The purpose of this cadaver study is to demonstrate a reliable ultrasound guided approach to selectively target the pectoral nerves and their branches. Portable ultrasound machine was used to guide the injection of 10 ml of 0.2% aqueous methylene blue solution in pectoral region on both sides.
The purpose of this cadaver study is to demonstrate a reliable ultrasound guided approach to selectively target the pectoral nerves and their branches. Portable ultrasound machine was used to guide the injection of 10 ml of 0.2% aqueous methylene blue solution in pectoral region on both sides.
The purpose of this cadaver study is to demonstrate a reliable ultrasound guided approach to selectively target the pectoral nerves and their branches. Portable ultrasound machine was used to guide the injection of 10 ml of 0.2% aqueous methylene blue solution in pectoral region on both sides.
Targeting in Breast Augmentation: How to Spare the Brachial Plexus Cords? JEAN DESROCHES, 1 URSULA GRABS, 2 AND DETLEV GRABS 2 * 1 Department of Anesthesia, Clinique Chirurgicale de Laval, Laval, Que bec, Canada 2 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 INTRODUCTION 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 V VC 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. MATERIALS AND METHODS 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. RESULTS 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). DISCUSSION 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 perfectly. 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 solution. 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. ACKNOWLEDGMENTS 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. REFERENCES Aszmann OC, Rab M, Kamolz L, Frey M. 2000. The anatomy of the pectoral nerves and their signicance in brachial plexus recon- struction. J Hand Surg Am 25:942947. Beheiry EE. 2012. Innervation of the pectoralis major muscle: Ana- tomical study. Ann Plast Surg 68:209214. Bell M. 2007. Ofce anesthesia for breast augmentation made easy. Can J Plast Surg 15:178. Benkhadra M, Faust A, Ladoire S, Trost O, Trouilloud P, Girard C, Anderhuber F, Feigl G. 2009. Comparison of fresh and Thiels TABLE 1. Course of the Pectoral Nerves in Relation to the Pectoralis Minor Muscle in Classical Anatomical Cadavers (125) and Thiel Cadavers (T1T3) Cadaver no. 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 24 Medial Perforating Medial + perforating Lateral 25 Medial Lateral Medial Lateral + perforating T1 Medial Lateral Medial Lateral T2 Medial Lateral Medial Lateral + perforating T3 Medial Lateral + perforating Medial Lateral 54 Desroches et al. embalmed cadavers according to the suitability for ultrasound- guided regional anesthesia of the cervical region. Surg Radiol Anat 31:531535. Benkhadra M, Gerard J, Genelot D, Trouilloud P, Girard C, Ander- huber F, Feigl G. 2011. Is Thiels embalming method widely known? A world survey about its use. Surg Radiol Anat 33:359 363. Blanco R. 2011. The pecs block: A novel technique for providing analgesia after breast surgery. Anaesthesia 66:847848. Boezaart AP, Raw RM. 2006. Continuous thoracic paravertebral block for major breast surgery. Reg Anesth Pain Med 31:470 476. Bremner-Smith AT, Unwin AJ, Williams WW. 1999. Sensory path- ways in the spinal accessory nerve. J Bone Joint Surg Br 81:226228. Cooter RD, Rudkin GE, Gardiner SE. 2007. Day case breast aug- mentation under paravertebral blockade: A prospective study of 100 consecutive patients. Aesthetic Plast Surg 31:666673. Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, Lyerly HK. 1998. Use of paravertebral block anesthesia in the surgical management of breast cancer: Experience in 156 cases. Ann Surg 227:496501. Evans HCL, Nielsen KC, Steele SM. 2008. Regional anesthesia. In: Twersky RS, Philip BK, editors. Handbook of Ambulatory Anes- thesia. 2nd Ed. New York: Springer. p 196230. Greengrass R, OBrien F, Lyerly K, Hardman D, Gleason D, DErcole F, Steele S. 1996. Paravertebral block for breast cancer surgery. Can J Anaesth 43:858861. Jaung R, Cook P, Blyth P. 2011. A comparison of embalming uids for use in surgical workshops. Clinical anatomy 24:155161. Kadam RV, Field JB. 2011. Ultrasound-guided continuous transverse abdominis plane block for abdominal surgery. J Anaesthesiol Clin Pharmacol 27:333336. Kerr AT. 1918. The brachial plexus of nerves in man, the variations in its formation and branches. Am J Anat 23:285395. Lemay E, Guay J, Cote C, Leclerc YE. 2004. Paravertebral blockade is not a suitable anesthetic technique for ambulatory minor breast surgery. Can J Aanaesth 51:852853. Loukas M, Louis RG Jr, Fitzsimmons J, Colborn G. 2006. The surgical anatomy of the ansa pectoralis. Clin Anat 19:685693. Macchi V, Tiengo C, Porzionato A, Parenti A, Stecco C, Mazzoleni F, de Caro R. 2007. Medial and lateral pectoral nerves: Course and branches. Clin Anat 20:157162. McCarthy CM, Pusic AL, Hidalgo DA. 2009. Efcacy of pocket irriga- tion with bupivacaine and ketorolac in breast augmentation: A randomized controlled trial. Ann Plast Surg 62:1517. McLeod G, Eisma R, Schwab A, Corner G, Soames R, Cochran S. 2010. An evaluation of Thiel-embalmed cadavers for ultrasound- based regional anaesthesia training and research. Ultrasound 18:125129. Naja MZ, Ziade MF, Lonnqvist PA. 2003. Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast sur- gery: A prospective randomized trial. Eur J Anaesthesiol 20:897903. Parker WL, Charbonneau R. 2004. Large area local anesthesia (LALA) in submuscular breast augmentation. Aesthet Surg J 24:436441. Pelosi MA III, Pelosi MA II. 2010. Breast augmentation. Obstet Gynecol Clin North Am 37:533546, viii. Pickrell KL, Puckett CL, Given KS. 1977. Subpectoral augmentation mammaplasty. Plast Reconstr Surg 60:325336. Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, de Caro R. 2012. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat 25:559575. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. 1999. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand 43:770 774. Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. 2010. Efcacy and safety of paravertebral blocks in breast sur- gery: A meta-analysis of randomized controlled trials. Br J Anaesth 105:842852. Sefa Ozel M, Ozel L, Toros SZ, Marur T, Yildirim Z, Erdogdu E, Kara M, Titiz IM. 2011. Denervation point for neuromuscular blockade on lateral pectoral nerves: A cadaver study. Surg Radiol Anat 33:105108. Tahiri Y, Tran de QH, Bouteaud J, Xu L, Lalonde D, Luc M, Nikolis A. 2011. General anaesthesia versus thoracic paravertebral block for breast surgery: A meta-analysis. J Plast Reconstr Aesthet Surg 64:12611269. Thiel W. 1992a. An arterial substance for subsequent injection during the preservation of the whole corpse. Ann Anat 174:197200. Thiel W. 1992b. The preservation of the whole corpse with natural color. Ann Anat 174:185195. Thiel W. 2002. Supplement to the conservation of an entire cadaver according to W. Thiel. Ann Anat 184:267269. Tubbs RS, Jones VL, Loukas M, Comert A, Shoja MM, Wellons JC III, Cohen-Gadol AA. 2010. Anatomy and landmarks for branches of the brachial plexus: A vade mecum. Surg Radiol Anat 32:261 270. Wallace MS, Wallace AM, Lee J, Dobke MK. 1996. Pain after breast surgery: A survey of 282 women. Pain 66:195205. 55 Selective Ultrasound Guided Pectoral Nerve Block