ANZ J. Surg. 2006; 76: 652654 doi: 10.1111/j.1445-2197.2006.03791.

SURGICAL TECHNIQUE

MEDIAL PECTORAL PEDICLE: A CRITICAL LANDMARK IN

AXILLARY DISSECTION

MANDAR S. NADKARNI, SUDEEP RAINA AND RAJENDRA A. BADWE

Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Surgery for breast cancer has evolved over the last century and has gone from limited to radical, extended radical and back to
conservative surgery. Along this journey, one constant feature has been the necessity for a complete axillary dissection. In recent
times, this concept has also been successfully challenged and now we are in an era of conservative or limited surgery in the axilla as
well. These surgical procedures such as four-node axillary sampling or the technology-driven sentinel node biopsy are conservative
axillary procedures and are often performed through very small incisions. With limited access to the surgical field, there is always an
increased chance of inadvertent and unnecessary injury to surrounding vital anatomical structures such as nerves or blood vessels. A
well-designed road map can definitely prevent such mishaps. This paper describes a simple technique of axillary surgery, which is
step-wise and makes use of a relatively constant landmark, namely the medial pectoral pedicle, present within the axilla. Such
a regimented systematic approach not only allows us to minimize the risks of complications during axillary surgery, but also enables
us to train beginners easily and efficiently.

Key words: anatomical landmark, axillary dissection, breast cancer, breast conservation, mastectomy, medial pectoral
pedicle, surgery, technique.
Abbreviations: ICBN, intercostobrachial nerve; LD, latissimus dorsi; MPP, medial pectoral pedicle.

INTRODUCTION surgery in a controlled and a precise manner. The advantage of

using a standard technique is that it can be understood and fol-
Anatomical landmarks play an important role in a surgeons
lowed by one and all, including trainees, which has helped us
career. They serve as guides to successful and safe surgery. With
minimize complications and deliver consistent results.
the growing awareness of breast cancer in the general population
In institutions where sentinel node biopsy has been accepted as
and widespread practice of breast screening, more early cancers
a standard-of-care, recommendations are that a complete axillary
are being detected. Consequently, the number of breast conserva-
lymph node dissection be carried out if the sentinel node or nodes
tions is increasing and the rate of positive axillary nodal disease is
are involved by cancer. In other institutions where the above
decreasing rapidly. Another important fact to note is that a com-
technology is not yet established, such as ours, all patients with
plete axillary dissection can result in sequelae such as lymphe-
infiltrating cancer undergo some type of axillary dissection. The
dema, nerve injury, shoulder dysfunction, persistent seroma
international recommendations are to carry out level I and II dis-
formation that may compromise functionality and quality of life.
sections only. However, these recommendations come from West-
This has led to the development of limited axillary dissection
ern countries where the average size of the primary breast lumps
techniques like sentinel node biopsy, axillary sampling that are
is much smaller than the sizes in our country. In developing coun-
limited in the extent of dissection as well as in their length of
tries such as ours the average tumour size is larger and conse-
incisions. The limited access makes identification of vital struc-
quently the chances of level III lymph node involvement by
tures difficult. Moreover, standard textbooks or atlases do not give
disease is higher and merits axillary dissection including all three
a detailed roadmap of axillary surgery and most surgeons have to
levels. Second, there is no evidence that the performance of level
learn this technique on their own. Beginners prefer to gently
III dissection increases morbidity over a more limited dissection
dissect and identify the important structures one at a time in a
(levels I and II only). Finally, if one has already dissected levels I
haphazard manner. This is not only cumbersome and time-
and II, it is neither difficult nor time-consuming to carry out the
consuming but the patient always runs the risk of suffering injury
additional dissection.
to one or many of the delicate structures in the axilla, especially if
The anatomy of the axilla or the axillary basin is important to
the patient is obese. At Tata Memorial Hospital, we follow a sim-
all oncologic surgeons as it represents the principal lymphatic
ple and stepwise technique for axillary dissection. This technique
drainage region of the breast. Lymphatic metastasis from a malig-
makes use of the various constant landmarks within the axilla in
nant breast lesion will most often occur in this region. Therefore,
a sequential and orderly manner to enable performance of this
a surgeon should have precise knowledge of the anatomy of the
M. S. Nadkarni MS, DNB; S. Raina MS; R. A. Badwe MS. axilla, its boundaries and its contents to carry out a safe, precise
and appropriate axillary dissection. Axillary dissection is a surgery
Correspondence: Dr Mandar S. Nadkarni, Department of Surgical Oncology, wherein the contents of the dissection are variable, for example,
Tata Memorial Hospital, Mumbai, Maharashtra, India.
Email: drmandar@gmail.com
number of nodes, blood vessels and nerves, but what remains
constant at all times is the boundaries of dissection. The surgical
Accepted for publication 12 January 2006. procedure involves resection of all contents from the chest wall
2006 Royal Australasian College of Surgeons
MEDIAL PECTORAL PEDICLE: A CRITICAL GUIDE
medially to the lateral border of the latissimus dorsi (LD) muscle
laterally and from the pectoral muscles anteriorly to the subsca-
pularis and LD muscles posteriorly. The superior extent of the
dissection is the axillary vein. For convenience of description, the
lymph node bearing area has been divided into three levels: level I,
lymph nodes that lie lateral and inferior to the lateral border of the
pectoralis minor muscle; level II, lymph nodes that lie behind the
pectoralis minor muscle and level III, lymph nodes that are situ-
ated medial to the pectoralis minor muscle. To dissect all the
above lymph node levels with minimal morbidity, it is imperative
to identify the individual constituents of the axilla and preserve
the important ones such as the axillary vein, the long thoracic
nerve of Bell (that innervates the serratus anterior muscle), the
thoraco-dorsal nerve and accompanying vessels (that supply the
LD muscle). The medial and lateral pectoral nerves (that inner-
vate the pectoral muscles) are often injured because of excessive
retraction and a purposeful attempt should be made to identify
these nerves and prevent unnecessary trauma to them. Injury to
these nerves leads to wasting of the pectoral muscles and thereby
defeats the very purpose of carrying out a modified radical mas-
tectomy. The intercostobrachial nerve (ICBN), a sensory nerve for
the medial aspect of the arm and the posterior aspect of the axilla,
usually arises from the second intercostal space and should be
preserved whenever possible.
TECHNIQUE
The standard recommended position is supine, with the patient
at the edge of the table and the arm abducted to 90 and well
supported on a padded arm support. Surgery for breast cancer
does not require any special equipment, although a good dia-
thermy is a boon. Usage of state-of-art diathermy machines def-
initely makes the surgical procedure easier, quicker and almost
bloodless. However, it must be reiterated that appropriate surgical
clearance should not be a servant to fancy equipment.
Step I: Identification of the medial pectoral pedicle
We consider the medial pectoral pedicle ((MPP) medial pectoral
nerve and accompanying vessels) as the pivotal point in the axilla.
The entire axillary dissection is carried out in relation to this
landmark. Therefore, it is very important to correctly identify
and preserve this structure as the first step of the axillary dissec-
tion. Any damage to this pedicle leads to wasting of the pectoralis
major muscle with a resultant loss of contour of the chest wall
especially post-mastectomy.
The skin incision is taken along the lower border of the axillary
hairline. The incision is then deepened to identify the lateral
border of the pectoralis major. Dissection is carried out deeper
to the pectoralis major to identify the pectoralis minor muscle.
The lateral border of the pectoralis minor muscle is then traced in
a cranial direction till the MPP is identified at a point where it
loops around the lateral border of the muscle. This loop of the
MPP is then followed till a point where it pierces (emerges from)
the clavipectoral fascia. This point is taken as the reference point
for further dissection in the axilla.
This point serves as a constant landmark to identify the axillary
vein as well as the ICBN. The axillary vein lies approximately
1 cm cranial and posterior to the MPP (Fig. 1), whereas the ICBN
is situated within 1.5 cm caudad and posterior to this anatomical
landmark.
2006 Royal Australasian College of Surgeons
653
Fig. 1. The landmarks in axillary dissection (pectoralis major mus-
cle has been omitted for clarity). A, axillary vein; B, brachial plexus;
C, intercostobrachial nerve (ICBN); D, latissimus dorsi muscle; E,
thoracodorsal vessels and nerve; F, subscapularis muscle; G, long
thoracic nerve of Bell (nerve to serratus anterior); H, pectoralis minor
muscle; I, medial pectoral pedicle (MPP). The axillary vein lies 1 cm
cranial and posterior to the MPP, whereas the ICBN lies 1.5 cm
caudad and posterior to the MPP.
The axilla is entered by incising the clavipectoral fascia along
the entire length of the pectoralis minor muscle. This incision is
curved around the emergence of the MPP till a point 11.5 cm
cranial to it. The direction in the incision (of the clavipectoral
fascia) is then turned laterally so that it is more or less parallel to
the abducted upper limb (in other words, parallel to the as yet
unexposed axillary vessels). Incising the fascia allows the axillary
fibrofatty tissue to bulge out. At the cranial-most extent, the fatty
tissue is then dissected down from the axillary vessels (still unex-
posed) using dissecting scissors in one swift move. This invariably
exposes the axillary vein (superior extent of axillary dissection).
A word of caution at this stage: sometimes the fat gets pulled
down from a higher level and this may expose the cephalic vein,
which may be initially mistaken for the axillary vein. Therefore, it
is a standard procedure in our hospital to identify the confluence
of the axillary and cephalic vein so as to ensure safety in carrying
out this manoeuvre.
Once the vein has been identified, the fibrofatty tissue is then
very gently swept downwards from the pedicle without using too
much force. This exposes two venous tributaries (rarely one or
three) of this pedicle that enter the axillary pad of fat. A genuine
attempt must be made to locate, diathermize and divide both
these branches to prevent unnecessary haemorrhage from them.
Attempts to control the bleeding, after it has occurred, more often
than not leads to inadvertent cauterization of the MPP. Once the
branches are diathermized and divided, the entire axillary dissec-
tion template moves away from the MPP and the axillary vein
with ease to facilitate demonstration of the ICBN. A majority
of the blood vessels found during this dissection can be safely
coagulated with a diathermy (provided the surgeon has access to
state-of-art diathermy machines); however, the safer technique is
to individually ligate these branches. Here onwards, the dissection
is carried out from medial to lateral, that is from the chest wall
654
across the thoracodorsal vessels and nerve to the lateral border
of the LD muscle.
Step II: Identification of the ICBN and the
long thoracic nerve of Bell
The next step in axillary dissection is the identification of the
ICBN. This step is very important because of two reasons: first,
in many patients, especially node negative, the ICBN can be pre-
served thereby preventing anaesthesia along the medial aspects of
the arm and second, the ICBN itself acts as a landmark for suc-
cessful identification and preservation of the long thoracic nerve
of Bell. The ICBN lies approximately 1.5 cm caudad and poste-
rior to the MPP (Fig. 1). The fibrofatty tissue is gently stripped
from the chest wall in the probable area of its origin and the ICBN
is identified running parallel to the axillary vein. It is then divided
(or preserved as required) flush with the chest wall and the
remainder of the axillary fat swept away laterally from the chest
wall (medial extent of the dissection). This manoeuvre allows
exposure of the long thoracic nerve that is usually identified as
a nerve running on the chest wall underneath a fascial covering.
The long thoracic nerve is usually accompanied by a vein. The
fascia is incised lateral to the nerve and the interneural fat is
completely swept away from the chest wall to expose the subsca-
pularis muscle (the posterior extent of the dissection). It is impor-
tant to note that the long thoracic nerve lies at a plane deeper to
the ICBN and that one cannot injure it (nor locate it) if the dis-
section has not proceeded deeper to the ICBN. The interneural
tissue is then dissected away from the axillary vein behind which
it occasionally extends. This step automatically leads us to the last
undissected important structure, namely the thoracodorsal nerve.
Step III: Identification of the thoracodorsal vessels
and nerve
The nerve to LD runs a short course on the subscapularis muscle
parallel to the axillary vein and then curves downward to run
along the thoracodorsal vessels to constitute the latissimus dorsi
pedicle (LD pedicle). Dissection of the interneural pad of fibro-
fatty tissue from the lower border of the axillary vein automati-
cally allows demonstration of the nerve to LD, which leads to the
LD pedicle. The entire fibrofatty tissue is then dissected off this
pedicle, taking care to identify, cauterize and divide the numerous
branches that arise from the pedicle and extend into the axillary
dissection template. Once the entire LD pedicle is dissected away,
the remaining fat is stripped from the anterior surface of the LD
muscle till its lateral border (the lateral extent of our dissection).
NADKARNI ET AL.
This completes a level I dissection. For the rest of the axillary
dissection (levels II and III), the pectoral muscles are retracted
anteriorly and the entire fibrofatty tissue is dissected off the chest
wall (that is situated posteriorly) and the axillary vein (subclavian
vein that is situated cranially) as the level II and III axillary
dissection template. An important vessel to identify while carry-
ing out this step is a direct tributary of the axillary vein that comes
off in to the level III fat. This vein is identified at the point where it
enters the axillary vein and this point is usually located in line
with the thoraco-acromial pedicle that supplies the pectoralis
major muscle. The vein needs to be securely ligated and divided
to avoid any mishaps. Another precaution to be taken is to avoid
unnecessary excessive retraction during this step as the metallic
retractors can cause inadvertent damage to the medial pectoral
nerve. After the axillary dissection is complete, the operating
surgeon should dissect between the pectoralis major and minor
muscles to look for the inter-pectoral pad of fat (that contains
Rotters nodes) and excise it.
This stepwise technique allows a systematic identification of
the vital anatomical structures in the axilla in an orderly fashion
without risking damage to any of them. It is easy to teach as well
as to follow and helps in carrying out complete bloodless axillary
dissection in optimum time.
COMMENT
With cancers being detected in early stages, more and more con-
servative approaches are being adopted in axillary dissection.
Techniques such as sentinel node biopsy and axillary sampling
are being extensively investigated worldwide as definitive proce-
dures for the management of the axilla. The incisions for these
techniques are also getting smaller and smaller. The better the
orientation of the three-dimensional anatomy of the surgical field
in a surgeons mind, the easier and more precise is the surgery.
This is possible if a stepwise method based on local anatomical
landmarks is followed.
Last but by no means least, in a training institution like ours,
surgical trainees follow postings of 4 months each during which
they are expected to observe, assist, learn and independently carry
out these surgical procedures. Although this short period of time
can allow the basics of these procedures to be understood, the
smaller nuances can be learnt only after repeatedly carrying out
them. The next best alternative is to standardize the steps in these
procedures. Strict regimentation of surgical steps can enable easy,
quick and uniform learning of surgical techniques. Above all, it
also helps maintain consistent results in surgical outcomes.
2006 Royal Australasian College of Surgeons