Bilateral Mastectomies with Axillary Node Dissection
DESCRIPTION OF OPERATION: After induction of general anesthesia, the right breast was prepped with alcohol for the lymphatic mapping. Then, 4 mL of Lymphazurin blue dye was injected in the subareolar area for lymphatic mapping. Bilateral breasts, chest, and axillae were prepped with Betadine and sterile drapes were applied in the usual manner.
An elliptical incision was made in the right breast excising the nipple-areolar complex. Flaps were raised in a subcutaneous plane using cautery dissection. The limits of the dissection just inferior to the clavicle, medially to the lateral border of the sternum, laterally to the latissimus muscle, and inferiorly to the costal margin. The breast tissue was dissected off the pectoralis major muscle using cautery dissection.
The axillary space was entered. Blue lymphatics and blue lymph nodes were identified. There were three that contained blue dye. One was firm and palpable. These were all sent as sentinel lymph nodes and were negative by touch prep. No additional palpable nodes were noted.
The operative field was irrigated with sterile water. Hemostasis was achieved with cautery. Marcaine was infiltrated in the muscle and irrigated the axillary area. Two Blake drains were brought out draining the flaps. Closure was accomplished with 3-0 Vicryl and subcuticular Monocryl. The drains were placed on suction.
Attention was directed to the left mastectomy. An elliptical incision was made through the skin and subcutaneous tissue excising skin overlying the area, where there was skin fixation inferiorly. Flaps were raised in a subcutaneous plane with cautery dissection.
With limited dissection, as described before, the breast tissue was mobilized off the pectoralis major muscle and the lateral chest wall. The pectoralis major muscle was cleared. Dissection was carried into the axilla where the intercostal brachial nerve was preserved. Fatty tissue and lymph nodes were mobilized. One lymph node appeared to be scarred tissue. This was dissected free from the inferior aspect of the axillary vein and the thoracodorsal neurovascular bundle. It appeared there was a treatment effect from the chemotherapy.
Hemostasis was achieved with cautery and clips throughout the dissection. Marcaine was placed over the muscle and in the axillary area. Blake drains were brought out, draining the axilla and the flap and secured with silk suture.
Closure was accomplished with 3-0 Vicryl and subcuticular Monocryl. Steri-Strips were applied. Dry dressings were applied to both incisions. She tolerated the procedure well and was taken to recovery in good condition.
