4.2.2 Key Points of Surgery
Design the incision and separation of the flap according to the elements of a simple mastectomy.From the inside，above along the chest large fascia deep outward，lower direction free breast，together with the chest large fissa separation，the removal of the breast to the chest muscle edge.Anatomy of the outer edge of the chest muscle，separating the edge of the chest muscle and turning up to the inside，separating the large chest，small muscle，removing the lymph nodes（Rotter lymph nodes）and adipose tissue between the pectoral muscles，and paying attention to protect the chest-shoulder peak artery chest muscle branch and the outer and inner branch of the chest nerve.For patients with broader lymph node metastasis of the armpits，patey can be used to cut off the starting and ending points of the chest muscles by more thorough lymph node cleaning.Cut the outer edge of the small muscle in the chest to lock the pleural membrane，reveal the veins and the under-collar veins，tie branches one by one，and clean the level Ⅱ area lymph nodes.
Sweep inward at the chest wall below the small pectoral muscle until the inner edge of the small pectoral muscle that crosses the armpit veins.If necessary，Modified radical mestectomy pull the small muscles of the chest outwards to sweep the level Ⅲ area lymph nodes.Modified radical mestectomy I can also clean the level Ⅲ area lymph nodes on the inside of the small muscle of，Level Ⅲ area lymph nodes cleaning will increase the chance of upper limb edema，so level Ⅲ cleaning is not often.
Ⅲ Regional lymph nodes.
Clean level I area lymph nodes should pay attention to protect the chest nerve，chest back nerve and chest-back venous，selectively retain the inter-rib arm nerve.The lower division of the front saw muscle fascia and the armpit back wall of the shoulder underthe muss，back broad muscle surface fascia，and finally the breast，chest muscle inter-muscular lymph nodes，armpit area lymph nodes of the whole lump severberated.Thoroughly stop the bleeding and rinse the wound，place a negative pressure drain tube on the chest wall and armpit sits and secures it.Absorption lines can be continuously stitched subcutaneous tissues，skin，armpits pressurized bandage.
Case Analysis 2
The patient，female，50，was admitted to hospital for“1 year of discovery of a right breast lump”.
Admission：double milk basic symmetry，skin normal，double nipples scavened，right breast can touch the outside of 4x 2cm size lump，hard，not clear boundaries，mobility acceptable.The right armpit can touch about 2 x 1cm of the swollen lymph nodes，the activity is not fused.The left breast is not visible，and the left armpit and the double-sided collarbone do not touch the swollen lymph nodes.(https://www.daowen.com)
Auxiliary inspection：B ultrasound：the right breast on the outside of 10 o'clock direction detected a 4.5x2.3cm low echo group，the boundary is not clear，the form is irregular，the rear accompaniment attenuation，seeing rich blood flow signal around.BI-RADS：Class 5.Right armpit protothesis and 1.9x 1.2cm swollen lymph nodes.BI-RADS：Class 5.
Breast X-rays：4.2x2.0cm irregular lumps visible on the outside of the right breast，with short burrs visible around.The scan range includes the swollen lymph nodes of the right armpit，about 2cm in diameter.BI-RADS：Class 5
MRI：A swelling visible on the outside of the right breast，about 38x 20mm in size，long T1 long T2 signal，unclear boundaries，irregular patterns，short burrs visible atthe edge of the lesions，DWI with uneven，slightly higher signal，ADC value reduced.The right armpit sees the swollen lymph nodes，with a maximum diameter of about 21mm，considering metastatic lymph node swelling.BI-RADS：Class 5.
Patients had right breast cirrhosis puncture biopsy and the disease was shown：right breast-soaked catheter cancer Level I，ER（+，45%），PR（+，50%），Cerb-B2（+），Ki-67（60%）.Right breast cancer had modified radical mestectomy，postoperative medical examination：right breast-immersed catheter cancer Grade Ⅲ，ER（+，50%），PR（+，40%），Cerb-B2（+），Ki-67（70%）.The lymph nodes of the right armpits（2/14）are seen as cancer metitated.
Preoperative surgery，postoperative Richard M Rainsbury.Nat.Clin.Prac.oncol.2007