The operation as thus described has been extended by Halsted to a degree which requires often much more work, and which has furnished even better results, since he includes in it, if necessary, the removal of both pectoral muscles, and even the division of the clavicle for better exposure of the axillary and lower cervical regions, and the more thorough extirpation of involved lymphatics. In other cases he makes a vertical incision along the posterior margin of the sternomastoid, exposing the junction of the internal jugular and subclavian veins, and removes the supraclavicular fat by a downward dissection and the infraclavicular fat by a dissection from below. This is facilitated by elevating the shoulder, by which the clavicle can be removed one inch or more from the first rib.

Figs. 527 and 528 illustrate the incision recommended by Halsted and the general method of attack.

Throughout these operations the primary question is removal of disease, the matter of subsequent closure of the wound being a secondary consideration. Nevertheless the extirpation being completed, there arises the question of how best to close the extensive defect thus created. This will depend on its size and upon the amount of loose skin in the vicinity furnished by the patient’s general physique. With emaciated patients, whose skin is tightly drawn, it is not easy to furnish flaps, whereas in those who are fatty, with flabby flesh and skin, it is easy to rearrange the latter. Beck has suggested to make quadrilateral instead of elliptical incisions, leaving a square defect, which can then be closed by sliding flaps from two directions. The names of Warren and Meyer are also connected with elaborately described plastic operations. Years before any of these were published the writer was doing similar sliding of flaps, but never endeavoring to make them conform to a single pattern, raising semilunar flaps, or those of any other shape, as might best fill the demand, and taking them from that portion of the thorax, side, or even the abdomen, which would seem best to furnish them. There is, therefore, no one method to be especially recommended, for every operator of good judgment will be able to secure sufficient integument from some surrounding location, so that it is rarely necessary to leave such a wound uncovered. In those cases which require an amount of dissection not permitting this it is a question if operation be advisable. Nevertheless should it happen that for some reason a sufficient skin covering is not thus easily available, Thiersch skin grafts may be applied to any uncovered area at the time of terminating the operation or later, and may be nearly always relied upon for their destined purpose.

At least one opening should be made in the lateral flap in such a location as to drain the axillary cavity when the patient is lying upon her back, and through this a drainage tube of sufficient size should be inserted. This should rarely be left more than forty-eight hours. Inasmuch as there will sometimes be considerable tension upon flaps a certain number of strong and reliable sutures (silkworm or thread) should be used, to prevent parting of the wound margins, while long retention sutures may be inserted if required. The balance of the suturing may easily be done with catgut. The intent should be to leave no dead spaces. Any isolated mass of fat which stands out by itself after the dissection is complete should be pared down to the common level, in order that it may not perish from ill-nutrition, nor disturb the general level of the adjoining surfaces. It is rarely necessary to keep patients in bed more than two or three days after even extensive operations of this kind, but it is necessary to ensure that equable pressure be made with the dressings, and that the entire arm be bound to the side and immobilized in such a way that the patient cannot move it nor disturb the dressing.