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Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1193e1198

The anatomy of the pectoral nerves and its


significance in breast augmentation, axillary
dissection and pectoral muscle flaps
Sylvain David a,*, Thierry Balaguer a, Patrick Baque b, Fernand de Peretti b,
Maxime Valla a, Elisabeth Lebreton a, Berengere Chignon-Sicard a

a
Nice Sophia Antipolis University, Plastic, Reconstructive and Hand Surgery Department, Saint Roch Hospital,
5 rue Pierre Devoluy, 06000 Nice, Nice, France
b
Department of Anatomy, Nice Sophia Antipolis University, Nice, France

Received 26 September 2011; accepted 20 March 2012

KEYWORDS Summary Background: In many plastic surgeries, a detailed understanding of the pectoral
Pectoral nerves; nerve anatomy is often required. However, the information available on the anatomy of
Breast augmentation; pectoral nerves is sparse and unclear. The purpose of this study is to provide detailed anatom-
Axillary dissection; ical information on the pectoral nerves to allow for their easy intra-operative localisation and
Pectoral muscles flap to improve the understanding of the pectoral muscle innervation.
Methods: We dissected 26 brachial plexuses from 15 fresh cadavers. The origins, locations,
courses and branches of the pectoral nerves were recorded.
Results: We found three constant branches of the pectoral nerve. The superior branch trav-
elled in a straight course to the pectoralis major to innervate the clavicular aspect. The middle
branch coursed on the under-surface of the pectoralis major near the pectoral branch of the
thoraco-acromial artery to innervate the muscle’s sternal aspect. The inferior branch passed
beneath the pectoralis minor muscle to innervate the pectoralis minor muscle and the costal
aspect of the pectoralis major muscle.
Conclusions: Knowing the pectoral nerves’ origins, courses and connections, in addition to
understanding the functional consequences of iatrogenically severing these nerves, leads to
a better understanding of the pectoral muscle’s innervation. Precise anatomical data on the
pectoral nerve allow for its easy localisation during axillary breast augmentation, axillary
dissection, removal of the pectoralis minor muscle and harvesting the pectoralis major muscle
island flap.
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ33 0492032960.


E-mail addresses: Contact@docteurdavid.pro, Sylvdavid@yahoo.fr (S. David).

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2012.03.032
1194 S. David et al.

In many plastic surgeries, a detailed understanding of the


pectoral nerve anatomy is often required, for example,
during axillary breast augmentation, axillary dissection,
harvesting the pectoralis major muscle island flap and
removal or harvesting the pectoralis minor muscle.1e6 In
those procedures, damage to the pectoral nerves can
occur, leading to the denervation of the pectoralis major
muscle and subsequent atrophy.
However, the necessary understanding of this nerve to
avoid damaging the innervation of the pectoralis major
muscle remains unclear. Indeed, recent studies on the
courses and branches of the pectoral nerves contradict the
classic description of the pectoral nerves.2,4,7e12 In the
classic anatomic descriptions, the pectoralis major muscle
is innervated by two pectoral nerves, but recent studies
found that the pectoralis major muscle is innervated by
three nerves.10e13
The purpose of this study was to provide detailed
anatomical information on the pectoral nerves to improve
the understanding of pectoral muscle innervation and to
allow for easy intra-operative localisation of these nerves
during the previously mentioned procedures.

Materials and methods

We dissected 26 brachial plexuses from 15 fresh cadavers. Figure 1 Schematic drawing of right brachial plexus showing
The dissecting procedure was as follows. We removed the the 3 branches of the pectoral nerves. SB, superior branch of
skin and subcutaneous fat from the entire supraclavicular, the pectoral nerves; MB, middle branch of the pectoral nerves;
infraclavicular and axillary areas. An axillary dissection was IB, inferior branch of the pectoral nerves; AP, ansa pectoralis;
performed to identify the inferior branch of the pectoral pM, pectoralis minor; PM, pectoralis major; TA, pectoral
nerve (medial pectoral nerve) and its relationship with the branch of the thoraco-acromial artery; LTA, lateral thoracic
pectoralis major muscle. Then, a supraclavicular dissection artery; TDN, thoraco-dorsal nerve; long thoracic nerve; SA,
was performed, and the brachial plexus was dissected serratus anterior.
carefully from the roots to the clavicle. Finally, an infra-
clavicular dissection was performed. The pectoralis major
muscle was reflected medially to allow for the dissection of In subtype A1, present in 62% (16 cases) of dissections,
the superior and middle branches of the pectoral nerves the superior branch and the middle branch arose separately
(lateral pectoral nerve). The pectoralis minor muscle was at the trunk level and were connected by an ansa from the
released from the coracoid process to follow the course of middle branch to the superior branch. In subtype A2,
the inferior branch of the pectoral nerves (medial pectoral present in 15% (four cases) of dissections, the superior and
nerve). the middle branches both arose from the lateral cord and
The clavicle was removed and the brachial plexus was were not connected. In type B, present in 23% (six cases) of
completely dissected to precisely determine the origin of dissections, the superior and the middle branches arose
each branch of the pectoral nerves. The origins, locations, from the same origin.
courses and branches of the pectoral nerves were recorded. The superior branch arose either from the anterior
We photographed and illustrated our findings in sche- division of the superior trunk or the lateral cord (roots
matic drawings. C5eC6). It appeared at the inferior border of the clavicle,
lateral to the axillary artery, and travelled straight to enter
the clavicular portion of the pectoralis major, usually with
Results three branches.
The middle branch arose either from the anterior divi-
In all dissections, we found three constant branches of the sion of the middle trunk or the lateral cord (root C7). The
pectoral nerves (Figures 1 and 2). The origin and the rela- middle branch appeared next to the superior branch,
tionship of these three branches were variable, especially crossed the axillary artery anteriorly and pierced the cor-
the superior and middle branches. In 77% (20 cases) of the acoclavicular fascia. It travelled on the under-surface of
dissections, the superior and the middle branches arose the pectoralis major near the pectoral branch of the
separately at trunk level, but in 23% (six cases) of the thoraco-acromial artery and entered into the pectoralis
dissections, the superior and the middle branches arose major distally to innervate its sternal aspect, usually with
from the same origin. To clarify the relationship between two branches (80% of cases). We found an ansa pectoralis
the superior and middle branches, we classified them based derived from the middle branch and connected to the
on their origins and connections (Figure 3). inferior branch in all dissections (Figure 4).
Anatomy of the pectoral nerves and its significance in breast augmentation 1195

inferiorly beneath the pectoralis minor, sending one or two


branches into the muscle. In 65% of the dissections, its
lower and larger branch pierced the pectoralis minor to
reach the pectoralis major, and in the other 35%, its branch
passed around the lower border of the pectoralis minor to
reach the pectoralis major (Figure 5).

Discussion

Our results did not confirm the classic anatomical descrip-


tions of the pectoral nerves. Classic anatomic descriptions
reported that the pectoralis major muscle is innervated by
two nerves: the superior and middle branches as a single
nerve (lateral pectoral nerve) and the inferior branch
(medial pectoral nerve).2,4,7e9,14 In a recent study, E.
Beheiry reported that the pectoralis major muscle is
innervated by four branches. He reported that the lateral
pectoral nerve innervated the clavicular aspect and the
upper third of the distal segment of the pectoralis major
muscle by two different branches. However, he did not find
that the two branches of the lateral pectoral nerve could
have two different origins at the trunk level. Moreover, the
medial pectoral nerve supplied the lower two-thirds of the
distal segment with its ventral division and the posterior
limb of the tendon by its dorsal division.15 By contrast,
some authors described three separate pectoral
nerves.10e13
In our study, we found three constant branches of
Figure 2 Dissection of the right plexus showing the pectoral pectoral nerves arising from three distinct origins in 77% of
nerves (type A1). SB, superior branch of the pectoral nerves; the cases and three constant branches arising from two
MB, middle branch of the pectoral nerves; TA, pectoral branch distinct origins in 23% of the cases.
of the thoraco-acromial artery; LTA, lateral thoracic artery; IB, The nomenclature of the pectoral nerves can cause
inferior branch of the pectoral nerves; AP, ansa pectoralis; PM, confusion. Anatomists name the nerves according to their
pectoralis major; pM, pectoralis minor; CL, clavicle. origins from the brachial plexus (the medial pectoral nerve
arose medial to the lateral pectoral nerve), but some
In all cases, the origin of the inferior branch arose from authors inverted the names of the pectoral nerves
the anterior division of the inferior trunk (roots C8eT1). according to their course (the course of the medial pectoral
The inferior branch appeared at the medial border of the nerve is lateral to the lateral pectoral nerve).4
axillary artery near the origin of the lateral thoracic artery. In our study, we used a new nomenclature based on our
After being joined by the ansa pectoralis, it travelled results and previous studies.10,12 We identified the three

Figure 3 Classification scheme of the pectoral nerves based on their origins and connections. SB, superior branch of the pectoral
nerves; MB, middle branch of the pectoral nerves; IB, inferior branch of the pectoral nerves. In type A, the superior and middle
branches arose separately (77%). In subtype A1, the superior and middle branches were connected (62%). In subtype A2, the
superior branch and the middle branches were not connected (15%). In type B, the superior branch and the middle branch arose
from the same origin (23%).
1196 S. David et al.

Figure 6 Schematic drawing of right brachial plexus showing


the 3 branches of the pectoral nerves (axillary view). SB,
Figure 4 Dissection of the right plexus showing the course of superior branch of the pectoral nerves; MB, middle branch of
the middle branch of the pectoral nerves on the deep surface the pectoral nerves; IB, inferior branch of the pectoral nerves;
of the pectoralis major next to the pectoral branch of the AP, ansa pectoralis; pM, pectoralis minor; PM, pectoralis
thoraco-acromial artery. AA, axillary artery; SB, superior major; TA, pectoral branch of the thoraco-acromial artery;
branch of the pectoral nerves; PM, pectoralis major; pM, LTA, lateral thoracic artery; TDN, thoraco-dorsal nerve; LTN,
pectoralis minor; MB, middle branch of the pectoral nerves; long thoracic nerve; SA, serratus anterior; ICN, intercostal
TA, pectoral branch of the thoraco-acromial artery; AP, ansa nerve.
pectoralis.

pectoral nerves by their origin and their course. Indeed, the


Indeed, Niechajej reported that the lateral thoracic vessels
superior branch arose and coursed superiorly to the middle
are always encountered in an axillary breast augmentation,
branch, which also arose and coursed superiorly to the
which is closely associated with inferior branch of the
inferior branch.
pectoral nerve.10,16,17 Moreover, the inferior branch of the
During an axillary breast augmentation or axillary
pectoral nerve is closely associated with the axillary central
dissection, the pectoral nerves can be divided.
and anterior lymph node and can be injured during an
Injury to the pectoral nerve inferior branch leads to
axillary dissection.18,19 However, this complication does not
atrophy of the costal aspect of the pectoralis major
result in important sequelae. According to many authors,
(Figure 6). The inferior branch of the pectoral nerve can be
this complication only leads to a slight loss of the major
severed during surgical access to the pocket during an
pectoral muscle strength.5,20 Because of the few functional
axillary breast augmentation due to its anatomic position.
consequences provoked by the injuries to the inferior
branch of the pectoral nerve, Hoffman and Elliot stated
that this partial denervation is valuable because a slight
weakening of the lower part of the pectoralis major muscle
allows a better projection and a better cosmetic result of
the breast augmentation.2
An injury to the middle branch of the pectoral nerves
leads to atrophy of the sternal aspect of the pectoralis
major (Figure 7). In fact, the middle branch of the pectoral
nerve travels on the deep surface of the major pectoral
muscle with the acromiothoracic vessels being nearby.
There is a risk of acromiothoracic vessel injury during
axillary breast augmentation, and some authors do not
recommend directly dissecting medially or using a blunt
technique when creating the pocket for the implant; this
will avoid bleeding from the acromiothoracic artery and
vein, which will necessitate electrocoagulation.2,6
However, in case of disruption of these vessels, a ligature
Figure 5 Right axillary dissection showing the inferior or electro-coagulation could injure the middle branch of
branch of the pectoral nerves. IB, inferior branch of the the pectoral nerve. Moreover, the middle branch of the
pectoral nerves; AP, ansa pectoralis; pM, pectoralis minor; PM, pectoral nerve is closely associated with the axillary apical
pectoralis major; LTA, lateral thoracic artery; LTN, long lymph node and can be injured during an axillary
thoracic nerve; ICN, intercostal nerve; AV, axillary vein. dissection.18,19
Anatomy of the pectoral nerves and its significance in breast augmentation 1197

have never been reported after an axillary breast


augmentation. However, they may be not adequately
researched and should be studied more closely. Scanlon
reported that muscle atrophy from pectoral nerve lesions
may not appear for up to 1 year after the injury.21
When harvesting the pectoralis major muscle island flap,
a detailed understanding of the pectoral nerves anatomy is
required to preserve the nerve supply to the clavicular
aspect of the pectoralis major muscle.1 The sternocostal
and clavicular aspects of the pectoralis major muscle both
have independent vascular and nerve supplies.22e25
Therefore, selective transposition of the sternocostal
aspect of the pectoralis major muscle as a true island flap
can be performed while preserving the superior branch of
the pectoral nerves to allow for maximal donor-site func-
tion and morphology.1,24,26
Moreover, during the removal of the pectoralis minor
muscle in a modified mastectomy or a free flap procedure,
the pectoral nerves can be divided. Those procedures
require a detailed understanding of the pectoral nerve
anatomy.5
Knowing the pectoral nerves’ origins, courses and
connections, in addition to understanding the functional
consequences of iatrogenically severing these nerves, leads
Figure 7 Patient with selective C7 brachial plexus injury. to a better understanding of the pectoral muscle innerva-
(Above) Atrophy of the sternal aspect of the pectoralis major tion. These new anatomical data can have surgical appli-
due to an injury of C7 root Z injury of middle branch of the cations in brachial plexus injuries.11,27,28 In plastic surgery,
pectoral nerve. The clavicular aspect (superior branch Z C5- precise anatomical data on the pectoral nerves allow for
C6) and the costal aspect (inferior branch Z C8-T1) of the their localisation during axillary breast augmentation,
pectoralis major are intact. (Below) Wrist drop from a C7 axillary dissection, removal of the pectoralis minor muscle
brachial plexus injury. and harvesting the pectoralis major muscle island flap.

Funding
Injury of the superior branch of the pectoral nerves
leads to atrophy of the clavicular aspect of the pectoralis
None.
major. However, the superior branch is generally not
injured during an axillary breast augmentation or axillary
dissection because of its straight path to the clavicular Conflict of interest
portion of the pectoralis major (Figure 6). This excludes
a total denervation of the pectoral muscles when per- None.
forming those two procedures. However, it is possible to
sever either the inferior branch or the inferior and middle
Acknowledgement
branches of the pectoral nerves.
The functional consequences of a single branch injury of
the pectoral nerve are almost undetectable.5,20 However, if The authors would like to thank Benjamin Maes and Michel
both branches are injured (inferior and middle branches), Chammas.
the consequences are more important. Indeed, Moosman
described the outcome of the Patey modified radical References
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