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are to supplement operative anesthesia, reduce acute postoperative pain, and reduce the incidence of post mastectomy pain syndrome (PMPS). Numerous regional anesthesia (RA) techniques (i.e., thoracic paravertebral block [TPVB] and interfascial plane blocks) have been extensively investigated in breast surgery. The PECS II block [1] may have a greater effect on reducing postoperative opioid consumption for the first 24 h and postoperative pain scores for the first 12 h compared to that of the TPVB, which is often thought of as the gold standard of RA for breast analgesia [2]. The PECS II block is easy to perform awake or under general anesthesia, is relatively devoid of any serious complications compared to TPVB, and may be better suited for outpatient surgery. The PECS II block is commonly performed as a single injection technique which is its biggest disadvantage because the duration of analgesia is limited to the pharmacokinetics of the local anesthetic (LA) mixture. The TPVB is often performed with a catheter to extend the duration of analgesia for several days postoperatively. Blanco et al. [1] described the placement of a catheter in his original description although this is uncommon practice because the PECS catheter lies within the surgical field during most breast surgeries. We describe a novel approach for the preoperative placement of a continuous catheter in the PECS II plane, allowing for preemptive analgesia while preserving the longevity of the block. We have named this novel technique the Retroclavicular Approach to the PECS II (RAP) block. This technique stems from an earlier description of an ultrasound (US)-guided posterior approach to the infraclavicular brachial plexus [3]. The patient is placed in the supine position with the ipsilateral arm adducted and the head rotated contralaterally to optimize space in the supraclavicular fossa. A linear transducer (6–15 MHz) is used for block placement. Sancheti et al. [4] recently reported the theoretical risk of inadvertent suprascapular nerve (SSN) injury while using a retroclavicular approach. A pre-block scan to locate the SSN in the supraclavicular fossa, inserting the needle lateral and posterior to its location, and utilizing a nerve stimulator while needling to monitor for motor response will reduce this risk. To perform the RAP block (Figs. 1A–1D), the transducer is placed in the infraclavicular fossa in a parasagittal orientation to identify the axillary vessels, the cords of the brachial plexus, and the pectoralis major and minor muscles (PMM, PmM). A 150-mm, 18-gauge Tuohy needle is inserted 2–3 cm posterior to the clavicle at the superior aspect of the trapezius muscle, medial to the acromioclavicular joint. The needle is advanced into the axillary inlet between the posterior border of the clavicle and the superior border of the scapula. An initial blind zone is encountered on US resulting from the acoustic shadow cast by the clavicle preventing needle visualization. Upon entering the infraclavicular region, the needle can be seen on US and is guided anterior to the axillary vessels towards the interfascial plane Letter to the Editor

The retroclavicular approach to the PECS II (RAP) block: a novel regional technique for breast surgery