Correspondence and communications symptoms of fractures of the area, can largely be learned from textbooks. Practical experience is essential however in reinforcing this knowledge and in developing the clinical and technical skills required for the management of these injuries. Plastic surgery trainees should be aware of this potential deficiency in their clinical exposure and should seek out opportunities to evaluate patients with dental and maxillofacial injuries. Formal training and/or elective rotations in dental and maxillofacial trauma is warranted, as the subject is an examinable part of the Intercollegiate Surgical Curriculum in Plastic Surgery and is relevant to ensure high quality care for those with facial injuries.
Conflict of interest None.
Funding None.
Ethical approval N/A.
References 1. Hutchison IL, Magennis P, Shepherd JP, Brown AE. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. Br Assoc Oral Maxillofac Surg Br J Oral Maxillofac Surg 1998;36:3e13. 2. Le BT, Holmgren EP, Holmes JD, Ueeck BA, Dierks EJ. Referral patterns for the treatment of facial trauma in teaching hospitals in the United States. J Oral Maxillofac Surg 2003;61: 557e60. 3. Walker TW, Byrne S, Donnellan J, et al. West of Ireland facial injury study. Part 1. Br J Oral Maxillofac Surg 2012;50: 631e5. 4. Intercollegiate Surgical Curriculum Project. The intercollegiate surgical curriculum; educating the surgeons of the future. Plast Surg; October 2013::105e9. 5. Nasr IH, Papineni McIntosh A, Mustafa S, Cronin A. Professional knowledge of accident and emergency doctors on the management of dental injuries. Community Dent Health 2013;30: 234e40.
C. de Blacam R. van der Rijt A.J.P. Clover Department of Plastic Surgery, Cork University Hospital, Wilton, Cork, Ireland E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.12.007
597
Axillary lymph node dissection: Do you know your boundaries?* Dear Sir, Axillary lymph node dissection (ALND) is an established subspecialist surgical treatment for patients with axillary nodal metastasis from skin cancers.1 We note that the boundaries for ALND are well documented and agreed, with the exception of the inferior boundary. Superiorly, the axilla is dissected to the axillary vein, anteriorly to the pectoralis major and minor, medially to the chest wall and serratus anterior, laterally to the latissimus dorsi muscle and posteriorly to the subscapularis and latissimus dorsi muscles.2 The importance of a thorough dissection at the superior boundary during ALND is well accepted. There is less emphasis placed on the standards for dissection at the inferior boundary. Currently no guidance for surgeons exists on the extent of inferior dissection and as a result the limit chosen is at the surgeons’ discretion. Inevitably, this will lead to individual variation in practice and makes comparison of results between surgeons inaccurate. This may also impact on the adequacy of lymph node dissection, local recurrence and survival.3 In view of this, an audit was undertaken to assess the current surgical practice during ALND amongst plastic surgeons. A questionnaire was devised and distributed to those who perform the procedure and who attended a recent British and Irish Association of Plastic Surgeons’ meeting. The aims of the audit were to determine whether each surgeon routinely identifies a specific anatomical boundary for the inferior aspect of ALND and to identify a standardised approach to the inferior boundary. Fifty responses to the questionnaire were completed in total, involving surgeons from 13 regions within the UK and Ireland. The mean number of ALND carried out per surgeon was 19 with a median number of 15 and a range between 2 and 60 procedures per surgeon, per year. The following options for the inferior anatomical boundary were listed on the questionnaire and the frequency of their use is as follows: 4th rib (2%), nipple areolar complex (NAC) in males or inframammary fold (IMF) in females (2%), the angular vein (0%) and the lower border of serratus anterior (16%). 18% used other landmarks (surgeon-specific) which included 10th rib (6%), 9th rib (4%), 6th rib (6%) and the lower border of axillary fat (2%). 62% of surgeons did not routinely use a specific inferior limit in their dissection. Anatomical texts and other published literature fail to agree on a defined inferior boundary for ALND. Table 1 is a comparison of boundaries that have been proposed. The angular vein is the most frequently discussed landmark in the literature.4,5 It is a tributary of the subscapular vein, which is formed by the confluence of the thoracodorsal vein and angular vein (Fig. 1).4 It is more commonly known as the vascular branch to the serratus anterior. Despite advocating its use, current literature fails to agree on the *
This work was presented in part at the European Society of Plastic, Reconstructive and Aesthetic Surgery Conference 7th July 2014, Edinburgh.
598
Correspondence and communications
Table 1 Comparison of the anatomical level for proposed inferior anatomical boundaries in ALND. Anatomical structure
Position in axilla
Angular vein
Vertical line corresponding to the 3rd intercostal space at the lateral border of the sternum with the patient supine.5 The point at which the thoracodorsal nerve enters the latissimus dorsi is just distal (1e2 cm) to the angular vein.5 4th intercostal space
Thoracodorsal nerve meets latissimus dorsi
Nipple areolar complex/inframammary fold (NAC/IMF) Fourth, sixth, ninth or tenth rib Inferior border of serratus anterior muscle
Level of the fourth, sixth, ninth or tenth rib Vertical line most frequently corresponding to the 8th rib in males and 9th rib in females with patient supine
application of the angular vein when identifying the inferior boundary of dissection.4,5 To our knowledge there is minimal published literature promoting the use of other inferior anatomical boundaries for ALND. A standardised approach to ALND has already been advocated to minimise complications and deliver consistent results.3 Kretschmer et al. found that standardising the approach to ALND for palpable nodes in metastatic melanoma led to an increase in the median number of lymph nodes dissected from six to 12 and a 30% decrease in local recurrence rates.3 The sixth rib was used as the standardised inferior boundary. This audit shows that there is considerable variation in surgical practice and no agreed standard. The majority of
surgeons do not routinely use an inferior boundary for dissection (62%). The angular vein has predominantly been described for axillary node dissection in breast cancer and there is some confusion over its use. Out of 50 BAPRAS and IAPS surgeons participating in the study, no participants identified the angular vein as the landmark of choice for the inferior anatomical boundary of dissection. A variety of other landmarks were identified, the most common of which was the lower border of the serratus anterior. Despite the lack of evidence, the audit implies that operating surgeons have concluded for themselves that the lower border of the serratus anterior muscle is a valuable landmark. As a minimum standard we recommend that when recording the procedure the inferior boundary of dissection is clearly documented, possibly with the aid of an operative record pro-forma. In light of this audit, our department now routinely uses the lower border of the serratus anterior as the inferior anatomical boundary of dissection in ALND. The landmark is reproducible, relatively caudal in the axilla to ensure sufficient lymph node yield, already visualised when identifying the long thoracic nerve and the most frequently used landmark by Plastic Surgeons currently. It is hoped that an international standard can be agreed on in the future.
Conflict of interest None.
Funding None.
References 1. National Institute for Health and Clinical Excellence. Improving outcomes for people with skin tumours including melanoma [accessibility verified 22.01.14], www.nice.org.uk/CSGSTIM; 2006. 2. Nadkarni MS, Raina S, Badwe RA. Medial pectoral pedicle: a critical landmark in axillary dissection. ANZ J Surg 2006;76:652e4. 3. Kretschmer L, Preusser K. Standardized axillary lymphadenectomy improves local control but not survival in patients with palpable lymph node metastases of cutaneous malignant melanoma. Langenbecks Arch Surg 2001;386:418e25. 4. O’Rourke MGE, Layt CWL. Angular vein of the axilla and the anatomy of the subscapular vein important in axillary node dissection. Aust N Z J Surg 1993;63:396e8. 5. Chan CY, Tan M. Spatial relations of the angular vein, an important landmark in axillary node dissection. Br J Surg 2003; 90:948e9.
F. Page N. Hamnett S. Chadwick Plastic Surgery Department, University Hospital of North Staffordshire NHS Trust, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK
Figure 1 Intraoperative image illustrating the angular vein (black arrow).
E-mail address: [email protected] K. Nelson Whiston Hospital, Warrington Road, Prescot, Merseyside, L35 5DR, UK
Correspondence and communications W. Jaffe Plastic Surgery Department, University Hospital of North Staffordshire NHS Trust, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK
599 ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.12.026
Conflict of interest None.
Funding None.
Ethical approval N/A.
References 1. Hutchison IL, Magennis P, Shepherd JP, Brown AE. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. Br Assoc Oral Maxillofac Surg Br J Oral Maxillofac Surg 1998;36:3e13. 2. Le BT, Holmgren EP, Holmes JD, Ueeck BA, Dierks EJ. Referral patterns for the treatment of facial trauma in teaching hospitals in the United States. J Oral Maxillofac Surg 2003;61: 557e60. 3. Walker TW, Byrne S, Donnellan J, et al. West of Ireland facial injury study. Part 1. Br J Oral Maxillofac Surg 2012;50: 631e5. 4. Intercollegiate Surgical Curriculum Project. The intercollegiate surgical curriculum; educating the surgeons of the future. Plast Surg; October 2013::105e9. 5. Nasr IH, Papineni McIntosh A, Mustafa S, Cronin A. Professional knowledge of accident and emergency doctors on the management of dental injuries. Community Dent Health 2013;30: 234e40.
C. de Blacam R. van der Rijt A.J.P. Clover Department of Plastic Surgery, Cork University Hospital, Wilton, Cork, Ireland E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.12.007
597
Axillary lymph node dissection: Do you know your boundaries?* Dear Sir, Axillary lymph node dissection (ALND) is an established subspecialist surgical treatment for patients with axillary nodal metastasis from skin cancers.1 We note that the boundaries for ALND are well documented and agreed, with the exception of the inferior boundary. Superiorly, the axilla is dissected to the axillary vein, anteriorly to the pectoralis major and minor, medially to the chest wall and serratus anterior, laterally to the latissimus dorsi muscle and posteriorly to the subscapularis and latissimus dorsi muscles.2 The importance of a thorough dissection at the superior boundary during ALND is well accepted. There is less emphasis placed on the standards for dissection at the inferior boundary. Currently no guidance for surgeons exists on the extent of inferior dissection and as a result the limit chosen is at the surgeons’ discretion. Inevitably, this will lead to individual variation in practice and makes comparison of results between surgeons inaccurate. This may also impact on the adequacy of lymph node dissection, local recurrence and survival.3 In view of this, an audit was undertaken to assess the current surgical practice during ALND amongst plastic surgeons. A questionnaire was devised and distributed to those who perform the procedure and who attended a recent British and Irish Association of Plastic Surgeons’ meeting. The aims of the audit were to determine whether each surgeon routinely identifies a specific anatomical boundary for the inferior aspect of ALND and to identify a standardised approach to the inferior boundary. Fifty responses to the questionnaire were completed in total, involving surgeons from 13 regions within the UK and Ireland. The mean number of ALND carried out per surgeon was 19 with a median number of 15 and a range between 2 and 60 procedures per surgeon, per year. The following options for the inferior anatomical boundary were listed on the questionnaire and the frequency of their use is as follows: 4th rib (2%), nipple areolar complex (NAC) in males or inframammary fold (IMF) in females (2%), the angular vein (0%) and the lower border of serratus anterior (16%). 18% used other landmarks (surgeon-specific) which included 10th rib (6%), 9th rib (4%), 6th rib (6%) and the lower border of axillary fat (2%). 62% of surgeons did not routinely use a specific inferior limit in their dissection. Anatomical texts and other published literature fail to agree on a defined inferior boundary for ALND. Table 1 is a comparison of boundaries that have been proposed. The angular vein is the most frequently discussed landmark in the literature.4,5 It is a tributary of the subscapular vein, which is formed by the confluence of the thoracodorsal vein and angular vein (Fig. 1).4 It is more commonly known as the vascular branch to the serratus anterior. Despite advocating its use, current literature fails to agree on the *
This work was presented in part at the European Society of Plastic, Reconstructive and Aesthetic Surgery Conference 7th July 2014, Edinburgh.
598
Correspondence and communications
Table 1 Comparison of the anatomical level for proposed inferior anatomical boundaries in ALND. Anatomical structure
Position in axilla
Angular vein
Vertical line corresponding to the 3rd intercostal space at the lateral border of the sternum with the patient supine.5 The point at which the thoracodorsal nerve enters the latissimus dorsi is just distal (1e2 cm) to the angular vein.5 4th intercostal space
Thoracodorsal nerve meets latissimus dorsi
Nipple areolar complex/inframammary fold (NAC/IMF) Fourth, sixth, ninth or tenth rib Inferior border of serratus anterior muscle
Level of the fourth, sixth, ninth or tenth rib Vertical line most frequently corresponding to the 8th rib in males and 9th rib in females with patient supine
application of the angular vein when identifying the inferior boundary of dissection.4,5 To our knowledge there is minimal published literature promoting the use of other inferior anatomical boundaries for ALND. A standardised approach to ALND has already been advocated to minimise complications and deliver consistent results.3 Kretschmer et al. found that standardising the approach to ALND for palpable nodes in metastatic melanoma led to an increase in the median number of lymph nodes dissected from six to 12 and a 30% decrease in local recurrence rates.3 The sixth rib was used as the standardised inferior boundary. This audit shows that there is considerable variation in surgical practice and no agreed standard. The majority of
surgeons do not routinely use an inferior boundary for dissection (62%). The angular vein has predominantly been described for axillary node dissection in breast cancer and there is some confusion over its use. Out of 50 BAPRAS and IAPS surgeons participating in the study, no participants identified the angular vein as the landmark of choice for the inferior anatomical boundary of dissection. A variety of other landmarks were identified, the most common of which was the lower border of the serratus anterior. Despite the lack of evidence, the audit implies that operating surgeons have concluded for themselves that the lower border of the serratus anterior muscle is a valuable landmark. As a minimum standard we recommend that when recording the procedure the inferior boundary of dissection is clearly documented, possibly with the aid of an operative record pro-forma. In light of this audit, our department now routinely uses the lower border of the serratus anterior as the inferior anatomical boundary of dissection in ALND. The landmark is reproducible, relatively caudal in the axilla to ensure sufficient lymph node yield, already visualised when identifying the long thoracic nerve and the most frequently used landmark by Plastic Surgeons currently. It is hoped that an international standard can be agreed on in the future.
Conflict of interest None.
Funding None.
References 1. National Institute for Health and Clinical Excellence. Improving outcomes for people with skin tumours including melanoma [accessibility verified 22.01.14], www.nice.org.uk/CSGSTIM; 2006. 2. Nadkarni MS, Raina S, Badwe RA. Medial pectoral pedicle: a critical landmark in axillary dissection. ANZ J Surg 2006;76:652e4. 3. Kretschmer L, Preusser K. Standardized axillary lymphadenectomy improves local control but not survival in patients with palpable lymph node metastases of cutaneous malignant melanoma. Langenbecks Arch Surg 2001;386:418e25. 4. O’Rourke MGE, Layt CWL. Angular vein of the axilla and the anatomy of the subscapular vein important in axillary node dissection. Aust N Z J Surg 1993;63:396e8. 5. Chan CY, Tan M. Spatial relations of the angular vein, an important landmark in axillary node dissection. Br J Surg 2003; 90:948e9.
F. Page N. Hamnett S. Chadwick Plastic Surgery Department, University Hospital of North Staffordshire NHS Trust, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK
Figure 1 Intraoperative image illustrating the angular vein (black arrow).
E-mail address: [email protected] K. Nelson Whiston Hospital, Warrington Road, Prescot, Merseyside, L35 5DR, UK
Correspondence and communications W. Jaffe Plastic Surgery Department, University Hospital of North Staffordshire NHS Trust, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK
599 ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.12.026
