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Axillary Space Exploration and ResectionsChapter 13James C. Wittig, Martin M. Malawer, Kristen Kellar-Graney,and Robert M. Henshaw

BACKGROUND■ The axilla is a common site for primary soft tissue sarco-mas as well as for metastatic disease that involves the axillarylymph nodes, such as advanced breast cancer or melanoma.■ Sarcomas typically arise from the muscles defining the axil-lary space (FIG 1). Occasionally, however, they may arise di-rectly from the brachial plexus or axillary vessels (eg, malig-nant peripheral nerve sheath tumors, neurosarcoma,leiomyosarcoma). Several types of malignant tumors may in-volve the axillary space and may require surgical resection.Primary sarcomas occur within the muscles (ie, the pectoralismajor, latissimus dorsi, teres major, and subscapularis mus-cles) that make up the borders of the axillary space. Rarely dothey develop within the axillary fat itself. More commonly,large metastatic deposits to the regional lymph nodes createlarge, matted masses that may require resection. The mostcommon of these are metastatic melanoma and recurrentbreast carcinoma. In addition, there are primary tumors thatarise from the brachial plexus, either the nerves or the vessels.These include leiomyosarcomas of the axillary vein and neu-rofibrosarcomas of the adjacent nerves.■ Small masses may be clinically silent, but large masses in-evitably will result in significant pain or loss of function due toinvolvement of the brachial plexus.■ Venous occlusion may be seen in neglected, massive tumorsand is a harbinger of loss of limb and possibly even of life dueto gangrene.■ Historically, surgical management of tumors in this locationconsisted of forequarter amputation; advances in radiographicimaging, adjuvant therapies, and surgical techniques havegreatly improved our ability to perform limb-sparing resec-tions in this location. The key to adequate and safe surgical re-section of axillary tumors is the complete visualization andmobilization of the infraclavicular portion of the brachialplexus and the axillary artery and vein and the cords that sur-round them. In general, imaging studies of the axillary spaceare not reliable for determining vascular or nerve sheath in-volvement. Multiple imaging studies are required, but the ulti-mate decision to proceed with a limb-sparing surgery is basedon the intraoperative findings at the time of exploration.■ Axillary tumors extending along the chest wall often can beelevated off the underlying ribs; however, tumor extensioninto the intercostal spaces may require thoracotomy and ribresection to ensure adequate margins.

ANATOMY■ The axilla is a pyramid-shaped space between the chest walland the arm defined by its surrounding muscles; it appears tri-angular when seen from either the coronal or axial views.■ The superior apex of the pyramid is formed by the junctionof the clavicle and the first rib, approximately 1 to 2 cm me-dial to the coracoid process.

■ The muscular boundaries of the axilla consist of the pectoralismajor muscle anteriorly; the subscapularis, teres major, andlatissimus dorsi muscles posteriorly; and the coracobrachialis,short head of the biceps, and triceps muscles laterally.■ Vital structures in the axilla include the major branches ofthe infraclavicular portion of the brachial plexus and the axil-lary vessels. Any surgery in this region requires detailedknowledge of and familiarity with these structures.■ Infraclavicular brachial plexus

■ The lateral, posterior, and medial cords of the infraclavic-ular brachial plexus are found at the level of the pectoralisminor muscle, where they then give rise to five majorbranches: the median, ulnar, radial, musculocutaneous, andaxillary nerves. The cords and branches run along the axil-lary vascular sheath as it passes through the axilla.■ The lateral cord gives rise to the musculocutaneous nerve,which travels along the medial aspect of the conjoint ten-don, where it innervates the coracobrachialis and short headof the biceps. This nerve is the first to be identified duringthe exploration, because it is located in the superficial axil-lary fat inferior to the coracoid process. The largest portionof the lateral cord combines with the medial cord to createthe median nerve.■ The posterior cord gives rise to the axillary nerve, whichtravels deep in the space and passes inferior to the gleno-humeral joint and subscapularis muscle, where it innervatesthe deltoid muscle. The main portion of the posterior cordbecomes the radial nerve, which travels posterior to thesheath and exits the axillary space along with the axillarysheath.■ The medial cord gives rise to the ulnar nerve, which trav-els along the most medial aspect of the sheath and exits dis-tally along with the sheath. Because of its medial positionalong the sheath, the ulnar nerve is the nerve most com-monly involved by tumors arising inferior to the brachialplexus, which can present with symptoms of either weak-ness or neuropathic pain. The median nerve, formed by acombination of the lateral and medial cords, is found on thelateral aspect of the sheath and exits the inferior aspect ofthe axillary space along the sheath.

■ Axillary vessels■ The axillary artery and vein are the continuation of thesubclavian vessels, changing name as they enter the apex ofthe axilla below the clavicle and first rib. These vessels runin a single sheath, surrounded by the cords of the brachialplexus. The vessels pass through the axillary space medial tothe coracoid to the medial aspect along the humeral shaft.Distal to the teres major, the vessels are renamed thebrachial vessels. Major vascular branches in the axillaryspace include the thoracoacromial artery (with its pectoral,deltoid, clavicular and acromial branches), the lateral tho-racic artery, the subscapular artery, and the anterior andposterior humeral circumflex vessels.

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■ Lymphatics■ A substantial amount of fat surrounds the vascular sheathas it runs through the axilla along with the lymphatics andlymph nodes. Major clusters of lymph nodes are foundalong the brachial and axillary vessels, the lateral thoracicvessels (anterior axillary nodes), and the subscapular vessels(posterior axillary nodes). Axillary tumors may arise fromlymph node metastases anywhere along the axillary vessels;the most common sites are nodes along the distal portion ofthe axillary vessels.

INDICATIONS■ Any mass in the axillary space should be considered forbiopsy or resection given the propensity for malignant tumorsto develop in the axilla and the predictability of neurogenicpain arising from continued tumor growth.■ Palpate radial and ulnar pulses and inspect for venouscongestion or swelling. Consider venography to evaluate lossof venous drainage indicative of tumor involving the brachialplexus.■ Dimunition of arterial flow is a late sign indicative of poten-tial loss of limb—consider forequarter amputation.■ Test sensation and strength of the axillary, radial, median,and ulnar nerves. Loss of nerve function typically is a very latefinding indicative of major tumor involvement of the brachialplexus—consider forequarter amputation

IMAGING AND OTHER STAGINGSTUDIES■ Three-dimensional imaging of the axillary space is impor-tant for accurate anatomic tumor localization and surgicalplanning. CT, MRI, angiography, and three-phase bone scansare used in the same manner as in other anatomic sites. In ad-dition, we have found that venography (of the axillary andbrachial veins) is essential to the evaluation of tumors of theaxilla and brachial plexus.

Plain Radiography■ Careful inspection of posterior–anterior chest, anterior shoul-der, and axillary view radiographs may reveal the presence of -increased soft tissue density corresponding to an axillary mass.■ Bone involvement and the presence of calcifications in thesoft tissues should be noted.

Computed Tomography and Magnetic ResonanceImaging■ Multiplanar MRI is extremely helpful in visualizing theanatomic contents of the axillary space and defining theanatomic extent of the tumor (FIG 2A–C).■ Axial CT imaging, with administration of IV contrast,demonstrates the major vascular structures, outlines the majormuscle planes, and can detect subtle matrix formation withinthe tumor. CT is most useful in evaluating the bony walls ofthe axilla, specifically the humerus, glenohumeral joint, andscapula (FIG 2D).■ Certain tumors, such as lipomas or hemangiomas, may havecharacteristic findings on T1- and T2-weighted MRI sequencessuggestive of the proper histologic diagnosis. The presence orabsence of lymphatic involvement should be noted, particu-larly in patients with a history of metastatic carcinoma.■ Although the brachial plexus may be very difficult to visual-ize, particularly when tumors distort or compress the sur-rounding fatty planes, the anatomic relationship of the nervesheath to the vessels helps pinpoint their location.■ Although CT imaging of the lungs is routinely performed aspart of patient staging, the chest wall should always be in-spected carefully to rule out tumor involvement of the rib cageand pleural cavity.

Nuclear Imaging■ Positron emission tomography (PET) imaging, particularlywhen fused with MRI or CT imaging data, may significantlyimprove the ability to detect lymphatic spread of tumor in andaround the axilla. Standardized uptake values (SUV) correlate

A B

FIG 1 • Anatomy of the axillary space. A. Schematic of the shoulder girdle and axilla showing the bony andsoft tissue contents. The axillary artery enters from the clavicle and exits at the lower portion of the axilla atthe level of the pectoralis major and latissimus dorsi muscles. The overlying pectoralis major muscle formingthe anterior wall and the latissimus dorsi muscle forming the posterior wall is visualized. B. MRI scan of anormal axilla. All of the muscles of the anterior and posterior wall as well as the deltoid are shown.

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with tumor metabolism and may help to distinguish betweenbenign and malignant lesions.

Angiography and Other Studies■ Angiography remains a valuable method of imaging the ax-illa, particularly for preoperative planning, because tumorsmay significantly distort the regional vascular anatomythrough mass effect as well as through angiogenesis (ie, forma-tion of abnormal vessels feeding the tumor; FIG 3).Venography, either alone or in conjunction with angiography,can demonstrate venous compression from surrounding tu-mors. The axillary arterial wall is thick and rarely shows signsof occlusion, whereas the axillary vein is a thin-walled struc-ture that is easily compressed and infiltrated by tumor.Therefore, occlusion is almost synonymous with involvementof the vascular sheath and brachial plexus. Venous occlusion,visualized as absent filling of the axillary vein, is characteristicof significant tumor involvement of the brachial plexus andwarrants careful thought as to whether a limb-sparing proce-dure is possible. The triad of axillary venous occlusion, distalmotor weakness, and neuropathic pain is a very reliable pre-dictor of tumor infiltration of the brachial plexus sheath.

■ Infraclavicular brachial plexus and vascular exploration ismandatory before resection is attempted. Tumor involvementof these structures usually indicates that a forequarter ampu-tation is required.

Biopsy■ Core needle biopsy is the preferred method of diagnosis,because it minimizes risk of injury and contamination of theaxillary contents. If a metastatic lesion is suspected, fine nee-dle aspiration is the most appropriate means to identify carci-noma cells.■ Large or superficial palpable masses are amenable to needlebiopsy in the clinic, whereas deep lesions are best approachedwith radiographic guidance using CT or ultrasound.■ The biopsy tract should be positioned after consultationwith the treating surgeon to ensure proper location along thepath of planned resection. The biopsy should be performedthrough the base of the axillary space, not through the pec-toralis major muscle or near the vascular sheath. It can eas-ily be performed under CT guidance. Deep-seated lesionsnear the chest wall also can be approached in this manner.Anterior lesions, on occasion, can be approached through

FIG 2 • Imaging studies of the axillary space. A. T2-weighted MRI scan showing a large mass (arrow)occupying the axillary space. B. Coronal T2-weightedMRI scan showing a large tumor below the pectoralismajor that fills the entire axillary space, from the clavicleto the lower end of the base of the pyramid that formsthe axillary space. C. Axial MRI scan of a large fungatingtumor from the axillary space. There are no muscle orskin components adjacent to the tumor, which pro-trudes anteriorly. D. CT scan of a primary bony sarcomawith a large extraosseous component that extends intothe axilla. This finding is an excellent indication for theuse of the anterior portion of the utilitarian incision forresections of large tumors of the proximal humerus. Itdemonstrates that the axillary space must be completelyvisualized and that the vessels must be mobilized.

A B

DC

A B

C D

FIG 3 • Schematic representation of an axillary tumorwith its relationship to the axillary sheath. A. The tumordoes not involve the sheath but it displaces the artery,vein, and accompanying nerves. B. The tumor has in-vaded the axillary sheath, occluding the axillary vein.This is a significant finding on venography that almostalways indicates vascular infiltration. C. Axillaryvenogram performed and shows complete occlusion ofthe axillary vein (red line). Collateral filling is seenaround the mass. Obliteration of the vein almost alwaysindicates infiltration of the infraclavicular plexus.D. Gross specimen following forequarter amputationshowing tumor infiltration around the nerves and cordsof the brachial plexus and surrounding the axillaryartery and vein.

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the lower portion of the pectoralis major muscle. The biopsysite must be removed in its entirety during resection of thetumor.■ Open biopsy should be reserved for those patients in whomcore needle biopsy was nondiagnostic or in those cases whenadditional samples of tumor are necessary for research pur-poses. Great care must be taken to avoid contamination ofcritical structures and otherwise uninvolved tissue planes. Asmall laterally placed incision, avoiding the pectoralis majormuscle and the axillary sheath, is recommended.■ Although small tumors are amenable to excisional biopsy,care must be taken to remove the entire pseudocapsule in theevent that the tumor is found to be a sarcoma.

SURGICAL MANAGEMENT■ Although many patients can safely undergo limb-sparing re-sections of the axillary space, extremely large or neglected tu-mors may present with significant involvement of the axillaryvessels and brachial plexus.■ Evidence of vascular involvement and, therefore, nervesheath invasion should raise the question as to whether the pa-tient is suitable for a limb-sparing resection; forequarter ampu-tation may be necessary.■ Proper placement of the biopsy tract is critical in limitingpotential injury or contamination of the axillary space; large,poorly planned open biopsy tracts may necessitate forequarteramputation.■ Adjuvant radiation to the axilla carries an increased risk ofsignificant lymphedema, which can be functionally disabling,as well as potential wound problems.

Preoperative Planning■ Careful review of preoperative imaging studies is necessaryto formulate a surgical plan.■ Extent of resection is determined by tumor size and stageand whether a palliative or curative option exists.

■ Consideration should be given to preoperative angiographyor venography when vascular involvement is suspected on thebasis of CT or MRI scans.■ A double-lumen endotracheal tube should be used wheneverpreoperative imaging suggests significant rib involvement.Deflation of the underlying lung protects the lung during therib resection.

Positioning■ Positioning of the patient for axillary resection is determinedby the size and anatomic extent of the tumor to be removed.■ Most axillary tumors are best approached via an extensileanterior incision with the patient in the supine position. Thepatient is brought to the edge of the table, and a large paddedbump is placed under the medial portion of the scapula to fa-cilitate exposure. After prepping and draping the arm, axilla,and anterior shoulder girdle, the arm is placed over a paddedMayo stand, and the surgeon stands inside the axilla for theprocedure. The surgical assistant is best placed superior to thearm to facilitate retraction■ Less commonly, the posterior or inferior portion of the ax-illa is involved, requiring access to the back of the axilla andshoulder girdle. When this is the case, the patient should beplaced in the lateral decubitus position so that the entire shoul-der girdle may be easily accessed. The arm is elevated over thepatient’s head and supported by an assistant to permit accessto the axilla. The surgeon should stand anterior to the patient,closest to the brachial plexus.

Approach■ Anterior/medial utilitarian approach. The most commonlyused approach for axillary resections is the common extensileapproach to the shoulder girdle and arm, running along thedeltopectoral groove. As the pectoralis major comprises theanterior anatomic boundary of the axilla, release of its broadtendon insertion into the humerus is vital to proper exposureof the axillary contents (FIG 4).

FIG 4 • Incisions. A. The typical axillary incision, used primarily by general surgeons for lymph node dissection.This incision is inadequate for resections of sarcomas or large bulky tumor masses. B. Anterior portion of the utili-tarian shoulder girdle incision. This is used for large axillary tumors. A large mass was palpated (T). By detachingthe pectoralis major, the entire axillary space can be visualized. C. A patient with a large metastatic lesion arisingfrom the coracoid. The anterior portion of the utilitarian shoulder girdle incision is used to mobilize the axillaryvessels prior to resection of the tumor. D. Operative photograph showing release and medial retraction of thepectoralis major muscle. The fascia covering the entire axillary space contents is seen (arrow).

B

C DA

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■ The traditional incision along the inferior boundary of theaxilla offers a very limited view of the axillary contents andmakes identification of the brachial plexus difficult. This inci-sion is best used only for patients with tumor limited to thechest wall (inferior axillary resection) or posterior (latissimus)axilla.

■ A combination of the traditional axillary incision with theanterior extensile incision may be performed by extending theskin incision across the pectoralis muscle, meeting the anteriorincision near the coracoid process (FIG 5). This is useful in thesalvage of patients having attempted resections or open biop-sies through the inferior axilla.

FIG 5 • Surgical technique of exposure and resection of axillary tumors. A. The anterior portion of the utilitarian shoulder gir-dle incision is used. This is an extended deltopectoral incision, which may be curved in a posterior direction toward the axilla.The pectoralis major is then released 1 cm from its insertion onto the humerus. This is the first layer of axillary space muscula-ture. B. Operative photograph showing the second muscle layer. The short head of the biceps and the pectoralis minor attachto the coracoid. The axillary contents with the vessels and nerves are not seen, because they are enclosed within the axillary fatand fascia. C. The musculocutaneous nerve is found 1 to 2 cm distal to the coracoid, below the insertion of the pectoralis minorand adjacent to the short head of the biceps. This nerve must be identified before the second layer of muscles is released. D,E. Resection bed following removal of the tumor of the axillary space. It is necessary to begin at the level of the clavicle andligate all branches that pass distal and inferior to the tumor mass. Most tumors arise inferior to the neurovascular bundle.

A B

C D E

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Axillary Exploration Through Anterior Approach■ Identify landmarks.

■ Palpate and mark the bony landmarks: coracoidprocess, acromion, acromioclavicular joint.

■ Palpate the groove between the deltoid and pec-toralis muscles.

■ Incision■ The skin incision should extend along the deltopec-

toral groove to the coracoid process and may curveinto the axilla as needed. Open this interval, sparingor ligating the cephalic vein as necessary.

■ Detachment of pectoralis major (TECH FIG 1)■ Identify the pectoralis major insertion into the

humeral shaft and release using the electrocautery ap-proximately 1 cm from the bone to preserve enoughinsertion for later repair. After the pectoralis major is

fully released from the humerus, retract the musclemedially over the anterior chest wall, preserving itsvascular pedicles and exposing the serratus anterior.

■ Development of anterior axillary fascial plane■ Develop the surgical plane along the clavipectoral

fascia, which is a thick, well-defined layer that con-tains the axillary space and structures.

■ Release of conjoint tendon and pectoralis minor■ Palpate the conjoint tendon insertion at the coracoid

process and release. Protect the musculocutaneousnerve inserting into the muscle belly just distal tothe tendon from the underlying brachial plexus bylimiting distal retraction. Release of these muscles iskey to exposing the vascular sheath and brachialplexus.

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■ Neurologic exploration■ Identify the sheath of the brachial plexus and axillary

vessels underneath the detached conjoint tendon.The musculocutaneous nerve comes around the lowerborder of the coracoid under the pectoralis minormuscle. The axillary nerve comes off deeper from theposterior cord and travels toward the shoulder joint.Both must be identified at this stage.

■ Vascular exploration■ Completely exposure and control the axillary vessels

and brachial plexus proximally by opening the pediclesheath and placing loops around the major structures;careful dissection is then used to mobilize these struc-tures distally into the arm. Mobilization often is nec-essary to facilitate adequate exposure prior to tumorresection.

■ Resection of tumor■ All of the feeding branches entering into the mass are se-

rially ligated and transected. Axillary fat is left aroundthe tumor mass as the only true margin. The tumor is re-moved, tagged for orientation, and sent to pathologyfor margins and histologic evaluation.

Resection of Anterior Axillary and Chest Wall Tumors■ Tumors involving the pectoralis and serratus anterior can

be resected safely following identification and mobiliza-tion of the critical neurovascular structures; these musclesmay be elevated directly off the underlying chest wall.

■ Resection of high-grade sarcomas may require sacrificeof one or more major branches of the brachial plexus toachieve an adequate oncologic margin. Loss of the me-dian nerve results in the greatest loss of hand function.

■ Chest wall involvement requires thoracotomy and resec-tion of contiguous ribs; the underlying lung is deflatedbefore opening the chest cavity to protect it.

■ Intrathoracic extent of tumor is determined by palpa-tion of the pleural surface following thoracotomy;osteotomy of the ribs using a rib cutter under directvisualization permits en bloc removal of the involvedchest wall.

■ Lymphatic involvement, frequently seen in patients withbreast cancer extending into the axilla, requires meticu-lous dissection of the axillary and subclavian vessels prox-imally; sampling of lymph nodes is crucial in patient withcarcinomas or melanoma.

Resection of Posterior AxillaryTumors■ Further exposure of the axilla is achieved by extending

the vascular and neurologic exploration further downthe arm, widening the area to reach posterior or distaltumors (TECH FIG 2).

■ Identify the latissimus insertion into the humerus, whichdefines the posterior aspect of the axilla distal and pos-terior to the pectoralis insertion.

■ Before performing tendon release, identify and protectthe axillary nerve proximal to and the radial nerve dis-tal to the tendon; both nerves serve to tether thebrachial plexus and reduce the ability to retract theplexus.

■ Tumor involvement of the latissimus may require sacri-fice of one or both of these nerves.

■ The latissimus muscle may be elevated off the chest wallas necessary for tumor resection.

■ Chest wall involvement may require thoracotomy and re-section of contiguous ribs; deflate the lung before open-ing the chest cavity to protect the underlying lung.

■ Intrathoracic extent of tumor may be determined bypalpation of the pleural surface following thoracotomy.Osteotomy of the ribs using a rib cutter under direct vi-sualization permits en bloc removal of the involvedchest wall.

Reconstruction Following TumorResection■ Repair and reconstruction of the axilla is necessary fol-

lowing tumor resection.■ Insertion of an epineural catheter into the sheath of the

brachial plexus permits postoperative administration oflocal anesthetics such as bupivacaine (Marcaine) to mini-mize postoperative pain.

TEC

HN

IQU

ES

A B

TECH FIG 1 • A. Schematic diagram of the muscles of the anterior aspect of the axillary space being released to expose a largeunderlying axillary tumor. Two layers of muscles are encountered: the pectoralis major muscle and the pectoralis minor withthe short head of the biceps. Both layers attach to the coracoid. The musculocutaneous nerve must be mobilized before thesecond layer of muscle is detached. B. Operative photograph taken following removal of a large axillary tumor shows all ofthe muscles of the axillary space, the axillary sheath, and corresponding cords of the brachial plexus.

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Chapter 13 AXILLARY SPACE EXPLORATION AND RESECTIONS 7TEC

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ES

■ Reattachment of the conjoint tendon and pectoralisminor to the coracoid with the use of mattressed, nonab-sorbable sutures covers the brachial plexus and axillaryvessels.

■ Defects of the chest wall can be covered with local rota-tion flaps using the latissimus dorsi or pectoralis majormuscle, which may be tenodesed to the subscapularistendon as needed.

■ Careful wound closure over closed suction drains andplacement of absorptive padding in the axilla reduce therisk of skin maceration and wound infection. Use of asling or shoulder immobilizer permits early mobilizationof the patient.

■ Functional deficits resulting from resection of portions ofthe brachial plexus may require delayed reconstructionafter completion of adjuvant treatment.

A BTECH FIG 2 • A. Extremely large, low-grade, fibrosarcoma of the axilla extending from the thoracic outlet to the posterioraxillary line and to the level of the breast. All tissues were removed through a combination of the anterior and posteriorportions of the utilitarian shoulder girdle incision. B. Intraoperative photograph taken before reconstruction and reattach-ment of the muscles of the back and anterior pectoralis major. This photograph demonstrates the advantage of a transpec-toralis approach anteriorly combined with a posterior approach.

PEARLS AND PITFALLSPreoperative angiogram and venogram ■ In addition to mapping out the course of the vessels, loss of flow through the

brachial or axillary vein is a worrisome sign that tumor involves the brachial sheath.This often is the first sign of an unresectable tumor (FIG 6) for which forequarteramputation should be considered

Axillary incision ■ The axillary incision is not easily extended and severely restricts the ability to dissectout the neurovascular bundle. This incision is rarely indicated.

Pectoralis major ■ Detachment of the humeral insertion is key to opening up the entire axilla andpermits exploration of all important structures. It is not necessary to reattach thepectoralis to its insertion; rotation of this muscle is valuable for reconstruction of defects around the shoulder.

Musculocutaneous nerve ■ Injury due to over-retraction of the conjoint tendon may occur, leading to loss ofelbow flexion and resulting disability. This may be unavoidable for tumors involvingthe conjoint tendon.

FIG 6 • Unresectable sarcoma ofthe axilla. A. Multiple recur-rences with a large soft tissuemass. B. Operative view throughthe anterior incision showing alarge tumor surrounding theaxillary sheathA B

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POSTOPERATIVE CARE■ Postoperatively, a sling or shoulder immobilizer is applied tosupport the arm. Closed suction drains are removed after out-put slows.■ Patients are mobilized on postoperative day 1, from bed tochair. Ambulation is begun as tolerated to improve pulmonaryfunction.■ A sling is used until the skin wound is sufficiently healed.■ Early shoulder motion with assistance is started as soon asthe wound permits.■ Aggressive wrapping of the arm and use of custom-fitted com-pression gloves is started if there is evidence of lymphedema.

OUTCOMES■ Functional outcome is determined by the amount of muscleresection and loss of particular nerves.■ Loss of shoulder motion results in mild disability, which iseasily compensated for by use of the other arm for overheadactivities.

COMPLICATIONS■ Although uncommon, the complication most often seen fol-lowing axillary resection is the accumulation of third-spacefluid with secondary wound problems. Previous radiationtherapy increases this probability. Use of suction drains andcompressive dressings helps mitigate this complication.■ Chronic pain may occur following nerve resection, especiallyafter radiation. Use of nerve sheath catheters with postopera-

tive infusion of local anesthetics may reduce the incidence ofneuropathic pain.■ Lymphedema may result in significant disability and chronicpain; early aggressive treatment may lessen the severity or du-ration of swelling. The risk is greatest following surgery andradiation therapy.■ Infections and flap necrosis following axillary tumor resec-tions rarely occur, because of the substantial network of sub-cutaneous blood vessels perfusing the shoulder girdle.

REFERENCES1. Kim JY, Subramanian V, Yousef A, et al. Upper extremity limb sal-

vage with microvascular reconstruction in patients with advancedsarcoma. Plast Reconstr Surg 2004;114:400–408.

2. Kim JY, Youssef A, Subramanian V, el al. Upper extremity recon-struction following resection of soft tissue sarcomas: a functional out-comes analysis. Ann Surg Oncol 2004;11:921–927.

3. Lohman RF, Nabawi AS, Reece GP, et al. Soft tissue sarcoma of theupper extremity: a 5-year experience at two institutions emphasizingthe role of soft tissue flap reconstruction. Cancer 2002;94:2256–2264.

4. Murray PM. Soft tissue sarcoma of the upper extremity. Hand Clin2004;20:325–333.

5. Nelson AA, Frassica FJ, Gordon TA, et al. Cost analysis of functionalrestoration surgery for extremity soft-tissue sarcoma. Plast ReconstrSurg 2006;117:277–283.

6. Popov P, Tukiainen E, Asko-Seljavaara S, et al. Soft-tissue sarcomasof the upper extremity: surgical treatment and outcome. PlastReconstr Surg 2004;113:222–230.

7. Toomayan GA, Robertson F, Major N, et al. Upper extremity com-partmental anatomy: clinical relevance to radiologists. Skeletal Radiol2006; 35:195–201.

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