Sentinel Lymph Node Detection in a Patient with Subungual Melanoma after Transaxillary Breast Augmentation

Abstract

Sir: Transaxillary breast augmentation is performed worldwide. It is associated with pleasant aesthetic results and the possibility of hiding and minimizing the scar out of the breast.1,2 However, there is great concern regarding possible injuries to lymphatic structures in the axilla and future oncologic consequences related to this. The sentinel lymph node investigation is a well-established method of axillary staging in breast cancer and upper limb melanoma. The possibility of alteration in the breast lymphatic drainage caused by axillary surgical access could interfere with sentinel lymph node mapping if the patient develops a future breast cancer or upper limb melanoma.1–3 A 45-year-old, white, previously healthy woman was submitted to transaxillary breast augmentation and evaluation of axillary lymphatic vessels and sentinel node mapping during research developed in our department.1,2 The incision was S-shaped, 4 cm long, in the main axillary fold, and 1 cm posterior to the lateral border of the major pectoralis muscle. A subcutaneous tunnel was dissected up to the superolateral border of the muscle, preserving an inferolateral triangle of soft tissue containing most of the lymphatic vessels (Fig. 1, left). The mammary implant was placed in a subfascial pocket and 0.5 ml of blue dye was injected subdermally at a point superior and lateral to the areola in both breasts (Fig. 1, right). After 1 minute of gentle pressure over the injected point, blue dye was seen in the lymphatic vessels of the soft-tissue triangle preserved lateral and inferior to the lateral border of the major pectoralis muscle. There was no diffusion of blue dye into surrounding tissues, suggesting no major injury of lymphatic structures in the axilla.Fig. 1.: Preoperative axillary markings showing the subcutaneous pathway to be dissected with preservation of the “soft-tissue triangle” (left). Identification of lymphatic structures in the axilla after periareolar blue dye injection (right).Two years later, the patient developed a subungual melanoma in the right thumb and was submitted to amputation of the distal phalanx plus investigation of sentinel node in the axilla (Fig. 2).Fig. 2.: Transaxillary breast augmentation (left) following amputation of the right thumb phalange (right); a diagnosis of subungual melanoma was made.The sentinel lymph node was identified successfully in the axilla with the technique of blue dye injection plus lymphoscintigraphic investigation. It was negative for malignancy and free of micrometastasis. The patient is free of the disease until the present. Concerning possible injuries to lymphatic structures during the transaxillary approach for breast augmentation, Prado et al.4 suggested that this surgical access could eventually traumatize the lymph nodes of the armpit in a perimeter of 5 to 6 cm, where the sentinel node is usually located.5 In recent lymphoscintigraphic study, Graf et al.1 and Sado et al.2 showed that although partial and transitory impairment of lymphatic drainage can occur shortly after transaxillary breast augmentation, it does not interfere with lymphatic drainage and location of the sentinel node in the postoperative period if dissection in the axilla is performed carefully and respects the axillary soft-tissue triangle described. Despite anatomical variations and clinical controversies, it is known that lymph vessels from both breast and upper limb drain to the axilla. This case illustrates the success of axillary sentinel lymph node investigation in a patient with upper limb melanoma after transaxillary breast augmentation. Ruth Maria Graf, M.D., Ph.D. André Ricardo Dall'Oglio Tolazzi, M.D., M.Sc. Paula Giordani Colpo, M.D. Gilvani Azor de Oliveira e Cruz, M.D., Ph.D. Division of Plastic Surgery Hospital de Clínicas School of Medicine Federal University of Paraná Curitiba, Paraná, Brazil