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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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PLACEMENT

Anatomy.

The nerves that must be blocked to carry out the breast block are the second through seventh intercostal nerves and some terminal branches from the superficial cervical plexus ( Fig. 32-1 ).

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Figure 32-1  Breast block anatomy: dermatomes.


Position.

The block can be carried out with the patient in the supine position if block of the intercostal nerves is undertaken in the mid-axillary line. Conversely, these same nerves can be blocked from a posterior approach if the patient is placed in the prone position.

Needle Puncture.

The breast block can be carried out with the patient in the supine position by performing intercostal nerve block from T2 to T7 in the patient’s mid-axillary line, as shown in Figure 32-2 A . The patient’s arm should be abducted at the shoulder and placed on an arm board or “tucked under” the head as shown in Figure 32-2 A . The intercostal nerve block can be carried out using a 22-gauge, short-beveled, 3-cm needle and placing 5 mL of local anesthetic solution inferior to each rib after walking the needle tip off each rib’s inferior border. If insufficient analgesia is produced, subcutaneous infiltration may have to be added, as the lateral cutaneous branches of the intercostal nerve may have been missed. This is possible because the lateral cutaneous nerve may branch more posteriorly in some patients. In addition to the intercostal nerve block, subcutaneous infiltration of local anesthetic must be performed in an “upside-down L” pattern, as shown in Figure 32-2 C . This infraclavicular infiltration must be added to interrupt those branches of the superficial cervical plexus that provide sensation to portions of the upper chest wall. Additionally, subcutaneous infiltration in the midline is required to block the intercostal nerve fibers that cross the midline from the contralateral side. Subcutaneous infiltration is facilitated by using a 10- to 12-cm needle.

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Figure 32-2  Breast block: positioning and technique.


If a posterior approach to the intercostal nerves is utilized, the patient must be placed in the prone position and intercostal nerve block carried out by walking the needle off, and immediately inferior to, the ribs from T2 through T7 ( Fig. 32-2 B ). This technique is described in Chapter 33 . If the posterior approach is chosen, subcutaneous infiltration, as previously outlined, must be added. Some practitioners use paravertebral blocks (C7–T7) rather than intercostal blocks to provide regional anesthesia for breast surgery.

Potential Problems.

Pneumothorax can occur with this technique (or with paravertebral block), although it should be infrequent.

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