There are several surgical variables that may be associated with more severe post-reconstruction pain. In a study of 152 adult female patients, postoperative pain control was compared between those undergoing prepectoral breast reconstruction versus dual-plane device-based breast reconstruction. It was found that patients who underwent prepectoral reconstruction required significantly fewer days of postoperative opioid medication (4 vs. 7,
p = 0.009) and a significantly smaller percentage of opioid prescription refills (10 vs. 17,
p = 0.005). Overall, it was found that patients undergoing prepectoral reconstruction used opioids of 33% fewer days than those who underwent dual-plane reconstruction, suggesting that this surgical approach may be associated with reduced chronic postoperative pain. However, this study was limited by the lack of data on nonopioid medication consumed by patients [
25]. In another study of 2207 women undergoing breast reconstruction, patients with deep inferior epigastric perforator (DIEP) flaps or superficial inferior epigastric (SIEA) perforator flaps had less pain 1 week post-operatively compared to tissue expanders/implant reconstruction on the McGill Pain Questionnaire-Sensory scale (
p < 0.01,
p = 0.02). On the BREAST-Q scale, pedicle transverse rectus abdominis musculocutaneous flap, DIEP, and SIEA were all associated with significantly less pain than tissue expander/implant surgery [
23]. This suggests that tissue expander-based reconstruction may be associated with significantly more pain that other forms of surgical reconstruction. This is consistent with another retrospective review where tissue expander-based implant reconstruction was associated with higher analgesic requirements than single-stage II based reconstruction. In this study of 378 women, those who underwent tissue expander-based reconstruction used substantially more non-opioid (
p = 0.04), opioid (
p < 0.01), and benzodiazepine and muscle relaxant (
p = 0.06) medications than those in the single-stage II reconstruction. There was no difference in those who had immediate versus delayed reconstruction following mastectomy. It is hypothesized that the larger area of dissection and sustained expansion may play in a role in increased pain post-operatively in tissue-expander implant reconstruction. Increased fill size (> 250 cc) was also associated with higher morphine equivalence compared to smaller fill size (< 250 cc) on postoperative day two [
26]. In a study of 216 patients undergoing various types of breast surgery, the pain burden index (PBI) was significantly higher 6 months post-operatively in those with any type of axillary nodal procedure (
p < 0.001). Duration of surgery did not impact pain [
3]. In a 2-year follow-up study of patients who underwent breast reconstruction surgery, bilateral reconstruction was associated with increased chronic post-surgical pain syndrome (
p = 0.037). This study of 1996 women was assessed preoperative and 2 years post-operatively for pain. They demonstrated that pedicle transverse rectus abdominis musculocutaneous flaps (PTRAM), DIEP, and SIEA reconstruction patients reported more severe pain than TE/I patients 2 years post-operatively. Although prior studies indicated that TE/I reconstruction is associated with greater pain outcomes, this study suggests that breast reconstruction pain may evolve over time. However, one potential limitation of this study is that 93% of patients received immediate reconstruction [
7]. Further research is needed to understand which surgical techniques are associated with long-term postoperative pain.