Lymph nodes are part of your immune system and are present throughout your body. Their job is to filter the liquid which naturally leaks out of blood vessels. This liquid (the lymph) travels to the nodes which contain lots of white blood cells designed to trap and fight germs which can cause infection. You may have felt swollen lymph nodes in your neck when you have had an infection such as a simple cold. As well as trapping germs, the lymph nodes can also trap cancer cells that have migrated from a primary tumour.

It is often not possible to tell how many nodes contain melanoma until after your operation. The nodes removed from the armpit are carefully looked at under a microscope. Your doctor will have already felt your armpit to see if there are any lumps and you will have had a special scan (CT or MRI) to look more closely at the nodes or had a sentinel node biopsy. Nodes can feel big if there is infection in the area, so if you can feel a lump in your armpit it does not necessarily mean that the cancer has spread.

If there is only a small amount of cancer cells present in the nodes then the armpit can feel normal and look normal on scan. This is often why we do not know if the cancer has spread to the nodes until they have been looked at under a microscope.

There are hundreds of lymph nodes throughout your body which will still be there to fight infection after your operation. However you will be at increased risk of infection in the affected limb.

• Bleeding (< 5%)
• Infection (< 5%)
• Seroma (10-15%)
• Numbness around the scar (common)
• Swelling of the arm or lymphoedema (10-15%)

Your surgeon will inject local anaesthetic around the wound and chart painkillers although the wound is not usually very painful.

Postoperative care includes one to two nights in hospital. Initially your arm will be immobilized in a sling or collar and cuff. This is to reduce the amount of fluid that comes out of your drain.

You will be discharged with a drain in the armpit which may stay for a few weeks. The district nurse will look after this and remove it when there is less than 20mls in the drain in 24 hours.

Ongoing care must continue to avoid infection or injury in the arm as this will make any swelling in the arm worse. Blood pressure measurement and blood tests should not be done on the affected side.

Physiotherapy following axillary dissection for melanoma surgery is aimed at maintaining your shoulder movement in order to prevent stiffness.

It takes a week or more to look at the lymph nodes properly so your doctors will not know until then whether additional treatment is necessary. Any additional treatment usually involves radiotherapy or sometimes chemotherapy.

These can be done 2-3 times a day when you go home. Do 1 set of 10 for each exercise. Initially, you may find that you are not able to get the full movement in your shoulder due to tightness or discomfort under your arm. Do not continue the exercises if you are experiencing pain. Over time the discomfort will ease and movement should return.

EXERCISE 1. FINGER WALKING UP THE WALL

Start with your hands on the wall. Move hand upwards out in front of you, by walking your hands up the wall towards shoulder height.

EXERCISE 2. ARM OUT TO THE SIDE

Start with your arm straight by your side. Raise your arm sideways away from your body towards shoulder height, then lower it back down to your side.

EXERCISE 3. SHOULDER ROTATION

Bend your elbow to 90 degrees, and tuck it into your side. In this position, rotate your hand away from your body, and then bring it back in towards your body.

EXERCISE 4. EXTENDING HAND TOWARDS SHOULDER

Place the back of your hand into the curve of your lower back. Progress your hand upwards.

EXERCISE 5. ELBOW BEND / STRAIGHTEN

Bend and straighten your elbow.

Remember: These exercises should NOT be forced. Perform only within the limits of pain.

Once you have had your drain and stitches removed, you can progress the above exercises in the following ways:

EXERCISE 1. FINGER WALKING UP THE WALL.

Walk your hands up the wall above shoulder height.

EXERCISE 2. ARM OUT TO THE SIDE

Raise your arm sideways above shoulder height.

EXERCISE 3. SHOULDER ROTATION

Place your hands on your head. Bring your elbows together in front of your face, and then stretch them apart and backwards. When your elbows are in the backward position, hold for 5 seconds.

Once the drain and stitches come out and your wound is closed and healed, it is time to start massaging moisturiser on your scar. This keeps the scar mobile and helps with your shoulder mobility. Initially the scar may be uncomfortable and more sensitive to touch. However, the more you touch it, the less sensitive and more comfortable it will become.

You can use Vitamin E cream, or any non-irritant moisturiser to massage your scar. Use your fingertip, and massage in a circular motion so that the scar and skin move over the underlying tissue. Begin gently, and as you get used to it, you can press a bit firmer. As a general rule, the tip of your fingernail should turn white while you are massaging your scar.

Occasionally fluid may collect in your armpit following an axillary dissection, this is called a lymphocoele. This may present as swelling and is accompanied by pain. If this does happen please contact your Surgeon or General Practitioner for advice.

Our wound care nurse Lynn is also available for advice should this happen. Lynn is available Monday to Friday.

It is a good idea to continue with your exercises and scar massage until your shoulder movement improves (this may take 1-2 months). If your shoulder movement does not improve over this time, or your scar remains very sensitive, your doctor may refer you to physiotherapy for further stretches and strengthening ex