Reply to Trignano et al.: General Anesthesia Plus Sacral Erector Spinae Plane Block-Redefining Safe Anesthesia and Analgesia in Gluteal Augmentation.

We read with great interest the retrospective study by Trignano et al. on intramuscular gluteal augmentation under tumescent anesthesia and sedoanalgesia. While we commend the authors for performing this procedure outside the traditional setting of general anesthesia, certain anesthesiological concerns must be highlighted. Tumescent anesthesia requires close monitoring due to the risk of local anesthetic systemic toxicity, and deep sedation may mask early neurological warning signs. Furthermore, sedoanalgesia in the prone position raises airway safety concerns, particularly for procedures lasting up to two hours. The use of lidocaine as the primary anesthetic may also predispose patients to inadequate postoperative analgesia and rebound pain. As an alternative, we present our experience with a 23-year-old female undergoing bilateral intramuscular gluteal implant placement under general anesthesia, supplemented with bilateral sacral erector spinae plane block (S-ESPB). The block was performed with a safe dose of bupivacaine and lidocaine solution, and ultrasound guidance confirmed the absence of implant compression on the sacral plexus. Postoperative pain scores remained ≤ 3 for 24 hours with only scheduled oral paracetamol. S-ESPB, first described in 2019, primarily targets posterior lumbosacral branches with potential spread to ventral rami and cluneal nerves. By addressing fascial tension and proprioceptive components of pain, it provides effective analgesia in gluteal implant surgery. We conclude that combining general anesthesia with fascial plane blocks can enhance the safety and quality of recovery in these patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .