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INTERPECTORAL NERVE BLOCK FOR BREAST SURGERY
The sensory innervation of the chest wall including the breast is
subsidiary of the intercostal nerves. Mammary gland also receives
innervation via the same lines
The skin of the breast and breast glandular tissue
receive innervation via the lateral and medial branches of each intercostal nerve (T2-T6)
however there are deeper structures
not receive their innervation through the same nerve branches
The pectoral mayor and minor muscles
have their own motor and sensitive innervation
through branches of brachial plexus
This branches are the medial pectoral nerve
and lateral pectoral nerve.
after his release, will be divided into upper, middle and lower primary trunks.
Primary trunks are gruped into secundary trunks or fascicles
The medial and lateral pectoral nerves arising from the brachial plexus
at the level of secondary trunks (fascicles) that give them their name (lateral and medial)
standing through the pectoralis minor, and between this one and
mayor to give its distal branches
The medial and lateral pectoral nerves gets into the clavipectoral fascia
with the acromiothoracic artery, good reference for this block
One of the most common surgeries
for cosmetic breast surgey is breast augmentation
The prosthesis implanted by the surgeon may be introduced below the
glandular breast tissue or under the pectoralis major muscle
The position of the prothesis is vital for
planning postoperative analgesia.
Paravertebrar, epidural and intercostal block
have been successfully employed, specialy paravertebral block
has been presented by many authors as the goldstandar for analgesia in breast surgery
but produce metameric block
including only skin and glandular breast tissue
leaving the pectoral muscles without block.
TAP block approach
is based in a interfascial compartment block
using high volumes of local anesthetic
achieves no visible nerves using ultrasound techniques
Using the same concept, the pectoralis nerves (not visible with ultrasound) could find benefits on this kind of technics
These nerves are not visible, but
the interpectoral space and clavipectoral fascia can be visualice with ultrasound
therefore
using large volumes of local anesthetic
would be possible to block them. We will star our
situating the ultrasound probe
parallel to the clavicle and below it
we can clearly identify the major pectoral muscle surface
and minor pectoral deeply. We can perform the approach fron craneal to caudal,
from medial to lateral or lateral to medial.
Lateral to medial should be better to promote medial diffusion
of local anesthetic
Ultrasonography is very easy to see the
local anesthetic diffusion along the fascia
needle progression being possible
to improve the distribution of anesthetic
For breast augmentation should be noted that the point
cutaneous prothesis insertion either Periareolar or
submammary probably not be covered by the block
so advise local infiltration in these points separately
Also, can be performed as a continuous technique
with a conventional epidural system and depending of surgery