The lateral edge of the pectoralis minor is cleared of fascia to near its insertion on the corticoid process and several veins are ligated as they come off the axillary vein (Figure 7). A careful search is made for the medial nerve to the pectoralis major, which is preserved. Ligation rather than electrocoagulation is preferred for all vessels about the axilla and for those adjacent to the sternum.
The pectoralis major and minor are retracted upward and medially, exposing the uppermost tissues to be divided over the axillary vein. Some prefer to divide the pectoralis minor muscle from its insertion on the coracoid process as to gain better exposure of the medial area of the axillary vein and its lymph nodes.
The fascia over the serratus anterior muscle is dissected free, and the axillary fat and lymph nodes are mobilized off the chest wall and the axillary vein (Figure 8). The arm, wrapped in sterile drapes, is lifted up or manipulated to enhance the exposure as the dissection progresses in the axilla. The long thoracic nerve should be identified deep to the axillary vein. As it lies within the loose fascia over the serratus anterior muscle, it is possible to lift this nerve away from the muscle; hence, it must be carefully sought and dissected out from the axillary contents to be contained within the resected specimen. This nerve should be retained intact, because a “winged” scapula will result if it is divided. A sensory nerve that is often sacrificed is the more transverse intercostobrachial that appears beneath the second rib and provides sensory innervation to the upper inner aspect of the arm.
As the breast is retracted laterally (Figure 9), the long thoracic nerve as well as the thoracodorsal nerve should be free of redundant tissue. The thoracodorsal nerve is characteristically located adjacent to the deep subscapular vein and artery. Division of the thoracodorsal nerve is avoided unless there is tumor involvement, since its sacrifice has only a partial effect upon the latissimus dorsi muscle.
The specimen is freed from the latissimus dorsi muscle (Figure 10) and finally from the suspensory ligaments in the axilla, where large veins and lymphatics should be carefully ligated. The operative area is repeatedly inspected for any bleeding points, which are ligated. The two major nerves are checked to be certain that their course is free of ligature, and their integrity is verified by a brisk but gentle pinch that results in an appropriate muscle twitch. The wound is irrigated with saline, and a final inspection is made for hemostasis prior to closure. Two closed-system perforated suction catheters are inserted for drainage. They are usually introduced through separate stab wounds made in the lower flap posteriorly. One catheter is directed up to the axilla. The other catheter is secured anterior to the pectoralis major muscle for drainage from under the skin flaps. The catheters are secured to the skin with nonabsorbable sutures and attached to a closed system of suction (Figure 11).
It is very important that the surgeon spend the necessary time and effort to compress the skin flaps into place in the axilla and elsewhere as the skin is finally closed. If the skin flaps are so thin that there is minimal subcutaneous tissue, interrupted sutures are used in the skin. Alternatively, some surgeons use a few interrupted absorbable sutures in the subcutaneous fat in medium-thickness skin flaps.
The manner of dressing the incision is controversial. In the Auchincloss method, the skin is cleaned, dried, prepared with tincture of benzoin, and approximated with very large strips of elastic tape. These start above the level of the clavicle and extend down to the level of the drains. Others apply a simple gauze dressing and a surgical bra, whereas some prefer bulky fluffed dressings followed by gauze or elastic bandage wrappings.
Skin sutures, if present, are removed in 3 to 5 days, with the incision being reinforced with “butterfly” adhesive strips. The suction catheters are removed in approximately 2 to 5 days, when the drainage is less than 30 mL per day. Any collections of fluid may be aspirated in the surgeon's office using strict adherence to aseptic precautions. Normal use of the arm is encouraged for the first week; thereafter, active shoulder exercises are performed to ensure return of full range of motion within the ensuing 2 weeks. Physical therapy may be necessary if progress is not apparent in this interval. The patient is cautioned to minimize cuts and possible infection in this arm and to report immediately any injury that results in infection, since a rapidly spreading lymphangitis is possible. Finally, a systematic regimen for lifelong follow-up is instituted even if the final pathologist's report does not indicate the need for additional therapy at the time.