mrm

17.  A modified radical mastectomy removes all breast tissue,
the nipple-areola complex, necessary skin, and the level I
and II axillary lymph nodes.
 The Patey modification of the modified radical mastectomy
also removes the pectoralis minor muscle, which permits
complete dissection of the apical (level III) axillary lymph
nodes

20. .

38.  Lymphedema: This complication occurs less frequently with the
standard axillary dissections performed nowadays ( level I and II). It
is more frequently seen when an axillary dissection is combined
with axillary radiation.
 Seroma: One of the main reasons for drain positioning is to avoid
seromas (closed simple drain or suction drain). These drains are
left in for approximately four to five days, however occasionally
this is not long enough and some patients will develop seromas.
This can be drained percutaneously using a large gauge needle.
There is no evidence to support the role of fibrin glue to prevent
seroma formation after breast surgery

41. Anatomic Complications of the Modified Radical
Mastectomy
Vascular Injury
The first and second perforating vessels are too large for cautery.They are
ligated.
The axillary vein, if torn, is repaired. Ligation may cause chronic edema.
Nerve Injury
Intercostobrachial nerve When cut, circumscribed numbness of the medial
aspect of the ipsilateral upper arm results.
Long thoracic nerve If cut, winging of scapula deformity results.
Medial and lateral thoracic nerves If cut, the pectoralis muscles atrophy.
Thoracodorsal nerve If cut, internal rotation and abduction of the shoulder are
weakened.

43.  Step by step
 1. Arm on the affected side is extended on a side table. The patient
is draped and the affected breast and axilla are exposed.
 2. Drawing incision line (an optimal wound closure without any
redundant skin must be taken into account)
 3. Skin incision and formation of upper flap.

44. The boundaries of dissection for a modified radical
mastectomy are
(a) the subclavius muscle superiorly,
(b) the anterior border latissimus dorsi muscle
laterally, (c) the
sternum medially, and
(d) the caudal extension of the breast (3 to 4 cm
inferior to the inframammary fold) inferiorly.

45.  7. Dissection of the breast from medial to lateral including pectoralis
major 's fascia
 8. Follow the lateral margin of the pectoralis major muscle and
opening clavipectoral fascia
 9. Identification of upper axillary margin (=axillary vein)

46.  10. Dissection of axillary top (along axillary vein)
 11. Identify and preserve thoracodorsal nerve/vessels
 12. Identify and preserve long thoracic nerve

47.  13. Finalize axillary dissection and remove all level I and II lymph
nodes (for a complete oncologic resection it is sometimes necessary
to cut the intercostobrachial nerve)
 14. Remove axillary content en bloc with the breast
 15. positioning of two drains (axilla-lower flap and upper flap)
 16. Woundclosure, avoid any redundant skin