Modified radical mastectomy for level III axillary lymph node clearance: a case report

Abstract

While modified radical mastectomy with level I and level II axillary lymph node clearance is a typical operating method in breast surgery, level III axillary lymph node clearance is necessary in some cases such as those involving apical axillary nodes. Level III dissection can provide accurate postoperative staging and essential guidance for postoperative adjuvant therapy. Although it is often difficult to expose the subclavian region and dissect level III axillary lymph nodes, in this case, the author split the pectoralis major muscle 2 cm inferior to the collarbone and performed a skeletonized complete level III axillary lymph node dissection. The author cut apart the fat on the surface of subclavian vein, lifted the fascia on the surface of the subclavian vein, removed the lymphoid adipose tissue along the fascial space completely and skeletonized subclavian vein. This approach provides less operating space, but it can fully expose the subclavian area, making it easier to dissociate and dissect the parasternal ligament, subclavian vein, medial border of the pectoralis minor muscle, and other important anatomical landmarks. In addition, the pectoralis branches of the thoracoacromial artery and the lateral cutaneous branches of the intercostal nerves were protected when removing the axillary nodes, which reduced postoperative complications such as upper limb numbness, tingling sensation, and muscle atrophy. Axillary lymph nodes were completely resected from inside to outside, and the important anatomical markers of axilla such as axillary vein, long thoracic nerve, thoracodorsal nerve and thoracodorsal vessels were clearly exposed.