Prepectoral Direct-to-Implant Breast Reconstruction: Early Outcomes and Analysis of Postoperative Pain

Abstract Background Direct-to-implant (DTI) breast reconstruction provides high-quality aesthetic results in appropriate candidates. Most commonly, implants are placed in the subpectoral space which can lead to pain and breast animation. Surgical and technological advances have allowed for successful prepectoral implant placement which may eliminate these trade-offs. Objectives Here we present early outcomes from 153 reconstructions in 94 patients who underwent prepectoral DTI. We sought to determine whether these patients have less postoperative pain and narcotic use than subpectoral implant or expander placement. Methods A retrospective review was performed for all prepectoral DTI reconstructions at our institution from 2015 to 2016. Data were collected on postoperative pain and narcotic use while in hospital. Results The average follow-up time was 8.5 months (range, 3–17 months) and the overall complication rate was 27% (n = 41) with the most common complications being skin necrosis (9%, n = 13) and infection (7%, n = 11). No statistically significant difference in complications was found in patients who underwent postmastectomy radiation therapy. Patients who underwent prepectoral DTI reconstruction did not have a statistically significant difference in postoperative pain and narcotic use while in-hospital compared with other techniques. Conclusion Prepectoral DTI reconstruction provides good results with similar complication rates to subpectoral techniques. Prepectoral DTI eliminates the problem of breast animation. Although our series did not reach statistical significance in pain scores or requirement for postoperative narcotics, we believe that it is an important preliminary result and with larger numbers we anticipate a more definitive conclusion. Level of Evidence: 4

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Comprehensive Comparison Between Shaped Versus Round Implants for Breast Reconstruction: A Systematic Review and Meta-Analysis

Aesthetic Surgery Journal ◽

10.1093/asj/sjaa128 ◽

2020 ◽

Vol 41 (1) ◽

pp. 34-44 ◽

Cited By ~ 1

Author(s):

So-Eun Han ◽

Kyeong-Tae Lee ◽

Saik Bang

Keyword(s):

Breast Reconstruction ◽

Meta Analysis ◽

Breast Implant ◽

Capsular Contracture ◽

Complication Rates ◽

Level Of Evidence ◽

Relative Risks ◽

Patient Reported ◽

Aesthetic Results ◽

Retrospective Cohort Studies

Abstract Background Prosthetic breast reconstruction has been gaining popularity and a variety of implant options are currently available. Therefore, it is important to evaluate the safety and efficacy of newly developed shaped implants compared with those of conventional round implants. To date, few studies have investigated the outcomes of breast reconstruction with shaped versus round implants. Objectives The present study aimed to comprehensively compare, via meta-analytic methodology, shaped and round breast implant reconstruction in terms of complication profiles and aesthetic satisfaction. Methods PubMed/MEDLINE, Ovid, and Cochrane databases were searched to identify relevant studies presenting the complication rates for shaped and round implant groups. The relative risks of the following complications between the groups were calculated: infection, seroma, capsular contracture, rupture, rippling, reconstruction failure, and implant exchange or removal. Outcomes of aesthetic satisfaction included aesthetic results and patient-reported outcomes. Results Meta-analysis of 8 retrospective cohort studies, representing 2490 cases of implant-based breast reconstruction, was performed. There were no significant differences in the risks of infection, seroma, capsular contracture, and reconstruction failure between the 2 groups. The risks of implant rupture and rippling were significantly reduced with shaped implants. In a subgroup analysis of shaped/textured and round/smooth implants, the risk of infection was significantly enhanced in the former, whereas incidences of other complications, including capsular contracture and reconstruction failure, were similar. Aesthetic satisfaction analysis of the 2 groups demonstrated similar outcome scores with favorable overall results. Conclusions Our results suggest that both shaped and round implants might provide favorable breast reconstruction outcomes with similarly low complication rates and aesthetic results. Level of Evidence: 4

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Rigid versus flexible neuroendoscopy: a systematic review and meta-analysis of endoscopic third ventriculostomy for the management of pediatric hydrocephalus

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.2.peds2121 ◽

2021 ◽

pp. 1-11

Author(s):

Daphne Li ◽

Vijay M. Ravindra ◽

Sandi K. Lam

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Statistical Significance ◽

Flexible Endoscopy ◽

Third Ventriculostomy ◽

Complication Rates ◽

Inclusion Criteria ◽

Related Complication ◽

Rigid Endoscopy ◽

Pediatric Hydrocephalus ◽

Significant Difference

OBJECTIVE Endoscopic third ventriculostomy (ETV), with or without choroid plexus cauterization (±CPC), is a technique used for the treatment of pediatric hydrocephalus. Rigid or flexible neuroendoscopy can be used, but few studies directly compare the two techniques. Here, the authors sought to compare these methods in treating pediatric hydrocephalus. METHODS A systematic MEDLINE search was conducted using combinations of keywords: “flexible,” “rigid,” “endoscope/endoscopic,” “ETV,” and “hydrocephalus.” Inclusion criteria were as follows: English-language studies with patients 2 years of age and younger who had undergone ETV±CPC using rigid or flexible endoscopy for hydrocephalus. The primary outcome was ETV success (i.e., without the need for further CSF diversion procedures). Secondary outcomes included ETV-related and other complications. Statistical significance was determined via independent t-tests and Mood’s median tests. RESULTS Forty-eight articles met the study inclusion criteria: 37 involving rigid endoscopy, 10 involving flexible endoscopy, and 1 propensity scored–matched comparison. A cumulative 560 patients had undergone 578 rigid ETV±CPC, and 661 patients had undergone 672 flexible ETV±CPC. The flexible endoscopy cohort had a significantly lower average age at the time of the procedure (0.33 vs 0.53 years, p = 0.001) and a lower preoperatively predicted ETV success score (median 40, IQR 32.5–57.5 vs 62.5, IQR 50–70; p = 0.033). Average ETV success rates in the rigid versus flexible groups were 54.98% and 59.65% (p = 0.63), respectively. ETV-related complication rates did not differ significantly at 0.63% for flexible endoscopy and 3.46% for rigid endoscopy (p = 0.30). There was no significant difference in ETV success or complication rate in comparing ETV, ETV+CPC, and ETV with other concurrent procedures. CONCLUSIONS Despite the lower expected ETV success scores for patients treated with flexible endoscopy, the authors found similar ETV success and complication rates for ETV±CPC with flexible versus rigid endoscopy, as reported in the literature. Further direct comparison between the techniques is necessary.

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Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

Neurosurgery ◽

10.1093/neuros/nyy636 ◽

2019 ◽

Vol 86 (1) ◽

pp. 30-45 ◽

Cited By ~ 7

Author(s):

Ketan Yerneni ◽

John F Burke ◽

Pranathi Chunduru ◽

Annette M Molinaro ◽

K Daniel Riew ◽

...

Keyword(s):

Safety Profile ◽

Meta Analysis ◽

Anterior Cervical Discectomy ◽

Complication Rates ◽

Outpatient Basis ◽

Level Of Evidence ◽

Cervical Discectomy ◽

Significant Difference ◽

Level I ◽

High Level

ABSTRACT BACKGROUND Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. OBJECTIVE To review the medical literature on the safety of outpatient ACDF. METHODS We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. RESULTS We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). CONCLUSION Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.

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A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques

Aesthetic Surgery Journal ◽

10.1093/asj/sjz045 ◽

2019 ◽

Vol 39 (9) ◽

pp. 927-942 ◽

Cited By ~ 15

Author(s):

Andrew A Jacono ◽

A Sean Alemi ◽

Joseph L Russell

Keyword(s):

Facial Nerve ◽

Nerve Injury ◽

Meta Analysis ◽

Complication Rates ◽

Level Of Evidence ◽

Facial Nerve Injury ◽

Significant Difference ◽

Meta Analyses ◽

Smas Flap

AbstractBackgroundSub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection.ObjectivesThe authors sought to aggregate and summarize data on complications among different SMAS facelift techniques.MethodsA broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsA total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01).ConclusionsThere are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile.Level of Evidence: 2

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Thermography in persistent postoperative pain after knee surgery

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00330 ◽

2020 ◽

Vol 8 (5_suppl4) ◽

pp. 2325967120S0033

Author(s):

David Friedrich ◽

Manuel Köhne

Keyword(s):

Postoperative Pain ◽

Control Region ◽

Local Anaesthesia ◽

Level Of Evidence ◽

Total N ◽

Diagnosis And Therapy ◽

Significant Difference ◽

Thermographic Image ◽

Persistent Postoperative Pain ◽

The Difference

Aims and Objectives: Background: Postoperative persistent pain occurs in approximately 10% of surgically treated patients. It incapacitates and reduces quality of life in those affected. The aetiology is poorly understood, predictive factors are currently unknown, diagnosis and therapy are difficult. Objectives: To evaluate the benefit of dermal thermography in the diagnosis and therapy of persistent postoperative pain. Study design: retrospective, Level of evidence IV Materials and Methods: A single surgeon performed highly standardized ACL reconstructions, arthroscopies and total endoprotheses of the knee. Patients were seen six weeks postoperative for clinical and thermographic evaluation. Regions of interest were defined for the affected knee, a control region defined for the contralateral knee. The thermographic image was used to pinpoint a site for subcutaneous local anaesthesia. The clinical evaluation was then repeated. Results: Patients in total (n=133), arthroscopy (n=21), total endoprothesis (n=42), ACL (n=50). If the temperature difference (TD) between the site of pathology and the average ipsilateral knee temperature was negative, pathology was classified as hypothermic (n=19), otherwise hyperthermic (n=94). Arthroscopically treated patients showed a TD of 0,88 ± 0,39 °C in hyperthermic (n=12) and -0,811 ± 0,623 °C in hypothermic (n=9) knees. Prosthetically treated patients showed a TD of 1,29 ± 0,51 °C in hyperthermic (n=37) and -0,88 ± 0,33 °C in hypothermic (n=5) knees. ACL treated patients showed a TD of 1,20 ± 0,48 °C in hyperthermic (n=45) and -0,62 ± 0,41 °C in hypothermic (n=5) knees. The difference in temperature between the site of pathology and the average temperature of the ipsilateral knee was significant for all subgroups: arthroscopy-hypothermic p < 0,001, arthroscopy-hypothermic p < 0,005; endoprothesis-hyperthermic p < 0,001, endoprothesis-hypothermic p < 0,004; ACL-hyperthermic p < 0,001, ACL-hypothermic p < 0,027. In contrast to the hyperthermic groups (for all p < 0,001), there was no significant difference between the site of pathology and the contralateral control region in the hypothermic groups. All patients reported a reduction of pain and better mobility after subcutaneous infiltration with Scandicain 2% at the thermographically defined site of pathology. Conclusion: Thermography is useful to pinpoint sites of pathology in persistent postoperative pain. Two types of thermal abnormality could be identified at the site of pathology: hypo- and hyperthermic. Local anaesthesia at the site of pathology resulted in pain reduction and improved mobility. Further studies are necessary to understand the postoperative thermal changes in order to devise a suitable therapy.

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Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1692168 ◽

2019 ◽

Vol 35 (08) ◽

pp. 622-630

Author(s):

Han Gyu Cha ◽

Min Kyu Kang ◽

Hyun Ho Han ◽

Eun Key Kim ◽

Jin Sup Eom

Keyword(s):

Breast Reconstruction ◽

Ct Angiography ◽

Patient Selection ◽

Surgical Outcomes ◽

Selection Criteria ◽

Diep Flap ◽

Complication Rates ◽

Abdominal Scar ◽

Significant Difference ◽

Patient Selection Criteria

Abstract Background The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. Methods We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. Results The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was −0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. Conclusion The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

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Discrepancy in Postoperative Outcomes between Auditing Databases: A NSQIP Comparison

The American Surgeon ◽

10.1177/000313481808400839 ◽

2018 ◽

Vol 84 (8) ◽

pp. 1294-1298 ◽

Cited By ~ 3

Author(s):

William B. Lyman ◽

Michael Passeri ◽

Allyson Cochran ◽

David A. Iannitti ◽

John B. Martinie ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Statistical Significance ◽

Postoperative Pancreatic Fistula ◽

Complication Rates ◽

Audit System ◽

Acs Nsqip ◽

Outcome Reporting ◽

Significant Difference ◽

Chi Squared

In 2014, ACS-NSQIP® targeted pancreatectomies to improve outcome reporting and risk calculation related to pancreatectomy. At the same time, our department began prospectively collecting data for pancreatectomy in the Enhanced Recovery After Surgery® Interactive Audit System (EIAS). The purpose of this study is to compare reported outcomes between two major auditing databases for the same patients undergoing pancreatectomy. The same 171 patients were identified in both databases. Clinical outcomes were then obtained from each database and compared to determine whether reported complication rates were statistically different between auditing databases. A combination of Wilcoxon rank sum and Pearson's chi-squared tests were used to calculate statistical significance. No significant difference was appreciated in captured demographics between EIAS and NSQIP. Significant differences in reported rates for renal dysfunction, postoperative pancreatic fistula, return to the operative room, and urinary tract infection were noted between EIAS and NSQIP. Although significant differences in reported complication rates were demonstrated between EIAS and NSQIP for pancreatectomy, much of the discrepancy is attributable to subtle differences in definitions for postoperative occurrences between the two auditing databases. It is vital for surgeons to understand the exact definition that determines the complication rate for a given database.

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The effect of chemotherapy on the complication rates of implant and free flap breast reconstruction: A Systematic Review

10.21203/rs.3.rs-1144851/v1 ◽

2021 ◽

Author(s):

Ishith Seth ◽

Gabriella Bulloch ◽

Damien Gibson ◽

Nimish Seth ◽

David J Hunter-Smith ◽

...

Keyword(s):

Breast Reconstruction ◽

Systemic Therapy ◽

Risk Of Bias ◽

Complication Rates ◽

Flap Reconstruction ◽

Reconstruction Surgery ◽

Significant Difference ◽

Complications Rate ◽

Grade Assessment ◽

Implant Reconstruction

Abstract Purpose This study investigated the impact of chemotherapy on complication rates of implant and free flap breast reconstruction. The effect of timing and dosage of chemotherapy in minimizing the breast reconstruction surgery (BRS) complications were also investigated. Methods PRISMA guidelines were used to search relevant studies published from January 2009 to September 2021. Quality of selected studies were assessed using GRADE assessment and risk of bias was performed using Cochrane Collaboration’s tool and ROBINS-I. Rates of major and minor complications of neoadjuvant systemic therapy (NST) and adjuvant systemic therapy (AST) were compared by t-test using GraphPad Prism v.9.3.0 and P value <0.05 was considered statistically significant. Results A total of 19 studies comprising 49,217 patients were included. The GRADE assessment showed low risk of bias and good quality across studies. Three-hundred and twenty patients had implant reconstruction, 3,172 had flap reconstruction and 46,062 had both flap and implant reconstruction surgery. There was no significant difference in complication rates of patients between flap reconstruction surgery and implants. (P=0.4) In all studies, total complication rates for post-chemotherapy BRS patients was 46.03% compared to 32.49% without chemotherapy (P=0.09). Overall major complications rate was 14.5% (P=0.61) with NST and 21.1% (P=0.69) with AST. Minor complications rate was 28.8% (P=0.97) with NST and 39.5% (P=0.59) with AST. Complication rate of NST was lower than AST, but not statistically significant (P=0.64). No significant correlation was found between timing/duration of chemotherapy and rates of BRS complications (P=0.76). Conclusion No significant difference in BRS complications with and without chemotherapy was established. Despite these results suggesting little difference between NST and AST or chemotherapy in BRS complications, prospective control studies are currently limited, and more are necessary to better inform surgeons and their patients.

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Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator flap breast reconstruction?

Archives of Plastic Surgery ◽

10.5999/aps.2019.01417 ◽

2020 ◽

Vol 47 (4) ◽

pp. 324-332

Author(s):

Alexander A. Azizi ◽

Anita T. Mohan ◽

Taj Tomouk ◽

Elizabeth B. Brickley ◽

Charles M. Malata

Keyword(s):

Postoperative Pain ◽

Breast Reconstruction ◽

Hospital Stay ◽

Diep Flap ◽

Inferior Epigastric Artery ◽

Epigastric Artery ◽

Significant Difference ◽

Deep Inferior Epigastric Artery ◽

Postoperative Morphine ◽

Artery Perforator

Background The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction.Methods A 7-year retrospective cohort study (2008–2015) of a single-surgeon’s DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression.Results The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients’ mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001).Conclusions Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions.

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Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia

Journal of Hand and Microsurgery ◽

10.1055/s-0037-1603734 ◽

2017 ◽

Vol 09 (02) ◽

pp. 080-083 ◽

Cited By ~ 1

Author(s):

Asif Ilyas ◽

Joseph Labrum

Keyword(s):

Postoperative Pain ◽

General Anesthesia ◽

Local Anesthesia ◽

Joint Arthroplasty ◽

Opioid Consumption ◽

Level Of Evidence ◽

Pain Experience ◽

Pain Scores ◽

Significant Difference ◽

Basal Joint

Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection. Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents. Results Two-tailed t-test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort. Conclusion The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients. Level of Evidence Therapeutic level III.

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