think people with more anterior nerves are more likely to get either numbness or pain from the capsule as it either has to be cut or displaced laterally by the implant which can "bowstring" it.

With really bad pain, I've had some success with marking the tender area on the breast and then doing a capsulotomy in that area.

Prior to that I'd prob. try a few things
1. high dose vitamin E - this is an old anecdotal tx. for capsule problems.
2. external ultrasound treatments
3. 2-3 months treatment with singulair or Acolate - these medicines are PDE inhibitors which apparently can attenuate the inflamatory process with some capsules.

 

[Winged Scapula]

Thanks Rob.

I have been going on the assumption that many of them were due to intercostal interruption or stretch, so glad to hear that you've had some thoughts in the same direction.

I generally recommend Evening Primrose Oil or Vit E, although the lit isn't very convincing, so generalized (non-aug) pain pts seem to get some relief with it. Thanks for the PDE info, I'll have to try that.

 

[droliver]

Kim,

A few things about those meds.

Singulair and Acolate can both cause liver enzyme elevation, with singulair believed to be a little less likely to. If you're going to try and treat this yourself, consider some baseline LFT's or (what I & most people do) just tell the patient what to look for ie. jaudice, RUQ pain, fevers.

Singulair just recently had some packaging label addition about how it can cause "suicidal ideation" this winter after a lawsuit. It's total bulls***, but it's in the PDR now. If people are on antidepressants you could inherit some liability by starting it if that's not discussed. The dosing is 10mg QHS, and I was told to use it for 2-3 months