A 40-year-old woman with a remote history of mantle radiation for Hodgkin's lymphoma presented with bilateral breast cancer diagnosed by mammography and by core biopsy. She underwent bilateral mastectomy with sentinel lymph node dissection (SLND). The sentinel node on the right was positive for carcinoma with extracapsular and lymphvascular invasion. Because of the pathology and because of her limited ability to tolerate additional radiation to the axilla, she underwent completion axillary lymph node dissection. The arm was prepped circumferentially to
the wrist and wrapped from hand to elbow in order to adduct the arm and
relax the pectoralis muscles and gain access to the apex of the axilla. There were palpable nodes up to level III (costoclavicular/Halsted's ligament) on opening the axilla, so a complete axillary lymph node dissection (ALND, see axillary anatomy) was performed. The pectoralis minor was elevated by dividing medial and lateral anterior thoracic (pectoral nerves) to reach the apex of the axilla. The completed dissection is shown, with visualization of long thoracic and thoracodorsal nerves. The long thoracic is medial and posterior, the thoracodorsal lateral and anterior.
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