Postoperative analgesia after breast surgery as an alternative to thoracic epidural or thoracic paravertebral blocks
Pecs I: analgesia after insertion of breast expanders and sub pectoral prosthesis, pacemakers, porth-a-caths and chest drains
Pecs II: analgesia of (1) the axilla – required for axillary clearance and (2) intercostal nerves – required for wide excisions including several types of mastectomies and sentinel node biopsy
The major pectoral muscle is not shown
A sagittal plane shows the fascial space that is delineated by the clavipectoral fascia, the axillary fascia, the major pectoral muscle, and the minor pectoral and subclavius muscles which are enveloped by the clavipectoral fascia
The major and minor pectoral muscles and the clavipectoral fascia are the components of the anterior wall of the axilla
The infero-lateral part of the clavicopectoral fascia that connects the lower margin of the minor pectoral muscle with the axillary fascia in the armpit is called “Gerdy’s ligament”.
It is also called the “suspensory ligament of the axilla” or “Campbell’s ligament” and it is responsible for the hollow of the armpit
The lateral pectoral nerve typically origins from the spinal nerve roots C5-C7 and branches off the lateral cord of the brachial plexus
It runs across the superior-medial margin of the minor pectoral muscle piercing the clavipectoral fascia (see next page) and enters the fascial space between the minor and major pectoral muscles; it innervates the two pectoral muscles
The medial pectoral nerve origins from C8-T1 and branches off the medial cord of the brachial plexus
It typically pierces the minor pectoral muscle and enters the fascial space between the minor and major pectoral muscles; it innervates the two pectoral muscles
The two pectoral nerves run adjacent to the pectoral branch of the thoracoacromial artery in the fascial space between the minor and major pectoral muscles
The clavipectoral fascia (synonym: costocoracoid membrane or coracoclavicular fascia) extends from the clavicle superiorly, medially it is fused with the fascia covering the medial end of the upper intercostal spaces, laterally it is attached to the coracoid process and the fascia over the short head of the biceps brachia muscle; caudally it is fused with the axillary fascia
It creates a fascial space behind the clavicular part of the major pectoral muscle containing the branches of the pectoral nerves and the pectoral branch of the thoracoacromial artery
It splits in two layers that enclose the subclavius and minor pectoral muscles
The portion extending from the first rib to the coracoid process is often stronger than the rest and is known as the costocoracoid ligament
The costocoracoid ligament is pierced by the cephalic vein and the thoracoacromial artery and vein, together with the lateral pectoral nerve (see picture on the left)
