Quick blog, as this will be boring to most of you, but this was a double blinded study in the recent Plastic Reconstructive Surgery Journal (March 2024) “Randomized Controlled Trial Comparing Liposomal to Plain Bupivacaine in the Transversus Abdominis Plane for DIEP Flap Reconstruction.”
I don’t do free flap breast reconstruction, but I do a lot of tummy tucks. When I do an abdominoplasty, I inject Exparel, which is a liposomal wrapped bupivacaine which is supposed to time release numbing for 72 hours, into the abdominal sheath. I have liked this. I for sure think it helps reduce abdominal pain after tummy tuck. Not only does this make you have less pain (yay!), but less pain means you get out of bed more, which lowers the risk of blood clots. It means you take deeper breaths, which lowers the risk of atelectasis and lung issues. It means you take less narcotics.
But is it worth it?
Exparel is not cheap. This study aimed to see if it is better than plain bupivacaine.
Study:
- Double blinded. 30 patients in each arm.
- Ultrasound guided TAP blocks were done
- They looked at narcotic use days 1-7, nonnarcotic pain use, time of first narcotic use, return of bowel function, and length of stay.
- ERAS protocol was followed (preop Tylenol and gabapentin, postop Tylenol, celebrex, and gabapentin)
- Discharge from hospital was 48 hours out.
- They used 20cc of 0.25% bupivacaine for the bupivacaine arm.
- The other arm was 20cc of 1.3% liposomal bupivacaine mixed with 20cc of .025% of bupivacaine for a total of 40cc.
Findings?
They found no difference between the two. In their discussion they do state that Exparel patients had better NPS scores but it did not reach statistical significance. They talk about how some postulate that the pH makes it difficult for the liposomal bupivacaine to penetrate cells and interrupt the signals to give numbing effect. (the first bupivicaines releases create an acidotic environment that prevents the later ones from working.)
My thoughts?
It is super interesting. I have used Exparel for years, and I think it helps my tummy tuck patients. Anything I can do to improve pain without narcotics is great. I try to come at the pain from many different directions. If just plain bupivacaine works as well? It would save money.