SURGICAL ANATOMY AND OPERATIVE TECHNIQUE OF

THE AXILLARY LYMPH NODE DISSECTION.

RANGONE, JUAN MANUEL.1
IPIÑA, MARTIN.2
QUILDRIAN, SERGIO.3
CERVELO, GONZALO.3
NIKISCH, LEANDRO.3
CHAPELA, JORGE ALBERTO.3

ABSTRACT
There is extensive literature regarding current indications of axillary dissection, the structures that should be
preserved during surgery and the postoperative complications. The aim of this article will be its surgical
technique.
The axilla is described, in a surgical position, as a rectangle trapezoid. We introduce the concept of the “vertical
elements” to describe the main vascular axes of the axilla. The term “lingular axillary lymph node fatty
tissue” (LALNFT) describes the content located between the “vertical elements”. We recognize three LALNFT
in the axillary fat pad. The complex surgical anatomy of the axilla is reviewed and systematic operative steps
are proposed. Our surgical technique allows to achieve a complete en bloc removal of the axillary fat pad
preserving important functional structures.
KEYWORDS
Axillary lymph node dissection; breast cancer surgery; melanoma surgery.

INTRODUCTION
There is extensive literature regarding current indications of axillary dissection, the structures that should be
preserved during surgery and the postoperative complications [1]. The aim of this article will be its surgical
technique.
The concept of “lingular axillary lymph node fatty tissue”, which will be introduced later on this article, finds its
roots in the axillary “pads” and “lymph nodes vertexes” which have been described by Alfonso R. Albanese in
1938 [2,3].
The anatomical studies developed by Isidoro Caplan [4,5,6,7] with the modified Gerota method (1970, 1979,
1986) and his classification of the axillary lymph nodes, we recognize best “fits the anatomic reality” [8]. Even so,
we believe that our division of the axillary lymph node fatty tissue into “lingular” pads, separated by recognizable
anatomic elements during the operative procedure, will be most useful in daily surgical practice.

SURGICAL TECHNIQUE
We will describe the axilla, in a surgical position, as a rectangle trapezoid (Figure 1). Its superior base is the
axillary vein. Its perpendicular side is represented by the lateral margin of the pectoralis major. Its oblique side is
the free edge of the latissimus dorsi (LD) muscle. We will see next, in this article, that there is no agreement in
the bibliography about the inferior boundary of the rectangle trapezoid.
We will call the intersection point between the pectoralis major muscle and the axillary vein, the “pectoral-
axillary vertex” (PAV). The exact place where the tendon of the LD muscle finds the vascular axis will be called
“dorsi-axillary vertex” (DAV).

1- Resident Instructor in Oncologic Surgery. Instituto de Oncología Ángel H. Roffo. Universidad de Buenos Aires. Buenos Aires, Argentina.
2- Department of Mastology. Instituto de Oncología Ángel H. Roffo. Universidad de Buenos Aires. Buenos Aires, Argentina.
3- Department of Soft Tissue Tumor Surgery. Instituto de Oncología Ángel H. Roffo. Universidad de Buenos Aires. Buenos Aires, Argentina.
1- Skin incision. It will vary according to the build of the patient, the necessity for the best exposure of the
vascular axis and, in several cases, the surgeons preference. (Figure 2)
The patient is placed in supine position with the arms extended at 90 degrees of abduction from the chest wall,
allowing maximum exposure of the axilla:
a- Transverse incision: It is performed between the anterior and posterior axillary line, 2 cm. below the
medial bicipital skin fold (MBSF). This landmark projects the axillary vascular axis. The main disadvantage of this
incision is the skin retraction which might be a long term side effect.
b- Vertical incision: the free edge of the major pectoralis will be followed up to the MBSF.
c- Arcuate incision: It describes a superior concavity between the anterior and posterior axillary folds,
just below the implantation of the axillary hairline. This trace is the one with better cosmetic results in the long
term.

2- Identification and aponeurectomy of the pectoralis major muscle: After recognizing it by palpation, we
incise the subcutaneous tissue and the epimysium of the muscle concerned, 1 cm. medially from its free edge.
(Figure 7) The incision should always follow the muscle fibers direction [9] and, should not extend beyond the
MBSF. This fascia will be included in the resected specimen. (Picture 1)

3- LD muscle (identification and beginning of its aponeurectomy): After recognizing its free edge by palpation,
a vertical incision is made on its epimysium following the muscle fibers direction. (Figure 7) The incision should
be done at least 1 cm. away from its free edge in order to avoid damaging the thoracodorsal pedicle. (Figure 9,
Picture 2) At least 3 cm. should be left between the upper extremity of the incision and the MBSF. Do not
extend the incision upwards as it may increase the risk of injury of the intercostobrachial nerve [10]. (Figure 6)

4- Exposure of the axillary vein: In thin patients, we can recognize by transparency the characteristic blue color
of the axillary vein. The axillary clavipectoral fascia and the suspensory ligament will be incised 1 cm. below the
MBSF. (Figure 1, Picture 3) The section of this fascia, described by Richet, produces the evisceration of the
axillary fat pad.
Separating the lax lobules of fat of the axillary fossa will allow us to find the neurovascular bundle of the arm.
The only element to be exposed is the axillary vein, more precisely, its anterior side. Care must be taken not to
open the axillary sheath and skeletonize the vein unless there is extensive nodal disease. Stripping the vascular
axis increases the risk to tear the small lymphatics ducts that extend from the arm to the neck and the medial
brachial cutaneous nerve.
If no clinically suspicious nodes are palpated above the anterior side of the vein, neither the axillary artery nor
the secondary trunks of the brachial plexus should be exposed. (Figure 9, Picture 5)
In 10% of the cases the axillary vein might be double. Do not divide the vein structures that flow transversally,
not even those which do not appear to be an axillary vein. In 10% of the cases there might be an axillary arch
of Langer [11,12,13,14,15,16,17,18,19]; its section is necessary in order to achieve a correct exposure of the
vascular axis [20]. (Picture 10)

5- Exposure of the PAV (Figure 1): Move forward in the exposure of the axillary vein towards the medial in
order to reach its intersection point with the free edge of the major pectoralis. (Figure 4, 6)

6- Exposure of the DAV (Figure 1): Move forward in the exposure of the axillary vein towards the lateral in
order to reach the intersection with the LD tendon. (Figure 4, 6)

7- Assessment of the interpectoral space: If grossly positive lymph nodes are revealed (Rotter´s lymph nodes),
perform a dissection in this region. (Figure 6. Picture 3) Remember that the medial pectoral nerve paired with
its small concominant vessels are placed in this compartment. The iatrogenic injury in such pedicle results in
muscular denervation of the pectoralis minor and the lateral muscle fibers of the pectoralis major, producing
atrophy and the consequent loss of boundary of the anterior axillary fold. (Figure 9)

8- Aponeurectomy of the pectoralis minor muscle: perform the fasciotomy following the direction of the
muscle fibers in an ascending manner. Keep the fascia section beyond 1 cm. from the PAV in order to diminish
the risk of injury of the medial pectoral pedicle [21,22]. (Figure 9)
Moosman et al. [23] studied the relation between the medial pectoral nerve and the pectoralis minor muscle in
100 formalin-fixed specimens. The branch that passes laterally around the muscle was present in 60/100 of the
cases and the perforating branches in 62/100. (Figure 5. Picture 9)

9- Identification of the intercostobrachial nerve (ICBN): If the nerve preservation does not compromise the
oncologic outcome of the surgical procedure, we strongly recommend its maintenance. The iatrogenic injure of
the ICBN may result in “the post-mastectomy pain syndrome”.
In the 75% of the cases, the ICBN is found as a single trunk [24,25,26] originated from the second intercostal
nerve. According to Zhu et al. [27] the distance from its origin to the inferior margin of the axillary vein is 29.3
(±) 6.7 mm. In agreement with this authors [27], we think the best way to identify the ICBN is by looking for at
the deep side of the inferior margin of the pectoralis minor muscle (where the nerve pierced the thoracic wall).
(Figure 6)
The ICBN passes almost vertically along the anterior side of the long thoracic nerve, the external mammary
vessels, the nerve of the LD muscle, the subscapular vessels and, finally, the free edge of the LD tendon. Its
terminal branches always originate towards the lateral of its intersection with the subscapular vessels. (Figure 6)
Once the ICBN is identified, it must be exposed up to the intersection with the LD tendon. It is not necessary
to divide the resected specimen in order to preserve the nerve; the adventitial tissues can be incised by sharp
dissection along the ICBN so that the nerve can be retracted anteriorly away from the underlying axillary fat
pad. (Picture 9, 10)

10- Ending the aponeurectomy of the LD: continue the incision of the epimysium upwards until the DAV. Be
careful not to damage the ICBN, retracted in the previous step. (Figure 3, 6)

11- Exposure of the inferior margin of the axillary vein and the following elements (from lateral to medial):
a. Subscapular/ thoracodorsal vessels.
b. External mammary vessels.
c. Medial pectoral pedicle [28,29,30,31,32].
In this article, we will call these 3 structures “vertical elements” and we will use the term “lingular axillary lymph
node fatty tissue” (LALNFT) to describe the content located between the “vertical elements”. (Figure 3, 4, 6)
We recognize:
a. “Thoracodorsal” or lateral LALNFT (placed between the LD tendon and the thoracodorsal pedicle).
b. “Thoraco-mammary” or middle LALNFT (placed between the subscapular/ thoracodorsal pedicle and
the external mammary vessels).
c. “Pectoral-mammary” or medial LALNFT (placed between the external mammary vessels and the
medial pectoral pedicle). Rotter’s lymph nodes represent the internal extension of the medial LALNFT.
(Figure 6)

12- “Descent” of the lateral and middle LALNFT: The lateral LALNFT may be dissected without risk, as it has
no content. (Figure 6) The lymphadenectomy of the middle LALNFT should be done carefully as it contains, in
its more apical portion, the LD nerve. This nerve has an oblique descending route, from the medial to the
lateral, seeking the anterior side of the thoracodorsal vascular axis. This “pre-vascular” section of the nerve
(previous to the intersection with the thoracodorsal vessels) should be exposed to ensure its indemnity.
(Figure 6, 9. Picture 6, 7, 8, 9)
The costoaxillary vein (thoracoepigastric or Braune´s vein) is not a constant vessel. It generally lays out between
the thoracodorsal pedicle and the external mammary vessels. (Figure 4, 9) It should be included in the resected
specimen once discarded it being a hypotrophic variant of the thoracodorsal vein (which enters more
posteriorly)[33, 34]. (Figure 11. Picture 4) Afterwards divide the external mammary vessels (Figure 3, 4, 6, 9.
Picture 5) with the precaution of having previously exposed the thoracodorsal neurovascular bundle (in 10% of
the cases, there is a common vascular trunk between the external mammary and the subscapular vessels) [35].
(Figure 8)

13- Identification of the long thoracic nerve [36,37,38,39,40,41,42] (Figure 6, 9): Applying gentle traction of
the resected specimen, the dorsal face of the fascial transition between the pectoralis minor and serratus
anterior aponeurosis is exposed. Performing an incision in the dorsal face of this fascia (approximately 1 cm.
laterally to the anterior axillary line) will lead us to expose the ventral side of the serratus anterior fascia.
(Figure 7)
We will find the long thoracic nerve by means of transparency, through the serratus anterior fascia. Once
reached, a second vertical incision laterally to the Bell´s nerve will be performed in order to create a gap in the
fascial layer. We will place our two index fingers opposing each other (“nail to nail”) through this gap. Pull
upwards and move the left index finger (in the case of a right axilla and if we are right handed) until you reach
the axillary vascular axis. (Figure 12) This maneuver will allows us to extend the vertical incision in the serratus
anterior fascia by blunt dissection. The long thoracic nerve will stand below the fascial layer against the chest
wall reducing the likelihood of injury [43]. (Pictures 6, 7, 8) The iatrogenic disruption of Bell´s nerve results in a
“winged” scapula deformity.

14- “Descent” of the medial LALNFT and dissection of the axillary lymph node level II: With a small
retractor, the first assistant raises the pectoralis minor to the zenith. Meanwhile, the surgeon performs the
dissection of the retropectoral axillary lymph node fatty tissue (Berg´s level II)[44]. The tissue concerned is
pulled out by gentle traction and divided as deep as possible. We should be extremely careful not to injure the
lateral pectoral nerve and the branches of the thoracoacromial artery. (Figure 9. Picture 9)
In general, level I and II anatomic lymphadenectomy is the preferred procedure for axillary assessment [45,46].
(Picture 10) Routine removal of level III nodes is unnecessary for staging but should be carried out to maximize
local control if grossly positive axillary lymph nodes are identified intraoperatively.

15- Final exposure of the thoracodorsal pedicle: After identifying the “pre-vascular” section of the LD nerve,
its intersection with the anterior side of the thoracodorsal vessels (“vascular section”) is exposed. This first
“neurovascular intersection point” (NVIP) matches with the inflow of the angular vein of the scapula towards
the thoracodorsal vein. (Figure 9, 10. Picture 6, 7, 9, 10)
We should continue with the exposure of the “post-vascular” section of the nerve towards the free edge of the
LD. (Figure 9,10) The accidental intraoperative injury of the thoracodorsal pedicle rarely implies important
functional sequelae; it should be preserved baring in mind the possible necessity of a later reconstructive option
in future surgeries.
Once the whole length of the nerve is exposed, the dissection of the venous branches coming from the
serratus anterior muscle is completed. These vessels are placed horizontally between the fascicles of such
muscle. They drain into the thoracodorsal vessel (underneath the angular vein) through a common trunk or
independently from each other. (Figure 9. Picture 6)
The serratus anterior vessels might be quite reliable landmarks in order to find Bell´s nerve when being
dissected towards the chest wall. The most voluminous venous branch of the serratus anterior veins usually
crosses the anterior side of the long thoracic nerve perpendicularly at the same level of the midaxillary line
(second NVIP). (Figure 9, 10. Picture 6)

16- Delimitation of the inferior boundary of the axillary dissection: There is no agreement on this issue.
Some authors limit the dissection to the first NVIP, where the angular vein enters the thoracodorsal vein [47].
(Figure 9. Picture 6)
The authors of this publication always extend the dissection below this intersection, in order to expose the
serratus anterior vessels and the thoracodorsal pedicle entrance to the free edge of the LD muscle. At this
level, the axillary fat pad is replaced by the subcutaneous fat tissue of the lateral region of the chest wall. (Figure
9. Picture 6, 7)
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