Axillary Lymph Node Dissection (Levels I–II)

Standard breast ALND removes level I and II nodes (lateral and posterior to pectoralis minor). Level III added for advanced disease or for melanoma at any level of involvement. Done as a stand-alone case after a positive SLN in select settings, or as the axillary component of a modified radical mastectomy.

Procedure Snapshot

• Indications:
  • Clinically or biopsy-proven positive axillary nodes in invasive breast cancer.
  • > 2 positive SLNs in patients not meeting Z0011 (see below).
  • Sentinel nodes not identified during SLNB attempt for a T1–T2 invasive cancer.
  • Inflammatory breast cancer — mandatory ALND with mastectomy.
  • Neoadjuvant chemotherapy with residual node-positive disease (biopsy-confirmed cN+ before NAC, ypN+ after).
  • Melanoma with positive SLN or clinical axillary involvement.
  • Axillary recurrence after prior SLNB / conservative therapy.
• Z0011 does NOT apply to: mastectomy patients, patients not receiving whole-breast RT, > 2 positive SLNs, matted / extracapsular extension, T3+.
• Levels:
  • Level I — lateral to pectoralis minor.
  • Level II — posterior to pectoralis minor.
  • Level III — medial to pectoralis minor. Add for melanoma always (levels I–III); add for breast only if grossly involved / matted.
• Expected duration: 45–90 min stand-alone; +30–45 min as component of MRM.
• Positioning: Supine, ipsilateral arm abducted 90° on a padded board, prepped into the field so the assistant can move the arm during dissection. Alternate: arm placed on a Mayo stand with sterile drape.
• Special instruments: Electrocautery with Bovie extender, nerve stimulator (optional but useful), right-angle retractors, DeBakey and fine tissue forceps, LigaSure or bipolar for larger vessels, closed-suction drain (JP).
• Prep: Cefazolin within 60 min. Shave axilla if hair-bearing.
• Frozen section: Not routine for the specimen — path processes en bloc.

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Step Workflow — Level I–II ALND

1. Incision
   • Curvilinear incision along the axillary crease, from the anterior axillary line to the posterior, ~ 6–8 cm long.
   • Use an existing incision from a prior mastectomy or SLNB when possible.
   • Divide skin, subcutaneous fat, and Scarpa’s fascia.
2. Flap Elevation and Clavipectoral Fascia Entry
   • Raise short skin flaps superiorly and inferiorly (~ 3 cm each way) to gain exposure.
   • Divide the clavipectoral fascia to enter the axillary space.
   • Retract the pectoralis major medially and superiorly with a right-angle or Deaver.
3. Identify the Axillary Vein — the Superior Boundary
   • The axillary vein is your cephalad limit — do not dissect above it (motor nerves to arm run above).
   • Work along the inferior surface of the axillary vein from lateral to medial, ligating small tributaries with cautery, clips, or LigaSure.
   • Do not skeletonize the vein — leave adventitia to preserve venous drainage; overly aggressive dissection causes lymphedema and post-op edema.
4. Preserve the Long Thoracic Nerve (Bell’s Nerve)
   • Sweep medially along the chest wall down to the serratus anterior.
   • Identify the long thoracic nerve on the medial border of the axilla, running vertically down the chest wall on the serratus. Protect it — injury causes winged scapula.
   • Use nerve stimulator to confirm if uncertain.
5. Preserve the Thoracodorsal Bundle
   • Identify the thoracodorsal artery, vein, and nerve on the anterior border of the latissimus dorsi, running vertically.
   • Nerve — motor to latissimus; injury causes shoulder adduction / internal rotation weakness (“can’t push up out of a chair”).
   • Vessels — protect for potential latissimus flap reconstruction, and to preserve latissimus function.
6. Address the Intercostobrachial Nerve
   • The intercostobrachial (T2) runs transversely through the axillary fat pad — sensory to the medial upper arm.
   • Preserve if easily identified; sacrifice if in the way — inform the patient preop that medial-arm numbness is expected.
7. En Bloc Removal of Level I and II Content
   • Continue dissection medially, sweeping fatty lymphatic tissue toward the specimen.
   • Take Level I (lateral to pec minor) first, then retract pectoralis minor laterally to expose and take Level II (behind pec minor).
   • Ligate large lymphatic channels with clips to reduce postop lymphocele.
   • Remove en bloc; orient with a suture (short → superior, long → lateral, or per institutional protocol).
8. Add Level III (Melanoma, Grossly Involved Breast Cancer)
   • Divide the pectoralis minor at its insertion on the coracoid — or retract firmly with a right angle to expose Level III (medial to pec minor).
   • Continue dissection to the costoclavicular ligament / Halsted’s ligament.
   • Level III adds risk of injury to the medial pectoral nerve (motor to pec major and minor).
9. Hemostasis, Drain, Closure
   • Meticulous hemostasis of the axillary space; irrigate; confirm hemostasis after Valsalva.
   • Place JP drain exiting through a separate lateral stab incision (not through the primary axillary wound — avoids scar-drain interaction).
   • Close skin in two layers: deep dermal 3-0 Vicryl, subcuticular 4-0 Monocryl.
   • No pressure dressing — encourages seroma.

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Rapid-Fire Questions

• Q: Boundaries of level I, II, III? A: I — lateral to pec minor. II — posterior to pec minor. III — medial to pec minor.

• Q: Standard breast ALND — which levels? A: I and II (add III only if grossly involved).

• Q: Melanoma axillary dissection — which levels? A: I, II, and III always.

• Q: Superior boundary of the dissection? A: Axillary vein. Do not dissect above it.

• Q: Winged scapula on post-op day 3 — which nerve did you injure? A: Long thoracic — motor to serratus anterior.

• Q: Weakness with pull-ups / adduction of the arm after ALND? A: Thoracodorsal nerve — motor to latissimus dorsi.

• Q: Medial upper-arm numbness after ALND? A: Intercostobrachial (T2) sacrificed. Very common; usually not functionally significant.

• Q: Which nerve innervates BOTH pec major and pec minor? A: Medial pectoral. (Lateral pectoral → pec major only.)

• Q: What are the interpectoral nodes called? A: Rotter’s nodes.

• Q: Lymphedema rate after ALND? A: 20–30% at 5 years; higher with radiation to the axilla, obesity, higher node count.

• Q: ACOSOG Z0011 — thresholds? A: T1–T2, cN0, planned BCT + whole-breast RT, ≤ 2 positive SLNs. No benefit to completion ALND.

• Q: AMAROS trial — what did it show? A: For cN0 patients with a positive SLN, axillary radiation vs ALND — equivalent regional recurrence and disease-free survival, less lymphedema with radiation. Extends the “less axillary surgery” logic to mastectomy patients.

• Q: Neoadjuvant chemo with initial cN+ disease — approach to the axilla? A: If cN+ node was clipped, target axillary dissection (TAD = SLNB + removal of clipped node with dye + gamma probe + imaging localizer). Any residual disease → completion ALND.

• Q: How many nodes should a standard breast ALND yield? A: ≥ 10 for adequate pathologic staging.

• Q: Chronic lymphedema for 10 years after ALND, now with a dark purple lesion on the upper arm? A: Stewart–Treves syndrome (lymphangiosarcoma). Aggressive malignancy — biopsy urgently.

• Q: Post-op day 7 with a fluctuant swelling in the axilla after drain removal? A: Seroma — aspirate. Recurrent → replace drain.

• Q: Rare axillary complication of pericollegial cording along the arm 3 weeks post-op? A: Axillary web syndrome (“cording”) — physical therapy, self-limiting.

• Q: SOZO surveillance — how often after ALND? A: Baseline preop, then every 3–6 months for 3 years, then annually. Rising L-Dex → early compression per PREVENT protocol.

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Critical Anatomy

• Boundaries of the axilla:
  • Anterior: pectoralis major and minor.
  • Posterior: subscapularis, latissimus dorsi, teres major.
  • Medial: serratus anterior on the chest wall.
  • Lateral: bicipital groove of the humerus.
  • Superior (apex): cervicoaxillary canal (between clavicle and first rib).
  • Inferior (base): axillary fascia and skin.
• Contents:
  • Axillary artery and vein (with branches / tributaries).
  • Brachial plexus cords and terminal branches.
  • Axillary lymph nodes (levels I / II / III).
  • Rotter’s (interpectoral) nodes.
  • Fat.
• Key nerves — preserve:
  • Long thoracic (C5–7) → serratus anterior. Runs vertically on the chest wall / serratus. Injury → winged scapula.
  • Thoracodorsal (C6–8) → latissimus dorsi. Runs vertically on the medial edge of latissimus. Injury → adduction / internal rotation weakness.
  • Medial pectoral → pec major AND pec minor.
  • Lateral pectoral → pec major only.
• Key nerves — accept sacrifice if needed:
  • Intercostobrachial (T2) → medial upper arm sensation.
• Danger zones:
  • Above the axillary vein — brachial plexus, cephalic vein, subscapular artery.
  • Deep to the latissimus tendon — thoracodorsal bundle.
  • Medial chest wall — long thoracic.
  • Pleura on deep dissection — pneumothorax risk if serratus is violated.

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Informed Consent Highlights

• Risks:
  • Lymphedema ~ 20–30% at 5 years (higher with radiation to axilla, obesity).
  • Seroma — nearly universal, drain-managed.
  • Chronic pain / paresthesias — 20%+ mild, 5–10% clinically significant.
  • Long thoracic injury → winged scapula.
  • Thoracodorsal injury → latissimus weakness.
  • Intercostobrachial sacrifice → medial-arm numbness — very common, expected.
  • Axillary vein injury — rare but morbid; can require repair or grafting.
  • Axillary web syndrome (cording) — physical therapy, self-limiting.
  • Wound infection ~ 5%.
  • Stewart–Treves syndrome (lymphangiosarcoma in chronic lymphedema — extremely rare, decades out).
• Benefits: Locoregional control, accurate staging (≥ 10 nodes), guides adjuvant systemic and radiation decisions.
• Alternatives:
  • SLNB alone if Z0011 criteria met.
  • Axillary radiation in place of ALND per AMAROS for select SLN-positive patients.
  • Targeted axillary dissection (TAD) for neoadjuvant patients with clipped nodes.

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Post-Op Considerations

• Disposition: Same-day or overnight; longer if combined with mastectomy or reconstruction.
• Drain: JP stays in until output < 30 mL/day for 2 consecutive days (typically 10–14 days). Empty and record 3× daily; strip PRN.
• Diet / activity: Regular diet; light activity POD 0–1. Gentle shoulder ROM day 1 to prevent frozen shoulder. No heavy lifting > 10 lb for 2 weeks.
• Analgesia: Multimodal, opioid-sparing.
• Follow-up:
  • Wound check at 1–2 weeks; drain management.
  • Path review meeting (# nodes, extracapsular extension, size of largest deposit).
  • Med onc + rad onc referrals; PMRT often indicated for ≥ 4 positive nodes.
• Red flags:
  • Expanding hematoma → return to OR.
  • Winged scapula on early exam → note the nerve status, refer to PT; usually improves.
  • Fever + fluctuance → axillary abscess.
• Lymphedema surveillance:
  • SOZO bioimpedance at baseline (preop) and every 3–6 months × 3 years, then annually (PREVENT trial protocol).
  • Compression sleeve education for air travel, heavy activity.
  • Early PT referral for arm heaviness / tightness / mild circumferential increase.
  • Avoid IV lines, blood draws, and BP cuffs on the affected arm — patient education routine.

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Clinical Pearls

• Axillary vein is your ceiling. Never dissect above it.
• Do not skeletonize the vein. Preserve adventitia to reduce arm edema.
• Nerve stimulator is cheap insurance if the anatomy is fibrotic or post-radiation.
• Ligate large lymphatic channels with clips — reduces prolonged drainage.
• Take ≥ 10 nodes for adequate staging.
• Level III for melanoma always; only for grossly involved breast cancer.
• Drain through a separate stab incision, not the main wound — better cosmesis and lower dehiscence risk.
• SOZO baseline preop on every ALND — you own the lymphedema surveillance conversation from that visit forward.

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Related Case Preps

• Lumpectomy + SLNB — first-line axillary staging.
• Total Mastectomy ± SLNB — alternative to BCT.
• Modified Radical Mastectomy — total mastectomy + ALND en bloc.

Related Topic Reviews

• Breast — staging, adjuvant therapy, ABSITE-level pearls.
• Melanoma / Skin cancer — melanoma-specific nodal management (if page exists).

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References

1. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases (Z0011). Ann Surg. 2010; 252(3): 426–432.
2. Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014; 15(12): 1303–1310.
3. Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: ACOSOG Z1071. JAMA. 2013; 310(14): 1455–1461.
4. Ridner SH, et al. Bioimpedance spectroscopy vs tape measurement for the prevention of lymphedema (PREVENT). Ann Surg Oncol. 2019; 26(10): 3250–3259.
5. Faries MB, Thompson JF, Cochran AJ, et al. Completion dissection or observation for sentinel-node metastasis in melanoma (MSLT-II). NEJM. 2017; 376(23): 2211–2222.