Figure 1.

Axillary rectangle trapezoid (The patient is placed in supine position with the arms extended at 90
degrees of abduction from the chest wall). A- Axillary vein. B- Lateral margin of the pectoralis major muscle. C-
Free edge of the LD muscle. D- Inferior inaccurate boundary. E- PAV. F- DAV. G- MBSF. H- Anterior axillary fold.

Figure 2. Most popular incisions for the axillary dissection. A- Transverse incision: placed approximately 2 cm.
from the vascular axis. 1- MBSF. 2- Anterior axillary fold. 3- Posterior axillary fold. B- Vertical incision: Parallel to
the free edge of the major pectoralis muscle. C- Arcuate incision.
Figure 3. The“vertical elements” in the axillary rectangle trapezoid. A- Superior boundary of the axillary
rectangle trapezoid: axillary vein. B- Medial boundary: lateral edge of the pectoralis major muscle. C- External
boundary: free edge of the LD muscle. D- Inferior inaccurate boundary. 1- Subscapular/ Thoracodorsal vessels.
2- External mammary vessels. 3- Medial pectoral pedicle.

Figure 4. LALFNT. A- Superior boundary of the axillary rectangle trapezoid: axillary vein. B- Medial boundary:
lateral edge of the pectoralis major muscle. C- External boundary: free edge of the LD muscle. D- Inferior
inaccurate boundary. 1- Subscapular/ Thoracodorsal vessels. 2- External mammary vessels. 3- Medial pectoral
pedicle. 4- Costoaxillary vein. 5- Lateral LALFNT. 6- Middle LALFNT. 7- Medial LALFNT. 8- DAV. 9- PAV.
Figure 5. Relation between the medial pectoral nerve and the pectoralis minor muscle. 1- Pectoralis minor
muscle. 2- Medial pectoral nerve. 3- Variant that passes around the lateral border of the muscle. 4- Variant that
perforates the muscle. 5- Upper perforator. 6- Middle perforator. 7- Low perforator.

Figure 6. LALNFT contents. A- Superior boundary of the axillary rectangle trapezoid: axillary vein. B- Medial
boundary: lateral edge of the pectoralis major muscle. C- External boundary: free edge of the LD muscle. D-
Inferior inaccurate boundary. 1- Medial pectoral pedicle. 2- External mammary vessels. 3- Subscapular/
toracodorsal vessels. 4- LD nerve. 5- Long thoracic nerve. 6- Intercostobrachial nerve. 7- Branch for the
internal brachial cutaneous nerve. 8- Branch for the posterior axillary skin fold. 9- Emerging point of the Hyrtl`s
nerve. 10- Axillary vein. 11- Lateral LALFNT. 12- Middle LALFNT. 13- Medial LALFNT.
Figure 7. Maneuver to preserve the long thoracic nerve: A. 1- Pectoralis mayor aponeurosis. 2-
Pectoralis minor fascia. 3- Pectoralis major muscle. 4- Pectoralis minor muscle. 5- Serratus anterior
fascia. 6- Bell´s nerve. 7- Serratus anterior muscle. 8- LD fascia. 9- LD muscle. B. 1- First incision that
delimits the internal margin of the dissection. 2- Section of the LD muscle fascia (ABOVE THE
MUSCLE) with its respective aponeurectomy: external boundary of the resection bloc. 3- Section of
the posterior side of the fascial transition between the fascia of the pectoralis minor and the serratus
anterior muscle. 4- Fat divulsion to separate the resection bloc from the ventral side of the serratus
anterior fascia (that protects the nerve). 5- Second section of the serratus fascia, this time, from
ventral to dorsal. (Preparation of the gap for the “nail to nail” maneuver.) 6- Axillary fat pad. 7 and 8-
Direction of the traction that should be made in order to perform the aponeurectomies. 9- Pectoralis
major aponeurectomy. 10- Pectoralis minor aponeurectomy. 11- Long thoracic nerve. C. Image of the
surgical lodge after achieve en bloc resection. The Bell´s nerve is protected by the plane of the
serratus anterior fascia.

Figure 8. Variants of the external mammary vein (according to Khan et al.). 1- Subscapular vein/
Thoracodorsal vessel. 2- Axillary vein. 3- External mammary vessel. A- Type I: Classic morphology (84%). B- Type
II. 10%.
Figure 9. Elements of the axillary region. 1- Axillary vein. 2- Subscapular vessels. 3- Circumflex scapular vessels.
4- Angular branch of the thoracodorsal vessel. 5- Thoracodorsal vessels. 6- Serratus anterior vessels. 7-
Transverse branch of the thoracodorsal pedicle. 8- Vertical branch of the thoracodorsal pedicle. 9- Hyrtl´s
intercostobrachial nerve. 10- “Pre-vascular section” of the LD nerve. 11- “Vascular section” of the LD nerve. 12-
“Post-vascular section” of the LD nerve. 13- Costoaxillary vein (inconstant). 14- External mammary vessels. 15-
Long thoracic nerve. 16- Medial pectoral pedicle (variant that passes around the pectoralis minor muscle). 17-
Lateral pectoral nerve. 18- Pectoralis minor muscle. 19- Fascicles of the serratus anterior muscle. 20- Free edge
of the LD muscle. 21- Terminal branches of the intercostobrachial nerve. 22- Axillary vein. 23- Halsted´s
costoclavicular ligament. 24- Axillary artery. 25- Cephalic vein. 26- Brachial plexus. 27- Pectoralis major tendon
(divided). 28- Inferior boundary of the axillary dissection performed by the authors of this publication (below
the serratus anterior veins).

A B

Figure 10. (detail of Figure 9) Neurovascular intersections of the axilla. A. Neurovascular intersection of the
LD nerve (first NVIP). B. Neurovascular intersection of the long thoracic nerve (second NVIP)
Figure 11. Morphology of Braune´s costoaxillary vein. A- The most frequent variant, found between the
external mammary vessels and the thoracodorsal vessels. B- The costoaxillary vein, located on the surface,
matches with the thoracodorsal vessel axis. C- Hypotrophic toracodorsal vessel. The two vessels match in their
axis but the thoracodorsal vessel is always deeper.

Figure 12. Digital maneuver

(“nail to nail”) in order to
preserve the fascia of the
serratus. 1- Por tion of
serratus fascia to preserve in
front of the nerve. 2- Long
thoracic nerve. 3- Axillary
lymph node fatty tissue (part
of the resected specimen).
4- Serratus muscle. 65-
Pectoralis major muscle. 6-
LD muscle. 7- Portion of the
serratus fascia that should be
included in the resected
specimen. The direction of
the blunt dissection which
should be performed in the
fascia is indicated with a red
arrow (towards the vascular
axis).