How I do it?: Selective surgical approach to the third axillary level

Current clinical guidelines for axillary lymphadenectomy recommend levels I and II and, only if nodal involvement is evident in level II, third level resection is indicated.¹ This can be an arduous technique, particularly under some circumstances, such as after chemotherapy and/or radiotherapy, because a higher degree of fibrosis and tissue adherence are produced.

Some modified radical mastectomy techniques (Pattey) takes out the pectoralis minor muscle to make easier the procedure. However, a surgical approach to the third axillary level without the resection of pectoralis minor was described by Muscolino et al.,² and it is presented here. A higher number of isolated nodes from level III and radicality are obtained when interpectoral approach is associated to subpectoral approach.³

Technique description: This can be done through the standard axillary incision for axillary lymphadenectomy. Lateral margin of the pectoralis muscles is localized and both muscles are separated to access to the intermuscular space, taking the interpectoral fat off together with the eventual Rotter's nodes in it. All the anterior surface of pectoralis minor muscle is exposed to reach and dissect the medial margin of it. Care should be taken in the identification and preservation of the external vasculonervous pedicle of pectoralis major muscle (Fig. 1). When the medial margin of minor pectoralis is free, its posterior surface must be dissected to allow surround it (Fig. 2) and move laterally using Roux separators: while it is laterally pulled, pectoralis major is medially pulled in the opposite direction. This way, a surgical window is created to Berg's third level where some structures can be identified: craneally and running from lateral to medial the axillary vein can be seen, and caudal and superficial from it, fat tissue with lymphoid structures that have to be resected can be identified (Fig. 3).

Figure 1.

Identification of the external vasculonervous pedicle of pectoralis major muscle (arrows). 1: pectoralis major muscle; 2: interpectoral fatty tissue.

Figure 2.

The arrow shows the maneuver to separate the minor and the major pectoralis muscles.

Figure 3.

A surgical window is created to Berg's third level.

White arrow: medially traction of major pectoralis muscle.

Black arrow: laterally traction of minor pectoralis muscle. 1:axillary vein; 2: level III's fat tissue to be resected.

Ethical approval

No clinical data has been used, so IRB approval is not required.

Conflict of interest

Antonio Piñero-Madrona is Editor of Revista de Senología y Patología Mamaria. The rest of the authors do not have any conflict of interest.