Brachial Plexus Impingement - Springer science & business media


Breast augmentation is one of the most commonly performed aesthetic procedures, with many studies documenting the early and long-term complications that might be expected. This report describes the case of an active young woman who experienced severe pain, particularly with movement. Surgical exploration showed the cause of this pain to be impingement of the patient’s lower brachial plexus by the mammary prosthesis. Such a complication has not, to the authors’ knowledge, been reported previously.

Case Report
A 28-year-old woman sought a second opinion with the senior author (JJS) for severe pain in her right breast. The pain was present constantly, but was exacerbated significantly by movement of the ipsilateral arm. It had been present to varying degrees since her original surgery. The patient had initially undergone augmentation mastopexy via submuscular implants 3 years previously. Her case had been complicated by an acute hematoma in the right breast that required evacuation and hemostasis on the day of surgery. After 6 months, she returned to the original surgeon with bilateral capsular contraction and underwent an otherwise uncomplicated bilateral capsulotomy, implant exchange, and revision mastopexy. After 1 month, she experienced right breast pain. Oil of evening primrose was prescribed, which ameliorated her symptoms to some extent.

The patient presented when the pain worsened noticeably after her annual vacation, during which she was particularly active with swimming. At this time, the right breast was painful, and any movement radiated pain into the shoulder and right arm such that she was exhibiting protective reflexes. Furthermore, the symptoms had not been controlled by a combination of ibuprofen, tramadol, and amitriptyline.

On examination, both nipple–areolar complexes and implants were high producing a pseudoptosis (Fig.1), but there was minimal palpable capsule formation. An area of inferolateral nodularity was tender on palpation of the right breast, but ultrasonography had been unable to detect parenchymal abnormality. This and an additional magnetic resonance imaging scan, requested by the original surgeon, also confirmed the lack of implant rupture. Otherwise, the patient was in good health with an unremarkable medical history. Due to the severity of her symptoms, surgical exploration was planned.

At surgery, bilateral, large, very tight muscular pockets were found extending superiorly to the level of the clavicle. Notably, the patient’s well-developed pectoralis major muscles remained attached to the chest wall inferiorly at the sites of origin, and these were divided accordingly. Both capsules, as expected from preoperative assessment, were thin and left in situ after explantation and revision mastopexy.

The patient’s postoperative course was uneventful. At the time of writing, she remains both pain free and highly satisfied with her result, although the pseudoptosis has not been entirely satisfactorily corrected (Fig.2).

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