Modified Radical Mastectomy

1. Breast tissue exposure

Substep Structure Actions Specification

1A Skin Mark Mark the breast contour, midline and cleavage line on the skin. Lift the nipple and draw the
borders caudal and cranial to the nipple to create an elliptical form, extending from lower medial
to higher lateral.

TIP: Extension skin excision

When there is tumor invasion in the skin, this should be included in the excision.

TIP: Scar localization

In view of future prospects regarding reconstructive surgery is expected, the scar should ideally
be just above the inframammary fold in order for the tissue to support a prosthesis later if needs
be.

Incise Incise the skin along the skin markings.

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Modified Radical Mastectomy

2. Breast tissue dissection

Substep Structure Actions Specification

2A Breast tissue Dissect Dissect the breast tissue away from the skin in the subcutaneous plane. Continue cranially until
the border of the breast contour is reached and caudally until the inframammary fold is
included.

HAZARD: Skin flap necrosis

Prevent creating the skin flap in a plane that is too superficial; this could damage the blood
supply of the skin. The use of electrocautery is minimized for the same reason.

Dissect Dissect the breast tissue away from the pectoralis major muscle starting from the craniomedial
aspect. Use electrocautery for the arterial perforators encountered. The pectoral fascia is
removed with the breast tissue.

TIP: Fascia preserving

When there is no sign of tumor invasion at the side of the fascia, the fascia can be preserved.

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Modified Radical Mastectomy

3. Axillary lymph node dissection

Substep Structure Actions Specification

3A Lymfatic tissue (level 1 and 2) Dissect Dissect the lymphatic tissue from the lateral border towards the dorsal side of the pectoralis
major muscle using electrocautery or scissors.

3B Long thoracic nerve Identify Identify the long thoracic nerve at the dorsolateral side of the thorax and follow this nerve
cranially.

HAZARD: Long thoracic nerve injury

Do not use electrocautery near the nerve to prevent injury. Injury to the nerve paralyses the
serratus anterior muscle causing winging of the scapula.

3C Lymphatic tissue (level 2 en 3) Dissect Dissect the lymphatic tissue from the thoracic wall in the direction of the apex of the axilla.

3D Axillary vein Identify Identify the axillary vein as it crosses the tendon of the latissimus dorsi muscle.

Dissect Dissect along the caudal side of the vein towards lateral and transect all tributaries towards the
breast.

3E Thoracodorsal neurovascular bundle Identify Identify the thoracodorsal nerve, artery and vein located halfway the axillary vein at a more
dorsal level and preserve them.

HAZARD: Thoracodorsal nerve injury

Avoid injury to the thoracodorsal nerve by avoidance of electrocautery close to this structure

3F Lymphatic tissue (level 3) Dissect Dissect the lymphatic tissue starting at the medial axillary apex, continuing caudally. Remove all
the tissue on top of the subscapularis.

Remove Remove the specimen en bloc.

Mark Mark the apex with a ligature, so the pathologist can identify the anatomy.

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Modified Radical Mastectomy

4. Wound closure

Substep Structure Actions Specification

4A Axilla Drain Drain the axilla by placing one drain directed at the apex of the axilla.

4B Subcutaneous tissue Close Close the subcutaneous tissue using multifilament interrupted sutures.

4C Skin Close Close the skin intracutaneously with a monofilament absorbable suture.

TIP: Dog ear formation prevention

To prevent dog ear formation in patients with a large habitus, the lateral fold is picked up with a
forceps and retracted medially. A rhomboid-shaped line is drawn and the excess skin is removed.

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