The intercostal nerves run in the intercostal spaces sandwiched between the socalled innermost intercostal muscle and the internal and external intercostal muscles superficially joined by the intercostal arteries and veins

The lateral cutaneous branches of the intercostal nerves branch off in the midaxillary line, pierce the internal and external intercostal muscles and branch into a posterior and an anterior terminal branch; the latter runs anterior to innervate the skin covering the infero-lateral part of the breast

The anterior cutaneous branches of the intercostal nerves run anterior to the internal mammary artery, pierce the intercostal membranes and innervate the medial part of the breast

The anterior wall of the axilla consists of the major and minor pectoral muscles and the clavipectoral fascia

The medial wall of the axilla is the lateral thoracic wall with costae I-IV and intercostal muscles – and the serratus anterior muscle

The lateral wall is the intertubercular groove of the humerus and the posterior wall is the subscapularis, teres major and latissimus dorsi muscles.

The axilla contains some nerves that are relevant for axillary extension of breast surgery:

1) the lateral cutaneous branches of the intercostal nerves
2) the anterior intercostal branches of the intercostal nerves
3) the long thoracic nerve that innervates the serratus anterior muscle
4) the thoracodorsal nerve that innervates the latissimus dorsi muscle

The local anaesthetic is injected into the fascial space between the muscle fascia of the major pectoral muscle anteriorly and the clavipectoral fascia with the minor pectoral muscle posteriorly

Place the patient supine

Place the probe in the sagittal plane below the lateral third of the clavicle and identify the axillary artery and vein below the pectoral muscles

Rotate the probe to obtain an oblique orientation with the proximal end of the probe medial and the distal end of the probe lateral

Visualize the sonoanatomical target (see next pages)

Insert the needle with in-plane technique from the proximal end of the probe and advance the needle tip to the target (see next pages) before injecting the local anaesthetic

Inject 10 mL for the PECS I block and step one of the PECS II block. Inject a supplementary 20 mL for step two of the PECS II block

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 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

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 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)