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Surgical Management of Axillary Tissue Hypertrophy

Prior to surgical incision, antibiotic prophylaxis is administered with appropriate intravenous antibiotics. The skin is incised and the posterior incision dissection is done perpendicular, straight down, through the subcutaneous fat. After the skin is incised, the dissection is beveled outward anteriorly. This creates a subcutaneous flap anteriorly. At all locations, the dissection is done down to, but not violating, the clavipectoral fascia. Anteriorly, any axillary creases or folds are obliterated by scoring of the subcutaneous tissue. The axillary breast tissue is then excised, marked for appropriate laterality, and submitted for permanent pathology. The resulting void is copiously irrigated and hemostasis is ensured. Long acting anesthetic is used to infiltrate the regional sites for postoperative analgesia. A 15-French Blake drain is placed posteriorly through a separate stab incision. The skin edges are meticulously aligned at the anterior and posterior edges with redundancy kept in the middle (Figure 6). The incisions are closed in two layers. An absorbable suture is used in interrupted buried fashion followed by an absorbable subcuticular stitch. 2-octyl cyanoacrylate liquid adhesive and self-adhering mesh (Dermabond Prineo) is placed superficially. Video 1 summarizes the technique.

Axillary tissue hypertrophy consists of ectopic breast tissue and occurs in up to six percent of women. Women complain of pain, interference with activity, and dissatisfaction with appearance. While it is recommended that accessory breast tissue be removed via surgical excision, there is lack of consensus on the best technique for surgical management of axillary tissue hypertrophy. This video present a simple and effective method to treat axillary tissue hypertrophy and contour the axilla.
Axillary breast tissue consists of ectopic mammary tissue that develops outside the normal breast region. Most commonly it is found in the axilla but can occur anywhere along the embryonic mammary streak. Accessory breast tissue originates from embryonic mammary ridge which forms during the 6th week of development. The ridge is a bilateral thickening of the ectoderm that runs from the axillae to the inguinal region and rapidly regresses, except for in the thorax.1 In the case of ectopic breast tissue, this embryonic mammary ridge, also referred to as the milk line, fails to degenerate. Most cases of axillary breast tissue are sporadic, but others can follow an autosomal-dominant inheritance pattern.2
Preoperative demarcation Axillary tissue hypertrophy is evaluated with the patient standing and the upper extremities in full abduction, adduction, and various angles in between. Ultimately, the patient is marked with the arm in 45 degrees abduction. Within the axillary fossa, a crescentic area of excision is marked, including the overlying skin and the underlying adipose and glandular tissue. The area of dissection that will be beveled outwards is also denoted. Any axillary folds or creases, if present, are also demarcated. The resulting scar is ensured to be within the axillary fossa so that postoperatively it will not be visible with the patient supine or arm adducted. Operative technique Prior to surgical incision, antibiotic prophylaxis is administered with appropriate intravenous antibiotics. The skin is incised and the posterior incision dissection is done perpendicular, straight down, through the subcutaneous fat. After the skin is incised, the dissection is beveled outward anteriorly. This creates a subcutaneous flap anteriorly. At all locations, the dissection is done down to, but not violating, the clavipectoral fascia. Anteriorly, any axillary creases or folds are obliterated by scoring of the subcutaneous tissue. The axillary breast tissue is then excised, marked for appropriate laterality, and submitted for permanent pathology. The resulting void is copiously irrigated and hemostasis is ensured. Long acting anesthetic is used to infiltrate the regional sites for postoperative analgesia. A 15-French Blake drain is placed posteriorly through a separate stab incision. The skin edges are meticulously aligned at the anterior and posterior edges with redundancy kept in the middle. The incisions are closed in two layers. An absorbable suture is used in interrupted buried fashion followed by an absorbable subcuticular stitch. 2-octyl cyanoacrylate liquid adhesive and self-adhering mesh (Dermabond Prineo) is placed superficially. Video 1 summarizes the technique. Pathology Axillary breast tissue was labeled and fixed in formalin for 64 hours, according to the standards set by the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) to ensure appropriate tissue quality for HER2 receptor testing. The breast specimen ischemic time is 0.0 hours, meeting the standard of 1 hour or less to ensure appropriate tissue quality for effective estrogen receptor (ER)/progesterone receptor (PR) and HER2 receptor testing. The cut surface is analyzed for tissue identity (breast, adipose, fibrous, and stromal). Histological processing was performed at Northwell Health at Manhasset Hospital’s Pathology Department and final interpretation was performed at Northwell Health Laboratory in Lake Success, NY.
Axillary tissue excision complications can include hypertrophic scarring, wound disruption, seroma, sensory disturbance, and axillary cording.
Axillary tissue hypertrophy is a common condition that has not received much attention in the literature, leading to a lack of consensus on the best treatment for individuals with axillary tissue excess.12 Axillary breast tissue can cause pain with cyclic hormonal changes, limitation in activity due to restriction of movement, and sweating or skin irritation.7 In addition, it can result in cosmetic concerns and aesthetic dissatisfaction. These effects of axillary breast tissue can cause psychological distress and anxiety for patients. The axillary area is often ignored in the evaluation of the aesthetic patient. As such, more attention is needed to optimize the surgical management of these patients.
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1. Schoenwolf GC, Bleyl SB, Brauer PR, Francis-West PH. Development of the skin and its derivatives. In: Larsen WJ, ed. Human embryology, 4th ed. Philadelphia, PA: Churchill Livingstone, 2009:193–216 2. Hwang SB, Choi BS, Byun GY, Koo BH, Lee SR. Accessory Axillary Breast Excision with Liposuction Using Minimal Incision: A Preliminary Report. Aesthetic Plast Surg. 2017 Feb;41(1):10-18. doi: 10.1007/s00266-016-0729-3. Epub 2016 Dec 28. PMID: 28032153. 3. Greer KE. Accessory axillary breast tissue. Arch Dermatol. 1974 Jan;109(1):88-9. PMID: 4809221. 4. Youn HJ, Jung SH. Accessory Breast Carcinoma. Breast Care (Basel). 2009;4(2):104-106. doi: 10.1159/000210638. Epub 2009 Apr 24. PMID: 20847887. 5. Sahu SK, Husain M, Sachan PK. Bilateral accessory breast. The Internet Journal of Surgery. 2008. 6. DeFilippis EM, Arleo EK. The ABCs of Accessory Breast Tissue: Basic Information Every Radiologist Should Know. American Journal of Roentgenology. 2014 202:5, 1157-1162

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