PLATE

199 B A  I

A. ANATOMY C. SIMPLE OR TOTAL MASTECTOMY

e regional anatomy of the breast is illustrated in figures 1 and 2. e prin-
INDICATIONS A simple or total mastectomy is indicated in patients who are
cipal blood supply to the breast comes from the medial perforating branches of
not candidates for breast-conserving (lumpectomy) operations. e principal
the internal mammary artery and vein a er they transverse the pectoralis major
indications are for large cancers that persist a er adjuvant therapy, especially in
muscle and its anterior investing fascia. e medial aspect of the breast has lym-
a smaller breast, in multicentric disease, and in elderly poor-risk patients with
phatic drainage into the internal mammary chain of lymph nodes within the
localized lesions.
chest; however, this is quite variable. e majority of the lymphatics from the
breast drain to the axillary lymph node basin. e most proximal node or nodes PREOPERATIVE PREPARATION (See Plate .)
may be located in atypical locations such as within the breast in the axillary tail
ANESTHESIA General anesthesia is given via an endotracheal tube. Short-
of the upper/outer quadrant or very low on the lateral chest wall. e identi ca-
tion of these nodes using radionuclide tags and blue dye localization techniques acting muscle depolarizing agents are used for the intubation.
is one of the additional bene ts of a sentinel lymph node dissection. Axillary POSITION e patient is placed in a comfortable supine position with the arm
lymph nodes have been classi ed according to three levels or areas delineated on the involved side abducted approximately degrees, in order to give maxi-
by anatomic boundaries of the pectoralis minor muscle (figure 2). In general, mum exposure of the region.
level I or II nodes are removed in axillary lymph node dissections. e overall
boundaries of this standard axillary lymph node dissection (ALND) are the OPERATIVE PREPARATION A routine skin prep is performed and the area
chest wall (serratus anterior muscle) medially, the axillary vein superiorly, the is draped in a sterile manner.
subscapularis muscle plus thoracodorsal and long thoracic nerves posteriorly, INCISION AND EXPOSURE A horizontal elliptical incision is inked so as to
and the axillary fat laterally. Level I nodes are de ned as those lateral to the edge include the entire areolar complex (figure 4). e two skin edges should be
of the pectoralis minor muscle. is area includes the external mammary, sub- of equivalent length, as measured with a free suture between hemostats at each
scapular, and lateral axillary nodes. Level II nodes are behind or posterior to the end. e two incisions should come together without tension.
muscle and are commonly de ned as the central axillary lymph nodes. Level III
nodes are located medial or superior to the pectoralis minor muscle. is group DETAILS OF PROCEDURE e skin incision is made sharply with the scalpel
includes the subclavicular or apical lymph nodes. ey reside in the apex of the for the depth of cm or so. Any signi cant vessels should be secured with ne
axillary space behind the clavicle and deep to the axillary vein. ligatures. e skin aps are elevated with large skin hooks that are li ed vertically
e axillary vein is the major structure de ning the superior border of so as to provide countertraction as the surgeon pulls the specimen away from
the surgical dissection. e axillary artery (posterior and pulsatile) plus the the skin ap. e dissection proceeds superiorly almost to the clavicle, medi-
brachial plexus (superior and solid) are palpable but not exposed. Common ally to the sternal edge, and inferiorly to the costal margin near the insertion of
regional ndings are dual axillary veins or a very large, long thoracic vein run- the rectus sheath. is should include virtually all of the glandular tissue of the
ning longitudinally along the lateral chest. A er the axillary vein is exposed breast. e lateral ap dissection is carried to the edge of the pectoralis major
by the surgeon, a key landmark aids in nding thoracodorsal nerve, which is muscle. is leaves the axillary fat and lymph nodes for a separate dissection.
deep upon the subscapularis muscle. A pair of subscapular veins are identi ed A subfascial dissection is performed, li ing the breast o of the pectoralis
(figure 1). e more super cial one is divided, revealing the deep subscapu- major muscle. It is easier to begin superiorly. As the dissection continues medi-
lar vein and the adjacent subscapular artery, which may be mistaken for the ally, the perforating internal branches of the mammary vessel are controlled
thoracodorsal nerve. is nerve, however, is posterior to the axillary vein and with electrocautery or ligature, using ne silk. Last, the axillary ap is devel-
medial to the deep subscapular vein. It tends to angle toward the deep subscap- oped such that the breast is removed from the lateral chest wall. e specimen
ular vein, whereas the subscapular artery is more parallel. A gentle mechanical is oriented for the pathologist. e wound is irrigated and careful hemostasis is
stimulation of this nerve will result in muscle contraction. obtained. e perimeter may be in ltrated with a long-acting local anesthetic.
Also running parallel to the axillary vein and rising perpendicularly from is allows the anesthesiologist to awaken the patient sooner and lessens the
between the ribs on the chest wall are the sensory intercostal brachial skin amount of pain medication required a er surgery. Either end of the incision
nerves. One or more of these nerves may pass directly through the axillary is retracted with single skin hooks. Scarpa’s fascia and the subcutaneous fat
fat and lymph nodes that will be removed in the dissection. Division results are approximated with interrupted absorbable sutures. ese sutures are
in hypesthesia in the posterior axillary web and in the upper/inner arm. Con- placed so as to serially bisect the incision, thus giving the best approximation if
versely, the long thoracic nerve runs longitudinally over the serratus anterior at the two skin incisions are not of equal length. Last, a absorbable suture is
the depth of an axillary dissection. If the surgeon dissects the axillary fat and placed for subcutaneous approximation of the skin. Adhesive skin strips and a
specimen cleanly o of the serratus anterior muscle, the long thoracic nerve dry sterile dressing complete the procedure.
will be found not on the muscle but rather out in the axillary fat about or POSTOPERATIVE CARE e patient may use the arm immediately for nor-
cm deep to the lateral edge of the pectoralis minor muscle. Gentle mechani- mal activities. Vigorous use should be curtailed for about a week, when it is
cal stimulation will elicit contraction of the serratus anterior muscle. It is also determined that the skin aps are well sealed to the pectoralis major muscle
important to note that the long thoracic nerve tends to arch anteriorly as it without accumulation of serum or hematoma.
proceeds caudally.
D. MODIFIED RADICAL MASTECTOMY
B. BREAST INCISIONS FOR EXCISIONAL BIOPSY
An elliptical incision is placed more obliquely, being angled toward the axilla.
e principal indication for biopsy is the presence of clinically suspicious nd- e entire areolar complex as well as the lesion or its biopsy scar should be
ings on physical examination or diagnostic studies. Studies may be sampled included within the ellipse. If no reconstruction is planned, the wider ellipse
with ne needle aspiration (FNA) and cytologic evaluation. A better diagnosis illustrated in figure 5 is used. A er the patient is prepped and draped, the
is obtained with a core-cutting biopsy and histologic study. Asymmetric nodu- incision is marked with ink. e incisions are created to be of equal length.
larity, architectural distortion, or suspicious patterns of microcalci cations may ere should be no redundant or excess skin at either end of the incision upon
require excisional biopsy guided by wire localization. In general, a wide exci- closure. In overweight patients or those with very large breasts, a more lateral
sional biopsy with a clear margin of several millimeters of surrounding normal incision with a wider angle is required. Conversely, very creative or comma-
glandular tissue is planned. e placement of the incision is determined by the shaped incisions that encircle only the areolar area and then proceed laterally as
location of the lesion (figure 3). If possible, incisions in the upper/inner quad- a single curvilinear extension to the base of the axilla may be used in coordina-
rants should be avoided, as they are most visible. Circumareolar or inframam- tion with the plastic surgeon, who will be performing a concurrent reconstruc-
mary incisions tend to give the best cosmetic result. Curvilinear incisions along tion (see also Plate , Modi ed Radical Mastectomy). is incision may be
Langer’s lines may be used in most areas; however, some surgeons prefer radial combined with a separate elliptical incision about a preceding biopsy site.
incisions, especially in the medial breast. e incision should be kept small and e full radical mastectomy is no longer included in this atlas, as most sur-
placed over the lesion. e incision for a wire localization need not be placed geons do not remove the entire pectoralis major muscle. Instead, a modi ed
about the entrance site of the wire, because most wires are exible enough to be radical mastectomy is performed with a wedging out of a full-thickness section
drawn through the skin and subcutaneous fat into an open biopsy site. of the underlying pectoralis major muscle where the cancer is attached. ■

428
429
 PLATE

200 M R M

INDICATIONS Over the past years, multiple international clinical stud- skin preparation and sterile draping. Every precaution should be taken to
ies have shown equivalent survival between patients treated with modi ed avoid seeding with malignant tumor.
radical mastectomy and appropriately selected patients treated with breast- With proof of malignancy, an oblique elliptical incision is made that may
conserving surgery and adjuvant radiation, hormonal therapy, and chemo- include a short extension laterally up toward the axilla to ensure a better
therapy. Accordingly, breast-conserving surgery has become the dominant exposure for the axillary dissection and a more cosmetically acceptable clo-
mode of treatment, with modi ed radical mastectomy becoming the alter- sure (figure 1). e transverse segment of the elliptical incision includes
nate choice in certain circumstances. A residual large cancer a er adjuvant the nipple and areola and an appropriate distance of to . cm beyond the
therapy (especially in a small breast), multicentric cancers, and patient limits of the tumor whenever possible. If reconstructive surgery is planned,
preference or concerns about the complications of radiation therapy are the a more limited incision (figure 1, dashed line) that preserves skin can
principal indications for the operation. Prior to surgery, the opposite breast be made in consultation with the plastic surgeon. e entire nipple plus
should be evaluated by physical examination and mammography. Appro- an adequate margin about the biopsy site must be taken, while a lateral,
priate blood tests and imaging scans and mammographic studies are made comma-like extension provides the exposure for the axillary dissection.
in a search for potential metastases to the lung, liver, or bone. e standard e initial incisions through the skin should be only cm or so deep,
preadmission physical examination and laboratory evaluations are done in since it is advisable to include most of the subcutaneous tissue, especially in
an ambulatory setting, as most patients are admitted to the hospital on the the region of the axilla, with the nal specimen (figure 2). e skin aps
day of operation. require careful elevation, with control of all bleeding points as the dissec-
tion progresses. e aps are elevated to the level of the clavicle superiorly,
PREOPERATIVE PREPARATION e skin over the involved area should to the edge of the sternum medially, to the rectus sheath and costal margin
be inspected for signs of infection. e skin is shaved and electrical hair inferiorly, and then laterally to the edge of the latissimus dorsi muscle. Par-
clippers may be used over the axillae. Some surgeons give a single periop- ticular attention is required to remove as much subcutaneous fat as possible
erative dose of parenteral antibiotics, particularly if a regional breast biopsy in the axillary region, because the lymph nodes and breast tissue are very
has recently been performed. close to the skin in this region.
ANESTHESIA General anesthesia is given via an endotracheal tube. Short- e fascia over the pectoralis major muscle as well as the breast is
acting muscle depolarizing agents should be requested for the intubation, resected as a subfascial dissection starting near the clavicle and extending
such that the motor nerves will be responsive during the axillary node downward over the midportion of the sternum (figure 3). e fascia is
dissection. meticulously dissected o the pectoralis muscle without including any of
the latter within the gross specimen. If the cancer has penetrated this fascia
POSITION e patient is placed nearest the margin of the operating table and invaded the pectoralis major muscle, that section of the muscle can be
on the side of the surgeon. e arm is abducted and held by an assistant or excised en bloc with the specimen. It is usually not necessary to perform a
placed upon a support at right angles to the patient to facilitate the prepara- full radical mastectomy with removal of the entire pectoralis major muscle.
tion of the skin. Some prefer to wrap the arm, including the hand, in sterile e perforating intercostal arteries and veins near the sternal margins must
drapes so that the arm can be moved upward as well as medially to facilitate be carefully clamped and ligated.
the subsequent dissection of the axilla. e axillary ap is retracted upward, and the fascia over the edge of the
OPERATIVE PREPARATION e skin is widely prepared with topical anti- pectoralis major is incised (figure 4), exposing the pectoralis minor muscle
septics. is includes not only the involved breast but also the area over the beneath and the junction of the coracobrachialis and pectoralis minor ori-
sternum; the supraclavicular region, shoulder, axilla, and collateral chest gins superiorly at the coracoid process. Electrodiathermy is o en used in this
wall; as well as the upper abdomen on the involved side. A slight Fowler operation, but it should be avoided about the axillary vessels and nerves and
position with a tilt away from the surgeon improves the exposure. e sur- for control of bleeding from intercostal perforating vessels lateral to the ster-
gical drape should be secured to the skin at appropriate points around the num. e loose tissue over the axillary vein is incised and the vein wall gently
margin of the proposed eld of operation. e arm should be free to be exposed for a short distance beyond the subscapular vessels (figure 5).
moved by an assistant as required for exposure in the axilla. Level I and II lymph nodes are removed in the axillary node dissec-
tion that begins by incising the clavipectoral fascia along the lateral edge
INCISION AND EXPOSURE If the diagnosis of malignancy has not been of the pectoralis minor muscle. Precautions are taken to avoid the medial
documented by previous biopsy, the diagnosis is rst con rmed by a and lateral nerves to the pectoralis major muscle. e medial nerve is so
biopsy of excised tumor using frozen-section examination by the patholo- named because it arises from the medial cord of the brachial plexus and then
gist. e specimen is also sent for hormone binding and other immunoas- passes through the pectoralis minor muscles in about percent of patients
says. e underlying pectoralis muscle should not be involved in any way or passes laterally around the pectoralis minor in percent en route to
by the biopsy; otherwise that section of the muscle should be excised en innervating the lower region of the pectoralis major muscle (figure 6). e
bloc with the specimen. A er the biopsy wound is closed and sealed, all dominant lateral nerve to the pectoralis major muscle arises from the lateral
instruments and gloves used in the procedure are discarded. Some prefer cord. It passes medial to the pectoralis minor muscle near its insertion and is
to have a second sterile table available, which results in a repeated complete closely associated with the acromial thoracic artery. CONTINUES

430
431
 PLATE

201 M R M

DETAILS OF PROCEDURE e lateral edge of the pectoralis muscle twitch. e wound is irrigated with saline, and a nal inspection is
minor is cleared of fascia to near its insertion on the corticoid process and made for hemostasis prior to closure. Two closed-system perforated suction
several veins are ligated as they come o the axillary vein (figure 7). A catheters are inserted for drainage. ey are usually introduced through
careful search is made for the medial nerve to the pectoralis major, which separate stab wounds made in the lower ap posteriorly. One catheter is
is preserved. Ligation rather than electrocoagulation is preferred for all ves- directed up to the axilla. e other catheter is secured anterior to the pec-
sels about the axilla and for those adjacent to the sternum. toralis major muscle for drainage from under the skin aps. e catheters
e pectoralis major and minor are retracted upward and medially, are secured to the skin with nonabsorbable sutures and attached to a closed
exposing the uppermost tissues to be divided over the axillary vein. Some system of suction (figure 11).
prefer to divide the pectoralis minor muscle from its insertion on the cora- It is very important that the surgeon spend the necessary time and e ort
coid process as to gain better exposure of the medial area of the axillary vein to compress the skin aps into place in the axilla and elsewhere as the skin
and its lymph nodes. is nally closed. If the skin aps are so thin that there is minimal subcuta-
e fascia over the serratus anterior muscle is dissected free, and the neous tissue, interrupted sutures are used in the skin. Alternatively, some
axillary fat and lymph nodes are mobilized o the chest wall and the axillary surgeons use a few interrupted absorbable sutures in the subcutaneous fat
vein (figure 8). e arm, wrapped in sterile drapes, is li ed up or manipu- in medium-thickness skin aps.
lated to enhance the exposure as the dissection progresses in the axilla. e e manner of dressing the incision is controversial. In the Auchin-
long thoracic nerve should be identi ed deep to the axillary vein. As it lies closs method, the skin is cleaned, dried, prepared with tincture of benzoin,
within the loose fascia over the serratus anterior muscle, it is possible to and approximated with very large strips of elastic tape. ese start above
li this nerve away from the muscle; hence, it must be carefully sought and the level of the clavicle and extend down to the level of the drains. Others
dissected out from the axillary contents to be contained within the resected apply a simple gauze dressing and a surgical bra, whereas some prefer bulky
specimen. is nerve should be retained intact, because a “winged” scapula u ed dressings followed by gauze or elastic bandage wrappings.
will result if it is divided. A sensory nerve that is o en sacri ced is the more
transverse intercostobrachial that appears beneath the second rib and pro- POSTOPERATIVE CARE Skin sutures, if present, are removed in to
vides sensory innervation to the upper inner aspect of the arm. days, with the incision being reinforced with “butter y” adhesive strips.
As the breast is retracted laterally (figure 9), the long thoracic nerve e suction catheters are removed in approximately to days, when the
as well as the thoracodorsal nerve should be free of redundant tissue. e drainage is less than mL per day. Any collections of uid may be aspi-
thoracodorsal nerve is characteristically located adjacent to the deep sub- rated in the surgeon’s o ce using strict adherence to aseptic precautions.
scapular vein and artery. Division of the thoracodorsal nerve is avoided Normal use of the arm is encouraged for the rst week; therea er, active
unless there is tumor involvement, since its sacri ce has only a partial e ect shoulder exercises are performed to ensure return of full range of motion
upon the latissimus dorsi muscle. within the ensuing weeks. Physical therapy may be necessary if progress
e specimen is freed from the latissimus dorsi muscle (figure 10) is not apparent in this interval. e patient is cautioned to minimize cuts
and nally from the suspensory ligaments in the axilla, where large veins and possible infection in this arm and to report immediately any injury
and lymphatics should be carefully ligated. e operative area is repeatedly that results in infection, since a rapidly spreading lymphangitis is possible.
inspected for any bleeding points, which are ligated. e two major nerves Finally, a systematic regimen for lifelong follow-up is instituted even if the
are checked to be certain that their course is free of ligature, and their integ- nal pathologist’s report does not indicate the need for additional therapy
rity is veri ed by a brisk but gentle pinch that results in an appropriate at the time. ■

432
433