The fascial groups of the constructive axilla are divided into two superficial and deep systems.
The pectoralis major muscle of the anterior wall, the supraspinatus of the posterior wall, the infraspinatus, the lesser circular muscle, the greater circular muscle and the latissimus dorsi all belong to the superficial fascial group.
The subclavian muscles of the forearm, the pectoralis minor, and the subscapularis of the posterior wall belong to the deep fascial group.
These muscles have associated fascia. The superficial fascia includes the pectoralis major fascia (thick anterior lobe and thin posterior lobe). The pectoralis major fascia folds backward inward at the lateral edge of the pectoralis major muscle to cover the base of the axilla, which in turn connects with the supraspinatus (gonad) fascia, the infraspinatus (gonad) fascia, the lesser round muscle fascia, the greater round muscle fascia, and the dorsal latissimus dorsi fascia at the base of the axilla as the superficial axillary fascia.
The deep fascia of the subclavian muscle fascia, the pectoralis minor muscle fascia, and the subscapularis muscle fascia are connected at the base of the axilla as the deep axillary fascia. In the medial wall of the axilla it covers the intercostal muscles, the anterior serratus and is connected to the subscapularis fascia. In the upper part of the thorax the fascia covering the ribs, intercostal muscles, and anterior serratus is thin and gradually thickens downward. The subclavian fascia, sternoclavicular fascia, pectoralis minor fascia, and rostral axillary fascia are interconnected to form the deep axillary fascia in a narrow sense.
The sieve-like oval portion of the sternocleidomastoid fascia is called the subclavian oval fossa where the superior pectoral nerve and accompanying blood vessels and radial cutaneous vein pass.
The deep axillary fascia is divided into four regions: the subclavian fascia surrounds the subclavian muscle into a cylinder, the pectoralis clavicularis fascia is the part of the fascia connecting the subclavian muscle to the pectoralis minor muscle, the pectoralis minor fascia surrounds the pectoralis minor muscle into a cylinder, and the rostral axillary fascia connects the pectoralis minor fascia, the rostro-humeral muscle, and the base of the axilla.
The sieve fascia of the axilla is formed by the fusion of the deep and superficial fascia layers in the axillary base portion and forms the axillary base together with the subcutaneous tissue and skin. The subcutaneous lymphatic vessels of the chest wall inject into the axilla through small holes in the axillary sieve fascia. The lymphatic vessels of the lateral breast are connected to the lymph nodes in the axilla through these small holes.
The fascia of the axilla divides the axillary cavity into several intervals, and only by knowing these intervals well during surgery can we achieve adequate clearance of the lymph nodes and fat, as well as avoid bleeding and preserve exactly both the nerves, and extra care should be taken when operating in contact with these fascia.
What is the significance for surgery?
1, to do surgery and the bull is a reason, in fact, to put it bluntly, the scalpel walk must be carried out in the natural cavity, in this natural gap to have a faster separation. Easier and sparse blood vessels, easier to separate, cut, stop bleeding, ligature, this natural cavity is actually the usual sparse connective tissue —- is these fascia.
There will generally be only slightly larger small vessels in these fascia, but generally not as many capillaries as there are in the parenchymal tissue. As long as care is taken not to be too reckless, the clarity of the operative field and the speed and appreciability of the surgery can generally be ensured.
We say that some surgeons do not operate well. The reality is that these fascial gaps are not found correctly, and there will be endless bleeding with countless capillaries in the parenchymal tissue when cut into. It is often said that surgery is the art of the plane, which I understand is “to use the scalpel to accurately find the tissue gap – the actual fascia, and to spread it into a plane, in order to further cut the deeper gap”.
2. It is important to note that large blood vessels, nerves, and lymphatic vessels generally travel and branch in the fascia, so care must be taken not to injure important blood vessels. The fascia is more easily torn open by violence than the parenchyma, thus damaging the blood vessels and nerves therein, so care must be taken.
3. When clearing the lymph nodes, it is important to clarify each fascial cavity so that as long as your clippers (some people also use electric knives, none of this matters) are inside the fascia and walk along the fascia to remove the complete fascial cavity that the fascia is wrapped around, you will not get lost in a pile of rotten fat, and you will not worry about going up to important organs or tissues.
4. In the case of lymph node dissection from inside to outside, such as lymph node dissection in breast conservation surgery without another opening in the axilla, the lymph node dissection from the breast incision to the axilla, that is, the axillary lymph node dissection starts from the lateral edge of the pectoralis major muscle (to preserve the pectoralis minor muscle) or the posterior lingual fat of the pectoralis minor muscle (to remove the pectoralis minor muscle), inward to the axillary tip, outward to the superficial layer of superficial fascia, inward downward to the superficial fascia of the lateral chest wall and the deep fascia covering the It is not necessary to further open the superficial fascia and remove the subcutaneous tissue of the skin of the axilla and lateral chest wall – because this area does not receive lymph from the breast and travels the sensory and vegetative nerves of the skin. More importantly, such preservation preserves the sensory and sweat function of the skin of the axilla (provided that the intercostal arms are preserved).
5, common mistakes, we are dealing with recurrent cases in external consultation, common sites are probably the same, the actual we are evaluating the good or bad of breast cancer surgery is also never whether we can take down the breast, even though some people have low appreciation of surgery, but the quality of surgery may be high instead, some people are very fast and fancy, but the quality of surgery we say is not high instead, the speed of tumor surgery, appreciability and quality of surgery are not necessarily correlated.
We summarize the cases over the past decades and found a very strange thing, some directors admittedly have bad surgery, slow surgery and much bleeding, but his patients have high postoperative survival rate, some directors have very nice surgery, but after summarizing the cases over the years, we found that the postoperative survival rate is not as outstanding as his surgery. Of course, for oncologic surgery, the postoperative survival rate is the gold standard of the surgeon’s level.
When doing axillary clearance, it is important to go backward to the posterior wall of the deep fascial cavity, otherwise the scapular lymph nodes will be left behind, and here the “inner triangle” and “outer triangle” are bounded by the subscapular vascular system and should be cleared separately.
This is the most common site of axillary lymph node recurrence: outwardly, we must clear the lateral group and find all the boundaries that surround the lateral group – these fascia, this is the second recurrence site; then the intermuscular, this is not to say, some places are too troublesome to clear, knowing that it will recur but not clear, this is not technology, it is responsibility; medially, we must go to the “axillary lymph nodes”. Medially, to the “axillary arch” is also called the semilunar ligament, we emphasize that “clear to the axillary tip” does not mean that taking down a piece of fat in the axillary tip is called “clearing the axillary tip”, in fact, it means clear to the axillary arch. It actually means clear to the axillary arch.
In our cases, single axillary metastases are not uncommon, and axillary metastases are an independent risk factor for poor prognosis regardless of other metastases. Therefore, the axillary tip should be placed separately for pathology. Outwardly, the “humeral arch” should be recognized clearly, as less than the lateral group is not cleared, more than the upper arm, and the upper limb should be swollen. As long as it does not go beyond the fascial cavity, the upper arm will not swell. The important reason for upper arm edema is to go beyond the fascial cavity in order to remove the lymph nodes more cleanly, thus destroying the lymphatic compensation deficit in the residual fascial cavity in the back of the shoulder.
6. The fossa ovalis is the entrance from the superficial fascial cavity to the deep fascial cavity when removing the pectoralis minor muscle. It is most important to protect the blood vessels and nerves that pass through the fossa ovalis under clear vision and destroy it, the pectoralis major muscle is atrophied or necrotic.
Remember, cutting is a process that travels along the fascia and does not enter the parenchymal tissue unless absolutely necessary. In my understanding, the surgical “blunt separation and sharp cutting” and the oncology “sharp separation and sharp cutting” are not contradictory, and the key is the fascial and fascial gap.
The “blunt separation and sharp cutting” in surgery is to use blunt forceps to insert into the fascia more easily, thus making the cutting easier and safer; the “sharp separation and sharp cutting” in oncology is to say that the tumor spreads easily along the fascia and the tissue gap is not clear enough due to the infiltration of the tumor. In this case, it is necessary to be familiar with each fascia and fascial gap.