Modified Radical Mastectomy
What the Examiner Expects
Total mastectomy combined with axillary lymph node dissection (ALND) of levels I and II, preserving the pectoralis major and minor muscles. The examiner expects you to know the nerve anatomy at risk during ALND: the long thoracic nerve (innervates serratus anterior — injury causes winged scapula), thoracodorsal nerve (innervates latissimus dorsi), and the medial pectoral nerve. The intercostobrachial nerve (T2 sensory branch) is commonly sacrificed, causing numbness along the medial upper arm — patients should be counseled preoperatively.
Key Examiner Focus Points
- Total mastectomy PLUS axillary lymph node dissection (levels I and II)
- Preserves the pectoralis major muscle (unlike Halsted radical mastectomy)
- Indicated for clinically node-positive breast cancer confirmed by FNA/core biopsy
- Long thoracic nerve (serratus anterior) and thoracodorsal nerve (latissimus dorsi) must be preserved
- Intercostobrachial nerve sacrifice causes medial arm numbness — warn patient preop
Common Curveballs
During ALND, you notice the long thoracic nerve is stretched but intact
Preserve it at all costs. Injury causes winged scapula, which is debilitating and difficult to reconstruct. Handle the nerve gently, avoid traction, and dissect around it carefully.
Postoperatively the patient develops lymphedema of the ipsilateral arm
Lymphedema is the most common long-term complication of ALND (15–25%). Management: compression garments, manual lymphatic drainage, complete decongestive therapy. Avoid blood draws, IVs, and blood pressure cuffs on the affected arm. Early referral to lymphedema therapy is critical.
Practice this topic with an AI-powered mock oral exam.
Browse Practice Cases