Regional anesthesia for breast surgery has evolved substantially over the past decade, driven by the goals of reducing perioperative opioid use, improving postoperative analgesia, and facilitating rapid recovery. A growing understanding of thoracic neuroanatomy and innovations in ultrasound-guided techniques have expanded the regional anesthesia techniques available. Although general anesthesia remains common, regional blocks—used alone or in combination with sedation—offer effective analgesia and can reduce systemic medication requirements. For medical professionals, familiarity with the range of options and their respective advantages is increasingly important in contemporary perioperative practice.
Breast surgery involves innervation from several overlapping neural territories, including the intercostal nerves, the supraclavicular branches of the cervical plexus, the pectoral nerves, and contributions from the sympathetic chain. No single block covers all these regions, making a multimodal regional anesthesia strategy particularly useful for breast surgery. The paravertebral block has long been considered a cornerstone technique because it provides unilateral segmental anesthesia by depositing local anesthetic near the thoracic spinal nerves. When used for procedures such as mastectomy or reconstructive surgery, it offers dense analgesia and can attenuate the stress response. Its limitations include technical difficulty, risk of pleural puncture, and potential hemodynamic changes, though ultrasound guidance has improved safety.
The erector spinae plane block has gained popularity as a simpler and potentially safer alternative. By administering local anesthetic deeply into the erector spinae muscle, anesthesiologists can achieve multilevel thoracic analgesia through anesthetic spread to the dorsal and ventral rami. While its mechanism continues to be studied, clinical experience suggests that it provides effective pain control for a range of breast procedures with a more superficial needle trajectory compared with the paravertebral approach. Although it may produce less dense anesthesia than a true paravertebral block, its technical ease and favorable safety profile make it an appealing option, especially in patients for whom deeper blocks pose higher risk or are difficult to achieve.
The pectoral nerve blocks, commonly referred to as PECS I and PECS II, specifically target the medial and lateral pectoral nerves, long thoracic nerve, thoracodorsal nerve, and the anterior branches of intercostal nerves. These blocks are particularly well suited for surgeries involving the pectoral fascia, implants, or axillary dissection. The PECS II modification extends coverage to the axilla, making it useful for oncologic procedures that include lymph node involvement. Because these blocks are performed in the fascial planes of the chest wall rather than near the neuraxis, they are generally well tolerated, with minimal hemodynamic impact.
The serratus anterior plane block offers another valuable option for regional anesthesia, especially for lateral breast surgery or extensive axillary work. By depositing anesthetic either superficially or deeply into the serratus anterior muscle, clinicians can achieve analgesia of the lateral thoracic wall and upper abdominal segments. This block is straightforward to perform and complements other techniques when broader coverage is needed.
In choosing among these approaches, clinicians must consider the extent and location of surgical manipulation, patient anatomy, anticoagulation status, and institutional expertise. Combining blocks can provide comprehensive analgesia when single techniques prove insufficient. Regardless of the specific method, ultrasound guidance has improved accuracy, reduced complications, and enabled wider adoption.
Regional anesthesia for breast surgery continues to expand as evidence supports its role in enhanced recovery pathways, reduction of chronic postsurgical pain risk, and improved patient satisfaction. For medical professionals, mastery of these techniques and their indications represents an important step toward optimizing perioperative care.