Surgical Steps for Axillary Dissection in Breast Cancer
Incision and Approach
The breast incision and axillary incision must be separate to avoid unsightly deformities. 1
- Make a transverse incision low in the axilla that stops at the posterior border of the pectoralis major muscle for excellent cosmetic results and optimal exposure. 1
- Alternatively, a linear incision posterior and parallel to the edge of the pectoralis major provides good exposure with a cosmetically acceptable scar. 1
- The only exception to separate incisions is an axillary tail tumor that can be readily removed through the axillary incision. 1
Extent of Nodal Dissection
For staging purposes, removal of level I and level II nodes permits accurate assessment of axillary nodal status. 1
- For invasive tumors ≤1 cm in diameter and favorable histologic types (tubular, mucinous, papillary), removal of level I nodes alone is adequate. 1
- Level III node removal is advised only when encompassing obvious disease is necessary. 1
- At least 10 lymph nodes should be removed for adequate staging when performing formal axillary dissection. 2
Critical Nerve Preservation
The thoracodorsal and long thoracic nerves must be preserved to prevent significant functional morbidity. 1
- The medial pectoral nerve should also be preserved. 1
- Preservation of the intercostal brachial nerve is desirable, but may not be possible if preservation compromises adequate excision of grossly positive or suspicious nodes. 1
- Circumferential stripping of the axillary vein is unnecessary and increases the incidence of edema. 1
Drainage and Wound Management
- Closed suction drainage is advisable to prevent seroma formation, which is one of the most common complications following axillary dissection. 1, 3
Postoperative Management
Early postoperative exercise must be prescribed to prevent frozen shoulder, despite potentially prolonging axillary drainage. 1, 2
- Shoulder immobilization with arm slings and wraps must be avoided. 1, 2
- Formal rehabilitation with exercise training is essential after axillary dissection to prevent frozen shoulder and minimize the 30-50% risk of lymphedema. 2
Important Caveats
- Meticulous surgical technique is mandatory to prevent significant morbidity, as axillary dissection carries risks of lymphedema, shoulder stiffness, pain, and sensory neuropathy. 3, 2
- The accuracy of staging increases with the number of lymph nodes resected, and there is little difference in morbidity between partial and total axillary lymphadenectomy. 4
- Sentinel lymph node biopsy has largely replaced routine axillary dissection for clinically node-negative patients, significantly reducing post-operative complications. 1, 3, 5