In vivo study of the surgical anatomy of the axilla

Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis

BACKGROUND

The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023.

MATERIALS AND METHODS

The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google.

RESULTS

We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%).

CONCLUSIONS

The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

Axillary Lymphadenectomy: Safe Dissection Through a Correct Technique

The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable.  In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.

Langer's arch in axillary dissections from patients with breast cancer: a retrospective study

PURPOSE

The study aimed to assess the frequency of Langer's arch in patients undergoing axillary dissection for breast cancer.

METHODS

From January-2015 to March-2020, in a general hospital in México City, female patients undergoing axillary dissection for breast cancer were studied. The analysis involved: demographic and anthropometric data, type of surgical treatment, histopathologic diagnosis, number of lymph nodes harvested, and frequency of Langer's arch finding.

RESULTS

The sample studied was 123 axillary dissections. The mean age of the patients was 59 ± 10.5-years. Modified radical mastectomy was done in 117 cases (95.1%). Ductal carcinoma occurred in 96 cases (78%). The mean number of lymph nodes harvested was 24 ± 6.5. Langer's arch finding occurred in 33 cases (26.8%).

CONCLUSION

Langer's arch is frequent in our patients undergoing axillary dissection for breast cancer.

Ultrasound imaging of the axilla

Axilla is a pyramidal-in-shape "virtual cavity" housing multiple anatomical structures and connecting the upper limb with the trunk. To the best of our knowledge, in the pertinent literature, a detailed sonographic protocol to comprehensively assess the axillary region in daily practice is lacking. In this sense, the authors have briefly described the anatomical architecture of the axilla-also using cadaveric specimens-to propose a layer-by-layer sonographic approach to this challenging district. The most common sonographic pathological findings-for each and every anatomical compartment of the axilla-have been accurately reported and compared with the corresponding histopathological features. This ultrasound approach could be considered a ready-to-use educational guidance for the assessment of the axillary region. CRITICAL RELEVANCE STATEMENT: Axilla is a pyramidal-in-shape "virtual cavity" housing multiple anatomical structures and connecting the upper limb with the trunk. The aim of this review article was to describe the anatomical architecture of the axilla, also using cadaveric specimens, in order to propose a layer-by-layer sonographic approach to this challenging district.

From Cadaveric Dissection to the Operating Room: A Unilateral Double Intercostobrachial Nerve and the Implications in Axillary Lymph Node Dissection

There are multiple treatment options for breast cancer (BC), including lumpectomy, chemo- and radiotherapy, complete mastectomy, and, when indicated, an axillary lymph node dissection. Such node dissections commonly lead the surgeon to encounter the intercostobrachial nerve (ICBN), which, if injured, leads to significant postoperative numbness of the upper arm. To assist in identifying the ICBN, we report a unilateral variation of a dual ICBN. The first ICBN (ICBN I) originates from the second intercostal space, as classically described in human anatomy. On the contrary, the second ICBN (ICBN II) originates from the second and third intercostal spaces. The anatomical knowledge of ICBN origin and its variations are crucial for axillary lymph node dissection in BC and other surgical interventions that involve the axillary region (e.g., regional nerve blocks). An iatrogenic injury of the ICBN has been associated with postoperative pain, paresthesia, and loss of upper extremity sensation in the dermatome supplied by this nerve. Therefore, maintaining the integrity of the ICBN is a worthy goal during axillary dissections in BC patients. Increasing the awareness of ICBN variants among surgeons reduces potential injuries, which would contribute to the BC patient's quality of life.

[Focus on axillary anatomy: The Carl Langer muscle, a great forgotten muscle in the training of medical residents in gynecology and obstetrics]

OBJECTIVE

The Carl Langer muscle is the main anatomical variation of the walls of the axillary area, its incidence being about 7%. The presence of this muscle crossing the anterior edge of the axillary vessels can induce difficulties of exposure, location and dissection during axillary surgery. In addition, it may be responsible for primary lymphedema of the upper limb, venous thrombosis of the axillary vein or thoracic outlet syndrome due to vascular or nervous compression. The objective of this work was to evaluate the state of knowledge on Carl Langer muscle of the gynecology-obstetrics medical residents of the French Eastern Region.

MATERIAL AND METHODS

All the medical residents enrolled in the specialized diploma in gynecology-obstetrics in the 5 regions (Alsace, Bourgogne, Lorraine, Champagne-Ardenne and Franche-Comté) were questioned by means of a questionnaire sent by e-mail.

RESULTS

From February to March 2021, 94 of the 160 medical residents interviewed answered to the questionnaire. Ninety-one of them (97%) did not know Carl Langer's muscle. Three medical residents thought they knew this muscle (3%) but their knowledge was imperfect.

CONCLUSION

Our work has highlighted the general lack of knowledge of this anatomical variation, which is relatively frequent, among French gynecology-obstetrics medical residents who are required to examine or perform surgery on this area. This updated review of the literature should optimize the knowledge of the anatomy of the axillary area and consequently its surgery.

Intercostobrachial Nerve (ICBN) Preservation Versus Sacrifice in Axillary Dissection: Randomized Controlled Trial

OBJECTIVES

Whether to preserve or sacrifice the intercostobrachial nerves (ICBN) is a controversial issue. In this trial, we aim to assess the effects of preservation of the ICBN during axillary dissection for patients with breast cancer in terms of pain score immediately postoperatively and several hours later, need for simple analgesia and narcotics, numbness and arm swelling.

MATERIALS AND METHODS

This is a single-institution, single-surgeon randomized controlled trial where a sample of 48 patients with breast cancer, of various age groups, were allocated randomly to any of the 2; preservation or sacrifice categories. Postoperatively, patients were asked by a physician to fill a predesigned questionnaire to assess the studied items during hospitalization and after discharge.

RESULTS

Among the 48 included patients, ICBN was sacrificed in 24 patients; of which 18 patients (75%) developed numbness in the inner aspect of the arm. While in the ICBN preservation group (24 patients) only 6 patients suffered numbness (25%) with a significant P-value of 0.001. Estimated duration of surgery with ICBN preservation was 100±22.02 minutes, while it is significantly shorter in the ICBN sacrifice group (83.48±21.55). However, with regard to other variables of pain, seroma formation, need of simple analgesia and narcotics, hospital admission days and arm swelling, there was no significant difference between the 2 groups.

CONCLUSION

This study can conclude that preservation of ICBN during axillary dissection in patients with breast CA can save these patients' additional suffering from inner arm numbness. That is at the expense of surgery duration, around 20 minutes longer, for the surgeon to take his/her time in carefully dissecting the axilla properly without injuring these ICBN.

Role of Intraoperative Nerve Monitoring in Postoperative Muscle and Nerve Function of Patients Undergoing Modified Radical Mastectomy

This study aimed to postoperatively evaluate the effects of intraoperative neural monitoring (IONM) on muscles and nerves in patients who underwent modified radical mastectomy (MRM). In the 11 patients included in the study, nerves were determined and protected by nerve monitoring during the axillary dissection (IONM group). In another 11 patients, nerve monitoring was not performed; however, protection of the same nerves was attempted through careful nerve dissection (cautious nerve dissection [CND] group). The control group consisted of 22 healthy subjects. Muscle and nerve functions were blindly evaluated by an experienced physical therapy and rehabilitation specialist using electromyography (EMG) and ultrasonography (US) methods. The EMG values of the pectoralis major muscle were similar in the IONM and control groups (1.97 mV/1.98 mV, p = 0.97) but significantly lower in the CND group (1.57 mV, p < 0.05). Significant differences were found in the US values of the pectoralis major and minor muscles between the IONM and CND groups. No significant difference was found between the IONM and control groups in terms of EMG values of the serratus anterior muscle. This is the first prospective randomized study to objectively evaluate preservation of the nerve through nerve monitoring and its functional results. Monitoring of nerves during MRM is of great importance in terms of demonstrating the positive effects on muscle and nerve functions.

Double axillary vein variation diagnosed with ultrasound guidance during infraclavicular nerve block intervention

The use of ultrasound guidance increases the safety of peripheral block interventions by allowing anaesthesiologists to simultaneously see the position of block needle, the targeted nerves and surrounding vessels. In this report, we represented three patients diagnosed with double axillary vein variation with ultrasound guidance during infraclavicular nerve block intervention. The patients were scheduled for different types of upper limb surgeries. All patients received infraclavicular nerve block for anaesthetic management. A double axillary vein variation was diagnosed with ultrasound during block interventions. Hydro-location technique was used in all cases and the procedures were completed uneventfully. In the current literature, there is limited number of reports concerning double axillary vein variation. Detailed knowledge of the axillary anatomy is important to avoid complications such as intravascular injection during peripheral nerve block interventions. The use of ultrasound guidance and hydro-location technique should be considered for nerve blocks, especially in the axillary area.

Anatomical variations of the subscapular pedicle and its terminal branches: an anatomical study and a reappraisal in the light of current surgical approaches

PURPOSE

While anatomical variations of the subscapular vessels are frequently encountered during axillary dissection, little is found in the literature. The aim of this cadaveric study was to define arterial and venous anatomical variations and frequencies of the subscapular vascular pedicle and its terminal/afferent vessels in women.

METHODS

We performed 80 dissections of the axillary region on forty female formalin-embalmed cadavers. Each anatomical arrangement was photographed and recorded on a scheme before analysis.

RESULTS

We propose a new classification of the subscapular pedicle variations. We observed three types of subscapular arterial variation. The type Ia was the most frequent arrangement (71% of our dissections), the type Ib was observed in 11% and the type II in 18% of cases. We observed four types of subscapular venous variation. The type Ia was observed in 63% of cases, the type Ib in 14%, the type II in 14% and the type III in 10% of cases.

CONCLUSIONS

This knowledge of the anatomical variation arrangement and frequencies of the subscapular vascular pedicle will assist the surgeon when dissecting the axillary region for malignant or reconstructive procedures.

An improved technical trick for identification of the thoracodorsal nerve during axillary clearance surgery: a cadaveric dissection study

Background

Accurate anatomical landmarks to locate the thoracodorsal nerve are important in axillary clearance surgery.

Methods

Twenty axillary dissections were carried out on ten preserved Sri Lankan cadavers. Cadavers were positioned dorsal decubitus with upper limbs abducted to 90⁰. An incision was made in the upper part of the anterior axillary line. The lateral thoracic vein was identified and traced bi-directionally. The anatomical location of the thoracodorsal nerve was studied in relation to the lateral border of pectoralis minor and from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein.

Results

The lateral thoracic vein was invariably present in all the specimens. All the lateral thoracic veins passed lateral to the lateral border of pectoralis minor except in one specimen, where the lateral thoracic vein passed along its lateral border. The thoracodorsal nerve was consistently present posterolateral to the lateral thoracic vein. The mean distance to the lateral thoracic vein from the lateral border of pectoralis minor was 28.7 ± 12.6 mm. The mean horizontal distance, depth, and displacement, from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein to the thoracodorsal nerve were 14.5 ± 8.9 mm, 19.7 ± 7.3 mm and 25 ± 5 mm respectively. The thoracodorsal nerve was found in a posterolateral direction, at a 54⁰ ± 12⁰ angle to the horizontal plane, 95% of the time.

Conclusions

The lateral thoracic vein is an accurate guide to the thoracodorsal nerve. We recommend exploring for the thoracodorsal nerve from a point 2 cm from the confluence of the lateral thoracic vein and the axillary vein for a distance of 25 ± 5 mm in a posterolateral direction, at a 54⁰ ± 12⁰ angle to the horizontal plane.

Prevalence and anatomy of the axillary arch and its implications in surgical practice: A meta-analysis

PURPOSE

The following research aimed to investigate the prevalence and anatomical features of the axillary arch (AA) - a muscular, tendinous or musculotendinous slip arising from the latissimus dorsi and that terminates in various structures around the shoulder girdle. The AA may complicate axillary lymph node biopsy or breast reconstruction surgery and may cause thoracic outlet syndrome.

METHODS

Major electronic databases were thoroughly searched for studies on the AA and its variations. Data regarding the prevalence, morphology, laterality, origin, insertion and innervation of the AA was extracted and included in this meta-analysis. The AQUA tool was used in order to assess potential risk of bias within the included studies.

RESULTS

The AA was reported in 29 studies (10,222 axillas), and its pooled prevalence estimate in this meta-analysis was found to be 5.3% of the axillas: unilaterally (61.6%) and bilaterally (38.4%). It was predominantly muscular (55.1% of the patients with the AA), originated from the latissimus dorsi muscle or tendon (87.3% of the patients with the AA), inserted into the pectoralis major muscle or fascia (35.2% of the patients with the AA), and was most commonly innervated by the thoracodorsal nerve (39.9% of the patients with the AA).

CONCLUSION

The AA is a relatively common variant, hence it should not be neglected. Oncologists and surgeons should consider this variant while diagnosing an unknown palpable mass in the axilla, as the arch might mimic a neoplasm or enlarged lymph nodes.

[Impact of the preservation of the branches of intercostobrachial nerve on the quality of life of patients operated for a breast cancer]

AIM

The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer.

METHODS

This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure.

RESULTS

Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P<0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P<0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar.

CONCLUSION

Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.

The intercostobrachial nerve as a sensory donor for hand reinnervation in brachial plexus reconstruction is a feasible technique and may be useful for restoring sensation

ABSTRACT Objective Few donors are available for restoration of sensibility in patients with complete brachial plexus injuries. The objective of our study was to evaluate the anatomical feasibility of using the intercostobrachial nerve (ICBN) as an axon donor to the lateral cord contribution to the median nerve (LCMN). Methods Thirty cadavers were dissected. Data of the ICBN and the LCMN were collected, including diameters, branches and distances. Results The diameters of the ICBN and the LCMN at their point of coaptation were 2.7mm and 3.7mm, respectively. The ICBN originated as a single trunk in 93.3% of the specimens and bifurcated in 73.3%. The distance between the ICBN origin and its point of coaptation to the LCMN was 54mm. All ICBNs had enough extension to reach the LCMN. Conclusion Transfer of the ICBN to the LCMN is anatomically feasible and may be useful for restoring sensation in patients with complete brachial plexus injuries.

Origin, Branching, and Communications of the Intercostobrachial Nerve: a Meta-Analysis with Implications for Mastectomy and Axillary Lymph Node Dissection in Breast Cancer

The intercostobrachial nerve (ICBN), which usually originates from the lateral cutaneous branch of the second intercostal nerve, innervates areas of the axilla, lateral chest, and medial arm. It is at risk for injury during operative procedures that are often used in the management of breast cancer and such injury has been associated with postoperative sensory loss and neuropathic pain, decreasing the quality of life. PubMed, Excerpta Medica Database (EMBASE), ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), Scientific Electronic Library Online (SciELO), Biosciences Information Service (BIOSIS), and Web of Science were searched comprehensively. Data concerning the prevalence, branching, origin and communications of the ICBN were extracted and pooled into a meta-analysis. A total of 16 studies (1,567 axillas) reported data indicating that the ICBN was present in 98.4% of person. It most often (90.6%) originated from fibers at the T2 spinal level and commonly coursed in two branching patterns: as a single trunk in 47.0% of cases and as a bifurcating pattern in 42.2%. In the latter cases, the bifurcation was usually unequal (63.4%). Additionally, the ICBN presented with anastomosing communication to the brachial plexus in 41.3% of cases. The ICBN is a prevalent and variable structure at significant risk for injury during operative procedures of the axilla. In view of the postoperative pain and paresthesia experienced by patients following injury, surgeons need to exercise caution and aim to preserve the ICBN when possible. Ultimately, careful dissection and knowledge of ICBN anatomy could allow postoperative complications to be reduced and patient's quality of life increased.

Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites.

METHODS

Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0 mm with successive half-millimeter graduations.

RESULTS

The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5 mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5 mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p = 0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p = 0.009).

CONCLUSIONS

This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.

Venous anomalies of the axilla: a single-institution experience

AIM

Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience.

PATIENTS AND METHODS

A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database.

RESULTS

Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed.

CONCLUSIONS

Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

Lymph nodes behind the axillary neurovascular bundle: case report and cadaveric study of frequency and distribution

Axillary clearance was undertaken in a 58-year-old male with massive lymph node enlargement caused by melanoma from an unknown primary site. We discovered a group of metastatic lymph nodes behind the axillary neurovascular bundle. This group of nodes (retro-axillary lymph nodes) could represent an extension of the subscapular group, or the seventh group of axillary lymphoid nodes. They were successfully removed using an ad hoc surgical technique, and the subsequent findings are presented herein. To check the frequency of these lymph nodes in this area, we conducted a study on 15 cadavers (30 armpits). The technique of cadaveric sampling is described. Retro-axillary tissue was histologically processed to determine the number of lymph nodes present. It was found that lymph nodes were present in the defined area in 18 of the 30 (60 %) armpits explored. We recommend assessment of the retro-axillary space during surgery entailing massive axillary lymph node involvement.

Anatomical variations of the axilla

Purpose

The present study aimed to measure the thickness of the subcutaneous adipose tissue (SAT) at the site of the surgical incision for axillary lymph node dissection (ALND) and to record potential anatomical variations in the medial cutaneous nerve of the arm (MCNA), the intercostobrachial nerve (ICBN), the lateral thoracic vein (LTV), the lateral thoracic artery (LTA) and the pectoral muscle pedicle (PMP), considering that some details of the anatomy of these structures within the axilla are still unclear.

Methods

A prospective study was conducted in 100 consecutive patients with breast cancer who underwent ALND as part of surgical treatment. The anatomy of the dissected axilla was video recorded.

Results

The SAT thickness ranged from 8 mm to 60 mm, with an average thickness of 25.9 mm. A positive correlation was observed between the SAT thickness and the body mass index (BMI) of the evaluated patients (r = 0.68; p < 0.0001). The MCNA was the anatomical structure that was least commonly observed in the axilla (22% of cases), while the PMP was the most constant element, identified in 100% of cases. All of the studied anatomical structures observed within the axilla showed variation in at least one of the aspects analyzed, i.e., the point of entry and exit, path, number and location of divisions or branches.

Conclusion

The present study demonstrated wide variation in thickness of the SAT overlying the axilla and identified the existence of broad normative anatomical variation of the axilla.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-306) contains supplementary material, which is available to authorized users.

How I do it: Simple and effortless approach to identify thoracodorsal nerve on axillary clearance procedure

Breast cancer surgery frequently involves an axillary clearance procedure for nodal metastases. Injury to the thoracodorsal nerve is one of the complications related to the axillary dissection. The thoracodorsal nerve innervates the latissimus dorsi muscle which facilitates in certain movements of the arm. Moreover, it can be used as a nerve graft in long thoracic nerve injury whether in trauma or surgery. Understanding the anatomy structures and good surgical technique in the axillary clearance procedure can identify and prevent such an injury to the thoracodorsal nerve. Here, we demonstrate a simple and effortless technique for identification of the thoracodorsal nerve during axillary surgery.