In the middle of last year (1924), the compiler of these short notes (Ravin Thatte) was most impressed by a presentation on the subject of “accessory breast” by Dr. Medha Bhave a plastic surgeon from the city of Thane in the state of Maharashtra India. What is more it was revealed at that time that her sub-classification of the axillary breast had been recognized in international literature (originally published in the Indian journal of plastic surgery in 2015). Her statement at that time that the axillary breast is not just a lump to be excised but must be carefully removed with due esthetic considerations was a crucial part of her presentation and she demonstrated her technique at that time. She was therefore requested to write a chapter on that subject for this blog which follows. Dr. Medha Bhave is the current president of the Indian association of aesthetic plastic surgeons (2025).
Definition and origin of an accessory breast and its types (Figure 1)
The accessory breast is defined as the presence of breast tissue or a component thereof in the form of a nipple or areola or breast tissue or any combination thereof. Sometimes such breast tissue is represented by a mere tuft of hair. If in a case of congenital absence of breast as in (a) Poland’s syndrome if breast tissue is present elsewhere in the body, it cannot be labeled as an accessory breast.
Embryology—The ectodermal ridge that ultimately differentiates into the breast is called the milk line or the mammary line. It extends from the axilla to the groin (see above figure 1). This can be easily understood when we see quadruped mammals with multiple breasts to feed more than one offspring. In the human fetus, the entire mammary or milk line appears around the 7thweek of gestation and totally disappears leaving only one breast bud on each side of the thorax before birth.
As the girl child attains puberty, the normal breast undergoes enlargement. If an accessory breast is present, it may undergo enlargement as well. In another group, high levels of hormones during pregnancy and lactation can similarly enlarge an accessory breast. Thus, we see two age groups of patients who present to the plastic surgeons with complaints of a lump located anywhere along the milk line or an accessory breast.
In a male child, the onset of puberty does not stimulate the breast bud normally. So far not a single case of accessory axillary breast has been reported in a male. However supernumerary nipples have been sporadically reported in males and such patients may seek surgical treatment.
The classification of accessory breast was proposed by Kajava (1884 to1929) in 1915 who was an esteemed professor of anatomy at the university of Helsinki in Finland (1921 to 1929). He classified the accessory breast depending upon its components present (Figure 2).
The classification may be difficult to remember. And therefore, the author of this chapter presented this in the form of symbols as shown in the figure above. In this, the breast tissue is represented by a solid ellipse, the areola by a hollow ellipse and the nipple by a solid rod. The hair is represented by arrows. It is much easier to represent the accessory breast tissue in this manner than to try and remember the roman numerals. A diagram is sufficient to depict the type without any chances for error.
How is it different from ectopic breast?
Ectopic breast tissue is the breast found in an aberrant location. This term has been used interchangeably with accessory breast in the literature. Some use it for the breast that is located away from the milk line. All said and done there is no clarity in the usage of these terms as axillary breast is often termed ectopic accessory breast.
The locations of the accessorybreast
The typical locations of accessory breast tissue are illustrated in Figure 3 below. The commonest locations along the milk line are chest wall and axilla. The locations away from the milk line are uncommon yet lateral thighs, knee, vulva, face and ear have been reported.
Note by the compiler of these short notes – These lesions because of their location are truly ectopic because the exact meaning of the word is “in an abnormal place or position”. The meaning of the word accessory is “additional or extra”. Based on the embryology of the development of the mammary glands across most mammals, a distinction should be made between the two terms ‘ectopic and accessory’.
The accessory breast located in the axilla is called axillary breast. The term accessory breast is a general term and has been ascribed to any location as described above by tradition. Figure 4 illustrates examples of type V and VI accessory breasts.
Standard classification and Bhave’s modification
The axillary breast is commonly type IV of Kajava classification. It is presence of only the mammary gland without any areola or nipple or both. The author has seen only one patient with an additional nipple and areola among 52 patients and 94 breasts handled so far.
Till the year 2015, an axillary breast was not classified. Bhave classified axillary breast (which is a subtype of accessory breast) as follows (Figure 5).
- Para mammary—The axillary breast is in the same skin envelope as the main breast tissue. There is not much separation between them medially. Laterally, there is a distinct separation between the axillary breast and the lateral wall of the axilla. This is likely to be a superimposition on the tail of Spencer passing through the foramen of Langer. The foramen is the gap in the pectoral fascia on the lateral border of Pectoralis Major muscle towards its insertion on the humerus
- Central—This type of axillary breast has a clear gap between the lesion (lump) and the medial wall of the axilla. There is also a clear gap between it and the lateral border. When a patient abducts the arm, one can see a well-defined swelling in the axilla. This requires a proper differential diagnosis from enlarged matted axillary lymph nodes due to tuberculous or other causes.
- Lateral arm—Some patients present with mass along the lateral border of axilla, which is an axillary breast. It can be removed through standard incision in the axilla. The excess skin can be removed from the axilla. Excess medial arm skin can be draped locally, improving the laxity and contour both.
Please see diagram of the concavity of the axilla below (figure 6).
The classification is important for proper diagnosis of various swellings in the axillary area. All the types of axillary breasts can be removed through axillary incision irrespective of the type.
Anatomy of the axilla (Figure 6).
The axilla is a pyramidal structure with four walls and a hair bearing concave floor. The apex of the axilla is gateway to various nerves and vessels that supply the arm. The lateral wall is formed by the intertubercular sulcus of the humerus. The medial wall is formed by the convex lateral thoracic wall with serratus anterior muscle. The anterior wall is formed by the pectoralis major and minor muscles. The posterior wall is formed by latissimus dorsi, scapularis and teres major muscles.
Axillary hair bearing skin is like the skin of the scalp. It is tough and not highly retractile. The sweat glands are apocrine. They reach deeper in the skin, secrete a substance thicker than sweat secreted by eccrine glands elsewhere on the body. This thick substance provides nutrition for the bacteria. Bacterial interaction is responsible for the odor. Notably these glands are activated around puberty due to sex hormone stimulation. On this count removal of axillary skin with hair is welcome by the patient.
The intercostobrachial nerve invariably passes through axillary breast as it also supplies axillary skin.
Reasons why such breast tissue is removed
The patients present with complaints of:
- Swelling in the axilla
- Discomfort
- Pain in the swelling — Menstrual variation in some patients
- Pain along the medial arm.
- Accumulation of sweat and stinking, sometimes rashes and itching
- Inability to keep arms by the side of the body leading to shoulder discomfort
- Fear of malignancy: It is important to note that any disease that can affect the breast can occur in axillary breast as well — be it mastitis, duct ectasia or malignancy. It is recommended that the removed lesion should be sent for microscopic examination irrespective of the symptoms.
- Inability to wear proper clothes because the arm hole needs to be much larger to accommodate the axillary lump, because it cannot effectively separate adjacent skin surfaces.
The surgical technique (photographs)
Investigation of axillary swelling with ultrasound examination to determine the nature of the swelling is crucial for correct treatment. Lipomas, inflamed lymph nodes, A-V malformation must be ruled out. Any changes in the breast in terms of inflammation and duct dilatation should be noted.
Pre-op Markings
The surgical procedure is done after pre-op markings are done in standing position. With arm raised above the head, the axillary skin is pinched in various directions. The smallest ellipse in the direction of maximum laxity should be marked for excision. It is not necessary to follow resting skin tension lines (RSTL) as the skin has expanded due to the lump. This allows for preserving the range of shoulder movements by preventing unnecessarily excessive removal of the skin. There are papers saying skin removal is not required. But the lump has acted like an expander over the years. In practice, therefore some removal helps to avoid a hanging skin fold post operatively in most of the patients. The footprint of the gland in the axilla is marked to allow complete excision (Figure 7). The anterior and posterior axillary aesthetic lines are marked. The incision must not cross these lines. Otherwise, the scar would become visible at rest.
The anterior and posterior axillary folds and Bra roll on the lateral chest wall are the areas that need to be addressed for liposuction to achieve satisfactory contour. If this fat is not removed, it moves to the empty axilla and leads to patient dissatisfaction
Anesthesia – Surgery is done under general anesthesia. A very co-operative or high anesthesia risk patient with unilateral swelling can be managed under local anesthesia.
Surgical technique – The surgery is done with arm placed at right angle on the arm rest. Infiltration of 20 to 50 ml saline and 1 in 1 lakh adrenalin is injected in subcutaneous plane and intradermally along the incision. The planned liposuction regions are infiltrated as needed. An incision is taken on the edges of the ellipse. Subcutaneous elevation of surrounding flaps is done to isolate the axillary breast (Figure 8).
The flap thickness should be good as too much thinning would cause irregularities and retraction of the flap. One always finds a plane that allows one to dissect in bloodless manner with finger or diathermy. As the root is reached one should shift to finger dissection. The intercostobrachial and many small (Figure 9) nerves should be protected.
The cephalic vein above should be preserved. The lump starts separating once the axillary fat pad is reached (Figure 10).
The latter must never be injured for the fear of lymphedema of the arm. One can locate the Foramen of Langer at this stage (Figure 11) and make anatomical diagnosis of axillary breast or extension of the tail of the breast through Langer’s foramen.
After the lump is excised, careful hemostasis is achieved. The Foramen of Langer is closed with figures of 8, 4-0 PDS or 3-0 Monocryl. The wound can be closed with temporary sutures to judge the amount of liposuction required. Open liposuction of the surrounding flaps and all the marked areas are completed. The arm is moved above the head in maximum abduction. Final skin adjustment to remove excess and the dog ears are done. The wound is thoroughly washed. Suturing is done with the same suture material, taking care to fix each layer to the lower one, thus fixing the suture line (Figure 12).
Final skin closure is done with surgical tapes; A bolster is kept in the axilla over which stretchable hypoallergic tape is applied with optimum pressure.
Post-operative care dressings drain?
Drains are not required if,
1. Careful hemostasis is achieved,
2. Wound is washed well
3. A good compression dressing fitting the axillary contour is done.
Patients can be discharged on the same day. The first review is typically done on the fourth post-operative day. If there is no collection, one can leave the surgical tapes open. Patient can have a bath daily, the tapes start coming off in a weeks’ time. The scar is reviewed and managed with silicon-based scar care creams or tapes
In the post operative period patient is asked not to strain the shoulders in any way for fear of hematoma and late seroma formation for a period of a month.
Their movements are not otherwise restricted, but they need to be careful when travelling to work. Working from home is the best option when possible.
Photographs Pre and post op
Figure 13 to 18 – Results of axillaplasty with limited open liposuction for axillary breasts.
Short Notes in Plastic Surgery 