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Selective Ultrasound Guided Pectoral Nerve

Targeting in Breast Augmentation: How to Spare
the Brachial Plexus Cords?
Department of Anesthesia, Clinique Chirurgicale de Laval, Laval, Que bec, Canada
Department of Chemistry-Biology, University of Quebec at Trois-Rivie `res, Trois-Rivie `res,
Que bec, Canada
Subpectoral breast augmentation surgery under regional anesthesia requires
the selective neural blockade of the medial and lateral pectoral nerves to di-
minish postoperative pain syndromes. The purpose of this cadaver study is to
demonstrate a reliable ultrasound guided approach to selectively target the
pectoral nerves and their branches while sparing the brachial plexus cords. Af-
ter evaluating the position and appearance of the pectoral nerves in 25 cadav-
ers (50 sides), a portable ultrasound machine was used to guide the injection
of 10 ml of 0.2% aqueous methylene blue solution in the pectoral region on
both sides of three Thiels embalmed cadavers using a single entry pointtri-
ple injection technique. This technique uses a medial to lateral approach with
the entry point just medial to the pectoral minor muscle and three subsequent
inltrations: (1) deep lateral part of the pectoralis minor muscle, (2) between
the pectoralis minor and major muscles, and (3) between the pectoralis major
muscle and its posterior fascia under ultrasound visualization. Dissection dem-
onstrates that the medial and lateral pectoral nerves were well stained while
leaving the brachial plexus cords unstained. We show that 10 ml of an injected
solution is sufcient to stain all the medial and lateral pectoral nerve branches
without a proximal extension to the cords of the brachial plexus. Clin. Anat.
26:4955, 2013. V VC
2012 Wiley Periodicals, Inc.
Key words: brachial plexus; pectoral nerves; local anesthesia; selective tar-
geting; anatomy; cadaver study; breast augmentation; ultrasound
Breast augmentation is the most commonly per-
formed cosmetic procedure among American women,
most often on an outpatient basis (Pelosi and Pelosi,
2010). Because of the increased tissue coverage
over the upper pole of the breast, the subpectoral
approach of breast implant insertion is the technique
most often employed in comparison with the sub-
glandular approach. With the subpectoral approach,
the breast implant is inserted under the pectoralis
major muscle and more severe pain is expected
compared with the subglandular approach (Wallace
et al., 1996). Thoracic paravertebral block has been
used as a sole anesthetic technique without the need
of general anesthesia for breast surgery; but almost
exclusively for breast cancer surgery (Greengrass
et al., 1996; Coveney et al., 1998; Pusch et al.,
1999; Naja et al., 2003). It has been rarely used as
an anesthetic technique for subpectoral breast aug-
mentation (Cooter et al., 2007; Schnabel et al.,
2010; Tahiri et al., 2011), because it provides only
an incomplete anesthesia for this type of surgery
due to the fact that innervation of the pectoral
*Correspondence to: Detlev Grabs, Department of Chemistry-
Biology, University of Quebec at Trois-Rivie `res, 3351 boul. des
Forges, Trois-Rivie `res, Que bec G9A 5H7, Canada.
E-mail: grabs@uqtr.ca
Received 26 February 2012; Revised 4 May 2012; Accepted 17
May 2012
Published online 21 June 2012 in Wiley Online Library
(wileyonlinelibrary.com). DOI 10.1002/ca.22117
2012 Wiley Periodicals, Inc.
Clinical Anatomy 26:4955 (2013)
muscles are not blocked by this regional technique
(Lemay et al., 2004; Boezaart and Raw, 2006) or is
used together with general anesthesia (personal
communication, Greengrass, 2011).
The pectoralis major and minor muscles are inner-
vated by the medial and lateral pectoral nerves
(Fig. 1). Description of pectoral nerves available in
general anatomy textbooks is often simplied and
confusing. However anatomical studies have been
investigating the course of the pectoral nerves for a
long time (Kerr, 1918) and recently articles on pec-
toral nerve anatomy have been published in the liter-
ature (Loukas et al., 2006; Macchi et al., 2007;
Tubbs et al., 2010; Porzionato et al., 2012; Sefa
Ozel et al., 2011). Even though these nerves are
described in most textbooks as purely motor nerves,
as seen in the daily surgical practice these nerves
can be considered to transport also proprioceptive
and nociceptive bers as shown for other motor
nerves (Bremner-Smith et al., 1999). In some
patients, there might be an additional innervation
from the fourth intercostal nerve as recently
described in the literature (Beheiry, 2012). To our
knowledge, a specic pectoral nerve block technique
targeting the entity of these nerves has not been
described. Partial targeting of the lateral pectoral
nerve (Blanco, 2011; Sefa Ozel et al., 2011) or crude
inltration of the pectoral region in an attempt to
block these nerves (Pickrell et al., 1977; Parker and
Charbonneau, 2004; Bell, 2007; McCarthy et al.,
2009) has been already described and utilized by
surgeon for breast augmentation under local anes-
thesia but cannot be considered a complete pectoral
nerve block. This cadaver study aims to show an
ultrasound guided technique to reach and stain all
the pectoral nerve branches in a selective fashion.
After approval of the local ethics committee of the
Universite du Que bec a ` Trois-Rivie `res, a total of 28
cadavers were investigated in this study. First, 25
cadavers, 15 male and 10 female subjects with an
average age of 75.3 years, embalmed with a classi-
cal formalin method were dissected to evaluate the
precise anatomical localization of the pectoral nerves
in relation to the pectoralis minor muscle (Fig. 2).
Three cadavers embalmed according to Thiels tech-
nique were then used (Thiel, 1992a,b, 2002) to eval-
uate the ultrasound guided pectoral nerve approach.
This embalming technique has been shown to offer
excellent conditions for ultrasound guided regional
technique (Benkhadra et al., 2009) because of the
cadavers impressive exibility and realistic tactile
sensation without postmortem rigidity (Jaung et al.,
2011). The Thiel cadavers, two male and one female
subjects which ranged in age from 67 to 88 years
with a BMI ranging from 20.3 to 28.3, were used to
accomplish six injections. The ultrasound guided
injection technique suggested here was developed
after reviewing the variable anatomy of the medial
and lateral pectoral nerves in the 25 cadavers and
the anatomical literature that has rened and stud-
ied in details the pectoral nerves.
An ultrasound machine (GE LogiqE, General Elec-
tric Company, Mississauga, ON) with its linear array
transducer was used (38 mm, 812 MHz). All needle
placements, using a 21 ga 100 mm echogenic needle
(Hakko Medical, Nagano, Japan) were performed by
Fig. 1. Anatomical position of the pectoral nerves.
Pectoral nerves arise distal to the clavicle and posterior
to the pectoralis major muscle (PM). Thereby the lateral
pectoral nerve (Npl) originates from the lateral cord (Cl)
of the brachial plexus and appears medial of the pector-
alis minor muscle (Pm) and is often accompanied by the
pectoral branch of the thoracoacromial artery (Ata), a
branch of the axillary artery (Aax). The medial cord
(Cm) often gives two medial pectoral nerve (Npm)
branches that appear laterally to or pierce the pectoralis
minor muscle that attaches to the coracoid process (Pc)
and often an ansa pectoralis (Ansa) can be found
between the medial and lateral branches.
Fig. 2. Appearance of the pectoral nerves in rela-
tion to the pectoralis minor muscle in classical cadavers.
50 Desroches et al.
one investigator (J.D.) who was procient with ultra-
sound guided regional anesthesia. The liquid injected
was an aqueous solution of 0.2% methylene blue
and the injection was made under real-time ultra-
sound visualization. The total volume injected was
arbitrarily set at 10 ml.
The ultrasound transducer was placed 4-cm cau-
dal to the coracoid process with the medial margin of
the transducer being situated at the midclavicular
line and perpendicular to the pectoralis minor muscle
(Fig. 3). The needle was inserted in-plane from
medial to a lateral direction (Figs. 3 and 4). The nee-
dle tip was aimed and visualized by ultrasound at the
deep lateral portion of the pectoralis minor muscle
and a third of the 10-ml dye solution was injected
between the muscle and its posterior fascia. The
needle was partially withdrawn and a second third of
the solution was injected when the tip was located
between the pectoralis minor and major muscles.
Finally, the needle was further withdrawn under
ultrasound guidance to its nal injection position and
the remaining third of the volume was applied
between the pectoralis major muscle and its poste-
rior fascia. The rst injection was intended to block
the medial pectoral nerve which courses on the deep
surface of the pectoralis minor muscle to nally
reach the lateral part of the pectoralis major muscle.
The second injection was intended to block the vari-
able number of perforating branches of the medial
pectoral nerve that emerge from the pectoralis minor
to reach the deep surface of the pectoralis major.
Finally, the third injection was intended to block the
lateral pectoral nerve that courses on the deep sur-
face of the pectoralis major parallel to the thoracoa-
cromial vessels (see Fig. 1).
Dissections were performed between 15 and 30
min after the injection by a single investigator
(D.G.). The skin and subcutaneous tissues were
removed from the pectoral region. The pectoralis
major muscle was dissected and detached from its
sternocostal and clavicular attachments and
reected carefully cephalad and lateral to expose the
pectoralis minor muscle, taking care not to disrupt
possible perforating nerve branches coming through
the pectoralis minor muscle. The lateral and medial
pectoral nerves were identied and examined to
determine if the dye had reached and colored them
and their course was followed up to their medial or
respectively lateral cord levels. Correct identication
of these nerves as the medial and lateral nerves was
conrmed after disarticulating the clavicle and fol-
lowing the nerves up to their origin at the brachial
plexus cord level. Dye coloration at the cord level
was also evaluated for its presence.
The initial evaluation of the course of the pectora-
lis nerves on the 25 cadavers revealed that there is
indeed a wide variability. Investigating these 25
cadavers (50 sites), the lateral pectoral nerves
appear in 90% of cases medial to the pectoralis
minor muscle while a majority of the medial pectoral
Fig. 3. External position of the ultrasound transducer and the injection needle.
The transducer is positioned perpendicular to the pectoralis minor muscle at 4 cm
caudal to the coracoid process (Pc) with the medial margin of the transducer
aligned to the midclavicular line. The needle is introduced from the medial side of
the transducer.
51 Selective Ultrasound Guided Pectoral Nerve Block
nerves appear only lateral to this muscle (72%,
Fig. 2 and Table 1). However it is not possible to pre-
dict the course of these nerves or additional upper or
lower branches in a given patient, making it difcult
to reach all branches innervating the pectoralis
muscles by simple inltration.
The appearance and course of the pectoral nerve
branches were also identied in the injected Thiel
cadavers. Four medial pectoral branches appeared
lateral to the pectoralis minor muscle, two medial
branches were found lateral and piercing the muscle
and all six lateral branches passing medial to the
pectoralis minor muscle, which is in concordance to
the other cadavers. For the six pectoral regions of
the three Thiel cadavers, the single entry pointtri-
ple inltration (Figs. 3 and 4) showed a contained
dye spread in each of the three injected planes.
There was no continuity of the dye solution between
the interpectoral region and the posterior pectoralis
minor muscle region (Fig. 5). We found that the lat-
eral and medial pectoral nerves and all their
branches were stained with the dye solution in all
investigated regions. These nerves were followed up
to their cord origin which did not show any dye stain-
ing (Fig. 6).
This cadaver study evaluates and demonstrates
the feasibility to use an ultrasound guided approach
to block the medial and lateral pectoral nerves. To
our knowledge this is the rst description of an ultra-
sound guided complete and selective pectoral nerve
block. Inltration of the pectoral region in an attempt
to block these nerves has been utilized by surgeons
for breast augmentation under local anesthesia
before (Pickrell et al., 1977; Blanco, 2011) The limi-
tations with the inltration technique are the high
volume of local anesthetic needed (up to 100 ml)
and the less precise nature of this technique not
being done with the help of ultrasound. This impreci-
sion might translate into a less optimal neural block-
ade and a higher risk of pneumothorax. Their inltra-
tion technique relied on the necessity of blocking the
pectoral nerves to afford a reliable and a comfortable
technique for the patient and we agree, as others
(Lemay et al., 2004; Boezaart and Raw, 2006), with
this principle.
Thiels embalmed cadavers are ideal models for
ultrasound guided block studies because of their
impressive exibility and realistic tactile sensation
(McLeod et al., 2010). This embalming technique
is still not used extensively in anatomical depart-
ment, one of the reasons being its higher cost
compared to traditional embalming technique
(Benkhadra et al., 2011). This higher cost has also
limited us in studying the ultrasound technique
on only three cadavers (six inltrations), which is
a study limitation, however all inltration worked
The technique proposed here is intended to gain
complete access for the anesthetic agent to the en-
tity of the multiple and variably located terminal
branches of the pectoral nerves in an easy and more
precise fashion. This triple injection approach was
developed after reviewing the results of our topo-
graphical nding which are in accordance to the
updated anatomy literature of the pectoral nerves
and their variable course in relation to the pectoral
muscles (Kerr, 1918; Macchi et al., 2007; Porzionato
et al., 2012; Sefa Ozel et al., 2011). However, our
technique does not rely on the precise identication
of the pectoral nerves but on the ultrasound localiza-
tion of the pectoralis major and minor muscles and
the presumed course of the pectoral nerves in this
area, making it easy to apply. In the clinical practice
the pulsatile pectoral branch of the thoracoacromial
artery could be used as an additional landmark
(Blanco, 2011; Sefa Ozel et al., 2011). This block is
conceptually similar to a fascial plane block like the
Fig. 4. Ultrasound image for the triple injection
technique. A: The pectoralis major (PM) and the pector-
alis minor (Pm) muscles are visualized by ultrasound.
The needle was inserted through the subcutaneous tis-
sue (SC) from the medial side (med) of the pectoralis
minor muscle until the tip (with etched markers) is visi-
ble at the deep injection point. B: The drawing indicates
that one third (3.3 ml) of the solution was placed lateral
(lat) below the Pm (1.). For further injection, the needle
was partially withdrawn until the needle tip was visual-
ized between the PM and Pm. The second third (3.3 ml)
of the solution was injected (2.). The needle tip is nally
placed to the posterior fascia of the PM and the remain-
ing volume of 3.4 ml was injected (3.).
52 Desroches et al.
Fig. 5. Dissection of the pectoralis muscles (left side). The pectoralis major
muscle (PM) has been detached from his sternocostal attachment and reected,
revealing the pectoralis minor muscle (Pm). The branches of the medial pectoral
(Npm) and lateral pectoral nerves (Npl) are visible and heavily stained by the color
Fig. 6. Dissection of the brachial plexus (left side).
The gure shows the precise localization of colored
injectate. The clavicle has been partially removed (Clav)
and the subclavian artery (Asub) has been cut. The pec-
toralis major (PM) and minor (Pm) muscle has been
reected showing their posterior sides. The brachial
plexus is seen emerging posterior to the scalene ante-
rior muscle (Mscalant). The medial (Npm) and lateral
pectoral (Npl) nerves are stained while the lateral cords
(Cl) and the medial cord (Cm) of the brachial plexus
and the ansa pectoralis (Ansa) remain unstained.
53 Selective Ultrasound Guided Pectoral Nerve Block
transversus abdominis plane block (Kadam and
Field, 2011).
The volume of 10 ml of solution was chosen so
that, if a breast augmentation was to be performed
under pectoral and paravertebral nerve block, a total
local anesthetic volume of 40 ml (10 ml per paraver-
tebral block each side and 10 ml per pectoral block
each side) would not be exceeded. Even though we
are aware that different types of local anesthetics
are being used in the clinical practice, if bupivacaine
0.5% was chosen, this volume would represent for
most patients the maximum recommended dose of
local anesthetic (Evans et al., 2008).
The triple injection technique is very efcacious in
staining the pectoral nerves without the extension to
the cords. This proximal extension was not desirable
because clinically this block would produce an upper
limb weakness. The medial to lateral direction of the
needle and the low volume of the solution injected in
the clavipectoral fascia in the triple injection tech-
nique are probably the reasons why the solution did
not reach the brachial plexus cords; however, it can
be presumed that potential variations of upper or
lower nerve branches innervating the pectoralis
muscles (Kerr, 1918; Aszmann et al., 2000; Beheiry,
2012) will be included in the target region. One has
to consider that the rst third of the injection is pos-
terior to the pectoralis minor muscle, so it carries a
higher risk of pneumothorax that can be lowered by
accurate ultrasound visualization.
This anatomical study has demonstrated that it is
possible to reach the entity of pectoral muscle nerve
branches with a single entry pointtriple injection
ultrasound technique. The technique demonstrated
here could be advantageous because a general
brachial plexus block was avoided. However, we are
well aware that this is a cadaver study and that the
clinical application needs to be further addressed.
The authors express their gratitude to the families
who participated in the donation program of the Uni-
versity of Quebec at Trois-Rivie `res. They thank the
Department of Chemistry-Biology of the University of
Quebec at Trois-Rivie `res and the team of the labora-
tory of anatomy for their support.
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TABLE 1. Course of the Pectoral Nerves in Relation to the Pectoralis Minor Muscle in Classical
Anatomical Cadavers (125) and Thiel Cadavers (T1T3)
Right site Left site
Lateral pectoral nerve Medial pectoral nerve Lateral pectoral nerve Medial pectoral nerve
1 Medial + perforating Lateral Medial Lateral
2 Medial Lateral + perforating Medial Lateral + perforating
3 Medial Lateral Medial Lateral
4 Medial Perforating Medial Lateral
5 Medial Lateral Medial Lateral
6 Medial Lateral Medial Lateral
7 Medial Perforating Medial Lateral + perforating
8 Medial Lateral Medial Lateral
9 Medial Lateral Medial Lateral + perforating
10 Medial Lateral Medial Lateral + perforating
11 Medial Lateral Medial Lateral
12 Medial + perforating Lateral Medial Lateral
13 Medial Lateral Medial Lateral
14 Medial Lateral + perforating Medial Lateral
15 Medial Lateral Medial Lateral
16 Medial Perforating Medial + perforating Lateral
17 Medial Lateral Medial Lateral + perforating
18 Medial Lateral Medial Lateral
19 Medial Lateral + perforating Medial Lateral
20 Medial Lateral Medial Lateral
21 Medial + perforating Lateral Medial Lateral
22 Medial Lateral Medial Perforating
23 Medial Lateral Medial Lateral
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25 Medial Lateral Medial Lateral + perforating
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55 Selective Ultrasound Guided Pectoral Nerve Block