Technique of forequarter (interscapulothoracic) amputation.

In the anterior approach to forequarter amputation, a segment of clavicle is removed and early dissection and division of the subclavian vessels are done. In the posterior approach after division of the trapezius and muscles attached to the vertebral border of the scapula, the trunks of the brachial plexus and the subclavian vessels are serially ligated and divided, while the pectoral muscles are intact. In both approaches, the dissection around the subclavian vessels can be slow and tedious to avoid bleeding, which could be difficult to control because the vessels have not been cleared circumferentially for application of a vascular clamp. Our technique combines an anterior and a posterior approach, which rapidly divides all the relevant muscles and clavicle, and leaves at the end the division of the nerves and subclavian vessels as the extremity is gently supported to avoid undue traction on the vessels. The trunks of the brachial plexus are divided posteriorly and the subclavian vessels at the thoracic inlet, allowing a greater proximal margin than that achieved by the anterior or posterior approach. When extra skin has to be removed from the axilla because of tumor involvement, a fasciocutaneous deltoid flap may provide coverage of the defect.