Liposomal bupivacaine in transversus abdominis plane blocks for autologous breast reconstruction - Letter to the Editor

Sep 29, 2026

The letter evaluates liposomal bupivacaine (LB) for transversus abdominis plane (TAP) blocks in abdominally based free-flap autologous breast reconstruction, focusing on whether it provides meaningful analgesic benefit and reduces opioid exposure. It summarizes mixed evidence: limited or marginal pain-score improvements in randomized trials, but some retrospective claims suggesting reduced perioperative opioid requirements and readmissions, alongside a lack of consistent hospitalization reduction. It emphasizes unresolved uncertainties, dosing/technique variability, rebound pain, industry backing, and the absence of clear patient-selection guidelines, concluding that ERAS and multimodal analgesia remain central.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Letter to the Editor

Rationale and background

Evidence from randomized and retrospective studies

Interpretation, limitations, and patient selection

Future research directions

Letter to the Editor Liposomal bupivacaine in transversus abdominis plane blocks for autologous breast reconstruction Fnu Shahzaib, MBBSa , Arifa Arifa, MBBSb , Khursheed Ahmed, MBBSc , Aman Kumar Shah, MBBSd To the Editor, Effective analgesia is essential in abdominally based free-flap breast reconstruction, both for patient comfort and to minimize opioid exposure. Liposomal bupivacaine (LB) is a long-acting form of bupivacaine that is often used in transversus abdominis plane (TAP) blocks because it can relieve pain for up to 72 hours. However, its high cost and unpredictable results make ita controversial tool. A thorough examination of recent studies indicates only limited advantages and underscores significant deficiencies. This article is compliant with the TITAN Guidelines 2025 governing the declaration and use of artificial intelligence tools in research and publication[1] . Park et al executed a randomized controlled trial (n = 117 deep inferior epigastric perforator artery (DIEP) flap patients) to compare standard bupivacaine TAP with LB-enhanced TAP. They discovered no substantial decrease in opioid consumption or duration of hospitalization with LB; only a marginal reduction in mean pain scores after 24 hours was noted[2] . In a retrospective cohort study by Knackstedt et al (PRS Global Open 2024), the analysis of approximately 1000 insurance claims revealed that LB TAP was linked to significantly reduced perioperative opioid requirements (395 vs 512 MME) and 72-hour opioid consumption (63 vs 140 MME) when compared to plain bupivacaine[3] . This study also discovered a reduced incidence of 3-month readmissions in the LB group. Nguyen et al (Eur J Anaesthesiol 2023), in a meta-study that included 27 randomized controlled trials (RCTs), discovered that LB resulted in statistically low pain rating (mean ~0.7–0.9 points on a 0–10 scale at 24–72 hours) but did not affect opioid consumption[4] . The authors determined that the analgesic enhancements were not clinically significant. Bajaj et al (PRS Global Open 2024) examined ERAS protocols in autologous reconstruction. They aDepartment of Internal Medicine, Gujranwala Medical College Pakistan, Pakistan, bDepartment ofMedicine Bolan Medical College, Pakistan, cDepartment of Internal Medicine, Bolan Medical College, Quetta, Pakistan and dDepartment of Internal Medicine, BP Koirala Institute of Health Sciences, Janakpur, Nepal Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. *Corresponding author. Address: Department of Internal medicine, BP Koirala Institute of Health Sciences, Janakpur 45600, Nepal. Tel.: 9807626856. [E-mail: shahaman120@gmail.com](E-mail: shahaman120@gmail.com) (A.K. Shah). Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons AttributionNon Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Annals of Medicine & Surgery (2026) 88:1108–1109 Received 18 October 2025; Accepted 20 November 2025 Published online 4 December 2025 [http://dx.doi.org/10.1097/MS9.0000000000004500](http://dx.doi.org/10.1097/MS9.0000000000004500) stated that ERAS patients who received LB TAP stayed in the hospital for less time (about 3.7 days instead of 4.1 days) and that it cost about US$900 less per day of stay avoided, which led them to conclude that LB TAP was “cost-effective” within comprehensive care pathways[5] . When looked at as a whole, these data suggest that LB may not be very helpful in this situation. In practice, adding LB toa TAP block may provide marginal enhancement in pain management beyond the initial postoperative day; however, it has not consistently diminished opioid requirements or abbrevi

FAQs

Why is analgesia important in free-flap breast reconstruction using TAP blocks?

Effective analgesia supports patient comfort and helps minimize opioid exposure, especially in abdominally based free-flap procedures.

What do randomized controlled trial data suggest about LB TAP blocks?

Randomized evidence indicates no substantial reduction in opioid consumption or hospitalization duration, with at most a marginal reduction in mean pain scores after 24 hours.

Why is the overall evidence for LB TAP blocks considered inconclusive?

Retrospective claims may show benefits while RCTs do not; results vary by dosing and technique, rebound pain is not well studied, industry-supported studies may bias findings, and no clear, agreed patient-selection guidelines exist.

Sep 29, 2026

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