c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

Axillary Lymph Node Dissection: 4

A D V E R T I S E M E N T

   
 

This and subsequent images are shown without skin margins for clarity. The plane between the underside of the pectoralis minor and fat pad is bluntly developed, again being careful not to injure the pectoral nerves. With the arm held up, there is adequate laxity in the pectoralis minor to reach even the level three region of the axilla.      

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Axillary Lymph Node Dissection: 5

A D V E R T I S E M E N T

   
 

Identifying the axillary vein which is encased in axillary fat is the key step in performing a safe, precise dissection. The apex of the axilla is at the costoclavicular ligament where the axillary vein crosses the lateral border of the first rib and becomes the subclavian vein. The safest approach to this fixed landmark is to tease the fat pad from the serratus below the ligament and carefully dissect bluntly (Kittner or open scissors points) up to the vein. The mid-portion of the vein bows lower than expected with the arm held up and identifying the location at one end or the other is safest. The other option is to find the thoracodorsal vessels inside the lip of the latissimus and follow them up to the lateral end of the vein.    

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Axillary Lymph Node Dissection: 6

A D V E R T I S E M E N T

   
 

The fat pad is then peeled off the chest wall, dividing all small vessels below the axillary vein. Rather than stripping the vein clean of adventitia as was done in the past, current practice is to leave a small cuff of adventitia on the underside of the vein to disrupt as few lymphatics as possible. As the fat pad is retracted laterally and caudally, the subscapular vessels and thoracodorsal nerve are exposed. The fat pad is carefully peeled off these structures. As exposure increases, the long thoracic nerve is identified deep and posterior. It is easy to peel the long thoracic nerve off the chest wall with the fat pad and care must be taken to identify the nerve near its origin and free it from proximal to distal.    

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This page was last modified on 6/20/1999.