Axillary lymph node dissection (ALND), also called axillary clearance, is the more extensive axillary procedure in which the lymph node-bearing fatty tissue of the axilla is surgically removed.

An average of 10 to 20 nodes are removed. It is performed when there is confirmed, significant cancer involvement of the axillary lymph nodes that requires both treatment and accurate staging.

When Is Axillary Dissection Recommended?

Axillary dissection is recommended in the following situations: when the sentinel lymph node biopsy confirms macrometastatic involvement and further axillary surgery is indicated based on the clinical picture; when the axillary lymph nodes are clinically involved with cancer at the time of diagnosis (palpable or confirmed on imaging and biopsy) and neoadjuvant treatment has not been given or has not cleared the nodal disease; or when there is extensive nodal disease identified at surgery that warrants complete clearance for both therapeutic and staging purposes.

The decision to proceed with axillary dissection versus axillary radiotherapy for management of node-positive disease is increasingly nuanced, and is made by the multidisciplinary team in the context of the extent of nodal involvement, the planned systemic and radiation therapy, and the patient's individual circumstances.

The Axillary Dissection Procedure

Axillary lymph node dissection is performed under general anaesthetic, usually at the same time as the breast surgery. The procedure involves careful dissection of the fatty tissue of the axilla to remove the lymph nodes within levels I and II of the axilla (and sometimes level III when more extensive involvement is present), while preserving the surrounding nerves and blood vessels as far as possible.

A surgical drain is placed at the conclusion of the procedure and remains in place for five to ten days after surgery, managing the fluid that accumulates in the axillary space during healing. The wound is closed with dissolving sutures.

Lymphoedema and Axillary Dissection

The most significant long-term risk of axillary lymph node dissection is lymphoedema — chronic swelling of the arm caused by disruption to the axillary lymphatic drainage. When axillary lymph nodes are removed, the remaining lymphatic channels must find alternative routes to drain the arm. When drainage is insufficient, fluid accumulates in the arm, causing swelling that can range from mild and manageable to severe and functionally limiting.

Lymphoedema affects approximately 15 to 25% of patients following axillary dissection, compared with around 5% after sentinel node biopsy alone. It can develop at any time after surgery, from weeks to years later, and is more likely in patients who also receive axillary radiotherapy, have a high BMI, or experience infection or injury to the arm.

Lymphoedema is a chronic condition that cannot be cured but can be effectively managed with a combination of specialist physiotherapy, manual lymphatic drainage massage, compression garments, and exercise. Our team coordinates closely with lymphoedema physiotherapists as part of post-operative care, and early referral at the first sign of arm swelling consistently produces better long-term outcomes.

Lymphovenous Anastomosis (LVA) for Lymphoedema Prevention

For patients undergoing axillary lymph node dissection, lymphovenous anastomosis (LVA) is an innovative microsurgical technique that can be performed at the time of axillary dissection to reduce the risk of developing lymphoedema.

LVA involves the creation of tiny connections (anastomoses) between small lymphatic vessels and adjacent venules (small veins) in the axilla or arm, using operating microscope-level precision. By creating these new bypasses, the technique allows lymphatic fluid to drain directly into the venous system, partially compensating for the disrupted axillary drainage and reducing the risk of fluid accumulation in the arm.

When performed prophylactically at the time of axillary dissection, LVA has been shown in recent clinical studies to significantly reduce the incidence and severity of lymphoedema compared to axillary dissection alone. It adds minimal time to the overall operative procedure and carries no meaningful additional risk, making it a clinically valuable adjunct for eligible patients.

LVA requires microsurgical expertise and specialised equipment. Our practice coordinates with microsurgically trained colleagues to offer prophylactic LVA to appropriate patients at the time of axillary dissection. Therapeutic LVA — performed after lymphoedema has already developed — is also available through our network for patients with established lymphoedema who have not responded adequately to conservative management.
If you are facing axillary lymph node dissection, please discuss prophylactic LVA with your surgeon at your pre-operative consultation.

Risks of Axillary Dissection

Beyond lymphoedema, additional risks of axillary dissection include seroma formation (very common, managed with drain placement and needle aspiration as needed), wound infection, shoulder stiffness and reduced range of motion (managed with physiotherapy), numbness of the inner upper arm and axilla from nerve disturbance, weakness of the serratus anterior muscle from long thoracic nerve injury (rare, causing a "winged scapula" appearance), and injury to the thoracodorsal nerve supplying the latissimus dorsi muscle (rare).

All risks will be discussed in detail at your pre-operative consultation.