The Course of the Intercostobrachial Nerve in the Axillary Region and As It Is Related to Transaxillary Breast Augmentation

Cadaveric study identifying clinical sonoanatomy for proximal and distal approaches of ultrasound-guided intercostobrachial nerve block

Background and objectives

The intercostobrachial nerve (ICBN) has significant anatomical variation. Localization of the ICBN requires an operator’s skill. This cadaveric study aims to describe two simple ultrasound-guided plane blocks of the ICBN when it emerges at the chest wall (proximal approach) and passes through the axillary fossa (distal approach).

Methods

The anatomical relation of the ICBN and adjacent structures was investigated in six fresh cadavers. Thereafter, we described two potential techniques of the ICBN block. The proximal approach was an injection medial to the medial border of the serratus anterior muscle at the inferior border of the second rib. The distal approach was an injection on the surface of the latissimus dorsi muscle at 3–4 cm caudal to the axillary artery. The ultrasound-guided proximal and distal ICBN blocks were performed in seven hemithoraxes and axillary fossae. We recorded dye staining on the ICBN, its branches and clinically correlated structures.

Results

All ICBNs originated from the second intercostal nerve and 34.6% received a contribution from the first or third intercostal nerve. All ICBNs gave off axillary branches in the axillary fossa and ran towards the posteromedial aspect of the arm. Following the proximal ICBN block, dye stained on 90% of all ICBN’s origins. After the distal ICBN block, all terminal branches and 43% of the axillary branches of the ICBN were stained.

Conclusions

The proximal and distal ICBN blocks, using easily recognized sonoanatomical landmarks, provided consistent dye spread to the ICBN. We encourage further validation of these two techniques in clinical studies.

Aberrant bifurcation of intercostobrachial nerve in the axilla: A case report

Intercostobrachial nerve (ICBN) studies have been undertaken by many authors as it is a highly variable structure with numerous patterns reported worldwide. ICBN is a frequently damaged structure in Axillary Lymph Node Dissection (ALND) or mastectomy. Compression of this nerve, due to the enlargement of axillary lymph nodes from cancer breast may be presented as referred pain along the medial side of arm. Different patterns on the course and distribution of the ICBN have been described in literature. We encountered a lesser known variation of the ICBN where it pierced the second intercostal space as a single trunk and immediately divided into two branches. The putative clinical implications of this aberrant bifurcation are of value in significantly diminishing complications such as pain and sensory disturbances presenting after mastectomy and ALND. The findings of the presentation may be of use by surgeons and interventionists in approaching the area in a more precautious manner.

Lymphatic and Sensory Function of the Upper Limb After Brachioplasty in Post-Bariatric Massive Weight Loss Patients

BACKGROUND

Varied deformities of the upper arm are common after massive weight loss. Brachioplasty techniques have been successively modified to improve aesthetic outcomes and avoid complications, especially lymphedema and sensory damage.

OBJECTIVES

The authors evaluated lymphatic drainage and sensory function of the upper limbs after brachioplasty performed with a double-ellipse marking technique, a medial incision, superficial undermining, and posterior arm liposuction.

METHODS

This prospective study included 12 women who underwent brachioplasty after bariatric surgery and massive weight loss. Lymphatic drainage was evaluated by forearm volumetry and indocyanine green lymphography of the entire limb. Cutaneous sensitivity thresholds were determined with Semmes-Weinstein monofilaments.

RESULTS

Patients received postoperative follow up for 12 months. Complications included a small dehiscence for 1 patient and hypertrophic scarring for 2 patients. Cutaneous sensitivity and forearm volumetry were unchanged after brachioplasty for all patients. Results of indocyanine green lymphography indicated that all patients had normal linear lymphatic patterns pre- and postoperatively.

CONCLUSIONS

Results of the study support the belief that this type of brachioplasty does not disrupt sensory or lymphatic function of the limb.

LEVEL OF EVIDENCE

4.

The intercostobrachial nerve as a sensory donor for hand reinnervation in brachial plexus reconstruction is a feasible technique and may be useful for restoring sensation

ABSTRACT Objective Few donors are available for restoration of sensibility in patients with complete brachial plexus injuries. The objective of our study was to evaluate the anatomical feasibility of using the intercostobrachial nerve (ICBN) as an axon donor to the lateral cord contribution to the median nerve (LCMN). Methods Thirty cadavers were dissected. Data of the ICBN and the LCMN were collected, including diameters, branches and distances. Results The diameters of the ICBN and the LCMN at their point of coaptation were 2.7mm and 3.7mm, respectively. The ICBN originated as a single trunk in 93.3% of the specimens and bifurcated in 73.3%. The distance between the ICBN origin and its point of coaptation to the LCMN was 54mm. All ICBNs had enough extension to reach the LCMN. Conclusion Transfer of the ICBN to the LCMN is anatomically feasible and may be useful for restoring sensation in patients with complete brachial plexus injuries.

Origin, Branching, and Communications of the Intercostobrachial Nerve: a Meta-Analysis with Implications for Mastectomy and Axillary Lymph Node Dissection in Breast Cancer

The intercostobrachial nerve (ICBN), which usually originates from the lateral cutaneous branch of the second intercostal nerve, innervates areas of the axilla, lateral chest, and medial arm. It is at risk for injury during operative procedures that are often used in the management of breast cancer and such injury has been associated with postoperative sensory loss and neuropathic pain, decreasing the quality of life. PubMed, Excerpta Medica Database (EMBASE), ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), Scientific Electronic Library Online (SciELO), Biosciences Information Service (BIOSIS), and Web of Science were searched comprehensively. Data concerning the prevalence, branching, origin and communications of the ICBN were extracted and pooled into a meta-analysis. A total of 16 studies (1,567 axillas) reported data indicating that the ICBN was present in 98.4% of person. It most often (90.6%) originated from fibers at the T2 spinal level and commonly coursed in two branching patterns: as a single trunk in 47.0% of cases and as a bifurcating pattern in 42.2%. In the latter cases, the bifurcation was usually unequal (63.4%). Additionally, the ICBN presented with anastomosing communication to the brachial plexus in 41.3% of cases. The ICBN is a prevalent and variable structure at significant risk for injury during operative procedures of the axilla. In view of the postoperative pain and paresthesia experienced by patients following injury, surgeons need to exercise caution and aim to preserve the ICBN when possible. Ultimately, careful dissection and knowledge of ICBN anatomy could allow postoperative complications to be reduced and patient's quality of life increased.

Nerve Injuries in Aesthetic Breast Surgery: Systematic Review and Treatment Options

BACKGROUND

The risk of nerve injuries in aesthetic breast surgery has not been well explored.

OBJECTIVES

The authors conducted a systematic review to provide evidence-based information on the incidence and treatment of nerve injuries resulting from aesthetic breast surgery.

METHODS

A broad literature search of Medline, Embase, and the Cochrane Database of Systematic Reviews was undertaken to identify studies in which nerve injury occurred after breast augmentation or mastopexy. Specific inclusion and exclusion criteria were established before the search was performed.

RESULTS

The initial 4806 citations were narrowed by topic, title, and abstract to 53 articles. After full-text review, 36 studies were included. The risk of any nerve injury after breast augmentation ranged from 13.57% to 15.44%. Specific nerve injury rates were calculated for the intercostal cutaneous nerves, branches to the nipple-areola complex, intercostobrachial nerve, long thoracic nerve, and brachial plexus. Also calculated were the total estimated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness. The meta-analysis showed no associations between the rates of breast nerve injury or sensation change and implant size, incision type, or implant position in patients who underwent breast augmentation. The data were insufficient to determine rates of nerve injury in mastopexy.

CONCLUSIONS

The possibility of nerve injury, sensation change, or chronic pain with breast augmentation is real, and estimating the incidences of these conditions is useful to both patients and surgeons. Optimizing patient outcomes requires timely treatment by a multidisciplinary team and may include peripheral nerve surgery.

LEVEL OF EVIDENCE

3.